Legalized Abortion and the Public Health Report of a Study (1975) / Chapter Skim
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3. Abortion and the Risk of Medical Complications
3. Abortion and the Risk of Medical Complications
Pages 47-71
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From page 47... ...
A brief review of the reports on long-term complications of legal abortion also is provided, largely based on foreign studies. Defining Medical Complications Data on medical complications associated with legal abortion are more difficult to assess and compare than are those on maternal mortality.
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From page 48... ...
Complication Rates Associated with Legal Abortion The lack of a consistent definition of "complication" makes it difficult to compare data on abortion-related complications collected by different investigators from different localities. Consequently, most of the findings reported in this chapter are drawn from the Joint Program for the Study of Abortion (JPSA)
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From page 49... ...
The JPSA study computed complication rates for total patients and for local patients with follow-up. Follow-up was defined as any contact with the woman 10 or more days after the abortion.
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From page 50... ...
"Induced Abortion: A Factbook," Reports on Population/Family Planning 14, December 1973.
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From page 51... ...
The risk of medical complications increases with the length of gestation, even within the first trimester. Women with pre-existing complications and women who underwent concurrent sterilization had substantially higher complication rates than did women who were subject only to the complications of the abortion procedure itself.
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From page 52... ...
Clinic physicians, who usually perform a higher number of abortions, may be more experienced than other physicians in performing abortions; and there may be less complete reporting of delayed complications for clinic patients than for those treated in hospitals. TABLE 9 Number and Complication Rates of Local Patients with Follow-up Who were Aborted by Suction, by Type of Facility Type of Complication Number of Patients a/ Perforation of uterus Other Injury Hemorrhage Pelvic infection Hemorrhage and Infection Fever only All other Hospital Inpatients 5,350 0.6 1.8 2.0 1.4 0.4 0.9 0.7 Type of Facility Hospital Outpatients 11,538 Rates per 100 women 0.3 1.2 1.2 1.1 0.3 0.4 1.0 Free-Standing Clinic Patients 6,968 0.2 0.2 0.6 0, 0.
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From page 53... ...
1971-1972 Type of Complication Rates per 100 Women Obtaining Abortions Suction D&C Perforation of uterus 0.0 0.6 Laceration of cervix 0.7 0.7 Complications of anesthesia 2.9 3.7 Heavy bleeding requiring agents to tighten the uterine walls a/ 3.9 6.0 Blood loss exceeding 300 ml b_/ -at abortion 1.9 3.3 - total first 48 hours 5.4 8.9 Post abortion bleeding - requiring treatment 9.6 10.0 - requiring hospitalization 1.5 1.9 Retention of tissue 0.9 1.3 Pelvic Infection or fever c_/ during hospitalization 2.0 1.6 -requiring readmission a/ 0.7 1.3 a/Statistically significant difference (P-.01) b/These data based on a subsample of 530 cases.
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From page 54... ...
The study concluded that hemorrhage from saline abortion can be markedly reduced if the placenta is removed within one hour after the fetus is delivered, and infection and fever can be reduced if the highest standards of asepsis are maintained.8/ Long-Term Complications Much concern and controversy have arisen over the potential long-term effects of legal abortion on the reproductive capabilities of women obtaining such abortions. Cervical incompetence, scar tissue from infection, or other trauma to the reproductive organs following abortion have been suggested as long-term complications which might result in subsequent spontaneous abortion or prematurity, in subsequent ectopic pregnancies, or infertility.
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From page 55... ...
The Task Force Report should be available in 1977.10/ Premature Births A review of much of the currently available data on the relationship between legal abortion and subsequent premature births indicates that many of the studies did not control for smoking, age of mother, overall maternal health, or socioeconomic status. Many of the studies also did not identify differences in the method of pregnancy termination or indicate whether prior abortions had been obtained illegally or in a medical setting.
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From page 56... ...
The frequency of premature births to women in the study was then examined for women who had had no previous abortions, previous induced abortions, previous spontaneous abortions, or a combination of the latter two types. Premature birth rates for women with previous abortions were found to be twice those of women without any abortions (17 percent of the total and eight percent of the total, respectively)
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From page 57... ...
The pregnancy-order differential is thus due to the known higher risk of prematurity among first-order births. Apparently induced abortion when it precedes such pregnancies neither increases this risk nor protects against it.17/ Spontaneous abortions A few studies have addressed independently the relationship between induced abortion and subsequent spontaneous second-trimester abortion.
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From page 58... ...
Those pregnancies ending in second-trimester spontaneous abortion are summarized below. Spontaneous Abortions Total Pregnancies Number Percent Group A (Prior 91 89 Induced abortion)
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From page 59... ...
Their data demonstrated only that there was an increasing risk of spontaneous abortion with older maternal age.2I/ Ectopic Pregnancies Existing data on the relationship between legal abortion and subsequent ectopic pregnancies are also limited but seem to suggest that no negative effects are likely to occur. This conclusion follows from a review of Eastern European literature by Emily Moore-Cavar22/ and from a controlled study conducted in Ljubljana, Yugoslavia.23/ In a study conducted in 1971 in Novi Sad, Yugoslavia, Beric and Kupresanin found that from 1960 to 1970, there was an increase in deliveries, an increase in legal abortions, a decrease in hospital admissions for "other" abortions (spontaneous and illegal)
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From page 60... ...
Even if data were developed with reasonable accuracy, they may not be relevant to the United States since the data base may be old, and may reflect medical complications arising from abortion methods such as hysterotomy, which are rarely used in the United States today.28/ Teenage Abortions and Long-Term Complications Teenage women constitute a special case, in that any pregnancy, be it terminated by abortion or by a full-term birth, seems to increase the risk of prematurity in subsequent pregnancies.23/ Russell reported on the first pregnancy outcome and subsequent reproductive history of 62 pregnant women under 16 whom he treated between January 1960 and December 1971. Fifty of these pregnancies were terminated by therapeutic abortion, 11 continued to term, and a single one ended in spontaneous abortion at 10 weeks gestation.
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From page 61... ...
The pregnancy order of women having the 53 subsequent pregnancies is not examined, although Russell provides anecdotal evidence that two women have had three and four spontaneous abortions, respectively, without being able to have a successful pregnancy.33/
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From page 62... ...
Perhaps recognizing these difficulties, Russell does not conclude a causal relationship between therapeutic abortion and subsequent reproductive difficulties. He cites the higher complication rates for teenagers undergoing full-term pregnancies (including subsequent prematurity, fetal deaths, and perinatal mortality)
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From page 63... ...
Illegal Abortion and Medical Complications In countries with laws that prohibit or greatly restrict legal abortion, induced abortions that are performed by physicians outside the strict limitations of the law, or those performed by non-medical personnel or by the woman herself are illegal. In the discussion below, illegal abortion is generally meant to refer only to those cases where abortion is performed by non-medical personnel or by the pregnant woman in a setting which is outside the formal health care system.
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From page 64... ...
The frequency of medical complications due to illegal abortions is difficult to determine. One measure that has been used is the number of hospital admissions due to incomplete or septic abortions.*
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From page 65... ...
642. Data from Brooklyn, Atlanta, Los Angeles and San Francisco also show that a decline in the number of hospital admissions for incomplete abortion is related to the growing availability of legal abortion, with its lower frequency of medical complications.
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From page 66... ...
The number of legal induced abortions at Grady Hospital during this period increased from 30 in all of 1969 to 498 in the first quarter of 1973.^9/ These data suggest that there may be a time lag in women's awareness of changed laws, and that both abortion legislation and practices must be non-restrictive before some women turn from illegal abortions to legal abortions.40/ FIGURE 7 to 00 V) Q < O z Number of Hospital Admissions for Complications due to Illegal Abortions, Grady Hospita1, Atlanta, 1969-1973 35 i -- 30 25 20 15 10 0 I I I J I J I I I I I I III IV I III IV I II III IV I II III IV I QUARTER 1969 1970 1971 1972 1973 Source: Ronald S
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From page 67... ...
Although it is impossible to estimate the frequency of medical complications due to illegal abortions, one indicator that has been used for this purpose is the number of hospital admissions due to incomplete or septic abortions. Existing trend data on hospital admissions and discharges indicate that abortion-related complications have declined over the past several years; in several hospitals the numbers and rates of women admitted for treatment of incomplete septic abortions fell sharply after the states in which the hospitals were located had introduced nonrestrictive abortion legislation or practices.
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From page 68... ...
68 In San Francisco, the number of septic abortions per 1,000 deliveries dropped by 68 percent between 1967 and 1969.41/ The Los Angeles County/ University of Southern California Medical Center reported a comparable decline of 78 percent from 1967 to the first nine months of 1971.42/ Although other factors, such as the increased use of effective contraception and a declining number of unwanted pregnancies might have contributed to the decline in high risk abortions, it is likely that the introduction of less restrictive legislation in 1967 was a major factor in reducing total illegal abortion-related complications in California.
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From page 69... ...
"Joint Program for the Study of Abortion (JPSA) : Early Medical Complications of Legal Abortion," Studies in Family Planning 3: 97-122, June 1972.
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From page 70... ...
Somatic Complications following Legal Abortion. Stockholm: Svenska Bokforlaget, 1959.
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From page 71... ...
"The Effect of Legal Abortion on the Rate of Septic Abortion at a Large County Hospita1," The American Journal of Obstetrics and Gynecology 115: 335-338, February 1973.
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