Safety of Abortion

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Surgical abortion is one of the safest types of medical procedures. Complications from having a first-trimester aspiration abortion are considerably less frequent and less serious than those associated with giving birth. Early medical abortion (using medications to end a pregnancy) has a similar safety profile.¹

Illegal Abortion is Unsafe Abortion

Abortion has not always been so safe. Between the 1880s and 1973, abortion was illegal in all or most U.S. states, and many women died or had serious medical problems as a result. Women often made desperate and dangerous attempts to induce their own abortions or resorted to untrained practitioners who performed abortions with primitive instruments or in unsanitary conditions. Women streamed into emergency rooms with serious complications - perforations of the uterus, retained placentas, severe bleeding, cervical wounds, rampant infections, poisoning, shock, and gangrene.

Around the world, in countries where abortion is illegal, it remains a leading cause of maternal death. An estimated 68,000 women worldwide die each year from unsafe abortions.²

Many of the doctors who provide abortions in the United States today are committed to providing this service under medically safe conditions because they witnessed and still remember the tragic cases of women who appeared in hospitals after botched, illegal abortions.

Evaluating the Risk of Complications

Since the Supreme Court reestablished legal abortion in the U.S. in the 1973 Roe v. Wade decision, women have benefited from significant advances in medical technology and greater access to high-quality services.³ Generally, the earlier the abortion, the less complicated and safer it is.

Serious complications arising from aspiration abortions provided before 13 weeks are quite unusual. About 88% of the women who obtain abortions are less than 13 weeks pregnant.⁴ Of these women, 97% report no complications; 2.5% have minor complications that can be handled at the medical office or abortion facility; and less than 0.5% have more serious complications that require some additional surgical procedure and/or hospitalization.⁵

Early medical abortions are limited to the first 9 weeks of pregnancy. Medical abortions have an excellent safety profile, with serious complications occurring in less than 0.5% of cases.⁶ Over the last five years, six women in North America have died as a result of toxic shock secondary to a rare bacterial infection of the uterus following medical abortion with mifepristone and misoprostol. This type of fatal infection has also been observed to occur following miscarriage, childbirth and surgical abortion, as well as other contexts unrelated to pregnancy. The Centers for Disease Control and Prevention's (CDC) continuing investigations have found no causal link between the medications and these incidents of infection. Although the Food and Drug Administration (FDA) has issued an updated advisory for warning signs of infection following medical abortion, it has recommended that there be no changes in the current standards for provision of medical abortion.^7,8

Complication rates are somewhat higher for surgical abortions provided between 13 and 24 weeks than for the first-trimester procedures. General anesthesia, which is sometimes used in surgical abortion procedures of any gestation, carries its own risks.

In addition to the length of the pregnancy, significant factors that can affect the possibility of complications include:

• the kind of anesthesia used;
• the woman's overall health;
• the abortion method used; and
• the skill and training of the provider.

Types of Complications from Surgical Abortion

Although rare, possible complications from a surgical abortion procedure include:

• blood clots accumulating in the uterus, requiring another suctioning procedure, (less than 0.2% of cases);⁹
• infections, most of which are easily identified and treated if the woman carefully observes follow-up instructions, (0.1%-2.0% of North American cases);⁹
• a tear in the cervix, which may be repaired with stitches (0.6%-1.2% of cases);¹⁰
• perforation (a puncture or tear) of the wall of the uterus and/or other organs (less than 0.4% of cases).^5,9 This may heal itself or may require surgical repair or, rarely, hysterectomy;
• missed abortion, which does not end the pregnancy and requires the abortion to be repeated (less than 0.3% of cases);⁹
• incomplete abortion, in which tissue from the pregnancy remains in the uterus, and requires a repeat suction procedure, (0.3%-2.0% of cases);⁹
• excessive bleeding requiring a blood transfusion (0.02%-0.3% of cases).^5,10

Death occurs in 0.0006% of all legal surgical abortions (one in 160,000 cases). These rare deaths are usually the result of such things as adverse reactions to anesthesia, embolism, infection, or uncontrollable bleeding.⁹ In comparison, a woman's risk of death during pregnancy and childbirth is ten times greater.⁵

Possible complications of a medical abortion include:

• failure of the medications to terminate the pregnancy (less than 2% of cases), requiring a suction procedure to complete the abortion;¹¹
• incomplete expulsion of the products of conception, requiring a suction procedure to complete the abortion (occurs in less than 6% of cases);¹²
• excessive bleeding, requiring a suction procedure, and rarely, transfusion (less than 1% of cases);¹¹
• uterine infection, requiring the use of antibiotics (0.09%-0.6% of cases) ;¹¹
• death secondary to toxic shock following infection with Clostridium sordellii (has occurred in less than 0.001% of cases in the US and Canada).⁶

Signs of a Post-Abortion Complication

If a woman has any of the following symptoms after having either a surgical or medical abortion, she should immediately contact the facility that provided the abortion for follow-up care¹³:

• severe or persistent pain;
• chills or fever with an oral temperature of 100.4° or more;
• bleeding that is twice the flow of her normal menstrual period or that soaks through more than one sanitary pad per hour for two hours in a row;
• malodorous discharge or drainage from her vagina; or
• continuing symptoms of pregnancy.

In addition, if a woman who is having a medical abortion notices the onset of severe abdominal pain, malaise or "feeling sick," even in the absence of fever, more than 24 hours after the administration of the second medication, she must immediately contact the facility that provided the abortion.⁷

Health care providers and clinics that offer abortion services should provide a 24-hour number to call in the event of complications or reactions that the patient is concerned about.

Preventing Complications

There are some things women can do to lower their risks of complications. One way to reduce risk of complications is to have the abortion procedure early. Generally, the earlier the abortion, the safer it is.

Asking questions is also important. Just as with any medical procedure, the more relaxed a person is and the more she understands what to expect, the better and safer her experience usually will be.

In addition, any woman choosing abortion should:

• find a good clinic or a qualified, licensed practitioner. For referrals, call NAF's toll-free Hotline at 1-800-772-9100 or find a provider online;
• inform the practitioner of any health problems, current medications or street drugs being used, allergies to medications or anesthetics, and other health information;
• follow post-operative instructions; and
• return for a follow-up examination.

Anti-Abortion Propaganda

Anti-abortion activists claim that having an abortion increases the risk of developing breast cancer and endangers future childbearing. They claim that women who have abortions without complications are more likely to have difficulty conceiving or carrying a pregnancy, develop ectopic pregnancies, which are pregnancies outside of the uterus (commonly in one of the fallopian tubes), deliver stillborn

babies, or become sterile. However, these claims have been refuted by a significant body of medical research. In February 2003, a panel of experts convened by the National Cancer Institute to evaluate the scientific data concluded that studies have clearly established that "induced abortion is not associated with an increase in breast cancer risk."¹⁵ Furthermore, comprehensive reviews of the data have concluded that a vacuum aspiration procedure in the first trimester poses virtually no risk to future reproductive health.¹⁶ (See Abortion Myths: Abortion and Breast Cancer.)

Women's Feelings after Abortion

Women have abortions for a variety of reasons, but in general they choose abortion because a pregnancy at that time is in some way wrong for them. Such situations can cause a great deal of distress, and although abortion may be the best available option, the circumstances that led to the problem pregnancy may continue to be upsetting.

Some women may find it helpful to talk about their feelings with a family member, friend, or counselor. Feelings of loss or of disappointment, resulting, for example, from a lack of support from the spouse or partner, should not be confused with regret about the abortion. Women who experience guilt or sadness after an abortion usually report that their feelings are manageable.

The American Psychological Association has concluded that there is no scientifically valid support or evidence for the so-called "post-abortion syndrome" of psychological trauma or deep depression. The most frequent response women report after having ended a problem pregnancy is relief, and the majority of women are satisfied that they made the right decision for themselves. (See Abortion Myths: Post-Abortion Syndrome.)

References

1. Comparison of two doses of mifepristone in combination with misoprostol for early medical abortion: a randomised trial. World Health Organization Task Force on Post-ovulatory Methods of Fertility Regulation. BJOG 2000; 107:524-30.
2. The World Health Report 2005 - Make every mother and child count. Geneva, Switzerland: World Health Organization, 2005.
3. AMA Council Report. Induced Termination of Pregnancy Before and After Roe v. Wade. Journal of the American Medical Association, 1992, 268: 3231.
4. Elam-Evans LD, Strauss LT, Herndon J, Parker WY, Whitehead S, Berg CJ. Abortion Surveillance-United States, 1999. Morbidity and Mortality Weekly Report 2002; 51 (SS09): 1-28.
5. Tietze C, Henshaw SK. Induced abortion: A worldwide review, 1986. Third edition. New York: Guttmacher Institute, 1996.
6. Grimes DA. Risk of mifepristone abortion in context. Contraception 2005; 71:161.
7. FDA, Center for Drug Evaluation and Research, Mifepristone Information. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsand Providers/ucm111323.htm
8. Centers for Disease Control and Prevention. Clostridium sordellii toxic shock syndrome after medical abortion with mifepristone and intravaginal misoprostol - United States and Canada, 2001-2005. MMWR Morb Mortal Wkly Rep 2005; 54:724.
9. Henshaw SK. Unintended pregnancy and abortion: A public health perspective. In Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG. A Clinician's Guide to Medical and Surgical Abortion. New York: Churchill Livingstone, 1999, pp. 11-22.
10. Haskell WM, Easterling TR, Lichtenberg ES. Surgical abortion after the first trimester. In Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG. A Clinician's Guide to Medical and Surgical Abortion. New York: Churchill Livingstone, 1999, pp. 123-138.
11. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists 2005; Number 67: Medical Management of Abortion. Obstet Gynecol 2005; 106(4):871-882.
12. Allen RH, Westhoff C, DeNonno L, Fielding AL, Schaff EA. Curettage after mifepristone-induced abortion: Frequency, timing and indications. Obstet Gynecol 2001; 98(1):101-106.
13. Lichtenberg ES, Grimes DA, Paul M. Abortion complications: Prevention and management. In Paul M, Lichtenberg ES, Borgatta L. Grimes DA, Stubblefield PG. A Clinician's Guide to Medical and Surgical Abortion. New York: Churchill Livingstone, 1999, pp. 197-216.
14. Hern WM. Abortion Practice. Philadelphia: J.B. Lippincott Company, 1990.
15. Summary Report: Early Reproductive Events and Breast Cancer Workshop, National Cancer Institute, www.nci.nih.gov/cancerinfo/ere-workshop-report
16. Rowland Hogue CJ, Boardman LA, Stotland NL, Peipert JF. Answering questions about long-term outcomes. In Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG. A Clinician's Guide to Medical and Surgical Abortion. New York: Churchill Livingstone, 1999, pp. 217-228.

For More Information

For unbiased information about abortion and other resources, including financial assistance, call toll-free 1-800-772-9100
Weekdays: 7:00 A.M.-11:00 P.M. Eastern time
Saturdays and Sundays: 9:00 A.M.-9:00 P.M.

For referrals to quality abortion providers call 1-877-257-0012 (no funding assistance provided on this line).
Weekdays: 9:00 A.M. - 8:00 P.M.
Saturdays: Noon - 5:00 P.M.

National Abortion Federation
1660 L Street, NW, Suite 450
Washington, DC 20036
202-667-5881

Writers: Susan Dudley, PhD, and Beth Kruse, MS, CNM, ARNP
Copyright© 2006, National Abortion Federation
Revised December 2006.

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