Abortion

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For other uses, see Abortion (disambiguation).
Induced abortion
Classification and external resources
ICD-10 O04
ICD-9 779.6
DiseasesDB 4153
MedlinePlus 002912
eMedicine article/252560

Abortion is the termination of pregnancy by the removal or expulsion from the uterus of a fetus or embryo prior to viability.[note 1] An abortion can occur spontaneously, in which case it is usually called a miscarriage, or it can be purposely induced. The term abortion most commonly refers to the induced abortion of a human pregnancy.

Abortion, when induced in the developed world in accordance with local law, is among the safest procedures in medicine.[1] However, unsafe abortions result in approximately 70,000 maternal deaths and 5 million hospital admissions per year globally.[2] An estimated 44 million abortions are performed globally each year, with slightly under half of those performed unsafely.[3] The incidence of abortion has stabilized in recent years,[3] having previously spent decades declining as access to family planning education and contraceptive services increased.[4] Forty percent of the world's women have access to legal induced abortions (within gestational limits).[5]

Induced abortion has a long history and has been performed by various methods, including herbal abortifacients, the use of sharpened tools, physical trauma, and other traditional methods. Contemporary medicine utilizes medications and surgical procedures. The legality, prevalence, cultural and religious status of abortion vary substantially around the world. Its legality can depend on specific conditions, such as incest, rape, fetal defects, a high risk of disability, socioeconomic factors or the mother's health being at risk. In many parts of the world there is prominent and divisive public controversy over the moral, ethical, and legal issues of abortion. Those who are against abortion generally posit that an embryo or fetus is a human with the right to life and may equate abortion with homicide, while proponents of abortion rights emphasize a woman's right to decide about matters concerning her own body.

Types

Induced

Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion.[3][6] Most abortions result from unintended pregnancies.[7][8] A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus, which increases in size as the pregnancy progresses.[9][10] Specific procedures may also be selected due to legality, regional availability, and doctor or patient preference.

Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically 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.[11][12] 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.[12] Confusion sometimes arises over the term "elective" because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not.[13]

Spontaneous

Main article: Miscarriage

Spontaneous abortion, also known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation.[14] A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth".[15] When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".[16] Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.[17]

Only 30% to 50% of conceptions progress past the first trimester.[18] The vast majority of those that do not progress are lost before the woman is aware of the conception,[12] and many pregnancies are lost before medical practitioners can detect an embryo.[19] Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman.[20]

The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus,[12][21] accounting for at least 50% of sampled early pregnancy losses.[22] Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus.[21] Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion.[22] A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.[23]

Methods

Gestational age may determine which abortion methods are practiced.

Medical

Main article: Medical abortion

Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone in the 1980s.[24][25][26]

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.[24] 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.[25] This regime is effective in the second trimester.[27]

In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue.[28] 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.[29] If medical abortion fails, surgical abortion must be used to complete the procedure.[30]

Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain,[31][32] France,[33] Switzerland,[34] and the Nordic countries.[35] In the United States, the percentage of early medical abortions is far lower.[36][37]

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,[26] in contrast to the United States where 96% of second-trimester abortions are performed surgically by dilation and evacuation.[38]

Surgical

A vacuum aspiration abortion at eight weeks gestational age (six weeks after fertilization).
1: Amniotic sac
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump

Up to 15 weeks' gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion.[39] Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) 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.

MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation. Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. Curettage refers to cleaning the walls of the uterus with a curette. The World Health Organization recommends this procedure, also called sharp curettage, only when MVA is unavailable.[40]

From the 15th week of gestation until approximately the 26th, other techniques must be used. Dilation and evacuation (D&E) consists of opening the cervix of the uterus and emptying it using surgical instruments and suction. Premature labor and delivery can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with hypertonic solutions containing saline or urea. After the 16th week of gestation, abortions can also be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called "partial-birth abortion," which has been federally banned in the United States.

In the third trimester of pregnancy, abortion may be performed by IDX as described above, induction of labor, or by hysterotomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy.[41]

First-trimester procedures can generally be performed using local anesthesia, while second-trimester methods may require deep sedation or general anesthesia.[37]

Other methods

Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine: tansy, pennyroyal, black cohosh, and the now-extinct silphium (see history of abortion).[42] The use of herbs in such a manner can cause serious—even lethal—side effects, such as multiple organ failure, and is not recommended by physicians.[43]

Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.[44] In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage.[45] One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld.[45]

Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where surgical abortion is legal and available.[46]

Safety

The health risks of abortion depend on whether the procedure is performed safely or unsafely. The World Health Organization defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities.[47] Legal abortions performed in the developed world are among the safest procedures in medicine.[1][48] In the US, the risk of maternal death from abortion is 0.6 per 100,000 procedures, making abortion about 14 times safer than childbirth (8.8 maternal deaths per 100,000 live births).[49][50] The risk of abortion-related mortality increases with gestational age, but remains lower than that of childbirth through at least 21 weeks' gestation.[51][52][53]

Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital. Complications are rare and can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate.[54] Preventive antibiotics (such as doxycycline or metronidazole) are typically given before elective abortion,[55] as they are believed to substantially reduce the risk of postoperative uterine infection.[37][56] Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen.

There is little difference in terms of 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.[28] 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.[57][58]

Some purported risks of abortion are promoted primarily by anti-abortion groups, but lack scientific support.[59] For example, the question of a link between induced abortion and breast cancer has been investigated extensively. Major medical and scientific bodies (including the World Health Organization, the US National Cancer Institute, the American Cancer Society, the Royal College of Obstetricians and Gynaecologists and the American Congress of Obstetricians and Gynecologists) have concluded that abortion does not cause breast cancer,[60] although such a link continues to be promoted by anti-abortion groups.[59]

Similarly, current scientific evidence indicates that induced abortion does not cause mental-health problems.[61][62] The American Psychological Association has concluded that a single abortion is not a threat to women's mental health, and that women are no more likely to have mental-health problems after a first-trimester abortion than after carrying an unwanted pregnancy to term.[63][64] Abortions performed after the first trimester because of fetal abnormalities are not thought to cause mental-health problems.[65] Some proposed negative psychological effects of abortion have been referred to by anti-abortion advocates as a separate condition called "post-abortion syndrome", which is not recognized by any medical or psychological organization.[66]

Unsafe abortion

Soviet poster circa 1925, warning against midwives performing abortions. Title translation: "Abortions performed by either trained or self-taught midwives not only maim the woman, they also often lead to death."
Main article: Unsafe abortion

Women seeking to terminate their pregnancies sometimes resort to unsafe methods, particularly when access to legal abortion is restricted. They may attempt to self-abort or rely on another person who does not have proper medical training or access to proper facilities. This has a tendency to lead to severe complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.[67]

Unsafe abortions are a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries.[1] Unsafe abortions are believed to result in millions of injuries[1][68] and approximately 37,100 deaths annually as of 2010,[69] accounting for 13% of all maternal deaths.[70] This is down from 56,100 deaths in 1990.,[69] Groups such as the World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.[71]

The legality of abortion is one of the main determinants of its safety. Countries with restrictive abortion laws have significantly higher rates of unsafe abortion (and similar overall abortion rates) compared to those where abortion is legal and available.[2][3][71][72][73][74] For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications,[75] with abortion-related deaths dropping by more than 90%.[76] In addition, a lack of access to effective contraception contributes to unsafe abortion. It has been 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.[77]

Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits,[5] while an additional 35 percent have access to legal abortion if they meet certain physical, mental, or socioeconomic criteria.[78] While maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year.[2] Complications of unsafe abortion account for approximately an eighth of maternal mortalities worldwide,[79] though this varies by region.[80] Secondary infertility caused by an unsafe abortion affects an estimated 24 million women.[73] The rate of unsafe abortions has increased from 44% to 49% between 1995 and 2008.[3] Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address this phenomenon.[81]

Incidence

There are two commonly used methods of measuring the incidence of abortion:

  • Abortion rate – number of abortions per 1000 women between 15 and 44 years of age
  • Abortion percentage – number of abortions out of 100 known pregnancies (pregnancies include live births, abortions and miscarriages)

The number of abortions performed worldwide has remained stable in recent years, with 41.6 million having been performed in 2003 and 43.8 million having been performed in 2008.[3] 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.[3] The same 2012 study indicated that in 2008, the estimated abortion percentage of known pregnancies was at 21% worldwide, with 26% in developed countries and 20% in developing countries.[3]

On average, the incidence of abortion is similar in countries with restrictive abortion laws and those with more liberal access to abortion. However, restrictive abortion laws are associated with increases in the percentage of abortions which are performed unsafely.[5][82][83] The unsafe abortion rate in developing countries is partly attributable to lack of access to modern contraceptives; according to the Guttmacher Institute, providing access to contraceptives would result in about 14.5 million fewer unsafe abortions and 38,000 fewer deaths from unsafe abortion annually worldwide.[84]

The rate of legal, induced abortion varies extensively worldwide. According to the report of employees of Guttmacher Institute it ranged from 7 per 1000 women (Germany and Switzerland) to 30 per 1000 women (Estonia) in countries with complete statistics in 2008. The proportion of pregnancies that ended in induced abortion ranged from about 10% (Israel, the Neatherlands and Switzerland) to 30% (Estonia) in the same group, though it might be as high as 36% in Hungary and Romania, whose statistics were deemed incomplete.[85][86]

The abortion rate may also be expressed as the average number of abortions a woman has during her reproductive years; this is referred to as total abortion rate (TAR).

Gestational age and method

Histogram of abortions by gestational age in England and Wales during 2004. Average is 9.5 weeks. (Data source: United Kingdom Department of Health) (left)

Abortion in the United States by gestational age, 2004. (Data source: Centers for Disease Control and Prevention) (right)

Abortion rates also vary depending on the stage of pregnancy and the method practiced. In 2003, the Centers for Disease Control and Prevention (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. 90.9% of these were classified as having been done 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).[87] According to the CDC, due to data collection difficulties the data must be viewed as tentative and some fetal deaths reported beyond 20 weeks may be natural deaths erroneously classified as abortions if the removal of the fetus is accomplished by the same procedure as an induced abortion.[88]

The Guttmacher Institute estimated there were 2,200 intact dilation and extraction procedures in the US during 2000; this accounts for 0.17% of the total number of abortions performed that year.[89] Similarly, in England and Wales in 2006, 89% of terminations occurred at or under 12 weeks, 9% between 13 to 19 weeks, and 1.5% at or over 20 weeks. 64% of those reported were by vacuum aspiration, 6% by D&E, and 30% were medical.[90] Later abortions are more common in China, India, and other developing countries than in developed countries.[91]

Motivation

Personal

The reasons why women have abortions are diverse and vary across the world.[88][92]

A bar chart depicting selected data from a 1998 AGI meta-study on the reasons women stated for having an abortion.

Some of the most common reasons are to postpone childbearing to a more suitable time or to focus energies and resources on existing children. Others include being unable to afford a child either in terms of the direct costs of raising a child or the loss of income while she is caring for the child, lack of support from the father, inability to afford additional children, desire to provide schooling for existing children, disruption of one's own education, relationship problems with their partner, a perception of being too young to have a child, unemployment, and not being willing to raise a child conceived as a result of rape or incest, among others.[92][93]

Societal

Some abortions are undergone as the result of societal pressures. These might include the preference for children of a specific sex, disapproval of single or early motherhood, stigmatization of people with disabilities, insufficient economic support for families, lack of access to or rejection of contraceptive methods, or efforts toward population control (such as China's one-child policy).[citation needed] These factors can sometimes result in compulsory abortion or sex-selective abortion.[citation needed]

An American study in 2002 concluded that about half of women having abortions were using a form of contraception at the time of becoming pregnant. Inconsistent use was reported by half of those using condoms and three-quarters of those using the birth-control pill; 42% of those using condoms reported failure through slipping or breakage.[94] The Guttmacher Institute estimated that "most abortions in the United States are obtained by minority women" because minority women "have much higher rates of unintended pregnancy."[95]

Maternal and fetal health

An additional factor is risk to maternal or fetal health, which was cited as the primary reason for abortion in over a third of cases in some countries and as a significant factor in only a single-digit percentage of abortions in other countries.[88][92]

In the U.S. the Supreme Court decisions in Roe vs Wade and Doe vs Bolton "ruled that the state's interest in the life of the fetus became compelling only at the point of viability, defined as 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. Under the right of privacy, physicians must be free to use their 'medical judgment for the preservation of the life or health of the mother.' On the same day that the Court decided Roe, it also decided Doe v. Bolton, in which the Court defined health very broadly: 'The medical judgment may be exercised in the light of all factors—physical, emotional, psychological, familial, and the woman's age—relevant to the well-being of the patient. All these factors may relate to health. This allows the attending physician the room he needs to make his best medical judgment.'"[96]:1200–1201

Pregnancies complicated by cancer

The rate of cancer during pregnancy is 0.02–1%, and in many cases, this leads 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. This is particularly true for cervical cancer, the most common type which occurs in 1 of every 2000-13000 pregnancies, for which initiation of treatment "cannot co-exist with preservation of fetal life (unless neoadjuvant chemotherapy is chosen)." Very early stage cervical cancers (I and IIa) may be treated by radical hysterectomy and pelvic lymph node dissection, radiation therapy, or both, while later stages are treated by radiotherapy. Chemotherapy may be used simultaneously. Treatment of breast cancer during pregnancy also involves fetal considerations, because lumpectomy is discouraged in favor of modified radical mastectomy unless late-term pregnancy allows follow-up radiation therapy to be administered after the birth.[97]

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. Exposures above 0.005–0.025 Gy cause a dose-dependent reduction in IQ.[97] It is possible to greatly reduce exposure to radiation with abdominal shielding, depending on how far the area to be irradiated is from the fetus.[98][99]

The process of birth itself may also put the mother at risk. "Vaginal delivery may result in dissemination of neoplastic cells into lymphovascular channels, haemorrhage, cervical laceration and implantation of malignant cells in the episiotomy site, while abdominal delivery may delay the initiation of non-surgical treatment."[100]

History

"French Periodical Pills." An example of a clandestine advertisement published in an 1845 edition of the Boston Daily Times.
Main article: History of abortion

Induced abortion has long history, and can be traced back to civilizations as varied as China under Shennong (c. 2700 BCE), Ancient Egypt with its Ebers Papyrus (c. 1550 BCE), and the Roman Empire in the time of Juvenal (c. 200 CE).[101] There is evidence to suggest that pregnancies were terminated through a number of methods, including the administration of abortifacient herbs, the use of sharpened implements, the application of abdominal pressure, and other techniques.

Some medical scholars and abortion opponents have suggested that the Hippocratic Oath forbade Ancient Greek physicians from performing abortions;[101] other scholars disagree with this interpretation,[101] and note the medical texts of Hippocratic Corpus contain descriptions of abortive techniques.[102] Aristotle, in his treatise on government Politics (350 BCE), condemns infanticide as a means of population control. He preferred abortion in such cases, with the restriction[103] "[that it] must be practised on it before it has developed sensation and life; for the line between lawful and unlawful abortion will be marked by the fact of having sensation and being alive."[104] In Christianity, Pope Sixtus V (1585–90) is noted as the first Pope to declare that abortion is homicide regardless of the stage of pregnancy;[105] the Catholic Church had previously been divided on whether it believed that abortion was murder, and did not begin vigorously opposing abortion until the 19th century.[101] Islamic tradition has traditionally permitted abortion until a point in time when Muslims believe the soul enters the fetus,[101] considered by various theologians to be at conception, 40 days after conception, 120 days after conception, or quickening.[106] However, abortion is largely heavily restricted or forbidden in areas of high Islamic faith such as the Middle East and North Africa.[107]

In Europe and North America, abortion techniques advanced starting in the 17th century. However, conservatism by most physicians with regards to sexual matters prevented the wide expansion of safe abortion techniques.[101] Other medical practitioners in addition to some physicians advertised their services, and they were not widely regulated until the 19th century, when the practice was banned in both the United States and the United Kingdom.[101] Church groups as well as physicians were highly influential in anti-abortion movements.[101] In the US, abortion was more dangerous than childbirth until about 1930 when incremental improvements in abortion procedures relative to childbirth made abortion safer.[note 2] The Soviet Union (1919), Iceland (1935) and Sweden (1938) were among the first countries to legalize certain or all forms of abortion.[108] In 1935 Nazi Germany, a law was passed permitting abortions for those deemed "hereditarily ill," while women considered of German stock were specifically prohibited from having abortions.[109] Beginning in the second half of the twentieth century, abortion was legalized in a greater number of countries.[101]

Society and culture

Abortion debate

Main article: Abortion debate

Induced abortion has long been the source of considerable debate, controversy, and activism. An individual's position concerning the complex ethical, moral, philosophical, biological, and legal issues which surround abortion is often related to his or her value system. Opinions of abortion may be described as being a combination of beliefs about abortion's morality the proper extent of governmental authority in public policy; and on the rights and responsibilities of the woman seeking to have an abortion. Religious ethics also has an influence on both personal opinion and the greater debate over abortion.

In both public and private debate, arguments presented in favor of or against abortion access focus on either the moral permissibility of an induced abortion, or justification of laws permitting or restricting abortion. Abortion debates, especially pertaining to abortion laws, are often spearheaded by groups advocating one of these two positions. Anti-abortion groups who favor greater legal restrictions on abortion, including complete prohibition, most often describe themselves as "pro-life" while abortion rights groups who are against such legal restrictions describe themselves as "pro-choice". Generally, the former position argues that a human fetus is a human being with a right to live, making abortion morally the same as murder. The latter position argues that a woman has certain reproductive rights, especially the choice whether or not to carry a pregnancy to term.

Modern abortion law

International status of abortion law

UN 2013 report on abortion law.[110]

  Legal on request
  Legal for rape, maternal life, health, mental health, socioeconomic factors, and/or fetal defects
  Illegal with exception for rape, maternal life, health, mental health, and/or fetal defects
  Illegal with exception for rape, maternal life, health, and/or mental health
  Illegal with exception for maternal life, health, and/or mental health
  Illegal with no exceptions
  Varies
  No information[111][dated info]
Main article: Abortion law
See also: History of abortion law debate

Current laws pertaining to abortion are diverse. Religious, moral, and cultural sensibilities continue to influence abortion laws throughout the world. The right to life, the right to liberty, the right to security of person, and the right to reproductive health are major issues of human rights that are sometimes used as justification for the existence or absence of laws controlling abortion.

In jurisdictions where abortion is legal, certain requirements must often be met before a woman may obtain a safe, legal abortion (an abortion performed without the woman's consent is considered feticide). These requirements usually depend on the age of the fetus, often using a trimester-based system to regulate the window of legality. Some jurisdictions require a waiting period before the procedure, prescribe the distribution of information on fetal development, or require that parents be contacted if their minor daughter requests an abortion.[112] Other jurisdictions may require that a woman obtain the consent of the fetus' father before aborting the fetus, that abortion providers inform patients of health risks of the procedure—sometimes including "risks" not supported by the medical literature—and that multiple medical authorities certify that the abortion is either medically or socially necessary. Many restrictions are waived in emergency situations. China, which has a one-child policy, has at times incorporated mandatory abortions as part of their population control strategy.[113]

Other jurisdictions ban abortion almost entirely. Many, but not all, of these allow legal abortions in a variety of circumstances. These circumstances vary based on jurisdiction, but may include whether the pregnancy is a result of rape or incest, the fetus' development is impaired, the woman's physical or mental well-being is endangered, or socioeconomic considerations make childbirth a hardship.[78] In countries where abortion is banned entirely, such as Nicaragua, medical authorities have recorded rises in maternal death directly and indirectly due to pregnancy as well as deaths due to doctors' fears of prosecution if they treat other gynecological emergencies.[114][115] Some countries, such as Bangladesh, that nominally ban abortion, may also support clinics that perform abortions under the guise of menstrual hygiene.[116] This is also a terminology in traditional medicine.[117] In places where abortion is illegal or carries heavy social stigma, pregnant women may engage in medical tourism and travel to countries where they can terminate their pregnancies.[118] Women without the means to travel can resort to providers of illegal abortions or attempt to perform an abortion by themselves.[119]

Emergency contraception is generally available in countries that have not restricted abortion and is also sometimes available in countries that have otherwise banned abortion, such as Chile.[120][121] This has caused controversy, as some anti-abortion groups assert that certain forms of emergency contraception are not contraceptives but abortifacients (See, e.g., Abortion in the Dominican Republic.)

Sex-selective abortion

Main article: Sex-selective abortion

Sonography and amniocentesis allow parents to determine sex before childbirth. The development of this technology has led to sex-selective abortion, or the termination of a fetus based on sex. The selective termination of a female fetus is most common.

Sex-selective abortion is partially responsible for the noticeable disparities between the birth rates of male and female children in some countries. The preference for male children is reported in many areas of Asia, and abortion used to limit female births has been reported in Taiwan, South Korea, India, and China.[122] This deviation from the standard birth rates of males and females occurs despite the fact that the country in question may have officially banned sex-selective abortion or even sex-screening.[123][124][125][126] In China, a historical preference for a male child has been exacerbated by the one-child policy, which was enacted in 1979.[127]

Many countries have taken legislative steps to reduce the incidence of sex-selective abortion. At the International Conference on Population and Development in 1994 over 180 states agreed to eliminate "all forms of discrimination against the girl child and the root causes of son preference",[128] which was also condemned by a PACE resolution in 2011.[129] The World Health Organization and UNICEF, along with other United Nations agencies, have found that measures to reduce access to abortion are much less effective at reducing sex-selective abortions than measures to reduce gender inequality.[128]

Anti-abortion violence

Main article: Anti-abortion violence

In a number of cases, abortion providers and these facilities have been subjected to various forms of violence, including murder, attempted murder, kidnapping, stalking, assault, arson, and bombing. Anti-abortion violence is classified by both governmental and scholarly sources as terrorism.[130][131] Only a small fraction of those opposed to abortion commit violence, often rationalizing their actions as justifiable homicide or defense of others, committed in order to protect the lives of fetuses. Invasion of privacy and stalking of doctors, clinic workers, and patients, even by police officers, is similarly justified.[132]

In the United States, four physicians who performed abortions have been murdered: David Gunn (1993), John Britton (1994), Barnett Slepian (1998), and George Tiller (2009). Also murdered, in the U.S. and Australia, have been other personnel at abortion clinics, including receptionists and security guards such as James Barrett, Shannon Lowney, Lee Ann Nichols, and Robert Sanderson. Woundings (e.g., Garson Romalis) and attempted murders have also taken place in the United States and Canada, Hundreds of bombings, arsons, acid attacks, invasions, and incidents of vandalism against abortion providers have also occurred.[133][134] Notable perpetrators of anti-abortion violence include Eric Robert Rudolph, Scott Roeder, Shelley Shannon, and Paul Jennings Hill, the first person to be executed in the United States for murdering an abortion provider.[135]

Legal protection of access to abortion has been brought into some countries where abortion is legal. These laws typically seek to protect abortion clinics from obstruction, vandalism, picketing, and other actions, or to protect patients and employees of such facilities from threats and harassment.

Art, literature and film

Bas-relief at Angkor Wat, Cambodia, c. 1150, depicting a demon inducing an abortion by pounding the abdomen of a pregnant woman with a pestle.[45][136]

Art serves to humanize the abortion issue and illustrates the myriad of decisions and consequences it has. One of the earliest known representations of abortion is in a bas relief at Angkor Wat (c. 1150). Anti-abortion activist Børre Knudsen was linked to a 1994 art theft as part of an anti-abortion drive in Norway surrounding the 1994 Winter Olympics.[137] A Swiss gallery removed a piece from a Chinese art collection in 2005, that had the head of a fetus attached to the body of a bird.[138] In 2008, a Yale student proposed using aborted excretions and the induced abortion itself as a performance art project.[139]

The Cider House Rules (novel 1985, film 1999) follows the story of Dr. Larch an orphanage director who is a reluctant abortionist after seeing the consequences of back-alley abortions, and his orphan medical assistant Homer who is against abortion.[140] Feminist novels such as Braided Lives (1997) by Marge Piercy emphasize the struggles women had in dealing with unsafe abortion in various circumstances prior to legalization.[141] Physician Susan Wicklund wrote This Common Secret (2007) about how a personal traumatic abortion experience hardened her resolve to provide compassionate care to women who decide to have an abortion. As Wicklund crisscrosses the West to perform abortions at remote clinics, she tells the stories of women she's treated and the sacrifices she and her loved ones made.[142] In 2009, Irene Vilar revealed her past abuse and addiction to abortion in Impossible Motherhood, where she aborted 15 pregnancies in 17 years. According to Vilar it was the result of a dark psychological cycle of power, rebellion and societal expectations.[143] In Annie Finch's mythic epic poem and opera libretto Among the Goddesses (2010), the heroine's abortion is contextualized spiritually by the goddesses Demeter, Kali, and Inanna.[144]

Various options and realities of abortion have been dramatized in film. In Riding in Cars with Boys (2001) an underage woman carries her pregnancy to term as abortion is not an affordable option, moves in with the father and finds herself involved with drugs, has no opportunities, and questioning if she loves her child. In Juno (2007) a 16-year-old initially goes to have an abortion but decides to bear the child and allow a wealthy couple to adopt it. The films Dirty Dancing (1987) and If These Walls Could Talk (1996) explore the availability, affordability and dangers of illegal abortions. The emotional impact of dealing with an unwanted pregnancy alone is the focus of Things You Can Tell Just By Looking at Her (2000) and Circle of Friends (1995). In The Godfather Part II (1974) Kay informed Michael Corleone that she had obtained an abortion without his knowledge nor consent.[145] On the abortion debate, an irresponsible drug addict is used as a pawn in a power struggle between abortion rights and anti-abortion groups in Citizen Ruth (1996).[146] The Law & Order television episode "Dignity" deals with the trial of a man who killed a late-term abortion doctor; the storyline was inspired by the assassination of abortion provider George Tiller.[147]

Other animals

Further information: Miscarriage

Spontaneous abortion occurs in various animals. For example, in sheep, it may be caused by crowding through doors, or being chased by dogs.[148] In cows, abortion may be caused by contagious disease, such as Brucellosis or Campylobacter, but can often be controlled by vaccination.[149] Eating pine needles can also induce abortions in cows.[150][151] In horses, a fetus may be aborted or resorbed if it has Lethal white syndrome (congenital intestinal aganglionosis). Foal embryos that are homozygous for the dominant white gene (WW) are theorized to also be aborted or resorbed before birth.[152]

Viral infection can cause abortion in dogs.[153] Cats can experience spontaneous abortion for many reasons, including hormonal imbalance. A combined abortion and spaying is performed on pregnant cats, especially in Trap-Neuter-Return programs, to prevent unwanted kittens from being born.[154][155][156]

Abortion may also be induced in animals, in the context of animal husbandry. For example, abortion may be induced in mares that have been mated improperly, or that have been purchased by owners who did not realize the mares were pregnant, or that are pregnant with twin foals.[157] Feticide can occur in horses and zebras due to male harassment of pregnant mares or forced copulation,[158][159][160] although the frequency in the wild has been questioned.[161] Male gray langur monkeys may attack females following male takeover, causing miscarriage.[162]

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Notes

  1. ^ Definitions of abortion, as with many words, vary from source to source. The following is a partial list of definitions as stated by obstetrics and gynecology (OB/GYN) textbooks, dictionaries, and other encyclopedias:
    Major OB/GYN textbooks
    • The National Center for Health Statistics defines an "abortus" as "[a] fetus or embryo removed or expelled from the uterus during the first half of gestation—20 weeks or less, or in the absence of accurate dating criteria, born weighing < 500 g." They also define "birth" as "[t]he complete expulsion or extraction from the mother of a fetus after 20 weeks' gestation. ... in the absence of accurate dating criteria, fetuses weighing <500 g are usually not considered as births, but rather are termed abortuses for purposes of vital statistics." Cunningham, FG; Leveno, KJ; Bloom, SL et al., eds. (2010). "1. Overview of Obstetrics". Williams Obstetrics (23 ed.). McGraw-Hill Medical. ISBN 978-0-07-149701-5. 
    • "[T]he standard medical definition of abortion [is] termination of a pregnancy when the fetus is not viable". Annas, George J.; Elias, Sherman (2007). "51. Legal and Ethical Issues in Obstetric Practice". In Gabbe, Steven G.; Niebyl, Jennifer R.; Simpson, Joe Leigh. Obstetrics: Normal and Problem Pregnancies (5 ed.). Churchill Livingstone. ISBN 978-0-443-06930-7. 
    • "Termination of a pregnancy, whether spontaneous or induced." Kottke, Melissa J.; Zieman, Mimi (2008). "33. Management of Abortion". In Rock, John A.; Jones III, Howard W. TeLinde's Operative Gynecology (10 ed.). Lippincott Williams & Wilkins. ISBN 978-0-7817-7234-1. 
    Other OB/GYN textbooks
    • "Termination of pregnancy before 20 weeks' gestation calculated from date of onset of last menses. An alternative definition is delivery of a fetus with a weight of less than 500 g. If abortion occurs before 12 weeks' gestation, it is called early; from 12 to 20 weeks it is called late." Katz, Vern L. (2007). "16. Spontaneous and Recurrent Abortion – Etiology, Diagnosis, Treatment". In Katz, Vern L.; Lentz, Gretchen M.; Lobo, Rogerio A. et al. Katz: Comprehensive Gynecology (5 ed.). Mosby. ISBN 978-0-323-02951-3. 
    • "Abortion is the spontaneous or induced termination of pregnancy before fetal viability. Because popular use of the word abortion implies a deliberate pregnancy termination, some prefer the word miscarriage to refer to spontaneous fetal loss before viability ... The National Center for Health Statistics, the Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) define abortion as pregnancy termination prior to 20 weeks' gestation or a fetus born weighing less than 500 g. Despite this, definitions vary widely according to state laws." Schorge, John O.; Schaffer, Joseph I.; Halvorson, Lisa M.; Hoffman, Barbara L.; Bradshaw, Karen D.; Cunningham, F. Gary, eds. (2008). "6. First-Trimester Abortion". Williams Gynecology (1 ed.). McGraw-Hill Medical. ISBN 978-0-07-147257-9. 
    Major medical dictionaries
    Other medical dictionaries
    • "[T]he termination of a pregnancy after, accompanied by, resulting in, or closely followed by the death of the embryo or fetus". "Medical Dictionary". Merriam-Webster's Medical Dictionary. Springfield, Mass.: Merriam-Webster. Archived from the original on 15 June 2011. Retrieved 15 June 2011. 
    • "Induced termination of pregnancy, involving destruction of the embryo or fetus." "abortion." The American Heritage Science Dictionary. Boston: Houghton Mifflin. 2005. ISBN 978-0-618-45504-1. 
    • "Interruption of pregnancy before the fetus has attained a stage of viability, usually before the 24th gestational week." "abortion." Cambridge Dictionary of Human Biology and Evolution. Cambridge; New York: Cambridge University Press. 2005. OCLC 54374716. 
    • "[A] spontaneous or deliberate ending of pregnancy before the fetus can be expected to survive." "abortion." Mosby's Emergency Dictionary. Philadelphia: Elsevier Health Sciences. 1998. OCLC 37553784. [verification needed]
    • "[A] situation where a fetus leaves the uterus before it is fully developed, especially during the first 28 weeks of pregnancy, or a procedure which causes this to happen ... [T]o have an abortion to have an operation to make a fetus leave the uterus during the first period of pregnancy." ""abortion"". Dictionary of Medical Terms. London: A & C Black. 2005. OCLC 55634250. 
    • "1. Induced termination of a pregnancy with destruction of the fetus or embryo; therapeutic abortion. 2. Spontaneous abortion." The American Heritage Medical Dictionary (reprint ed.). Houghton Mifflin. 2008. p. 2. ISBN 0-618-94725-6. OCLC 608212441. 
    • "Although the term abortion is generic and implies a premature termination of pregnancy for any reason, the lay public better understands the word 'miscarriage' for involuntary fetal loss or fetal wastage." The Dictionary of Modern Medicine. Parthenon Publishing. 1992. p. 3. ISBN 1-85070-321-3. 
    • "The termination of pregnancy or premature expulsion of the products of conception by any means, usually before fetal viability." Churchill's Medical Dictionary. Churchill Livingstone. 1989. p. 3. ISBN 0-443-08691-5. 
    Major English dictionaries (general-purpose)
    • "1. a. The expulsion or removal from the womb of a developing embryo or fetus, spec. (Med.) in the period before it is capable of independent survival, occurring as a result either of natural causes (more fully spontaneous abortion) or of a deliberate act (more fully induced abortion); the early or premature termination of pregnancy with loss of the fetus; an instance of this." "abortion, n.". Oxford English Dictionary (Third ed.). Oxford University Press. September 2009; online version September 2011. 
    • "[A]n operation or other procedure to terminate pregnancy before the fetus is viable" or "[T]he premature termination of pregnancy by spontaneous or induced expulsion of a nonviable fetus from the uterus". "abortion". Collins English Dictionary – Complete & Unabridged 11th Edition. HarperCollins Publishers. Retrieved 7 October 2012. 
    • "[T]he removal of an embryo or fetus from the uterus in order to end a pregnancy" or "[A]ny of various surgical methods for terminating a pregnancy, especially during the first six months." "abortion". Dictionary.com Unabridged. Random House, Inc. 27 June 2011. 
    • "[T]he termination of a pregnancy after, accompanied by, resulting in, or closely followed by the death of the embryo or fetus: as (a) spontaneous expulsion of a human fetus during the first 12 weeks of gestation (b) induced expulsion of a human fetus (c) expulsion of a fetus by a domestic animal often due to infection at any time before completion of pregnancy." Merriam-Webster Dictionary, from Merriam-Webster, an Encyclopedia Brittanica Company.
    • "1. medicine the removal of an embryo or fetus from the uterus before it is sufficiently developed to survive independently, deliberately induced by the use of drugs or by surgical procedures. Also called termination or induced abortion. 2. medicine the spontaneous expulsion of an embryo or fetus from the uterus before it is sufficiently developed to survive independently. Also called miscarriage, spontaneous abortion." Chambers 21st Century Dictionary. London: Chambers Harrap, 2001.
    • "a medical operation to end a pregnancy so that the baby is not born alive". Longman Dictionary of Contemporary English, online edition.
    Other dictionaries
    • "The deliberate termination of a pregnancy, usually before the embryo or fetus is capable of independent life." The American Heritage New Dictionary of Cultural Literacy (3rd ed.). Houghton Mifflin Company. 2005. 
    • "A term that, in philosophy, theology, and social debates, often means the deliberate termination of pregnancy before the fetus is able to survive outside the uterus. However, participants in these debates sometimes use the term abortion simply to mean the termination of pregnancy before birth, regardless of whether the fetus is viable or not." "abortion." Dictionary of World Philosophy. London: Routledge, 2001.
    • "1. An artificially induced termination of a pregnancy for the purpose of destroying an embryo or fetus. 2. The spontaneous expulsion of an embryo or fetus before viability;" Garner, Bryan A. (June 2009). Black's Law Dictionary (9th ed.). Thomson West. ISBN 978-0-314-19949-2. 
    Encyclopedias
    • "[T]he expulsion of a fetus from the uterus before it has reached the stage of viability (in human beings, usually about the 20th week of gestation)." "Abortion (pregnancy)". Encyclopædia Britannica Online. Encyclopædia Britannica. 2011. Archived from the original on 26 June 2011. Retrieved 26 June 2011. 
    • "Expulsion of the products of conception before the embryo or fetus is viable. Any interruption of human pregnancy prior to the 28th week is known as abortion." "Abortion". The Columbia Encyclopedia. New York: Columbia University Press. 2008. 
    • "The expulsion or removal of a fetus from the womb before it is capable of independent survival." "Abortion". World Encyclopedia. Oxford University Press. 2008. 
    • "[Abortion] is commonly misunderstood outside medical circles. In general terms, the word 'abortion' simply means the failure of something to reach fulfilment or maturity. Medically, abortion means loss of the fetus, for any reason, before it is able to survive outside the womb. The term covers accidental or spontaneous ending, or miscarriage, of pregnancy as well as deliberate termination. The terms 'spontaneous abortion' and 'miscarriage' are synonymous and are defined as loss of the fetus before the twenty-eighth week of pregnancy. This definition implies a legal perception of the age at which a fetus can survive out of the womb. With great advances in recent years in the ability to keep very premature babies alive, this definition is in need of revision." "Abortion and miscarriage". The Royal Society of Medicine Health Encyclopedia. London: Bloomsbury Publishing. 2000. 
    • "Abortion is the intentional removal of a fetus or an embryo from a mother's womb for purposes other than that of either producing a live birth or disposing of a dead embryo." "Abortion". Encyclopedia of Human Rights Issues since 1945 (1 ed.). Santa Barbara, California: Routledge. 1999. ISBN 978-1-57958-166-4. 
  2. ^ By 1930, medical procedures in the US had improved for both childbirth and abortion but not equally, and induced abortion in the first trimester had become safer than childbirth. In 1973, Roe vs. Wade acknowledged that abortion in the first trimester was safer than childbirth:

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