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Public Health Abortion
by
Andrzej Kulczycki

Introduction

An abortion refers to the termination of a pregnancy. It can be induced (see Definitions, Terminology, and Reference Resources) through a pharmacological or a surgical procedure, or it may be spontaneous (also called miscarriage). Both in the United States and globally, approximately one-fifth of all known pregnancies end in abortion, which is currently one of the safest procedures in medicine when performed by a trained professional in hygienic conditions using modern methods. However, of the estimated 44 million abortions performed worldwide each year, about 21.6 million are unsafe, causing some 47,000 maternal deaths or 13 percent of all maternal deaths. The incidence of abortion may be reduced through good access to a range of effective contraceptive methods, sex education, and appropriate support for women who want to have a child. Historically, women who underwent abortions risked their personal health and social standing. In the 20th century, this situation changed slowly in many countries as abortion procedures became safer and efforts to legalize abortion gained momentum. Nevertheless, abortion is often a controversial matter of health and social policy due to divergent views on such matters as when human life begins, on women’s roles and rights, and the role of government in individuals’ private lives. This entry reflects the broad scope of public health issues concerning the demography of abortion, its epidemiology, legality, and abortion-related methods. It also provides a collection of resources on postabortion care. This article first briefly reviews the terminology used for different types of abortion and outlines resources that detail the history of abortion as well as its general public heath contours in the United States and the world. Less attention is paid to the ethical aspects of abortion, arguments for or against the practice, different cultural or religious views on abortion, and public or political aspects of conflict concerning abortion.

General Overviews

Although recent textbooks on the public health aspects of abortion are lacking, Faúndes and Barzelatto 2006 provides an accessible account of many pertinent issues written in plain language for nonspecialists. Singh, et al. 2009 summarizes recent trends in abortion incidence, with a focus on unsafe abortion, as well as changes in legality, safety, and accessibility of abortion services worldwide. Sedgh, et al. 2012 presents the most recent abortion estimates for major world regions. Paul, et al. 2009 offers an informative text written primarily for clinicians on the provision of abortion care. A well-referenced handbook, World Health Organization 2012 (WHO) gives guidance to health professionals inside and outside governments who are working to reduce poor maternal health on the many ways of ensuring access to abortion care as allowed by law. Several reference guides explore the evolution of the US abortion debate from various viewpoints and may assist those working in the medical, social science, historical, legal, and public health fields. McBride 2007 includes a collection of biographical sketches, chronology, and excerpts from key statutes and court cases that have pushed the abortion controversy into the public arena, and Rose 2008 provides a selection of forty-one primary source documents from medical workers, judges, feminists, religious leaders, and politicians from the 19th century through 2007.

  • Faúndes, Anibal, and José S. Barzelatto. 2006. The human drama of abortion: A global search for consensus. Nashville: Vanderbilt Univ. Press.

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    This book includes overviews of why women have abortions, the scale of the practice, consequences of unsafe abortions, effective interventions, values, and conclusions about what can be done to reach a necessary and practical societal consensus.

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  • McBride, Dorothy E. 2007. Abortion in the United States: A reference handbook. Santa Barbara, CA: ABC-CLIO.

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    This reference covers multiple aspects of how abortion is considered in the United States. The guide also provides commentary on major Supreme Court cases and current state laws regulating abortion policy as well as other background information.

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  • Paul, Maureen, E. Steve Lichtenberg, Lynn Borgatta, David A. Grimes, Phillip G. Stubblefield, and Mitchell D. Creinin, eds. 2009. Management of unintended and abnormal pregnancy: comprehensive abortion care. Oxford: Wiley-Blackwell.

    DOI: 10.1002/9781444313031Save Citation »Export Citation »E-mail Citation »

    This widely used evidence-based reference text in abortion care discusses abortion methods, pre- and postprocedure care, the management of ectopic and other abnormal pregnancies (including the risks of multiple pregnancies resulting from assisted reproductive technologies), and public health aspects of abortion service delivery.

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  • Rose, Melody. 2008. Abortion: A documentary and reference guide. Westport, CT: Greenwood.

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    This reference work carries primary documents and commentary on the public health situation and socio-political controversy concerning abortion in the United States. Excerpts are also included from popular women’s self-help books, memoirs of early abortion providers, important legal papers, and the text of Pope Paul VI’s 1968 encyclical, Humanae Vitae.

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  • Sedgh, Gilda, Susheela Singh, Iqbal Shah, Elizabeth Åhman, Stanley K. Henshaw, and Akinrinola Bankole. 2012. “Induced abortion: Incidence and trends worldwide from 1995 to 2008.” Lancet 379.9816: 625–632.

    DOI: 10.1016/S0140-6736(11)61786-8Save Citation »Export Citation »E-mail Citation »

    The most recent update on abortion levels and trends worldwide, including for countries and major regions in which abortion is legally permitted and generally available, as well as for those in which it is not. Available online for purchase or by subscription.

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  • Singh, Susheela, Deirdre Wulf, Rubina Hussain, Akinrinola Bankole, and Gilda Sedgh. 2009. Abortion worldwide: A decade of uneven progress. New York: Guttmacher Institute.

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    This report reviews changes in abortion incidence, legality, and safety in the past decade, with greater attention paid to unsafe abortion and the situation in low-income countries. The report also examines the relation among unintended pregnancy, contraception, and abortion. Also available in Spanish.

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  • World Health Organization. 2012. Safe abortion: Technical and policy guidance for health systems. 2d ed. Geneva, Switzerland: World Health Organization.

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    This updated and expanded version of the report gives guidance to health professionals and others on actions to ensure the provision of safe, quality abortion services as allowed by law. It also provides an overview of the public health challenges including clinical aspects of care, health system issues, and the legal, regulatory, and policy environment for improving the quality and accessibility of care.

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Definitions, Terminology, and Reference Resources

Definitions of abortion vary across and within countries as well as among different institutions. Language used to refer to abortion often also reflects societal and political opinions and not only scientific knowledge (Grimes and Gretchen 2010). Popular use of the word abortion implies a deliberate pregnancy termination, whereas a miscarriage is used to refer to spontaneous fetal loss when the fetus is not viable (i.e., not yet unable to survive independently outside the womb). Spontaneous abortions may account for up to one in four pregnancies. Most occur in the first two weeks after conception, typically due to embryonic malformations or chromosomal abnormalities, and before a woman is aware that she is pregnant (Wilcox 2010). Induced abortion is the deliberate termination of pregnancy before viability (which may vary from twenty to twenty-eight weeks’ gestation, but medical advances now imply that viability can be generally assumed at about twenty-four weeks). An abortion can be induced for medical reasons or because of an elective decision to end the pregnancy. In an incomplete abortion, parts of the fetus or placental tissue are retained in the uterus and can result in hemorrhage, intense pain, uterine infection, and death if left untreated. An unsafe abortion may have adverse consequences for women’s health because it is performed by persons lacking the necessary skills in an environment lacking the minimal medical standards, or both. A range of electronic resources maintained by various nonprofit organizations provide helpful and free downloadable materials on different aspects of abortion. Health professional organizations with useful websites include the Association of Reproductive Health Professionals, whose members provide reproductive health services and education, conduct reproductive health research, and influence reproductive health policy. Another authoritative source is the American College of Obstetricians and Gynecologists, whose 52,000 members comprise over 90 percent of US board-certified obstetrician-gynecologists. The broad international focus of the WHO’s Sexual and Reproductive Health division means that many of its materials relate to all major parts of the world. Gynuity Health Projects and Ipas conduct research and technical assistance focused on improving and expanding access to methods, including safe and more acceptable abortion services that reduce maternal mortality and morbidity. The Guttmacher Institute conducts research and policy analysis related to abortion in the United States and internationally and makes much of its information available online.

Historical Perspectives

Abortion and infanticide were historically used after conception to control fertility. Riddle 1992 documents how women from ancient Egyptian times to the 15th century relied on an extensive pharmacopoeia of herbal abortifacients and contraceptives as well as manipulation to regulate fertility. Himes 1963 outlines the widespread knowledge of such ancient and premodern practices and of their menstrual-regulating qualities, which herbalists, laywomen, and health healers across the world handed down for generations. However, knowledge of these practices, many risky and ineffective, gradually became viewed with more suspicion by medical and pharmaceutical personnel keen to assert their professional role and interests. Mohr 1978 reviews the history of abortion in the United States since the colonial days, with a focus on the enactment of restrictive 19th-century laws at the state level. The author further examines how the medical establishment was far more instrumental than religious activism in pushing through the late 19th-century wave of antiabortion legislation, even though it became among its foremost advocates a century later. Stringent antiabortion laws were also passed in Europe in the 19th century. Both Gordon 2007 and Joffe 1995 report how safe abortions were performed for some women by highly skilled laypersons and physicians through the 20th century, when attitudes slowly became more liberal. Tribe 1990 provides one of the more widely cited surveys of the historical, legal, and moral issues related to abortion. By the 1970s, abortion had been legalized in Japan and most European countries. In the United States, the 1973 Supreme Court ruling Roe v. Wade permitted abortions during the first three months of pregnancy and with increasing restrictions thereafter. The court subsequently reaffirmed its landmark decision despite numerous legal challenges, although in 1976 the US Congress passed the Hyde Amendment, which barred the use of Medicaid funds for abortion except for all but the most extreme circumstances (rape, incest, or if the pregnant woman’s life was threatened). Abortion-related mortality fell greatly after nationwide legalization as documented by numerous sources including Coble, et al. 1992. However, conflict over abortion continues, with many of its underpinnings described by Luker 1984. This authoritative study avoids common negative stereotypes and shows that the contrasting worldviews of pro-choice and pro-life activists are rooted in different sets of values and ideas about women’s roles.

  • Coble, Yank D., E. Harvey Estes, C. Alvin Head, et al. 1992. “Induced termination of pregnancy before and after Roe v. Wade: Trends in the mortality and morbidity of women.” Journal of the American Medical Association 268.22: 3231–3239.

    DOI: 10.1001/jama.1992.03490220075032Save Citation »Export Citation »E-mail Citation »

    This article compares the mortality and morbidity of women who terminated their pregnancy before the 1973 Supreme Court decision with post-Roe v. Wade mortality and morbidity. Available online for purchase or by subscription.

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  • Gordon, Linda. 2007. The moral property of women: A history of birth control politics in America. Rev. ed. Urbana: Univ. of Illinois Press.

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    An updated edition of a widely cited history of the intense struggles over reproductive rights, including abortion, that have taken place over the past 150 years in America as seen from the perspective of women who are seeking sexual and reproductive self-determination.

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  • Himes, Norman E. 1963. Medical history of contraception. New York: Gamut.

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    Written by an anthropologist, this significant study provides extensive documentation of the use of birth control from preliterate cultures to the 1930s and reports that many earlier societies relied on abortion and infanticide. Originally published in 1936.

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  • Joffe, Carole E. 1995. Doctors of conscience: The struggle to provide abortion before and after Roe v. Wade. Boston: Beacon.

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    In contrast to other accounts, this study of the experiences of physicians is placed within a discussion of important health policy issues. It also examines how the medical profession has marginalized abortion services before and since their legalization as well as the role it could play in improving abortion services.

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  • Luker, Kristin. 1984. Abortion and the politics of motherhood. Berkeley: Univ. of California Press.

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    Based on detailed fieldwork, this work is a detailed sociological examination of the different perceptions of abortion and related issues held by different groups of women.

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  • Mohr, James C. 1978. Abortion in America: The origins and evolution of national policy, 1800–1900. New York: Oxford Univ. Press.

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    An influential and heavily cited history of abortion in 19th-century America. This study also highlights the role of regularly-trained physicians in the movement to criminalize abortion.

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  • Riddle, John M. 1992. Contraception and abortion from the ancient world to the renaissance. Cambridge, MA: Harvard Univ. Press.

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    This study collates disparate historical sources of knowledge about fertility control and how this female-centered, oral culture was passed on until it was lost in the early modern period due to the organization of medicine. Physicians’ ties with folk traditions were broken as they became increasingly trained in universities, where fertility regulation was not part of the curriculum.

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  • Tribe, Laurence H. 1990. Abortion: The clash of absolutes. New York: Norton.

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    This work is a review by a well-known constitutional law scholar of the historical, legal, and moral issues related to abortion both in the United States and in different parts of the world.

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Laws and Public Health Consequences

Laws determine the official availability of abortion services and also their safety. The United Nations provides summaries of abortion legislation for all countries of the world (United Nations Department of Economic and Social Affairs 2001–2002). Kulczycki 1999 analyzes the transnational development of abortion laws and policies. In countries where abortion is illegal, the risk of death and injury to women seeking abortion is on average thirty times higher than countries where abortion is legally permitted (Grimes, et al. 2006). However, safe abortion services are readily accessible for those able to pay for them, as in nearly all of Latin America, the region of the world with the most restrictive abortion laws (Kulczycki 2011). Two well-documented case studies demonstrate how legalizing abortion increases the safety of the procedure. When Romania banned abortion and contraceptives in 1966, maternal deaths soared, but after the procedure was legalized again in 1990 and access to modern contraceptives improved, they fell sharply (David 1999; Stephenson, et al. 1992). After abortion became available on the request of a pregnant woman in South Africa in 1997 and postabortion care and family planning services improved, abortion-related deaths fell by 91 percent over 1994–2001, with steep declines in serious morbidity also observed (Jewkes, et al. 2005). The actual implementation of laws as well as societal and cultural views on sexuality and reproduction further conditions access to abortion. India has more abortion-related deaths than any other country despite closely following the United Kingdom in allowing abortion on public health grounds. Poor and rural women are most likely to have clandestine procedures, often performed by untrained persons in unhygienic conditions at sites other than registered government institutions. Many women are not aware of the legal status of abortion and services are insufficient to meet the demand. In 1994, India banned prenatal testing when done solely to determine the sex of the fetus, but sex-selective abortion, especially for pregnancies after a first-born girl, has increased substantially. Jha, et al. 2011 shows that most of India’s population now lives in states where selective abortion of girls is common.

Demography and Epidemiology

An estimated one in five pregnancies worldwide are aborted, but the incidence of abortion is only known in detail for those countries where abortion is legally permitted with few restrictions and official statistics are reasonably complete. Sedgh, et al. 2012 (cited under General Overviews) provides a recent summary of these trends. Rossier 2003 and Singh, et al. 2010 review the range of estimation methodologies developed for use in contexts where abortion is legally restricted and where it remains a very sensitive issue. In the United States, the Centers for Disease Control and Prevention compiles annual numbers and basic characteristics of women obtaining abortions, such as its report for 2008 (Pazol, et al. 2011). However, these data are unavailable for some states and are of varying reliability for others in which reporting is not mandatory or is poorly enforced. A more complete count of the total number of abortions is available from the Guttmacher Institute based on its periodic census of abortion providers (Jones and Kooistra 2011), with certain characteristics also available through its surveys of women having abortions. Both unintended pregnancy and abortion rates are higher among certain groups of women, typically including those under age thirty, in poverty, and from more disadvantaged racial and ethnic minority groups. Internationally, the World Health Organization presents estimates of unsafe abortion and associated mortality for countries in which they occur, along with regional and global rates, as well as ratios of unsafe abortions (Åhman and Shah2011). Evidence from a diverse set of countries shows that over time abortion rates fall as levels of contraceptive use rise, as reviewed by Marston and Cleland 2003. The highest abortion rates in the world are found in many former Soviet Bloc republics, and Westoff 2005 reports how levels of abortion fell to a varying degree as the availability, accessibility, and quality of available contraceptive options improved. However, even widespread modern contraceptive use will not entirely eliminate abortions because no contraceptive works perfectly every time. Women have abortions for many reasons, most often because they feel unable in their current circumstances to fulfill their parental responsibilities as they would like or to provide the kind of family support they believe their children deserve (Finer, et al. 2005).

Safety, Techniques, and Health-related Controversies

Abortion is one of the safest procedures in medicine when it is conducted early in a pregnancy by a trained provider under hygienic conditions. Estimates using diverse sets of data show that for the United States the risk of death associated with childbirth is about ten times as high as that associated with all abortion (Christiansen and Collins 2006) and may be now as much as fourteen times higher (Raymond and Grimes 2012). Paul, et al. 2009 (cited under General Overviews) describes both surgical and medical methods of abortion. For surgical procedures early in gestation, vacuum aspiration is the preferred surgical method prior to twelve weeks’ gestation, and the suction mechanism may be electric or manual (MVA). Dilatation and curettage (D&C or sharp curettage) is the second most common method. Although a standard gynecological procedure performed for a variety of reasons, D&C carries higher risks and is now only recommended by the WHO when MVA is unavailable. A medical (or medication abortion) ends an early-term pregnancy (typically before nine weeks’ gestation) by pharmacological drugs. It involves a combination of mifepristone (an antiprogrestogen, also known by its brand name, Mifeprex and previously as RU-486) followed by a prostaglandin, usually misoprostol, that causes uterine contractions. It is safe, effective, and acceptable to most women, with some cases needing subsequent surgical intervention for incomplete abortion. Early abortion before nine weeks gestation with mifepristone/misoprostol combinations has replaced many surgical procedures. Although less effective, the use of misoprostol alone for abortion has increased throughout Latin America, reducing complications related to self-induced procedures and other unsafe abortions, thereby also decreasing the number of women admitted to hospitals (Ipas 2010). In the United States, about one in nine abortions are performed in the second trimester, for which a very rarely used procedure, intact dilatation and extraction (which requires surgical decompression of the fetus’s head before evacuation) developed into a focal point of controversy and was federally banned in 2003. Opponents labeled it “partial-birth abortion,” a term that remains vernacularly but is not recognized medically (Johnson, et al. 2005). Several hypothesized potential side-effects of abortion have been the subject of much controversy. Breast cancer and adverse mental health effects are two such disputed side effects. Abortion has been postulated to increase the risk of developing breast cancer, but based on extensive rigorous studies, the scientific consensus is that no such association exists (e.g., National Cancer Institute 2003–; Collaborative Group on Hormonal Factors in Breast Cancer 2004). Claims have also been made about the emotional effects of abortion, but research studies indicate that these are largely benign, at least in countries where abortion is legal and safely performed (Charles, et al. 2008). Also, postabortion syndrome is not a valid psychiatric or medical diagnosis (Major, et al. 2008).

  • Charles, Vignetta E., Chelsea B. Polis, Srinivas K. Sridhara, and Robert W. Blum. 2008. “Abortion and long term mental health outcomes: A systematic review of the evidence.” Contraception 78.6: 436–450.

    DOI: 10.1016/j.contraception.2008.07.005Save Citation »Export Citation »E-mail Citation »

    Articles focused on the potential association between abortion and long-term mental health outcomes are rated for their methodological quality and appropriateness to explore the research question. Better quality studies suggest few, if any, differences between women who had abortions and their respective comparison groups in terms of mental health sequelae. Available online for purchase or by subscription.

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  • Christiansen, Lydia R., and Kim A. Collins. 2006. “Pregnancy-associated deaths: A 15-year retrospective study and overall review of maternal pathophysiology.” American Journal of Forensic Medicine and Pathology 27.1: 11–19.

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    The authors review the challenges of identifying many pregnancy-associated deaths, regional variation in common causes of maternal death in the United States, and results of all such forensic cases referred for autopsy in part of South Carolina. Risks from maternal demise are significantly greater than from abortion. Available online for purchase or by subscription.

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  • Collaborative Group on Hormonal Factors in Breast Cancer. 2004. “Breast cancer and abortion: Collaborative reanalysis of data from 53 epidemiological studies, including 83,000 women with breast cancer from 16 countries.” Lancet 363.9414: 1007–1016.

    DOI: 10.1016/S0140-6736(04)15835-2Save Citation »Export Citation »E-mail Citation »

    A meta-analysis of available epidemiological evidence worldwide, this study shows no relation between induced abortion (or previous miscarriage) and the risk of subsequent breast cancer. Available online for purchase or by subscription.

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  • Ipas. 2010. Misoprostol and medical abortion in Latin America and the Caribbean. Chapel Hill, NC: Ipas.

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    This report discusses how misoprostol, a proven medication for a variety of obstetric and gynecologic uses, is being increasingly used in Latin America, thereby reducing incomplete abortions and related mortality and morbidity.

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  • Johnson, Timothy R. B., Lisa H. Harris, Vanessa K. Dalton, and Joel D. Howell. 2005. “Language matters: Legislation, medical practice, and the classification of abortion procedures.” Obstetrics & Gynecology 105.1: 201–204.

    DOI: 10.1097/01.AOG.0000149803.31623.b0Save Citation »Export Citation »E-mail Citation »

    This article discusses changing medical practice concerning abortion, efforts to clarify and obfuscate medical language, and legislative attempts to keep up with such changes. Available online for purchase or by subscription.

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  • Major, Brenda, Mark Appelbaum, Linda Beckman, Mary Ann Dutton, Nancy Felipe Russo, and Carolyn West. 2008. Report of the APA task force on mental health and abortion. Washington, DC: American Psychological Association.

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    This report concludes that a first abortion does not lead to any increased risk of mental health problems. Evidence for multiple terminations is more equivocal in part due to methodological difficulties and also because the same factors that predispose a woman to multiple unwanted pregnancies may also predispose her to mental health problems.

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  • National Cancer Institute. 2003–. Summary report: Early reproductive events and breast cancer workshop. Atlanta: National Institutes of Health.

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    This report emerged from an extensive workshop on early reproductive events and cancer and was updated with more recent evidence in 2010. The review of the available evidence does not support any hypothesis that early termination of pregnancy causes breast cancer.

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  • Raymond, Elizabeth G., and David A. Grimes. 2012. “The comparative safety of legal induced abortion and childbirth in the United States.” Obstetrics & Gynecology 119.2, Part 1: 215–219.

    DOI: 10.1097/AOG.0b013e31823fe923Save Citation »Export Citation »E-mail Citation »

    Using national surveillance, survey, and birth certificate data for 1998–2005, the authors find that the risk of death associated with childbirth (8.8 deaths per 100,000 live births) is approximately fourteen times higher than that with abortion (0.6 deaths per 100,000). Similarly, the overall morbidity associated with childbirth exceeds that with abortion. Available online for purchase or by subscription.

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Postabortion Care

Postabortion care (PAC) is needed to provide both emergency treatment for complications caused by incomplete or spontaneous abortion and family planning counseling and services to prevent future unplanned pregnancies that may result in repeat abortions. The Postabortion Care Consortium was formed in 1993 by family planning and reproductive health agencies, nongovernmental organizations, and donor agencies. Its expanded and updated Essential Elements of PAC model includes emergency treatment of postabortion complications, strengthening contraceptive provision and family planning services, providing referrals to other accessible facilities for other reproductive health services, building partnerships with communities and service providers, and counseling for women’s emotional and physical health needs and other concerns. Billings and Benson 2005 and Senlet, et al. 2001 describe the experience of several Latin American countries and Turkey, respectively, in institutionalizing the provision of the main elements of PAC. The revised PAC model was extended in practice by the CATALYST Consortium of reproductive health and family planning agencies initiated by the US Agency for International Development (USAID; CATALYST Consortium 2005). Curtis 2007 describes more recent strategies by USAID in tandem with multiple organizations to provide this critical health-care service, and multiple downloadable resources available from USAID’s Information and Knowledge for Optimal Health (INFO) Project. Overall, PAC services have expanded in a number of countries and their quality has generally improved, but a recent assessment by RamaRao, et al. 2011 points out that in many countries where abortion is legally restricted or otherwise sensitive, PAC services are often deficient, and postabortion contraceptive counseling is still poorly integrated with family planning and other reproductive health care.

LAST MODIFIED: 04/22/2013

DOI: 10.1093/OBO/9780199756797-0090

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