Understanding the Impacts of the Supreme Court Case FDA v Alliance for Hippocratic Medicine

This Viewpoint outlines the potential effects of the Supreme Court case regarding mifepristone restrictions: a decision for the FDA would allow current dispensing, while ruling against the FDA would severely curtail access to reproductive health options.

The Shift From Criminalization to Legalization of Abortion in Argentina

This Viewpoint discusses passage and implementation of Law 27.610, which legalized abortion in Argentina under certain circumstances, and examines the ongoing clinical issues and legal challenges to the law.

[['Love them Both': Abortion in a Globalized World].]

This article explores the origins and the development of women-protective anti-abortion arguments in a globalized world. Unlike fetus-base pro- life arguments, women protective ones focus on gender stereotypes and on the theory of gender complementarity. The article traces the influence of US conservative groups in spreading such arguments beyond the US borders, so that in today's globalized world, womnen-protective arguments have become central in abortion and contraception related legislation and litigation in the US, Europe and Russia. The article points to the dangers of the women-protective anti-abortion strategy, which aims at disempowering women, by denying them agency and control over reproduction, resulting in a direct challenge to gender equality.

[The Incidence of Biomedical Advances in Women. Some Reflections on the Spanish Legislation]

This article will examine how and to what extent advances in biomedical sciences have played a role in transforming the status of women. It will highlight the positive aspects of these transformations but it will also examine the issues which are currently debated and which, in my opinion, require calm and considered reflection.

Game change in Colorado: widespread use of long-acting reversible contraceptives and rapid decline in births among young, low-income women

CONTEXT

Long-acting reversible contraceptive (LARC) methods are recommended for young women, but access is limited by cost and lack of knowledge among providers and consumers. The Colorado Family Planning Initiative (CFPI) sought to address these barriers by training providers, financing LARC method provision at Title X-funded clinics and increasing patient caseload.

METHODS

Beginning in 2009, 28 Title X-funded agencies in Colorado received private funding to support CFPI. Caseloads and clients' LARC use were assessed over the following two years. Fertility rates among low-income women aged 15-24 were compared with expected trends. Abortion rates and births among high-risk women were tracked, and the numbers of infants receiving services through the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were examined.

RESULTS

By 2011, caseloads had increased by 23%, and LARC use among 15-24-year-olds had grown from 5% to 19%. Cumulatively, one in 15 young, low-income women had received a LARC method, up from one in 170 in 2008. Compared with expected fertility rates in 2011, observed rates were 29% lower among low-income 15-19-year-olds and 14% lower among similar 20-24-year-olds. In CFPI counties, the proportion of births that were high-risk declined by 24% between 2009 and 2011; abortion rates fell 34% and 18%, respectively, among women aged 15-19 and 20-24. Statewide, infant enrollment in WIC declined 23% between 2010 and 2013.

CONCLUSIONS

Programs that increase LARC use among young, low-income women may contribute to declines in fertility rates, abortion rates and births among high-risk women.

Physicians' practices when frustrating patients' needs: a comparative study of restrictiveness in offering abortion and sedation therapy

In this paper it is argued that physicians' restrictive attitudes in offering abortions during 1946-1965 in Sweden were due to their private values. The values, however, were rarely presented openly. Instead physicians' values influenced their assessment of the facts presented--that is, the women's' trustworthiness. In this manner the physicians were able to conceal their private values and impede the women from getting what they wanted and needed. The practice was concealed from both patients and physicians and never publicly discussed. It is also argued that a similar tacit practice could currently be applied by palliative care physicians. Such practice might allow palliative care physicians to be restrictive when offering sedation therapy without appearing paternalistic or declaring conscientious objections. However, the practice runs counter to patients' right to participate in making decisions. The women seeking abortion began to oppose the situation and eventually a new abortion law was introduced 1975. Patients at the end of life will never be able to protest against palliative care physicians' restrictive attitudes. This is a vulnerable and weak group, unable to lodge complaints after the treatment. In order to respect patients' autonomy, even suffering patients at the end of their lives, it is suggested that physicians should openly declare their values when it comes to providing treatments that might shorten life. Such transparency might facilitate more genuine shared decision-making and accordingly less suboptimal end-of-life care.

Increased number of applications for late termination of pregnancy in Denmark

INTRODUCTION

Last year, it was 40 years since the introduction of legal abortion until the 12th week of gestation and the possibility of late termination of pregnancy in Denmark. The aim of this study was to describe the development in applications for late termination of pregnancy in the 1986-2011-period focusing on indications related to the women's conditions.

MATERIAL AND METHODS

All applications for late termination of pregnancy in 1986 were reviewed by Nordentoft et al, and access to all applications from 2011 was granted by the abortion committees and the Appeals Board. All applications were reviewed in order to explore the development since 1986.

RESULTS

The total number of applications for late termination of pregnancy has increased by 45% from 1986 to 2011 with 594 and 862 applications, respectively. Despite this increase, the number of permissions granted with reference to the women's conditions has decreased. In 1986 and 2011, 488 and 382 women, respectively, applied for late termination of pregnancy with reference to the women's conditions. Of the 519 women who were granted permission in 1986, 31% were ≤ 20 years of age. In 2011 this age group represented only 12%.

CONCLUSION

Significant changes in the women's age and the reasons they provide when applying for late termination of pregnancy have been observed from 1986 to 2011. Further investigation of this subject will contribute to securing the best possible conditions for women going through late termination of pregnancy.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Induced abortion: incidence and trends worldwide from 1995 to 2008

BACKGROUND

Data of abortion incidence and trends are needed to monitor progress toward improvement of maternal health and access to family planning. To date, estimates of safe and unsafe abortion worldwide have only been made for 1995 and 2003.

METHODS

We used the standard WHO definition of unsafe abortions. Safe abortion estimates were based largely on official statistics and nationally representative surveys. Unsafe abortion estimates were based primarily on information from published studies, hospital records, and surveys of women. We used additional sources and systematic approaches to make corrections and projections as needed where data were misreported, incomplete, or from earlier years. We assessed trends in abortion incidence using rates developed for 1995, 2003, and 2008 with the same methodology. We used linear regression models to explore the association of the legal status of abortion with the abortion rate across subregions of the world in 2008.

FINDINGS

The global abortion rate was stable between 2003 and 2008, with rates of 29 and 28 abortions per 1000 women aged 15-44 years, respectively, following a period of decline from 35 abortions per 1000 women in 1995. The average annual percent change in the rate was nearly 2·4% between 1995 and 2003 and 0·3% between 2003 and 2008. Worldwide, 49% of abortions were unsafe in 2008, compared to 44% in 1995. About one in five pregnancies ended in abortion in 2008. The abortion rate was lower in subregions where more women live under liberal abortion laws (p<0·05).

INTERPRETATION

The substantial decline in the abortion rate observed earlier has stalled, and the proportion of all abortions that are unsafe has increased. Restrictive abortion laws are not associated with lower abortion rates. Measures to reduce the incidence of unintended pregnancy and unsafe abortion, including investments in family planning services and safe abortion care, are crucial steps toward achieving the Millennium Development Goals.

FUNDING

UK Department for International Development, Dutch Ministry of Foreign Affairs, and John D and Catherine T MacArthur Foundation.

Legal abortion worldwide in 2008: levels and recent trends

CONTEXT

Periodic assessments of abortion incidence are essential for monitoring trends in unintended pregnancy and gaps in contraceptive services and use.

METHODS

Statistics and estimates of legal induced abortions in 2008 were compiled for 64 of the 77 countries in which legal abortion is generally available; the 64 are home to 98% of women aged 15-44 who live in the countries eligible for inclusion. Data sources included reports or completed questionnaires from national statistical offices and nationally representative surveys. The completeness of official figures was assessed by in-country and regional experts. Trends since 1996 and 2003 were examined.

RESULTS

Of the 77 countries with liberal abortion laws, 36 are in the developing world. In 2008, abortion rates in the 25 countries with complete records-all of which were developed-ranged from seven (Germany and Switzerland) to 30 (Estonia) per 1,000 women aged 15-44. Abortion rates declined in about half of the 20 countries with consistently reliable information on trends between 1996 and 2008; declines were generally steeper than increases, although the pace of decline slowed after 2003. The highest observed abortion rates were in developing countries with incomplete estimates. For most developing countries that had liberal laws, the reported abortion rates were incomplete and varied widely.

CONCLUSIONS

High abortion rates in some countries, and small increases in rates in others, indicate a great need for more effective family planning services for these populations. Reliable data collection systems, needed to ensure that trends can be effectively monitored, are lacking in many countries.

Abortion incidence and access to services in the United States, 2008

CONTEXT

The incidence of abortion has declined nearly every year between 1990 and 2005, but this trend may be ending, or at least leveling off. Access to abortion services is a critical issue, particularly since the number of abortion providers has been falling for the last three decades.

METHODS

In 2009 and 2010, all facilities known or expected to have provided abortion services in 2007 and 2008 were contacted, including hospitals, clinics and physicians' offices. Data on the number of abortions performed were collected and combined with population data to estimate national and state-level abortion rates. Abortion incidence, provision of early medication abortion, gestational limits, charges and antiabortion harassment were assessed by provider type and abortion caseload.

RESULTS

In 2008, an estimated 1.21 million abortions were performed in the United States. The abortion rate increased 1% between 2005 and 2008, from 19.4 to 19.6 abortions per 1,000 women aged 15-44; the total number of abortion providers was virtually unchanged. Small changes in national abortion incidence and number of providers masked substantial changes in some states. Accessibility of services changed little: In both years, 35% of women of reproductive age lived in the 87% of counties that lacked a provider. Fifty-seven percent of nonhospital providers experienced antiabortion harassment in 2008; levels of harassment were particularly high in the Midwest (85%) and the South (75%).

CONCLUSIONS

The long-term decline in abortion incidence has stalled. Higher levels of harassment in some regions suggest the need to enact and enforce laws that prohibit the more intrusive forms of harassment.

Abortion surveillance--United States, 2005

PROBLEM/CONDITION

CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions.

REPORTING PERIOD COVERED

This report summarizes and describes data voluntarily reported to CDC regarding legal induced abortions obtained in the United States in 2005.

DESCRIPTION OF SYSTEM

For each year since 1969, CDC has compiled abortion data by state or area of occurrence. Information is requested each year from all 50 states, New York City, and the District of Columbia. For 2005, data were received from 49 reporting areas: New York City, District of Columbia, and all states except California, Louisiana, and New Hampshire. For the purpose of trends analysis, data were evaluated from the 46 reporting areas that have been consistently reported since 1995.

RESULTS

A total of 820,151 legal induced abortions were reported to CDC for 2005 from 49 reporting areas, the abortion ratio (number of abortions per 1,000 live births) was 233, and the abortion rate was 15 per 1,000 women aged 15--44 years. For the 46 reporting areas that have consistently reported since 1995, the abortion rate declined during 1995--2000 but has remained unchanged since 2000. For 2005, the highest percentages of reported abortions were for women who were known to be unmarried (81%), white (53%), and aged <25 years (50%). Of all abortions for which gestational age was reported, 62% were performed at </=8 weeks' gestation and 88% at <13 weeks. From 1992 (when detailed data regarding early abortions were first collected) through 2005, the percentage of abortions performed at </=6 weeks' gestation has increased. A small percentage of abortions occurred at >15 weeks' gestation (3.7% at 16--20 weeks and 1.3% at >/=21 weeks). A total of 35 reporting areas submitted data stating that they performed and enumerated medical (nonsurgical) procedures, making up 9.9% of all known reported procedures from the 45 areas with adequate reporting on type of procedure. In 2004 (the most recent years for which data are available), seven women died as a result of complications from known legal induced abortion. One death was associated with known illegal abortion.

INTERPRETATION

For the 46 reporting areas that have consistently reported since 1995, the number of abortions has steadily declined over the previous 10 years. The abortion rate declined from 1995 to 2000, but remained unchanged since 2000. In 2004, as in the previous years, deaths related to legal induced abortions occurred rarely.

PUBLIC HEALTH ACTION

Abortion surveillance in the United States continues to provide the data necessary for examining trends in numbers and characteristics of women who obtain legal induced abortions and to increase understanding of this pregnancy outcome. Policymakers and program planners use these data to improve the health and well-being of women and evaluate efforts to prevent unintended pregnancies.

Legal abortion in England and Wales

Ninety-eight per cent of abortions on British women resident in England or Wales are performed for social reasons. The Abortion Act (1967) insists on the opinion of two doctors but is broadly phrased and, by allowing that abortion can protect mental health, permits abortion when social factors are causing or likely to cause significant stress. The abortion rate has been stable at 11-12 per 1000 women aged 15-44 since 1973, suggesting that factors causing unplanned pregnancy are remaining constant for women in the fertile years and that, overall, the available facilities are adequate. However, only 49% of women obtain a free abortion in the National Health Service (NHS) and there are wide regional variations. Serious delays in the NHS are associated with inadequate access to pregnancy tests, attitudes of medical staff to abortion, and gynaecological units that are fully occupied with other problems. Women can choose to pay for abortions in services run either by charities or by commercial organizations. These services are used electively by a minority of women but most would prefer an NHS abortion if it was easily available. Women who seek help outside the NHS receive prompt and efficient management.

Abortion round the world

In the recent UK debates about the upper time limit for termination of pregnancy, attention focused on the number of abortions since legalisation. But, as Hannah Brown reports, rates of abortions have been falling faster in Western countries than elsewhere

Termination of pregnancy: a case for a change in the law

In recent months there has been renewed public and parliamentary debate on whether the abortion law in the United Kingdom should be reformed. Parliament has debated the issue on three occasions and now the House of Commons Select Committee on Science and Technology are calling for evidence in support of their inquiry into reform of the Abortion Act 1967. The inquiry gives district nurses the opportunity to inform the debate and ensure that their voices are heard given that topics for reform include nurse-led abortions and home abortions. In this article Richard Griffith and Cassam Tengnah review the development of the law relating to abortion and highlight the areas of reform to be considered by the select committee.

Abortion surveillance--United States, 2003

PROBLEM/CONDITION

CDC began abortion surveillance in 1969 to document the number and characteristics of women obtaining legal induced abortions.

REPORTING PERIOD COVERED

This report summarizes and describes data voluntarily reported to CDC regarding legal induced abortions obtained in the United States in 2003.

DESCRIPTION OF SYSTEM

For each year since 1969, CDC has compiled abortion data by state or area of occurrence. During 1973-1997, data were received from or estimated for 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City. In 1998 and 1999, CDC compiled abortion data from 48 reporting areas. Alaska, California, New Hampshire, and Oklahoma did not report, and data for these states were not estimated. During 2000-2002, Oklahoma again reported these data, increasing the number of reporting areas to 49, and for 2003, Alaska again reported and West Virginia did not, maintaining the number of reporting areas at 49.

RESULTS

A total of 848,163 legal induced abortions were reported to CDC for 2003 from 49 reporting areas, representing a 0.7% decline from the 854,122 legal induced abortions reported by 49 reporting areas for 2002. The abortion ratio, defined as the number of abortions per 1,000 live births, was 241 in 2003, a decrease from the 246 in 2002. The abortion rate was 16 per 1,000 women aged 15-44 years for 2003, the same as for 2002. For the same 47 reporting areas, the abortion rate remained relatively constant during 1998-2003. During 2001-2002 (the most recent years for which data are available), 15 women died as a result of complications from known legal induced abortion. One death was associated with known illegal abortion. The highest percentages of reported abortions were for women who were unmarried (82%), white (55%), and aged <25 years (51%). Of all abortions for which gestational age was reported, 61% were performed at < or =8 weeks' gestation and 88% at <13 weeks. From 1992 (when detailed data regarding early abortions were first collected) through 2002, steady increases have occurred in the percentage of abortions performed at < or =6 weeks' gestation, with a slight decline in 2003. A limited number of abortions were obtained at >15 weeks' gestation, including 4.2% at 16--20 weeks and 1.4% at > or =21 weeks. A total of 36 reporting areas submitted data documenting that they performed and enumerated medical (nonsurgical) procedures, making up 8.0% of all known reported procedures from the 45 areas with adequate reporting on type of procedure.

INTERPRETATION

During 1990-1997, the number of legal induced abortions gradually declined. When the same 47 reporting areas are compared, the number of abortions decreased during 1996-2001, then slightly increased in 2002 and again decreased in 2003. In 2000 and 2001, even with one additional reporting state, the number of abortions declined slightly, with a minimal increase in 2002 and a further decrease in 2003. In 2001 and 2002, as in the previous years, deaths related to legal induced abortions occurred rarely.

PUBLIC HEALTH ACTION

Abortion surveillance in the United States continues to provide the data necessary for examining trends in numbers and characteristics of women who obtain legal induced abortions and to increase understanding of this pregnancy outcome. Policymakers and program planners use these data to improve the health and well-being of women and infants.

Impact of the Choice on Termination of Pregnancy Act on maternal morbidity and mortality in the west of Pretoria

AIM

To evaluate the impact of the Choice on Termination of Pregnancy Act on maternal morbidity and mortality in the west of Pretoria.

SETTING

Indigent South Africans managed in two public hospitals in the west of Pretoria.

METHOD

Data were collected on all abortions (incomplete or induced) treated in the hospitals in the study area in 1997-1998 and 2003-2005. All cases of severe acute maternal morbidity and maternal deaths due to abortion were identified for these time periods. Data exclude referrals from outside the west of Pretoria.

OUTCOME MEASURES

The case fatality rate (CFR), mortality index (MI) and maternal mortality ratio (MMR) due to abortions.

RESULTS

In 1997-1998 there were 2 050 abortions, of which 80.2% were regarded as being incomplete, and in 2003-2005 there were 3 999 abortions, of which 42.8% were regarded as incomplete. Twenty-four women who were critically ill due to complications of abortion presented in 1997-1998 (a rate of 3.05/1 000 births), compared with 50 (2.76/1 000 births) in 2003-2005. There were 5 deaths in 1997-1998 (CFR of 2.4/1 000 abortions) compared with 1 death in 2003-2005 (CFR 0.25/1 000 abortions) (p = 0.01, relative risk (RR) 0.1, 95% confidence interval (CI) 0.01 - 0.89). The MI fell from 21.7% to 2.0% (p = 0.02, RR 0.1, 95% CI 0.01 - 0.89). The MMR was 63.6/100 000 births in 1997-1998 compared with 5.54/100 000 in 2003-2005 (p = 0.017, RR 0.09, 95% CI 0.01 - 0.74).

CONCLUSION

The introduction of the Choice on Termination of Pregnancy Act has been associated with a massive reduction in women presenting with incomplete abortions. The prevalence of critically ill women due to complications of abortion has not changed, but the CFR, MI and MMR have declined significantly.

Changes in abortions and births and the Texas parental notification law

BACKGROUND

On January 1, 2000, Texas began enforcement of a law that requires physicians to notify a parent of a minor child seeking an abortion at least 48 hours before the procedure.

METHODS

We assessed changes in the rates in Texas of abortions and births (events per 1000 age-specific population) before enforcement of the parental notification law (1998 to 1999) and after enforcement (2000 to 2002). We did this by comparing the rate changes among minors 15 to 17 years of age at the time of conception (i.e., those who were subject to the law) with those of teens 18 years of age at the time of conception (i.e., those who were not subject to the law).

RESULTS

After enforcement of the law, abortion rates fell by 11 percent among 15-year-olds (rate ratio, 0.89; 95 percent confidence interval, 0.83 to 0.94), 20 percent among 16-year-olds (rate ratio, 0.80; 95 percent confidence interval, 0.76 to 0.85), and 16 percent among 17-year-olds (rate ratio 0.84; 95 percent confidence interval, 0.80 to 0.87), relative to the rates among 18-year-olds. Among the subgroup of minors 17.50 to 17.74 years of age at the time of conception (who would have been subject to the parental notification law in early pregnancy), birth rates rose by 4 percent relative to those of teens 18.00 to 18.24 years of age (rate ratio, 1.04; 95 percent confidence interval, 1.00 to 1.08). The adjusted odds ratio for having an abortion after 12 weeks' gestation among minors 17.50 to 17.74 years of age as compared with 18-year-olds was 1.34 (95 percent confidence interval, 1.10 to 1.62).

CONCLUSIONS

The Texas parental notification law was associated with a decline in abortion rates among minors from 15 to 17 years of age. It was also associated with increased birth rates and rates of abortion during the second trimester among a subgroup of minors who were 17.50 to 17.74 years of age at the time of conception.

Medical abortion for Australian women: it's time

Medical termination of pregnancy with mifepristone, a progesterone antagonist, is available to women in North America, the United Kingdom, much of Western Europe, Russia, China, Israel, New Zealand, Turkey and Tunisia, but not Australia. Experience of mifepristone use in around two million abortions has shown that it is safe, effective, cheap to produce, and highly acceptable to women. Mifepristone is usually used in combination with a prostaglandin analogue, such as misoprostol; these drugs have been added to the World Health Organization's list of essential medicines for developing countries. Availability of this drug in Australia might largely overcome many of the inequities of access to abortion, and is critical for many women in rural areas and women in some ethnic groups whose access to surgical abortion is limited.

Abortion in the United States

Abortion is an extremely safe and common medical procedure. In the United States, over one million women had an abortion in the year 2000. Advances in early abortion techniques have helped to increase the proportion of early procedures, the safest type. Abortion rates have been declining since the early nineties among adults and adolescents, but rates among poor, minority women remain high. State restrictions to abortion have a larger impact on poor women and young women. Restrictions and regulations have also resulted in the concentration of abortion services in specialized clinics. These clinics are subject to harassment. The expansion of abortion services to more types of providers could increase access, as well as integrate abortion into women's health care.

Abortion patterns and reported sex ratios at birth in rural Yunnan, China

High sex ratio at birth due to son preference has been known in China historically, but it was thought this phenomenon would diminish with modernisation. The aim of this study was to investigate abortion decisions and reported sex ratios at birth in the context of successive family planning policies in Huaning County, Yunnan Province, in China. Abortion patterns and reported sex ratios at birth of a random sample of 1,336 women aged 15-64 were analysed for the period 1980--2000, in relation to parity and sex of previous children. There was a mole bias in the abortion pattern during the 1980s, but by the end of the 1990s most pregnancies of women with two children were being terminated. Sex ratio at birth rose from 107 in 1984--87 to 110 between 1988--2000 in Huaning. While women's reproductive decisions were influenced by son preference over the whole period, the means used to ensure a son differed with changing family planning policies. We conclude that rising sex ratios in the context of falling fertility and modernisation is an alarming socio-demographic issue, which defies historical experience. Assumptions that discrimination against girls would diminish with economic development and female education have proven simplistic. Action is urgently needed to reduce and mitigate the effects of discrimination against girls.

Increase in obstacles to abortion: the American perspective in 2004

This paper summarizes the barriers to abortion in the United States, including the determination of viability, cost and insurance coverage, waiting periods and parental consent laws, restrictions on medical abortion, provider unavailability, harassment, targeted regulation of abortion providers laws, refusal clauses, anti choice laws, and the fetal legal rights movement. Federally subsidized abstinence-only sex education, which has not been shown to decrease the rate of unintended pregnancy (and may increase it), has expanded and access to a full range of contraceptive options has been limited. The policies of the current and past administrations have strengthened barriers to abortion both at home and abroad. Preserving women's right to choose will require improved public and professional education, legislative and legal efforts, and advocacy by physicians and other health care professionals.

Fertility and parental consent for minors to receive contraceptives

OBJECTIVES

I examined the effect of imposing a requirement for parental consent before minors can receive medical contraceptives.

METHODS

Birth and abortions among teens, relative to adults, in a suburban Illinois county that imposed a parental consent requirement in 1998 were compared with births and abortions in nearby counties during the period 1997-2000.

RESULTS

The relative proportion of births to women under age 19 years in the county rose significantly compared with nearby counties, whereas the relative proportion of abortions to women under age 20 years declined insignificantly, with a relative increase in the proportion of pregnancies (births and abortions) to young women in the county.

CONCLUSIONS

Imposing a parental consent requirement for contraceptives, but not abortions, appears to raise the frequency of pregnancies and births among young women.