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Abortion, Induced

Abortion, induced

Definition

Induced abortion is the intentional termination of a pregnancy before the fetus can live independently. An abortion may be elective (based on a woman's personal choice) or therapeutic (to preserve the health or save the life of a pregnant woman).


Purpose

An abortion may be performed whenever there is some compelling reason to end a pregnancy. An abortion is termed "induced" to differentiate it from a spontaneous abortion in which the products of conception are lost naturally (also called a miscarriage).

An abortion is considered to be elective if a woman chooses to end her pregnancy, and it is not for maternal or fetal health reasons. Some reasons a woman might choose to have an elective abortion are:

  • Continuation of the pregnancy may cause emotional or financial hardship.
  • The woman is not ready to become a parent.
  • The pregnancy was unintended.
  • The woman is pressured into having one by her partner, parents, or others.
  • The pregnancy was the result of rape or incest.

A therapeutic abortion is performed in order to preserve the health or save the life of a pregnant woman. A health care provider might recommend a therapeutic abortion if the fetus is diagnosed with significant abnormalities or not expected to live, or if it has died in utero. Therapeutic abortion may also be used to reduce the number of fetuses if a woman is pregnant with multiples; this procedure is called multifetal pregnancy reduction (MFPR).

A therapeutic abortion may be indicated if a woman has a pregnancy-related health condition that endangers her life. Some examples of such conditions include:

  • severe hypertension (high blood pressure)
  • cardiac disease
  • severe depression or other psychiatric conditions
  • serious kidney or liver disease
  • certain types of infection
  • malignancy (cancer)
  • multifetal pregnancy

Demographics

Abortion has been a legal procedure in the United States since 1973. Since then, more than 39 million abortions have taken place. It is estimated that approximately 1.31.4 million abortions occur in the United States annually. Induced abortions terminate approximately half of the estimated three million unplanned pregnancies each year and approximately one-fifth of all pregnancies.

In 2000 an estimated 21 out of 1,000 women aged 1544 had an abortion. Out of every 100 pregnancies that year that ended in live birth or abortion, approximately 24 were elective terminations. The highest abortion rates in 2000 occurred in New Jersey, New York, California, Delaware, Florida, and Nevada (greater than 30 per 1,000 women of reproductive age). Kentucky, South Dakota, Wyoming, Idaho, Mississippi, Utah, and West Virginia had the lowest rates (less than seven per 1,000 women).

In 2000 and 2001, the highest percentage of abortions were performed on women between the ages of 20 and 30, with women ages 2024 having the highest rate (47 per 1,000 women). Adolescents ages 1519 accounted for 19% of elective abortions, while 25% were performed on women older than 30. Approximately 73% of women having an abortion had previously been pregnant; 48% of those had a previous abortion.

Non-hispanic, white women reported the highest percentage of abortions in 2000 and 2001 (41%). African American women accounted for 32%, Hispanic women for 20%, Asian and Pacific Islander women for 6%, and Native American women for 1%. The highest abortion rates occurred among African American women (49 per 1,000 women), with Hispanic and Asian women also reporting higher-than-average rates (33 and 31 per 1,000 women, respectively). The rate was the lowest among white women (13 per 1,000 women).


Description

Abortions are safest when performed within the first six to 10 weeks after the last menstrual period (LMP). This calculation is used by health care providers to determine the stage of pregnancy. About 90% of women who have abortions do so in the first trimester of pregnancy (before 13 weeks) and experience few complications. Abortions performed between 13 and 24 weeks (during the second trimester) have a higher rate of complications. Abortions after 24 weeks are extremely rare and are usually limited to situations where the life of the mother is in danger.

Although it is safer to have an abortion during the first trimester, some second trimester abortions may be inevitable. The results of genetic testing are often not available until 16 weeks gestation. In addition, women, especially teens, may not have recognized the pregnancy or come to terms with it emotionally soon enough to have a first trimester abortion. Teens make up the largest group having second trimester abortions.

Very early abortions cost between $200 and $400. Later abortions cost more. The cost increases about $100 per week between the thirteenth and sixteenth week. Second trimester abortions are much more costly because they often involve more risk, more services, anesthesia, and sometimes a hospital stay. Private insurance carriers may or may not cover the procedure. Federal law prohibits federal funds (including Medicaid ) from being used to pay for an elective abortion.


Medical abortions

Medical abortions are brought about by taking medications that end the pregnancy. The advantages of a first trimester medical abortion are:

  • The procedure is non-invasive; no surgical instruments are used.
  • Anesthesia is not required.
  • Drugs are administered either orally or by injection.
  • The outcome resembles a natural miscarriage.

Disadvantages of a medical abortion are:

  • The effectiveness decreases after the seventh week.
  • The procedure may require multiple visits to the doctor.
  • Bleeding after the abortion lasts longer than after a surgical abortion.
  • The woman may see the contents of her womb as it is expelled.

As of 2003, two drugs were available in the United States to induce abortion: methotrexate and mifepristone.

methotrexate. Methotrexate (Rheumatrex) targets rapidly dividing fetal cells, thus preventing the fetus from further developing. It is used in conjunction with misoprostol (Cytotec), a prostaglandin that stimulates contractions of the uterus. Methotrexate may be taken up to 49 days after the first day of the last menstrual period.

On the first visit to the doctor, the woman receives an injection of methotrexate. On the second visit, about a week later, she is given misoprostol tablets vaginally to stimulate contractions of the uterus. Within two weeks, the woman will expel the contents of her uterus, ending the pregnancy. A follow-up visit to the doctor is necessary to assure that the abortion is complete.

With this procedure, a woman will feel cramping and may feel nauseated from the misoprostol. This combination of drugs is approximately 9296% effective in ending pregnancy. Approximately 50% of women will experience the abortion soon after taking the misoprostol; 3540% will have the abortion up to seven days later.

Methotrexate is not recommended for women with liver or kidney disease, inflammatory bowel disease, clotting disorders, documented immunodeficiency, or certain blood disorders.

mifepristone. Mifepristone (RU-486), which goes by the brand name Mifeprex, works by blocking the action of progesterone, a hormone needed for pregnancy to continue. It was approved by the Food and Drug Administration (FDA) in September 2000 as an alternative to surgical abortion. Mifepristone can be taken up to 49 days after the first day of a woman's last period.

On the first visit to the doctor, a woman takes a mifepristone pill. Two days later she returns and, if the miscarriage has not occurred, takes two misoprostol pills, which causes the uterus to contract. Approximately 10% will experience the abortion before receiving the dose of misoprostol.

Within four days, 90% of women have expelled the contents of their uterus and completed the abortion. Within 14 days, 9597% of women have completed the abortion. A third follow-up visit to the doctor is necessary to confirm through observation or ultrasound that the procedure is complete. In the event that it is not, a surgical abortion is performed. Studies show that 4.58% of women need surgery or a blood transfusion after taking mifepristone, and the pregnancy persists in about 1%. Surgical abortion is then recommended because the fetus may be damaged. Side effects include nausea, vaginal bleeding, and heavy cramping. The bleeding is typically heavier than a normal period and may last up to 16 days.

Mifepristone is not recommended for women with ectopic pregnancy or an intrauterine device (IUD), or those who have been taking long-term steroidal therapy, have bleeding abnormalities, or on blood-thinners such as Coumadin.


Surgical abortions


manual vacuum aspiration. Up to 10 weeks gestation, a pregnancy can be ended by a procedure called manual vacuum aspiration (MVA). This procedure is also called menstrual extraction, mini-suction, or early abortion. The contents of the uterus are suctioned out through a thin plastic tube that is inserted through the cervix; suction is applied by a syringe. The procedure generally lasts about 15 minutes.

A 1998 study of women undergoing MVA indicated that the procedure was 99.5% effective in terminating pregnancy and was associated with a very low risk of complications (less than 1%). Menstrual extractions are safe, but because the amount of fetal material is so small at this stage of development, it is easy to miss. This results in an incomplete abortion that means the pregnancy continues.

dilatation and suction curettage. Dilation and suction curettage may also be called D & C, suction dilation, vacuum curettage, or suction curettage. The procedure involves gentle stretching of the cervix with a series of dilators or specific medications. The contents of the uterus are then removed with a tube attached to a suction machine, and walls of the uterus are cleaned using a narrow loop called a curette.

Advantages of an abortion of this type are:

  • It is usually done as a one-day outpatient procedure.
  • The procedure takes only 1015 minutes.
  • Bleeding after the abortion lasts five days or less.
  • The woman does not see the products of her womb being removed.

Disadvantages include:

  • The procedure is invasive; surgical instruments are used.
  • Infection may occur.

The procedure is 9799% effective. The amount of discomfort a woman feels varies considerably. Local anesthesia is often given to numb the cervix, but it does not mask uterine cramping. After a few hours of rest, the woman may return home.

dilatation and evacuation. Some second trimester abortions are performed as a dilatation and evacuation (D & E). The procedures are similar to those used in a D & C, but a larger suction tube must be used because more material must be removed. This increases the amount of cervical dilation necessary and increases the risk and discomfort of the procedure. A combination of suction and manual extraction using medical instruments is used to remove the contents of the uterus.

other surgical options. Other surgical procedures are available for performing second trimester abortions, although are rarely used. These include:

  • Dilatation and extraction (D & X). The cervix is prepared by means similar to those used in a dilatation and evacuation. The fetus, however, is removed mostly intact although the head must be collapsed to fit through the cervix. This procedure is sometimes called a partial-birth abortion. The D & X accounted for only 0.17% of all abortions in 2000.
  • Induction. In this procedure, an abortion occurs by means of inducing labor. Prior to induction, the patient may have rods inserted into her cervix to help dilate it or receive medications to soften the cervix and speed up labor. On the day of the abortion, drugs (usually prostaglandin or a salt solution) are injected into the uterus to induce contractions. The fetus is delivered within eight to 72 hours. Side effects of this procedure include nausea, vomiting, and diarrhea from the prostaglandin, and pain from uterine contractions. Anesthesia of the sort used in childbirth can be given to reduce pain. Many women are able to go home a few hours after the procedure.
  • Hysterotomy. A surgical incision is made into the uterus and the contents of the uterus removed through the incision. This procedure is generally used if induction methods fail to deliver the fetus.

Diagnosis/Preparation

The doctor must know accurately the stage of a woman's pregnancy before an abortion is performed. The doctor will ask the woman questions about her menstrual cycle and also do a physical examination to confirm the stage of pregnancy. This may be done at an office visit before the abortion or on the day of the abortion.

Pre-abortion counseling is important in helping a woman resolve any questions she may have about having the procedure. Some states require a waiting period (most often of 24 hours) following counseling before the abortion may be obtained. Most states require parental consent or notification if the patient is under the age of 18.


Aftercare

Regardless of the method used to perform the abortion, a woman will be observed for a period of time to make sure her blood pressure is stable and that bleeding is controlled. The doctor may prescribe antibiotics to reduce the chance of infection. Women who are Rh negative (lacking genetically determined antigens in their red blood cells that produce immune responses) should be given an injection of human Rh immune globulin (RhoGAM) after the procedure unless the father of the fetus is also Rh negative. This prevents blood incompatibility complications in future pregnancies.

Bleeding will continue for about five days in a surgical abortion and longer in a medical abortion. To decrease the risk of infection, a woman should avoid intercourse, tampons, and douches for two weeks after the abortion.

A follow-up visit is a necessary part of the woman's aftercare. Contraception will be offered to women who wish to avoid future pregnancies, because menstrual periods normally resume within a few weeks.


Risks

Complications from abortions can include:

  • uncontrolled bleeding
  • infection
  • blood clots accumulating in the uterus
  • a tear in the cervix or uterus
  • missed abortion (the pregnancy is not terminated)
  • incomplete abortion where some material from the pregnancy remains in the uterus

Women who experience any of the following symptoms of post-abortion complications should call the clinic or doctor who performed the abortion immediately:

  • severe pain
  • fever over 100.4°F (38.2°C)
  • heavy bleeding that soaks through more than one sanitary pad per hour
  • foul-smelling discharge from the vagina
  • continuing symptoms of pregnancy

Normal results

Usually the pregnancy is ended without complication and without altering future fertility.


Morbidity and mortality rates

Serious complications resulting from abortions performed before 13 weeks are rare. Of the 90% of women who have abortions in this time period, 2.5% have minor complications that can be handled without hospitalization. Less than 0.5% have complications that require a hospital stay. The rate of complications increases as the pregnancy progresses.

Only one maternal death occurs per 530,000 abortions performed at eight weeks gestation or less; this increases to one death per 17,000 abortions performed from 16 to 20 weeks, and one death per 6,000 abortions performed over 20 weeks.


Alternatives

Adoption is an option for pregnant women who do not want to raise a child but are unwilling or unable to have an abortion. Adoption agencies, crisis pregnancy centers, family service agencies, family planning clinics, or state social service agencies are available for women to contact for more information about the adoption process.


Resources

periodicals

Centers for Disease Control and Prevention. "Abortion SurveillanceUnited States, 1999." Morbidity and Mortality Weekly Report 51 (2002): SS09.

Finer, L. B. and S. K. Henshaw. "Abortion Incidence and Services in the United States in 2000." Perspectives on Sexual and Reproductive Health 35 (2003): 615.

Jones, R. K., J. E. Darroch, and S. K. Henshaw. "Patterns in the Socioeconomic Characteristics of Women Obtaining Abortions in 20002001." Perspectives on Sexual and Reproductive Health 34 (2002): 22635.

organization

Alan Guttmacher Institute. 1120 Connecticut Ave., NW, Suite 460, Washington, DC 20036. (202) 296-4012. <http://www.agi-usa.org>.

Centers for Disease Control and Prevention, Division of Reproductive Health. 4770 Buford Highway, NE, Mail Stop K-20, Atlanta, GA 30341-3717. (770) 488-5200. <http://www.prochoice.org>.

National Abortion Federation. 1755 Massachusetts Ave., NW, Suite 600, Washington, DC 20036. (202) 667-5881. <http://www.prochoice.org>.

Planned Parenthood Federation of America. 810 Seventh Ave., New York, NY 10019. (212) 541-7800. <http://www.plannedparenthood.org>.

other

"Abortion After the First Trimester." Planned Parenthood Federation of America. July 2001 [cited February 26, 2003]. <http://www.plannedparenthood.org/library/facts/abotaft1st_010600.html>.

"Choosing Abortion: Questions and Answers." Planned Parenthood Federation of America. February 2003 [cited February 26, 2003]. <http://www.plannedparenthood.org/ABORTION/chooseabort1.html>.

"Manual Vacuum Aspiration." Reproductive Health Technologies Project. 2002 [cited February 26, 2003]. <http://www.rhtp.org/early/early_manvac.htm>.

"Medical Abortion: Questions and Answers." Planned Parenthood Federation of America. June 2002 [cited February 26, 2003]. <http://www.plannedparenthood.org/abortion/medicalabortion.html>.

Roche, Natalie E. "Therapeutic Abortion." eMedicine. May 22, 2002 [cited February 26, 2003]. <http://www.emedicine.com/med/topic3311.htm>.

"Surgical Abortion: Questions and Answers." Planned Parenthood Federation of America. April 23, 2003 [cited February 26, 2003]. <http://www.plannedparenthood.org/ABORTION/surgabort1.html>.

Trupin, Suzanne R. "Abortion." eMedicine. December 2, 2002 [cited February 26, 2003]. <http://www.emedicine.com/med/topic5.htm>.


Debra Gordon Stephanie Dionne Sherk

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


An induced abortion must be done under the supervision of a physician. Under normal circumstances, the abortion is performed by a licensed obstetrician or gynecologist. In some states, however, advanced clinicians such as nurse practitioners, certified nurse midwives, or physician assistants can perform an abortion under the direct supervision of a physician.

Most women are able to have abortions at clinics or outpatient facilities if the procedure is performed early in pregnancy and the woman is in relatively good health. Women with heart disease, previous endocarditis, asthma, lupus erythematosus, uterine fibroid tumors, blood clotting disorders, poorly controlled epilepsy, or some psychological disorders usually need to be hospitalized in order to receive special monitoring and medications during the procedure. In 2000 over 93% of abortions were performed in a clinic setting; clinics accounted for nearly half (46%) of all abortion providers. Hospitals were the site of 5% of abortions (accounting for 33% of abortion providers), while only 3% of abortions were performed at physician offices (21% of abortion providers).

QUESTIONS TO ASK THE DOCTOR


  • What abortion options are available to me based on my stage of pregnancy?
  • What are the short- and long-term complications of the procedure?
  • What type of pain relief/anesthesia is available to me?
  • Who can be in the procedure room with me?
  • What will the abortion cost? What do the fees include?
  • Is pre-abortion counseling offered?
  • How is follow-up or emergency care provided?
  • Does the doctor who will perform the abortion have admitting privileges at a hospital in case of a problem?

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induced abortion

induced abortion (in-dewst) n. see abortion.

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Abortion, Induced

Abortion, Induced

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Aftercare
Risks
Normal results
Morbidity and mortality rates
Alternatives

Definition

Induced abortion is the intentional termination of a pregnancy before the fetus can live independently. An abortion may be elective, based on a woman’s personal choice; or therapeutic, to preserve the health or save the life of a pregnant woman.

Purpose

An abortion may be performed whenever there is some compelling reason to end a pregnancy. An abortion is termed “induced” to differentiate it from a spontaneous abortion in which the products of conception are lost naturally. A spontaneous abortion is also called a miscarriage.

An abortion is considered to be elective if a woman chooses to end her pregnancy, and it is not for maternal or fetal health reasons. Some reasons a woman might choose to have an elective abortion are:

  • continuation of the pregnancy may cause emotional or financial hardship;
  • the woman is not ready to become a parent;
  • the pregnancy was unintended;
  • the woman is pressured into aborting by her partner, parents, or others; and
  • the pregnancy was the result of rape or incest.

A therapeutic abortion is performed in order to preserve the health or save the life of a pregnant woman. A health care provider might recommend a therapeutic abortion if the fetus is diagnosed with significant abnormalities or not expected to live, or if it has died in utero. Therapeutic abortion may also be used to reduce the number of fetuses if a woman is pregnant with multiples; this procedure is called multi-fetal pregnancy reduction (MFPR).

A therapeutic abortion may be indicated if a woman has a pregnancy-related health condition that endangers her life. Some examples of such conditions include:

  • severe hypertension (high blood pressure);
  • cardiac disease;
  • severe depression or other psychiatric conditions;
  • serious kidney or liver disease;
  • certain types of infection;
  • malignancy (cancer); and
  • multifetal pregnancy.

Demographics

Abortion has been a legal procedure in the United States since 1973. Since then, more than 39 million abortions have taken place. It is estimated that approximately 1.3-1.4 million abortions occur in the United States annually. Induced abortions terminate approximately half of the estimated three million unplanned pregnancies each year and approximately one-fifth of all pregnancies.

The total number of abortions performed has declined from 1.31 million in 2000, to 1.21 million performed in 2005. From 1973 through 2005, more than 45 million legal abortions took place. The estimated number of abortions during 2004–2006 were 1,287,000. In 2000 an estimated 21 out of 1,000 women aged 15-44 had an abortion. Out of every 100 pregnancies that year that ended in live birth or abortion, approximately 24 were elective terminations. The highest abortion rates in 2000 occurred in New Jersey, New York, California, Delaware, Florida, and Nevada (greater than 30 per 1,000 women of reproductive age). Kentucky, South Dakota, Wyoming, Idaho, Mississippi, Utah, and West Virginia had the lowest rates (less than seven per 1,000 women).

In 2000 and 2001, the highest percentage of abortions were performed on women between the ages of 20 and 30, with women ages 20-24 having the highest rate (47 per 1,000 women). Adolescents ages 15-19 accounted for 19% of elective abortions, while 25% were performed on women older than 30. Approximately 73% of women having an abortion had previously been pregnant; 48% of those had a previous abortion.

KEY TERMS

Curette— A spoon-shaped instrument used to remove tissue from the inner lining of the uterus.

Endocarditis— An infection of the inner membrane lining of the heart.

Fibroid tumors— Non-cancerous (benign) growths in the uterus; they occur in 30-40% of women over age 40 and do not need to be removed unless they are causing symptoms that interfere with a woman’s normal activities.

Lupus erythematosus— A chronic inflammatory disease in which inappropriate immune system reactions cause abnormalities in the blood vessels and connective tissue.

Prostaglandin— Responsible for various hormonal reactions such as muscle contraction.

Rh negative— Lacking the Rh factor, which are genetically determined antigens in red blood cells that produce immune responses. If an Rh-negative woman is pregnant with an Rh-positive fetus, her body will produce antibodies against the fetus’s blood, causing a disease known as Rh disease. Sensitization to the disease occurs when the women’s blood is exposed to the fetus’s blood. Rh immune globulin (RhoGAM) is a vaccine that must be given to a woman after an abortion, miscarriage, or prenatal tests in order to prevent sensitization to Rh disease.

Non-Hispanic, white women reported the highest percentage of abortions in 2000 and 2001 (41%). African American women accounted for 32%, Hispanic women for 20%, Asian and Pacific Islander women for 6%, and Native American women for 1%. The highest abortion rates occurred among African American women (49 per 1,000 women), with Hispanic and Asian women also reporting higher-than-average rates (33 and 31 per 1,000 women, respectively). The rate was the lowest among white women (13 per 1,000 women). As of 2005, 50% of women in the United States who obtained abortions were younger than age 25, 33% of those having abortions were between the ages of 20-25, and 17% were teenagers. About 60% of women having abortions were women who already had one or more children.

Description

Abortions are safest when performed within the first six to 10 weeks after the last menstrual period (LMP). This calculation is used by health care providers to determine the stage of pregnancy. About 90% of women who have abortions do so in the first trimester of pregnancy (before 13 weeks) and experience few complications. Abortions performed between 13 and 24 weeks (during the second trimester) have a higher rate of complications. Abortions after 24 weeks are extremely rare and are usually limited to situations where the life of the mother is in danger.

Although it is safer to have an abortion during the first trimester, some second trimester abortions may be inevitable. The results of genetic testing are often not available until 16 weeks gestation. In addition, women, especially teens, may not have recognized the pregnancy or come to terms with it emotionally soon enough to have a first trimester abortion. Teens make up the largest group having second trimester abortions.

Very early abortions cost between $200 and $400. Later abortions cost more. The cost increases about $100 per week between the thirteenth and sixteenth week. Second trimester abortions are much more costly because they often involve more risk, more services, anesthesia, and sometimes a hospital stay. Private insurance carriers may or may not cover the procedure. Federal law prohibits federal funds (including Medicaid ) from being used to pay for an elective abortion.

Medical abortions

Medical abortions are brought about by taking medications that end the pregnancy. The advantages of a first trimester medical abortion are:

  • the procedure is non-invasive, so no surgical instruments are used;
  • anesthesia is not required;
  • drugs are administered either orally or by injection; and
  • the outcome resembles a natural miscarriage.

Disadvantages of a medical abortion are:

  • the effectiveness decreases after the seventh week;
  • the procedure may require multiple visits to the doctor;
  • bleeding after the abortion lasts longer than after a surgical abortion; and
  • the woman may see the contents of her womb as it is expelled.

As of 2003, two drugs were available in the United States to induce abortion: methotrexate and mifepristone.

METHOTREXATE. Methotrexate (Rheumatrex) targets rapidly dividing fetal cells, thus preventing the fetus from further developing. It is used in conjunction with misoprostol (Cytotec), a prostaglandin that stimulates contractions of the uterus. Methotrexate may be taken up to 49 days after the first day of the last menstrual period.

On the first visit to the doctor, the woman receives an injection of methotrexate. On the second visit, about a week later, she is given misoprostol tablets vaginally to stimulate contractions of the uterus. Within two weeks, the woman will expel the contents of her uterus, ending the pregnancy. A follow-up visit to the doctor is necessary to assure that the abortion is complete.

With this procedure, a woman will feel cramping and may feel nauseated from the misoprostol. This combination of drugs is approximately 92-96% effective in ending pregnancy. Approximately 50% of women will experience the abortion soon after taking the misoprostol; 35–40% will have the abortion up to seven days later.

Methotrexate is not recommended for women with liver or kidney disease, inflammatory bowel disease, clotting disorders, documented immunodeficiency, or certain blood disorders.

MIFEPRISTONE. Mifepristone (RU-486), which goes by the brand name Mifeprex, works by blocking the action of progesterone, a hormone needed for pregnancy to continue. It was approved by the Food and Drug Administration (FDA) in September 2000 as an alternative to surgical abortion. Mifepristone can be taken up to 49 days after the first day of a woman’s last period.

On the first visit to the doctor, a woman takes a mifepristone pill. Two days later she returns and, if the miscarriage has not occurred, takes two misoprostol pills, which causes the uterus to contract. Approximately 10% will experience the abortion before receiving the dose of misoprostol.

Within four days, 90% of women have expelled the contents of their uterus and completed the abortion. Within 14 days, 95-97% of women have completed the abortion. A third follow-up visit to the doctor is necessary to confirm through observation or ultrasound that the procedure is complete. In the event that it is not, a surgical abortion is performed. Studies show that 4.5-8% of women need surgery or a blood transfusion after taking mifepristone, and the pregnancy persists in about 1%. Surgical abortion is then recommended because the fetus may be damaged. Side effects include nausea, vaginal bleeding, and heavy cramping. The bleeding is typically heavier than a normal period and may last up to 16 days.

Mifepristone is not recommended for women with ectopic pregnancy or an intrauterine device (IUD), or those who have been taking long-term steroidal therapy, have bleeding abnormalities, or on blood-thinners such as Coumadin.

In 2005, 57% of abortion providers performed one or more medication induced abortions (a 70% increase from medication induced abortions during the first half of 2001). In 2005, 13% of all abortions were attributable to medication induced abortions and the incidence of medication induced abortions performed outside a traditional hospital setting was estimated to total about 161,100.

Surgical abortions

MANUAL VACUUM ASPIRATION. Up to 10 weeks gestation, a pregnancy can be ended by a procedure called manual vacuum aspiration (MVA). This procedure is also called menstrual extraction, minisuction, or early abortion. The contents of the uterus are suctioned out through a thin plastic tube that is inserted through the cervix; suction is applied by a syringe. The procedure generally lasts about 15 minutes.

A 1998 study of women undergoing MVA indicated that the procedure was 99.5% effective in terminating pregnancy and was associated with a very low risk of complications (less than 1%). Menstrual extractions are safe, but because the amount of fetal material is so small at this stage of development, it is easy to miss. This results in an incomplete abortion that means the pregnancy continues.

DILATATION AND SUCTION CURETTAGE. Dilation and suction curettage may also be called D & C, suction dilation, vacuum curettage, or suction curettage. The procedure involves gentle stretching of the cervix with a series of dilators or specific medications. The contents of the uterus are then removed with a tube attached to a suction machine, and walls of the uterus are cleaned using a narrow loop called a curette.

Advantages of an abortion of this type are:

  • it is usually done as a one-day outpatient procedure;
  • the procedure takes only 10-15 minutes;
  • bleeding after the abortion lasts five days or less; and
  • the woman does not see the contents of her womb being removed.

Disadvantages include:

  • the procedure is invasive, so surgical instruments are used; and
  • infection may occur.

The procedure is 97-99% effective. The amount of discomfort a woman feels varies considerably. Local anesthesia is often given to numb the cervix, but it does not mask uterine cramping. After a few hours of rest, the woman may return home.

DILATATION AND EVACUATION. Some second trimester abortions are performed as a dilatation and evacuation (D & E). The procedures are similar to those used in a D & C, but a larger suction tube must be used because more material must be removed. This increases the amount of cervical dilation necessary and increases the risk and discomfort of the procedure. A combination of suction and manual extraction using medical instruments is used to remove the contents of the uterus.

OTHER SURGICAL OPTIONS. Other surgical procedures are available for performing second trimester abortions, although are rarely used. These include:

  • Dilatation and extraction (D & X)—the cervix is prepared by means similar to those used in a dilatation and evacuation; however, the fetus is removed mostly intact although the head must be collapsed to fit through the cervix. This procedure is sometimes called a partial-birth abortion. D & X accounted for only 0.17% of all abortions in 2000.
  • Induction—in this procedure, an abortion occurs by means of inducing labor. Prior to induction, the patient may have rods inserted into her cervix to help dilate it or receive medications to soften the cervix and speed up labor. On the day of the abortion, drugs (usually prostaglandin or a salt solution) are injected into the uterus to induce contractions. The fetus is delivered within eight to 72 hours. Side effects of this procedure include nausea, vomiting, and diarrhea from the prostaglandin, and pain from uterine contractions. Anesthesia of the sort used in childbirth can be given to reduce pain. Many women are able to go home a few hours after the procedure.
  • Hysterotomy—a surgical incision is made into the uterus and the contents of the uterus removed through the incision. This procedure is generally used if induction methods fail to deliver the fetus.

Diagnosis/Preparation

The doctor must know accurately the stage of a woman’s pregnancy before an abortion is performed. The doctor will ask the woman questions about her menstrual cycle and also do a physical examination to confirm the stage of pregnancy. This may be done at an office visit before the abortion or on the day of the abortion.

Pre-abortion counseling is important in helping a woman resolve any questions she may have about having the procedure. Some states require a waiting period (most often of 24 hours) following counseling before the abortion may be obtained. Most states require parental consent or notification if the patient is under the age of 18.

Aftercare

Regardless of the method used to perform the abortion, a woman will be observed for a period of time to make sure her blood pressure is stable and that bleeding is controlled. The doctor may prescribe antibiotics to reduce the chance of infection. Women who are Rh negative (lacking genetically determined antigens in their red blood cells that produce immune responses) should be given an injection of human Rh immune globulin (RhoGAM) after the procedure unless the father of the fetus is also Rh negative. This prevents blood incompatibility complications in future pregnancies.

Bleeding will continue for about five days in a surgical abortion and longer in a medical abortion. To decrease the risk of infection, a woman should avoid intercourse, tampons, and douches for two weeks after the abortion.

A follow-up visit is a necessary part of the woman’s aftercare. Contraception will be offered to women who wish to avoid future pregnancies, because menstrual periods normally resume within a few weeks.

Risks

Complications from abortions can include:

  • uncontrolled bleeding;
  • infection;
  • blood clots accumulating in the uterus;
  • a tear in the cervix or uterus;
  • missed abortion (the pregnancy is not terminated); and
  • incomplete abortion where some material from the pregnancy remains in the uterus.

Women who experience any of the following symptoms of post-abortion complications should call the clinic or doctor who performed the abortion immediately:

  • severe pain;
  • fever over 100.4°F (38.2°C);
  • heavy bleeding that soaks through more than one sanitary pad per hour;
  • foul-smelling discharge from the vagina; and
  • continuing symptoms of pregnancy.

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

An induced abortion must be done under the supervision of a physician. Under normal circumstances, the abortion is performed by a licensed obstetrician or gynecologist. In some states, advanced clinicians such as nurse practitioners, certified nurse midwives, or physician assistants can perform an abortion under the direct supervision of a physician.

Most women are able to have abortions at clinics or outpatient facilities if the procedure is performed early in pregnancy and the woman is in relatively good health. Women with heart disease, previous endocarditis, asthma, lupus erythematosus, uterine fibroid tumors, blood clotting disorders, poorly controlled epilepsy, or some psychological disorders usually need to be hospitalized in order to receive special monitoring and medications during the procedure. In 2000, over 93% of abortions were performed in a clinic setting; clinics accounted for nearly half (46%) of all abortion providers. Hospitals were the site of 5% of abortions (accounting for 33% of abortion providers), while only 3% of abortions were performed at physician offices (21% of abortion providers).

Normal results

Usually the pregnancy is ended without complication and without altering future fertility.

Morbidity and mortality rates

Serious complications resulting from abortions performed before 13 weeks are rare. Of the 90% of women who have abortions in this time period, 2.5% have minor complications that can be handled without hospitalization. Less than 0.5% have complications that require a hospital stay. The rate of complications increases as the pregnancy progresses.

Only one maternal death occurs per 530,000 abortions performed at eight weeks gestation or less; this increases to one death per 17,000 abortions performed from 16 to 20 weeks, and one death per 6,000 abortions performed over 20 weeks.

Alternatives

Adoption is an option for pregnant women who do not want to raise a child but are unwilling or unable

QUESTIONS TO ASK THE DOCTOR

  • What abortion options are available to me based on my stage of pregnancy?
  • What are the short- and long-term complications of the procedure?
  • What type of pain relief/anesthesia is available to me?
  • Who can be in the procedure room with me?
  • What will the abortion cost? What do the fees include?
  • Is pre-abortion counseling offered?
  • How is follow-up or emergency care provided?
  • Does the doctor who will perform the abortion have admitting privileges at a hospital in case of a problem?

to have an abortion. Adoption agencies, crisis pregnancy centers, family service agencies, family planning clinics, or state social service agencies are available for women to contact for more information about the adoption process.

Resources

PERIODICALS

Elam-Evans, Laurie D., Lilo T. Strauss, Joy Herndon, Wilda Y. Parker, Sara Whitehead, and Cynthia J. Berg. “Abortion Surveillance—United States, 1999.” Morbidity and Mortality Weekly Report 51 (November 29, 2002): 1–9.

Finer, L. B. and S. K. Henshaw. “Abortion Incidence and Services in the United States in 2000.” Perspectives on Sexual and Reproductive Health 35, no. 1 (January/ February 2003): 6–15.

Jones, R. K., J. E. Darroch, and S. K. Henshaw. “Patterns in the Socioeconomic Characteristics of Women Obtaining Abortions in 2000–2001.” Perspectives on Sexual and Reproductive Health 34, no. 5 (September/October 2002): 226–235.

OTHER

“Abortion After the First Trimester in the United States.” Planned Parenthood Federation of America May 2007. http://www.plannedparenthood.org/issues-action/abortion/trimester-abortion-6140.htm.

“Choosing Abortion: Questions and Answers.” Planned Parenthood Federation of America February 2003. http://www.plannedparenthood.org/health-topics/abortion/choosing-abortion.htm (February 26, 2003).

“Facts on Induced Abortion in the United States.” Guttmacher Institute. January 2008. http://www.guttmacher.org/pubs/fb_induced_abortion.html.

James, Denise and Natalie E. Roche. “Therapeutic Abortion.” eMedicine May 22, 2002. http://www.emedicine.com/med/topic3311.htm (February 26, 2003).

“Manual Vacuum Aspiration.” Reproductive Health Technologies Project 2002 http://www.rhtp.org/abortion/mva/default.asp (February 26, 2003).

Trupin, Suzanne R. “Abortion.” eMedicine December 2, 2002. http://www.emedicine.com/med/topic5.htm (February 26, 2003).

ORGANIZATIONS

Alan Guttmacher Institute, 1301 Connecticut Ave., NW, Suite 700, Washington, DC, 20036, (202) 296-4012, http://www.guttmacher.org.

Centers for Disease Control and Prevention, Division of Reproductive Health, 4770 Buford Highway, NE, Mail Stop K-20, Atlanta, GA, 30341-3717, (770) 488-5200, http://www.cdc.gov/reproductivehealth/.

National Abortion Federation, 1660 L Street, NW, Suite 450, Washington, DC, 20036, (202) 667-5881, http://www.prochoice.org.

Planned Parenthood Federation of America, 434 West 33rd St., New York, NY, 10001, (212) 541-7800, http://www.plannedparenthood.org.

Debra Gordon

Stephanie Dionne Sherk

Laura Jean Cataldo, R.N., Ed.D.

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Induced Abortion

INDUCED ABORTION


HISTORY    Etienne van de Walle

PREVALENCE    Stanley K. Henshaw

LEGAL ASPECTS    Laura Katzive
Stanley Henshaw

HISTORY

Women throughout the world have probably attempted to procure abortion–premature artificial termination of pregnancy–from before recorded history. The earliest recorded version of the Hippocratic Oath (c. 500 b.c.e.) includes the physician's pledge: "I shall not give women a [fetus]-destroying pessary." This constitutes a testimony both to medical attitudes and practices in antiquity, and to the technology of the time.

Attitudes

Plato and Aristotle accepted the practice of abortion for eugenic reasons. Roman and Jewish law considered that the fetus had no independent existence and was part of the woman's body, subject to the authority of her husband. Legal conflicts originated when the termination of pregnancy was the result of violence inflicted by a third party, or was carried out by a woman against her husband's wishes. Opposition to abortion, together with opposition to infanticide, crystallized under the influence of Christianity. The Church fathers associated abortion first with magical procedures, and second with fornication and adultery, as the epitome of sexual sin. The fetus was thought to become formed or alive only after a delay, such as 40 days; a corollary of this belief was that penalties for abortion increased with the duration of gestation. Christian beliefs from the fourth century on identified this stage–40 days after conception, called "quickening"–with animation, the time when the fetus was endowed with an immortal soul; a similar belief prevailed in Islam. The distinction between abortion before and after quickening survived for a long time in canon law and civil jurisprudence (including common law in England and the United States), although it was abandoned by the Catholic Church in modern times.

Physicians of antiquity generally admitted the legitimacy of therapeutic abortion when the woman was immature or ill-formed, where pregnancy or delivery would endanger her life. Soranus, the Greek gynecologist of the second century c.e., gave recipes for abortion under these conditions, although he preferred the use of contraception for the same purpose. Soranus's position influenced the western medical tradition through Rome, Byzantium, and the translations of Arabic medical texts in the Middle Ages, and justified the publication of Materia Medica featuring abortive herbs and their continued availability to physicians. Although some Christian theologians accepted abortions for therapeutic reasons, most were opposed to the practice. Civil codes condemned abortion with great severity, but it remained a rare event until the nineteenth century, reserved for desperate women. Its practice spread with the need for better methods of birth control, even against the increasing opposition of physicians. During the second half of the twentieth century, early-term abortion (with various definitions of what qualifies as such) was legalized in many countries of the world. However, the moral acceptability of abortion remains controversial. Powerful movements of public opinion support the right of the fetus to life; others, equally influential, support a woman's freedom to choose the outcome of her pregnancy.

Techniques

Methods of abortion in the past either were ineffective or endangered the life of the mother. Vaginal suppositories appear to have been the most commonly used medical technique in the ancient world, because of the intuitive appeal of this route of access to the uterus; they were still mentioned in medical texts of the eighteenth century. Reference to abortive drugs in classical writings or Church pronouncements may refer either to suppositories or oral poisons, or even to spells and magic. The most frequently mentioned alternative technique consisted of violent movements, massage or blows, although milder methods like bleeding or cold baths were also cited. The use of sharp objects is rare before the seventeenth century, although various obstetrical instruments that could have been used for abortion have been described or even unearthed by archeologists. Soranus cautioned against the use of "something sharp-edged to separate the embryo." Dioscorides's second-century c.e.Materia Medica mentioned a number of drugs that would kill a fetus. In addition he listed more than one hundred substances that hastened delivery, expelled a dead fetus, or stimulated the menses. The latter were not abortifacients, but were supposed to act on the uterus. Learned as well as popular medicine and folklore in Europe through the medieval and modern periods attributed abortive properties to many herbal substances, including rue, artemisia, pennyroyal, ergot of rye, tansy, and saffron. A tea or potion made from savin, a species of juniper, was the most widely reputed abortifacient. These substances are implicated in many court proceedings, although it was the attempt (often unsuccessful) to procure an abortion, rather than the actual abortion, that was prosecuted. (Abortion was featured much less often in the courts than infanticide.) Similar substances are reputed as abortifacients in all world cultures, but their effectiveness has never been reliably ascertained. It seems their reputation was greatly inflated, although their popular use in the nineteenth and twentieth centuries, and their deplorable reputation among physicians, suggest that attempts at abortion through oral means were sometimes successful.

Other techniques, such as injections and the use of sharp instruments to kill the fetus, became increasingly common from the seventeenth century in Europe. In the early nineteenth century, most professional abortionists who were prosecuted on the basis of existing penal codes appeared to belong to the medical professions and to use uterine sounds and curettes. By the end of the century, some relatively proficient abortionists operated underground. The numerical importance of abortion during the fertility transition is a matter of controversy.

Throughout most of history, abortion must have been a dangerous and rare procedure, probably practiced almost exclusively outside of marriage, and with little impact on fertility. With the development of antisepsis the procedure of dilatation and curettage could be performed with relative safety by skilled medical personnel. The introduction of methods of early abortion during the second half of the twentieth century–by vacuum aspiration, as well as chemical procedures such as the administration of prostaglandins–coincided with the widespread legalization of abortion, and the blurring of the boundaries between contraception (particularly its post-coital forms) and abortion.

See also: Birth Control, History of; Infanticide.

bibliography

Brodie, Janet Farell. 1994. Contraception and Abortion in 19th-Century America. Ithaca, NY: Cornell University Press.

McLaren, Angus. 1984. Reproductive Rituals: The Perception of Fertility in England from the Sixteenth to the Nineteenth Century. London: Methuen.

Noonan, John, ed. 1970. The Morality of Abortion: Legal and Historical Perspectives. Cambridge, MA: Harvard University Press.

Potts, Malcolm, Peter Diggory, and John Peel. 1977. Abortion. Cambridge, Eng.: Cambridge University Press.

Van de Walle, Etienne. 1999. "Towards a Demographic History of Abortion." Population. An English Selection 11: 115–132.

Etiennevan de Walle

PREVALENCE

The term "abortion" as used in this article refers to the induced termination of a pregnancy with intent other than to produce a live birth. An abortion may be induced legally or illegally, according to the laws of each country. It is to be distinguished from spontaneous abortion, including stillbirth, which is a natural outcome for a small proportion of pregnancies.

Sources of Data

The most accurate sources of information on the incidence of induced abortion are official statistics in countries where abortion is legal. In most of these countries, abortions are required to be reported to health authorities. However, the completeness and accuracy of reporting and the quantity and quality of the resulting tabulations vary widely among and even within countries. Reporting is probably most complete where a procedure for authorization is prescribed by statute and where abortions are required to be performed in hospitals or other facilities subject to official licensure.

In countries where no statistics are kept because abortion is illegal or there is no reporting system, a number of methods have been used to estimate the incidence of abortion. Household surveys yield minimum estimates because underreporting of abortions is common, even where the procedure is legal. These estimates may nevertheless be useful where abortion is widely practiced and accepted. Several studies have estimated abortion rates from the number of women treated in hospitals for abortion complications. These estimates rely on assumptions about the proportion of treated complications that result from induced rather than spontaneous abortions, the proportion of women needing treatment who seek hospital care, and the proportion of induced abortions that cause complications requiring treatment. A third approach is to survey the providers of abortions; this is rarely possible in countries where abortion is illegal. A fourth approach is to infer the abortion rate from the difference between the fertility rate and natural fertility, taking

TABLE 1

into account the reduction in fertility caused by contraceptive use, women not in unions, and rates of infecundity. This method, however, is extremely sensitive to the assumed rate of natural fertility and to small errors in calculating the impact of the other factors.

Incidence

With appropriate caution regarding the high margin of error, it has been estimated that 46 million abortions were performed worldwide in 1995–about 26 million legal abortions and 20 million that were illegal (see Table 1). (The true numbers could be several million higher or lower.) This estimate implies an average annual rate of 35 abortions per 1,000 women aged 15 to 44. Cumulated, the estimate would mean that women, on average, have close to one abortion

TABLE 2

during their lifetimes. About 26 percent of all pregnancies, excluding miscarriages and stillbirths, were ended by induced abortion.

The abortion rates in developed and developing regions are broadly similar, despite the prevalence of restrictive laws in most developing countries. China, India, and Vietnam account for almost all of the legal abortions in the developing regions. Most abortions in other parts of Asia and also in Africa and Latin America are illegal.

Eastern Europe, including the Russian Federation, is the subregion with the highest abortion rate. In these countries, the lack of access to contraceptive methods and ready availability of abortion services under Communism resulted in heavy reliance on abortion to limit fertility. Western Europe, where abortion is legal and readily available, has the lowest rate. The percentage of pregnancies ending in abortion is lowest in Africa, a consequence of the region's high birth rates.

Abortion rates vary widely among countries, as indicated in Table 2. Among low-fertility countries, the level of abortion appears to be determined primarily by the availability, accessibility, and acceptability of contraceptive services. During the 1990s, the lowest recorded rate–less than 7 abortions per 1,000 women aged 15 to 44–was in the Netherlands, despite a low fertility rate and abortion services that are readily available without charge. Only 11 percent of pregnancies nationwide were ended by abortion, with only 3 to 4 percent among the Dutchborn population. The highest abortion rate ever recorded for a country was 252 per 1,000 women in Romania in 1964 and 1965.

Abortion rates are generally higher in developing countries, because of less established contraceptive use, less accessible contraceptive services, and the limited range of contraceptive methods available. The example of Tunisia, however, demonstrates that the use of modern contraceptives can keep the rate low even where abortion services are available and free. Vietnam, on the other hand, had one of the highest abortion rates in the 1990s as a consequence of a rapid drop in desired family size and limited access to modern contraceptive methods. Including abortions performed in the private sector and not counted officially, the abortion rate in Vietnam was estimated to be 111 per 1,000 women in 1996. Estimates of abortion rates in several countries where abortion is illegal are in the range of 23 to 41 per 1,000 women, and the percentage of pregnancies ended by abortion ranges from 12 to 30.

Trends

During the 1990s, abortion rates fell slowly in several Western European countries and the United States, and they fell rapidly in most of the formerly-Communist countries as contraceptive supplies and services became more available. In many developing areas, the demand for both abortion and contraception increased as desired fertility fell, marriage was delayed, and sexual activity before marriage became more common.

In developed countries, non-surgical abortion by means of mifepristone (RU-486) together with a prostaglandin became increasingly common but did not appear to affect overall abortion rates. In developing countries where abortion is illegal, misoprostol, a prostaglandin used to prevent stomach ulcers among long-term users of pain medications, is increasingly used to induce abortion, although it is not always effective. Its effect on abortion rates is unknown, but in Brazil and other countries it has reduced the number of serious complications of illegal and unsafe abortions.

See also: Contraceptive Prevalence; Fertility, Proximate Determinants of; Spontaneous Abortion.

bibliography

Henshaw, Stanley K., Susheela Singh, and Taylor Haas. 1999. "The Incidence of Abortion Worldwide." International Family Planning Perspectives 25(Supplement): S30–S38.

Henshaw, Stanley K., Taylor Ann Haas, Kathleen Berentsen, and Erin Carbone, eds. 2001. Readings on Induced Abortion, Volume 2: A World Review 2000. New York: The Alan Guttmacher Institute.

Koonin, Lisa M., Lilo T. Strauss, Camaryn E. Chrisman, and Wilda Y. Parker. 2000. "Abortion Surveillance–United States, 1997." Morbidity and Mortality Weekly Report, CDC Surveillance Summaries 49(SS—11): 1–43.

World Health Organization Division of Reproductive Health. 1998. Unsafe Abortion: Global and Regional Estimates of Incidence of and Mortality Due to Unsafe Abortion, with a Listing of Available Country Data (WHO/RHT/MSM/97.16). Geneva: World Health Organization.

Stanley K. Henshaw

LEGAL ASPECTS

Around the world, the widely varying legal status of abortion reflects a range of social priorities and values, including women's health, views on religion or morality, and reproductive rights. While over 60 percent of the world's population lives in countries where abortion is a woman's choice or available on broad grounds, in many countries it is a crime and the procedure is permitted by law only under limited circumstances.

In any given country, abortion may be treated in multiple legal codes, statutes, and regulations. Where abortion is or has historically been criminalized, it is usually included in the country's penal code. Numerous other sources of law, including judicial opinions and health codes, may elaborate upon and sometimes moderate criminal laws, delineating the circumstances in which abortion may be legally performed. Abortion's legal status may also be affected by "general principles" of law, which are widely recognized legal norms used to interpret legislation. Many countries that ostensibly prohibit the procedure under all circumstances may permit life-saving abortions under the general principle of necessity, which justifies actions taken reasonably to save one's life or the life of another.

Abortion laws within one country also may vary according to jurisdiction. Several countries, including Australia, Canada, Mexico, and the United States, have legal systems at the provincial or state level as well as the national level, creating variations in abortion regulation among jurisdictions. While constitutional guarantees in Canada and the United States provide protection for women's right to choose abortion, its legality varies by state in Australia and Mexico, where no such guarantees have been recognized.

Categories of Abortion Laws

The world's abortion laws can be classified into five broad categories, reflecting varying degrees of restrictiveness. They are described below, in order from the most to the least restrictive.

  1. Abortion is prohibited entirely or permitted only to save a woman's life. This category, the most restrictive, applies to 73 countries with about one-quarter of the world's population. These countries, primarily in Africa, Asia, and Latin America, include Brazil, Chile, Colombia, Ireland, Iran, Indonesia, Kenya, the Philippines, Senegal, Syria, and Uganda. In some countries in this category, including El Salvador and Guatemala, criminal prohibitions of abortion are supported by constitutional provisions protecting life from the moment of conception.
  2. Abortion is permitted only when a woman's life or physical health is in jeopardy. Laws in this only slightly less restrictive category apply in 33 countries, affecting nearly 10 percent of the world's population. Argentina, Bolivia, Peru, Morocco, Saudi Arabia, Pakistan, Thailand, Poland, Burkina Faso, and Zimbabwe are among the countries in this category. While some of the laws in this category may be interpreted to permit abortion on mental health grounds, none does so expressly.
  3. Abortion is explicitly permitted on the grounds of mental as well as physical health. Laws in this category are in effect in 19 countries with just over 2.5 percent of the world's population. These include Israel, Malaysia, Portugal, Spain, Ghana, Namibia, and New Zealand. The term "mental health" is potentially open to broad interpretation; it can, for example, address the psychological distress associated with pregnancy resulting from rape or incest in situations where abortion on these grounds is not explicitly recognized in the law.
  4. Abortion is permitted on socioeconomic grounds. These laws are in force in 14 countries accounting for nearly 21 percent of the world's population, including Great Britain (not Northern Ireland), India, Japan, and Zambia. They typically permit consideration of a woman's economic resources, her age, her marital status, and the number of children she has. Such laws tend to be interpreted liberally and, in their implementation, may differ very little from laws in category 5.
  5. Abortion is permitted without restriction as to reason during a prescribed period of the pregnancy. In most countries, this period corresponds to the first 12 or 14 weeks of the pregnancy. Among the 52 nations in this category, representing about 41 percent of the world's population, are most industrialized countries, including the United States, Canada, China, Vietnam, France, Germany, Italy, the Russian Federation, and South Africa. Countries that require a woman to affirm that she is in a state of "distress" or "crisis" in order to terminate a pregnancy–like Belgium, France, and Hungary–have been included in this least restrictive category, because it is the woman herself who ultimately decides whether she qualifies for an abortion.

Additional Grounds and Requirements

Countries that fall into any of the five categories described above may permit abortion on other grounds, such as in cases of rape, incest, and fetal impairment. Likewise, a country may place additional legal restrictions on abortion. These may include requirements that women obtain permission for abortion from spouses or parents, conditions on the type of providers who may perform abortions and the facilities in which they may be provided, mandatory counseling and waiting periods, constraints on abortion advertising, and restrictions on public funding for abortion. Where son preference is widespread, some countries have adopted legal measures to prevent the practice of sex-selective abortion. India has prohibited prenatal sex determination for the purpose of sex-selective abortion and, more recently, China and Nepal have adopted similar provisions while also prohibiting sex-selective abortion itself.

Even where abortion laws are highly restrictive, criminal prosecutions of abortion providers and patients may be rare or inconsistent. Similarly, laws providing for legal abortion do not guarantee access to the service for all women who qualify under the law.

Trends over Time

Abortion laws are not static. A global trend toward liberalization began during the latter half of the twentieth century and has continued into the twenty-first century, albeit with some signs of a restrictive counter-trend in Latin America and Central Europe. Some countries, such as Malaysia and Ghana, have made incremental steps toward liberalization, maintaining abortion's criminal status while recognizing therapeutic and/or juridical grounds for abortion. Other countries, such as Nepal and Cambodia, have rejected longstanding criminal bans on abortion in favor of laws that are among the world's least restrictive.

In societies that have traditionally placed a high value on fertility, abortion is often illegal and the prohibition is supported by strong social norms. Women in these societies who seek to limit their family size because of changing economic and social conditions often turn to illegal abortions performed by poorly trained practitioners. The need to protect women's health from unsafe abortion providers has historically been the main impetus for liberalizing abortion laws. Other motivations for reducing abortion restrictions have included bringing the law into conformity with practice, responding to demographic considerations, and, most recently, recognizing women's reproductive rights.

The world is likely to see further liberalization of abortion laws in the years to come, as reform movements develop momentum in countries around the world. In national and international forums, governments have shown increasing recognition of the costs of restrictive abortion laws, which are borne not only by the women immediately affected, but also by their families, communities, and societies.

See also: Feminist Perspectives on Population Issues; Reproductive Rights.

bibliography

Rahman, Anika, Laura Katzive, and Stanley Henshaw. "A Global Review of Laws on Induced Abortion, 1985–1997." International Family Planning Perspectives 24(2): 56–64.

internet resources.

United Nations Department for Economic and Social Development. 1999. Abortion Policies: A Global Review. <http://www.un.org/esa/population/publications/abortion/abortion.htm>.

United Nations Population Fund and Harvard Law School. 2002. Annual Review of Population Law.<http://www.law.harvard.edu/programs/annual_review/annual_review.htm>.

Laura Katzive

Stanley K. Henshaw

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Encyclopedia.com gives you the ability to cite reference entries and articles according to common styles from the Modern Language Association (MLA), The Chicago Manual of Style, and the American Psychological Association (APA).

Within the “Cite this article” tool, pick a style to see how all available information looks when formatted according to that style. Then, copy and paste the text into your bibliography or works cited list.

Because each style has its own formatting nuances that evolve over time and not all information is available for every reference entry or article, Encyclopedia.com cannot guarantee each citation it generates. Therefore, it’s best to use Encyclopedia.com citations as a starting point before checking the style against your school or publication’s requirements and the most-recent information available at these sites:

Modern Language Association

http://www.mla.org/style

The Chicago Manual of Style

http://www.chicagomanualofstyle.org/tools_citationguide.html

American Psychological Association

http://apastyle.apa.org/

Notes:
  • Most online reference entries and articles do not have page numbers. Therefore, that information is unavailable for most Encyclopedia.com content. However, the date of retrieval is often important. Refer to each style’s convention regarding the best way to format page numbers and retrieval dates.
  • In addition to the MLA, Chicago, and APA styles, your school, university, publication, or institution may have its own requirements for citations. Therefore, be sure to refer to those guidelines when editing your bibliography or works cited list.