Abortion

Abortion is the termination of a pregnancy by the removal or expulsion of

a fetus or embryo from the uterus, resulting in or caused by its death.[1] An
abortion can occur spontaneously due to complications during pregnancy or can
be induced, in humans and other species. In the context of human pregnancies,
an abortion induced to preserve the health of the gravida (pregnant female) is
termed a therapeutic abortion, while an abortion induced for any other reason is
termed an elective abortion. The term abortion most commonly refers to the
induced abortion of a human pregnancy, while spontaneous abortions are usually
termed miscarriages.
Abortion has a low risk of maternal mortality except for abortions performed
unsafely, which result in 70,000 deaths and 5 million disabilities per year.
[2]
Abortions are unsafe when performed by persons without the proper skills or
outside of a medically safe environment. An estimated 42 million abortions are
performed annually with 20 million of those abortions done unsafely.[2] Forty
percent of the world's women are able to access therapeutic and elective
abortions within gestational limits.[3]
Abortion has a long history and has been induced by various methods including
herbal abortifacients, the use of sharpened tools, physical trauma, and
other traditional methods. Contemporary medicine utilizes medications and
surgical procedures to induce abortion. The legality, prevalence, cultural, and
religious views on abortion vary substantially around the world. In many parts of
the world there is prominent and divisive public controversy over the ethical and
legal issues of abortion. Abortion and abortion-related issues feature prominently
in the national politics in many nations, often involving the opposing pro-
life and pro-choice worldwide social movements (both self-named). Incidence of
abortion has declined worldwide, as access to family planning education and
contraceptive services has increased.[4]

Types
Spontaneous
Main article: Miscarriage
Spontaneous abortion (also known as miscarriage) is the expulsion of an embryo
or fetus due to accidental trauma or natural causes before approximately the
22nd week of gestation; the definition by gestational age varies by country.
[5]
 Most miscarriages are due to incorrect replication of chromosomes; they can
also be caused by environmental factors. A pregnancy that ends before 37
weeks of gestation resulting in a live-born infant is known as a "premature birth".
When a fetus dies in utero after about 22 weeks, or during delivery, it is usually
termed "stillborn". Premature births and stillbirths are generally not considered to
be miscarriages although usage of these terms can sometimes overlap.
Between 10% and 50% of pregnancies end in clinically apparent miscarriage,
depending upon the age and health of the pregnant woman.[6] Most miscarriages
occur very early in pregnancy, in most cases, they occur so early in the
pregnancy that the woman is not even aware that she was pregnant. One study
testing hormones for ovulation and pregnancy found that 61.9%
of conceptuses were lost prior to 12 weeks, and 91.7% of these losses occurred
subclinically, without the knowledge of the once pregnant woman.[7]
The risk of spontaneous abortion decreases sharply after the 10th week from
the last menstrual period (LMP).[6][8] One study of 232 pregnant women showed
"virtually complete [pregnancy loss] by the end of the embryonic period" (10
weeks LMP) with a pregnancy loss rate of only 2 percent after 8.5 weeks LMP.[9]
The most common cause of spontaneous abortion during the first trimester is
chromosomal abnormalities of the embryo/fetus,[10] accounting for at least 50% of
sampled early pregnancy losses.[11]Other causes include vascular disease (such
as lupus), diabetes, other hormonal problems, infection, and abnormalities of the
uterus.[10] Advancing maternal age and a patient history of previous spontaneous
abortions are the two leading factors associated with a greater risk of
spontaneous abortion.[11] A spontaneous abortion can also be caused by
accidental trauma; intentional trauma or stress to cause miscarriage is
considered induced abortion or feticide.[12]
Induced
A pregnancy can be intentionally aborted in many ways. The manner selected
depends chiefly upon the gestational age of the embryo or fetus, which increases
in size as the pregnancy progresses.[13]Specific procedures may also be selected
due to legality, regional availability, and doctor-patient preference. Reasons for
procuring induced abortions are typically characterized as either therapeutic or
elective. An abortion is medically referred to as a therapeutic abortion when it is
performed to:

 save the life of the pregnant woman;[14]

 preserve the woman's physical or mental health;[14]
 terminate pregnancy that would result in a child born with a congenital
disorder that would be fatal or associated with significant morbidity;[14] or
 selectively reduce the number of fetuses to lessen health risks associated
with multiple pregnancy.[14]
An abortion is referred to as elective when it is performed at the request of the
woman "for reasons other than maternal health or fetal disease."[15]

Methods

Gestational age may determine which abortion methods are practiced.

Medical
Main article: Medical abortion
"Medical abortions" are non-surgical abortions that use pharmaceutical drugs. As
of 2005, medical abortions constitute 13% of all abortions in the United States.
[16]
 Combined regimens include methotrexate or mifepristone, followed by
a prostaglandin (eithermisoprostol or gemeprost: misoprostol is used in the U.S.;
gemeprost is used in the UK and Sweden.) When used within 49 days gestation,
approximately 92% of women undergoing medical abortion with a combined
regimen completed it without surgical intervention.[17] Misoprostol can be used
alone, but has a lower efficacy rate than combined regimens. In cases of failure
of medical abortion, vacuum or manual aspiration is used to complete the
abortion surgically.
Surgical

A vacuum aspiration abortion at eight weeks gestational age (six weeks after fertilization).
1: Amniotic sac
2: Embryo
3: Uterine lining
4: Speculum
5: Vacurette
6: Attached to a suction pump

In the first 12 weeks, suction-aspiration or vacuum abortion is the most common

method.[18] Manual vacuum aspiration (MVA) abortion consists of removing
the fetus or embryo, placenta and membranes by suction using a manual
syringe, while electric vacuum aspiration (EVA) abortion uses an electric pump.
These techniques are comparable, and differ in the mechanism used to apply
suction, how early in pregnancy they can be used, and whether cervical dilation
is necessary. MVA, also known as "mini-suction" and "menstrual extraction", can
be used in very early pregnancy, and does not require cervical dilation. Surgical
techniques are sometimes referred to as 'Suction (or surgical) Termination Of
Pregnancy' (STOP). From the 15th week until approximately the 26th,dilation and
evacuation (D&E) is used. D&E consists of opening the cervix of the uterus and
emptying it using surgical instruments and suction.
Dilation and curettage (D&C), the second most common method of surgical
abortion, is a standard gynecological procedure performed for a variety of
reasons, including examination of the uterine lining for possible malignancy,
investigation of abnormal bleeding, and abortion. Curettage refers to cleaning the
walls of the uterus with a curette. The World Health Organization recommends
this procedure, also called sharp curettage, only when MVA is unavailable.[19]
Other techniques must be used to induce abortion in the second trimester.
Premature delivery can be induced with prostaglandin; this can be coupled with
injecting the amniotic fluid with hypertonic solutions containing saline or urea.
After the 16th week of gestation, abortions can be induced by intact dilation and
extraction (IDX) (also called intrauterine cranial decompression), which requires
surgical decompression of the fetus's head before evacuation. IDX is sometimes
called "partial-birth abortion," which has been federally banned in the United
States. A hysterotomy abortion is a procedure similar to a caesarean section and
is performed under general anesthesia. It requires a smaller incision than a
caesarean section and is used during later stages of pregnancy.[20]
The Royal College of Obstetricians and Gynaecologists has recommended that
an injection be used to stop the fetal heart during the first phase of the surgical
abortion procedure to ensure that the fetus is not born alive.[21]
Other methods
Historically, a number of herbs reputed to possess abortifacient properties have
been used in folk medicine: tansy, pennyroyal, black cohosh, and the now-
extinct silphium (see history of abortion).[23] The use of herbs in such a manner
can cause serious—even lethal—side effects, such as multiple organ failure, and
is not recommended by physicians.[24]
Abortion is sometimes attempted by causing trauma to the abdomen. The degree
of force, if severe, can cause serious internal injuries without necessarily
succeeding in inducing miscarriage.[25] Both accidental and deliberate abortions
of this kind can be subject to criminal liability in many countries. In Southeast
Asia, there is an ancient tradition of attempting abortion through forceful
abdominal massage.[26] One of the bas reliefs decorating the temple ofAngkor
Wat in Cambodia depicts a demon performing such an abortion upon a woman
who has been sent to the underworld.[26]
Reported methods of unsafe, self-induced abortion include misuse
of misoprostol, and insertion of non-surgical implements such as knitting needles
and clothes hangers into the uterus. These methods are rarely seen in developed
countries where surgical abortion is legal and available.[27]

Health risks
See also: Health risks of unsafe abortion
Abortion, when legally performed in developed countries, is among the safest
procedures in medicine.[28][29] In such settings, risk of maternal death is between
0.2–1.2 per 100,000 procedures.[30][31][32][33] In comparison, by 1996, mortality from
childbirth in developed countries was 11 times greater.[30][34][35][36][37][38] Unsafe
abortions (defined by the World Health Organization as those performed by
unskilled individuals, with hazardous equipment, or in unsanitary facilities) carry a
high risk of maternal death and other complications.[39] For unsafe procedures,
the mortality rate has been estimated at 367 per 100,000 (70,000 women per
year worldwide).[2][40]
Physical health
Surgical abortion methods, like most minimally invasive procedures, carry a small
potential for serious complications.[41]
Surgical abortion is generally safe and the rate of major complications is
low[42] but varies depending on how far pregnancy has progressed and the
surgical method used.[43] Concerning gestational age, incidence of major
complications is highest after 20 weeks of gestation and lowest before the 8th
week.[43] With more advanced gestation there is a higher risk of uterine
perforation and retained products of conception,[44] and specific procedures
like dilation and evacuation may be required.[45]
Concerning the methods used, general incidence of major complications for
surgical abortion varies from lower for suction curettage, to higher for saline
instillation.[43] Possible complications includehemorrhage, incomplete abortion,
uterine or pelvic infection, ongoing intrauterine pregnancy,
misdiagnosed/unrecognized ectopic pregnancy, hematometra (in the
uterus), uterine perforation and cervical laceration.[46] Use of general
anesthesia increases the risk of complications because it relaxes uterine
musculature making it easier to perforate.[47]
Women who have uterine anomalies, leiomyomas or had previous difficult first-
trimester abortion are contraindicated to undertake surgical abortion
unless ultrasonography is immediately available and the surgeon is experienced
in its intraoperative use.[48] Abortion does not impair subsequent pregnancies, nor
does it increase the risk of future premature births, infertility, ectopic pregnancy,
or miscarriage.[29]
In the first trimester, health risks associated with medical abortion are generally
considered no greater than for surgical abortion.[49]
Mental health
Main article: Abortion and mental health
No scientific research has demonstrated that abortion is a cause of poor mental
health in the general population. However there are groups of women who may
be at higher risk of coping with problems and distress following abortion.[50] Some
factors in a woman's life, such as emotional attachment to the pregnancy, lack of
social support, pre-existing psychiatric illness, and conservative views on
abortion increase the likelihood of experiencing negative feelings after an
abortion.[51] The American Psychological Association (APA) concluded that
abortion does not lead to increased mental health problems.[52]
Some proposed negative psychological effects of abortion have been referred to
by anti-abortion advocates as a separate condition called "post-abortion
syndrome." However, the existence of "post-abortion syndrome" is not
recognized by any medical or psychological organization.[53][54][55]

Incidence
There are two commonly used methods of measuring incidence of abortion:

 Abortion rate - number of abortions per 1000 women between 15 and 44

years of age
 Abortion ratio - number of abortions out of 100 known pregnancies
(excluding miscarriages and stillbirths)
The number of abortions performed worldwide has decreased between 1995 and
2003 from 45.6 million to 41.6 million, which means a decrease in abortion rate
from 35 to 29 per 1000 women. The greatest decrease has occurred in the
developed world with a drop from 39 to 26 per 1000 women in comparison to the
developing world, which had a decrease from 34 to 29 per 1000 women. Out of a
total of about 42 million abortions 22 million occurred safely and 20 million
unsafely.[2]
On average, the frequency of abortions is similar in developing countries (where
abortion is generally restricted) to the frequency in developed countries (where
abortion is generally much less restricted).[56][3] Abortion rates are very difficult to
measure in locations where those abortions are illegal,[57] and anti-abortion
groups have criticized researchers for allegedly jumping to conclusions about
those numbers.[58] According to the Guttmacher Institute and the United Nations
Population Fund, the abortion rate in developing countries is largely attributable
to lack of access to modern contraceptives; assuming no change in abortion
laws, providing that access to contraceptives would result in about 25 million
fewer abortions annually, including almost 15 million fewer unsafe abortions.[59]
The incidence of induced abortion varies regionally. Some countries, such as
Belgium (11.2 out of 100 known pregnancies) and the Netherlands (10.6 per
100), had a comparatively low ratio of induced abortion. Others like Russia (62.6
out of 100), Romania (63 out of 100) and Vietnam (43.7 out of 100) had a high
ratio (data for last three countries of unknown completeness). The estimated
world ratio was 26%, the world rate - 35 per 1000 women.[60]
By gestational age and method

Histogram of abortions by gestational age in England and Wales during 2004. Average is
9.5 weeks. (left) Abortion in the United States by gestational age, 2004. (Data source:
Centers for Disease Control and Prevention) (right)

Abortion rates also vary depending on the stage of pregnancy and the method
practiced. In 2003, from data collected in those areas of the United States that
sufficiently reported gestational age, it was found that 88.2% of abortions were
conducted at or prior to 12 weeks, 10.4% from 13 to 20 weeks, and 1.4% at or
after 21 weeks. 90.9% of these were classified as having been done by
"curettage" (suction-aspiration, Dilation and curettage, Dilation and evacuation),
7.7% by "medical" means (mifepristone), 0.4% by "intrauterine instillation" (saline
or prostaglandin), and 1.0% by "other" (including hysterotomy andhysterectomy).
[61]
 The Guttmacher Institute estimated there were 2,200 intact dilation and
extraction procedures in the U.S. during 2000; this accounts for 0.17% of the
total number of abortions performed that year.[62] Similarly, in England and Wales
in 2006, 89% of terminations occurred at or under 12 weeks, 9% between 13 to
19 weeks, and 1.5% at or over 20 weeks. 64% of those reported were by vacuum
aspiration, 6% by D&E, and 30% were medical.[63] Later abortions are more
common in China, India, and other developing countries than in developed
countries.[64]
By personal and social factors

A bar chart depicting selected data from the 1998 AGI meta-study on the reasons women stated
for having an abortion.

A 1998 aggregated study, from 27 countries, on the reasons women seek to

terminate their pregnancies concluded that common factors cited to have
influenced the abortion decision were: desire to delay or end childbearing,
concern over the interruption of work or education, issues of financial or
relationship stability, and perceived immaturity.[65] A 2004 study in which
American women at clinics answered a questionnaire yielded similar results.[66] In
Finland and the United States, concern for the health risks posed by pregnancy
in individual cases was not a factor commonly given; however, in Bangladesh,
India, and Kenya health concerns were cited by women more frequently as
reasons for having an abortion.[65] 1% of women in the 2004 survey-based U.S.
study became pregnant as a result of rape and 0.5% as a result of incest.
[66]
 Another American study in 2002 concluded that 54% of women who had an
abortion were using a form of contraception at the time of becoming pregnant
while 46% were not. Inconsistent use was reported by 49% of those
using condoms and 76% of those using the combined oral contraceptive pill; 42%
of those using condoms reported failure through slipping or breakage.[67] The
Guttmacher Institute estimated that "most abortions in the United States are
obtained by minority women" because minority women "have much higher rates
of unintended pregnancy."[68]
Some abortions are undergone as the result of societal pressures. These might
include the stigmatization of disabled people, preference for children of a specific
sex, disapproval of single motherhood, insufficient economic support for families,
lack of access to or rejection of contraceptive methods, or efforts
toward population control (such as China's one-child policy). These factors can
sometimes result in compulsory abortion or sex-selective abortion.
Unsafe abortion

Soviet poster circa 1925, warning against midwives performing abortions. Title translation:
"Abortions performed by either trained or self-taught midwives not only maim the woman, they
also often lead to death."

Main article: Unsafe abortion

One of the main determinants of the availability of safe abortions is the legality of
the procedure. Forty percent of the world's women are able to access therapeutic
and elective abortions within gestational limits.[3] Women seeking to terminate
their pregnancies sometimes resort to unsafe methods, particularly where and
when access to legal abortion is restricted. The World Health
Organization (WHO) defines an unsafe abortion as being "a procedure ... carried
out by persons lacking the necessary skills or in an environment that does not
conform to minimal medical standards, or both."[69] Unsafe abortions are
sometimes known colloquially as "back-alley" abortions. They may be performed
by the woman herself, another person without medical training, or a professional
health provider operating in sub-standard conditions. Unsafe abortion remains a
public health concern due to the higher incidence and severity of its associated
complications, such as incomplete abortion, sepsis, hemorrhage, and damage to
internal organs. While maternal mortality seldom results from safe abortions,
unsafe abortions result in 70,000 deaths and 5 million disabilities per year.
[2]
 Complications of unsafe abortion are said to account, globally, for
approximately 13% of all maternal mortalities, with regional estimates including
12% in Asia, 25% in Latin America, and 13% in sub-Saharan Africa.[70]Although
 the global rate of abortion declined from 45.6 million in 1995 to 41.6 million in
2003, unsafe procedures still accounted for 48% of all abortions performed in
2003.[71] Health education, access to family planning, and improvements in health
care during and after abortion have been proposed to address this phenomenon.
[72]

Types of Abortion

Surgical

Home pregnancy tests available at a drug store can indicate pregnancy early after conception.
Terminations performed in this very early time frame have sometimes been termed menstrualextractions.

 Abortions performed prior to nine weeks from the last menstrual period (seven weeks from
conception) are performed either surgically (a procedure) or medically (with drugs). 

 From nine weeks until 14 weeks, an abortion is performed by a dilatation and suction curettage
procedure. 

 After 14 weeks, surgical abortions are performed by a dilatation and evacuation procedure. 

 After 20 weeks of gestation, abortions can be performed by labor induction,prostaglandin labor

induction, saline infusion, hysterotomy, or dilatation and extraction.

Most abortions are performed in an outpatient office setting (doctor's office, ambulatory clinic) under local
anesthesia with or without sedation.
Medical

Medical abortion is a term applied to an abortion brought about by medication taken to induce it. This can
be accomplished with a variety of medications given either as a single pill or a series of pills. Medical
abortion has a success rate that ranges from 75-95%, with about 2-4% of failed abortions requiring
surgical abortion and about 5-10% of incomplete abortions (not all tissue is expelled and it must be taken
out by surgery), depending on the stage of gestation and the medical products used.

Women who select a medical abortion express a slightly greater satisfaction with their route of abortion
and, in the majority of cases, express a wish to choose this method again should they have another
abortion. Research needs to be performed to more clearly establish which method is best, which
medications are preferable, and how successfully women and adolescents can diagnose a complete
versus an incomplete abortion.

Medical abortions can provide some measure of safety in that they eliminate the risk of injury to a
woman's cervix or uterus from surgical instruments. Some women require an emergency surgical
abortion, and, for safety concerns, women undergoing medical abortions need access to providers willing
to perform a surgical abortion should it be necessary.
In September 2000, the FDA approved the drug mifepristone (known as RU-486) for use in a specific
medical plan that includes giving another drug, misoprostol, for those who do not abort with mifepristone
alone. Methotrexate and misoprostol are drugs approved for other conditions that can also be used for
medical termination of pregnancy. Additional research will determine exactly which drug or combination is
ideal for medical abortions.

The process of a medical abortion involves bleeding, often like a heavy menstrual period, which must be
differentiated from hemorrhage (a serious problem). Regardless of the amount of tissue passed, the
woman must see a doctor for evaluation to make sure the process is complete (and not an incomplete
abortion). A rare and serious infection by the bacteria Clostridium sordellii is related to medical abortions.
There have been reports of four deaths associated with this infection since 2001. Fatal infections are rare,
occurring in fewer than 1 in 100,000 uses of mifepristone medical abortions, which is far less than the
number of cases of fatal penicillin-induced anaphylaxis (1 in 50,000 uses).

Explanation of the Procedures

Once your pregnancy has been confirmed, and the doctor knows how many
weeks along the pregnancy is, and you have decided to end the pregnancy, the
procedure offered typically reflects your stage of gestation. Early abortions can
be accomplished medically or surgically, but most facilities do not have the
protocols established or personnel with the technical ability to offer medical
abortions (with pills). Therefore, most abortions are performed surgically.

 Women often travel far for their abortion procedure and feel comfortable
completing the preoperative preparation in a short office visit. In states where
laws require waiting periods, this can be done in stages. 

 The assessment process involves only a targeted history, physical

examination, laboratory work, and ultrasound (including dating of the
pregnancy, if indicated) followed by a counseling session. 

 Second-trimester abortion preparation is more difficult. Preparing the

cervix in less than 24 hours is almost impossible, but the basic assessment
process is identical. 

 Ultrasound examinations may be used to look specifically for obvious

problems with the fetus. 

 Some centers also offer an intra-amniotic injection of the drug digoxin,

which stop heart activity in the fetus before a second-trimester abortion.
Medical abortion

 First- and second-trimester medical abortion 

o First-trimester (first three months of a pregnancy) terminations are

accomplished medically with misoprostol alone, methotrexate-misoprostol
combination regimens, or Mifeprex (RU-486) with or without misoprostol.
Other prostaglandins are used in other countries. 

o Medical abortions are indicated for women who consent to a

medical abortion but are also willing to undergo a surgical abortion if the
medical abortion fails. Gestational age is usually less than 42-49 days, but
many protocols can be used, including for gestations up to 63 days from
the last menstrual period. 

o The Mifeprex/misoprostol drugs are given as follows: 

 On day one, Mifeprex (200mg or 600mg) as pills are taken

by mouth in the doctor's office. 

 On day two or three, misoprostol (800mcg is taken as pilsl

or inserted vaginally) or in an office setting with four hours of
observation. 

 Between days 7 and 10, you return to the office to

determine if the abortion has been completed. 

 If it has not, a repeat dose of misoprostol is given or you

may undergo a surgical abortion. 

 About 50% will abort in the first three days, about 80% of
patients by the next day, and only about 5% of patients will need a
surgical abortion.

o The methotrexate/misoprostol regimen is similar, as follows: 

 Methotrexate is injected on day one. 

  On days six to seven, misoprostol is taken at home
vaginally, and you return to the office on day eight to determine if the
abortion has taken place. Misoprostol can be repeated with monitoring,
or surgical abortion may be completed.

 Prostaglandin-induced second-trimester abortion: Medication can be

given vaginally, orally, or injected into the fetus. The most typical regimen is
usually 200mcg vaginally every four hours until the process is complete. 

 Saline-induced abortion:A long process that was used 20 years ago is not
often performed but is safe. 

Surgical abortion

 Cervical dilatation and preparation 

o For a first-trimester termination, particularly at less than 10 weeks'

gestation, rarely do you need to have your cervix dilated (enlarged so the
contents of the uterus can pass through and out of your body). If you are in
the latter part of the first trimester (first three months), you may have a
small sterilized stick called a laminaria japonica (or more than one) placed
in your cervix to open it. These laminaria take about four hours to be useful
and may be placed overnight. 

o Before inserting the stick, your cervix may be swabbed with

Betadine, a cleaning solution. You may be given an injection of numbing
solution into the cervix. This is the beginning of the abortion procedure.
Please understand your risks, and they should have been explained in the
counseling process, before you start the dilatation process.

 Sedation during abortion 

o Most women are coached through an abortion as the health care

provider explains each step. Some women prefer to have some numbing in
their cervix. Most do not require IV sedation. 

o If heavy sedation is selected, then IV fluids will be used.

 First-trimester surgical abortion 

o Early terminations are performed with little cervical dilatation and

using a hand-held syringe or a small-bore cannula (a tube) attached to a
suction machine. Abortions performed with a syringe are referred to as
manual aspirations (or menstrual extractions). Those performed with the
suction generated by a vacuum aspirator are referred to as a
vacuum aspiration. Both procedures take only a few minutes. 

o Tools are used to grasp the cervix after it has been prepared with
Betadine and possibly numbed. The cannula is carefully inserted through
the cervix into your uterus. The actual evacuation is performed by applying
suction to the syringe or via the machine. The procedure takes a few
minutes to complete. There is a small amount of blood loss. 

o The doctor will check the tissue to make sure it has all been taken
out.

 Dilatation and curettage (D&C) 

o This specifically is a term that is usually applied to a diagnostic

procedure or the treatment of an incomplete abortion. 

o The procedure is usually accomplished with similar dilatation

procedures, but the uterus is emptied with a sharp metal curette. These
curettes are more dangerous than the flexible or rigid plastic devices,
which are used in the suction procedures, and are not recommended for
abortion procedures.

 Second-trimester dilatation and evacuation 

o Dilatation and evacuation is the safest and most common method

of second-trimester termination used by experienced health care
professionals. Dilation takes place over hours and possibly days with the
sticks to enlarge the cervix. 

o Once the cervix is enlarged enough, the procedure is

accomplished using a combination of suction curettage and manual
 evacuation of the fetus and placenta. Ultrasound may be used to guide the
tools. 

o The procedure is longer and more uncomfortable than a first-

trimester procedure, but many women can comfortably go through the
procedure with local anesthesia.

 Dilatation and extraction 

o This procedure is accomplished by cervical preparation similar to

cases of dilatation and evacuation, but the fetus is removed in a mostly
intact condition. The fetal head s able to be collapsed after the contents
are evacuated so that it may pass through the cervix. 

o Very few providers perform the procedure. It is usually reserved for

cases of maternal medical complications or serious medical problems with
the fetus. 

o The procedure, referred to as intact dilatation and extraction, called

partial-birth abortion, has now been banned by a 2007 Supreme Court
ruling. 

o To avoid performing a partial birth abortion while performing a legal

dilatation and extraction, digitalis or potassium chloride may be injected
onto the fetus to induce preoperative fetal death. Fetal cord cutting may
accomplish this as well. 

o Research has not firmly established at what age a healthy fetus

can feel pain, but generally it is thought that this occurs around 24-28
weeks.

 Induction of labor 

o Most doctors have experience with the standard drugs used to

induce labor for birth. These can be used in the second trimester of
pregnancy. 

o Premature rupture of membranes is one indication for this method. 

 o o Cervical ripening agents are typically necessary with either
laminaria or misoprostal.

After the Procedure

 Activity: You may be referred for ongoing counseling and support after

an abortion. You may eat a regular diet and resume normal activity. Avoid
heavy activity or lifting for a few days. Do not use tampons,douche, or have
sexual intercourse for one week. 

 Medications: You may be given medication for pain, but these are

usually not necessary. Your doctor may prescribe medications for painful
contractions and cramping of your uterus, but with a first-trimester procedure,
none are usually needed. f you have pain, your doctor may
suggest acetaminophen (such as Tyleno)l or ibuprofen (such as Advil) and
similar pain relievers.

Follow-up

Abortion does not require a stay in the hospital unless you have a medical
condition that requires you to be monitored or if you have a complication with the
surgical procedure.

 Medical care after a surgical abortion 

o Your health care provider will watch you for at least 30 minutes
after the surgery, checking for abdominal painand unusual bleeding.

o If you have decided to use an IUD for birth control, it will be

inserted. If you have decided to use a hormonal injection form of birth
control, you may receive your injection on this day. 

o You will be asked to return to the clinic in one to three weeks to

make sure the pregnancy has been terminated and to check for any
medical complications. 
 o If you have these symptoms, you should see your health care
provider: 

 Severe pain 

 Fever of 100.4°F or higher 

 Bleeding through more than four or five pads per hour or

more than 12 pads in 24 hours

o You may be given pain relievers during the first 24 hours after
surgery, such as acetaminophen (Tylenol). After that time you can switch
to a pain reliever such as ibuprofen (Advil) or aproxen. 

o You should make sure you have been given emergency contact
numbers and instructions regarding where to go if you have an emergency
and cannot reach your health care provider. You may bleed very little, if at
all. The most common bleeding pattern is bleeding the day of the
procedure, then not much until the fifth day after surgery, when heavier
cramping and clotting occurs. 

o You should not use tampons for five days and should not have
intercourse until bleeding has stopped for a week or you have been
cleared by your doctor at your appointment after the surgery. 

 Psychological effects of abortion 

o You may feel normal emotions such as sadness and grief after an

abortion. You may also feel depression. The most common feeling
experienced after an abortion is that of relief and confidence in the
decision. Few women may experience feelings of grief and guilt, and these
feelings usually pass within days to weeks in most cases and do not lead
to mental health problems. One study showed that women who had
abortions had mental health issues such as depression 1% of the time,
compared with 10% of women who gave birth who experienced
depression. 
 o How you feel may be affected by your emotional status during the
decision making, your relationships, religion, age, social support networks,
and whether you have had mental health issues before If you were a victim
of rape or incest, you may have entirely different feelings and emotions
undergoing an abortion. 

o Counseling may help you work through your emotions and cope
with your feelings.

Legal basis for Philippine abortion ban

Article II of the 1987 Philippine Constitution says, in part, "Section 12. The State
recognizes the sanctity of family life and shall protect and strengthen the family
as a basic autonomous social institution. It shall equally protect the life of the
mother and the life of the unborn from conception. ..."[2]
The act is criminalized by the Revised Penal Code of the Philippines, which was
enacted in 1930 and remains in effect today. Articles 256, 258 and 259 of the
Code mandate imprisonment for the woman who undergoes the abortion, as well
as for any person who assists in the procedure, even if they be the woman's
parents, a physician or midwife. Article 258 further imposes a higher prison term
on the woman or her parents if the abortion is undertaken "in order to conceal
[the woman's] dishonor".
There is no law in the Philippines that expressly authorizes abortions in order to
save the woman's life; and the general provisions which do penalize abortion
make no qualifications if the woman's life is endangered. It may be argued that
an abortion to save the mother's life could be classified as a justifying
circumstance (duress as opposed to self-defense) that would bar criminal
prosecution under the Revised Penal Code. However, this has yet to be
adjudicated by the Philippine Supreme Court.
Proposals to liberalize Philippine abortion laws have been opposed by
the Catholic Church, and its opposition has considerable influence in the
predominantly Catholic country. However, the constitutionality of abortion
restrictions has yet to be challenged before the Philippine Supreme Court.
The present Constitution of the Philippines, enacted in 1987, pronounces as
among the policies of the State that "[The State] shall equally protect the life of
the mother and the life of the unborn from conception." (sec. 12, Art. II) The
provision was crafted by the Constitutional Commission which drafted the charter
with the intention of providing for constitutional protection of the abortion ban,
although the enactment of a more definitive provision sanctioning the ban was
not successful. It is also notable that the provision is enumerated as among
several state policies, which are generally regarded in law as unenforceable in
the absence of implementing legislation.[3]

[edit]Abortion practices in the Philippines

One study estimated that, despite legal restrictions, in 1994 there were
400,000 abortions performed illegally in the Philippines and 80,000
hospitalizations of women for abortion-related complications. 12% of all maternal
deaths in 1994 were due to unsafe abortion according to the Department of
Health of the Philippines. Two-thirds of Filipino women who have abortions
attempt to self-induce or seek solutions from those who practice folk medicine. [4]
The Department of Health has created a program to address the complications of
unsafe abortion, Prevention and Management of Abortion and its Complications.
This program had been tested in 17 government-run hospitals by 2003. [4]