American College of Pediatricians – February 2015
ABSTRACT: Induced abortion is the most common surgical procedure performed on females of child-bearing age, including adolescent women. Consequently, pediatricians should be familiar with the short-term and long-term risks of induced abortion and also be able to compassionately discuss these risks with adolescents and involved family members.
Some of the potential short- and long-term risks include increased mortality from suicide and other violence, as well as natural causes; increased risk of breast cancer; greater rates of substance abuse; and higher risk of morbidity and mortality for subsequent children due to premature births, especially very premature births.
Patient education on the risks of induced abortion should be considered during anticipatory guidance discussions at well-child visits during the immediate pre- and adolescent years.
The annual number of induced abortions in the United States was 1,058,000 in 20111 (and an unknown number worldwide); of these approximately 186,200 were on early/middle (teenaged) adolescents.
Including those performed on older adolescents/young women of college age (20-24), approximately 540,000 induced abortions2 occur annually on US adolescent/young adults prior to full brain maturation.
The prefrontal cortex of the brain, the area used in complex decision-making, is not fully mature until about age 25.3 From 1967-2011, nearly 54 million abortions have been reported in the US (all ages).4
Aside from any ethical considerations, the magnitude of these numbers makes it important to consider associated risks and sequelae from a public health perspective.
I. Inherent Difficulties in Studying Induced Abortion
A. Researcher bias
The highly charged issue of induced abortion has, unfortunately, often been characterized by polarized research: Many of the individuals who perform and support widespread legal access to induced abortion tend to downplay the associated risks while those who find abortion-on-demand ethically problematic tend to publish findings that emphasize the risks.
In addition, much of the research addressing induced abortion has been conducted by affiliates of organizations that profit financially from performing abortions, such as Planned Parenthood,5 creating a significant conflict of interest. Bias not only impacts study design, but also how results are reported. In addition, many studies, which reveal both positive and negative results, are poorly designed.
One salient example of pro-abortion bias is a study that concluded that vacuum aspiration abortion does not lower birth weight in subsequent children. Indeed, the average birth weight of the next child was essentially the same.
However, the authors omitted mentioning that the percentage of babies weighing between 1001 and 2000 grams inclusively was two to three times higher in women whose previous pregnancy had been aborted compared with those who had not aborted their previous pregnancy.6
Another example of bias is the study by Melbye et al that minimized the evidence supporting the hypothesis that second trimester abortions do increase the risk of breast cancer.7
No person or organization of persons is immune from bias. Consequently, in an effort to achieve the greatest level of objectivity, an attempt to review, report and synthesize the findings from researchers on both sides of the ethical debate is presented here.
B. Poor availability of accurate records
The lack of accurate records is another challenge in studying induced abortion. For example, many deaths after both childbirth and abortion are not coded as such, underestimating the mortality of each.8-10 Death certificates may list the complication (e.g., infection or suicide) rather than the underlying cause.
Deaths from suicide that occurred as a result of abortion-related depression, for example, would not be coded as an abortion-related death.
No Federal laws mandate States to report abortion data to the Centers for Disease Control and Prevention (CDC) and Federal regulations do not require abortion facilities to report such data to State Health Departments. In most but not all States, however, the abortion facilities report statistics to local health departments, which, in turn, report to the State Health Departments, which report to the CDC.
These abortion providers collect only limited data regarding immediate complications that occur while women physically remain in their facilities. They do not track or report any potential longer-term complications.
Moreover, when a complication does occur later, it typically results in a visit to either a primary care physician or an emergency department, and the woman may fail to disclose the preceding abortion to the physician. Also, financial and billing records are of little use in tracking caseload because many, if not most, induced abortions are paid for in cash.
A number of studies have sought to overcome these obstacles by linking death records with medical records that contain abortion histories (California Medicaid, Finland, and Denmark).11-14
Unfortunately, some studies have erroneously assumed that no abortions occurred during periods prior to the establishment of a national abortion registry (for example, 60,000 women in Denmark who had abortions before 1973 were misclassified in a 1997 study on abortion and breast cancer).
A Finnish paper examining the effect of data linkages on identifying pregnancy-associated deaths (deaths within one year of pregnancy) found that, without such linkages, 73% of all pregnancy-associated deaths and 94% of induced abortion-related deaths would have been missed.
In only 6% of deaths in the year after induced abortion was the abortion reported on death certificates (the report was in the narrative portion of the death certificate); in only a third of these death certificates mentioning the abortion (2% of all deaths in the year following abortion) was abortion listed as the cause of death.8 Similar omissions have been found in US records.15
C. Selection of appropriate control groups
In evaluating the comparative risks of abortion, researchers have used different control groups: at some times nulligravidas (women who have never been pregnant) and at other times women with an equal number of pregnancies to those who had had an abortion. Which is appropriate? Comparison to nulligravidas is invalid – a woman’s body is forever affected by the hormonal changes of pregnancy.
Therefore, in comparing the risks of induced abortion with the risks of giving birth, the two groups should have the same reproductive histories prior to the pregnancy in question, with the variable group undergoing induced abortion while the control group gives birth.
From the perspective of the pregnant woman making a decision for or against abortion, these are the comparison groups that will give her valid information – ones with her past history that then compare the results of a subsequent pregnancy.
D. Bias and errors in study designs
Due to multiple challenges in studying induced abortion, it is difficult to design high-quality, well-controlled, prospective studies.
Retrospective studies have been criticized as being crippled by recall bias: These studies theorize that women who are sick (for example, with breast cancer) are more likely to admit to past abortions than controls, thus falsely elevating abortion correlates. However, studies designed to evaluate recall bias have found none.16-18
On the other hand, some prospective studies failing to link abortion to the development of breast cancer have been criticized for other methodological flaws. For example, non-abortive control groups were overrepresented by older women – at higher risk for breast cancer by virtue of age alone. In fact, many of these women were mis-categorized as having had no abortions when they may have had one or more.
Other studies utilized variable cohorts with an over-representation of younger women, who may not have had enough time since their abortions to develop cancer, and compared them to control groups with older women who did not have abortions.19
Some meta-analyses included unpublished studies that failed to find elevated breast cancer risk and simultaneously omitted inclusion of published peer-reviewed studies that support the opposite conclusion.20
E. Assessment of safety
Statistics purporting to show abortion is safer than childbirth21 are flawed for at least four reasons.
With regard to both pregnancy and abortion, death certificates, as discussed previously, are often inaccurate.
In fact, researchers in Finland, a country with the highest quality of statistical reporting due to its longstanding national healthcare registry, concluded that only 1 in 4 overall pregnancy-associated deaths and only 1 in 16 abortion-associated deaths were able to be identified solely from death records.11
Even official statistics that investigate “late maternal deaths” (those occurring from 42 days after the end of pregnancy until a year after the end of pregnancy), miss deaths, whether after abortion or after childbirth, that occur years later from both medical (for example, breast cancer or cardiomyopathy) or psychological (for example, suicide) causes.
Studies that do investigate long-term mortality rates after induced abortion versus childbirth are discussed in detail later in the paper.
When evaluating the comparative safety of abortion versus childbirth, researchers fail to account for the protective health effects of giving birth. For example, carrying a pregnancy to term is associated with lower rates of risk for suicide, serious injury, breast cancer, and certain other diseases.11,22,13,23
Consistent with this protective effect, women who have given birth also have lower mortality rates in their age cohort than women who were never pregnant.17,24,25,26,27
Finally, the broader picture assesses the effect of abortion versus childbirth on a woman’s future children: are they put at risk by her choice?
II. Risks of Abortion to a Woman’s Subsequent Health
Maternal mortality rates in countries with permissive versus restrictive abortion laws
Proponents of legal abortion claim that legalized abortion results in lowered maternal mortality rates.
However, Ireland, Poland, and Malta – nations with the most restrictive abortion laws – have some of the lowest maternal mortality in the world. Note comparisons (Table 1) to neighboring countries with similar socioeconomic standing.
***TO VIEW REMAINDER OF STUDY, AND ALL TABLES, VISIT — http://www.acpeds.org/the-college-speaks/position-statements/health-issues/induced-abortion-risks-that-may-impact-adolescents-young-adults-and-their-children
***FOR A PDF VERSION OF THIS ENTIRE ARTICLE, VISIT — http://www.acpeds.org/wordpress/wp-content/uploads/2.24.15-Induced-Abortion.pdf
VI. Concluding Comments
In summary, the health risks associated with induced abortion, when compared with childbirth, are significant and substantial and can include higher long-term mortality rates from suicide and other violent causes, as well as elevated mortality rates due to natural causes.
There are increased risks of breast cancer and subsequent premature births among post-abortive women. There is also an increased lifetime prevalence of mental illness and substance abuse in women who have abortions, though causality has not yet been established.
Premature delivery significantly increases the chance of neurodevelopmental and other medical morbidities in the resulting offspring. Maternal mental health and substance abuse problems can place existing as well as future children at risk of maladaptive parenting, abuse, and neglect. Higher rates of associated maternal mortality and suicidality may result in children losing their mother at a young age.
While the decline in the rate of abortion over the past two decades is a very positive development, much work remains to be done to fully protect these most vulnerable unborn patients, their siblings, and their young parents.
The American College of Pediatricians urges pediatricians to educate adolescent patients and their parents about the risks of promiscuous sexual activity as well as the harmful consequences of abortion and to do so before patients become sexually active.
Clearly, abortion prevention is best accomplished by delaying onset of sexual debut. Mindful of the only foolproof method to accomplish these goals, pediatricians should encourage patients and parents to promote a culture of abstinence-until-marriage within their families, as well as to discourage cohabitation before marriage.108,109
Pediatricians should consider including information on the risks of abortion during routine anticipatory guidance on sexuality given at appropriately-aged well-child visits and again before the patient leaves home.
Furthermore, pediatricians are likely to encounter the effects of abortion not only when it involves their adolescent patients (who may be fathers or mothers to an unborn child), but also when young patients are affected by the consequences of a parent’s abortion.
Pediatricians therefore must be prepared to consider how the emotional toll of past abortions affects the parenting dynamics within families in their practices.
Finally, from a public health perspective, pediatricians should engage in advocacy within their communities and beyond by educating about the health risks of abortion, which include an increased rate of prematurity-related morbidity, an increased risk of breast cancer, suicide, and potentially other mental illness and substance abuse, all of which can exact a heavy toll on the patient and financial burden on society.
Primary author: Patricia Lee June, MD, FCP
The American College of Pediatricians is a national medical association of licensed physicians and healthcare professionals who specialize in the care of infants, children, and adolescents. The mission of the College is to enable all children to reach their optimal physical and emotional health and well-being.
Please click on this link, Induced Abortion, for a PDF version of this statement — http://www.acpeds.org/wordpress/wp-content/uploads/2.24.15-Induced-Abortion.pdf (Feb 2015)
Additional information is available in a recently published paper by the British Medical Journal, Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states.
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2. Calculated from Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011, Perspect Sex Reprod Health, 2014;46(1):3-14, and Jones RK, Finer LB, Singh S. Characteristics of U.S. abortion patients, 2008. Guttmacher Institute website. http://www.guttmacher.org/pubs/US-Abortion-Patients.pdf. Published May 2010. Accessed May 8, 2014.
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4. United States abortion rates, 1960-2012, compiled by Wm. Robert Johnston, last modified 28 November 2014. http://www.johnstonsarchive.net/policy/abortion/graphusabrate.html. Accessed January 15, 2015.
5. The Guttmacher Institute was the research arm of Planned Parenthood, http://www.plannedparenthood.org/files/7413/9620/1089/AR-FY13_111213_vF_rev3_ISSUU.pdf. Planned Parenthood’s 2013 Annual Report lists 327,166 abortions in 2012. The average cost is $500, according to http://mediamatters.org/research/2011/02/18/laura-ingraham-grossly-misrepresents-planned-pa/176611. This calculates to $163,583,000 annually.
6. Meirik O, Bergstrom R. Outcome of delivery subsequent to vacuum-aspiration abortion in nulliparous women. Acta Obstet Gynecol Scand. 1983;62(5):499-509. The authors omitted mentioning that the percentage of babies weighing between 1001 and 2000 grams inclusively was two to three times higher in women whose previous pregnancy had been aborted compared to that in those who had not aborted their previous pregnancy. Although not mentioned in the text, this is apparent from the graph. Statistical analysis was not reported for these low/very low birth-weight babies.
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73. Davood S, Kazem P and Sepideh E. Selected Pregnancy Variables in Women with Placenta Previa. Research Journal of Obstetrics and Gynecology (2008) Volume 1, Issue 1, Pg 1-5. Accessed Nov 7, 2014 at http://scialert.net/fulltext/?doi=rjob.2008.1.5 (Iran) OR for lack of abortion 0.7 (0.57-0.83) p<.001.
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