Estimated 26 million pregnancies terminated legally and 20 million are terminated illegally throughout the world each year with an associated 78,000 deaths.
Approximately 1.2 million induced abortions were performed in the United States in 2008.
There were nearly 700,000 legal abortions performed in the US in 2012 (CDC).
Nearly 1,000,000 people seek abortion care annually.
Switzerland had the lowest abortion rate at 5 per 1,000 women.
The U.S. rate is 13 per 1,000 women, the same as Britain’s.
Colombia and Mexico had abortion rates of 34 per 1,000 women.
Pakistan’s estimated abortion rate is the highest at 50 per 1,000 women.
Approximately one in three women will have an induced abortion by menopause.
Approximately 90% of induced abortions are performed in the first trimester because the pregnancy is unwanted or unintended.
1-2% of induced abortions are performed after the first trimester because of a fetal abnormality or serious illness in the pregnant woman.
Most widely used method for terminating pregnancy early in the first trimester is surgical vacuum aspiration.
Vacuum aspiration has less than 1% associated serious complications such as uterine perforation and retained products of conception.
The risk of dying from childbirth is 50 to 130 times greater than dying from an abortion.
The use of misoprostol is an effective way to soften and dilate the cervix prior to vacuum aspiration.
Use of osmotic dilators can lower rates of uterine perforation and cervical injury in vacuum aspiration procedures.
Cervix preparations, however, are not routinely used before vacuum aspirations.
Vacuum aspiration is routinely utilize with local anesthesia, indicating that hemorrhage, cervical injury and uterine perforation are more common with the use of general anesthesia.
Vacuum aspiration can be electric or manual with similar effectiveness and acceptability.
Manual vacuum aspiration is preferred during early gestational ages, as greater amount of tissue occurs after nine weeks gestation, and limits its effectiveness.
Following aspiration tissue is expected to confirm the presence of the trophoblast.
Surgical vacuum aspiration is performed with deep sedation or general anesthesia and paracervical block’s are widely used.
In trials comparing medical to surgical abortion women find medical abortion less acceptable than surgical abortion for up to 13 weeks of gestation.
A Scottish study suggested equal acceptability for medical and surgical abortion for up to 50 days of gestation, and a lower rate of acceptability for medical abortion and 50-63 days of gestation (Henshaw RC et al).
Medical abortion is associated with more pain, prolonged bleeding and a slightly higher failure rate than surgical abortion.
2-5% women undergoing medical abortion at approximately 9 weeks of gestation will require a repeat procedure to complete the emptying of the uterus, as compared with 1% of patients undergoing surgical evacuation.
Hemorrhage after spontaneous or induced abortion is an uncommon event ranging from 0.1 to 21 per thousand cases.
Spontaneous abortion has been reported in as many as 1/5 of pregnancies in some low and medium income country populations.
Miscarriage rates are higher among women who are HIV-positive than among those who are HIV negative.
Hysterectomy after abortion is most commonly performed for hemorrhage estimated at 1.4 per 10,000.
15-18% of abortion-related deaths from hemorrhage.
1.4% abortions are performed at or after 21 weeks of gestation.
Rate of death from surgical termination of pregnancy is 0.6 per 100,000 women while serious morbidity is less than 1 percent of women.
Vacuum aspiration in the first trimester of pregnancy is effective in 98 to 99 percent of women.
Medical induced abortions are increasing and involved the combined use of progesterone antagonist RU-486 (mifepristone), and a prostaglandin.
Mifepristone in the eight abortion and prostaglandin causes uterine contractions and empties the uterus (Baird DT).
Prostaglandin used 1 to 2 days after mifepristone dramatically increases the effectiveness of the abortion.
Most common prostaglandin utilized is prostaglandin E analog misoprostol.
Misoprostol can be administered vaginally, buccal, sublingually or orally.
In the United States 400 to 800 mg vaginally is typically used, and a second dose further increases the likelihood of complete abortion.
Misoprostol 800 microg vaginally is widely used as the initial dose.
Randomized trial of mifepristone utilizing 200 mg had a similar effectiveness as 600 g of for abortion at all gestational ages, and 600 microgm is the dose approved by the FDA (WHO).
Medical abortion can be completed at home following the administration of the medications, although access to emergency facilities is required.
Medical abortions account for approximately 10% of induced abortions in the United States.
Illegal abortion is associated with significant morbidity and mortality.
Typically characterized as either therapeutic or elective.
Referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman, prevent harm to the woman’s physical or mental health, terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled, or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.
An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons.
Spontaneous abortion, is known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation.
As many as 15% of all spontaneous abortions have the 45,X karyotype.
When a fetus dies in utero after viability, or during delivery, it is usually termed stillborn.
Only 30% to 50% of conceptions progress past the first trimester, and the vast majority of those that do not progress are lost before the woman is aware of the conception,
Many pregnancies are lost before medical practitioners can detect an embryo.
Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman.
80% of spontaneous abortions happen in the first trimester.
The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities accounting for at least 50% of sampled early pregnancy losses.
Other causes of spontaneous abortion include vascular disease such as lupus, diabetes, other hormonal problems, infection, and abnormalities of the uterus.
Advancing maternal age and a women’s history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion.
A spontaneous abortion can also be caused by accidental trauma.
Intentional trauma or stress to cause miscarriage is considered induced abortion.
Gestational age may determine which abortion methods are practiced.
Medical abortions are those induced by abortifacient pharmaceuticals.
The most common early first-trimester medical abortion regimens use mifepristone in combination with a prostaglandin analog ,misoprostol or gemeprost, up to 9 weeks gestational age, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone.
Mifepristone-misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate-misoprostol combination regimens, and combination regimens are more effective than misoprostol alone.
Above regimes are effective in the second trimester.
In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone-misoprostol combination regimen is considered to be more effective than vacuum aspiration, especially when clinical practice does not include detailed inspection of aspirated tissue.
Early medical abortion regimens using mifepristone, followed 24-48 hours later by buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age.
If medical abortion fails, surgical abortion must be used to complete the procedure.
Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain, France, Switzerland, and the Nordic countries, but in the United States, the percentage of early medical abortions is far lower.
Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second-trimester abortions in Canada, most of Europe, China and India,
In the United States 96% of second-trimester abortions are performed surgically by dilation and evacuation.
Up to 15 weeks’ gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion.
Manual vacuum aspiration consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration uses an electric pump.
These techniques differ in the mechanism used to apply suction, in how early in pregnancy they can be used, and in whether cervical dilation is necessary.
Manual vacuum aspiration can be used in very early pregnancy, and does not require cervical dilation.
Dilation and curettage is the second most common method of surgical abortion.
World Health Organization recommends this procedure, also called sharp curettage, only when manual vacuum aspiration is unavailable.
From the 15th week of gestation until approximately the 26th, other techniques must be used.
After the 16th week of gestation, abortions can also be induced by intact dilation and extraction, also called intrauterine cranial decompression.
Intrauterine cranial decompression is requires surgical decompression of the fetus’s head before evacuation.
Intrauterine cranial decompression is referred to as partial birth abortion.
In the third trimester of pregnancy, induced abortion may be performed surgically by intact dilation and extraction or by hysterotomy.
Hysterotomy abortion is similar to a caesarean section and requires a smaller incision than a caesarean section and is used during later stages of pregnancy.
First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require general anesthesia.
Where facilities lack medical skill for dilation and extraction, or where preferred by practitioners, an abortion can be induced by first inducing labor and then inducing fetal demise, sometimes called “induced miscarriage”.
Induced miscarriage may be performed from 13 weeks gestation to the third trimester, and is very uncommon in the United States.
More than 80% of induced abortions in the second trimester are labor induced abortions in Sweden and other nearby countries.
Labor induced abortions after 18 weeks may be complicated by the occurrence of brief fetal survival, which may be legally characterized as live birth.
The health risks of abortion depend upon whether the procedure is performed safely or unsafely.
Legal abortions performed in the developed world are among the safest procedures in medicine.
In the US, the risk of maternal death from abortion is 0.7 per 100,000 procedures, making abortion about 13 times safer for women than childbirth (8.8 maternal deaths per 100,000 live births).
75% of patients seeking abortion are poor or low income.
Risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth through at least 21 weeks’ gestation.
Abortion has a lower mortality rate than plastic surgery.
Vacuum aspiration in the first trimester is the safest method of surgical abortion.
Complications of vacuum aspiration are rare and include: uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate.
Infections account for one-third of abortion-related deaths in the United States.
Complications rate of vacuum aspiration abortion in the first trimester is similar whether the performed in a hospital, surgical center, or office.
Preventive antibiotics are typically given before elective abortion, as they are believed to substantially reduce the risk of postoperative uterine infection.
Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen.
Safety and efficacy between medical abortion using a combined regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration) in early first trimester abortions up to 9 weeks gestation have similar results.
Medical abortion using the prostaglandin analog misoprostol alone is less effective and more painful than medical abortion using a combined regimen of mifepristone and misoprostol or surgical abortion.
There is no relationship between most induced abortions and mental-health problems.
A woman’s first abortion is not a threat to mental health when carried out in the first trimester, with such women no more likely to have mental-health problems than those carrying an unwanted pregnancy to term.
The mental-health outcome of a woman’s second or greater abortion is less certain.
Women seeking to terminate their pregnancies sometimes resort to unsafe methods, particularly
When access to legal abortion is restricted, women seeking to terminate their pregnancies sometimes resort to unsafe methods.
Women may attempt to self-abort or rely on another person who does not have proper medical training or access to proper facilities.
Illegal abortion has a tendency to lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.
Unsafe abortions are a major cause of injury and death among women worldwide.
Estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries.
Unsafe abortions are believed to result in millions of injuries.
Estimates of deaths have ranged from 37,000 to 70,000 in the past decade.
To reduce the number of unsafe abortions, advocates emphasize the legalization of abortion, training of medical personnel, and ensuring access to reproductive-health services.
Whether abortions are performed safely or not relates to the legal status of abortion.
Countries with restrictive abortion laws have higher rates of unsafe abortion, yet similar overall abortion rates compared to those where abortion is legal and available.
A lack of access to effective contraception contributes to unsafe abortion.
It is estimated that the incidence of unsafe abortion could be reduced by up to 75%, from 20 million to 5 million annually, if modern family planning and maternal health services were readily available globally.
Rates of abortions may be difficult to measure because they can be reported variously as miscarriage, induced miscarriage, and menstrual regulation.
Maternal mortality seldom results from safe abortions.
Unsafe abortions result in 70,000 deaths and 5 million disabilities per year.
Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide.
Secondary infertility caused by an unsafe abortion affects an estimated 24 million women.
Although it is very uncommon, women undergoing surgical abortion after 18 weeks gestation sometimes give birth to a fetus that may survive briefly, while longer term survival is possible after 22 weeks.
Emergency medical care is given if the child has a good chance of survival and palliative care if not.
Induced fetal demise before termination of pregnancy after 20-21 weeks gestation is recommended to avoid the above crisis.
Death following live birth which is caused by abortion is approximately 4 per 100,000 abortions.
In many places, where abortion is illegal or carries a social stigma, medical reporting of abortion is not reliable.
The number of abortions performed worldwide has remained stable.
In 2012 the abortion rate worldwide was 28 per 1000 women, though it was 24 per 1000 women for developed countries and 29 per 1000 women for developing countries.
On average, the incidence of abortion is similar in countries with restrictive abortion laws and those with more liberal access to abortion.
Restrictive abortion laws are associated with increases in the percentage of abortions which are performed unsafely.
The unsafe abortion rate in developing countries is partly attributable to lack of access to modern contraceptives.
Providing access to contraceptives would result in about 14.5 million fewer unsafe abortions and 38,000 fewer deaths from unsafe abortion annually worldwide.
In 2003 CDC reported that 26% of abortions in the United States were known to have been obtained at less than 6 weeks’ gestation, 18% at 7 weeks, 15% at 8 weeks, 18% at 9 through 10 weeks, 9.7% at 11 through 12 weeks, 6.2% at 13 through 15 weeks, 4.1% at 16 through 20 weeks and 1.4% at more than 21 weeks.
In above study 90.9% performed by curettage(suction-aspiration, dilation and curettage, dilation and evacuation), 7.7% by medical means (mifepristone), 0.4% by intrauterine instillation (saline or prostaglandin), and 1.0% by other (including hysterotomy and hysterectomy).
Rationale women have abortion: to postpone childbearing to a more suitable time, to focus on existing children, inability to afford a child, inability to afford additional children, disruption of one’s education, relationship problems with their partner, too young to have a child, unemployment, and not being willing to raise a child conceived as a result of rape or incest.
Some abortions result from of societal pressures; preference for children of a specific sex or race, disapproval of single or early motherhood, stigmatization of people with disabilities, insufficient economic support, lack of access to contraceptive methods, or efforts toward population control.
About half of women having abortions were using a form of contraception at the time of becoming pregnant.
In three above situation inconsistent use of condoms occurred by half of individuals and 3/4 of those using birth control pills.
Most abortions in the United States are obtained by minority women
Minority women have much higher rates of unintended pregnancy.
Risk to maternal or fetal health is cited as the primary reason for abortion in single digits to over a third of cases in some countries.
Roe vs Wade ruled that the state’s interest in the life of the fetus became compelling only at the point of viability, the point at which the fetus can survive independently of its mother.
Even after the point of viability, the state cannot favor the life of the fetus over the life or health of the pregnant woman.
The rate of cancer during pregnancy is 0.02-1%, and can lead to consideration of abortion to protect the life of the mother, or in response to the potential damage that may occur to the fetus during treatment.
Exposure to a single chemotherapy drug is estimated to cause a 7.5-17% risk of teratogenic effects on the fetus, with higher risks for multiple drug treatments.
Treatment with more than 40 Gy of radiation usually causes spontaneous abortion.
Exposure to much lower doses during the first trimester, especially 8 to 15 weeks of development, can cause intellectual disability or microcephaly, and exposure at this or subsequent stages can cause reduced intrauterine growth and birth weight.
Radiation exposures above 0.005-0.025 Gy cause a dose-dependent reduction in IQ.
The process of birth itself may also put the mother at risk, as vaginal delivery may result in dissemination of neoplastic cells into lymphovascular channels, hemorrhage, cervical laceration and implantation of malignant cells in the episiotomy site,.
Sonography and amniocentesis allow parents to determine sex before childbirth, leading to sex-selective abortion, or the termination of a fetus based on sex.
Sex-selective abortion is partially responsible for the disparities between the birth rates of male and female children in some countries.