What is Abortion?
Abortion is the removal or expulsion of an embryo or fetus from a pregnant woman. A miscarriage, also known as a “spontaneous abortion,” is a spontaneous abortion that happens in around 30 percent to 40 percent of pregnancies. An induced abortion, or less often “induced miscarriage,” is when deliberate measures are taken to end a pregnancy. The term “abortion” in its original form refers to an induced abortion.
Abortion is one of the safest medical procedures when performed properly, but unsafe abortion is a leading cause of maternal mortality, especially in developed countries, while making safe abortion legal and affordable decreases maternal deaths.
Induced abortions do not raise the risk of long-term mental or physical problems when done lawfully and professionally on a woman who wants it. Unsafe abortions, on the other hand, result in 47,000 deaths and 5 million hospitalizations per year. They are performed by untrained people, using dangerous devices, or in unsanitary facilities. “Access to lawful, secure, and adequate abortion services, including post-abortion treatment,” according to the World Health Organization, is “necessary for achieving the highest possible level of sexual and reproductive health.”
According to the World Health Organization, about 56 million abortions are performed worldwide each year, with around 45 percent being performed in an inappropriate manner. Abortion rates changed little between 2003 and 2008, before which they decreased for at least two decades as access to family planning and birth control increased. As of 2018, 37 percent of women around the world had unrestricted access to medical abortions.
Abortions have been performed in the past through the use of herbal remedies, sharp instruments, forceful massage, and other conventional techniques. Around the globe, abortion policies and cultural or theological beliefs on abortion vary. In certain countries, abortion is only legal in some circumstances, such as rape, fetus complications, poverty, danger to a woman’s life, or incest. The religious, ethical, and legal questions around abortion are hotly debated. Opponents of abortion also contend that an embryo or fetus is a human being with a right to life, and compare abortion to murder. Supporters of abortion legalization also argue that it is a woman’s right to make choices about her own body. Others advocate for abortion to be lawful and affordable as a public health measure.
Types of Abortion
Abortion can be classified into two main categories which are:
- Induced abortion; and
- Spontaneous abortion
Induced Abortion
Induced abortion is defined by the Fédération Internationale de Gynécologie et d’Obstétrique (International Federation of Gynecology and Obstetrics) (FIGO) Ethics Committee as the termination of pregnancy using drugs or surgical intervention after implantation and before the embryo or fetus has become independently viable.
Per year, about 205 million pregnancies occur around the world. About a third of pregnancies was accidental, and over a quarter of those result in induced abortion. The majority of abortions are caused by unplanned pregnancy. A pregnancy may be terminated in a variety of ways. The method used is often determined by the embryo’s or fetus’ gestational age, which grows in size as the pregnancy continues. Legality, regional availability, and a doctor’s or a woman’s personal choice can all influence which procedures are chosen.
Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. When an abortion is performed to save the pregnant woman’s life, to prevent harm to the woman’s physical or mental health, to terminate a pregnancy where there are indications that the child may have a significantly increased risk of mortality or morbidity, or to selectively reduce the number of fetuses to reduce health risks associated with a pregnancy, it is referred to as a therapeutic abortion. When an abortion is done at the behest of the mother for non-medical purposes, it is referred to as an elective or voluntary abortion. Confusion sometimes arises over the term “elective” because “elective surgery” generally refers to all scheduled surgery, whether medically necessary or not.
Spontaneous Abortion
Miscarriage, also known as spontaneous abortion, occurs when an embryo or fetus is unintentionally expelled before the 24th week of pregnancy. A “premature birth” or “preterm birth” is a pregnancy that ends before 37 weeks of conception and results in a live-born child. “Stillborn” refers to a fetus that dies in utero after viability or after childbirth. Premature pregnancies and stillbirths are usually not called miscarriages, but the terms are often used interchangeably.
Just 30 to 50 percent of pregnancies make it through the first trimester. Many pregnancies are lost before medical personnel can locate an embryo, and the great majority of those who do not develop are lost before the mother is aware of the pregnancy. Depending on the age and condition of the pregnant mother, between 15% and 30% of known pregnancies result in clinically noticeable miscarriage. In the first trimester, 80 percent of spontaneous abortions occur.
Chromosomal defects in the embryo or fetus are the most frequent cause of spontaneous abortion during the first trimester, responsible for at least half of all early pregnancy losses sampled. Vascular disorder (such as lupus), diabetes, other hormonal issues, infection, and uterine anomalies are among the other factors. The two main factors linked to a higher risk of spontaneous abortion are maternal age and a woman’s history of prior spontaneous abortions. Accidental trauma may cause a spontaneous abortion; deliberate trauma or stress to cause miscarriage is referred to as induced abortion or feticide.
Methods Used in Elective Abortion
Depending on the duration of the pregnancy, expertise of the medical practitioner and/or the choice of the women seeking an elective abortion, the following methods are commonly used.
- Medical abortion
- Surgical method; and
- Labour induced abortion
Medical Abortion
Abortions triggered by abortifacient pharmaceuticals are known as medical abortions. With the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486) in the 1980s, medical abortion became an alternative form of abortion.
Mifepristone in conjunction with misoprostol (or sometimes another prostaglandin analog, gemeprost) up to 10 weeks (70 days) gestational duration, methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone are the most typical early first-trimester medical termination regimens. Mifepristone–misoprostol combination regimens are more efficient than methotrexate–misoprostol combination regimens at later gestational periods, and combination regimens are more effective than misoprostol alone. In the second trimester, this regimen is effective. When done before 70 days’ gestation, medical abortion regimens containing mifepristone accompanied by misoprostol in the cheek between 24 and 48 hours later are effective.
Medical abortion with a mifepristone–misoprostol combination regimen is thought to be more effective than surgical abortion (vacuum aspiration) in very early abortions, up to 7 weeks gestation, particularly where clinical procedure does not involve detailed examination of aspirated tissue. Up to 9 weeks gestational age, early medical abortion regimens using mifepristone accompanied by buccal or vaginal misoprostol are 98 percent effective; from 9 to 10 weeks, effectiveness drops to 94 percent. If medical abortion fails, the procedure must be completed by surgical abortion.
Surgical Method
The most common surgical methods of induced abortion up to 15 weeks of pregnancy are suction-aspiration or vacuum aspiration. In manual vacuum aspiration (MVA), the fetus or embryo, placenta, and membranes are suctioned out with a manual syringe, while in electric vacuum aspiration, an electric vacuum pump is used (EVA). Both of these methods should be used very early in pregnancy. MVA is effective for up to 14 weeks.
MVA, also known as “mini-suction” and “menstrual extraction” or EVA, is a procedure that can be performed in the early stages of pregnancy without the need for cervical dilation. To open the cervix (dilation) and extract tissue, the words dilation and curettage (D&C) and suction or sharp instruments are used (curettage). D&C is a popular gynecological procedure that is used for a variety of reasons, including cancer screening of the uterine lining, examination of unexplained bleeding, and abortion. The World Health Organization only recommends sharp curettage where suction aspiration is not feasible.
Dilation and evacuation (D&E) is a procedure that entails opening the cervix and clearing the uterus with surgical instruments and suction after 12 to 16 weeks. D&E is a vaginal operation without the need for an incision. Intact dilation and extraction (D&X) is a variant of D&E that is often used after 18 to 20 weeks when extracting an intact fetus improves surgical protection or for other purposes.
An abortion can also be performed surgically using a hysterotomy or gravid hysterectomy. A hysterotomy abortion is a procedure identical to a caesarean section that is performed under general anesthesia. It requires a smaller incision than a caesarean section, and can be done later in pregnancy. A “gravid hysterectomy” is where the entire uterus is removed while the pregnancy is still contained. In comparison to D&E or induction abortion, hysterotomy and hysterectomy have considerably higher maternal morbidity and death rates.
Procedures performed in the first trimester are normally performed under local anesthesia, while procedures performed in the second trimester may require deep sedation or general anesthesia.
Labor Induction Abortion
In areas where surgical ability for dilation and evacuation is unavailable, or where doctors choose, an abortion will be performed by first inducing labour and then, if possible, inducing fetal death. This is referred to as a “induced miscarriage” on occasion. This operation can be done somewhere between 13 weeks and the third trimester of pregnancy.
Safety Concerns Associated with Induced Abortion
The health risks of abortion are largely determined by whether the operation is carried out safely or not. The World Health Organization (WHO) defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities. Legal abortions performed in the developed world are among the safest procedures in medicine.
The risk of death from abortion rises with gestational age, but it is still lower than the risk of death from childbirth. For 64 to 70 days of pregnancy, outpatient abortion is just as safe as it was until 63 days.
In early first trimester abortions up to 10 weeks gestation, there is no distinction in terms of safety and effectiveness between medical abortion using a combination regimen of mifepristone and misoprostol and surgical abortion (vacuum aspiration). Medical abortion with the prostaglandin analog misoprostol alone is less safe and painful than medical abortion with mifepristone and misoprostol together or surgical abortion.
The safest method of surgical abortion is vacuum aspiration in the first trimester, which can be done in a primary care office, an abortion clinic, or a hospital. Uterine perforation, pelvic infection, and retained products of conception, which require a second procedure to remove, are also unusual complications. Infections are responsible for one-third of all abortion-related deaths. If the procedure is performed in a hospital, surgical facility, or office, the incidence of complications associated with vacuum aspiration abortion in the first trimester is similar. Antibiotics (such as doxycycline or metronidazole) are often offered before abortion procedures to decrease the chance of uterine infection after the procedure; however, antibiotics are not regularly given with abortion pills. If the abortion is done by a specialist or a mid-level practitioner, the incidence of botched operations does not seem to differ substantially.
Second-trimester abortion complications are similar to first-trimester abortion complications, although they vary depending on the procedure used. The risk of death from abortion falls to about half that of childbirth as a woman’s pregnancy progresses, from one in a million before 9 weeks to almost one in ten thousand at 21 weeks or more (as measured from the last menstrual period). It seems that previous surgical uterine evacuation (whether for induced abortion or miscarriage treatment) is associated with a minor rise in the probability of preterm birth in subsequent pregnancies.
Abortion and Mental health
According to current research, there is no connection between most induced abortions and mental health issues other than those that would be expected from any unwanted pregnancy. According to an American Psychological Association study, a woman’s first abortion is not harmful to her mental wellbeing when performed in the first trimester, with those women having no more mental-health issues than those who bring an unwanted pregnancy to term; however, the mental-health effect of a woman’s second or subsequent abortion is less clear. Some older studies found a link between abortion and an increased risk of psychological problems.
While some studies suggest that women who choose abortions after the first trimester due to fetal anomalies have poor mental health consequences, further comprehensive research is required to prove this conclusively. Anti-abortion activists have used the term “post-abortion syndrome” to describe some of the alleged damaging psychological consequences of abortion.
Five years after having an abortion, almost 99 percent of women in a long-term survey of US women thought they had made the correct decision. The most common emotion was relief, with few women experiencing sorrow or remorse.
Unsafe Abortion
Women seeking abortions can resort to unsafe methods, particularly when it is prohibited by law. They can try to self-induce abortion or obtain assistance from someone who lacks medical training or facilities. This can result in serious complications such as an incomplete abortion, sepsis, hemorrhage, and organ injury.
Abortion is a leading cause of injuries and death for women all over the world. Despite the lack of detailed statistics, it is estimated that nearly 20 million illegal abortions occur per year, with 97 percent occurring in developed countries. Millions of people are thought to have been injured as a result of unsafe abortions. Estimates of deaths have ranged from 37,000 to 70,000 in the last decade, depending on methodology; unsafe abortion deaths account for about 13% of all maternal deaths.
Public health groups have typically supported legalizing abortion, training healthcare professionals, and providing access to reproductive-health care to decrease the number of unsafe abortions. Opponents to abortion argue that abortion restrictions have little effect on prenatal healthcare for women who chose to bear their child to term. According to the Dublin Declaration on Maternal Health, which was signed in 2012,”the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women.”
The legal status of abortion is a significant determinant of whether or not abortions are performed safely. As compared to countries where abortion is legal and affordable, countries with stricter abortion laws have higher rates of unsafe abortion and similar total abortion rates. The legalizing of abortion in South Africa in 1996, for example, had an immediate positive effect on the prevalence of abortion-related complications, with abortion-related deaths down by more than 90%. Other nations, such as Romania and Nepal, have seen similar decreases in maternal mortality since liberalizing their abortion laws. According to a 2011 survey, anti-abortion laws at the state level in the United States are linked to reduced abortion rates in that state. However, the study did not account for abortions obtained in jurisdictions where those rules do not exist. Furthermore, the lack of adequate contraception leads to unsafe abortion. If current family planning and reproductive health systems were widely available around the world, the rate of unsafe abortion could be decreased by up to 75% (from 20 million to 5 million each year). Since such abortions can be reported as miscarriage, “induced miscarriage,” “menstrual regulation,” “mini-abortion,” and “regulation of a delayed/suspended menstruation,” rates of such abortions can be difficult to calculate.
Within gestational limits, 40% of the world’s women have access to therapeutic and elective abortions, while another 35% have legal abortion whether they fulfill some physical, mental, or socioeconomic requirements. Though safe abortions rarely result in maternal mortality, unsafe abortions cause 70,000 deaths and 5 million disabilities per year. Unsafe abortion complications account for around an eighth of maternal deaths worldwide, though this varies by country. An approximate 24 million women suffer from secondary infertility as a result of an unsafe abortion. Around 1995 and 2008, the percentage of unsafe abortions rose from 44% to 49%. To counter this problem, health education, access to family planning, and reforms in health care during and after abortion have been proposed.
Common Reasons why Women go for Elective Abortion
Personal Reasons
Women have abortions for a variety of reasons, which differ from country to country. Inability to afford a child, domestic abuse, a lack of resources, a belief that they are too young, and a need to complete schooling or advance a career are all possible factors. Other causes include the inability or unwillingness to raise a baby born as a result of rape or incest.
Societal Factors
Many abortions are carried out due to social factors. This may include preferences for children of a certain gender or ethnicity, stigmatization of persons with disabilities, inadequate economic resources for families, lack of access to or denial of contraception methods, or population reduction measures (such as China’s one-child policy). Compulsory abortion or sex-selective abortion may occur as a result of these factors.
Maternal and Fetal Health
Abortion is also considered when the health of the mother or the child is at risk. When it is medically proven that the outcome of the pregnancy will lead to unfavorable outcome if allowed to progress. An additional factor is maternal health which was listed as the main reason by about a third of women in 3 of 27 countries and about 7% of women in a further 7 of these 27 countries.
In the U.S., the Supreme Court decisions in Roe v. Wade and Doe v. 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.
Occurrence of Certain Cancers
Cancer occurs at a rate of 0.02–1% during pregnancy, and in certain instances, the mother’s cancer contributes to the possibility of termination to preserve the mother’s health or to avoid any harm to the child during treatment. This is especially true for cervical cancer, which affects one out of every 2,000–13,000 pregnancies and for which treatment “cannot coexist with fetal life preservation (unless neoadjuvant chemotherapy is chosen).” Cervical cancers in the early stages (I and IIa) can be treated with a radical hysterectomy and pelvic lymph node dissection, radiation therapy, or a combination of the two, while cervical cancers in the latter stages are treated with radiotherapy. Chemotherapy may be used in conjunction with other treatments. Since lumpectomy is avoided in favour of adapted radical mastectomy unless the pregnancy is late-term and follow-up radiation therapy should be performed after the delivery, treatment of breast cancer after pregnancy often entails prenatal concerns.
The mother’s safety can also be jeopardized during the birthing period. “Vaginal delivery may result in neoplastic cell proliferation through lymphovascular pathways, haemorrhage, cervical laceration, and implantation of malignant cells in the episiotomy site, while abdominal delivery may prolong non-surgical treatment.”
History Background on Elective Abortion
Abortions have been performed using a variety of techniques since ancient times, including herbal remedies, sharp instruments, force, and other traditional means. Induced abortion has a long tradition that can be traced back to cultures as diverse as Shennong’s China (c. 2700 BCE), Ancient Egypt’s Ebers Papyrus (c. 1550 BCE), and Juvenal’s Roman Empire (c. 200 CE). A bas relief at Angkor Wat depicts one of the best known artistic depictions of abortion (c. 1150). It portrays the procedure of abdominal abortion and is part of a sequence of friezes that reflect judgement after death in Hindu and Buddhist culture.
Some medical historians and abortion opponents claim that the Hippocratic Oath prohibits Ancient Greek doctors from administering abortions; however, other scholars disagree, claiming that the Hippocratic Corpus medical texts contain examples of abortion procedures alongside the Oath. In 43 CE, the physician Scribonius Largus, like Soranus, wrote that the Hippocratic Oath forbids abortion, though not all doctors followed it strictly at the time. According to Soranus’ 1st or 2nd century CE work Gynaecology, one group of medical practitioners was willing to administer abortions only for the mother’s health, as prescribed by the Hippocratic Oath; the other group, to which he belongs, was willing to prescribe abortions only for the mother’s health. In his treatise on government politics (350 BCE), Aristotle rejects infanticide as a population management method. In those circumstances, he prefers abortion with the caveat that “it must be done before it has produced sensation and life; for the line between legal and illegal abortion would be marked by the reality of getting sensation and being alive.”
Before 1869, Pope Sixtus V (1585–90) was the first Pope to decree that abortion is homicide regardless of conception stage, and his declaration of 1588 was revoked three years later by his successor. The Catholic Church was divided for much of its existence over whether early abortion was murder, and it did not begin to actively oppose abortion until the 19th century. According to some historians, several Catholic scholars prior to the 19th century did not consider abortion to be the termination of a fetus until “quickening” or “ensoulment.” Excommunication became the penalty for abortions in 1750. The Catechism of the Catholic Church, a codified explanation of the Church’s doctrines, made statements against abortion in 1992.
In a 2014 Guttmacher poll of abortion patients in the United States, 24 percent said they were Catholic and 30 percent said they were Protestant. According to a 1995 poll, Catholic women are much like the rest of the country when it comes to terminating a pregnancy, whereas Protestants are less likely and Evangelical Christians are the least likely. The Islamic practice has historically allowed abortion before the soul reaches the fetus, which is thought to occur at conception, 40 days after conception, 120 days after conception, or quickening, according to different theologians. Abortion is, however, severely controlled or prohibited in places where Islam is highly practiced, such as the Middle East and North Africa.
Abortion methods advanced in Europe and North America beginning in the 17th century. However, most doctors’ aversion to discussing sexual issues has stifled the widespread adoption of legal abortion methods. Other medical practitioners, in addition to certain doctors, marketed their services, and the practice (also known as restellism) was not universally regulated until the 19th century, when it was outlawed in both the United States and the United Kingdom. Anti-abortion protests were heavily influenced by church leaders and doctors. According to some accounts, abortion was more risky than childbirth in the United States until about 1930, when gradual changes in abortion practices made abortion safer. Other accounts, on the other hand, claim that early abortions were comparatively safe in the 19th century under the sanitary conditions under which midwives typically served. Furthermore, despite changed medical practices, some observers have claimed that the time from the 1930s to legalization saw more zealous enforcement of anti-abortion rules, as well as an increase in organized crime regulation of abortion services.
The Soviet Union (1919), Iceland (1935), and Sweden (1938) were among the first countries to make abortion legal under any or all circumstances. In Nazi Germany, a law was passed in 1935 that allowed abortions for those that were branded “hereditarily ill,” but women of German stock were expressly barred from getting abortions. Abortion became legal in a growing number of countries in the second half of the twentieth century.
