Leah Torres MD and I tweet each other often about abortion. Leah asked what my thoughts were on a blog she wrote called 'Universal Truths'. Although Leah and I sit on either side of the abortion debate, I am confident in saying that each of us are genuinely happy when we can find common ground on issues relating to abortion and can simply agree.
So when I read her blog I was pleased to say that I did agree with all the main points of her blog, which Leah refers to as 'universal truths':
1. Everyone wants fewer abortions.
2. Abortions will always be needed.
3. When abortion is legal and accessible, it is safe.
However, I wanted to respond in detail to Leah's discussion on each and share some different views on each point and also make some suggestions.
Everyone wants fewer abortions.. how true. Leah aptly describes how scary and difficult it is for a woman to face an unexpected pregnancy. "She never wanted to consider having an abortion .. yet not everything.. works out the way we plan..Thus, what I mean by "everyone wants fewer abortions", is that beginning with the woman who is facing an unplanned pregnancy, everyone wants fewer abortions."
Leah stongly urges comprehensive sexual health education and access to highly effective contraception in order to lower the rate of abortion. I agree education and access to a variety of effective contraception methods that people feel comfortable using, for health or religious reasons too, are important to avoid pregnancies. However, as Leah says, 'no birth control method is perfect'. There will always be unexpected pregnancies even with good sex education and use of contraception. We must look at other ways also to lower the rate of abortion. What first sprung to my mind, there could be much better support in our communities for women that specifically address the problems many face in an unexpected pregnancy, rather than just offering one solution: abortion.
Leah mentions a woman must consider her health, her family situation, her financial situation. These are important points. Good maternal health services are critical to ensure all women can enjoy healthy pregnancies and deliveries. But unfortunately, even in developed countries such as the United States1, maternal health is not consistently to the high standard it should be nor is prenatal care available to all women (either because available care is poor or it is too costly). Women should not have to pay for ultrasounds or to give birth in a hospital. This directly impacts the health of women in pregnancy and any risks she might experience in continuing a pregnancy. Improving maternal health services (particularly in hospitals) and ensuring all women can receive a high standard of prenatal care through universal health care would have a direct and positive impact on lowering pregnancy risks for many women.
A woman in unexpected pregnancy also considers her family situation: this would include her relationships with her husband/partner, any children and probably her parents too. The situation she finds herself in and relationships with those closest to her may have great influence on whether a woman feels she can continue a pregnancy or not. But what happens if she is unsure she really wants an abortion but is unsupported by her parents or partner? Without support she feels she will not cope. What if she knew she could get the support she needs elsewhere? Would she feel then she could continue the pregnancy? Quality, accessible services like personalised care in an unexpected pregnancy, relationship counselling, pregnancy and parenting support services (including home visits) can give women who would otherwise feel they have no other choice but abortion due to lack of support, a real choice to continue in the pregnancy.
Also Leah mentions the financial situation for a women. In many places, this is the number 1 reason women have an abortion. Is there another solution? Yes, financial help can be a solution and, not just temporary financial help in pregnancy but well into the future. For many women, giving birth comes with the financial responsibility of raising a child. What financial support is offered mothers in your area? If a single mum has to take time off paid work because of pregnancy and to care for a child, could she get by? Can she afford to provide for the child? What about a student or dependent - is there any help for them in an unexpected pregnancy? What about the mother with two young children already who is the main breadwinner in the family? Is there financial support available if she can't work for months and months? Unexpected pregnancies lead to the possibility of an unexpected financial crisis for many people. It is for times like this that I think a broad social welfare net and financial support of women and families in need in our communities is completely justified.
Also importantly there should be financial support for women who choose adoption over abortion. They should not have to struggle to pay for regular visits to the doctor or to receive prenatal/materal care and may need financial support for time off work due to the pregnancy. Adoption is a very difficult decision and women should be well supported with free specialised support, particularly counselling, both before and well after an adoption.
There are of course many complex and personal reasons why a woman may consider an abortion. Here we've just discussed a few but I think we should look at the main rasons why women seek abortion and consider 'are there other solutions to these reasons and are women being offered these solutions as well as abortion?' If not, why not?
Abortions will always be needed.. I agree with that too, for certain kinds of abortions.
First, to be clear, by 'abortion' we are referring to an 'induced abortion' and not a miscarriage (medically called a 'spontaneous abortion'). "Abortion" is the deliberate ending of a pregnancy before an embryo or fetus is viable (capable of surviving outside the womb). This is the standard medical definition of an abortion.2 However, abortions occur after viability also, well into the 2nd or 3rd trimesters and although these may be called a 'late termination of pregnancy' or a 'delivery' or a 'birth' by the medical community, they are nevertheless still what is generally understood to be an 'abortion' if the intention of the procedure is to produce a nonviable fetus.
The U.S. Center for Disease Control and Prevention (CDC) in collecting data on abortion in the USA, defines legal induced abortion as:
"a procedure, performed by a licenced physician or someone acting under the supervision of a licensed physician, that was intended to terminate a suspected or known intrauterine pregnancy and to produce a nonviable fetus at any gestational age."3 (emphasis added)
There are differences in the aim of some abortions. A procedure may be performed to deliberately end a pregnancy but the aim of the abortion is not to cause the death of the embryo or fetus but to treat the mother. Charles Camosy, philosopher and a professor of social ethics, refers to abortions as either direct or indirect depending on whether the procedure aims at the death of the embryo or fetus.4 I find this a helpful distinction between different kinds of abortions.
A direct abortion aims at the death of the embryo or fetus. Procedures that are always direct abortions (by their very nature) are vacuum aspiration and dilation & extraction (D&E) abortions.
An indirect abortion does not aim (as an end or by its method) at the death of the fetus (although this may be likely or inevitable). Procedures that may be used to perform an indirect abortion are an induction of labour, removing the uterus (hysterectomy) or the abortion pill, RU486. (RU486 arguably causes the embryo to detach from the woman without directly attacking the embryo itself). It is important to note that these procedures are not indirect abortions, however, if the aim of the procedure is the death of the embryo or fetus.
The abortions I agree will always be needed are indirect abortions for reasons such as ectopic pregnancy or pre-eclampsia or other medical conditions (such as cancer of the uterus), as a last resort. Medical situations when a pregnancy poses a very serious threat to a woman's life and health and there is no alternative method of treatment other than an abortion are rare.
Leah submits that abortions will always be needed by women who receive news later in pregnancy that her child has a life limiting diagnoses and will either die before birth or shortly after delivery. Also that abortion will always be needed for women whose health is placed seriously at risk due to a pregnancy in the second and third trimesters (perhaps jeopardising future pregnancies). I disagree an abortion will always be needed for pregnancies where the child has a life limiting diagnoses, however an indirect abortion may be needed later in pregnancy if a woman's health is at risk. What is definitely needed and is often lacking today is personal and specialised care to help parents confronted with the news their child has a life limiting diagnoses and through a very difficult time.
When abortion care is legal and accessible, it is safe.. well I mostly agree with this statement but partly disagree too. Not all legal abortions are safe for women. More than 400 women are known to have died from legal abortions, since abortion was legalised in the United States in 1973.5 The risk of death from a legal abortion significantly increases each week from very early in a pregnancy. Available data on abortion-related deaths from 1988-1997 in the U.S. showed that, after 8 weeks of pregnancy, the risk of mortality increases by 38% each week.6 So what is a "safe" abortion? Since a pregnant woman can only continue in pregnancy or have an abortion, I think it is reasonable to say that by "safe", we are talking about how safe it is in comparison to giving birth. In the period 1988-1997, per trimester, the risk of mortality in abortion was 14.7/100,000 at 13-15 weeks pregnancy, 29.5/100,000 at 16-20 weeks pregnancy and 76.6/100,000 after 21 weeks pregnancy.6 During 1988-1997, the risk of death in childbirth was approximately 8-10/100,000.1 So in the 2nd and 3rd trimester, the risk of death from legal abortion exceeded that of childbirth.
Hence I would have to qualify that I agree abortions early in the first trimester of pregnancy when legal and accessible, are safe. Also any necessary medical procedure performed by a qualified medical practitioner in a hospital or approved facility will of course be much safer than one performed by an unqualified person or without a regulated standard of care.
How do we reduced the need for abortions? I would like to add to Leah's answer to provide comprehensive sex education and highly effective methods of contraception with a few more suggestions: provide free, high standard maternal care, including hospital delivery; welfare support for pregnant women and children after birth; counselling, social and psychological support services available both during and after an unexpected pregnancy; social change for non-discrimination of pregnant women at school, college, in the workplace and in public facilities.
I thank Leah for inviting discussion on this important topic and I hope others will join in constructive discussion and efforts towards the change everyone wants.. fewer abortions.
1 Kilpatrick SJ. "Next Steps to Reduce Maternal Morbidity and Mortality in the USA." Medscape, Women's Health. 2015; 11(2): 193-199 http://www.medscape.com/viewarticle/842588. Introduction:
"Maternal mortality in the USA, after a dramatic fall from 900s/100,000 live births in the early 1900s, largely due to the advent of antibiotics, plateaued at 8-10/100,000 from 1980 until the late 1990s at which point maternal mortality rose. Worldwide between 1990 and 2013 maternal mortality increased in nearly every country, except the USA, where it increased by 1.7%."
2 Annas GJ, Elias S. "Legal and Ethical Issues in Obstetric Practice." 2007. 51:
"[T]he standard medical definition of abortion [is] termination of a pregnancy when the fetus is not viable."
3 Centers for Disease Control and Prevention. "Abortion Surveillance - United States, 2007", Morbidity and Mortality Weekly Report 60, no. 1 (February 25, 2011), p.2. Available at http://www.cdc.gov/mmwr/pdf/ss/ss6001.pdf
4 Camosy, C. "Beyond the Abortion Wars. A Way Forward for a New Generation" 2015. Wm. B. Eerdmans Publishing Co. p. 64-65, 81.
5 Centers for Disease Control and Prevention. "Abortion Surveillance - United States, 2007", Morbidity and Mortality Weekly Report 60, no. 1 (February 25, 2011), p.36. Available at http://www.cdc.gov/mmwr/pdf/ss/ss6001.pdf
6 Barlett LA, Berg CJ, Shulman HB, Zane SB, Green CA, Whitehead S, Atrash HK. "Risk factors for legal induced abortion-related mortality in the United States." 2004; Obstet Gynewcol 103: 729-37. Available at http://www.researchgate.net/publication/8648767_Risk_Factors_for_Legal_Induced_AbortionRelated_Mortality_in_the_United_States