Safety and Harm for the Woman

POSSIBLE PHYSICAL HARM. There is a close tie between medical information on the safety of abortion practices and ethical positions on abortion. For example, at a time when abortions were frequently harmful to women—such as when legal restrictions increased recourse to untrained practitioners—opponents of abortion appealed to information on the likelihood of medical harm to the woman and risks of future pregnancies as arguments against abortion (Kunins and Rosenfield).

As of 2003, induced abortions performed within the first twelve weeks of pregnancy are among the safest and simplest forms of surgery and, based on maternal mortality ratios (number of deaths per 100,000 live births), both first-and second-trimester abortions, when performed by properly trained personnel, in general are safer than carrying a pregnancy to term (Cates and Grimes). As a result, ethical arguments against abortion tend to be restricted to areas other than maternal safety. Nonetheless, some aspects of medical safety and harm—including possible complications and psychological sequelae—continue to be important for ethical discourse, especially since a basic tenet of medical ethics is to avoid harm.

The major immediate complications of induced abortion, listed in order of frequency, are infection, hemorrhage, uterine perforation, and anesthesia-related complications. Overall complication rates for legal first-trimester abortions are less than 0.5 deaths per 100,000 abortions performed (as compared to more than four per 100,000 in the early 1970s, before the U.S. Supreme Court decision Roe v. Wade [1973] permitted medically supervised abortions). Medical complications associated with induced abortion are directly related to gestational age and the type of procedure used to terminate the pregnancy. Most abortions (over 90%) done in the United States are performed within the first twelve weeks of pregnancy, when abortion is safest. More serious complications may occur in procedures done later in pregnancy.

ABORTION PROCEDURES. Information on abortion procedures often sheds light on questions of safety as well as on other aspects of abortion that are relevant to ethics. The most common early-trimester abortion procedure (done between seven and twelve weeks' gestation) is suction curettage, in which a thin plastic tube (canula) is inserted through the cervix and, by negative pressure vacuum, the contents of the uterus are aspirated. Usually, following the aspiration procedure, a curettage (using a sharp, spoon-shaped surgical instrument, a curette) is performed to ensure that all fetal tissue has been removed.

Complications of suction curettage procedures are rare, and even when they occur, are usually not serious. General anesthesia is considered by many to be an unnecessary additional risk, since local anesthesia, injected into the cervix, often is quite effective (Grimes et al.). A short course of prophylactic antibiotics is sometimes prescribed, although postabortion infection is uncommon with suction curettage. Because of its safety, suction curettage is performed most often in free-standing clinics or outpatient centers in hospitals.

At twelve to twenty weeks' gestation, the most common method used for abortion is dilation and evacuation (D&E), which uses specially designed forceps in conjunction with vacuum aspiration to facilitate the removal of the uterine contents. Prior to initiating the procedure, the cervix is dilated gradually over a number of hours using sponge-like materials that expand as they absorb local cervical fluids. Though still considered a minor surgical procedure, D&E is clearly more involved and invasive than suction curettage, and a trained and skilled clinician is essential. Although it is possible to use only local anesthesia for D&E, the procedure is considerably more uncomfortable than suction curettage, and general anesthesia is often used, making the procedure more risky. The D&E procedure can be performed in freestanding clinics, but often ambulatory surgical services in a hospital setting are chosen for the procedures performed later in pregnancy (after the fourteenth week) because emergency care can be quickly provided in case of a complication. Informed-consent procedures require that the various methods of abortion be discussed as well as the possible anesthesia alternatives.

The other abortion procedure used fairly commonly in the second trimester is instillation abortion, in which a solution instilled into the amniotic cavity through the abdomen via amniocentesis results in the death of the fetus and termination of the pregnancy. Uterine contractions signaling labor begin twelve to twenty-four hours later and culminate with the expulsion of the fetus. Anesthesia is not commonly used for instillation procedures. Discomfort varies widely among patients, usually in relation to the length of labor and the time before complete expulsion of the fetus and placenta. More serious complications can occur during instillation procedures, including inadvertent introduction of the solution into the mother's bloodstream, excessive bleeding at the time of expulsion of the fetus, or retention of placenta, and for this reason hospital admission is usually advised. Instillation procedures are used mainly for procedures beyond the twentieth week of gestation. All late-pregnancy abortion procedures carry significant risk if carried out by physicians not specially trained in the technique.

A promising alternative to surgical abortion for early first-trimester terminations of pregnancy is chemical abortion. For example, the antiprogestin drug RU-486 works by blocking progesterone production by the ovaries, an essential hormone in the early stages of pregnancy and in the implantation of the embryo. The drug is given within the first forty-nine days of a confirmed pregnancy and is used in conjunction with a prostaglandin, which produces uterine contractions and subsequent expulsion of the uterine contents. A follow-up visit is necessary eight to twelve days later to ensure that complete termination of the pregnancy has occurred.

On September 28, 2000, the U.S. Food and Drug Administration (FDA) approved RU-486 for use in the United States, and it has been distributed since the following November by Danco Laboratories, LLC under the brand name Mifeprex. According to the guidelines set forth by the FDA, it has been distributed only to physicians and is not available through pharmacies; furthermore, the FDA has approved a specific regimen for the use of RU—486. Three visits are necessary for this medical means of pregnancy termination: the first to make the diagnosis and to give the RU-486, the second, two days later, for the prostaglandin, and the third within two weeks for the final follow-up. In France, a fourth visit is required by law since a one-week delay between the diagnosis of pregnancy and the initiation of an abortion procedure is mandated.

As a result of the requirement for three visits (or four in France), because there may be a few days before the abortion occurs and as many as ten or more days of vaginal bleeding thereafter, and because it may be more expensive than surgical abortion, many women in France and the United States still prefer suction curettage as their method of choice (Kolata). However, there is anticipation that as awareness grows, many women will still prefer a medical means of abortion, not wishing to undergo surgery (albeit a minor procedure) or to be subjected to the harassment that may occur outside some clinic facilities.

Successful termination has been shown to occur in 97 percent of patients using the RU-486 regimen, with the remaining patients requiring suction curettage for complete removal of the products of conception. In comparison, for surgical procedures, less than 1 percent of patients require a second curettage because the procedure was incomplete. Most women develop strong cramping after taking the prostaglandin (because the drug induces uterine contractions) and usually have the abortion within a few hours after receiving prostaglandin. In France, RU-486 is therefore provided only through clinic facilities and in this setting, the abortion often occurs during the same four hours women remain in the clinic after taking the prostaglandin. However, some French physicians believe that a clinic setting is not essential. In the United States, specific requirements for facilities providing abortion vary from state to state. Federal guidelines, however, require only that RU-486 be prescribed by or under the supervision of a physician who can diagnose the duration of pregnancy accurately, diagnose an ectopic pregnancy, and either can provide surgical intervention in cases of incomplete abortion or who has made arrangements to provide such care through others.

While studies have demonstrated the safety and effectiveness of RU-486 as a morning after pill for use after unexpected midcycle intercourse (Ashok), preparations containing the same hormones as are found in oral contraceptive pills (estrogen and progestin or progestin alone) have been approved for this purpose. Furthermore, the copper-T intrauterine device (IUD) can be inserted up to five days after unprotected intercourse to prevent pregnancy. Both emergency contraceptive pills (ECPs) and the IUD are more readily available and remain the standard of care for postcoital contraception in the United States (American College of Obstetricians and Gynecologists [ACOG], 2001).

AVAILABILITY OF ABORTION PROVIDERS. The majority of abortion procedures in the United States are provided by obstetrician-gynecologists, with a small percentage performed by other providers such as family practice physicians, mid-wives, or nurse practitioners. There are serious concerns about the provision of abortion procedures in the future for several reasons. Although most obstetrician-gynecologists believe that women should have the right to choose to terminate a pregnancy, at the same time, most do not wish to perform abortions. As a result, approximately 84 percent of counties in the United States do not have an abortion facility, and the number rises to 94 percent outside metropolitan areas.

Many ob-gyn residency training programs do not offer abortion training routinely and as a result, many graduating residents have little or no training in this area. However, over the last decade there has been an increase in the number of residency programs providing training in abortion procedures. In 1996, the Accreditation Council for Graduate Medical Education required ob-gyn residency programs to include family planning and abortion training for its students, though abortion is generally still presented as an elective part of training. The impact of these requirements was demonstrated in a survey conducted by the National Abortion Federation (NAF). The investigators of the NAF report found that from 1992 to 1998, ob-gyn residency programs reporting routine first trimester abortion training increased almost fourfold, from 12 percent to 46 percent, and routine second trimester abortion training from 7 percent to 44 percent (Almeling et al.).

Finally, even where training has taken place, the increasing incidence of harassment and even violence (including the 1993 and 1994 murders of abortion providers in Florida) has resulted in more reluctance on the part of physicians to be involved in the provision of this service. In response to the escalating violence, Congress enacted the

Freedom of Access to Clinic Entrances Act, or FACE, in 1994. This statute established federal criminal penalties and civil remedies for violent, obstructionist, or damaging conduct affecting reproductive healthcare providers and recipients, and supplemented the penalties available under then-existing federal criminal statutes such as the Hobbs Act, the Travel Act, and federal arson and firearms statutes. Rising violence as well as the federal response highlight serious ethical questions as to the social responsibility of professionals in this field to make certain that this procedure is available to all patients.

POSSIBLY HARMFUL EFFECTS ON SUBSEQUENT PREGNANCIES. Questions have been raised about possible long-term harmful effects of induced abortion, especially for women who have had multiple abortions. Much of the concern centers on subsequent pregnancies, following one or more induced abortions. Medical evidence has consistently shown that a woman who has one properly performed induced abortion in the first trimester of pregnancy has the same chance of a normal outcome of a subsequent pregnancy as a woman who has never had an abortion. The evidence is less definitive for women who have had more than one induced abortion or an abortion with complications, although there is no reason to believe that additional abortion procedures, carried out by well-trained professionals, will have a long-term adverse effect. Overall, in terms of medical risk, abortion procedures, particularly those carried out in the first trimester of pregnancy, are among the safest of all surgical procedures.

PSYCHOLOGICAL EFFECTS. A much grayer area is that of the psychological consequences of induced abortion. It is difficult to generalize about the emotional responses of patients to pregnancy termination but, like physical complications, psychological complications may be related to the type of procedure and the gestational age at the time of termination, with earlier suction curettage theoretically leading to fewer psychological complications than later procedures. However, most studies in this area suffer from methodological problems, including a lack of consensus about symptoms, inadequate study design, and lack of adequate follow-up. Furthermore, the so-called postabortion syndrome does not meet the American Psychiatric Association's definition of trauma (Gold).

Despite the many problems with most investigations, "the studies are consistent in their findings of relatively rare instance of negative responses after abortion and of decreases in psychological distress after abortion compared to before abortion" (Adler et al., p. 42). Former U.S. Surgeon General C. Everett Koop, at the request of the White House, undertook a major assessment of the literature on this topic and concluded in a 1989 congressional hearing that "the data were insufficient ... to support the premise that abortion does or does not produce a postabortion syndrome and that emotional problems resulting from abortion are minuscule from a public health perspective" (Human Resources and Intergovernmental Relations Subcommittee of the Committee on Governmental Operations, p. 14). Given Koop's personal opposition to abortion, the conclusions of his assessment are of particular importance.

Approximately 10 percent of induced abortions in the United States take place between twelve and twenty weeks of gestation, and less than 1 percent take place between twenty and twenty-four weeks. This means that more than 150,000 second-trimester procedures occur each year, a much larger number than in other developed nations where abortion is legal. Most would agree that decreases in the total numbers of abortions would be highly desirable, particularly decreases in second-trimester procedures.

The most common reasons for these later procedures, particularly among younger teens, are indecision about termination and failure to recognize (or denial of) pregnancy. A smaller percentage of these later abortions occur because of medical or genetic reasons, which theoretically may correlate with greater psychological distress. Although techniques such as nuchal translucency measurement with serum screening, chorionic villus sampling, and early am-niocentesis have allowed earlier diagnosis, the results of more commonly used techniques of antenatal fetal diagnosis with midtrimester amniocentesis are generally not available until well into the second trimester.

Choosing to terminate a pregnancy is a serious decision that is rarely made lightly. In addition to complete information about abortion procedure options, counseling should be made available to women faced with a decision about an unplanned pregnancy.

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