Abortion what is it? It can be spontaneous, that is to say occur without being researched (health problem, genetic, etc.), or provoked and therefore voluntary.
- Spontaneous abortion. We also talk about miscarriage. By definition, it is the death or expulsion from the mother’s body of an embryo or fetus weighing less than 500 grams or less than 22 weeks gestation or without periods (= 20 weeks of pregnancy). If the miscarriage occurs later in pregnancy, it is called “fetal death in utero”.
- The induced abortion , also called “abortion” (or abortion) can be triggered in several ways, including taking medication “abortifacients” or the aspiration of the fetus. The laws governing access to abortion (or its ban) differ from country to country.
- Medical termination of pregnancy (GMI) is an induced abortion, performed for medical reasons, often because of an abnormality or disease of the life-threatening fetus after birth or leading to serious health problems, or when the mother’s life is in danger.
|Whether psychologically or medically, induced abortion is very different from spontaneous miscarriage, although there are many commonalities. This fact sheet will therefore deal with these two subjects separately.|
Spontaneous abortion: prevalence and causes
Miscarriages are a very common phenomenon. They are, for the most part, linked to a genetic or chromosomal abnormality of the embryo, which is then expelled naturally by the mother.
We distinguish :
- early miscarriages, occurring during the first trimester of pregnancy (less than 12 weeks of gestation). They concern 15 to 20% of pregnancies but sometimes go unnoticed when they occur in the very first weeks because they are sometimes confused with the rules.
- late miscarriages, occurring in the second trimester, between about 12 and 24 weeks of gestation. They occur during approximately 0.5% of pregnancies.
- fetal deaths in utero, in the third trimester.
There are many causes that can lead to miscarriage or even recurrent miscarriages.
Among these causes, there are first of all genetic or chromosomal abnormalities of the embryo, implicated in 30 to 80% of early miscarriages.
Other possible causes of spontaneous abortion are:
- an abnormality of the uterus (eg septate uterus, yawning of the cervix, uterine fibroids, uterine synechiae, etc.), or DES syndrome concerning women who have been exposed in utero to distilbene (born between 1950 and 1977).
- hormonal disorders, which prevent pregnancy from being completed (thyroid disorders, metabolic disorders, etc.).
- multiple pregnancies that increase the risk of miscarriages.
- the occurrence of an infection during pregnancy. Many infectious or parasitic diseases can indeed cause a miscarriage, in particular malaria, toxoplasmosis, listeriosis, brucellosis, measles, rubella, mumps, etc.
- certain medical exams, such as amniocentesis or trophoblast biopsy, can cause miscarriage.
- the presence of an IUD in the uterus at the time of pregnancy.
- Certain environmental factors (consumption of drugs, alcohol, tobacco, drugs, etc.).
- Immunological (immune system) disorders, mostly involved in repeated miscarriages.
Induced abortion: state of play
Worldwide induced abortion statistics
The World Health Organization (WHO) regularly publishes reports on induced abortions around the world. In 2008, around one in five pregnancies were said to have been terminated voluntarily.
In total, nearly 44 million abortions were performed in 2008. The rate is higher in developing countries than in industrialized countries (29 abortions per 1,000 women aged 15 to 44 compared to 24 per 1,000, respectively).
According to a study published in 2012 , the world abortion rate decreased from 35 to 29 per 1000 women between 1995 and 2003. Today, there are on average 28 abortions per 1000 women.
Abortion is not legalized everywhere in the world. According to the Center for Reproductive Rights , more than 60% of the world’s population lives in countries where abortion is allowed with or without restrictions. On the contrary, around 26% of the population lives in states where this act is prohibited (although it is sometimes authorized if the woman’s life is in danger for medical reasons).
|The WHO estimates that out of the approximately 210 million pregnancies that occur each year worldwide (2008 figures), approximately 80 million of them are unwanted, or 40%.|
Statistics on induced abortion
In 2011, 222,300 voluntary terminations of pregnancy were carried out. This number has been stable since 2006, after a decade of increase between 1995 and 2006. On average, the rate of abortion is 15 induced abortions per 1000 women.
The rate is comparable, with approximately 17 abortions per 1,000 women, or approximately 27,000 per year.
In Canada, rates vary between 12 and 17 abortions per year per 1,000 women of reproductive age, depending on the provinces (100,000 abortions in total reported in 2003).
In these two countries, around 30% of pregnancies result in an abortion.
In Canada as in France, voluntary termination of pregnancy is legal . This is also the case in most European countries.
As for Canada, it is the only western country where there are no laws that limit or regulate late abortions. According to studies conducted in 2010, abortions after 20 weeks of pregnancy, however, represent less than 1% of abortions, or about a hundred cases per year.
Who is affected by induced abortions?
Induced abortions concern all age groups in women of reproductive age, and all social backgrounds.
The abortion rate is higher among women aged 20 to 24. Four-fifths of the abortions performed there relate to women between 20 and 40 years of age.
In two thirds of cases, abortions are performed in women who use contraception.
Pregnancy occurs due to failure of the method in 19% of cases and following its incorrect use in 46% of cases. For women on oral contraception, forgetting the pill is involved in more than 90% of cases.
In developing countries, more than contraceptive failure, it is especially the complete lack of contraception that leads to unwanted pregnancies.
Possible complications of abortion
According to the WHO, a woman dies every 8 minutes worldwide due to complications related to an abortion.
Of the 44 million abortions performed each year worldwide, half are performed in unsafe conditions, by a person “who does not have the necessary skills or in an environment that does not meet minimum medical standards , or both “.
There are about 47,000 deaths directly linked to these abortions, 5 million women suffering from complications after the act, such as hemorrhages or septicemia.
Unsafe abortions are one of the most preventable causes of maternal mortality (they were responsible for 13% of maternal deaths in 2008).
The main causes of death related to abortions are:
- infections and septicemia
- poisonings (due to the consumption of plants or abortifacient drugs)
- genital and internal injuries (intestine or perforated uterus).
Non-fatal sequelae include scarring problems, infertility, urinary or fecal incontinence (linked to physical trauma during the procedure), etc.
Almost all illegal or unsafe abortions (97%) are performed in developing countries. The African continent alone accounts for half of the mortality attributable to these abortions.
According to the WHO, “these deaths and disabilities could have been avoided if these induced abortions had been performed within a legal framework and in good safety conditions, or if their complications had been properly managed beforehand, if the patients had access to sex education and family planning services. ”
In countries where abortion is performed in a safe manner, the associated mortality is around three deaths per one million abortions, a tiny risk. The main complications are, when the abortion is done by surgery:
- uterine perforation (1 to 4 ‰)
- cervical tear (less than 1%).
|Contrary to certain beliefs, in the long term, abortion does not increase either the risk of miscarriage, or that of fetal death in utero, ectopic pregnancy, or sterility.|
Symptoms of spontaneous abortion
Depending on the case, spontaneous abortion can result in:
- stopping the course of pregnancy without expulsion (often marked by disappearance or reduction of signs of pregnancy such as nausea or breast pain);
- expulsion of the embryo or fetus.
Symptoms are generally:
- more or less heavy vaginal bleeding. However, bleeding during pregnancy is not systematically linked to a miscarriage, far from it.
- abdominal cramps, stomach or lower back pain.
- vaginal loss of fluid, blood clots, or debris from the uterus.
After a voluntary termination of pregnancy , abdominal cramps and bleeding may occur, with varying intensity, for a few days. Symptoms related to pregnancy gradually disappear as the amount of pregnancy hormones in the blood decreases.
Risk factors for spontaneous abortion
In the first trimester of pregnancy, early miscarriages are frequent and should not cause undue concern. The vast majority of these are sporadic events that correspond to a natural process of elimination of non-viable embryos. Having a single miscarriage does not increase the risk of having another during the next pregnancies.
For about 1 to 2% of couples wanting a child, however, miscarriages occur repeatedly (at least three pregnancies terminated spontaneously before 12 weeks of pregnancy, by definition).
The higher the number of miscarriages, the greater the risk in subsequent pregnancies. This risk is therefore:
- 17 to 35% after 2 spontaneous miscarriages
- 25 to 46% after 3 miscarriages
- greater than 50% after 6 miscarriages.
The factors likely to increase the risk of natural miscarriage are:
- age (35 and over)
- health problems (infections, blood clotting problems, endocrine, autoimmune diseases, uterine or ovarian problems, etc.)
- consumption of alcohol, drugs or tobacco.
- exposure to certain chemicals, such as pesticides
- taking certain medicines or herbs
Risk factors for voluntary termination of pregnancy
Although abortions affect all women, of all ages and all social classes, certain factors are associated with an increased risk of resorting to abortion:
- lack of easy access to contraception
- lack of sex education programs
- having already had an abortion, which is a risk factor for having it a second time, or several other times
|Can we prevent?|
|It is obvious that preventing voluntary terminations of pregnancy is tantamount to preventing unwanted pregnancies by means of adequate contraception and by sexual information and education.As for miscarriages and terminations of pregnancy linked to a medical problem, concerning either the fetus or the mother, their prevention is rarely possible, except when the cause is well identified and treatment exists.Some data on contraception: According to the 2010 Health Barometer of the National Institute for Prevention and Education for Health (Inpes), 90.2% of women sexually active in the past 12 months, not sterile, having a male partner, not pregnant and not trying to have a child use contraception, according to the 2008 Population Health Survey, 67% of sexually active women regularly used a contraceptive method in the year before the survey. The proportion of women aged 15 to 24 who use contraceptives is 90%.The pill is by far the most used contraceptive by women. Worldwide, according to INED, 63% of couples use a contraceptive method.The most widely used method is sterilization (37% worldwide). The other most common methods of contraception are the IUD (23%), the pill (14%), the condom (10%) and withdrawal (4%).According to the WHO, however, 215 million women living in developing countries do not have access to modern contraceptives despite the desire to limit births. 82% of unintended pregnancies in developing countries, for example, occur in women whose contraceptive needs are not met.There are still many fears (side effects, in particular), beliefs, family pressures or from the husband, in addition to difficult and sometimes expensive access to contraceptives, which hinder women’s access to contraception .|
Two techniques are used to achieve a voluntary termination of pregnancy:
- The drug technique
- Surgical technique
|Whenever possible, women should be able to choose the technique, medical or surgical, as well as the mode of anesthesia, local or general.|
The drug technique
Medicated abortion is based on taking medication to bring about the termination of pregnancy and the expulsion of the embryo or fetus. It can be used up to 9 weeks of amenorrhea. In 2011, more than half of abortions (55%) were done by medication.
There are several “abortion” drugs, but the most common method is to administer:
- an anti-progestogen, which inhibits progesterone, the hormone that allows pregnancy to continue;
- in combination with a drug from the prostaglandin family (misoprostol), which triggers contractions of the uterus and allows the evacuation of the fetus.
Thus, the WHO recommends, for pregnancies of gestational age up to 9 weeks (63 days) the taking of mifepristone followed 1 to 2 days later by misoprostol.
Mifepristone is administered orally. The recommended dose is 200 mg. Misoprostol administration is recommended 1 to 2 days (24 to 48 hours) after taking mifepristone. It can be done vaginally, buccally or sublingually for up to 7 weeks of amenorrhea (5 weeks of pregnancy).
The effects are mostly related to misoprostol, which can cause bleeding, headache, nausea, vomiting, diarrhea and painful abdominal cramps.
In practice, drug abortion can therefore be performed up to the 5 th week of pregnancy without hospitalization ( at home ) and until the 7 th week of pregnancy with a few hours of hospitalization.
From 10 weeks of amenorrhea, the drug technique is no longer recommended.
|In Canada, mifepristone is not authorized, due to possible infectious risks (and no company has made a request to market this molecule in Canada, at least until the end of 2013). This non-marketing is controversial and denounced by medical associations, which judge the use of mifepristone safe (it is widely used in 57 countries). Medical abortions are therefore much less common in Canada. They can be done with another drug, methotrexate, followed by misoprostol, but with less effectiveness. Methotrexate is usually given by injection, and five to seven days later, misoprostol tablets are inserted into the vagina. Unfortunately, in 35% of cases,|
The surgical technique of abortion
Most abortions in the world are performed by a surgical technique, usually the suction of the contents of the uterus, after dilation of the cervix (either mechanically, by inserting larger and larger dilators, or medically). It can be performed whatever the term of the pregnancy, either by local anesthesia or by general anesthesia. The intervention generally takes place during the day. Aspiration is the recommended technique for surgical abortion up to a gestational age of 12 to 14 weeks of gestation, according to the WHO.
Another procedure is sometimes used in some countries, dilation of the cervix followed by curettage (which involves “scraping” the uterine lining to remove debris). WHO recommends that this method be replaced by suction, which is safer and more reliable.
When gestational age is more than 12-14 weeks, dilation and evacuation can be recommended as well as medication methods, according to the WHO.
In all countries that allow abortion, its realization is framed by a well defined protocol.
It is therefore necessary to inquire to know the procedures, the deadlines, the places of intervention, the legal age of access , the modalities of refund.
You should know that the procedures take time and that there are often waiting times. It is therefore important to consult a doctor quickly or to go to a facility performing abortions as soon as the decision is made, so as not to delay the date of the act and risk arriving at a date of pregnancy where it will be more complex.
For example, two medical consultations are compulsory before abortion, separated by a reflection period of at least one week (2 days in an emergency). “Consultation-interviews” can be offered to women before and after the intervention, in order to allow the patient to talk about her situation, the intervention and receive information on contraception.
Psychological follow-up after an abortion
The decision to terminate a pregnancy is never easy and the act is not trivial.
Having been unwanted and having an abortion can leave psychological marks, raise questions, leave a feeling of doubt or guilt, sadness, sometimes regret.
Obviously, reactions to an abortion (whether natural or induced) are diverse and specific to each woman, but psychological counseling should be offered to all.
However, several studies show that abortion is not a long-term psychological risk factor.
The place of the man is often forgotten in pregnancy, and in the decision to keep the child or to consider an abortion. In my opinion, this would be an essential element to consider in the sexual education of adolescents. In fact, many women suffer from having an abortion or experiencing a miscarriage without sufficient support from their partner. This results in sometimes deep and lasting couple tensions, intense resentments which could be avoided by the simple communication of a couple allowing to express each other’s feelings. So it is as important to teach young women to ask for support as it is for young men to behave as supportive partners. Dr Catherine Solano