Abortion is a generic term for pregnancies that do not end in a livebirth or a stillbirth. It is the premature expulsion from the uterus of the products of conception, which include the placenta, bag of waters, and fetus, if present.
TYPES OF ABORTION
There are two types of abortions. Spontaneous abortion refers to a natural biological process by which some pregnancies end. Induced abortion refers to pregnancies terminated through human intervention.
Spontaneous Abortions. A large percentage of the products of the union of an egg and a sperm never become infants. If there is something seriously wrong with the fetus, the uterus often expels it. This may occur very early in the pregnancy, with the woman only experiencing a larger than usual blood flow around the time of her expected menstrual period, or it may occur later in the pregnancy. This latter event is commonly called a miscarriage, but technically it is a spontaneous abortion if it occurs before twenty weeks of pregnancy. Spontaneous abortions are often the body's way of preventing the birth of a defective child, although sometimes they are due to maternal health problems.
Induced Abortions. In contrast, induced abortions result from the planned interruption of a pregnancy. Throughout recorded history, humans have taken a variety of steps to control family size: before conception by delaying marriage or through abstinence or contraception; or after the birth by
Therapeutic Abortions. This term refers to abortions thought necessary because of fetal anomalies, rape, or to protect the health of the mother when a birth might be life threatening or physically or psychologically damaging.
Elective or Voluntary Abortions. Interruption of a pregnancy before viability at the woman's request for reasons other than fetal anomalies or maternal risk is often referred to as elective or voluntary abortion. Such abortions often result from social problems, such as teenage pregnancy or non-marital births; economic difficulties, such as insufficient income to support a child; or inappropriate timing.
Legal and Illegal Abortions. Induced abortions may be legal or illegal. According to the United States Centers for Disease Control and Prevention (CDC), the federal agency that collects data on abortions, a legal abortion is "a procedure, performed by a licensed physician or someone acting under the supervision of a licensed physician, that was intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age." An illegal abortion may be self-induced, induced by someone who is not a physician or not acting under her or his supervision, or induced by a physician under conditions that violate state laws governing abortions.
A HISTORICAL PERSPECTIVE
Almost all human societies place a high value on human life. Thus, the further along the continuum from heterosexual intercourse to a live child, the less likely is the method of fertility control to be allowed. In the modern period, most societies allow contraception, but there is more variability around abortion. The leading institutional opposition comes from the Roman Catholic Church, but other institutions also take active positions against abortion. Survey research suggests that many Americans are ambivalent about whether abortion should be legal and, if so, under what circumstances.
Induced abortion was almost universally illegal at the beginning of the twentieth century. This changed first in the early years of the Soviet Union, which made abortion legal, widely available, and encouraged as the primary method of fertility control. In the period after World War II, abortion was legalized first in the Scandinavian countries and later in most of Western and Eastern Europe. With the broaching of the Iron Curtain in the early 1990s, abortion was legalized in more of Eastern Europe, while the more restrictive policy in West Germany was extended to the former East Germany. At the beginning of the twenty-first century, abortion was legal in most of England and Asia, but illegal in most of Africa and South America.
In the United States, abortion was universally illegal from at least the late nineteenth century until the mid-1960s, when an abortion reform movement led to legalization of abortion in some states. (The regulation of abortion, like most medical issues, is a state function.) Then, in its 1973 Roev. Wade decision, the United States Supreme Court found a constitutional right to abortion before viability, at that time about twenty-eight weeks. (By the beginning of the twenty-first century, advances in the techniques of caring for very premature infants had reduced the age of viability to around twenty-three weeks.) The Court stated, however, that after viability is reached, the state's important and legitimate interest in potential life becomes compelling and it may regulate and even prohibit abortions, with the exception of those necessary to preserve the life or health of the mother.
ACCESS TO ABORTIONS
Access to legal abortions is limited by laws and regulations, financial considerations, and the availability of providers.
Laws and Regulations. Since the 1973 decision, many states have enacted measures to limit abortion, which have led to considerable litigation.
Some laws have been disallowed as inconsistent with Roe, while others have been allowed. For example, in the late 1990s, about thirty states restricted the access of minors to abortions by requiring the notification or the consent of one or both parents before an abortion could be performed, and more are considering such legislation. The Supreme Court requires that states with parental notification or consent laws must provide for a judicial bypass; that is, the minor must be allowed to obtain permission from a court for the abortion if she is unwilling or unable to seek permission from her parent(s). States may also require a waiting period between the request for an abortion and its actual performance. Or they may require the physician who is to conduct the abortion to inform the mother about the fetus's stage of development and about alternative ways of managing an unwanted pregnancy, such as putting the baby up for adoption.
Financial Considerations. Abortion is not among the medical procedures covered by Medicaid, the federal-state program that provides health care to many poor women. Federal law, the socalled Hyde Amendment, passed in 1977 and amended in 1993, prohibits the use of federal Medicaid funds for abortion except in cases of rape, incest, or when the life of the pregnant
woman is in danger. Some states use their own Medicaid funds to pay for abortions that physicians consider "medically necessary," and a few fund them in cases of fetal anomaly or grave physical health danger. Some private organizations, such as Planned Parenthood agencies, assist low-income women in states with restrictive funding policies by performing abortions for reduced fees. In 1999, less than two-fifths of women with employer-based health insurance were covered for abortion services.
Provider Availability. On the basis of a survey of abortion providers, the Alan Guttmacher Institute estimated that in 1996 there were slightly over two thousand abortion providers in the United States, a drop of 14 percent from 1992, perhaps as a result of anti-abortion publicity and disturbances. Eighty-nine of the country's 320 metropolitan areas had no known abortion providers and an additional twelve had providers who together reported fewer than fifty abortions. Abortion providers were even less available in non-metropolitan areas.
According to the Guttmacher survey, 452 abortion clinics (defined as nonhospital facilities in which half or more of patient visits were for abortion services) performed 70 percent of the abortions in 1996. Four hundred and seventeen other clinics performed 21 percent of the abortions; 703
hospitals performed 7 percent (only 9% of those on an in-patient basis); and 470 physicians' offices performed 3 percent.
NUMBER AND RATES OF ABORTIONS
There is no definitive information about the number and rate of spontaneous abortions, although worldwide it is estimated that approximately 15 percent of women who have been pregnant for five or more weeks spontaneously abort or experience stillbirths.
The CDC has been conducting surveillance of legal induced abortions in the United States since 1969. It reported 1,186,039 legal abortions in 1997, but noted that this was probably an underestimate. The number of abortions per 1,000 women between 15 and 44 years of age (the abortion rate) was 20 and the number of abortions per 1,000 live births (the abortion ratio) was 306. Most legal abortions were performed in California, New York City, Texas, and Florida. The number of legal abortions increased from 1970 until 1990 and, with the exception of 1996, has fallen ever since.
Both the abortion rate and the abortion ratio began to decline earlier (see Figure 1).
Information on the characteristics of the women who obtain abortions and the timing of abortions is available from most, but not all, areas. Based on the information available in 1997, women between the ages of 20 and 24 obtained almost a third (31.5%) of all abortions. Abortion rates were highest for women between the ages of 20 and 24 and lowest for the youngest and oldest women. Abortion ratios, however, were highest for women under 20 and for women 40 and over, at least partially because there are fewer births in these age groups (see Figures 2–3). Slightly over half(56.3%) of women who obtained abortions were white, but the abortion rate and the abortion ratio for African Americans was slightly more than two and a half times the rate for white women. For Hispanic women in the District of Columbia, New York City, and the twenty-six states reporting ethnicity, the abortion ratio was similar to the one for non-Hispanics in the same areas, but the rate was higher. Seventy-nine percent of women who obtained abortions were unmarried, 41 percent had no previous live births, and half were obtaining abortions for the first time. Eighty-six percent of women obtaining abortions had the procedure during the first twelve weeks of pregnancy (see Figures 4–5).
ABORTIONS AND PUBLIC HEALTH
There is no evidence that abortions are detrimental to the health of women. The CDC reported that in 1992, the last year for which data on abortionrelated deaths were available, only twenty-seven women died of abortion-related causes, ten due to induced abortions, seventeen to spontaneous abortions, and none to illegal abortions. This is a case-fatality rate for legal induced abortions of 0.7 per 100,000 legal induced abortions, a lower fatality rate than for pregnancies. (In 1992, the maternal mortality rate was 7.8 per 100,000 live births.) Injuries and illness, both physical and emotional, are also rare. Deaths and other adverse consequences are more likely to occur when women are unable to obtain abortions legally and attempt to induce abortions themselves or turn to providers outside the conventional medical care system. There were thirty-nine deaths due to illegal abortions in 1972 before the Roe v. Wade decision and nineteen in 1973. Since then, the number of such deaths has declined markedly: There were only two between 1988 and 1992. Studies in Czechoslovakia have shown that women who are denied abortions suffer psychological difficulties.
Most induced abortions today are the result of unwanted pregnancies. The best way to prevent this safe—but uncomfortable and usually undesirable—procedure is to make family planning counseling and methods easily available to all women.
LORRAINE V. KLERMAN
JACOB A. KLERMAN
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