|March 26, 2016|
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An abortion is the termination of a pregnancy associated with the death of an embryo or a fetus. In medicine, the following terms are used to define an abortion:
In common parlance, the term "abortion" is synonymous with induced abortion of a human fetus.
In the 20th century, the ethics and morality of induced abortion became the subject of an intense debate in various areas of the world, particularly in the United States of America, but also to a lesser extent in Canada and a number of countries in Europe. The debate still continues, and has become a major issue in politics.
A pregnancy that terminates early, but where the fetus survives to become a live infant, is instead termed a premature birth. A pregnancy that ends with an infant dead upon birth, due to causes such as spontaneous abortion or complications during delivery, is termed a stillbirth. Certain forms of birth control prevent the implantation of the fertilized ovum. These acts of emergency contraception are not classified as abortion by the medical profession, though they are still opposed by many anti-abortion groups on ethical grounds. Any female mammal can experience abortion, however this article focuses exclusively on abortion in women.
Spontaneous abortions, generally referred to as miscarriages, occur when an embryo or fetus is lost due to natural causes. A miscarriage is spontaneous loss of the embryo or fetus before the 20th week of development. Spontaneous abortions after the 20th week are generally considered preterm deliveries. Up to 78% of all conceptions may fail, in most cases even before pregnancy is confirmed. 15% of all confirmed pregnancies end in a miscarriage. Most miscarriages occur very early in a pregnancy.
Early embryonic development is an error prone process, and the body may spontaneously abort if a fetus is not viable (i.e., due to genetic deformities, such as most cases of trisomy), or when the womb is unable to support the development of the fetus. Other causes can be infection (of either the mother or the fetus), immune responses, or serious systemic diseases of the mother.
The risk for spontaneous abortion is greater in women over age 35, those with a history of more than three previous (known) spontaneous abortions, and those with systemic diseases.
A spontaneous abortion can also be caused by accidental trauma; intentional trauma to cause miscarriage is considered an induced abortion. Some states have laws increasing the criminal liability of a person who causes a miscarriage during an assault or other violent crime.
The term "abortion" is usually used by lay people to refer to induced abortion. Women from 27 nations reported the following reasons for seeking an induced abortion: ref|abortion1
In many areas of the world, especially developing nations or where induced abortions are illegal, many women choose or are forced to perform abortions on themselves. These self-induced abortion|self-induced abortions are commonly unsafe abortions as described by the World Health Organization. Furthermore, some abortions are induced because of societal pressures, such as stigma of disabled persons and similar eugenic ideals, societal and religious disapproval of single motherhood, insufficient economic support for families, or laws such as under China's one-child policy. These policies and societal pressures can lead to sex-selective abortion and infanticide, which is illegal in most countries, but difficult to stop.
Depending on the gestational age of the embryo or fetus, different methods of abortion can be performed to remove the embryo or fetus from the womb.
Effective in the first trimester of pregnancy, chemical, or non-surgical abortions comprise 10% of all abortions in the United States and Europe. The process begins with the administration of either methotrexate or mifepristone, followed by misoprostol. While misoprostol may also be used alone to induce abortion, the need for surgical intervention is slightly elevated to about 10%, compared to the 8% when medications are combined. When surgical intervention is necessary, primarily vacuum uterine aspiration is used.
In the first fifteen weeks, suction-aspiration abortion|suction-aspiration or vacuum abortion are the most common methods, replacing the more risky dilation and curettage (D & C). Manual vacuum aspiration, or MVA abortion, consists of removing the fetus or embryo by suction using a manual syringe, while the Electric vacuum aspiration or EVA abortion method uses suction produced by an electric pump to remove the fetus or embryo. From the fifteenth week up until around the eighteenth week, a surgical 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 suction curettage consists of emptying the uterus by suction using a different apparatus. Curettage refers to the cleaning of the walls of the uterus with a curette. Dilation and curettage (D & C) is a standard gynaecological procedure performed for a variety of reasons, such as examination.
As the fetus grows, other techniques must be used to induce abortion in the third trimester. Premature delivery of the human fetus can be induced with prostaglandin; this can be coupled with injecting the amniotic sac|amniotic fluid with caustic solutions containing saline (medicine)|saline or urea. Very late abortions can be brought about by the controversial intact dilation and extraction (intact D & X) which requires the surgical decompression of the fetus's head before evacuation and is controversially termed "partial-birth abortion". A hysterotomy abortion, similar to a caesarian section but resulting in a terminated fetus, can also be used at late stages of pregnancy. Hysterotomy abortion can be performed vaginally, with an incision just above the cervix, in the late mid-trimester.
Other means of abortion
A number of herbs are effective abortifacients. Using herbs in this way can cause serious side effects, including multiple organ failure and other serious injury, and are not recommended by physicians.ref|abortion7 Physical trauma to a pregnant woman's womb can cause an abortion. The severity of the impact required to cause an abortion carries high risk of injury, without necessarily inducing a miscarriageref|abortion8. Both accidental and deliberate abortions of this kind carry criminal liability in many countries.
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As with most surgical procedures, the most common surgical abortion methods carry the risk of potentially serious complications. These risks include: a perforated uterus, perforated bowel or bladder, septic shock, sterility, and death.
It is difficult to accurately assess the risks of induced abortion due to a number of factors. These factors include wide variation in the quality of abortion services in different societies and among different socio-economic groups, a lack of uniform definitions of terms, and difficulties in patient follow-up and after-care.
Use of other methods (e.g., overdose of various drugs, insertion of various objects into uterus) for abortion is potentially dangerous, carrying a significantly elevated risk for permanent injury or death compared to abortions done by physicians.
Each phase of the abortion carries separate risks, and practitioners are not in agreement as to the best methods of mitigating those risks. The degree of risk depends upon the skill and experience of the practitioner; maternal age, health, and parity; gestational age; pre-existing conditions; methods and instruments used; medications used; the skill and experience of those assisting the practitioner; and the quality of recovery and follow-up care. A highly-skilled practitioner, operating under ideal conditions, will tend to have a very low rate of complications; an inexperienced practitioner in an ill-equipped and ill-staffed facility, on the other hand, will often have a higher incidence of complications.
Some practitioners advocate using the minimal possible anesthesia, so that patient pain can alert the practitioner to possible complications. Others recommend general anesthesia in order to prevent patient movement which might cause a perforation. General anesthesia carries its own risks and most public health officials recommend against its routine use in abortion due to an increased risk of death.
Dilation of the cervix carries the risk of cervical tears or perforations, including small tears that might not be apparent and might cause cervical incompetence in future pregnancies. Most practitioners recommend using the smallest possible dilators, and using osmotic rather than mechanical dilators after the first trimester of pregnancy.
Instruments are placed within the uterus to remove the fetus. These can, on rare occassions, cause perforation or laceration of the uterus, and damage to structures surrounding the uterus. Laceration or perforation of the uterus or cervix can, again on rare occassions, lead to even more serious complications.
Incomplete emptying of the uterus can cause hemorrhage, and infection. Use of ultrasound verification of the location and duration of the pregnancy prior to abortion, with immediate follow-up of patients reporting continuing pregnancy symptoms after the procedure, will virtually eliminate this risk. The sooner a complication is noted and properly treated, the lower the risk of permanent injury or death.
In rare cases, the abortion will be unsuccessful and the pregnancy will continue. Most practitioners recommend a second procedure to terminate the pregnancy due to the possibility that the first attempt has caused injury to the fetus. An unsuccessful abortion can also result in the delivery of a live neonate, or infant. This, termed a failed abortion, is more likely to occur if the procedure is carried out later in the pregnancy. Some doctors faced with this situation have voiced concerns about the ethical and legal ramifications of then letting the neonate die. As a result, recent investigations have been launched in the United Kingdom by the Confidential Enquiry into Maternal and Child Health (CEMACH) and the Royal College of Obstetricians and Gynaecologists, in order to determine how widespread the problem is and what an ethical response in the treatment of the infant might be. ref|abortion3
There is controversy over a number of proposed risks and effects of abortion. Evidence, whether in support of or against such claims, might in part be influenced by the political and religious affiliations of the parties behind it.
main|Abortion-breast cancer (ABC) hypothesis
The controversial abortion-breast cancer (ABC) hypothesis posits a causality| causal relationship between having an induced abortion and a higher risk of developing breast cancer in the future. An increased level of estrogen in early pregnancy helps to initiate cellular differentiation (growth) in the breast in preparation for lactation. If this process is terminated, through abortion, before full differentiation in the third trimester, then more "vulnerable" undifferentiated cells will be left than there were prior to the pregnancy. It is proposed that this might result in an elevated risk of breast cancer. The majority of interview-based studies have indicated a link, and some have been demonstrated to be statistically significant, http://www.etters.net/cancerTP.htm#3 but there remains debate as to their reliability because of possible response bias.
Larger and more recent record-based studies, such as one in 1997 which used data from two national registry|registries in Denmark, found the correlation to be negligible to non-existent after statistical adjustment. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8988884 The National Cancer Institute conducted an official workshop with dozens of experts on the issue, between February 24-26, 2003, which concluded from its examination of various evidence that it is "well established" that "induced abortion is not associated with an increase in breast cancer risk." http://www.cancer.gov/cancerinfo/ere-workshop-report These findings and how the Denmark study statistically adjusted their overall results have been disputed by Joel Brind|Dr. Joel Brind, http://www.bcpinstitute.org/nci_minority_rpt.htm an invitee to the workshop and the leading scientific advocate of the abortion-breast cancer hypothesis. Nevertheless, gaps and inconsistencies remain in the research, and the subject continues to be one of political and scientific contention; although the current scientific consensus is there is no ABC link.
The experience of the fetus during abortion is a matter of consideration among scientists and political activists. Evidence is conflicting, with some authorities claiming that the fetus is capable of feeling pain from the first trimester, while others hold that the neuro-anatomical requirements for such experience do not exist until the second or third trimester.
Pain|Pain receptors begin to appear in the seventh week of pregnancy. The thalamus, the part of the brain which receives signals from the nervous system and then relays them to the cerebral cortex, starts to form in the fifth week. However, other anatomical structures involved in the pain|nociceptic process are not present until much later in gestation. Links between the thalamus and cerebral cortex aren't forged until around the 23rd week. http://www.parliament.uk/post/pn094.pdf Myelin, an insulation on nerve fibres whichs aids in the conduction of electrical impulses, does not begin to develop until the sixth month. ref|Emory
Researchers have observed changes in the heart rates and hormones| hormonal levels of neonates after circumcision, blood tests, and surgery ??? effects which were alleviated with the administration of anaesthesia. http://www.cirp.org/library/pain/anand/#n99 Others suggest that the human experience of pain, being more than just physiological, cannot be measured in such reflexive responses.
It is indisputable that some women will experience negative feelings as a result of elective abortion. However, whether this phenomenon is significant enough to warrant a general diagnosis, or even classification as an independent syndrome (see abortion debate), is a subject that is debated among members of the medical community.
Data on the incidence of clinical depression, mental illness, post-traumatic stress disorder, and suicide in association with abortion remain inconclusive.
http://bmj.bmjjournals.com/cgi/content/abstract/bmj.38623.532384.55v1 A comparative analysis of the suicide rates among postnatal| postpartum and post-abortive women in Finland found a raw statistics| statistical correlation between abortion and suicide. http://bmj.bmjjournals.com/cgi/content/full/313/7070/1431 Other studies have suggested a link between the elective termination of an unwanted pregnancy and an improvement in reported mental well-being. The majority of evidence would seem to indicate that adverse emotional reactions to the procedure are most strongly influenced by pre-existing psychology| psychological conditions and other negative factors. http://www.apa.org/ppo/issues/womenabortfacts.html
Elective abortion may reduce the occurrence of depression in cases of unwanted pregnancy, as compared to cases in which the pregnancy has been carried to completion, but it is also sometimes reported as an additional stressor.
Spontaneous abortion, or miscarriage, is known to present an increased risk of depression in women. http://www.medicinenet.com/script/main/art.asp?articlekey=619
main|History of abortion
Image:TansyPills.jpg|thumb|right|90px|Bottom-most: "Dr. Caton's Tansy Pills!" An example of a clandestine advertisement.
The practice of induced abortion, according to some anthropologists, can be traced to ancient times. There is evidence to suggest that, historically, pregnancies were terminated through a number of methods, including the administration of abortifacient herbs, the use of sharpened implements, the application of abdominal pressure, and other techniques.
Soranus, a 2nd century Ancient Greece|Greek physician, suggested in his work Gynaecology that women wishing to abort their pregnancies should engage in violent exercise, energetic jumping, carrying heavy objects, and riding animals. He also prescribed a number of recipes for herbal bathes, pessary| pessaries, and bloodletting, but advised against the use of sharp instruments to induce miscarriage due to the risk of organ perforation. http://www.stoa.org/diotima/anthology/wlgr/wlgr-medicine355.shtml It is also known that the ancient Greeks relied upon the herb silphium as both a contraceptive and an abortifacient. The plant, as the chief export of Cyrene, was driven to extinction, but it is suggested that it might have possessed the same abortive properties as some of its closest extant relatives in the Apiaceae|Apiaceae family.
Such folk remedies, however, varied in effectiveness and were not without risk. Tansy and pennyroyal, for example, are two poison|poisonous herbs with serious Adverse effect (medicine)|side effects that have at times been used to terminate pregnancy.
19th-century medicine saw advances in the fields of surgery, anaesthesia, and sanitation, in the same era that doctors with the American Medical Association lobbied for bans on abortion in The United States and the British Parliament passed the Offences Against the Person Act. Demand for the procedure continued, however, as the disguised, but nonetheless open, advertisement of abortion services in Victorian times would seem to suggest. http://users.telerama.com/~jdehullu/abortion/abhist.htm
Main article|Abortion debate
Throughout the history of abortion, induced abortions have been a source of considerable debate and controversy regarding the morality and legality of this practice. An individual's position on the complex ethical, moral, philosophical, biological, and legal issues have a strong relationship with that individual's value system. A person's position on abortion may be best described as a combination of their personal beliefs on the morality of induced abortion, and that person's beliefs on the ethical scope and responsibility of legitimate government|governmental and legal authority. Another factor for many individuals is religious doctrine. See religion and abortion for more.
Abortion debates, especially pertaining to abortion laws, are often spearheaded by advocacy|advocacy groups belonging to one of two camps. Most often those in favor of legal prohibition of abortion describe themselves as pro-life while those against legal restrictions on abortion describe themselves as pro-choice. Both are used to indicate the central principles in arguments for and against abortion: "Is the fetus a human being with a fundamental right to life?" for pro-life advocates, and, for those who are pro-choice, "Should the state or the individual have choice on the matter of abortion?"
In both public and private debate, arguments presented in favour of or against abortion focus on either the moral permissibility of an induced abortion, or justification of laws permitting or restricting abortion. Arguments on morality and legality tend to collide and combine, complicating the issue at hand.
Political sides have largely been divided into moral absolutism|absolutes. The abortion debate, as such, tends to centre around individuals who hold strong positions. However, public opinion varies from poll to poll, country to country, and region to region:
Main article|Abortion law
Image:AbortionLawsMap.png|thumb|250px|International status of abortion law
The Soviet Union (1920) and Iceland (1935) were some of the first countries to generally allow abortion. The second half of the twentieth century saw the liberalization of abortion laws in many other countries. In 1973, the U.S. Supreme Court struck down state laws banning abortion, controversially ruling that such laws violated an inferred right to privacy in the U.S. Constitution. The Supreme Court of Canada, similarly, discarded its criminal code regarding abortion in 1988, after ruling that such restrictions violated the security of person guaranteed to women under in the Canadian Charter of Rights and Freedoms. Ireland, on the other hand, added an Eighth Amendment of the Constitution of Ireland| amendment to its Constitution of Ireland|Constitution in 1983 by popular referendum, recognizing "the right to life of the unborn." (see Abortion in Ireland).
Current laws pertaining to abortion are diverse. Religious, moral, and cultural sensibilities continue to influence abortion laws throughout the world. The right to life, the right to liberty, and the right to security of person are major issues of human rights that are sometimes used as justification for the existence or the absence of laws controlling abortion. Many countries in which abortion is legal require that certain criteria be met in order for an abortion to be obtained, often, but not always, using a trimester-based system to regulate the window in which abortion is still legal to perform:
Other countries, in which abortion is illegal, will allow one to be performed in the case of rape, incest, or danger to the pregnant woman's life or health. A handful of nations ban abortion entirely, such as Chile, El Salvador, and Malta.
# note|abortion1 Bankole, Akinrinola; Singh, Susheela; Haas, Taylor. "Reasons Why Women Have Induced Abortions: Evidence from 27 Countries." International Family Planning Perspectives, 1998
# note|abortion2 Moreau, C. et al, http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15777440&query_hl=8 "Previous induced abortions and the risk of very preterm delivery", BJOG. 2005; 112(4):430-7
#note|failedhttp://www.timesonline.co.uk/article/0,,2087-1892696,00.html The Sunday Times (Britain) November 27, 2005
# note|abortion3 http://news.telegraph.co.uk/news/main.jhtml?xml=/news/2005/05/15/nabort15.xml http://news.telegraph.co.uk/news/main.jhtml?xml=/news/2005/05/15/nabort15.xml
# note|Beral Beral V, Bull D, Doll R, Peto R, Reeves G; Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and abortion: collaborative reanalysis of data from 53 epidemiological studies, including 83?000 women with breast cancer from 16 countries. Lancet. 2004 Mar 27;363(9414):1007-16. PMID 15051280
# note|Emory http://www.pediatrics.emory.edu/neonatology/dpc/brain.htm Emory University Department of Pediatrics Neonatology Division
# note|abortion7 Ciganda C, Laborde A., http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12807304&query_hl=9 "Herbal infusions used for induced abortion", J Toxicol Clin Toxicol. 2003; 41(3):235-9
# note|abortion8 http://www.efc.org.uk/Foryoungpeople/Factsaboutabortion/Unsafeabortion Education For Choice – Unsafe abortion
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