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Medical abortion: Public health and private lives
American Journal of Obstetrics and Gynecology Founded in 1920 volume 183 number 2 AUGUST 2000
Medical abortion: Public health and private lives David A. Grimes, MD Chapel Hill, North Carolina
Induced abortion is a common event in the lives of women and their families. Indeed, legal abortion remains one of the most frequent operations performed in the United States. Each year over one million women have induced abortions,1 and the cohort of women who have had safe, legal abortions since Roe v Wade now numbers in the tens of millions. Each year between 2% and 3% of all women of reproductive age have an abortion. This translates into one of every four recognized pregnancies.1 By the time they reach the age of 45 years, 43% of US women will have had an induced abortion.2 Thus nearly half of all women in the United States personally benefit from abortion. Because of its frequency, abortion is important as both a medical and a social issue. This symposium on medical abortion explores both of these dimensions. When medical historians look back on the 20th century, the legalization of abortion will stand out as one of its public health triumphs.3, 4 Few innovations, aside from antibiotics and immunization, have transformed the medical scene so profoundly and so fast. Promulgated in the 1800s to protect women from charlatans and quacks, laws prohibiting abortion had a paradoxic effect in the 1900s. These laws prevented women from having safe abortions provided by physicians, and women resorted to the back alleys of America instead.5 In the 1960s every large municipal hospital in the United States had a ward filled with women affected by complications of illegal abortion. In the mid 1960s, state laws began to change to allow women access to safe abortions provided by licensed physicians. Soon thereafter these “septic abortion wards” emptied and then closed.6 In the 1940s >1000 US women died each year of complications of illegal abortion; today that number is only a handful.7 Deaths from illegal abortion, however, do not adequately measure the scope of the tragedy. For every woman who died, many more were left wounded—often sterile, castrated, or both.8 In most developing countries From the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine. Reprint requests: National Abortion Federation, 1755 Massachusetts Ave NW, Suite 600, Washington, DC 20036. (Am J Obstet Gynecol 2000;183:S1-S2.) Copyright © 2000 by Mosby, Inc. 0002-9378/2000 $12.00 + 0 6/0/106047 doi:10.1067/mob.106047
today the leading cause of admission to gynecology services remains complications of unsafe abortions. Estimates of abortion-related deaths worldwide range from 60,000 to 100,000 each year.9 Romania taught the world a painful lesson about the human cost of restricting access to safe abortion.10 When the Ceausescu regime made abortion largely unattainable, the maternal mortality rate rose to become the highest in Europe (around 150 deaths per 100,000 live births). After Ceausescu was deposed and abortion was made available again, maternal mortality rates plummeted. Regardless of one’s feelings about the divisive issue of abortion, the public health record is incontrovertible: legal abortion improves the health of women.3 Legal abortion is one of the safest operations in contemporary practice, and its safety has improved through the years. Better methods have evolved, surgical skills have improved, and physicians have become more adept at preventing and treating complications. Today the overall risk of death from legal abortion is less than 1 per 100,000 operations.11 By comparison, the risk of death from hysterectomy is about 100 times higher.12 The mortality rate from legal abortion is less than that from an injection of penicillin.13 The technology of suction curettage abortion came to the United States from Russia and Eastern Europe.14 Change came quickly during the early years of legal abortion. Results from the Joint Program for the Study of Abortion (which was initiated by the Population Council and continued by the Centers for Disease Control and Prevention) and from other studies revolutionized abortion practice. Suction curettage proved to be faster and safer than traditional sharp curettage.4 Local anesthesia was found to be safer than general anesthesia.15 Paradoxically, abortions provided in freestanding clinics proved to be safer than those done in hospitals.16 Dilatation and evacuation abortion rapidly replaced labor induction as the most frequent means of secondtrimester abortion.1, 4 After this rapid modernization in the 1970s, however, progress slowed. Investigators explored early medical abortion with prostaglandins alone, but this approach proved unsatisfactory. Although prostaglandins could induce abortions at any gestational age, the resultant nausea, vomiting, and diarrhea were prohibitive. Thus surgical S1
S2 Grimes
abortion remained the only practical type of early abortion for a quarter century. Hence the notion of “choice” in early abortion has meant “no choice” of method. Many have complained that the technology of surgical abortion is intrusive. The provision of abortion services has remained centralized and controlled by physicians.17 Access to service has become increasingly difficult, particularly for women in rural America.18 Medical abortion has now opened a new era in fertility control, and the pace of research has again accelerated. Frustration regarding the lack of availability of mifepristone for abortion in the United States led to the exploration of methotrexate as an alternative. Numerous studies have confirmed the favorable results originally reported by Creinin and Darney.19 A voluminous literature now documents the safety and efficacy of mifepristone abortion regimens.20 Another byproduct of medical abortion research has been interest in the therapeutic uses of misoprostol as an adjunct to abortion. For cervical dilatation before suction curettage vaginal administration of misoprostol works better than does oral administration. The dilatation achieved rivals that with Laminaria used for several hours.21, 22 Early medical abortion represents an important new technology.8 These regimens offer the prospect of a more private, less intrusive form of abortion that is both safe and effective. Because of the simplicity more providers may offer this type of abortion than currently provide surgical abortions. If so, access to care may improve. As described in this symposium, medical approaches will make “choice” of an early abortion method a reality, rather than an empty promise. REFERENCES
1. Koonin LM, Strauss LT, Chrisman CE, Montalbano MA, Bartlett LA, Smith JC. Abortion surveillance—United States, 1996. MMWR Morb Mortal Wkly Rep 1999;48(SS-4):1-42. 2. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24-9, 46.
August 2000 Am J Obstet Gynecol
3. Cates W Jr. Legal abortion: the public health record. Science 1982;215:1586-90. 4. Anonymous. Induced termination of pregnancy before and after Roe v Wade. Trends in the mortality and morbidity of women. Council on Scientific Affairs, American Medical Association. JAMA 1992;268:3231-9.. 5. Polgar S, Fried ES. The bad old days: clandestine abortions among the poor in New York City before liberalization of the abortion law. Fam Plann Perspect 1976;8:125-7. 6. Stewart GK, Hance F. Legal abortion: influences upon mortality, morbidity and population. Adv Plan Parent 1974;9:1-7. 7. Binkin N, Gold J, Cates W Jr. Illegal-abortion deaths in the United States: why are they still occurring? Fam Plann Perspect 1982;14:163-7. 8. World Health Organization. Medical methods for termination of pregnancy. Geneva: The World Health Organization; 1997. 9. Bernstein PS, Rosenfield A. Abortion and maternal health. Int J Gynaecol Obstet 1998;63 Suppl 1:S115-22. 10. Stephenson P, Wagner M, Badea M, Serbanescu F. Commentary: the public health consequences of restricted induced abortion— lessons from Romania. Am J Public Health 1992;82:1328-31. 11. Lawson HW, Frye A, Atrash HK, Smith JC, Shulman HB, Ramick M. Abortion mortality, United States, 1972 through 1987. Am J Obstet Gynecol 1994;171:1365-72. 12. Wingo PA, Huezo CM, Rubin GL, Ory HW, Peterson HB. The mortality risk associated with hysterectomy. Am J Obstet Gynecol 1985;152:803-8. 13. Rudolph AH, Price EV. Penicillin reactions among patients in venereal disease clinics: a national survey. JAMA 1973;223:499501. 14. Kerslake D, Casey D. Abortion induced by means of the uterine aspirator. Obstet Gynecol 1967;30:35-45. 15. Peterson HB, Grimes DA, Cates W Jr, Rubin GL. Comparative risk of death from induced abortion at ≤12 weeks’ gestation performed with local versus general anesthesia. Am J Obstet Gynecol 1981;141:763-8. 16. Grimes DA, Cates W Jr, Selik RM. Abortion facilities and the risk of death. Fam Plann Perspect 1981;13:30-2. 17. Winikoff B. Acceptability of medical abortion in early pregnancy. Fam Plann Perspect 1995;27:142-8, 185. 18. Henshaw SK. Abortion incidence and services in the United States, 1995-1996. Fam Plann Perspect 1998;30:263-70, 287. 19. Creinin MD, Darney PD. Methotrexate and misoprostol for early abortion. Contraception 1993;48:339-48. 20. Grimes DA. Medical abortion in early pregnancy: a review of the evidence. Obstet Gynecol 1997;89:790-6. 21. Singh K, Fong YF, Prasad RN, Dong F. Randomized trial to determine optimal dose of vaginal misoprostol for preabortion cervical priming. Obstet Gynecol 1998;92:795-8. 22. MacIsaac L, Grossman D, Balistreri E, Darney P. A randomized controlled trial of Laminaria, oral misoprostol, and vaginal misoprostol before abortion. Obstet Gynecol 1999;93:766-70.
Medical abortion: Public health and private lives David A. Grimes, MD Chapel Hill, North Carolina
Induced abortion is a common event in the lives of women and their families. Indeed, legal abortion remains one of the most frequent operations performed in the United States. Each year over one million women have induced abortions,1 and the cohort of women who have had safe, legal abortions since Roe v Wade now numbers in the tens of millions. Each year between 2% and 3% of all women of reproductive age have an abortion. This translates into one of every four recognized pregnancies.1 By the time they reach the age of 45 years, 43% of US women will have had an induced abortion.2 Thus nearly half of all women in the United States personally benefit from abortion. Because of its frequency, abortion is important as both a medical and a social issue. This symposium on medical abortion explores both of these dimensions. When medical historians look back on the 20th century, the legalization of abortion will stand out as one of its public health triumphs.3, 4 Few innovations, aside from antibiotics and immunization, have transformed the medical scene so profoundly and so fast. Promulgated in the 1800s to protect women from charlatans and quacks, laws prohibiting abortion had a paradoxic effect in the 1900s. These laws prevented women from having safe abortions provided by physicians, and women resorted to the back alleys of America instead.5 In the 1960s every large municipal hospital in the United States had a ward filled with women affected by complications of illegal abortion. In the mid 1960s, state laws began to change to allow women access to safe abortions provided by licensed physicians. Soon thereafter these “septic abortion wards” emptied and then closed.6 In the 1940s >1000 US women died each year of complications of illegal abortion; today that number is only a handful.7 Deaths from illegal abortion, however, do not adequately measure the scope of the tragedy. For every woman who died, many more were left wounded—often sterile, castrated, or both.8 In most developing countries From the Department of Obstetrics and Gynecology, University of North Carolina School of Medicine. Reprint requests: National Abortion Federation, 1755 Massachusetts Ave NW, Suite 600, Washington, DC 20036. (Am J Obstet Gynecol 2000;183:S1-S2.) Copyright © 2000 by Mosby, Inc. 0002-9378/2000 $12.00 + 0 6/0/106047 doi:10.1067/mob.106047
today the leading cause of admission to gynecology services remains complications of unsafe abortions. Estimates of abortion-related deaths worldwide range from 60,000 to 100,000 each year.9 Romania taught the world a painful lesson about the human cost of restricting access to safe abortion.10 When the Ceausescu regime made abortion largely unattainable, the maternal mortality rate rose to become the highest in Europe (around 150 deaths per 100,000 live births). After Ceausescu was deposed and abortion was made available again, maternal mortality rates plummeted. Regardless of one’s feelings about the divisive issue of abortion, the public health record is incontrovertible: legal abortion improves the health of women.3 Legal abortion is one of the safest operations in contemporary practice, and its safety has improved through the years. Better methods have evolved, surgical skills have improved, and physicians have become more adept at preventing and treating complications. Today the overall risk of death from legal abortion is less than 1 per 100,000 operations.11 By comparison, the risk of death from hysterectomy is about 100 times higher.12 The mortality rate from legal abortion is less than that from an injection of penicillin.13 The technology of suction curettage abortion came to the United States from Russia and Eastern Europe.14 Change came quickly during the early years of legal abortion. Results from the Joint Program for the Study of Abortion (which was initiated by the Population Council and continued by the Centers for Disease Control and Prevention) and from other studies revolutionized abortion practice. Suction curettage proved to be faster and safer than traditional sharp curettage.4 Local anesthesia was found to be safer than general anesthesia.15 Paradoxically, abortions provided in freestanding clinics proved to be safer than those done in hospitals.16 Dilatation and evacuation abortion rapidly replaced labor induction as the most frequent means of secondtrimester abortion.1, 4 After this rapid modernization in the 1970s, however, progress slowed. Investigators explored early medical abortion with prostaglandins alone, but this approach proved unsatisfactory. Although prostaglandins could induce abortions at any gestational age, the resultant nausea, vomiting, and diarrhea were prohibitive. Thus surgical S1
S2 Grimes
abortion remained the only practical type of early abortion for a quarter century. Hence the notion of “choice” in early abortion has meant “no choice” of method. Many have complained that the technology of surgical abortion is intrusive. The provision of abortion services has remained centralized and controlled by physicians.17 Access to service has become increasingly difficult, particularly for women in rural America.18 Medical abortion has now opened a new era in fertility control, and the pace of research has again accelerated. Frustration regarding the lack of availability of mifepristone for abortion in the United States led to the exploration of methotrexate as an alternative. Numerous studies have confirmed the favorable results originally reported by Creinin and Darney.19 A voluminous literature now documents the safety and efficacy of mifepristone abortion regimens.20 Another byproduct of medical abortion research has been interest in the therapeutic uses of misoprostol as an adjunct to abortion. For cervical dilatation before suction curettage vaginal administration of misoprostol works better than does oral administration. The dilatation achieved rivals that with Laminaria used for several hours.21, 22 Early medical abortion represents an important new technology.8 These regimens offer the prospect of a more private, less intrusive form of abortion that is both safe and effective. Because of the simplicity more providers may offer this type of abortion than currently provide surgical abortions. If so, access to care may improve. As described in this symposium, medical approaches will make “choice” of an early abortion method a reality, rather than an empty promise. REFERENCES
1. Koonin LM, Strauss LT, Chrisman CE, Montalbano MA, Bartlett LA, Smith JC. Abortion surveillance—United States, 1996. MMWR Morb Mortal Wkly Rep 1999;48(SS-4):1-42. 2. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24-9, 46.
August 2000 Am J Obstet Gynecol
3. Cates W Jr. Legal abortion: the public health record. Science 1982;215:1586-90. 4. Anonymous. Induced termination of pregnancy before and after Roe v Wade. Trends in the mortality and morbidity of women. Council on Scientific Affairs, American Medical Association. JAMA 1992;268:3231-9.. 5. Polgar S, Fried ES. The bad old days: clandestine abortions among the poor in New York City before liberalization of the abortion law. Fam Plann Perspect 1976;8:125-7. 6. Stewart GK, Hance F. Legal abortion: influences upon mortality, morbidity and population. Adv Plan Parent 1974;9:1-7. 7. Binkin N, Gold J, Cates W Jr. Illegal-abortion deaths in the United States: why are they still occurring? Fam Plann Perspect 1982;14:163-7. 8. World Health Organization. Medical methods for termination of pregnancy. Geneva: The World Health Organization; 1997. 9. Bernstein PS, Rosenfield A. Abortion and maternal health. Int J Gynaecol Obstet 1998;63 Suppl 1:S115-22. 10. Stephenson P, Wagner M, Badea M, Serbanescu F. Commentary: the public health consequences of restricted induced abortion— lessons from Romania. Am J Public Health 1992;82:1328-31. 11. Lawson HW, Frye A, Atrash HK, Smith JC, Shulman HB, Ramick M. Abortion mortality, United States, 1972 through 1987. Am J Obstet Gynecol 1994;171:1365-72. 12. Wingo PA, Huezo CM, Rubin GL, Ory HW, Peterson HB. The mortality risk associated with hysterectomy. Am J Obstet Gynecol 1985;152:803-8. 13. Rudolph AH, Price EV. Penicillin reactions among patients in venereal disease clinics: a national survey. JAMA 1973;223:499501. 14. Kerslake D, Casey D. Abortion induced by means of the uterine aspirator. Obstet Gynecol 1967;30:35-45. 15. Peterson HB, Grimes DA, Cates W Jr, Rubin GL. Comparative risk of death from induced abortion at ≤12 weeks’ gestation performed with local versus general anesthesia. Am J Obstet Gynecol 1981;141:763-8. 16. Grimes DA, Cates W Jr, Selik RM. Abortion facilities and the risk of death. Fam Plann Perspect 1981;13:30-2. 17. Winikoff B. Acceptability of medical abortion in early pregnancy. Fam Plann Perspect 1995;27:142-8, 185. 18. Henshaw SK. Abortion incidence and services in the United States, 1995-1996. Fam Plann Perspect 1998;30:263-70, 287. 19. Creinin MD, Darney PD. Methotrexate and misoprostol for early abortion. Contraception 1993;48:339-48. 20. Grimes DA. Medical abortion in early pregnancy: a review of the evidence. Obstet Gynecol 1997;89:790-6. 21. Singh K, Fong YF, Prasad RN, Dong F. Randomized trial to determine optimal dose of vaginal misoprostol for preabortion cervical priming. Obstet Gynecol 1998;92:795-8. 22. MacIsaac L, Grossman D, Balistreri E, Darney P. A randomized controlled trial of Laminaria, oral misoprostol, and vaginal misoprostol before abortion. Obstet Gynecol 1999;93:766-70.