Elective termination of pregnancy remains common in the United States and worldwide, and controversy and debate are ongoing.
Accurate statistics have been kept since the enactment of the 1973 US Supreme Court decisions legalizing abortions. Note the following:
Since the 1973 decision, approximately 1.3-1.4 million abortions have been performed annually in the United States.
Abortion is one of the most common medical procedures performed in the United States each year.
Medical termination of pregnancy with mifepristone was approved in the United States in 2000 and is used in 31 countries worldwide. Approximately half of all abortions are performed with this method.
More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives. Based on estimated lifetime risk, each American woman is expected to have 3.2 pregnancies, of which 2 will be a live birth, 0.7 will be an induced abortion, and 0.5 will be a miscarriage. Using 1996 data, this translates into 3.89 million live births, 1.37 million abortions, and 0.98 million miscarriages.
The pregnancy-associated mortality rate in the United States from 1998-2005 among women who delivered live neonates was 8.8 deaths per 100,000 live births. The mortality rate related to induced abortion was 0.6 deaths per 100,000 abortions. The risk of death associated with childbirth is approximately 14 times higher than that with abortion, and overall morbidity associated with childbirth exceeds that with abortion.
Worldwide, some 20-30 million legal abortions are performed annually, with another 10-20 million abortions performed illegally (see The Alan Guttmacher Institute). Illegal abortions are unsafe and account for 13% of all maternal mortality and serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
Statistic reporting in the United States is from the Centers for Disease Control and Prevention (CDC). The Alan Guttmacher Institute (AGI) is a private organization that is not subject to the reporting limitations of state health departments. AGI contacts abortion providers directly and provides abortion data every 4-5 years. A previous report documented a discrepancy of approximately 12% between statistical figures presented by the CDC compared with those of AGI (the latter generally having higher estimates).
In spite of the introduction of newer, more effective, and more widely available contraceptive methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these pregnancies, approximately half end in elective terminations.
Each year in the United States, almost 3% of all reproductive-aged women terminate their pregnancies. While women of every social class seek terminations, the typical woman who terminates her pregnancy is young, white, unmarried, and poor.
Among practicing obstetricians and gynecologists in the United States, 97% encountered patients seeking abortions, whereas only 14% performed them.
Access to abortion was particularly limited in rural communities and in the South and Midwest.
Legalization of abortion
Termination of pregnancy has been practiced since ancient times and by all cultures. The indications and social context for termination of pregnancy vary with culture and time.
The use of abortion to preserve the life of the mother has been widely accepted. Early Jewish scholars’ interpretation of the Talmud required that the fetus be destroyed if it posed a threat to the mother during delivery. The ancient Greeks allowed abortion under certain circumstances. The ancient Romans did not consider a fetus a person until after birth, and abortion was practiced widely. Early Christians had varying practices regarding abortion. By 1869, the Catholic Church declared abortion a sin punishable by excommunication.
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of some medical personnel.
Since the landmark 1973 US Supreme Court decision legalizing abortion, hundreds of laws, federal and state, have been proposed or passed, making this the most actively litigated and highly publicized area in the field of medicine. Many of these laws are enjoined by court order and are thus not enforceable. They span a variety of controversial rulings, including provisions to establish viability before termination, parental or spousal notification, mandatory waiting periods, mandatory wording for counseling sessions, denial of public funding, denial of public funds for counseling (gag orders), targeted regulations specific to abortion providers, and provisions against specific abortion techniques.
Laws in several states mandate the examination of fetal tissue removed at the time of surgical abortion; how these laws will apply to medical abortions remains unclear. Because virtually all the laws regulating abortions were written before the legalization of medical abortions, some of these laws, such as the fetal tissue examination statutes, may be non sequiturs. Laws in some states criminalize these procedures, and performing a specific abortion constitutes a felony offense by the provider. Thirty-one states have forced parental consent or notification. Nine state courts block these laws. Thirty-one states ban abortion coverage for low-income women, and 19 states pay for abortion for low-income women.
In the context of international laws, restrictive regulations and laws do more to increase the morbidity and mortality associated with abortions and do not present alternatives to obtaining abortions. In states where the laws are very restrictive, a trend exists toward delaying abortion procedures until later gestational ages, which makes access to care harder to achieve and actually increases medical risk unnecessarily.
The abortion debate
Advances in neonatal medicine leading to improved fetal survival very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on the beginning of life.
Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments has kept the debate both vocal and contentious. These potential therapies may be indicated in the treatment of diabetes, Parkinson disease, kidney disease, and cartilage diseases, among others.
Current national regulations prohibit most fetal tissue research, but the National Institute of Health revealed late in the year 2000 that it would allow stem cell research. In June 2002, however, President Bush enacted a law restricting stem cell research to only preexisting cell lines and embryos “left over” from in vitro fertilization procedures.
Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface. The American Congress of Obstetrics and Gynecology specifically has a policy against the use of sex determination for the expressed purpose of selectively terminating female children.
Before Roe v Wade
Before the 19th century, most US states had no specific abortion laws. The provisions of British common law took precedence, and women had the right to terminate a pregnancy prior to viability. The first antiabortion legislation appeared in the 1820s; the preservation of pregnant women’s health was the motivating force. Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion. During this time, the mortality rate from abortion was high, while the mortality rate from childbirth was less than 3%. By 1900, abortion in the United States at any time during pregnancy was a crime, with the exception of therapeutic abortion performed to save the mother’s life.
The first US federal law on the subject was the notorious Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception to suppress the circulation of “obscene” materials. From 1900 until the 1960s, abortions were prohibited by law. During the 1950s, the practice of medicine came under increasing scrutiny, and guidelines were set to define the indications for therapeutic abortion. The guidelines allowed therapeutic abortion if (1) pregnancy would “gravely impair the physical and mental health of the mother,” (2) the child born was likely to have “grave physical and mental defects,” or (3) the pregnancy was the result of rape or incest.
Prior to the 1960s, an estimated 9 of 10 out-of-wedlock pregnancies were electively aborted. These procedures were performed in a variety of medical and lay settings, and almost 20% of all pregnancy-related complications were due to illegal abortions (Kinsey). Public and clinician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and assured their right to autonomy in this process. No decision was more important than Griswold v Connecticut in 1965, which recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain contraceptives from their provider.
Roe v Wade
Roe v Wade was the culmination of the work of a wide consortium of individuals and groups who collectively crafted a strategy to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL). Lawyers were committed to expediting universal access to rights at a time when states were slowly liberalizing pertinent laws. Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff “Jane Roe.” Although the ruling came too late for McCorvey’s abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
In 1973, the Roe vs Wade law, in the opinion written by US Supreme Court judge Harry Blackmun (appointed by Richard Nixon), the court ruled that a woman had a right to induced abortion during the first 2 trimesters of pregnancy. He cited the safety of the procedures and the fundamental right of women to be free from the states’ legislation concerning this inherently medical decision in the first trimester of pregnancy.
Blackmun sidestepped the question of viability of the pregnancy, specifically stating that scholars in many respected disciplines could not resolve this issue. Therefore, he felt that the court need not resolve this either. Since this ruling, the states have regained much control, and serious restrictions have been placed on abortion services. The Hyde amendment in 1976 prohibited the use of federal funds for abortions, except in the case of maternal life endangerment. Since then, an estimated one third of public funding recipients cannot obtain an abortion because of inability to pay for the service.
Loosely defined, the term viability is the fetus’ ability to survive extrauterine life with or without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri’s requirement for preabortion viability testing after 20 weeks’ gestation. However, there are no reliable or medically acceptable tests for this prior to 28 weeks’ gestation.
The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (eg, anencephaly). In Colautti v Franklin, the court overturned a Pennsylvania law requiring physicians to follow specific directives in certain medical circumstances and recognized physician judgment as sacrosanct and important.
Parental consent is not required in the case of carrying a pregnancy to term, seeking contraception, or being treated for a variety of conditions, including sexually transmitted diseases. In 2 decisions handed down in 1991, Hodgson v Minnesota and Ohio v Akron Center for Reproductive Health, the US Supreme Court held that it is legal to have parental notification laws for abortions. These provisions often include waiting periods and fairly limited provisions for judicial bypass. On February 12, 2002, the West Virginia Senate Health and Human Resources Committee passed a bill requiring women seeking an abortion to give informed consent and wait for at least 24 hours before undergoing the abortion procedure. Specifically, the women must be furnished with written material, printed by the state, that would outline alternatives to abortion and the potential risks of the procedure.
On February 21, 2002, the Kentucky Senate passed 2 abortion-related bills. Kentucky SB 151 makes the existing consent laws more rigorous by requiring a woman to meet with a provider in person to receive preabortion counseling. Given that women must travel to access services, these laws quickly become restrictive for low-income care recipients.
Sociologic research shows that a good portion of minors (persons < 18 y) do involve their parents in their decision to abort (45%). However, these laws have fostered a new ominous trend, ie, minors obtaining abortions significantly later in their pregnancies and often traveling great distances to states with no such law.
By 1999, 38 states had such laws, and 29 states enforce their laws. Currently, only Connecticut, Maine, and the District of Columbia have laws that affirm the rights of a minor to seek her own abortion. For a summary of laws, see Minors’ Right to Consent to Health Care and to Make Other Important Decisions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents who may travel hundreds of miles to seek an abortion.
Parental consent is not required in the case of carrying a pregnancy to term, seeking contraception, or being treated for a variety of conditions, including sexually transmitted diseases. In 2 decisions handed down in 1991, Hodgson v Minnesota and Ohio v Akron Center for Reproductive Health, the US Supreme Court held that it is legal to have parental notification laws for abortions. These provisions often include waiting periods and fairly limited provisions for judicial bypass.
Mandatory waiting periods
Mandatory waiting periods mandate by law that the woman seeking to terminate a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives anywhere from 24 to 72 hours prior to her procedure.
These laws have the effect of increasing the percentage of second-trimester abortions in states with these laws. Given that women must travel long distances to access services, these laws quickly become restrictive for low-income care recipients.
State-developed counseling materials
A variety of state-developed counseling materials have come into use across the United States. These counseling materials may include falsified information such as suggesting an increased risk of breast cancer for women who have had an abortion, although a 2003 National Cancer Institute census report found no such link. Other states have developed unfounded and unreferenced materials on topics such as fetal pain, the psychological effects of abortion, and coercion.
Although only 2% of the population verbalizes opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.
By 1998, 28 states had passed bans on this procedure, referred to in the lay press as a partial-birth abortion, which is the medical procedure intact dilatation and extraction. The descriptive language in the US Criminal Code defines “partial-birth abortion” as “partially vaginally delivering a living fetus before killing the fetus and completing the delivery.” This delineation is so overly broad that both legal and expert gynecologic testimony claim this definition encompasses virtually all methods of second-trimester abortion, including dilation and extraction and inductions.
In 19 US states, laws have banned these procedures; in only 8 US states are these laws enforced. In his first administration, US President Clinton vetoed 2 bills banning such abortions. The US Supreme Court ruled on June 28, 2000 that the Nebraska law and all other laws banning partial-birth abortion are unconstitutional. The reasons for the US Supreme Court’s decision was that the Nebraska law did not contain an exception to protect the health of the mother, and the law was also thought to “unduly burden” a woman’s choice to end her own pregnancy.
Similarly, in Stenberg v Carhart, the US Supreme Court struck down Nebraska’s ban on late-term abortions for the same reason, ie, because it may be necessary if a woman’s life is in danger. However, the US Department of Justice states the Ohio ban is constitutional because it includes the provisions set up by the US Supreme Court in Stenberg v Carhart.
Eroding abortion rights
Although the fundamental right to have an abortion has remained intact by basic statute, poor women have had their rights eroded by the Hyde amendment in 1976 that prohibited the use of federal funds for abortions except in the case of maternal life endangerment. This, in conjunction with a rise in the takeover of hospitals in some regions by religious organizations opposed to abortion and contraception, has restricted access to abortion. Almost one third of publicly funded recipients are prevented from having a termination by lack of access to care. Public controversy has raged on the specific question of whether individuals or institutions should be allowed to refuse medical care. Although 45 states have enacted laws allowing such refusal, only 5 have also enacted laws that require the provider to notify patients of their refusal. These provisions extend to contraceptive and sterilization services.
Providers of elective induced abortions are generally obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers—physicians, physician assistants, midwives, and nurse practitioners—to perform these procedures. Various factors over the years have influenced the number of providers.
Abortion is the only common surgical procedure that is elective in obstetric and gynecologic residencies. Thus, few board-certified gynecologists are actually qualified to perform the procedure. Increasing violence against providers and clinics has further decreased providers’ willingness to provide abortion services. A “graying” has occurred in providers who continue to perform abortions. Most represent an older population of clinicians who became committed to providing access to safe, legal abortions after caring for young women who experienced morbidity or died from complications of an illegal abortion. The lack of abortion providers is underscored by the fact that 86% of counties in the United States have no abortion services.
New York City’s former mayor, Michael Bloomberg, proposed a policy that would include abortion training for medical residents in all 11 of the city’s hospitals. It has been shown that the availability and type of abortion training is independently associated with abortion procedural experience.
The number of abortion providers in the United States has declined because of the aging population of providers and the lack of training during residency.
Students, of course, are able to opt out of the training if they are morally opposed to abortion.
Medical abortion protocols have the potential to expand the number of available providers because arranging for backup with a provider who can perform a surgical abortion is necessary, while having a staff willing to assist at a surgical abortion is not necessary. The role of nurse practitioners, with valid prescription privileges, is unclear at the present time, but these providers may also aid in expanding abortion access.
The US Food and Drug Administration (FDA) has recently approved mifepristone (Mifeprex), also known as RU-486, for medical abortions. Multiple regimens for medical terminations using medications approved by the FDA for indications other than termination of pregnancy have come into use. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination. This may be difficult to track statistically but may actually lead to an increased number of abortions in the United States.
Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (eg, family practitioners, nurses) can be taught to perform abortions safely. Physicians are generally receptive to the concept of legal abortions being available in the United States. Epidemiologic research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.
Keeping abortions safe, legal, and rare are the goals of abortion providers. For information from physicians regarding these goals, see Physicians for Reproductive Choice and Health.
As providers have decreased in number, women are traveling farther to obtain abortions, presenting later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.
Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.
A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.
An understanding of the laws (enacted, enjoined, and pending) on local and federal levels is important to providers, and these legal ramifications are also reviewed in this article.
Abortion postoperative care is often provided at sites where the abortion was not performed, and strategies for follow-up care for women whose pregnancies have been terminated are important for all providers of primary care for women.
The ability to define therapeutic abortion performed for maternal indications is difficult because of the subjective nature of decisions made about potential morbidity and mortality in pregnant women. A variety of medical conditions in pregnant women have the potential to affect health and cause complications that may be life threatening.
Prenatal screening in the form of prenatal diagnostic testing continues to improve the antepartum diagnosis of fetal anomalies. The decision to continue or terminate a pregnancy complicated by fetal anomalies is a difficult decision. The most difficult decisions are associated with anomalies that are unpredictable or highly variable in their expression.
The increase in the use of assisted reproductive technologies has been associated with an enormous increase in multifetal pregnancies. Twins have increased in frequency from 1 set per 90 pregnancies to 1 set per 45 pregnancies. Higher-order multifetal pregnancies have quadrupled in the past 20 years. These pregnancies are complicated by increased fetal morbidity and mortality rates, which are largely caused by prematurity and growth retardation. Selective reduction has been introduced as a technology to improve perinatal outcomes in these pregnancies and has been successful in reducing preterm deliveries and associated perinatal morbidity and mortality.
Indications for pregnancy termination
There are medical factors both maternal and fetal that contribute to the decision. These factors have been termed therapeutic abortion, defined as the termination of pregnancy for medical indications, including the following:
Medical illness in the mother in which continuation of the pregnancy has the potential to threaten the life or health of the mother is a factor. The maternal medical condition and a reasonable prediction of future circumstances as well as the consequences of the pregnancy as it progresses must be considered.
The total incidence of malignancy during pregnancy is estimated at 1 case per 1000 pregnancies. The most common cancers found in pregnant women mirror those found in their nonpregnant counterparts, to include the following:
Cervical cancer (1 case per 2200 pregnancies)
Breast cancer (1 case per 3000 pregnancies)
Melanoma (0.14-2.8 cases per 1000 pregnancies)
Colorectal carcinoma (0.10-1.0 cases per 1000 pregnancies)
Rape or incest and fetal anomalies when pregnancy outcome is likely to be birth of a child with significant mental or physical defects or high likelihood of intrauterine or neonatal death are also considered.
Approximately 3-5% of all newborns have a recognizable birth defect. According to Cunningham and MacDonald,
the suggested causes of fetal anomalies are as follows:
Genetic (ie, chromosomal) (20-25%)
Fetal infections (3-5%)
Maternal disease (4%)
Drugs/medications (< 1%)
The data that indicate increased maternal risk from fetal demise primarily date from the preultrasonography era, when prolonged retained products of conception put the patient at risk of coagulopathies. Current management thus centers on prompt diagnosis and uterine evacuation, particularly in the second trimester.