What is abortion?

The Controversy Surrounding Abortion

Induced abortion is the deliberate ending of a pregnancy before the fetus is viable or capable of surviving outside a female’s body. Abortion has been practiced in every culture since the beginning of civilization. It has also been controversial. The first law designating it as a crime dates to ancient Assyria, where, in the fourteenth century BCE, women who were convicted of abortion were impaled on a stake and left to die. Early Hebrew law also condemned abortion, except when necessary to save the woman’s life. The Greeks allowed abortion, but the famous physician Hippocrates (ca. 460 BCE–ca. 370 BCE) denounced the procedure and said that it violated a doctor’s responsibility to heal. Roman law said that a fetus was part of a woman and that abortion was her decision, although a husband could divorce his wife if she had an abortion without his consent. Most abortions in ancient times seemed to be related to unwanted pregnancies.

The Christian church determined abortion to be a sin in the first century. In the fifth century, however, Saint Augustine argued that the fetus did not have a soul before “quickening,” that point during a pregnancy, usually between the fourth and sixth months, at which the woman first senses movement in her womb. Until 1869, abortion until quickening was legal in most of Europe. In that year, however, Roman Catholic pope Pius IX declared abortion at any point to be murder. This position has been upheld by all subsequent popes.

In Protestant countries, the principle of legality until quickening held true until around 1860. In that year, the British Parliament declared abortion a felony; that law remained on the books for more than one hundred years. In 1968, the Abortion Act passed by Parliament radically reduced the restrictions, allowing abortions in cases in which doctors determined that the pregnancy threatened the physical or mental health of the woman.

In the United States, abortion before quickening was legal until the 1840s. By 1841, ten states had declared abortion to be a criminal act, but punishments were weak and the laws frequently ignored. The movement against abortion was led by the American Medical Association (AMA), founded in 1847. In 1859, the AMA passed a resolution condemning abortion as a criminal act. Within a few years, every state declared abortion a felony. Not until 1950 did the AMA reverse its position, when it began a new campaign to liberalize abortion laws. Many doctors were concerned about the thousands of women suffering from complications and even death from illegal abortions. Consequently, seventeen states, including California, passed laws providing for legal abortions under certain conditions. The remaining states, however, continued to prohibit abortions. In 1973, the US Supreme Court ruled in
Roe v. Wade
that abortions in all states were generally legal. This ruling made abortions in the United States available on the request of the pregnant woman.

About 25 percent of the world’s population live in countries that have very restrictive abortion laws. Most other nations authorize abortions under various conditions. The Guttmacher Institute estimates that there were approximately 43.8 million induced abortions conducted in 2008 alone. As of 2012, the World Health Organization (WHO) estimated that of the millions of abortions performed throughout the world each year, twenty-two million are performed unsafely, leading to the deaths of thousands of women. In the United States, according to the Guttmacher Institute's 2014 report, the number of abortions performed had decreased by 13 percent from 2008 to 2011.

Before 1970, statistics on abortions in the United States were generally not kept or reported, and they can only be estimated. In the nineteenth century, it is believed that there was one abortion for every four live births, a rate only a bit lower than that in the latter part of the twentieth century. The number of abortions in any year varied from five hundred thousand to one million, most of them illegal. In 1969, the Centers for Disease Control (CDC), a branch of the US Department of Health and Human Services, began an annual abortion count. Legal abortions in 1970 numbered about two hundred thousand. The number of illegal abortions is unknown. Ten years later, legal abortions reached 1.2 million, and by 1990, they had increased to 1.6 million; they have dropped slightly but steadily since 1990. The CDC estimated that there were about 325 abortions for every one thousand live births in the 1980s, a number consistent with findings for the 1990s. For 2010, the CDC estimated there were 228 abortions for every one thousand live births. The following year, the CDC reported a ratio of 219 abortions for every one thousand live births.

Ireland, which has traditionally had the most stringent abortion laws, passed legislation in 2013 allowing for abortion in cases in which the mother's life is threatened. Eastern European countries, with more abortions than live births, have abortion rates three to four times higher than Western European countries.

In Roe v. Wade the Supreme Court ruled that abortions are legal under certain conditions. These conditions include the welfare of the woman and the viability of the fetus. During the first three months of pregnancy, according to the Court, the government has no legitimate interest in regulating abortions—with one exception: states can require that abortions be performed by a licensed physician in a “medical setting.” These physician-only statutes, enacted by some states, have made it more difficult for nurse practitioners and certified nurse midwives to expand their role to surgical abortion, but in many states they can provide medication abortion. In all other circumstances, the decision to abort is strictly that of the pregnant woman as a constitutional right of privacy.

During the second trimester, abortions are more restricted. They are legal only if the woman’s health needs to be protected, and they require the consent of a doctor. The interest of the fetus is protected during the third trimester, when it becomes able to survive on its own outside the woman’s body, with or without artificial life support. At this point, states can prohibit abortions except in cases where the life or health of the mother is threatened. In a companion case,
Doe v. Bolton
, “health” was defined as “all factors—physical, emotional, psychological, familial, and the woman’s age.” This broad definition of health effectively makes it possible for a woman to have an abortion at any time during her pregnancy, circumventing state restrictions. The determination of viability is to be made by doctors, not by legal authorities. This ruling effectively struck down all antiabortion laws across the United States.

In the aftermath of Roe v. Wade, abortion became an intensely emotional political issue in the United States. The Hyde Amendment of 1976 eliminated federal funding for abortions, and other legislation blocked foreign aid to family planning programs, which members of Congress who were opposed to abortion saw as “pro-abortion.” In
Webster v. Reproductive Health Services
(1989), the Supreme Court upheld its ruling in Roe v. Wade, but it also sustained a rule forbidding the use of public facilities or public employees for carrying out abortions. The Court also supported a requirement that a test for viability be done before any late-term abortion and ruled that states could ban funding for abortion counseling. The issue continued to divide North Americans, with opponents arguing that abortion at any point during the pregnancy constituted murder.

A 2004 survey of women who had abortions, conducted by the Guttmacher Institute, revealed the most common reasons for making that decision. Seventy-five percent said that having a baby would interfere with work or going to school. About 75 percent said they could not afford a child. Half of the women said that they did not want to be a single parent. Women beneath the poverty level, regardless of race, religion, or ethnic background, were more likely to have an abortion than were middle-class women. African American women and latinas had higher rates of abortion than did white women (three and two times as likely, respectively). Fifty-two percent of abortions were performed on women under the age of twenty-five.

Religion appears to be a factor in the decision to seek an abortion: The percentage of Catholic women having abortions was 29 percent higher than the percentage of Protestant women. The lowest percentage of abortions was found among evangelical, “born-again” Christians. Nonreligious women had abortions at four times the rate of religious women. Teenagers under the age of fifteen and women over the age of forty had the highest rates of abortion of any age group. Thirty-three percent of all abortions occur before the fetal period of development. Fifty-five percent of abortions were performed between eight and twelve weeks into the pregnancy. The risk of death associated with abortion increases from one death for every 530,000 abortions at eight weeks or fewer to one death per six thousand abortions performed at twenty-one or more weeks of gestation.

In 2015, several states, including Oklahoma and Florida, began enacting bills that instituted a waiting period—often two or three days—between the time that a woman decides to have an abortion and the actual procedure. Defended as a means to give women more time to reach the most appropriate decision regarding the pregnancy, some have criticized the policy for the potential to increase the cost of the procedure through additional loss of wages and travel expenses.

Techniques and Procedures

A variety of techniques can be used to perform abortions. They vary according to the length of the pregnancy, which is usually measured by the number of weeks since the last menstrual period (LMP). Instrumental techniques are usually used very early in a pregnancy. They include a procedure called menstrual extraction, in which the entire contents of the uterus are removed. It can be done as early as fourteen days after the expected onset of a period. A major problem with this method is a high risk of error; the human embryo may still be so small at this age that it can be missed. It is also true that a high proportion of women undergoing this procedure are in fact not pregnant. Nevertheless, this method is easy and very safe. Death rates from this technique average less than one in one hundred thousand.

The majority of abortions in the United States are done by a procedure known as vacuum aspiration, or suction curettage. This technique can be used up to about fourteen weeks after the LMP. It can be performed with local anesthesia and follows several steps. First, the cervix is expanded with metal rods that are inserted one at a time, with each rod being slightly larger than the previous one. When the cervix is expanded to the right size, a transparent, hollow tube called the vacuum cannula is placed into the uterine cavity. This instrument is attached to a suction device, which looks something like a drinking straw. An electric or hand-operated vacuum pump then empties the uterus of its contents. Finally, a spoon-shaped device called a curette is used to check for any leftover tissue in the uterus. The entire procedure takes less than five minutes. This method, first used in China in 1958, is among the safest procedures in medicine. There are about six times more maternal deaths during regular birth than during vacuum aspiration.

An older method, dilation and curettage (D & C), was common up to the 1970s, but it has largely been replaced by vacuum aspiration. In a D & C, the cervix is expanded or dilated and a curette is used to scrape out the contents of the uterus. The biggest difference is the use of general anesthesia during the process. Since most abortion-related deaths result from complications from anesthesia, a method that requires only local anesthesia, such as aspiration, greatly reduces the dangers of the procedure.

For the period from thirteen to twenty weeks, a method called dilation and evacuation (D & E) is usually preferred. The cervix is expanded with tubes of laminaria (a type of seaweed), and the fetus is removed with the placenta, the part of the uterus by which the fetus is nourished. Forceps, suction, or a sharp curette is sometimes used. The procedure is usually safe, but sometimes if the fetus is large, it must be crushed and dismembered to remove it through the cervix. One variation of this procedure involves delivering the fetus breech, except for the head, and then inserting a suction tube through an incision made in the head. The brain is then sucked out, which collapses the skull, and the fetus is then easily removed. In 2003, legislation banning this procedure, called the Partial-Birth Abortion Ban Act of 2003, was passed by Congress and signed into law by President George W. Bush. The act’s constitutionality, which had been challenged, was upheld by the Supreme Court in 2007.

Along with these methods of menstrual extraction, physicians can use “medical induction” techniques when required. Amnioinfusion is an old example of this method that was used on fetuses from sixteen to twenty weeks old. This process has largely been replaced by D & E, which has proven far less dangerous.

Amnioinfusion usually requires hospitalization, local anesthesia, and the insertion of a large needle into the uterus. Between 100 and 200 milliliters of fluid is withdrawn and a similar amount of hypertonic saline solution infused into the uterine cavity. Within ninety minutes, the fetal heart stops. The woman then goes into labor and delivers a dead fetus within twenty-four to seventy-two hours. These kinds of abortions generally have much higher risk of complications than did D & E. On rare occasions, a fetus has been born alive, but the main risks are infection, hemorrhage, and cervical injuries to the woman. The psychological difficulties associated with this procedure can be severe, especially the knowledge that the fetus delivered would be dead.

Another method uses prostaglandins, naturally occurring hormones that cause uterine contractions and expulsion of the fetus, rather than a saline solution. The hormones can be given to the patient in several different ways: intravenously, intramuscularly, through vaginal suppositories, or directly into the amniotic sac. Prostaglandins are used for inducing second-trimester abortions and are as safe as saline solutions. Their major advantage is to reduce the duration of the abortion, but they also have severe side effects. They cause intense stomach cramps and other gastrointestinal discomfort, and about 7 percent of the fetuses expelled show some sign of life.

Surgical techniques for abortion are very rare, although sometimes they prove necessary in special cases. Hysterotomy resembles a cesarean section. An incision is made in the abdomen, and the fetus is removed. Hysterotomy is usually used in the second trimester, but only in cases where other methods have failed. The risk of death is much higher in this procedure than in most others. Even more rare is a hysterectomy, the removal of the uterus. This is done only in cases in which a malignant tumor threatens the life of the pregnant woman.

In the late 1980s, the French “abortion pill,” RU-486, was approved for use in many parts of Europe. By the mid-1990s, it had been safely and effectively used in more than fifty thousand abortions. Progesterone is a hormone that causes the uterus to develop the lining that houses a fertilized egg. If the egg is not fertilized, the production of progesterone stops, and the uterine lining is discarded during menstruation. RU-486 contains an antiprogesterone; it prevents the production of progesterone.

The antiprogesterone mifepristone was approved for legal use in the United States in 2000. It is usually used in a regimen in conjunction with misoprostol, which augments the effect of mifepristone by causing the uterus to contract. The regimen begins with the oral administration of mifepristone, followed by at-home administration of misoprostol. It has proved to be highly safe and effective, although a few serious side effects can sometimes occur, the major one being sustained bleeding. Because of this, women are carefully screened to determine if they are candidates for mifepristone use; women with low blood counts are not offered the procedure. Cramps and nausea are also reported in a number of cases, and women are provided medication to relieve these symptoms. There is apparently no effect on subsequent pregnancies.

The drug is administered in the United States mostly under protocols that involve an ultrasound or the testing of serum hormone levels to determine that the pregnancy is in an appropriately early stage. Next comes follow-up care with a physical examination, an ultrasound or test for hormone levels, and contraceptive counseling and provision that meets the woman’s needs. Properly done, medication abortion may be up to 95 to 97 percent effective, but women must return for follow-up care to ensure that the procedure was successful.

Because the abortion will take place at home, there is sufficient privacy. To be a candidate for the procedure, however, a woman must be capable of managing her medication and the passage of the fetus, with associated side effects. Various evidence-based protocols are employed in respect to timing the administration of the drug and the number of days of gestation at which the drug will be provided. The drug is intended only for termination of early first-trimester pregnancies. In many states, medication abortion is provided by nurse practitioners and certified nurse midwives, while surgical abortion is provided by physicians.

Perspective and Prospects

Abortion is the most frequently performed surgical procedure in the United States. As long as women have restricted access to contraceptive choice and unwanted pregnancies, that will continue to be the case. Abortion is a very safe procedure, although there can be complications. Generally, the earlier the procedure is performed, the less severe the risk. The lowest chance of medical complications occurs during the first eight weeks of pregnancy. After eight weeks, the risk of complications increases by 30 percent for each week of delay. Nevertheless, the death rate per case is very low, about half that for tonsillectomy. These statistics apply only to those areas of the world where abortion is legal, since women in those places tend to have earlier abortions.

In parts of the world where it remains against the law, abortion is a leading cause of death for women. As of 2012, WHO estimates that as many as forty-seven thousand women die each year throughout the world due to abortions that are performed unsafely. Before the Roe v. Wade decision, it was estimated that anywhere from a few hundred to several thousand American women died every year from the procedure. The best estimate was that in the 1960s about 290 women died every year as a result of complications from abortions. In the 1980s, the average was twelve per year, mostly from anesthesia complications. As of 2013, 0.6 deaths result per one hundred thousand legal induced procedures. Safe and legal abortion is an important component of women’s health and reproductive freedom.

In 2015, an antiabortion group further ignited the abortion debate by publicly accusing Planned Parenthood of illegally selling tissues and organs of aborted fetuses for research purposes. Federal law states that profits cannot be made from the sale of such tissue, but the group released several videos that it claimed showed the organization nonchalantly abusing the little-known practice. Republican lawmakers went so far as to introduce a bill to halt federal funding for Planned Parenthood, which was ultimately blocked by the Senate.

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