Abortion

• 1. Introduction

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  Abortion occurs without anyone choosing it in roughly 30 to 40 percent of all pregnancies. The body simply stops. That silent, common outcome is called miscarriage, or spontaneous abortion, and most of it happens before a woman even knows she is pregnant. The word abortion, though, usually means something deliberate: the induced termination of a pregnancy by removing or expelling an embryo or fetus. Around 73 million induced abortions are performed each year worldwide, and about 45 percent of them are done unsafely. How can a procedure be among the safest in all of medicine in one country and a leading cause of death for women in another? Why do abortion rates barely differ between nations that ban it and nations that allow it? And how did a practice traced to ancient China, Vedic India, and the Roman Empire become one of the most contested debates of the modern era?

• 2. Two Kinds Of Ending

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  Miscarriage, the unintentional expulsion of an embryo or fetus before the 24th week of gestation, follows rules no one writes. Studies of pregnant women in the US and China found that between 40 and 60 percent of embryos never progress to birth. Between 15 and 30 percent of known pregnancies end in clinically apparent miscarriage, and 80 percent of those happen in the first trimester. The most common cause early on is chromosomal abnormality in the embryo or fetus, accounting for at least half of sampled early losses. Advancing maternal age and a history of previous spontaneous abortions are the two leading risk factors. A pregnancy ending before 37 weeks with a live-born infant is a premature birth, not a miscarriage. A fetus that dies in utero after viability or during delivery is usually termed stillborn. These distinctions matter because the same biological event, an ended pregnancy, carries entirely different names depending on cause and timing.

• 3. Inside The Procedure

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  Mifepristone, also known as RU-486, arrived as an antiprogestogen in the 1980s, after prostaglandin analogs became available in the 1970s. Together they made medical abortion possible without surgery. The most common early regimen combines mifepristone with misoprostol up to 10 weeks, or 70 days, of gestational age. Taken with misoprostol 24 to 48 hours later, the combination is 98 percent effective up to 9 weeks, dropping modestly to 94 percent from 9 to 10 weeks. If a medical abortion fails, surgical abortion must complete it. Up to 15 weeks of gestation, suction-aspiration or vacuum aspiration are the most common surgical methods. Manual vacuum aspiration uses a hand syringe; electric vacuum aspiration uses a pump. After 12 to 16 weeks, dilation and evacuation opens the cervix and removes tissue with suction and forceps, performed vaginally with no incision. Rarer still are hysterotomy, similar to a caesarean section under general anesthesia, and gravid hysterectomy, removal of the whole uterus while it still contains the pregnancy. Both carry much higher rates of maternal morbidity and mortality than dilation and evacuation. In Sweden and nearby countries, more than 80 percent of second trimester abortions are induced through labor, a method very uncommon in the United States.

• 4. The Safety Paradox

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  A 2012 study in Obstetrics & Gynecology found that in the United States the risk of maternal mortality is 14 times lower after induced abortion than after childbirth. The CDC estimated US pregnancy-related mortality in 2019 at 17.2 deaths per 100,000 live births, against an abortion mortality rate of 0.43 per 100,000 procedures. From 2000 to 2009, abortion in the US carried a mortality rate lower than plastic surgery, similar to running a marathon, and about equivalent to traveling 760 miles in a passenger car. Yet the same procedure, performed by unskilled people with hazardous equipment in unsanitary facilities, causes between 22,000 and 44,000 deaths each year and 6.9 million hospital admissions. Roughly 20 million unsafe abortions are performed annually, with 97 percent in developing countries. South Africa's 1996 legalization brought an immediate drop in complications, with abortion-related deaths falling by more than 90 percent. The Guttmacher Institute estimates that universal access to contraceptives would mean about 14.5 million fewer unsafe abortions and 38,000 fewer deaths each year. The legal standing of abortion, not the procedure itself, is what determines whether women live or die.

• 5. The Mental Health Myth

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  Post-abortion syndrome is a name with no medical recognition. Anti-abortion advocates have proposed it as a distinct psychological condition, but it is not acknowledged by medical or psychological professionals in the United States. Current evidence finds no relationship between most induced abortions and mental health problems beyond those expected for any unwanted pregnancy. The American Psychological Association concluded that a woman's first abortion in the first trimester is no more a threat to mental health than carrying an unwanted pregnancy to term. Older reviews that found a link, later analysis showed, had failed to use an appropriate control group. When a proper control group is used, abortion is not associated with adverse psychological outcomes, though women denied access show increased anxiety after the denial. A 2020 long-term study of US women found that about 99 percent felt they had made the right decision five years later. Relief was the primary emotion, with few feeling sadness or guilt, and social stigma was the main factor predicting negative emotions. The researchers concluded that those emotions came from personal and social context, not from the procedure itself. A similar pattern of disproven claims surrounds the supposed link between abortion and breast cancer, which the WHO, the National Cancer Institute, and the American Cancer Society have all rejected.

• 6. Herbs Needles And History

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  Silphium, now extinct, was once reputed to end pregnancies, alongside tansy, pennyroyal, and black cohosh in folk medicine. In 1978, one woman in Colorado died and another suffered organ damage after taking pennyroyal oil to terminate their pregnancies. The reach of these attempts goes back millennia. Abortifacient knowledge in ancient China is often attributed to the mythological ruler Shennong. Egypt's Ebers Papyrus dates to around 1550 BCE, and one of the earliest artistic depictions survives in a bas relief at Angkor Wat in Cambodia, around 1150, showing a demon performing an abdominal abortion on a woman sent to the underworld. In Politics, written around 350 BCE, Aristotle preferred abortion to infanticide for population control, but only before the fetus had developed sensation and life. In 1920, Soviet Russia became the first country to legalize abortion, after Lenin insisted that no woman be forced to give birth. Iceland followed in 1935, Sweden in 1938, and Japan in 1948. Historian Linda Gordon noted that illegal abortions in the US had an impressive safety record, and a 1940s American physician spoke of his pride in performing 13,844 illegal abortions without a single fatality.

• 7. Faith And Conflict

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  Pope Sixtus V, in 1588, became the first Pope to label all abortion as homicide regardless of the stage of pregnancy. His successor, Pope Gregory XIV, reversed that pronouncement in 1591. The Catholic Church did not begin vigorously opposing abortion until the 19th century, and several historians note that before then most Catholic authors did not regard termination before quickening or ensoulment as abortion. Other traditions draw the line elsewhere. In Judaism, the fetus is not considered to have a human soul until it is safely outside the woman, viable, and has taken its first breath, and abortion is deemed necessary when a pregnant woman's life is in danger. In Islam, abortion is traditionally permitted until the soul enters the fetus, placed by various theologians at conception, 40 days, 120 days, or at quickening. Beyond doctrine, the conflict has turned violent. In the United States, at least four physicians have been murdered in connection with abortion clinic work: David Gunn in 1993, John Britton in 1994, Barnett Slepian in 1998, and George Tiller in 2009. Paul Hill became the first person executed in the United States for murdering an abortion provider.

• 8. Beyond The Human Question

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  Female rodents will terminate a pregnancy when exposed to the smell of a male not responsible for it, a phenomenon called the Bruce effect. Spontaneous abortion runs through the animal world in patterns that mirror and diverge from the human one. In sheep, stress or physical exertion such as crowding through doors or being chased by dogs can trigger it. In cows, contagious diseases like brucellosis or Campylobacter are culprits, often controllable by vaccination, while eating pine needles can also induce abortion. Among many species of sharks and rays, stress-induced abortions occur frequently upon capture. Male gray langur monkeys may attack females after a male takeover, causing miscarriage. Sex-selective abortion, by contrast, is a distinctly human invention, made possible by sonography and amniocentesis that reveal sex before birth. The selective termination of a female fetus is most common, reported in Taiwan, South Korea, India, and China. At the 1994 International Conference on Population and Development, more than 180 states agreed to eliminate all forms of discrimination against the girl child and the root causes of son preference, a commitment that still shapes the disputed birth ratios of the present day.