ABORTION

Abortion is one of the most common medical procedures performed in the United States each year.More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives.
While women of every social class seek terminations, the typical woman who ends her pregnancy is either young, white, unmarried, poor, or over the age of 40.
In the United States and worldwide, abortion (known also as elective termination of pregnancy) remains common.
• The US Supreme Court legalized abortion in the well-known Roe v Wadedecision in 1973; currently, there areabout 1.2 million abortions are performed each year in the United States.
• Worldwide, some 20-30 million legal abortions are performed each year, with another 10-20 million abortions performed illegally. Illegal abortions are unsafe and account for 13% of all deaths of women because of serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
In spite of the introduction of newer, more effective, and more widely available birth control methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these unplanned pregnancies, about half end in abortion.
Making abortion legal
Since the landmark 1973 US Supreme Court decision that made abortion legal, hundreds of federal and state laws have been proposed or passed. Abortion is one of the most visible, controversial, and legally active areas in the field of medicine. These laws address a variety of controversial questions including:
• The issue of parental notification. A number of state laws do require that some minors notify parents before obtaining an abortion, but what provisions are necessary to protect young women who feel they cannot notify their parents?
• Should spouses be notified before a woman has an abortion?
• Has the pregnancy progressed far enough that the fetus could live on its own before termination (termed viability)?
• Should there be mandatory waiting periods before an abortion can take place?
• What might be mandatory wording for counseling sessions or consent forms?
• Should public funds be used for abortions?
• What regulations if any should apply to abortion providers?
• What provisions might be made against specific abortion techniques?
• Should emergency contraception be allowed?
• Should the rules be different in cases of sexual assault and rape?
Before abortion was legal
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of medical personnel.
• Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion.
• The first US federal law on the subject was the Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception in order to suppress the circulation of "obscene" materials.
• From 1900 until the 1960s, abortions were prohibited by law. However, theKinsey report noted that premarital pregnancies were electively aborted, and public and physician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and ensured their right to choice in this process. No decision was more important than Griswold v Connecticut, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain birth control from their health care provider.
The Supreme Court decision: Roe v Wade
The Supreme Court case of Roe v Wade was the result of the work of a wide group of people who worked to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL).
• Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
• In 1973, the Roe v Wade law, in the opinion written by US Supreme Court justice Harry Blackmun, the court ruled that a woman had a right to an abortion during the first 2 trimesters (6 months) of pregnancy. He cited the safety of the procedures and the basic right of women to make their own decisions.
• Since this ruling, the states have regained much control. Serious restrictions have been placed on abortion services.Debate continues by federal and state lawmakers. The US Senate approved the first federal ban on a specific abortion procedure (called partial-birth abortion, defined later in this topic) in October 2003. The bill was signed byPresident George W. Bush.
Determining life
When does "life" begin?That is one of the issues surrounding the controversy about abortion. The legal issues are these:
• Loosely defined, the term viability is the ability of the fetus to survive outside the mother's womb without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation (gestation is the period of time a fetus develops in the mother's uterus, usually 40 weeks). However, there are no reliable or medically acceptable tests for viability prior to 28 weeks' gestation.
• The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (for example, a developing fetus with certain brain disorders will never live on its own). In Colautti v Franklin, the court overturned a Pennsylvania law requiring doctors to follow specific directives in certain medical cases and recognized the judgment of the doctor in these matters.
Parental consent
Various federal and state decisions have tried to require parental notification, waiting periods, informed consent, and abortion counseling.
People against abortion argue that parents need to be informed about and approve an abortion for a daughter younger than 18 years.Those supporting the rights of a woman to choose abortion say parental consent is not required for a woman to carry a pregnancy to term (the birth of a baby), nor do parents need to give permission for a woman seeking birth control such as pills or an intrauterine device (IUD). Parents are also not consulted when a woman seeks treatment for asexually transmitted disease.
Research shows that many young women younger than 18 yearsdo involve their parents in their decision to abort (45%). Laws requiring parental consent are forcing minors to obtain abortions much later in their pregnancies. Some minors must travel great distances to states with no such law.
Intact dilation and extraction
The recently crafted political term partial-birth abortion loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This definition broadly includes all methods of second-trimester abortion (done after the first three months of pregnancy. A 2007 Partial Birth Abortion ban was passed by the Supreme Court, and although its wording is open to interpretation, it essentially states that the act of termination of fetal life cannot occur in a partially extracted fetus.
Providers
Providers of abortions are generally specialists in women's health such as obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers (physicians, physician assistants, midwives, and nurse practitioners) to perform these procedures.
Various factors over the years have influenced the number of medical professionals available and trained to perform abortions:
• Medical student training in this procedure is limited or absent from many programs. Some students may opt not to be trained in the procedure. Pharmacists may decide not to dispense medical abortion medications.
• Increasing violence against providers and clinics has further decreased their willingness to provide abortion services.
• The US Food and Drug Administration (FDA) has approved Mifeprex (mifepristone, RU-486), a drug for medical abortions. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination.
• A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.
Abortion statistics
In the United States: In 2003, about 16 women for every 1,000 women aged 15-44 years had an abortion, and for every 1,000 live births, about 241 abortions were performed, according to the Centers for Disease Control and Prevention. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social issues surrounding abortion have led to more women seeking terminations later in pregnancy.
• Safety: Legal abortion is a safe procedure. Infection rates are less than one percent, and fewer than 1 in 100,000 deaths occurs from first-trimester abortions. Abortion is safer for the mother than carrying a pregnancy to term. Medical and surgical abortions are both safe and effective when performed by trained practitioners.
• Race: Most women seeking abortion are white (53%); 36% are black, 8% are of another race, and 3% are of unknown race.
• Age: Abortion rates are highest among 20- to 24-year-old women. Rates are lowest among women younger than 20 or older than 40 years but these women are far more likely to have an abortion if they become pregnant.
In the world: Abortion causes at least 13% of all deaths among pregnant women. New estimates are that 50 million abortions are performed world wide each year, with 30 million of them in developing countries. Approximately 20 million of these are performed unsafely because of conditions or lack of provider training.

Abortion is one of the most common medical procedures performed in the United States each year.More than 40% of all women will end a pregnancy by abortion at some time in their reproductive lives.
While women of every social class seek terminations, the typical woman who ends her pregnancy is either young, white, unmarried, poor, or over the age of 40.
In the United States and worldwide, abortion (known also as elective termination of pregnancy) remains common.
• The US Supreme Court legalized abortion in the well-known Roe v Wadedecision in 1973; currently, there areabout 1.2 million abortions are performed each year in the United States.
• Worldwide, some 20-30 million legal abortions are performed each year, with another 10-20 million abortions performed illegally. Illegal abortions are unsafe and account for 13% of all deaths of women because of serious complications. Death from abortion is almost unknown in the United States or in other countries where abortion is legally available.
In spite of the introduction of newer, more effective, and more widely available birth control methods, more than half of the 6 million pregnancies occurring each year in the United States are considered unplanned by the women who are pregnant. Of these unplanned pregnancies, about half end in abortion.
Making abortion legal
Since the landmark 1973 US Supreme Court decision that made abortion legal, hundreds of federal and state laws have been proposed or passed. Abortion is one of the most visible, controversial, and legally active areas in the field of medicine. These laws address a variety of controversial questions including:
• The issue of parental notification. A number of state laws do require that some minors notify parents before obtaining an abortion, but what provisions are necessary to protect young women who feel they cannot notify their parents?
• Should spouses be notified before a woman has an abortion?
• Has the pregnancy progressed far enough that the fetus could live on its own before termination (termed viability)?
• Should there be mandatory waiting periods before an abortion can take place?
• What might be mandatory wording for counseling sessions or consent forms?
• Should public funds be used for abortions?
• What regulations if any should apply to abortion providers?
• What provisions might be made against specific abortion techniques?
• Should emergency contraception be allowed?
• Should the rules be different in cases of sexual assault and rape?
Before abortion was legal
Before the 19th century, most US states had no specific abortion laws. Women were able to end a pregnancy prior to viability with the assistance of medical personnel.
• Beginning with a Connecticut statute and followed by an 1829 New York law, the next 20 years saw the enactment of a series of laws restricting abortion, punishing providers, and, in some cases, punishing the woman who was seeking the abortion.
• The first US federal law on the subject was the Comstock Law of 1873, which permitted a special agent of the postal service to open mail dealing with abortion or contraception in order to suppress the circulation of "obscene" materials.
• From 1900 until the 1960s, abortions were prohibited by law. However, theKinsey report noted that premarital pregnancies were electively aborted, and public and physician opinion began to be shaped by the alarming reports of increased numbers of unsafe illegal abortions.
In 1965, 265 deaths occurred due to illegal abortions. Of all pregnancy-related complications in New York and California, 20% were due to abortions. A series of US Supreme Court decisions granted increased rights to women and ensured their right to choice in this process. No decision was more important than Griswold v Connecticut, which, in 1965, recognized a constitutional right to privacy and ruled that a married couple had a constitutional right to obtain birth control from their health care provider.
The Supreme Court decision: Roe v Wade
The Supreme Court case of Roe v Wade was the result of the work of a wide group of people who worked to repeal the abortion laws. In 1969, abortion rights supporters held a conference to formalize their goals and formed the National Association for the Repeal of Abortion Laws (NARAL).
• Lawyers Linda Coffee and Sarah Weddington met the Texas waitress, Norma McCorvey, who wished to have an abortion but was prohibited by law. She would become plaintiff "Jane Roe." Although the ruling came too late for McCorvey's abortion, her case was successfully argued before the US Supreme Court in a decision that instantly granted the right of a woman to seek an abortion.
• In 1973, the Roe v Wade law, in the opinion written by US Supreme Court justice Harry Blackmun, the court ruled that a woman had a right to an abortion during the first 2 trimesters (6 months) of pregnancy. He cited the safety of the procedures and the basic right of women to make their own decisions.
• Since this ruling, the states have regained much control. Serious restrictions have been placed on abortion services.Debate continues by federal and state lawmakers. The US Senate approved the first federal ban on a specific abortion procedure (called partial-birth abortion, defined later in this topic) in October 2003. The bill was signed byPresident George W. Bush.
Determining life
When does "life" begin?That is one of the issues surrounding the controversy about abortion. The legal issues are these:
• Loosely defined, the term viability is the ability of the fetus to survive outside the mother's womb without life support. A number of landmark US Supreme Court decisions dealt with this question. In Webster v Reproductive Health Services (1989), the court upheld the state of Missouri's requirement for preabortion viability testing after 20 weeks' gestation (gestation is the period of time a fetus develops in the mother's uterus, usually 40 weeks). However, there are no reliable or medically acceptable tests for viability prior to 28 weeks' gestation.
• The preamble to this law states that life begins at conception, and the unborn are entitled to the same constitutional rights as all others. By 1992, in a ruling controversial for its inclusion of mandatory waiting periods, elaborate consent processes, and record-keeping regulations, Planned Parenthood v Casey tried to address the issue of viability by inserting language recognizing that some fetuses never attain viability (for example, a developing fetus with certain brain disorders will never live on its own). In Colautti v Franklin, the court overturned a Pennsylvania law requiring doctors to follow specific directives in certain medical cases and recognized the judgment of the doctor in these matters.
Parental consent
Various federal and state decisions have tried to require parental notification, waiting periods, informed consent, and abortion counseling.
People against abortion argue that parents need to be informed about and approve an abortion for a daughter younger than 18 years.Those supporting the rights of a woman to choose abortion say parental consent is not required for a woman to carry a pregnancy to term (the birth of a baby), nor do parents need to give permission for a woman seeking birth control such as pills or an intrauterine device (IUD). Parents are also not consulted when a woman seeks treatment for asexually transmitted disease.
Research shows that many young women younger than 18 yearsdo involve their parents in their decision to abort (45%). Laws requiring parental consent are forcing minors to obtain abortions much later in their pregnancies. Some minors must travel great distances to states with no such law.
Intact dilation and extraction
The recently crafted political term partial-birth abortion loosely means "partially vaginally delivering a living fetus before killing the fetus and completing the delivery." This definition broadly includes all methods of second-trimester abortion (done after the first three months of pregnancy. A 2007 Partial Birth Abortion ban was passed by the Supreme Court, and although its wording is open to interpretation, it essentially states that the act of termination of fetal life cannot occur in a partially extracted fetus.
Providers
Providers of abortions are generally specialists in women's health such as obstetricians and gynecologists. However, many studies have shown the safety of allowing a variety of other health care providers (physicians, physician assistants, midwives, and nurse practitioners) to perform these procedures.
Various factors over the years have influenced the number of medical professionals available and trained to perform abortions:
• Medical student training in this procedure is limited or absent from many programs. Some students may opt not to be trained in the procedure. Pharmacists may decide not to dispense medical abortion medications.
• Increasing violence against providers and clinics has further decreased their willingness to provide abortion services.
• The US Food and Drug Administration (FDA) has approved Mifeprex (mifepristone, RU-486), a drug for medical abortions. The lack of abortion providers to perform surgical terminations has led to the popular belief that individuals not willing or not skilled enough (through training or licensure) to perform surgical terminations will be willing to prescribe medications for medical termination.
• A variety of medical, social, ethical, and philosophical issues affect the availability of and restrictions on abortion services in the United States.
Abortion statistics
In the United States: In 2003, about 16 women for every 1,000 women aged 15-44 years had an abortion, and for every 1,000 live births, about 241 abortions were performed, according to the Centers for Disease Control and Prevention. In the past 20 years, considerable progress has been made in the technology used for second-trimester abortion. This and the social issues surrounding abortion have led to more women seeking terminations later in pregnancy.
• Safety: Legal abortion is a safe procedure. Infection rates are less than one percent, and fewer than 1 in 100,000 deaths occurs from first-trimester abortions. Abortion is safer for the mother than carrying a pregnancy to term. Medical and surgical abortions are both safe and effective when performed by trained practitioners.
• Race: Most women seeking abortion are white (53%); 36% are black, 8% are of another race, and 3% are of unknown race.
• Age: Abortion rates are highest among 20- to 24-year-old women. Rates are lowest among women younger than 20 or older than 40 years but these women are far more likely to have an abortion if they become pregnant.
In the world: Abortion causes at least 13% of all deaths among pregnant women. New estimates are that 50 million abortions are performed world wide each year, with 30 million of them in developing countries. Approximately 20 million of these are performed unsafely because of conditions or lack of provider training.

Abortion Preparation
History
Most abortions are performed after your health care provider takes a brief and targeted medical history. You will be asked questions about prior pregnancies and any treatment or care during the current pregnancy. You will be asked about any diseases or conditions that affect your reproductive organs, such as sexually transmitted infections.
The provider will ask whether you have a history of diabetes, high blood pressure, heart disease,anemia, bleeding disorders, or surgery (on your ovaries or uterus, for example). If you have active medical problems, you may need to be stabilized before an abortion or have the procedure performed in a facility that can handle special medical problems.
• If there are known problems with the fetus, such as severe brain abnormalities that will either not allow the fetus to live, and if these problems are known through diagnostic testing, the woman may choose to end the pregnancy with abortion.
• The most common problems with the fetus encountered in abortion counseling include major system development failures and problems that cannot be repaired dealing with the heart, nervous system, spine, brain, abdomen, kidneys, and breathing and digestive systems.
Physical
A brief physical examination is usually performed before an abortion. The focus is on determining when your pregnancy began and checking for sexually transmitted disease and whether you are healthy enough to undergo the procedure.
Lab tests
Pregnancy tests are used to confirm that you are pregnant. Home tests are reliable, so providers will accept these results in some cases. Blood will be tested for sexually transmitted diseases and for hepatitis. Urine may be checked to see if you have a urinary tract infection.
Imaging studies
An ultrasound is virtually always dome for pregnancy confirmation and dating. Doctors are looking for how many fetuses may be developing, the size of the fetus or fetuses, a picture of the uterus and ovaries, and to rule out a problem such as an ectopic pregnancy (a life-threatening condition in which the fetus develops outside the uterus).
Medications
Your health care provider may give you antibiotics as a precaution against infection. Antibiotic use for the procedure is usually given the day of the procedure and for the next day or two.

Abortion Counseling
Most abortion counseling focuses on the decision-making process, the options for continuing the pregnancy, medical issues of the pregnancy, information regarding the pregnancy itself, full disclosure of the risks of continuing the pregnancy to deliver a baby, information and options for the abortion procedure, and, finally, information regarding a birth control decision. The risks and benefits of both medical and surgical abortions are often reviewed.
• The counseling process is aimed primarily at the woman herself but may also include other people she chooses to be involved. Studies indicate that men are involved in more than 40% of the decisions, but only scant research has been performed on male involvement in the process. Some women can reach a decision quickly. Others take longer to decide. The counseling process may provide referrals if you need ongoing support.
• You should not feel pressured to make a decision. Take time to consider your options.
• During the counseling, you may be asked questions designed to encourage meaningful discussion of the issues as they pertain to you. You will have many emotions.Counseling may take a day or longer.
Some state laws may apply to the counseling process. Some states have mandatory waiting times between the information session and the actual abortion. Other states require family or parental notification, and some states mandate that certain subjects be covered during abortion counceling.


Explanation of the Procedures
Once your pregnancy has been confirmed, and the doctor knows how many weeks along the pregnancy is, and you have decided to end the pregnancy, the procedure offered typically reflects your stage of gestation. Early abortions can be accomplished medically or surgically, but most facilities do not have the protocols established or personnel with the technical ability to offer medical abortions (with pills). Therefore, most abortions are performed surgically.
• Women often travel far for their abortion procedure and feel comfortable completing the preoperative preparation in a short office visit. In states where laws require waiting periods, this can be done in stages.
• The assessment process involves only a targeted history, physical examination, laboratory work, and ultrasound (including dating of the pregnancy, if indicated) followed by a counseling session.
• Second-trimester abortion preparation is more difficult. Preparing the cervix in less than 24 hours is almost impossible, but the basic assessment process is identical.
• Ultrasound examinations may be used to look specifically for obvious problems with the fetus.
• Some centers also offer an intra-amniotic injection of the drug digoxin, which stop heart activity in the fetus before a second-trimester abortion.
Medical abortion
• First- and second-trimester medical abortion
o First-trimester (first three months of a pregnancy) terminations are accomplished medically with misoprostol alone, methotrexate-misoprostol combination regimens, or Mifeprex (RU-486) with or without misoprostol. Other prostaglandins are used in other countries.
o Medical abortions are indicated for women who consent to a medical abortion but are also willing to undergo a surgical abortion if the medical abortion fails. Gestational age is usually less than 42-49 days, but many protocols can be used, including for gestations up to 63 days from the last menstrual period.
o The Mifeprex/misoprostol drugs are given as follows:
 On day one, Mifeprex (200mg or 600mg) as pills are taken by mouth in the doctor's office.
 On day two or three, misoprostol (800mcg is taken as pilsl or inserted vaginally) or in an office setting with four hours of observation.
 Between days 7 and 10, you return to the office to determine if the abortion has been completed.
 If it has not, a repeat dose of misoprostol is given or you may undergo a surgical abortion.
 About 50% will abort in the first three days, about 80% of patients by the next day, and only about 5% of patients will need a surgical abortion.
o The methotrexate/misoprostol regimen is similar, as follows:
 Methotrexate is injected on day one.
 On days six to seven, misoprostol is taken at home vaginally, and you return to the office on day eight to determine if the abortion has taken place. Misoprostol can be repeated with monitoring, or surgical abortion may be completed.
• Prostaglandin-induced second-trimester abortion: Medication can be given vaginally, orally, or injected into the fetus. The most typical regimen is usually 200mcg vaginally every four hours until the process is complete.
• Saline-induced abortion:A long process that was used 20 years ago is not often performed but is safe.
Surgical abortion
• Cervical dilatation and preparation
o For a first-trimester termination, particularly at less than 10 weeks' gestation, rarely do you need to have your cervix dilated (enlarged so the contents of the uterus can pass through and out of your body). If you are in the latter part of the first trimester (first three months), you may have a small sterilized stick called a laminaria japonica (or more than one) placed in your cervix to open it. These laminaria take about four hours to be useful and may be placed overnight.
o Before inserting the stick, your cervix may be swabbed with Betadine, a cleaning solution. You may be given an injection of numbing solution into the cervix. This is the beginning of the abortion procedure. Please understand your risks, and they should have been explained in the counseling process, before you start the dilatation process.
• Sedation during abortion
o Most women are coached through an abortion as the health care provider explains each step. Some women prefer to have some numbing in their cervix. Most do not require IV sedation.
o If heavy sedation is selected, then IV fluids will be used.
• First-trimester surgical abortion
o Early terminations are performed with little cervical dilatation and using a hand-held syringe or a small-bore cannula (a tube) attached to a suction machine. Abortions performed with a syringe are referred to as manual aspirations (or menstrual extractions). Those performed with the suction generated by a vacuum aspirator are referred to as a vacuum aspiration. Both procedures take only a few minutes.
o Tools are used to grasp the cervix after it has been prepared with Betadine and possibly numbed. The cannula is carefully inserted through the cervix into your uterus. The actual evacuation is performed by applying suction to the syringe or via the machine. The procedure takes a few minutes to complete. There is a small amount of blood loss.
o The doctor will check the tissue to make sure it has all been taken out.
• Dilatation and curettage (D&C)
o This specifically is a term that is usually applied to a diagnostic procedure or the treatment of an incomplete abortion.
o The procedure is usually accomplished with similar dilatation procedures, but the uterus is emptied with a sharp metal curette. These curettes are more dangerous than the flexible or rigid plastic devices, which are used in the suction procedures, and are not recommended for abortion procedures.
• Second-trimester dilatation and evacuation
o Dilatation and evacuation is the safest and most common method of second-trimester termination used by experienced health care professionals. Dilation takes place over hours and possibly days with the sticks to enlarge the cervix.
o Once the cervix is enlarged enough, the procedure is accomplished using a combination of suction curettage and manual evacuation of the fetus and placenta. Ultrasound may be used to guide the tools.
o The procedure is longer and more uncomfortable than a first-trimester procedure, but many women can comfortably go through the procedure with local anesthesia.
• Dilatation and extraction
o This procedure is accomplished by cervical preparation similar to cases of dilatation and evacuation, but the fetus is removed in a mostly intact condition. The fetal head s able to be collapsed after the contents are evacuated so that it may pass through the cervix.
o Very few providers perform the procedure. It is usually reserved for cases of maternal medical complications or serious medical problems with the fetus.
o The procedure, referred to as intact dilatation and extraction, called partial-birth abortion, has now been banned by a 2007 Supreme Court ruling.
o To avoid performing a partial birth abortion while performing a legal dilatation and extraction, digitalis or potassium chloride may be injected onto the fetus to induce preoperative fetal death. Fetal cord cutting may accomplish this as well.
o Research has not firmly established at what age a healthy fetus can feel pain, but generally it is thought that this occurs around 24-28 weeks.
• Induction of labor
o Most doctors have experience with the standard drugs used to induce labor for birth. These can be used in the second trimester of pregnancy.
o Premature rupture of membranes is one indication for this method.
o o Cervical ripening agents are typically necessary with either laminaria or misoprostal.


After the Procedure
• Activity: You may be referred for ongoing counseling and support after an abortion. You may eat a regular diet and resume normal activity. Avoid heavy activity or lifting for a few days. Do not use tampons,douche, or have sexual intercourse for one week.
• Medications: You may be given medication for pain, but these are usually not necessary. Your doctor may prescribe medications for painful contractions and cramping of your uterus, but with a first-trimester procedure, none are usually needed. f you have pain, your doctor may suggest acetaminophen (such as Tyleno)l or ibuprofen (such as Advil) and similar pain relievers.


Follow-up
Abortion does not require a stay in the hospital unless you have a medical condition that requires you to be monitored or if you have a complication with the surgical procedure.
• Medical care after a surgical abortion
o Your health care provider will watch you for at least 30 minutes after the surgery, checking for abdominal painand unusual bleeding.

o If you have decided to use an IUD for birth control, it will be inserted. If you have decided to use a hormonal injection form of birth control, you may receive your injection on this day.
o You will be asked to return to the clinic in one to three weeks to make sure the pregnancy has been terminated and to check for any medical complications.
o If you have these symptoms, you should see your health care provider:
 Severe pain
 Fever of 100.4°F or higher
 Bleeding through more than four or five pads per hour or more than 12 pads in 24 hours

o You may be given pain relievers during the first 24 hours after surgery, such as acetaminophen (Tylenol). After that time you can switch to a pain reliever such as ibuprofen (Advil) or aproxen.
o You should make sure you have been given emergency contact numbers and instructions regarding where to go if you have an emergency and cannot reach your health care provider. You may bleed very little, if at all. The most common bleeding pattern is bleeding the day of the procedure, then not much until the fifth day after surgery, when heavier cramping and clotting occurs.
o You should not use tampons for five days and should not have intercourse until bleeding has stopped for a week or you have been cleared by your doctor at your appointment after the surgery.
• Psychological effects of abortion
o You may feel normal emotions such as sadness and grief after an abortion. You may also feel depression. The most common feeling experienced after an abortion is that of relief and confidence in the decision. Few women may experience feelings of grief and guilt, and these feelings usually pass within days to weeks in most cases and do not lead to mental health problems. One study showed that women who had abortions had mental health issues such as depression 1% of the time, compared with 10% of women who gave birth who experienced depression.
o How you feel may be affected by your emotional status during the decision making, your relationships, religion, age, social support networks, and whether you have had mental health issues before If you were a victim of rape or incest, you may have entirely different feelings and emotions undergoing an abortion.
o Counseling may help you work through your emotions and cope with your feelings.


Abortion Rights in the United States
The abortion ethics debate has kept termination of pregnancy in the courts and media since the landmark decision in Roe v Wade. The original ruling was fairly straightforward, legally confirming a woman's right to a private medical decision when selecting a medical procedure (abortion).
As the debate has raged and the medical issues have become more complex, rulings in the courts and in the legislatures have extended beyond this simplistic question to restrictions on gestational age, viability determinations, spousal and parental consents, enforced waiting periods, enforced language in consents, enforcement of provider qualifications, the right to use fetal tissue for research or medical treatments, the rights of providers and patients to be shielded from overt protest, and, finally, on access to birth control.
In a typical year, hundreds of laws and rulings are proposed, and some even specifically criminalize performing abortions. Current laws are difficult to follow, but a summary is available in the State Policies in Brief section on The Alan Guttmacher Institute Web site.
Prior to the 1960s, an estimated nine of 10 out-of-wedlock pregnancies were electively aborted. These procedures were performed in a variety of medical and nonmedical settings, and almost 20% of all pregnancy-related complications were due to illegal abortions.
• Roe v Wade
o An important early decision by the US Supreme Court constitutionally establishing a woman's right to privacy was Griswold v Connecticut in 1965.
o In the early 1970s, political support was overwhelmingly in support of legalized abortion, and activists for abortion rights specifically sought a plaintiff so that a legal challenge to abortions could be argued in court. The plaintiff, Norma McCorvey, was the "Jane Roe" for whom the decision is named. The Centers for Disease Control and Prevention define aninduced abortion as "a procedure intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age."
• Late-term abortions
o Although only 2% of people express opposition to abortion in any circumstance, wider political support exists for abortion bans on late-term abortions or abortions performed in the third trimester of pregnancy. Since advances in surgical techniques have allowed for surgical terminations to be performed later in pregnancy, another divisive factor has crept into the debate. Abortion opponents have lobbied against specific procedures performed late in pregnancy, and they have the stance that other techniques are preferable.
o By 1998, 28 states had passed bans on this procedure, referred to as a partial-birth abortion, which is the medical procedure called intact dilatation and extraction.
o o In November, 2003, President George Bush signed a partial birth abortion ban. This Act was not in effect because of a court order, and in 2007 the Supreme Court passed the Partial Birth Abortion Ban.
• Parental consent
o Most young women have parents or family involvement in their decision to have an abortion. Adolescents who are older, especially those living independently, often do not. In spite of ample scientific evidence that many teens seek parental involvement and widespread legal concern that young women who do not seek parental involvement may be at risk physically or emotionally, a barrage of legislation mandates that all minors seek parental consents or that the parents be notified in advance of a minor child having an abortion.
o The laws that have enabled this to occur legally are backed by the US Supreme Court. As of 2007, 35 states require some sort of parental involvement in a minor's decision to have an abortion. Twentytwo states require parental consent only, 11 states require parental notification only, and two states require both parental consent and parental notification. Currently, only Connecticut, Hawaii, Maine, New York, Oregon, Vermont, and Washington do not require parental involvement. For a summary of laws, see Parental Involvement in Minors' Abortions. As a result, abortion providers in states that do not require parental consent for minors have begun to see adolescents who may travel hundreds of miles to seek an abortion.
o Patient rights bills have been developed by a variety of groups, including the Consumers' Bill of Rights and Responsibilities that has been developed by a presidential task force. These bills specifically state that patients have a right to access knowledge and that providers have a right to discuss care they think is medically appropriate regardless of the source of that care.
• Mandatory waiting periods
o Mandatory waiting periods mandate by law that the woman seeking to end a pregnancy must first, in person, receive specific information about the pregnancy and pregnancy alternatives.
o In spite of the fact that these laws typically only mandate a short 24-hour waiting period, they have the effect of increasing the percentage of second-trimester abortions in states with these laws.
• Special concerns
o Advances in neonatal medicine leading to improved survival by babies born very early in gestation have fueled the abortion debate in the past 2 decades, overshadowing the continued cultural debate on when life begins.
o Recently, the progress in using fetal tissue, fetal stem cells, or even discarded embryos for research and medical treatments continues. These potential therapies may be indicated for the treatment of diabetes,Parkinson's disease, kidney disease, and cartilage diseases, among others.
o Current national regulations prohibit most fetal tissue research, but theNational Institutes of Health revealed late in 2000 that it will allow stem cell research. In June 2002, President Bush enacted a law restricting stem cell research to only preexisting cell lines and embryos "left over" from in vitro fertilization procedures.
o Many world cultures place a premium on male children, and reports of selective abortion of female fetuses have continued to surface.
• Provider issues
o Most abortion providers are obstetricians and gynecologists. However, providers from a variety of backgrounds (such as family practitioners and nurses) can be taught to perform abortions safely. Physicians are generally receptive to the concept of legal abortions being available in the United States. Research shows those most receptive tend to be non-Catholic and trained in a residency program where abortion observation was a requirement.
o Keeping abortions safe, legal, and rare are the goals of abortion providers.
o As providers have decreased in number, women are traveling farther to obtain abortions, seeking abortions later in pregnancy, and are unable to obtain services if they are poor and live in most rural areas.
o Posttraumatic stress has been reported in abortion workers exposed to violent abortion protests at their clinics.
• Insurance Coverage
o While few state public funding sources cover abortions except in cases of jeopardy to maternal life, many private health care plans do cover abortion counseling and procedures.