Abortion. I INTRODUCTION Abortion, termination of a pregnancy before birth, resulting in the death of the fetus. Some abortions occur naturally because a fetus does not develop normally or because the mother has an injury or disorder that prevents her from carrying the pregnancy to term. This type of spontaneous abortion is commonly known as a miscarriage. Other abortions are induced--that is, intentionally brought on--because a pregnancy is unwanted or presents a risk to a woman's health, or because the fetus is likely to have severe physical or mental health problems. Induced abortion, the focus of this article, is one of today's most intense and polarizing ethical and philosophical issues. Modern medical techniques have made induced abortions simpler and less dangerous. But in the United States, the debate over abortion has led to legal battles in the courts, in the Congress of the United States, and state legislatures. The debate has spilled over into confrontations, which are sometimes violent, at clinics where abortions are performed. This article discusses the most common methods used to induce abortions, the social and ethical issues surrounding abortion, and the history of the regulation of abortion in the United States. II ABORTION METHODS Induced abortions are performed using drugs or surgery. The safest and most appropriate method is determined by the age of the fetus, which is calculated from the beginning of the pregnant woman's last menstrual period. Most pregnancies last an average of 39 to 40 weeks. This period is divided into three stages known as trimesters. The first trimester consists of the first 13 weeks, the second trimester spans weeks 14 to 28, and the third trimester lasts from the 29th week to birth. Abortions in the first trimester of pregnancy are easier and safer to perform while abortions in the second and third trimesters require more complicated procedures and pose greater risks to a woman's health. In the United States, a pregnant woman's risk of death from a first-term abortion is less than 1 in 100,000. The risk increases by about 30 percent with each week of pregnancy after 12 weeks. A Drug-Based Abortion Methods Drug-based abortion, also known as medication abortion, typically requires that a woman take two types of drugs within the first weeks of a confirmed pregnancy. In one method, a pregnant woman first takes the drug mifepristone, also known as RU-486, which blocks progesterone, a hormone needed to maintain the pregnancy. About 48 hours later, she takes another drug called misoprostol. Misoprostol is a prostaglandin (a hormone-like chemical produced by the body) that causes contractions of the uterus, the organ in which the fetus develops. These uterine contractions expel the fetus. Another type of drug combination that induces abortion is the use of misoprostol with methotrexate, an anticancer drug that interferes with cell division. A physician first injects a pregnant woman with methotrexate. About a week later, the woman takes a pill containing misoprostol to induce uterine contractions and expel the fetus. These drug-based abortion methods effectively end pregnancy in approximately 96 percent of the women who take them and are most effective when performed very early in a pregnancy. These methods require no anesthesia. However, the use of drugs to induce abortion has not been widely adopted by women in the United States for a number of reasons. These drugs can cause unpleasant side effects--some women experience nausea, cramping, and bleeding. More serious complications, such as arrhythmia, edema, and pneumonia, affect the heart and lungs and may cause death. Perhaps the primary deterrent is that these drug-based abortion methods require at least two visits to a physician over a period of several days, and these methods are no cheaper than a surgical abortion. B Surgical Abortion Methods Legal surgical abortion, when done by a trained provider, is essentially 100 percent effective. A number of surgical methods can be used to induce abortions. To end a pregnancy before it reaches eight weeks, a doctor typically performs a preemptive abortion or an early uterine evacuation. In both procedures a narrow tube called a cannula is inserted through the cervix (the opening to the uterus) into the uterus. The cannula is attached to a suction device, such as a syringe, and the contents of the uterus, including the fetus, are extracted. Preemptive abortion uses a smaller cannula and is performed in the first four to six weeks of pregnancy. Early uterine evacuation, which uses a slightly larger cannula, is performed in the first six to eight weeks of pregnancy. Both types of abortions typically require no anesthesia and can be performed in a clinic or physician's office. The entire procedure lasts for only several minutes. In preemptive abortions the most common complication is infection. Women who undergo early uterine evacuation may experience heavy bleeding for the first few days after the procedure. Vacuum aspiration is a procedure used for abortions in the 6th to 14th week of pregnancy. It requires that the cervix be dilated, or enlarged, so that a cannula can be inserted into the uterus. Progressively larger, tapered instruments called dilators may be used to dilate the cervix. During the procedure, the cannula is attached to an electrically powered pump that removes the contents of the uterus. In some cases, the lining of the uterus must also be scraped with a spoonlike tool called a curette to loosen and remove tissue. This procedure is referred to as curettage. Vacuum aspiration may require local anesthesia and can be performed in a clinic or physician's office. Minor bruising or injuries to the cervix may occur when the cannula is inserted. Dilation and curettage (D&C), performed during the 6th to 16th week of pregnancy, involves dilating the cervix and then scraping the uterine lining with a curette to remove the contents. A D&C often requires general anesthesia and must be performed in a clinic or hospital. Possible complications include a reaction to the anesthesia and cervical injuries. Since the development of vacuum aspiration, the use of D&C has declined. After the first 16 weeks of pregnancy, abortion becomes more difficult. One method that can be used during this period is dilation and evacuation (D&E), which requires greater dilation of the cervix than other methods. It also requires the use of suction, a large curette, and a grasping tool called a forceps to remove the fetus. D&E is a complicated procedure because of the larger size of the fetus and the thinner walls of the uterus, which stretch to accommodate a growing fetus. Bleeding in the uterus often occurs. D&E is often performed under general anesthesia in a clinic or hospital. It is typically used in the first weeks of the second trimester but can be performed up to the 24th week of pregnancy. An induction abortion can also be performed in the second trimester, usually between the 16th and 24th week of pregnancy. In this type of abortion a small amount of amniotic fluid, the fluid that surrounds the fetus, is withdrawn and replaced with another fluid. About 24 to 48 hours later, the uterus begins to contract and the fetus is expelled. When this method was first developed, physicians used a strong saline (salt) solution to abort the fetus; today they may also use solutions containing prostaglandins or pitocin, a synthetic form of a chemical produced by the pituitary gland that induces labor. Heavy bleeding, infection, and injuries to the cervix can occur. This procedure is performed in the hospital and requires a stay of one or more days. Abortions performed at the end of the second trimester and during the third trimester require major surgery. Two such late-term procedures include hysterotomy and intact dilation and extraction. In hysterotomy, the uterus is cut open and the fetus is removed surgically in an operation similar to a cesarean section, but a hysterotomy requires a smaller incision. Hysterotomy is major abdominal surgery performed under general anesthesia. Intact dilation and extraction, also referred to as a partial birth abortion, consists of partially removing the fetus from the uterus through the vaginal canal, feet first, and using suction to remove the brain and spinal fluid from the skull. The skull is then collapsed to allow complete removal of the fetus from the uterus. III SOCIAL AND ETHICAL ISSUES Abortion has become one of the most widely debated ethical issues of our time. On one side are pro-choice supporters--individuals who favor a woman's reproductive rights, including the right to choose to have an abortion. On the other side are the pro-life advocates, who may oppose abortion for any reason or who may only accept abortion in extreme circumstances, as when the mother's life would be threatened by carrying a pregnancy to term. At one end of this ethical spectrum are pro-choice defenders who believe the fetus is only a potential human being when it becomes viable, that is, able to survive outside its mother's womb. Until this time the fetus has no legal rights--the rights belong to the woman carrying the fetus, who can decide whether or not to bring the pregnancy to full term. At the other end of the spectrum are pro-life supporters who believe the fetus is a human being from the time of conception. As such, the fetus has the legal right to life from the moment the egg and sperm unite. Between these positions lies a continuum of ethical, religious, and political positions. A variety of ethical arguments have been made on both sides of the abortion issue, but no consensus or compromise has ever been reached because, in the public policy debate, the most vocal pro-choice and pro-life champions have radically different views about the status of a fetus. Embryology, the study of fetal development, offers little insight about the fetus's status at the time of conception, further confounding the issue for both sides. In addition, the point during pregnancy when a fetus becomes viable has changed over the years as medical advances have made it possible to keep a premature baby alive at an earlier stage. The current definition of viability is generally accepted at about 24 weeks gestation; a small percentage of babies born at about 22 weeks gestation have been kept alive with intensive medical care. Despite the most advanced medical care, however, babies born prematurely are more at risk for long-term medical and developmental problems. This combination of medical ambiguities and emotional political confrontations has led to considerable hostility in the abortion debate. For many people, however, the lines between pro-choice and pro-life are blurred and the issue is far less polarized. Many women who consider themselves pro-life supporters are concerned about possible threats to reproductive rights and the danger of allowing the government to decide what medical options are available to them. Similarly, many pro-choice individuals are deeply saddened by the act of abortion and seek to minimize its use through better education about birth control, and, in particular, emergency contraception, birth-control methods that prevent pregnancy after unprotected sexual intercourse. IV REGULATION OF ABORTION Abortion has been practiced around the world since ancient times as a crude method of birth control. Although many religions forbade or restricted the practice, abortion was not considered illegal in most countries until the 19th century. There were laws prior to this time, however, that banned abortion after quickening--that is, the time that fetal movement can first be felt. In 1803 England banned all abortions, and this policy soon spread to Asia, Africa, and Latin America. Throughout the middle and late 1800s, many states in the United States enacted similar laws banning abortion. In the 20th century, however, many nations began to relax their laws against abortion. The former Union of Soviet Socialist Republics (USSR) legalized abortion in 1920, followed by Japan in 1948, and several Eastern European countries in the 1950s. In the 1960s and 1970s, much of Europe and Asia, along with the United States, legalized abortion. An estimated 46 million abortions are performed worldwide each year, of which 20 million are performed in countries where abortion is restricted or prohibited by law. Illegal abortions are more likely to be performed by untrained people, in unsanitary conditions, or with unsafe surgical procedures or drugs. As a result, illegal abortion accounts for an estimated 78,000 deaths worldwide each year, or about one in seven pregnancy-related deaths. In some African countries, illegal abortion may contribute to up to 50 percent of pregnancy-related deaths. In Romania, where abortion was outlawed from 1966 to 1989, an estimated 86 percent of pregnancyrelated deaths were caused by illegal abortion. In countries where abortion is legal, less than 1 percent of pregnancy-related deaths are caused by abortion. A Legalization of Abortion in the United States In the United States, the legalization of abortion began in 1966 when Mississippi passed a law permitting abortion in cases of rape. In the following four years, other states expanded the use of abortion to include cases in which a pregnancy threatens a woman's health, the fetus has serious abnormalities, or the pregnancy is the result of incest (sexual intercourse between close relatives). In early 1973 the Supreme Court of the United States decided two cases, Roe v. Wade and Doe v. Bolton, that effectively legalized abortion for any reason before the 24th week of pregnancy, the point when the fetus becomes viable. The ruling allowed individual states to enact laws restricting abortion after viability, except in cases when abortion is necessary to preserve the life or health of the woman. In 1976 the Supreme Court recognized the right of pregnant girls under the age of 18, known as mature minors, to have abortions. Three years later the Court ruled that states may require the consent of one parent of a minor requesting an abortion. Parental consent is not necessary if a confidential alternative form of review, such as a judicial hearing, is made available for young women who choose not to involve their parents. The Court stated that a judge in a hearing must approve a minor's abortion, in place of her parents, if the judge finds that the minor is mature enough to make the decision on her own. If the judge finds that the minor is not capable of making this decision on her own, he or she can decide whether the abortion is in the minor's best interest. Since these decisions, about 40 states have enacted and enforced parental consent or notification laws, although some laws have been contested in courts for years. In 1990, for example, in Hodgson v. Minnesota, the Supreme Court upheld a law requiring that prior notice be provided to both parents of a minor before an abortion is performed. In a similar case arising in Ohio that same year, the court upheld a requirement for notice or consent of one parent. In 2000, however, the New Jersey Supreme Court struck down a law requiring parental notice for unmarried girls under age 18. Other state-imposed restrictions regulate who pays for abortions, where abortions are performed, and what information is provided to women seeking abortions. For example, in 1977 the Supreme Court allowed states to limit the use of Medicaid funds (government assistance for health care) for payment of elective abortions--that is, those abortions not medically required. A law upheld by the Supreme Court in 1980 restricted the availability of federal Medicaid funding for abortions deemed medically necessary. After that ruling, abortion payments for poor women in many states were limited to cases in which pregnancy threatened the woman's life. Also in 1977, the Supreme Court allowed the city of St. Louis, Missouri, to exclude elective abortions from procedures performed in a public hospital. In 1983 the Court found it unconstitutional to require that a woman considering an abortion be given information developed by the state about risks or consequences and wait 24 hours after receiving information before having the abortion. Similarly, in 1986 the Court struck down a comprehensive Pennsylvania law requiring that state-developed materials about abortion be offered to women undergoing the procedure. Since the 1989 Supreme Court decision in Webster v. Reproductive Health Services, the Court has permitted several state-imposed restrictions to stand. The Webster case upheld a Missouri law that prohibits the use of public facilities or public employees for abortion and requires a physician to determine the viability of a fetus older than 20 weeks before performing an abortion. In the 1991 case of Rust v. Sullivan, the Court upheld a federal policy that prevented health-care providers who received federal funding from engaging in any activities that encouraged or promoted abortion as a method of family planning. President Bill Clinton later revoked this policy in 1993. In 1992 the Supreme Court decided Planned Parenthood of Southeastern Pennsylvania v. Casey, a case in which the Court reaffirmed the central ruling of Roe v. Wade--that no undue burden on access to abortion should exist for a woman over 18 years of age prior to fetal viability. But the case also permitted states more freedom in regulating abortion. The Court overturned prior rulings, making it possible for states to again require that a woman be given state-developed information about abortion risks and consequences and wait 24 hours before undergoing the procedure. In 1996 the Congress of the United States enacted a bill banning the practice of so-called partial birth abortions, also known as the intact dilation and extraction procedure. President Clinton vetoed the law because it failed to permit use of the procedure when a fetus displays severe abnormalities or when carrying a pregnancy to term presents a serious threat to a woman's health or life. Over 30 states passed laws in the 1990s banning use of the procedure. In June 2000, in Stenberg v. Carhart, the Supreme Court struck down a Nebraska ban on partial birth abortion. The Court stated that the ban was an unconstitutional violation of both Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey. But after Congress passed the Partial Birth Abortion Ban Act of 2003 and President George W. Bush signed it into law, the Court revisited the issue in a 2007 ruling in Gonzales v. Planned Parenthood and Gonzales v. Carhart. This time, with Justice Samuel A. Alito, Jr. replacing the retired Justice Sandra Day O'Connor, the Court upheld the ban on the partial birth abortion procedure in a 5 to 4 decision. Under the law, physicians who perform the banned procedure could face fines and up to two years in prison. The law allows for use of intact dilation and extraction only in cases where the mother's life is endangered without the procedure. Since the Supreme Court ruling that legalized abortion in 1973, opponents of abortion have worked continuously to reverse the decision. They have lobbied state and federal officials to place restrictions on women seeking abortions or on individuals providing abortions. They have also held protests directed at clinics that perform abortions, and, in some cases, have accosted and obstructed patients and health-care providers at such clinics. In May 1994 the Freedom of Access to Clinic Entrances Act was enacted, which made it a federal crime to use force, threat of force, or physical obstruction to injure, intimidate, or interfere with reproductive health-care providers and their patients. That same year, in a case known as Madsen v. Women's Health Center, the Supreme Court upheld the basic right to protest in peaceful, organized demonstrations outside abortion clinics. But the case upheld a Florida law that created a 36 ft (11 m) buffer zone around a clinic to ensure that demonstrations do not prevent access to clinics or disrupt clinic operations. In February 1997 the Court upheld buffer zones around clinics but struck down certain floating, or moveable, buffer zones around individuals approaching clinics. The Supreme Court's ruling in 2007 upholding the federal Partial Birth Abortion Ban Act of 2003 was expected to spur further attempts to restrict abortion, if not overturn Roe v. Wade. Supporters of the right to abortion noted that the Court's majority opinion in the 2007 decision represented the first time since the 1973 Roe ruling that the Court permitted a ban on an abortion procedure, effectively intruding on the privacy of a decision between a woman and her physician. Supporters of the ruling countered that the Court's decision addressed the moral and ethical concerns put forward by opponents of abortion. They cited Justice Anthony Kennedy's argument in the majority opinion that "the government has a legitimate and substantial interest in preserving and promoting fetal life." Contributed By: Glenn McGee Jon F. Merz Microsoft ® Encarta ® 2009. © 1993-2008 Microsoft Corporation. All rights reserved.