Induced abortion is the deliberate termination of pregnancy in a manner that ensures that the embryo or fetus will not survive. Attitudes of society toward elective abortion have undergone marked changes in the past few decades. In some situations the need for abortion is accepted by most people, but political and medical attitudes regarding induced abortion have continued to lag behind changing philosophies. Some religious concepts remain unchanged, resulting in personal, medical, and political conflicts.

About one-third of the world’s population lives in nations with nonrestrictive laws governing abortion. Another third live in countries with moderately restrictive abortion laws, ie, where unwanted pregnancies may not be terminated as a matter of right or personal decision but only on broadly interpreted medical, psychologic, and sociologic indications. The remainder live in countries where abortion is illegal without qualification or is allowed only when the woman’s life or health would be severely threatened if the pregnancy were allowed to continue.

An estimated 1 out of every 4 pregnancies in the world is terminated by induced abortion, making it perhaps the most common method of reproduction limitation. In the U.S., estimates of the number of criminal abortions performed prior to legalization of the procedure ranged from 0.25-1.25 million per year. The number of legal abortions now being performed in this country approximates 1 abortion per 4 live births. In 1997, there were 1.33 million induced abortions compared to 3.88 million live births.

The procedures being used in the U.S. for legally induced abortions during the first trimester are relatively safe.

Table 33-2 shows that first-trimester legal abortions are consistently safer for the woman than if she used no birth control method and gave birth. Note also in

Table 33-2 that whereas the number of maternal deaths related to births steadily increased from 5.6 to 22.6 per 100,000 women as age increased, age-related increase in number of deaths per 100,000 women per year from legal abortions was insignificant.

In general, the risk of death from legal abortion is lowest when it is performed at 8 menstrual weeks or sooner.

Table 33-3 shows the relationship between death due to legal abortion and the gestational age at the time of the procedure.

Paracervical anesthesia has replaced general anesthesia in many health settings, resulting in fewer complications related to anesthesia. Midtrimester abortion techniques are still problematic and are associated with a higher mortality rate. Hysterectomy carries a far greater risk than induction of labor by amnioinfusion or dilatation and evacuation.

Legal Aspects of Induced Abortion in the United States
The United States Supreme Court ruled in 1973 (1) that the restrictive abortion laws in the U.S. were invalid, largely because these laws invaded the individual’s right to privacy, and (2) that an abortion could not be denied to a woman in the first 3 months of pregnancy. The Court indicated that after 3 months a state may “regulate the abortion procedure in ways that are reasonably related to maternal health” and that after the fetus reaches the stage of viability (about 24 weeks) the states may refuse the right to terminate the pregnancy except when necessary for the preservation of the life or health of the mother. Still, much opposition is raised by various “right-to-life” groups and religious groups. In spite of this opposition, over 1 million procedures are still performed annually in the United States, with about one-third being performed on teenaged women. This dramatically emphasizes the inadequacy of sex education and the need for greater availability of adequate contraceptive methods in order to avoid such pregnancy wastage.

The patient must be informed regarding the nature of the procedure and its risks, including possible infertility or even continuation of pregnancy. The rights of the spouse, parents, or guardian must also be considered and permission obtained when indicated (until the individual woman’s rights are clearly established).

State laws must be obeyed with special reference to residence, duration of pregnancy, indications for abortion, consent, and consultations required.

Evaluation of Patients Requesting Induced Abortion
Patients give varied reasons for requesting abortion. Since in some cases the request is made at the urging of the woman’s parents or in-laws, husband, or peers, every effort should be made to ascertain that the patient herself desires abortion for her own reasons. In addition, one should be certain that she knows she is free to choose among other methods of solving the problem of unplanned pregnancy, eg, adoption or single-parent rearing.

Although the majority of abortions are performed as elective procedures, ie, because of social or economic reasons as opposed to medical reasons, some women still request such services for medical or surgical indications. For example, for women with certain medical conditions, such as Eisenmenger’s complex and cystic fibrosis, continuation of pregnancy may pose a threat to the life of the mother. Other indications are pregnancy resulting from a rape or pregnancy with a fetus affected with a major disorder, eg, trisomy 13. In any event, the ultimate decision rests with the pregnant woman.

Help from social agencies should be made available as necessary. A complete social history, medical history, and physical examination are required. Particular attention must be given to uterine size and position; the importance of accurate calculation of the duration of pregnancy (within 2 weeks but preferably within 1 week) cannot be overstated. With uncertainty, pelvic sonography should be used liberally. Routine laboratory tests should include pregnancy tests, urinalysis, hematocrit, Rh typing, serologic tests for syphilis, culture for gonorrhea, and Pap smear.