Changes in association between previous therapeutic abortion and preterm birth in Scotland, 1980 to 2008: a historical cohort study.

BACKGROUND: Numerous studies have demonstrated that therapeutic termination of pregnancy (abortion) is associated with an increased risk of subsequent preterm birth. However, the literature is inconsistent, and methods of abortion have changed dramatically over the last 30 years. We hypothesized that the association between previous abortion and the risk of preterm first birth changed in Scotland between 1 January 1980 and 31 December 2008. METHODS AND FINDINGS: We studied linked Scottish national databases of births and perinatal deaths. We analysed the risk of preterm birth in relation to the number of previous abortions in 732,719 first births (≥24 wk), adjusting for maternal characteristics. The risk (adjusted odds ratio [95% CI]) of preterm birth was modelled using logistic regression, and associations were expressed for a one-unit increase in the number of previous abortions. Previous abortion was associated with an increased risk of preterm birth (1.12 [1.09-1.16]). When analysed by year of delivery, the association was strongest in 1980-1983 (1.32 [1.21-1.43]), progressively declined between 1984 and 1999, and was no longer apparent in 2000-2003 (0.98 [0.91-1.05]) or 2004-2008 (1.02 [0.95-1.09]). A statistical test for interaction between previous abortion and year was highly statistically significant (p<0.001). Analysis of data for abortions among nulliparous women in Scotland 1992-2008 demonstrated that the proportion that were surgical without use of cervical pre-treatment decreased from 31% to 0.4%, and that the proportion of medical abortions increased from 18% to 68%. CONCLUSIONS: Previous abortion was a risk factor for spontaneous preterm birth in Scotland in the 1980s and 1990s, but the association progressively weakened and disappeared altogether by 2000. These changes were paralleled by increasing use of medical abortion and cervical pre-treatment prior to surgical abortion. Although it is plausible that the two trends were related, we could not test this directly as the data on the method of prior abortions were not linked to individuals in the cohort. However, we speculate that modernising abortion methods may be an effective long-term strategy to reduce global rates of preterm birth.

Menstrual regulation, unsafe abortion, and maternal health in Bangladesh.

Maternal mortality has declined considerably in Bangladesh over the past few decades. Some of that decline--though precisely how much cannot be quantified--is likely attributable to the country's menstrual regulation program,which allows women to establish nonpregnancy safely after a missed period and thus avoid recourse to unsafe abortion. Key Points. (1) Unsafe clandestine abortion persists in Bangladesh. In 2010, some 231,000 led to complications that were treated at health facilities, but another 341,000 cases were not. In all, 572,000 unsafe procedures led to complications that year. (2) Recourse to unsafe abortion can be avoided by use of the safe, government sanctioned service of menstrual regulation (MR)--establishing nonpregnancy after a missed period, most often using manual vacuum aspiration. In 2010, an estimated 653,000 women obtained MRs, a rate of 18 per 1,000 women of reproductive age. (3) The rate at which MRs result in complications that are treated in facilities is one-third that of the complications of induced abortions--120 per 1,000 MRs vs. 357 per 1,000 induced abortions. (4) There is room for improvement in MR service provision, however. In 2010, 43% of the facilities that could potentially offer it did not. Moreover, one-third of rural primary health care facilities did not provide the service. These are staffed by Family Welfare Visitors, recognized to be the backbone of the MR program. In addition, one-quarter of all MR clients were denied the procedure. (5) To assure that trends toward lower abortion-related morbidity and mortality continue, women need expanded access to the means of averting unsafe abortion. To that end, the government needs to address barriers to widespread, safe MR services, including women's limited knowledge of their availability, the reasons why facilities do not provide MRs or reject women who seek one, and the often poor quality of care.

The incidence of spina bifida in Sweden 1973-2003: the effect of prenatal diagnosis.

BACKGROUND: Many studies have been conducted on the accuracy of prenatal ultrasound diagnosis of foetal CNS-malformations. These studies were mostly hospital-based or, sometimes, multicentre studies. We present here a population-based study of the prenatal diagnosis of spina bifida in Sweden over a period of 31 years. METHODS: We compared the number of newborns with spina bifida and the elective terminations because of the prenatal diagnosis of spina bifida for different periods. RESULTS: The rate of spina bifida among newborns diminished gradually from 0.55 per 1000 to 0.29 per 1000 during the study period. In M county the rate of spina bifida at birth decreased very rapidly and from 1993 onwards was about half of that in the rest of the country. CONCLUSION: There has been a decline in the rate of spina bifida at birth. This decline can be seen earlier in the southern part of the country, M county. The decline is probably, to a great extent, a consequence of prenatal ultrasound screening.

[Progress in methods of therapeutical abortions during the second trimester in gynecological clinic "Umbal - Pleven"].

The aim of the authors is to discover the progress in the methodology for the interruption of pregnancy by medical indications during the second trimester in Gynecological clinic in UMBAL - Pleven. A retrospective study has been performed for the used methods in the last 10 years. For the same period were performed abortions in 49 women by medical indications. The interruption of pregnancy until the 16th gestational week (g.w.) of gestation was performed in one-stage. From the 16th g.w. to the 20th g.w., the most common method till the year 2001 was intraamniotic instillation of 25% solution of NaCl by Aburel (1934). After the 20th g.w. the pregnancy was interrupted either by metrierasis (using balloon catheter), or by sectio parva. After the 2001 was described radical change in conduct by therapeutic abortion during the second trimester, after the beginning of the prostaglandins use in obstetrical practice. The authors analyze the results of the use of prostaglandins describing the type, dosage of used medicine, period of abortion, contraindications and the risk for the mother. They reach to the conclusion that the prostaglandins are presently suitable means for therapeutical abortion during the second trimester, which fully replace the classical, traumatically and risky methods for the pregnant woman.

Social impacts of technological diffusion: prenatal diagnosis and induced abortion in Brazil.

Scientific and technological development plays an essential part in shaping contemporary societies, and medicine and health care are considered to be particularly receptive to the incorporation of new concepts, techniques and products, producing impacts not only on the health problems for which they were originally intended, but also varied 'side-effects', less frequently recognised and studied. In this study the point of departure was the hypothesis that the intensive diffusion in Brazil of prenatal ultrasound would create new problems for individuals (pregnant women, their families and health professionals) and society in coping with foetal malformations, due to the existence of a very restrictive induced abortion legislation. The objective of the research was to study the social visibility of these problems, in the written mass media. The period under analysis went from 1991 to 1996. The four most important daily newspapers and two medical council journals were studied, with a criteria oriented selection of articles, and their macrotextual thematic analysis. The results indicate that the basic elements in the relationships between medical technology, prenatal diagnosis, foetal malformations and induced abortions stayed the same along the period - a restrictive Penal Code, the public recognition of the disseminated and usually tolerated practice of induced abortion, done in risky conditions for the majority of women, with very evident consequences on maternal health, a divided Congress, a divided 'public opinion', religious opposition and new scientific and technological practices in health care. Nevertheless, tension between these 'contradictory' factors increases, so much so, that new elements are introduced which make an accommodation possible, without implying in major changes of position. This is achieved through the development of new alliances between Science, the judiciary and obstetrical leaders, which benefit individual initiatives, instead of leading to a public recognition of the problem and changes in the law.

Abortion and maternal health.

Since the beginning of recorded history, women have attempted to terminate unwanted pregnancies. Despite the safety of modern techniques of abortion, many women throughout the world still have to resort to unsafe abortions, placing themselves at considerable risk. The World Health Organization estimates that there are approximately 20 million unsafe abortions performed each year, and estimates of maternal deaths as a result of abortion range between 60,000 and 100,000 per year. With free and legal access to safe abortions, rates of complications and mortality drop dramatically. There is an urgent need for efforts to prevent unwanted pregnancies in order to reduce the need for abortion; for the early identification of abortion complications and easy access to treatment for women suffering those complications; for expansion of safe abortion availability; and for proper training and resources for providers of abortion services.

[Trends in therapeutic abortion management from 1986 to 1994]. / Prise en charge des interruptions médicales de grossesse. Evolution de 1986 à 1994.

OBJECTIVE: This study was performed in order to evaluate indications, techniques and maternal risks of medical abortions, and technical difficulties encountered in these procedures. TYPE OF THE STUDY: A monocentric, descriptive and retrospective study. MATERIALS AND METHODS: Four hundred seventeen medical abortions (MA) were performed in our fetal medicine Unit between 1986 and 1994, including 117 (28%) performed for maternal reasons and 300 (72%) for fetal reasons. Each indication was discussed in a collegial system and varied protocols of labor induction were used, mainly prostaglandins, RU 486, or feticide. MAIN PARAMETERS MEASURED: They were duration of the labor, maternal accidents, number of the fetal post-mortem examinations, counselling given to the couples. We considered that a MA is correctly managed when the intervention corresponded to the following criteria: expulsion by natural route without uterine damage, an examinable fetus and examination by a foetopathologist. MAIN RESULTS: Mean rate of MA satisfying our definition was about 45% in 1988 and reached to 74% in 1994. Our results show that the procedure is rarely complicated and that vaginal expulsion can be obtained. The foetopathologist examination rate increased regularly over the period. The mean gestational age of MA due to maternal indications was 14.5 weeks vs 23.9 weeks when dealing with fetal indications. The infection rate is about 6.2%, hemorrhage rate following expulsion was about 5.9% and the rate of uterine rupture was about 0.48%. CONCLUSIONS: These data suggest that medical abortion need to be evaluated regularly.

Second trimester abortions: trends and medical complications.

As a proportion of total abortions, those performed in the second trimester declined from 21% in 1974 to 10% in 1991. Second trimester (13 to 24 weeks) abortions were more frequent among women who were single, under age 20, and without prior deliveries or abortions. The stage of pregnancy at which an abortion was performed and the method used were associated with the risk of medical complications. Complication rates increased directly with the period of gestation. The complication rate for second trimester abortions was 13 times higher than that of first trimester abortions (under 13 weeks). The lowest complication rates were found among abortions performed using surgical D&C and suction D&C. The procedures primarily used for abortions at 16 or more weeks' gestation (i.e. the administration of prostaglandin, urea or saline) were associated with higher complication rates.

[Study of the reasons for therapeutic abortions, stillbirth and neonatal mortality in the Brittany region in 1991]. / Etude des causes des interruptions thérapeutiques de grossesse, de mortinatalité et de mortalité néonatale en région Bretagne, année 1991.

The reasons for 186 medically indicated terminations of pregnancy, 178 stillbirths, and 126 neo-natal deaths were analysed by a multi-disciplinary team after a thorough enquiry into the social and medical context for the deaths or for the decision to interrupt the pregnancies. This was undertaken on the initiative of the regional technical consultative commission for enquiring into births, and according to a protocol that had already been partly used by a group studying the neonatal period in Ille and Vilaine. A comparison of the causes according to the type of death shows the value of following up these three indicators to the plan and appropriate policy for three weeks following delivery. A certain number of questions about definitions and classifications still have arisen.

Medically indigent women seeking abortion prior to legalization: New York City, 1969-1970.

If the efforts now underway to limit access to abortion services in the United States are successful, their greatest impact will be on women who lack the funds to obtain abortions elsewhere. There is little published information, however, about the experience of medically indigent women who sought abortions under the old, restrictive state laws. This article details the psychiatric evaluation of 199 women requesting a therapeutic abortion at a large municipal hospital in New York City under a restrictive abortion law. Thirty-nine percent had tried to abort the pregnancy. Fifty-seven percent had concrete evidence of serious psychiatric disorder. Forty-eight percent had been traumatized by severe family disruption, gross emotional deprivation or abuse during childhood. Seventy-nine percent lacked emotional support from the man responsible for the pregnancy, and the majority were experiencing overwhelming stress from the interplay of multiple problems exacerbated by their unwanted pregnancy.

PIP: A series of 199 medically indigent women who applied for therapeutic abortion at Bellview Hospital in New York City from December 1968-April 1970 is discussed by a psychiatric staff member who evaluated the patients as part of their application. At that time, abortion candidates were required to have 2 psychiatrists state that pregnancy was a risk to their life. They ranged from 14-41 years old; 30% were Black, 23% Hispanic; 62% were never-married, 20% were married. 56% had been pregnant before, 8% had prior induced abortions. 15% had infants or twins 1 year old. 22% were on public assistant, 42% had low-paying jobs, 20% were students. 75% successfully obtained hospital abortions. Of the remaining 49, 6 had spontaneous or clandestine abortions, 6 obtained induced abortion illegally, 9 decided to carry their pregnancy to term included 4 who attempted self abortion and 4 who attempted suicide during the pregnancy. 57% showed objective evidence of serious psychiatric disturbance, not including depression, anxiety, or threatened suicide. The 10 who were not recommended for abortion for lack of psychiatric grounds included a mother of a mentally retarded and a brain-damaged child and 5 other children, and a retarded woman abandoned by her husband. The 5 minors who were not approved for lack of parental consent included an 18-year old whose father had attempted to strangle her and whose mother abused her. 3 of these minors obtained abortions illegally. During the application process, which normally took 2 weeks, or after approval, 23 were lost to follow-up. Those lost during the process included 4 with severe psychiatric diagnoses, and 4 who attempted self-abortion. In the group there were 33% who had attempted abortion, 5% whose pregnancy was a result of rape, 11 who abused their children, 7 who did not have custody of their children, and 79 whose relationship with the father was marked by lack of support, abuse, marital conflict, or the partner was dead, ill, or dying. The prevalence of poverty, family pathology, severe stress, and psychopathology was presented in detail. It is likely that the ability to care for children of the index pregnancy in the women for whom abortion was refused was impaired. The author believes that the psychosocial pathology in this population has increased, and that newly enacted restrictions on abortion would be even more stressful for today's indigent women.

Mortalidad en sepsis materna: factores predisponentes / Mortality in maternal sepsis: predisposing factors

En este trabajo se analiza, la mortalidad materna producida por sepsis. Las causas predisponentes a la infección materna así como todos aquellos factores que inciden en una mayor mortalidad de los pacientes sépticos de un modo general, tratando de puntualizar todos aquellos que puedan tener valor predictivo de mortalidad y que conduzcan a un mejor criterio administrativo de los recursos tan dispensiosos que se utilizan en el manejo del paciente crítico. Se analiza la falta de múltiples órganos en relación a la sepsis y las implicaciones que tienen en la mortalidad materna

Therapeutic abortions, Canada, 1987.

A total of 63,662 therapeutic abortions were performed in hospitals in Canada in 1987, an increase of 0.2% from the 63,508 performed in 1986. The abortion rate per 1,000 women 15-44 years was 10.2 in 1987, as it had been in 1986. Looking at marital status at the time of abortion, 67.3% of women were single, 21.8% married and the remaining 10.9% were separated, divorced, widowed or living common-law. About 22% of the women were under 20 years of age, 54.3% were between 20-29 years, 21.3% were from 30 to 39 years and 2.4% were over 39 years of age. At time of pregnancy termination, the gestation period was under 13 weeks for 88.5% of abortion cases, 13 to 16 weeks for 8% of cases, and over 16 weeks for 3.5% of cases.

Termination of pregnancy in teenagers.

This is a study of some epidemiological aspects of fifty-three unmarried girls, aged sixteen years and under, who were referred for therapeutic termination of pregnancy during the year 1976. Although the results showed that the overall abortion rate in Canada is much higher than in Newfoundland, the abortion rate in the 14-16 year age group is higher in the Province than in the rest of Canada. Secondly, the abortion rate for the fifteen year age group in this Province is higher than that for the sixteen year old girls, suggesting that more pregnancies in the older age group go to term. The rate of abortions among some religious denominations is significantly higher than in others. Urban living does not appear to produce an increase in abortion rates in these age groups. Interruption of schooling due to the occurrence of pregnancy is not a cause for concern in about half of this group. There is some evidence in support of the contention that precocious maturation is related to early pregnancy.

Therapeutic abortion on psychiatric grounds. Part III. Implementing the Abortion and Sterilization Act (1975-1981).

This article reviews the experience of the Pregnancy Advisory Service (PAS) of the Department of Psychiatry, Groote Schuur Hospital. Demographic and personal data from the women referred to the PAS during the period 1975-1981 (since the passing of the Abortion and Sterilization Act of 1975) are recorded. Follow-up information from many of the 1251 patients seen over this period confirms the findings of a previous report that in a significant percentage of cases in which a woman was refused legal abortion pregnancy did not proceed to term. For reasons which are not clear there has been a fall in the number of cases seen for assessment. The PAS performs a valuable function in enabling women to examine the circumstances of an unplanned pregnancy and in providing expert counselling.

Why is the number of pregnancies among teenagers decreasing?

The issue of pregnancy among adolescent women has received considerable attention from the media. Contrary to common belief, both the numbers and the rates of such pregnancies, even when data on abortion are included, have been declining. Patterns of contraception may account for some of the decrease; however, more study is required. In the past, unmarried teenagers who became pregnant either got married or put the baby up for adoption. Now they can either have an abortion or keep the baby. Solutions to the problems of pregnancy among teenagers must therefore be addressed to these altered social consequences rather than to misleading comments about "epidemics", with their suggestion of increased rates of pregnancy.