abortion

abortion means the end of a pregnancy before the fetus can survive. It may be either spontaneous — when it is also known as miscarriage — or induced, when it is a deliberate termination of pregnancy.

Spontaneous abortion

Spontaneous abortion is defined in the UK as a pregnancy loss occurring before 24 completed weeks of pregnancy. Approximately 50–70% of pregnancies end in spontaneous abortion. Most of these losses are unrecognized because they occur before or at the time of the next expected menstrual period. About 15–20% of clinically diagnosed pregnancies are lost by 16 weeks. Recurrent abortion, defined as the loss of three or more consecutive pregnancies, occurs in 0.5–1% of pregnant women. Causes of spontaneous abortion may relate to the fetus, the placenta, or the uterus. Genetic factors, developmental problems, placental problems, and infection are known causes, but in a quarter of all spontaneous abortions the cause is unknown. This may be due to lack of ability to investigate these cases.

It is generally accepted that 50% of all recognized pregnancy losses in the first 3 months are due to a genetic abnormality. Abnormalities of the placenta have probably greater importance than is realized, but information on this aspect is scanty. A number of organisms have been associated with spontaneous abortion, such as listeria, brucella infection from animals, and the rubella virus. In isolated instances fetal or placental infection with various organisms may result in spontaneous abortion, but there is no evidence of their involvement in a recurrent problem. Some cases of recurrent abortion are due to congenital abnormalities of the uterus and these may be corrected surgically; 70–80% of women with the most frequent abnormalities have successful pregnancies following surgery.

Spontaneous abortion may become evident clinically either as ‘threatened’ or ‘inevitable’. A threatened abortion is said to occur when a woman bleeds from the uterus before 24 weeks of pregnancy. There are three possible outcomes: the bleeding may settle and the pregnancy continue; the fetus may die but be retained in the uterus (confirmed by an ultrasound examination) and this is known as a ‘missed’ abortion; a missed abortion may proceed to an inevitable abortion, with continued or intensified bleeding and expulsion of the products of conception. Bleeding may be severe, causing shock; in some cases this is life-threatening and blood transfusion may be required. Death occurs in a few cases where medical care is poor or absent. In the UK the death rate is of the order of 12.5 per million pregnancies.

If the pregnancy is expelled intact the abortion is said to be ‘complete’, but this is rare in the first 3 months of pregnancy. More commonly some material is left behind and only when it is removed surgically will bleeding cease. If this is not done, bleeding may continue and the uterus become infected, with serious consequences for the woman. Rarely in developed countries, but commonly in underdeveloped regions and where abortion laws are restrictive, infection occurs and abortion is a well-recognized cause of maternal death.

The emotional effects of an abortion vary greatly. A majority of women have feelings of depression, and there is usually associated fear and anxiety caused by the pain and bleeding and the uncertainty as to the cause. Reaction to abortion as a bereavement means that women require to grieve after the event. Often the intensity of the emotional reaction is not appreciated by the carers or by friends or relatives. Health workers should help the woman to express her grief. Women who have experienced such loss require considerable reassurance and support in a subsequent pregnancy.

Recurrent spontaneous abortion

Recurrent spontaneous abortion is a particularly distressing condition and there is very limited understanding of its causes. Genetic factors such as parental chromosome abnormalities are a major known cause which should be looked for. Anatomical factors such as uterine abnormalities account for perhaps 10–15% of recurrent loss. Hormonal factors, such as deficient production of progesterone, which is important for the maintenance of early pregnancy, are also cited — but evidence for such causes is scanty.

In some cases an immune response is mounted by the mother against the pregnancy, causing its demise. Chronic maternal disease such as diabetes and kidney disease may also be associated. Smoking and alcohol consumption have been linked to recurrent abortion but there is no hard evidence for this.

In the case of genetic abnormalities, genetic counselling is advisable and if, for example, the abnormality is traced to the male partner, insemination of the woman with sperm from a donor (donor insemination, DI) may be a possible solution. An abnormally shaped uterus can be corrected by surgery. Hormonal therapy has not proved successful. In the case of an immunological cause, immunotherapy has been helpful, and in some women with no ascertainable cause psychotherapy has been of value. In the event intervention may not be the best answer and it may be just as successful to wait and see.

Induced abortion: termination of pregnancy

The study of induced abortion, especially where abortion is illegal, is a major challenge in the contexts of reproductive health and women's rights.

At the International Conference on Population and Development in Cairo in 1994 the following statement was made: ‘Since unsafe abortion is a major threat to the health and lives of women, research to understand and better address the determinants and consequences should be promoted’. The conference also recognized that unsafe abortion was a world-wide public health problem and agreed that each country should legislate to solve the problem. In developed countries like the UK where abortion is readily available the related mortality is extremely low — less than 1 per 100 000 procedures. In less optimal settings where women are only able to find unsafe abortion, mortality is high. World-wide, estimates vary from a minimum of 50 000 up to 150 000 abortion-related deaths per annum.

Experience from many countries confirms that permissive legislation on abortion does not increase the abortion rate: it only determines whether it is performed under safe or unsafe conditions. The restrictive legislation which some countries have, for cultural or religious reasons, prevents a reduction in the death rate and health hazards of abortion.

In the UK restrictive legislation was still in place in 1938 — the year when Mr Alec Bourne, an eminent London gynaecologist, terminated a woman's pregnancy which had resulted from rape. He was reported for this criminal offence and was prosecuted. The judge allowed the mental health of the woman to be taken into account and Bourne was acquitted, marking a changing attitude to abortion in the UK. In 1967 the Abortion Act legalized abortion under certain circumstances, and amendments were made in 1990. Currently the Act permits termination of pregnancy if two doctors:
are of the opinion in good faith a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family; or b) that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; or c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; or d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

It is essential that a woman who seeks abortion receive proper counselling. If she wishes her partner to be involved he may be, but this is not mandatory. This involves giving the woman as much information as possible after a medical, social, and family history has been obtained: information regarding the methods of termination, their risks, and their benefits, and alternative courses of action such as adoption, and also advice which may help to determine her real wishes. All is designed to help her to reach a decision. Certain high risk groups require special counselling: teenagers; those with genetic factor risks; cases of sexual abuse; and those seeking late terminations or repeated terminations.

Most terminations are done in the first 3 months of pregnancy. At this stage it is done surgically under an anaesthetic, by dilating the cervix and removing the pregnancy by suction or by forceps. Alternatively, up to 8 weeks or so, termination using drugs is possible, and is now common. A choice may therefore be offered. In 85% of early cases no further treatment is required as the abortion is complete. Where it is not complete surgery is required.

After 3 months it is usual to use a method of termination by administration of prostaglandins. These drugs cause contractions of the uterus and the fetus and placenta are expelled.

Complications which may occur are bleeding, perforation of the uterus, tearing of the cervix, and sepsis — but these are rare when the procedure is properly performed. Where abortion is performed in unsafe circumstances these complications are common and have serious consequences.

Abortion has been regarded in some countries as a method of birth control. This should not be so. Abortion services should include advice on contraception and the better this advice the less often will abortion be resorted to. See also antenatal development; contraception; pregnancy.

Malcolm Macnaughton

Abortion: historical and social aspects

For many centuries women finding themselves pregnant have endeavoured to implement retroactive birth control by means of abortion. This practice was often occluded from legal and medical eyes, information being passed on within a female oral subculture. However manuscripts survive from a range of historical periods which record numerous substances reputed to be abortifacients, though some are also highly toxic to the woman; and various practices have also been believed to induce miscarriage. For many centuries the law only concerned itself with pregnancy subsequent to ‘quickening’. This traditional distinction and the persistent conceptualization by women of the problem as ‘bringing on’ menstruation, suggest that women did not experience pregnancy as an absolute, either/or, state.

The law, however, at least in Europe and North America, increasingly formulated the ending of all pregnancy as abortion, possibly reflecting developing medical ability in accurate, early recognition of conception. In England and Wales abortion initially became a statutory offence in 1803 under Lord Ellenborough's Act, at a time when the medical profession was increasingly concerning itself with previously woman-controlled areas such as obstetrics, and desirous of differentiating the medical man from the irregular practitioner. The concept of ‘unlawful’ abortion enabled medical practitioners to claim a right to use their clinical judgement over ‘lawful’ therapeutic abortion. Induced abortion, pre-antibiotics, was a significant cause of female mortality and morbidity, although many ‘back street’ operators were not lacking in skill. It was largely married women who patronized these, since they could more readily pass off miscarriages without need of concealment. The ‘Female Pills’ widely purveyed in the later nineteenth and early twentieth centuries were a successful commercial racket, with little in the way of effective ingredients.

Laws on the availability of surgical abortion have varied widely from nation to nation: medical expertise may be privileged over unlicensed operators, or operations even by regular practitioners regarded as a crime. Though legally condemned, abortion has frequently been available to those with the right contacts and able to pay. While certain religious groups, especially Roman Catholics, have strongly condemned abortion, such condemnation has not universally prevented women from seeking it. The role of popular feeling and debate has been influential in altering the law: in Britain the important legal case of Rex v. Bourne, 1938, establishing a common-law precedent for abortion on the grounds of a woman's mental, not merely physical, health, took place in the context of widespread debate and agitation for reform of the law. In the US, however, there was no such climate of opinion, and similarly idealistic and concerned abortionists paid the full legal penalty.

Abortion became legalized in many countries during the late 1960s and early 1970s. Unfortunately the overt inscription of the right to abortion in law (as opposed to something performed, if at all, within the privileged secrecy of the doctor/patient encounter) has provoked a vigorous ‘backlash’, particularly violent in the US. There is little evidence that abortions would be fewer if illegal; only more dangerous, and the availability of the operation more erratic and inequitable.

Lesley A. Hall