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Impact of Vacuum Aspiration Abortion on Future Childbearing: A Review
Abstract
Ever since induced abortion was legalized in the United States, there has been a running controversy over whether induced abortion affects subsequent childbearing; for example, it has been claimed that women who terminate a pregnancy are at a greater risk of miscarrying a subsequent pregnancy or of having a low-birth-weight baby. Ten studies of the later impact of first-trimester induced abortion by vacuum aspiration (the dominant method in the United States) are examined here; they find that compared with women who carry their first pregnancy to term, women whose first pregnancy ends in induced abortion have no greater risk of bearing low-birth-weight babies, delivering prematurely or suffering spontaneous abortions in subsequent pregnancies. However, these studies also show that induced abortion of a woman's first pregnancy does not have the protective effect on her first live birth that carrying a first birth to term has on later deliveries. In addition, some evidence from other studies links dilatation and curettage (D&C) procedures with later infertility, but most studies have found no such association. No definite conclusions can be reached about the impact of multiple induced abortions, since the results of 13 different epidemiologic studies are almost evenly divided between those that show no effect and those reporting related reproductive problems.
... 4 Many studies have examined the association between history of TOPs and perinatal outcomes. [5][6][7][8][9][10][11][12][13] It has been evidenced that a single TOP is not a risk factor for preterm birth, 12,13 however, repeat TOPs are associated with increased perinatal risks. [5][6][7][8][9][10][11] The previous studies did not consider the methods of TOP in relation to adverse perinatal outcomes; however, most of the TOPs were surgical. ...
... 4 Many studies have examined the association between history of TOPs and perinatal outcomes. [5][6][7][8][9][10][11][12][13] It has been evidenced that a single TOP is not a risk factor for preterm birth, 12,13 however, repeat TOPs are associated with increased perinatal risks. [5][6][7][8][9][10][11] The previous studies did not consider the methods of TOP in relation to adverse perinatal outcomes; however, most of the TOPs were surgical. ...
... In addition, medical TOPs cause less trauma to the cervix than the surgical ones. 7,12,30 In line with our previous (unpublished) study and an earlier Finnish study, 11 this study found no significant association between perinatal deaths and previous induced TOP(s). In keeping line with the earlier Chinese study, 14 we found significantly higher risk for preterm birth when comparing the women having had at least two surgical TOPs with those having had at least two medical TOPs; however, the significance was disappeared in our study when adjusted for confounders. ...
Background:
Repeat terminations of pregnancy (TOPs) are associated with an increased risk of adverse outcomes in the subsequent birth. The perinatal outcomes after repeat TOPs by their methods have not yet been properly studied. This study aimed to examine perinatal outcomes in subsequent pregnancy among the women with a singleton birth and a history of TOPs.
Methods:
All the first-time mothers (n = 419 879) with a singleton birth during 1996-2013 in Finland were identified from the Medical Birth Register and linked to the Abortion Register. Adjusted multivariable logistic regression analysis was used to estimate risks of adverse perinatal outcomes.
Results:
The increased incidence of adverse perinatal outcomes was found with increasing number of surgical TOPs. After adjusting for confounders, the women with one surgical TOP had slightly increased but significant odds of 1.07 (95% CI 1.02, 1.13) for being small for gestational age compared with the women having no TOP. A significantly high risk for extremely preterm birth (OR 1.51, 95% CI 1.03, 2.23) was found among the women having had repeat surgical TOPs when compared to the women with no TOP. Non-significant risks were found for adverse perinatal outcomes after women's repeat surgical TOPs than repeat medical TOPs.
Conclusion:
Information regarding the consequences of repeat induced TOPs will be significant in sexual health education as well as counselling women after first termination.
... Similar conflicting data exist regarding previous terminations of pregnancy and adverse pregnancy outcomes (Hogue et al., 1983;Pickering and Forbes, 1985;Atrash and Hogue, 1990;Lang et al., 1996;Zhou et al., 1999;Ancel et al., 2004;Moreau et al., 2005;Raatikainen et al., 2006;Smith et al., 2006). No difference in the risk of miscarriage, preterm delivery or small for gestational age (SGA) was observed in women with a previous termination of pregnancy managed by a medical technique or by vacuum aspiration, respectively, in one of the most recent large (11 814 participants) long-term safety studies on termination of pregnancy (Virk et al., 2007). ...
... Some studies have reported that miscarriage is associated with an increased risk of preterm delivery and PPROM (Swingle et al., 2009;Buchmayer et al., 2004) and SGA (Basso et al., 1998;Bhattacharya et al., 2008), whereas others have not (Schoenbaum et al., 1980;de Haas et al., 1991;Ekwo et al., 1993;Hammoud et al., 2007). Similarly, conflicting evidence exists regarding previous termination of pregnancy and subsequent adverse pregnancy outcomes (Hogue et al., 1983;Pickering and Forbes, 1985;Atrash and Hogue, 1990;Lang et al., 1996;Zhou et al., 1999;Ancel et al., 2004;Moreau et al., 2005;Raatikainen et al., 2006). Few studies have examined whether the mode of management of miscarriage or termination of pregnancy is relevant (Lohmann-Bigelow et al., 2007;Virk et al., 2007). ...
STUDY QUESTION
Do women with a previous miscarriage or termination of pregnancy have an increased risk of spontaneous preterm birth and is this related to previous cervical dilatation and curettage?
SUMMARY ANSWER
A single previous pregnancy loss (termination or miscarriage) managed by cervical dilatation and curettage is associated with a greater risk of SpPTB.
WHAT IS KNOWN ALREADY
Miscarriage affects ∼20% of pregnancies and as many as a further 20% of pregnancies undergo termination.
STUDY DESIGN, SIZE, DURATION
We utilized data from 5575 healthy nulliparous women with singleton pregnancies recruited to the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study performed between November 2004 and January 2011.
PARTICIPANTS/MATERIALS, SETTING, METHODS
The primary outcome was spontaneous preterm birth (defined as spontaneous preterm labour or preterm premature rupture of membranes (PPROM) resulting in preterm birth
... Therefore, it shows that cervical and uterine damage increases the risk of premature delivery, complication of labour and abnormal development of the placenta in later pregnancies. These reproductive complications are the leading causes of handicaps among newborns (Hogue, Cates & Tietz 1983). Frank (1985) affirmed that "the most common "mirror" complications include: infection, bleeding, fever, second degree burns, chronic abdominal pains, vomiting, gastro-intestinal disturbances, and Rh sensitization". ...
A social issue is an issue that relates to society's perception of a person's personal life. Different cultures have different perceptions and what may be "normal" behavior in one society may be a significant social issue in another society. Abortion is one of such social issues that have been engraved with debates on whether it should be legalized the world over or not. The problems are lack of proper education on sexual activity to women of reproductive age, untrained health care givers, and churches have become quasi clinics/hospitals. The research was carried out to investigate abortion's moral implication in Abak Local Government Area, assess the effects of abortion on health of women of reproductive age and to examine the reasons why women prefer the option of committing abortion in Abak Local Government Area. The study is based on the ex-post facto research design which refers to those studies which investigate possible cause and effect relationships by observing an existing condition and searching back in time for plausible factors. The study identified freedom from child bearing, avoidance of being ostracized, fear of parents, economic hardship, culture of silence, and lack of respect for the tenets of religion as some of the reasons women undertake abortion and submits that the collaborative and concerted efforts by government at local, state and national levels as well as individuals would serve as a solution in curbing abortion.
... Soulignons deux exceptions notables, mais rares : 1) la rétention de fragments osseux après un AC au deuxième trimestre; 2) la formation d'adhérences intra-utérines après un AC310,313,315,323,324 .La plupart des études cas-témoin d'envergure dont le groupe témoin était adéquat et où les facteurs de confusion avaient bien été pris en compte n'ont trouvé aucun lien entre les antécédents d'AC et le risque de GEU[325][326][327][328][329][330][331][332][333][334] . Une association significative a été observée dans des études où le nombre de cas de GEU était faible, où des facteurs de risque importants étaient ignorés, ou dont le groupe témoin était inadéquat, et dans des études menées dans des pays où l'avortement est illégal et associé à des infections ou à la rétention de PC 311,332,335-338 .La majorité des études de cohorte rétrospectives et des études cas-témoin d'envergure dont le groupe témoin était adéquat et où les facteurs de confusion avaient bien été pris en compte n'ont trouvé aucun lien entre les antécédents d'AC et le risque de fausse couche332,[338][339][340][341][342][343][344][345][346] . Aucun rapport dose-effet n'a été prouvé339,343,345,347 . ...
Résumé
Objectif
La présente directive clinique examine les données probantes sur l'avortement chirurgical et l'avortement médical au deuxième trimestre, y compris les soins prodigués avant et après l'intervention.
Utilisateurs cibles
Gynécologues, médecins de famille, infirmières, sages-femmes, résidents et autres fournisseurs de soins de santé qui pratiquent ou enseignent, ou ont l'intention de pratiquer ou d'enseigner, l'avortement provoqué (AP).
Population cible
Femmes dont la grossesse de premier ou de deuxième trimestre est non désirée ou anormale.
Évidence
Des recherches ont été menées dans PubMed, Medline et la base de données Cochrane à l'aide des mots-clés « first-trimester surgical abortion », « second-trimester surgical abortion », « second-trimester medical abortion », « dilation and evacuation », « induction abortion », « feticide », « cervical preparation », « cervical dilation » et « abortion complications ». Nous n'avons tenu compte que des revues systématiques, des essais cliniques randomisés, des essais cliniques et des études observationnelles de langue anglaise ou française publiés entre 1979 et juillet 2017. Des directives cliniques nationales et internationales ont été consultées. Nous n'avons pas effectué de recherches dans la littérature grise (non publiée).
Valeurs
La qualité des données probantes a été évaluée au moyen de l'approche GRADE (Grading of Recommendations Assessment, Development and Evaluation). Le résumé des conclusions peut être fourni sur demande.
Avantages, inconvénients et coûts
L'AP est sûr et efficace. Les avantages en surpassent les dommages et les coûts potentiels. Aucun nouveau dommage ou coût direct n'a été associé à la présente directive clinique.
... Having had a TOP reflects fertility, and this may explain the better outcomes among those mothers having had medical TOPs compared to the mothers without history of TOPs. Poorer outcomes after surgical TOPs might be due to the reason that the medical TOPs cause less physical trauma to the cervix and the less endometrial damage than the surgical TOPs [6,13,26,27]. ...
Background
Women with previous terminations of pregnancy (TOPs) before their first birth have been associated with poorer perinatal outcomes. However, previous studies on the perinatal outcomes by the method in previous TOPs are inconsistent.
Objective
To examine the perinatal outcomes of the first-time mothers with singleton births, by the method of previous TOP (medical and surgical vs no TOP, and surgical vs medical).
Method
This is a nationwide register-based study including 419,879 first-time Finnish mothers with singleton birth during the time period 1996–2013. Mothers having their first birth were identified from the Medical Birth Register and linked to the Abortion Register by their identification numbers. Multinomial logistic regression analysis was performed to examine the risk for preterm birth, low birth weight, small for gestational age and perinatal death by the method in previous TOPs.
Results
Among the first-time mothers, 87.0% had no history of TOPs, 3.2% had a history of medical TOP(s), 9.2% had a history of surgical TOP(s) and 0.6% had a history of both (medical and surgical) TOP(s). No significant differences in perinatal outcomes were found among the women with surgical TOPs, compared to the women with no TOPs. In unadjusted analysis, increased odds for preterm birth and low birth weight were found when comparing women having previous surgical TOPs with medical TOPs. Even after the adjustment of potential confounders, odds for preterm birth < 37 weeks (OR = 1.19, 95% CI = 1.04–1.36) and low birth weight < 2500 g (OR = 1.16, 95% CI = 1.00–1.35) remained significant. After restricting data to the single TOP, the results were similar; OR for both preterm birth and low birth weight was 1.18 (95% CIs = 1.02–1.36 and 1.01–1.38).
Conclusion
Perinatal outcomes did not differ among the mothers with surgical TOPs compared to the mothers with no TOPs, while the outcomes were poorer after surgical TOP(s) than after medical TOP(s).
... Legalizing abortion in the US and the Western Europe on broad grounds at the end of the 1960s and during the 1970s initiated research about possible health and public health consequences of pregnancy terminations (Hogue et al., 1983; Tietze, 1975 Tietze, , 1984). It has been found that surgical abortion is one of the most commonly practiced gynaecological procedures and legal abortion in developed countries is impressively safe (Flett and Templeton, 2002; Virk et al., 2007). ...
Käesolevas uurimuses analüüsiti noorte naiste seksuaaltervise erinevaid näitajaid: suundumusi teismeliste raseduste esinemises kiirete sotsiaal-majanduslike muudatuste perioodil aastatel 1992−2001, hinnati teismelise sünnitaja vanuse efekti perinataalsele tulemile, uuriti teismeliste planeerimata rasedustega seotud individuaalseid ja perekondlikke tegureid ning hinnati eelneva indutseeritud abordi seost platsentaarperioodi tüsistustega. Uuringuperioodil vähenes märgatavalt nii teismeliste sünnituste kui indutseeritud abortide üldarv, samuti abortiivsus- ja sündimuskordajad 1000 teismelise kohta. Teismelistel oli suurenenud enneaegsuse ja madala sünnikaaluga lapse sünni risk võrreldes 20−24aastaste emadega. Surnultsünni risk polnud teismelistel emadel suurem. 17aastastel ja noorematel tütarlastel oli suurenenud lapse surma risk neonataalses ja postneonataalses perioodis, mis ilmselt tulenes enneaegsusest. Planeerimata raseduse risk teismeeas oli seotud madala teadmiste tasemega rasestumisvastaste vahendite ja suguorganite talitluse kohta ning negatiivse hoiakuga kooliskäimise suhtes ja alkoholi sagedase kasutamisega pereliikmete poolt. Esimese trimestri kirurgiline abort anamneesis oli esmassünnitajatel seotud tüsistuste (emakaõõne manuaalne revisioon, platsenta manuaalne eemaldamine, emakaõõne abrasioon) riski tõusuga sünnituse platsentaarperioodis.The general objective of this study was to get additional knowledge of young women’s sexual health and behaviour in Estonia. We examined trends in teenage pregnancies in Estonia during the years of rapid socio-economic changes in 1992−2001, assessed the risk of young maternal age on perinatal outcome – low birth weight, preterm birth, stillbirth, neonatal and postneonatal death. We investigated individual and familial factors associated with teenage unintended pregnancy and analysed the risk of complications in the third stage of labour in deliveries following surgically induced abortion(s). Both the number and rates of teenage births and abortions declined remarkably in Estonia during the years of rapid socio-economic changes. Mother’s age of 19 years and less may be a risk factor for low birth weight and preterm births. Risk of stillbirths is not higher among teenagers. The risk of neonatal and postneonatal death of the newborn child is higher among younger teenagers aged 17 years and less, presumably due to increased risks in preterm birth. Low level of knowledge about the functioning of reproductive organs and contraception, and dislike of school (individual factors), as well as the reporting of alcohol abuse by family members (familial factor), were associated with higher risk of unintended teenage pregnancy. A positive association was observed between one or more first trimester surgically induced abortions and the risk of complications in the third stage of labour (retained placenta and/or tissue and/or haemorrhage needing manual revision of uterine cavity or curettage) in subsequent singleton vaginal delivery.
... Additionally, a previous review indicated that I-TOP was not protective for risk of LBW associated with primiparity; that is, the risk of LBW was higher for women with a history of I-TOP compared with women who had carried to full-term. 64 The results of our review differ from previous reviews; 5,10,64,66 mainly because this is the first attempt to quantify results reported in various studies. We are aware that the major critique of our review is suitability of studies for combining their results. ...
History of induced termination of pregnancy (I-TOP) is suggested as a precursor for infant being born low birthweight (LBW), preterm (PT) or small for gestational age (SGA). Infection, mechanical trauma to the cervix leading to cervical incompetence and scarred tissue following curettage are suspected mechanisms.
To systematically review the risk of an infant being born LBW/PT/SGA among women with history of I-TOP.
Medline, Embase, CINAHL and bibliographies of identified articles were searched for English language studies.
Studies reporting birth outcomes to mothers with or without history of induced abortion were included.
and analyses Two reviewers independently collected data and assessed the quality of the studies for biases in sample selection, exposure assessment, confounder adjustment, analytical, outcome assessments and attrition. Meta-analyses were performed using random effect model and odds ratio (OR), weighted mean difference and 95% confidence interval (CI) were calculated.
Thirty-seven studies of low-moderate risk of bias were included. A history of one I-TOP was associated with increased unadjusted odds of LBW (OR 1.35, 95% CI 1.20-1.52) and PT (OR 1.36, 95% CI 1.24-1.50), but not SGA (OR 0.87, 95% CI 0.69-1.09). A history of more than one I-TOP was associated with LBW (OR 1.72, 95% CI 1.45-2.04) and PT (OR 1.93, 95% CI 1.28-2.71). Meta-analyses of adjusted risk estimates confirmed these findings.
A previous I-TOP is associated with a significantly increased risk of LBW and PT but not SGA. The risk increased as the number of I-TOP increased.
... Most of the terminated pregnancies are unintentional and many of these have resulted from contraceptive failure (Fleissig, 1991; Bromham and Cartmill, 1993; Hannaford, 1999). Becoming pregnant as a result of contraceptive failure may reflect, at least partly, high fecundity of the couple (Baird et al., 1994; Olsen et al., 1998) but the effect of termination of pregnancy (TOP) on subsequent fecundity and its association with subsequent adverse reproductive outcomes remains controversial (Venkatacharya, 1972; Kreibich and Ehrig, 1978; Obel, 1979, 1980; Hogue et al., 1983; Skjeldestad and Atrash, 1997; Thorp et al., 2003). ...
Effect of past reproductive performance on subsequent fecundity is uncertain.
A total of 2983 consecutive pregnant women self-completed questionnaires about time to pregnancy (TTP), pregnancy planning, previous pregnancies, contraceptive use, age, and individual/lifestyle variables. Outcome measures were: TTP, conception rates (CR) and, subfecundity odds ratio (OR; with 95% confidence intervals) before and after each outcome of last pregnancy.
After miscarriage, TTP was longer than before miscarriage [2.1 (1.4-3.0), P < 0.001] and than TTP after livebirth [OR = 2.1 (1.6-2.6), P < 0.001]. Also subfecundity OR after miscarriage increased [1.7 (1.2-2.4), 1.8 (1.2-2.5), P = 0.001, 0.002 respectively]. This effect was more evident in older and obese women. Compared with livebirth, time to ectopic pregnancy (EP) was longer [OR = 13.8 (1.8-108.5), P = 0.001] but TTP after EP was not significantly different. Subfecundity OR relative to livebirth were 12.8 (3.6-45.0) (P<0.001) before, and 3.9 (1.4-11.0) (P=0.01) after, EP. The CR after EP increased 3-fold (1.1-8.3) over those prior to EP. Time to the terminated pregnancies even without contraceptive failures was shorter than that to livebirth [OR = 0.5 (0.3-0.7), P = 0.001] and than TTP after termination [0.35 (0.1-0.8), P = 0.001]. Also subfecundity OR increased after termination [7.2 (1.8-29.7), P = 0.02].
Miscarriers should be counselled about short-term reduction in subsequent fecundity, and earlier investigations should be considered in those who have other potential risk factors for reduced fertility. Further studies are required to clarify the relatively favourable effect on fecundity following EP and the relative reduction in fecundity after termination of pregnancy.
... Although a cohort study in Denmark using data from the Danish Medical Birth Registry, the Hospital Discharge Registry and the Induced Abortion Registry suggested a direct association between induced abortion and risk of low birth weight in subsequent singleton term live births when the interpregnancy interval was longer than 6 months, the effect of induced abortion on the risk of subsequent delivery of small-forgestational-age (SGA) babies is a matter of controversy. [2][3][4][5][6][7][8] A review of studies 9 on the association between induced abortion and risk of low birth weight published in the period from the early 1960s to the early 1980s suggested that low birth weigh was more frequent in pregnancies after abortions performed using dilatation and currettage under general anaesthesia, but not after abortions performed using other methods. However, the studies considered in the review generally included babies that weighed 2500 g or less but were not necessarily SGA at birth, and so the association found may have been, at least in part, caused by an effect of induced abortion on the risk of preterm birth. ...
To investigate the possibility of an association between previous induced abortion and subsequent birth of a small-for-gestational-age (SGA) infant.
Case-control study.
General and university hospitals.
Cases were 555 women who delivered SGA babies. Controls were 1966 women who gave birth at term (>37 weeks of gestation) to healthy infants of normal weight on randomly selected days at the hospital where cases had been identified. All women in the case and control categories were interviewed on the obstetric wards by one of a team of six interviewers. During the interviews, information was obtained regarding general socio-demographic factors, personal characteristics and habits, gynaecological and obstetric history, general anamnesis, family history of obstetric and gynaecological diseases, and the age of the father of the child. Further information on current pregnancy and delivery was also collected. We used conditional multiple logistic regression (with age as the matching variable), with maximum likelihood fitting, to obtain odds ratios and their corresponding 95% CIs. Included in the regression equations were terms for education, plus terms significantly associated in this data set with the risk of SGA birth (smoking in pregnancy, history of SGA, gestational hypertension and parity).
Women admitted to a general and a university hospital.
No significant increase in the risk of SGA birth was observed in women with a previous induced abortion [odds ratio (OR) 1.0; 95% CI 0.6-1.7]. The OR for SGA birth was 1.2 (95% CI 0.7-2.1) for preterm and 1.0 (95% CI 0.7-1.4) for term SGA births.
This study found no association between risk of SGA birth and induced abortion.
Objective:
This guideline reviews evidence relating to the provision of surgical induced abortion (IA) and second trimester medical abortion, including pre- and post-procedural care.
Intended users:
Gynaecologists, family physicians, nurses, midwives, residents, and other health care providers who currently or intend to provide and/or teach IAs.
Target population:
Women with an unintended or abnormal first or second trimester pregnancy.
Evidence:
PubMed, Medline, and the Cochrane Database were searched using the key words: first-trimester surgical abortion, second-trimester surgical abortion, second-trimester medical abortion, dilation and evacuation, induction abortion, feticide, cervical preparation, cervical dilation, abortion complications. Results were restricted to English or French systematic reviews, randomized controlled trials, clinical trials, and observational studies published from 1979 to July 2017. National and international clinical practice guidelines were consulted for review. Grey literature was not searched.
Values:
The quality of evidence in this document was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology framework. The summary of findings is available upon request.
Benefits, harms, and/or costs:
IA is safe and effective. The benefits of IA outweigh the potential harms or costs. No new direct harms or costs identified with these guidelines.
Originally published in 1986, Abortion and the Private Practice of Medicine was the first book to look at abortion from the perspective of physicians in private practice. Jonathan B. Imber spent two years observing and interviewing all twenty-six of the obstetrician-gynecologists in "Daleton," a city that did not have an abortion clinic. The decision as to whether, when, and how to perform abortions was therefore essentially up to the individual doctor. Imber begins the volume with a historical survey of medical views on abortion and the medical profession's response to the legalization of abortion in the United States. Quoting extensively from his interviews, he looks at various characteristics of doctors that may affect their professional opinion on abortion: their age, gender, religious background, and length of residence in the community; the nature of their training and prior experience; and the setting of the practice (whether group or solo). Imber found that the physicians' reasons for agreeing or refusing to perform abortions revealed considerable differences of opinion about how they construe their responsibilities.
Abortion is an inimitable experience that poses a host of unique ethical and philosophical questions not generated by other medical procedures. In spite of a massive amount of literature discussing abortion, there is little theoretical work examining the relationship between abortion and informed consent. This is a problematic oversight because informed consent plays a prominent role in contemporary abortion practices. In an effort to address this lacuna, my dissertation explores the concept of informed consent as it functions within abortion discourse.
Informed consent and abortion are both interdisciplinary terms and thus a robust critique of their intersection requires an interdisciplinary analysis. Therefore, I critically track the concept of informed consent across four unique discourses: traditional informed consent literature, Supreme Court rulings on abortion regulations, state-sponsored informed consent materials distributed to women seeking an abortion, and women’s firstperson narratives. As a contribution to feminist and bioethics scholarship, I argue that informed consent is a deeply inadequate concept in the context of abortion. Importantly, however, the reasons for this inadequacy change relative to the discourse in question. ! Thus, Chapters One, Two, Three, and Four each take as their focus a distinct discursive engagement of informed consent. In Chapter Five, I confront a series of questions generated by my interdisciplinary survey.
In bridging the gaps between informed consent theory and abortion discourse, I demonstrate two important points. First, I illustrate how popular articulations of informed consent are ill-equipped to address the moral and medical issues particular to abortion. Secondly, I illuminate cases where the rhetoric of informed consent is, in fact, being used to undermine and jeopardize women’s reproductive autonomy. This dissertation concludes with a plea for a revised conception of informed consent within the abortion context, one that deploys the subjective standard of disclosure and recognizes the value of flexible dialogue between the woman and her abortion provider.
It is a great honor and indeed a privilege to be present at this symposium in memory of one of the stalwarts of international health, Dr. Christopher Tietze. I cannot say that I had the privilege to know Chris Tietze well. Of the three great pioneers in those days, I mention Alan Guttmacher, Bernard Berelson, and Christopher Tietze. I happen to have known Guttmacher and Berelson a little better than I knew Chris. Happily though, by chance I spent a week at the same conference with him in Rehovot, Israel; and on one occasion we had a delightful luncheon chat ranging over many issues. I was profoundly impressed by his dedication to family planning.
Abstract
Objective This systematic review and meta-analysis assessed whether enhanced peri-abortion contraceptive counselling had an effect on subsequent unplanned pregnancies and the uptake and continuation of contraceptive methods.
Methods and materials A systematic review of English-language articles published prior to May 2014 was conducted, using MEDLINE, EMBASE and the Cochrane Library. Only randomised controlled trials (RCTs) involving enhanced pre- and post-abortion contraceptive counselling were included. The authors independently applied the inclusion and exclusion criteria to the identified records, and extracted data from each included paper using a predefined extraction form. Risk of bias was assessed using the Cochrane Collaboration's tool. Meta-analyses were undertaken where appropriate and based on random effects models.
Results Six RCTs met the inclusion criteria. Three RCTs investigated the effect of enhanced counselling on subsequent unplanned pregnancy. The results of the meta-analysis were non-significant [pooled odds ratio (OR) 0.47; 95% confidence interval (95% CI) 0.12–1.90]. Four RCTs reported results relating to the uptake of long-acting reversible contraception (LARC) and continuation of chosen method of contraception at 3 months. Findings were non-significant (pooled OR 1.07; 95% CI 0.20–5.69 and pooled OR 3.22; 95% CI 0.85–12.22, respectively).
Conclusions This review found no evidence of effect resulting from enhanced peri-abortion contraceptive counselling on subsequent unplanned pregnancy rate or the uptake of LARC. However, these findings are limited by the small number of relevant studies available and the marked heterogeneity between published studies. Further, larger-scale RCTs should be undertaken to ensure that there is sufficient power to detect an effect.
How much does the capacity to reproduce decline with age? Until quite recently, it was believed that fecundity declined slightly from age 20 to the early thirties, but more sharply after 35. Then a French study (Federation CECOS, 1982) published in February, 1982, reported results from a group of women who had undergone artificial insemination (Table I). Approximately 74% of women who were not over 30 conceived within 12 menstrual cycles. The percentage fell to only 62 for women 31–35, and to 56 for women 36–40. An accompanying editorial and many later newspaper and magazine articles suggested that risks of infertility rose sharply starting as early as age 30. The purpose of this chapter is to review evidence of the level and age pattern of decline in fecundity for women and for men and then to focus on delayed childbearing.
Background: To evaluate the impact of surgically induced first-trimester abortion on the risk of miscarriage in a subsequent pregnancy. Methods: The study is a pregnancy cohort study. It was conducted among 15 general hospitals or maternity and infant health institutes in Shanghai China from November 1993 to March 1998. The abortion cohort consisted of pregnant women whose previous pregnancies were terminated by vacuum aspiration (98%). The reference cohort consisted of primigravidae. Subjects were recruited at 35–63 days of gestational age. A total of 2953 pregnant women were enrolled; 1502 in the abortion cohort 1451 in the reference cohort. Results: There were only 62 women lost to follow-up. The remaining 2891 women had 2732 live births and 137 miscarriages. About 5.5% of pregnancies in the abortion cohort were miscarried and 4.0% in the reference cohort. Once potential confounders were controlled for by logistic regression odds ratio (OR) of miscarriage between the abortion cohort and the reference cohort was 1.55 (95% CI: 1.08–2.23). The adjusted OR were 2.44 (95% CI: 1.16–5.15) among women who were recruited within 49 days of gestational age and 1.72 (95% CI: 1.09–2.72) for the first-trimester miscarriage. Conclusions: Induced abortion by vacuum aspiration is associated with an increased risk of first-trimester miscarriage in the subsequent pregnancy. (authors)
Objective: To examine whether induced abortion influences subsequent pregnancy duration.
Methods: Women who had their first pregnancies during 1980, 1981, and 1982 were identified in three Danish national registries. A total of 15,727 women whose pregnancies were terminated by first-trimester induced abortions were compared with 46,026 whose pregnancies were not terminated by induced abortions. All subsequent pregnancies until 1994 were identified by register linkage.
Results: Preterm and post-term singleton live births were more frequent in women with one, two, or more previous induced abortions. After adjusting for potential confounders and stratifying by gravidity, the odds ratios of preterm singleton live births in women with one, two, or more previous induced abortions were 1.89 (95% confidence interval [CI] 1.70, 2.11), 2.66 (95% CI 2.09, 3.37), and 2.03 (95% CI 1.29, 3.19), respectively. Odds ratios of post-term singleton live births in women with one, two, or more previous induced abortions were 1.34 (95% CI 1.24, 1.44), 1.50 (95% CI 1.26, 1.78), and 1.58 (95% CI 1.09, 2.28), respectively.
Conclusion: The study showed an increase in preterm and post-term pregnancies after induced abortions. The risk of post-term delivery was high regardless of the interpregnancy interval, whereas increased risk of preterm delivery was seen mainly when interpregnancy intervals were longer than 12 months.
Social, cultural, and economic factors that influence fertility must work through the intermediate variables or proximate determinants that directly affect reproduction. This paper reviews the proximate determinants framework and recent advances in knowledge of its components. In addition, efforts to develop a comparable model for analysis of mortality are described. It is concluded that, for fertility, although gaps in knowledge of proximate determinants remain and continuing periodic measurement is necessary to monitor their levels and changes, the primary need now is to improve understanding of the causal links between the social and economic features of a population and the proximate determinants.
We set out to study the risk of spontaneous abortion following a first trimester induced abortion as a function of the interpregnancy interval between two pregnancies. The cohort study is based on the following databases: Danish national registries: the Medical Birth Registry (MBR), the Hospital Discharge Registry (HDR), and the induced Abortion Registry (IAR). All primigravid women in the time period from 1980 to 1982 were identified in the MBR, the HDR and the IAR. A total of 15 727 women who terminated the pregnancy with a first trimester induced abortion were selected as the induced abortion cohort, and 46 026 women who did not terminate the pregnancy with an induced abortion constituted the control cohort. By register linkage all subsequent pregnancies which were not terminated by induced abortion were identified from 1980 to 1994. Only women who had a non-terminated pregnancy following the index pregnancy were selected. Women whose first pregnancy was terminated following a first trimester induced abortion had a risk of spontaneous abortion of 11.0% vs. 9.4% in the control cohort. This relative difference of 1.17 was not statistically significant in logistic regression analyses. An increased risk was only found for women who had an interpregnancy interval of less than 3 months (OR=4.06, 95% C.I.=1.98-8.31). The abortion method, vacuum aspiration with dilatation or evacuation with dilatation did not modify this elevated risk. Overall the study did not show an increased risk of spontaneous abortion following one or more induced abortions, except for women with a short interpregnancy interval between an induced abortion and a subsequent pregnancy. We recommend women who have a first trimester induced abortion be advised to wait at least 3-6 months before trying to become pregnant again.
Utilizing research that focuses on adolescents as well as findings in samples which might have special relevance to young, unmarried women, this report summarizes research on the consequences of abortion among adolescents. It discusses prior literature in the area of parental notification and parental consent, subjects on which public opinion is not divided along familiar pro-choice/anti-choice lines. Following a discussion of methodological problems identified in prior research, it reports on a study designed to address these problems in an adolescent population; it discusses implications for the current debate of this and other studies' findings that there are no identifiable adverse sequelae of the abortion process.
There is a very small correlation, if any, between the prior use of OCs and congenital malformations, including Down's syndrome. There are few, if any, recent reports on masculinization of a female fetus born to a mother who took an OC containing 1 mg of a progestogen during early pregnancy. However, patients suspected of being pregnant and who are desirous of continuing that pregnancy should not continue to take OCs, nor should progestogen withdrawal pregnancy tests be used. Concern still exists regarding the occurrence of congenital abnormalities in babies born to such women. The incidence of postoperative infection after first trimester therapeutic abortion in this country is low. However, increasing numbers of women are undergoing repeated pregnancy terminations, and their risk for subsequent pelvic infections may be multiplied with each succeeding abortion. The incidence of prematurity due to cervical incompetence or surgical infertility after first trimester pregnancy terminations is not increased significantly. Asherman's syndrome may occur after septic therapeutic abortion. The pregnancy rate after treatment of this syndrome is low. The return of menses and the achievement of a pregnancy may be slightly delayed after OCs are discontinued, but the fertility rate is within the normal range by 1 year. The incidence of postpill amenorrhea of greater than 6 months' duration is probably less than 1%. The occurrence of the syndrome does not seem to be related to length of use or type of pill. Patients with prior normal menses as well as those with menstrual abnormalities before use of OCs may develop this syndrome. Patients with normal estrogen and gonadotropin levels usually respond with return of menses and ovulation when treated with clomiphene. The rate for achievement of pregnancy is much lower than that for patients with spontaneous return of menses. The criteria for defining PID or for categorizing its severity are diverse. The incidence of PID is higher among IUD users than among patients taking OCs or using a barrier method. The excess risk of PID among IUD users, with the exception of the first few months after insertion, is related to sexually transmitted diseases and not the IUD. Women with no risk factors for sexually transmitted diseases have little increased risk of PID or infertility associated with IUD use. There appears to be no increased risk of congenital anomalies, altered sex ratio, or early pregnancy loss among spermicide users. All present methods of contraception entail some risk to the patient. The risk of imparied future fertility with the use of any method appears to be low.(ABSTRACT TRUNCATED AT 400 WORDS)
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This is a comprehensive review of the risk of infertility or adverse effects on pregnancy outcome, such as chromosomal or congenital birth defects, amenorrhea, pelvic inflammatory disease (PID), or spontaneous abortion, after use of oral contraceptives, IUDs, induced abortion or spermicides. The sequelae reported for orals are chromosomal abnormalities, the VACTERL anomalies, masculinization of female fetus, Down's syndrome and post-pill amenorrhea. Several large studies found no increased risks for birth defects, although the risk of malformations when pregnant women inadvertently take the pill in early pregnancy was high in 1 of 2 such studies. Masculinization was reported with high dose combined hormone treatment and in 2 infants of a woman who took Enovid. the bulk of recent studies on secondary amenorrhea indicate that it is rare, but just as likely to occur in women with prior normal or abnormal menstrual patterns. One study found that amenorrhea is 7.7 times more likely to develop in women who took the pill to regulate menses. It is recommended that women with amenorrhea be screened for pituitary tumors and counseled before prescribing pills, and that those who fail to ovulate after stopping the pill be treated at least 6 months with clomiphene. A massing of all studies on the impact of 1st trimester induced abortion on subsequent fertility, premature delivery and spontaneous abortion, shows all relative risks around 1.0. After multiple abortions, the results are conflicting. In contrast, prior series analyzing illegal abortion have an unquestioned adverse effect on fertility and pregnancy outcome. Asherman's syndrome, a rare disorder of intrauterine adhesions, menstrual abnormalities, infertility and habitual abortion, has been associated with D & C abortion concurrent with pelvic sepsis, or traumatic pregnancy with D & C. This condition can be treated with moderate success. The bulk of IUD studies conclude that there is no overall decrement in fertility, while some disaggregated studies point the Dalkon shield as a higher risk and copper IUDs as a lower risk. PID and its consequences are now considered related to the immediate post-insertion time frame, or specifically to women who are at risk of contracting sexually transmitted disease, i.e., those with multiple partners, those with prior PID and nulliparas. Comprehensive review of current large series on spermicides shows no relationship between their use and spontaneous abortion or congenital malformation.
A variety of conditions have been anecdotally ascribed to induced abortion, including subsequent reproductive complications. Since most women obtaining induced abortions are at the beginning of their reproductive life, the effect of induced abortion on subsequent reproduction becomes a very significant one. Our review of the literature confirms findings reported previously. First, except in the case where an infection complicates induced abortion, there is no evidence of an association between induced abortion and secondary infertility or ectopic pregnancy. Second, the risk of midtrimester abortion, premature delivery and low birthweight in women whose first pregnancy is terminated by vacuum aspiration is not higher than that in women in their first pregnancy or women in their second pregnancy whose first pregnancy was carried to term. However, the risk of having a premature delivery or a low birthweight baby tends to be higher (but not significantly) among women whose first pregnancy is terminated by induced abortion when compared with women in their second pregnancy than when compared with women in their first pregnancy. This suggests that an induced abortion does not protect a women against the known risk of low birthweight for first-born offspring. Finally, women whose pregnancy is terminated by dilatation and evacuation may have an increased risk of subsequent premature delivery and a low birthweight baby. Very little has been published and no conclusions can be made regarding the effects of instillation procedures and repeat abortions on future reproduction. In conclusion, except for the association between pregnancies following dilatation and evacuation procedures and premature delivery and low birthweight, no significantly increased risk of adverse reproductive health has been observed following induced abortion.
A group of 360 black teenage women of similar socioeconomic background who sought pregnancy tests from two Baltimore family planning providers was followed for two years to determine if those who obtained abortions were adversely affected by their abortion experience. After two years, the young women who had terminated their pregnancies were far more likely to have graduated from high school or to still be in school and at the appropriate grade level than were those who had decided to carry their pregnancy to term or those whose pregnancy test had been negative. Those who had obtained an abortion were also better off economically than were those in the other two groups after two years. An analysis of psychological stress showed that those who terminated their pregnancy had experience no greater levels of stress or anxiety than had the other teenagers at the time of the pregnancy test, and they were no more likely to have psychological problems two years later. The teenagers who had obtained abortions were also less likely than the other two groups to experience a subsequent pregnancy during the following two years and were slightly more likely to practice contraception. Thus, two years after their abortions, the young women who had chosen to terminate an unwanted pregnancy were doing as well as (and usually better than) those who had had a baby or who had not been pregnant.
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This article outlines the current modalities of pregnancy termination, as well as their risks and complications, in 3 phases of pregnancy: 1) up to 49 days past the last menstrual period, 2) 8-15 weeks, and 3) 16-24 weeks. Before 8 weeks of pregnancy, suction dilatation and curettage (D and C) is the preferred method. However, a medical approach, possibly self-administered, is viewed as more satisfactory and requires only an improvement in side effects. From 8-15 weeks' gestation, suction D and C and dilatation and evacuation (D and E) are the methods of choice. The use of laminaria tents improves both the facility and safety of these procedures in nulliparous patients and perhaps in multiparous patients. Priming of the cervix with prostaglandin could further decrease the difficulty and risks of these procedures. The use of a hydrogel compound is especially worthy of consideration. There is controversy about the preferred method between 16-20 weeks' gestation. D and E appears to have fewer complications and to be more cost-effective than hypertonic saline injection. Urea-prostaglandin has fewer and less severe complications than saline injection, and seems to be more cost-effective than saline injection in terms of duration of hospitalization. The high frequency of failure and side effects, combined with the possibility of expulsion of a live fetus, make prostaglandin-only injection less desirable. After 20 weeks' gestation, urea-prostaglandin injection is probably the safer method. Given the rapid increase in complications with passing weeks, any delay in providing late abortion services should be avoided. 2nd trimester pregnancy terminations, especially those after 18 weeks' gestation, are associated with increased mortality and morbidity and should be performed at specialized centers where providers are better equipped to manage complications.
The impact of abortion on subsequent fecundity has been extensively studied, especially since abortion was legalized in Eastern Europe during the 1950s and 1960s and in Western Europe and the USA during the 1960s and 1970s. A review of this literature reveals a number of consistent findings. First, women who choose to have their first pregnancy terminated are at no increased risk of failing to conceive at a later date. Exceptions include abortions complicated by infection leading to pelvic inflammatory disease (PID). However, this combination of factors occurs very infrequently. Second, women whose first pregnancy is terminated by vacuum aspiration are at no increased risk of subsequent ectopic pregnancy. Exceptions may be women whose abortion is complicated by pre-existing C. trachomatis and others who experience post-abortion infection leading to PID. Third, women whose first pregnancy is terminated by vacuum aspiration are at no increased risk of subsequent mid-trimester spontaneous abortion, preterm delivery or low birthweight, when compared with women who are pregnant for the first time. Fourth, women whose first pregnancy is terminated by D&C may have an increased risk of subsequent ectopic pregnancy, mid-trimester spontaneous abortion and low birthweight. Fifth, more research is needed before it is clear whether multiple induced abortions carry an increased risk of adverse pregnancy outcomes. Finally, too little is known about fecundity following mid-trimester abortion procedures to state definitively that they carry no increased risk of adverse outcomes. However, studies to date suggest that instillation procedures carry little, if any, excess risk. Risks related to dilation and evacuation, if any, may be related to the method and extent of cervical dilation.
Direct evidence on age patterns of infecundity and sterility cannot be obtained from contemporary populations because such large fractions of couples use contraception or have been sterilized. Instead, historical data are exploited to yield upper bounds applicable to contemporary populations on the proportions sterile at each age. Examination of recent changes in sexual behavior that may increase infecundity indicates that sexually transmitted infections, the prime candidate for hypothesized rises in infertility, are unlikely to have added to infecundity to any great extent. These results imply that a woman in a monogamous union faces only moderate increases in the probability of becoming sterile (or infecund) until her late thirties. Nevertheless, it appears that recent changes in reproductive behavior were guaranteed to result in the perception that infecundity is on the rise.
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An estimated 40% of US females now 14 years of age can be expected to experience pregnancy by age 19 years, and the majority of these pregnancies will be unintended. In 1981, there were 1,343,200 pregnancies among US females under 20 years of age and 448,570 abortions in this same age group. The abortion ratio is highest for adolescents under 15 years of age (1379 abortions/1000 live births), while the abortion rate is highest for 18-19 year olds (61.8/1000). When compared to adult women, adolescents obtain abortions at a later gestational age--a factor that increases both the psychological and medical risks of the procedure. Adolescents are also more likely than adults to base their decision regarding the pregnancy on the opinions of significant others. Comparative studies have shown teenagers who continue a pregnancy to have underdeveloped conceptualizations of the future, high levels of anxiety, and an external locus of control. Adolescents at greatest risk of psychological sequelae of abortion are those with pre-existing mental illness, strong religious beliefs, limited coping skills, a narrow support network, and abortion at later gestational stages. If the teenager feels pressured by her family to terminate the pregnancy, she is also at high risk for adverse psychological sequelae and a repeat pregnancy soon after abortion. Thus, counselors should maintain a neutral position while helping teens to examine the positive and negative aspects of their options. In terms of medical effects, teenagers have been shown to have the lowest risk of all age groups for abortion-related mortality. However, because of the later gestational age at which adolescents seek abortion, there is a higher risk of complications such as endometritis. Emphasis should be placed on expediting the abortion decision making process among adolescents to reduce delays and the potential risks.
Today I would like to talk about two demographic issues, both of which may have far-reaching effects in the United States and neither of which is well-understood. The first of these is infertility, which has received extensive but often ill-considered attention in the press and other forms of popular media. The second issue is related, although the connections are not immediately apparent. This issue is the changing size of successive generations of mothers, daughters, and granddaughters, and how such change affects the family. This subject has thus far received little attention, but is also likely to have far-reaching consequences because demographic change has altered the boundaries of the expectations and obligations that parents and children have for one another. Let me begin with the issue of infertility and what is said about it in the popular media. I use the term infertility to mean reduced ability to conceive and bear a live child. Popular presentations are often inaccurate, but they playa role beyond the province of the experts in defining what is seen to be a social problem. Perhaps the most common topic for articles has been the new and innovative techniques that can be called into use when old-fashioned copulation has failed to produce a wanted child-techniques like artificial insemination, surrogate motherhood, in vitro fertil ization. Few articles have attempted to describe the facts about the extent of infertility, and the one that received the most attention, published in the New England Journal of Medicine, concluded that fecundity declines more rapidly with age than had previously been thought (Federation CECOS, Schwartz and Mayaux, 1982). This article was accompanied by an editorial suggesting that the shift to later ages of childbearing would at best have to be reevaluated if not reversed, and that women who cared to have children would have to revise their plans and have their children earlier if they were to have them at all (DeCherney and Berkowitz, 1982). Many later magazine and newspaper articles reported the sad stories of women, often high-powered career women, who postponed childbearing until they thought themselves ready to take on the joy and responsibilities of motherhood, and then found themselves far less successful in the bedroom than they had been in the boardroom. Given this attention, it is useful to begin by describing what we know and, equally importantly, what we do not know about infertility. We know that in record numbers, women are remaining childless in the prime reproductive years. Let's talk about two age groups, women in their late twenties and those in their early thirties. In 1981 nearly 40 percent of the younger group were childless, as were over 20 percent of women in their early thirties (U.S. Bureau of the Census, 1983). In the previous twenty years, the proportion childless nearly doubled for the younger ones and increased by over 50 percent for the older women, but still has not reached the levels observed in the early 1940s (Heuser, 1976). Some of these women are surely * The Presidential Address presented at the Annual Meeting of the Population Association of America, Boston, Massachusetts, March 28-30, 1985
Judicial bypass laws, laws that say that an unmarried minor who seeks an abortion is required to notify or obtain consent of their parents, were passed with the idea of encouraging family communication. However, family communication is not being encouraged in many United States families. Many minors feel that they cannot do this. They are often living in a difficult tumultuous family situation. Many judges believe that, when this is the case, forcing the girl to appear in court before she can have an abortion does no good. Many people believe that these laws have made it harder for teenagers to obtain abortions. This is what the sponsors of these laws had in mind. Many teenagers have to travel long distances to get to court. Courts are not open evenings or weekends. On the whole, it is the 16 and 17-year-olds who go to court. Younger teenagers are more likely to consult their parents. In Massachusetts between April 23, 1981--the day the abortion consent law took effect--and mid-September, 1983, 1571 minors went to court. Of the 563 petitions heard by the Suffolk County Superior Court in Boston, 297 (53%) were filed by 17-year-olds; and 76 (31%), by 16-year-olds. In Minnesota, 1478 minors went to court between August 1, 1981 and August 31, 1983. The juvenile court in Minneapolis which heard 974 of these petitions reports that 527 (54%) were filed by 17-year-olds; and and 326 (33%) by 16-year-olds. In the Minneapolis-St. Paul area, the minors who go to court are mostly white, and middle or upper-class. In Minnesota, Massachusetts, and Rhode Island there is a 2-4 day wait for a hearing. Minority, poor, and rural minors are denied the option of going to court.
Experience with 50 first time aborters, 50 second time aborters, and 50 third time aborters residing in an urban area of Copenhagen suggests that women having a repeat abortion are more similar than dissimilar to women having a first induced abortion. There were no differences in socioeconomic status, educational level, or stated reasons for choosing abortion (usually socioeconomic and family considerations). Though similar to first and second time aborters in their life situations and greater contraceptive risk-taking, third timers seemed to become pregnant more readily. They were also less willing to be interviewed. Related studies and suggestions for postabortion counseling are discussed.
Since the beginning of recorded history, women have attempted to terminate unwanted pregnancies. Despite the safety of modern techniques of abortion, many women throughout the world still have to resort to unsafe abortions, placing themselves at considerable risk. The World Health Organization estimates that there are approximately 20 million unsafe abortions performed each year, and estimates of maternal deaths as a result of abortion range between 60,000 and 100,000 per year. With free and legal access to safe abortions, rates of complications and mortality drop dramatically. There is an urgent need for efforts to prevent unwanted pregnancies in order to reduce the need for abortion; for the early identification of abortion complications and easy access to treatment for women suffering those complications; for expansion of safe abortion availability; and for proper training and resources for providers of abortion services.
To examine whether induced abortion increases the risk of low birthweight in subsequent singleton live births.
Cohort study using the Danish Medical Birth Registry (MBR), the Hospital Discharge Registry (HDR), and the Induced Abortion Registry (IAR). All women who had their first pregnancy during 1980-1982 were identified in the MBR, the HDR, and the IAR. We included all 15,727 women whose pregnancy was terminated by a first trimester induced abortion in the induced abortion cohort and 46,026 women whose pregnancy was not terminated by an induced abortion were selected for the control cohort. All subsequent pregnancies until 1994 were identified by register record linkage.
Low birthweight (<2500 g) in singleton term live births occurred more frequently in women with one, two, three or more previous induced abortions, compared with women without any previous induced abortion of similar gravidity, 2.2% versus 1.5%, 2.4% versus 1.7%, and 1.8% versus 1.6%, respectively. Adjusting for maternal age and residence at time of pregnancy, interpregnancy interval, gender of newborn, number of previous spontaneous abortions and number of previous low birthweight infants (control cohort only), the odds ratios (OR) of low birthweight in singleton term live births in women with one, two or more previous first trimester induced abortions were 1.9 (95% CI: 1.6, 2.3), and 1.9 (95% CI: 1.3, 2.7), respectively, compared with the control cohort of similar gravidity. High risks were mainly seen in women with an interpregnancy interval of more than 6 months.
The findings suggest a positive association between one or more first trimester induced abortions and the risk of low birthweight in subsequent singleton term live births when the interpregnancy interval is longer than 6 months. This result was unexpected and confounding cannot be ruled out.
Surgical abortion by vacuum aspiration is one of the most commonly reported surgical procedures in the United States. The developments of highly sensitive urinary pregnancy tests and transvaginal ultrasonography have encouraged the application of surgical abortion methods at earlier gestational ages. Manual vacuum aspiration with a handheld syringe safely accomplishes early abortion in a variety of settings, from elective abortion in the office or clinic setting to emergency care of a patient with an incomplete abortion. As a wider range of clinicians expresses interest in offering medical abortion, the appropriate use and technique of surgical backup are crucial in safely providing medical abortion. This article reviews vacuum aspiration during the first few weeks of pregnancy, with special attention to manual vacuum aspiration, both for elective surgical abortion and when intervention is required after medical abortion.
To evaluate the impact of surgically induced first-trimester abortion on the risk of miscarriage in a subsequent pregnancy.
The study is a pregnancy cohort study. It was conducted among 15 general hospitals or maternity and infant health institutes in Shanghai, China from November 1993 to March 1998. The abortion cohort consisted of pregnant women whose previous pregnancies were terminated by vacuum aspiration (98%). The reference cohort consisted of primigravidae. Subjects were recruited at 35-63 days of gestational age. A total of 2953 pregnant women were enrolled; 1502 in the abortion cohort, 1451 in the reference cohort.
There were only 62 women lost to follow-up. The remaining 2891 women had 2732 live births, and 137 miscarriages. About 5.5% of pregnancies in the abortion cohort were miscarried and 4.0% in the reference cohort. Once potential confounders were controlled for by logistic regression, odds ratio (OR) of miscarriage between the abortion cohort and the reference cohort was 1.55 (95% CI: 1.08-2.23). The adjusted OR were 2.44 (95% CI: 1.16-5.15) among women who were recruited within 49 days of gestational age, and 1.72 (95% CI: 1.09-2.72) for the first-trimester miscarriage.
Induced abortion by vacuum aspiration is associated with an increased risk of first-trimester miscarriage in the subsequent pregnancy.
Follow-up information on subsequent pregnancies after mifepristone (RU486)-induced abortion is scarce. The authors examined whether one mifepristone-induced first-trimester abortion affects the outcome of a subsequent wanted pregnancy. In a study conducted in 1998-2001 at antenatal clinics in Beijing, Chengdu, and Shanghai, China, the authors enrolled 4,925 women with no history of induced abortion, 4,931 women with one previous mifepristone-induced abortion, and 4,800 women with one previous surgical abortion and followed them through pregnancy and childbirth. The adjusted odds ratio for preterm delivery in women with one mifepristone abortion compared with women with no abortion was 0.77 (95% confidence interval: 0.61, 0.98). Although the mean birth weight of infants born to women with mifepristone abortion was 33 g (95% confidence interval: 17, 49) higher than that of infants born to women with no abortion, the frequencies of low birth weight and mean lengths of pregnancy were similar. There were no significant differences in risk of preterm delivery, frequency of low birth weight, or mean infant birth weight in the comparisons of women with previous mifepristone abortion and women with surgical abortion. This study suggests that one early abortion induced by mifepristone in nulliparous women has no adverse effects on the outcome of a subsequent pregnancy.
Abortion has been alleged to cause sterility. To address this issue, 1235 postabortal women, 912 women recently delivered, and 939 women from the authors' gynecology clinics were studied for as long as 3.5 years. Cumulative pregnancy rates were similar for abortion group patients, delivery group patients, and the previously pregnant clinic group. When pregnancy rates were examined by different assumptions as to entrance into follow-up, the abortion group differed only in a somewhat lower pregnancy rate after nine months, when the use of contraceptives was greater than that of the other two groups. Pregnancy rates for all three groups were influenced by age of subject, parity, race, marital and Medicaid status, and a history of urinary tract infections. Induced abortion status did not influence pregnancy rates except that women reporting three or more induced abortions had a higher pregnancy rate.
We compared the prior pregnancy histories of 85 multigravid women with an ectopic pregnancy and 498 multigravid delivery comparison subjects. We found a relationship between the number of prior induced abortions and the risk of ectopic pregnancy: the crude relative risk of ectopic pregnancy was 1.6 for women with one prior induced abortion and 4.0 for women with two or more prior induced abortions; however, use of multivariate techniques to control confounding factors reduced the relative risks to 1.3 (95 per cent confidence interval, 0.6-2.7) and 2.6 (95 per cent confidence interval, 0.9-7.4), respectively. The analysis suggests that induced abortion may be one of several risk factors for ectopic pregnancy, particularly for women who have had abortions plus pelvic inflammatory disease or multiple abortions.
We compared prior pregnancy histories of two groups of multigravidas--240 women having a pregnancy loss up to 28 weeks' gestation and 1,072 women having a term delivery. Women who had had two or more prior induced abortions had a twofold to threefold increase in risk of first-trimester spontaneous abortion, loss between 14 to 19 and 20 to 27 weeks. The increased risk was present for women who had legal induced abortions since 1973. It was not explained by smoking status, history of prior spontaneous loss, prior abortion method, or degree of cervical dilatation. No increase in risk of pregnancy loss was detected among women with a single prior induced abortion. We conclude that multiple induced abortions do increase the risk of subsequent pregnancy losses up to 28 weeks' gestation.
Thesis (Ph. D.)--University of Washington, 1977. Includes bibliographical references (ℓ66-68). Photocopy.
A study of 576 pregnant women, whose previous pregnancy had been terminated by legally induced abortion, has shown that the rate of pregnancy and delivery complications could not be correlated with the interval between the abortion and the subsequent pregnancy, nor with the gestational age at the time of abortion, nor the number of previous induced abortions. Neither was the abortion technique found to correlate with the frequency of complications in a subsequent pregnancy. It was found, however, that more infants with a birth weight below 2 501 grams were born to women whose cervical canal during abortion had been dilated more than 12 mm, and by women who had been submitted to récurettage. The latter group also demonstrated a higher frequency of retained placenta or placental tissue.
The incidence of spontaneous abortions was observed among 31,917 women followed from their first prenatal visit. Life-table analysis showed that losses in the first trimester were not significantly affected by previous induced abortions, nor was any change in the risk of second-trimester losses detected among the 1493 parous women who reported having had induced abortions after childbirth. There was, however, an increase in the incidence of midtrimester losses among the 2019 nulliparous women with previous induced abortions; the age-adjusted rate of loss was 59.9 per 100,000 women at risk per day, as compared with 24.2 among the 12,042 control nulliparous women (P less than 0.001). The relative risk increased with the number of previous induced abortions and was not explained by the distribution of demographic and social variables. The risk decreased from 3.27 (95 per cent confidence limits, 1.72 to 6.23) after abortions induced before 1973, mainly by dilation and curettage, to 1.42 (0.76 to 2.65) after those done since 1973, when the more gentle technic of cervical dilation by use of laminaria was introduced. These findings indicate that there is little or no risk of spontaneous abortions after induced abortions when performed by current technics.
The frequency of pregnancy and delivery complications in women whose previous pregnancy had been terminated by a legally induced abortion is evaluated in a prospective and a retrospective study. Bleeding before 28 weeks of gestation and retention of placenta or placental tissue occurred more frequently after legal abortion that in a control group matched for age, parity, and socio-economic status. Other pregnancy and delivery complications did not occur more frequently after legal abortion. It is of particular interest that the study could not demonstrate an increased frequency of low birth weight among women whose previous pregnancy had been terminated by legal abortion.
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Both a prospective and a retrospective study were carried out to evaluate longterm consequences of a legally induced abortion. Data used for the study were taken from a WHO (World Health Organization) study of longterm sequelae of induced abortion. Both studies used Danish women and matched controls. It was found that bleeding before 28 weeks of gestation and retention of placenta or placental tissue in subsequent pregnancies occurred more frequently in women who had previously experienced a legally induced abortion. No comparison revealed an increased rate of low birth weights for subsequent births. Other pregnancy and delivery complications were not found to occur more frequently after legal abortion. The study did not establsh with certainty that the risk of prematurity is elevated following induced abortion. Previous studies of longterm sequelae of induced abortion have failed to state the type of abortion technique used. No correlation between type and later prematurity has been found.
Prior induced abortion and outcome of the next pregnancy are investigated, allowing for two intervening and potentially confounding variables: 1) length of interval between the termination of the first pregnancy and the conception of the next (inter-pregnancy interval) and 2) the utilization of contraception during this interval. Results show that non-contracepting (susceptibility) intervals which immediately precede a subsequent pregnancy are significantly shorter following an induced abortion than those following a spontaneous abortion or delivery. A life table analysis of all susceptibility intervals confirmed this finding. To investigate outcome of subsequent pregnancy as influenced by preceding pregnancy outcome, inter-pregnancy interval and contraceptive use in the interval, a categorical linear model has been developed. Among non-contraceptors, the model indicates no differences in proportions of succeeding adverse outcomes (spontaneous abortion or low birth weight) regardless of inter-pregnancy interval and whether or not the preceding pregnancy had been terminated by an induced abortion. For the contraceptive users, however, proportions of adverse outcomes increased with length of inter-pregnancy interval, and, within each interval category, proportion of adverse outcomes was higher when the preceding pregnancy had terminated in an induced abortion.
In the fall of 1972, interviews were conducted with 948 Yugoslavian women whose first pregnancies had been terminated by induced abortion (222) or delivery (726) during 1968-1969. Subjects were indentified from records of the Obstetrics and Gynecology Clinic of Skopje University, Macedonia. Subsequent pregnancies were studied to determine the relative effects of first-pregnancy abortion or delivery on incidences of adverse outcomes. No significant difference were found between first-pregnancy aborters and deliverers for subsequent conception rates, spontaneous abortions, or low-birth-weight rates. The data suggest that while induced abortion of the first pregnancy did not protect against the greater risk of low birth weight for a primiparous birth, neither did it increase that risk. The high proportion of women who denied their abortion raises questions about results of retrospective abortion studies which depend on patient recall.
A mail questionnaire of 2, 825 and an interview survey of 650 Japanese women age 20–44 was conducted in March 1971. Results
show that the prevalence of induced abortion in Kochi prefecture is higher than previous reports based on national family
planning surveys in Japan.
The pregnancy histories of 2, 476 mail survey and 614 interview survey respondents who had completed at least one pregnancy
prior to the date of questioning showed that:
(a) Pregnancy wastage and infertility were reported in similar proportions of women who did and did not use induced abortion;
(b) Live births and pregnancies (excluding induced abortions) corrected for age and duration of marriage, showed similar ratios
among women who did and did not use induced abortion.
(c) Induced abortion represented excess fertility in all age groups and was associated with a high degree of contraceptive
failure. Women who used induced abortion attempted more use of contraception than non-aborters. Younger women used more efficient
contraceptive methods than older women.
(d) Maternal age-specific analysis showed that the outcomes of pregnancies subsequent to an induced abortion were qualitatively
similar to the outcomes of pregnancles in women who did not use abortion.
(e) A secular decline in fertility occurred after age 30. This was accompanied by an increase in pregnancy wastage seen in
similar proportions among women whether or not they had used induced abortion.
An inverse relationship between education and the use of induced abortion was found. This was independent of age.
Younger marriage age and longer duration of marriage was associated with higher prevalence of induced abortion. The distribution
of socioeconomic characteristics was not related to abortion status.
The history and present status of abortion practices in Japan are discussed.
The authors reviewed over 200 anecdotal, descriptive, and observational epidemiologic reports, and identified more than 150 studies in 11 languages from 21 countries that employed one of four standard research designs. Using these investigations as their foundation, they evaluated the influence of induced abortion on secondary infertility, ectopic pregnancy, spontaneous abortion, shortened gestation, low birth weight, complications of pregnancy or delivery, and infant outcome. They systematically re-examined the data from each of these investigations. Where the data were incomplete, they requested additional information directly from the authors. They categorized these studies by such factors as their research design, the type of abortion procedure used, and whether potential confounding variables were considered. Finally, to compare the relative power of studies, they also calculated, where possible, the 95% confidence interval around the point estimate of relative risk. Studies that did not take into account the many confounding factors associated with both induced abortion and adverse pregnancy outcome were of limited value because women who obtain induced abortions differ substantially from those who do not. Results from these studies usually indicated a higher risk estimate than results from better designed, controlled investigations.
In a historical prospective study covering 1970-1978, the authors evaluated the outcome of delivery to 429 parous women subsequent to a legally induced first-trimester vacuum-aspiration abortion during 1970-1975 in Uppsala County, Sweden. This outcome was compared with the outcome of delivery to 391 randomly chosen matched parous women and that of all parous women in Sweden in 1975. Confounding variables were controlled for in multiple regression analysis using infant birth weight and gestational duration as dependent variables. In this analysis, no harmful effects of vacuum-aspiration abortion were found. Pre-term deliveries and low birth weight infants did not occur more frequently after such abortions. The study did not disclose any association between vacuum-aspiration abortion in parous women and an unfavorable outcome of subsequent delivery.
To the Editor.—
The article "Association of Induced Abortion With Subsequent Pregnancy Loss" by Levin et al (1980;243:2495) reported that women who had had two or more previous induced abortions had a twofold to threefold increase in risks of pregnancy losses up to 28 weeks of gestation.This is to point out that there is an inherent statistical problem associated with a study of pregnancy loss as a sequela to previous induced abortion. The problem arises because of two factors. First, there is competition between induced abortion and early spontaneous fetal loss in pregnancies of those women who are determined not to carry the pregnancy to term. These pregnancies may be referred to as unwanted pregnancies, and they result in either spontaneous or induced abortion. When the outcome is spontaneous abortion before eventually expected induced abortion, it is included as an observation in the case group in a case-control study
Akron Center for Reproductive Health, Inc., 651 F.21) 1198 (6th Cir
- Citv
- Akron
Citv of Akron v. Akron Center for Reproductive Health, Inc., 651 F.21) 1198 (6th Cir. 1981).
Short-Term Complications of Uterine Evacua-tion Techniqtues for Abortion at 12 Weeks' Gestation or Earlier
- A Grimes
- C W Tyler
- G I Jr
- J J Zatuchni
- J J Sciarra
- D A Speidel
- W Grimes
- Cates
- Jr
A. Grimes and C. W. Tyler, Jr., "Short-Term Complications of Uterine Evacua-tion Techniqtues for Abortion at 12 Weeks' Gestation or Earlier," in G. I. Zatuchni, J. J. Sciarra and J. J. Speidel, eds., Pregnancy Termination: Procedures, Safety and New Developments, Harper and Row, Hagerstown, Md., 1979, p. 127; and D. A. Grimes and W. Cates, Jr., "Com-plications from Legally Induced Abortions: A Review," Obstetrics and Gynecology Survey, 34:177, 1979.
Low Birth-Weight After Indticed Abortion in Singapore," paper pre-sented at the annual meeting of the
- T H Lean
- C J R Hogue
- J Wood
T. H. Lean, C. J. R. Hogue and J. Wood, "Low Birth-Weight After Indticed Abortion in Singapore," paper pre-sented at the annual meeting of the American Public Health Association, Washington, D.C., Oct. 31, 1977.
Effect of Induced Abortion on Subsequent Reproductive Function
- V M Logrillo
- P Quickenton
- G D Therriault
- M A Ellrott
V. M. Logrillo, P. Quickenton, G. D. Therriault and M. A. Ellrott, Effect of Induced Abortion on Subsequent Reproductive Function, New York State Health Depart-ment, Albany, 1980.
Ef-fects of Induced Abortion on Subsequent Reproductive Function and Pregnancy OutcomeInduced Abortion and Spontane-ous Fetal Loss in Subsequent Pregnancies
- C S Chung
- P G Steinhoff
- R G Smith
- C S Chung
- R G Smith
- P G Stein-Hoff
C. S. Chung, P. G. Steinhoff and R. G. Smith, Ef-fects of Induced Abortion on Subsequent Reproductive Function and Pregnancy Outcome, University of Hawaii, Honolulu, 1981; C. S. Chung, R. G. Smith, P. G. Stein-hoff and M. Ming-Pi, "Induced Abortion and Spontane-ous Fetal Loss in Subsequent Pregnancies," Amenrican Journal of Public Health, 72:548, 1982; and, "In-dticed Abortion and Ectopic Pregnancy in Subsequenit Pregnancies," American Journal of Epidemiology, 115: 579, 1982.
Prospective Study of the Outcome of Pregnancy Subsequent to Previous In-duced Abortion, Downstate Medical Center, State Uni-versity of
- Varma
Varma, Prospective Study of the Outcome of Pregnancy Subsequent to Previous In-duced Abortion, Downstate Medical Center, State Uni-versity of New York, New York, 1981.
Induced Abortion and Secon-dary Infertility British Journal of Obstetrics and Gyne-cologyRole of Induced Abortion in Secondary Infertility
- D Trichopoulos
- N Handanos
- J Danezis
- A Kalan
- V Kalapothaki
- J R Daling
- L R Spadori
- I Emanuel
D. Trichopoulos, N. Handanos, J. Danezis, A. Kalan-didi and V. Kalapothaki, "Induced Abortion and Secon-dary Infertility, " British Journal of Obstetrics and Gyne-cology, 83:645, 1976; and J. R. Daling, L. R. Spadori and I. Emanuel, "Role of Induced Abortion in Secondary Infertility," Obstetrics and Gynecologyt, 57:59, 1981. Volume 15, Number 3, May /June 1983 Vacuum Aspiration Abortion and Future Childbearing 22. D. Trichopoulos et al., 1976, op. cit. (see reference 21).