cant advances in medical technology and greater access to high-quality services.3 Gener- ally, the earlier the abortion, the less compli- cated and safer it is. Serious complications arising from aspiration Safety of Abortion abortions provided before 13 weeks are quite Surgical abortion is one of the safest types of unusual. About 88% of the women who ob- medical procedures. Complications from hav- tain abortions are less than 13 weeks preg- ing a first-trimester aspiration abortion are nant.4 Of these women, 97% report no com- considerably less frequent and less serious than plications; 2.5% have minor complications those associated with giving birth. Early that can be handled at the medical office or medical abortion (using medications to end a abortion facility; and less than 0.5% have more 1 pregnancy) has a similar safety profile. serious complications that require some addi- Illegal Abortion is Unsafe Abortion tional surgical procedure and/or hospitaliza- tion.5 Abortion has not always been so safe. Between the 1880s and 1973, abortion was illegal in all Early medical abortions are limited to the first or most U.S. states, and many women died or 9 weeks of pregnancy. Medical abortions have had serious medical problems as a result. an excellent safety profile, with serious com- 6 Women often made desperate and dangerous plications occurring in less than 0.5% of cases. attempts to induce their own abortions or re- Over the last five years, six women in North sorted to untrained practitioners who per- America have died as a result of toxic shock formed abortions with primitive instruments secondary to a rare bacterial infection of the or in unsanitary conditions. Women streamed uterus following medical abortion with into emergency rooms with serious complica- mifepristone and misoprostol. This type of tions - perforations of the uterus, retained pla- fatal infection has also been observed to occur centas, severe bleeding, cervical wounds, ram- following miscarriage, childbirth and surgical pant infections, poisoning, shock, and gan- abortion, as well as other contexts unrelated to grene. pregnancy. The Centers for Disease Control and Prevention’s (CDC) continuing investiga- Around the world, in countries where abor- tions have found no causal link between the tion is illegal, it remains a leading cause of medications and these incidents of infection. maternal death. An estimated 68,000 women Although the Food and Drug Administration worldwide die each year from unsafe abor- 2 (FDA) has issued an updated advisory for tions. warning signs of infection following medical Many of the doctors who provide abortions in abortion, it has recommended that there be no the United States today are committed to pro- changes in the current standards for provision viding this service under medically safe condi- of medical abortion.7,8 tions because they witnessed and still remem- Complication rates are somewhat higher for ber the tragic cases of women who appeared in surgical abortions provided between 13 and 24 hospitals after botched, illegal abortions. weeks than for the first-trimester procedures. Evaluating the Risk of Complications General anesthesia, which is sometimes used Since the Supreme Court reestablished legal in surgical abortion procedures of any gesta- abortion in the U.S. in the 1973 Roe v. Wade tion, carries its own risks. decision, women have benefited from signifi- In addition to the length of the pregnancy, Possible complications of a medical abortion significant factors that can affect the possibil- include: ity of complications include: • failure of the medications to terminate the • the kind of anesthesia used; pregnancy (less than 2% of cases), requir- • the woman's overall health; ing a suction procedure to complete the abortion;11 • the abortion method used; and • incomplete expulsion of the products of • the skill and training of the provider. conception, requiring a suction procedure Types of Complications from Surgical Abor- to complete the abortion (occurs in less tion than 6% of cases);12 Although rare, possible complications from a • excessive bleeding, requiring a suction pro- surgical abortion procedure include: cedure, and rarely, transfusion (less than • blood clots accumulating in the uterus, 1% of cases);11 requiring another suctioning procedure, 9 • uterine infection, requiring the use of an- (less than 0.2% of cases); tibiotics (0.09%-0.6% of cases) ;11 • infections, most of which are easily identi- • death secondary to toxic shock following fied and treated if the woman carefully ob- infection with Clostridium sordellii (has oc- serves follow-up instructions, (0.1%-2.0% 9 curred in less than 0.001% of cases in the of North American cases); 6 US and Canada). • a tear in the cervix, which may be repaired 10 Signs of a Post-Abortion Complication with stitches (0.6%-1.2% of cases); If a woman has any of the following symp- • perforation (a puncture or tear) of the wall toms after having either a surgical or medical of the uterus and/or other organs (less 5,9 abortion, she should immediately contact the than 0.4% of cases). This may heal itself facility that provided the abortion for follow- or may require surgical repair or, rarely, 13 up care : hysterectomy; • severe or persistent pain; • missed abortion, which does not end the pregnancy and requires the abortion to be • chills or fever with an oral temperature of repeated (less than 0.3% of cases);9 100.4° or more; • incomplete abortion, in which tissue from • bleeding that is twice the flow of her nor- the pregnancy remains in the uterus, and mal menstrual period or that soaks requires a repeat suction procedure, (0.3%- through more than one sanitary pad per 2.0% of cases);9 hour for two hours in a row; • excessive bleeding requiring a blood trans- • malodorous discharge or drainage from fusion (0.02%-0.3% of cases).5,10 her vagina; or Death occurs in 0.0006% of all legal surgical • continuing symptoms of pregnancy. abortions (one in 160,000 cases). These rare In addition, if a woman who is having a medi- deaths are usually the result of such things as cal abortion notices the onset of severe ab- adverse reactions to anesthesia, embolism, in- dominal pain, malaise or “feeling sick,” even in fection, or uncontrollable bleeding.9 In com- the absence of fever, more than 24 hours after parison, a woman's risk of death during preg- the administration of the second medication, nancy and childbirth is ten times greater.5 she must immediately contact the facility that claims have been refuted by a significant body provided the abortion.7 of medical research. In February 2003, a panel Health care providers and clinics that offer of experts convened by the National Cancer abortion services should provide a 24-hour Institute to evaluate the scientific data con- number to call in the event of complications or cluded that studies have clearly established reactions that the patient is concerned about. that "induced abortion is not associated with an increase in breast cancer risk."15 Further- Preventing Complications more, comprehensive reviews of the data have There are some things women can do to lower concluded that a vacuum aspiration procedure their risks of complications. One way to re- in the first trimester poses virtually no risk to duce risk of complications is to have the abor- future reproductive health.16 (See Abortion tion procedure early. Generally, the earlier the Myths: Abortion and Breast Cancer at abortion, the safer it is. www.prochoice.org.) Asking questions is also important. Just as Women's Feelings after Abortion with any medical procedure, the more relaxed Women have abortions for a variety of rea- a person is and the more she understands what sons, but in general they choose abortion be- to expect, the better and safer her experience cause a pregnancy at that time is in some way usually will be. wrong for them. Such situations can cause a In addition, any woman choosing abortion great deal of distress, and although abortion should: may be the best available option, the circum- • find a good clinic or a qualified, licensed stances that led to the problem pregnancy may practitioner. For referrals, call NAF's toll- continue to be upsetting. free Hotline at 1-800-772-9100 or find a Some women may find it helpful to talk about provider online at www.prochoice.org; their feelings with a family member, friend, or • inform the practitioner of any health prob- counselor. Feelings of loss or of disappoint- lems, current medications or street drugs ment, resulting, for example, from a lack of being used, allergies to medications or an- support from the spouse or partner, should not esthetics, and other health information; be confused with regret about the abortion. • follow post-operative instructions; and Women who experience guilt or sadness after an abortion usually report that their feelings • return for a follow-up examination. are manageable. Anti-Abortion Propaganda The American Psychological Association has Anti-abortion activists claim that having an concluded that there is no scientifically valid abortion increases the risk of developing breast support or evidence for the so-called "post- cancer and endangers future childbearing. abortion syndrome" of psychological trauma They claim that women who have abortions or deep depression. The most frequent re- without complications are more likely to have sponse women report after having ended a difficulty conceiving or carrying a pregnancy, problem pregnancy is relief, and the majority develop ectopic pregnancies, which are preg- of women are satisfied that they made the nancies outside of the uterus (commonly in right decision for themselves. (See Abortion one of the fallopian tubes), deliver stillborn Myths: Post-Abortion Syndrome at babies, or become sterile. However, these www.prochoice.org.)

References 11. ACOG Practice Bulletin. Clinical Management 1. Comparison of two doses of mifepristone in Guidelines for Obstetrician-Gynecologists 2005; combination with misoprostol for early medical Number 67: Medical Management of Abortion. abortion: a randomised trial. World Health Or- Obstet Gynecol 2005; 106(4):871-882. ganization Task Force on Post-ovulatory Meth- 12. Allen RH, Westhoff C, DeNonno L, Fielding ods of Fertility Regulation. BJOG 2000; AL, Schaff EA. Curettage after mifepristone- 107:524-30. induced abortion: Frequency, timing and indica- 2. The World Health Report 2005 - Make every mother tions. Obstet Gynecol 2001; 98(1):101-106. and child count. Geneva, Switzerland: World 13. Lichtenberg ES, Grimes DA, Paul M. Abortion Health Organization, 2005. complications: Prevention and management. In 3. AMA Council Report. Induced Termination of Paul M, Lichtenberg ES, Borgatta L. Grimes Pregnancy Before and After Roe v. Wade. Journal DA, Stubblefield PG. A Clinician's Guide to of the American Medical Association, 1992, 268: Medical and Surgical Abortion. New York: Chur- 3231. chill Livingstone, 1999, pp. 197-216. 4. Elam-Evans LD, Strauss LT, Herndon J, Parker 14. Hern WM. Abortion Practice. Philadelphia: J.B. WY, Whitehead S, Berg CJ. Abortion Surveil- Lippincott Company, 1990. lance-United States, 1999. Morbidity and Mortal- 15. Summary Report: Early Reproductive Events and ity Weekly Report 2002; 51 (SS09): 1-28. Breast Cancer Workshop, National Cancer Insti- 5. Tietze C, Henshaw SK. Induced abortion: A tute, www.nci.nih.gov/cancerinfo/ere-workshop- worldwide review, 1986. Third edition. New report York: Guttmacher Institute, 1996. 16. Rowland Hogue CJ, Boardman LA, Stotland 6. Grimes DA. Risk of mifepristone abortion in NL, Peipert JF. Answering questions about long- context. Contraception 2005; 71:161. term outcomes. In Paul M, Lichtenberg ES, Bor- 7. FDA, Center for Drug Evaluation and Research, gatta L, Grimes DA, Stubblefield PG. A Clini- Mifepristone Information. cian's Guide to Medical and Surgical Abortion. New www.fda.gov/cder/drug/infopage/mifepristone/de York: Churchill Livingstone, 1999, pp. 217-228.

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8. Centers for Disease Control and Prevention. For More Information Clostridium sordellii toxic shock syndrome after For referrals to abortion providers who offer quality medical abortion with mifepristone and intra- care, call NAF's toll-free hotline: 1-800-772-9100. vaginal misoprostol – United States and Canada, Weekdays: 8:00A.M. - 9:00P.M. Saturdays: 9:00A.M. 2001-2005. MMWR Morb Mortal Wkly Rep - 5:00P.M. EST 2005; 54:724. 9. Henshaw SK. Unintended pregnancy and abor- National Abortion Federation tion: A public health perspective. In Paul M, c/o Clinicians for Choice Lichtenberg ES, Borgatta L, Grimes DA, 1660 L Street NW, Suite 450 Stubblefield PG. A Clinician's Guide to Medical Washington, DC 20036 and Surgical Abortion. New York: Churchill Liv- 202-667-5881

ingstone, 1999, pp. 11-22. 10. Haskell WM, Easterling TR, Lichtenberg ES. Writers: Susan Dudley, PhD, and Beth Kruse, MS, Surgical abortion after the first trimester. In Paul CNM, ARNP Copyright© 1996, National Abortion M, Lichtenberg ES, Borgatta L, Grimes DA, Federation

Stubblefield PG. A Clinician's Guide to Medical Revised December 2006. and Surgical Abortion. New York: Churchill Liv- ingstone, 1999, pp. 123-138.