Abortion

ANATOMY OR SYSTEM AFFECTED: Reproductive system, uterus

DEFINITION: The induced termination of pregnancy, which usually is legal only before the fetus is viable

History and Controversy

Induced abortion is the deliberate ending of a pregnancy before the fetus is viable or capable of surviving outside a woman's body. By the twenty-first century some debate existed among the general public as to the exact definition of an abortion; some people argued that the term only referred to surgical procedures which removed a fetus, while others felt the term included so-called “morning after pills" and other medication taken to terminate pregnancy. At that time, the American Congress of Obstetricians and Gynecologists broadly defined abortion as “medical intervention provided to individuals who need to end the medical condition of pregnancy.” Abortion has been practiced in every culture since the beginning of civilization. It has also been controversial.

The first law designating abortion as a crime dates to ancient Assyria, where, in the fourteenth century BCE, women who were convicted of abortion were impaled on a stake and left to die. Early Hebrew law also condemned abortion, except when necessary to save the woman's life. The Greeks allowed abortion, but the famous physician Hippocrates (ca. 460 BCE–ca. 370 BCE) denounced the procedure and said that it violated a doctor's responsibility to heal. Roman law said that a fetus was part of a woman and that abortion was her decision, although a husband could divorce his wife if she had an abortion without his consent. Most abortions in ancient times seemed to be related to unwanted pregnancies.

The Christian church determined abortion to be a sin in the first century. In the fifth century, however, Saint Augustine argued that the fetus did not have a soul before “quickening,” that point during a pregnancy, usually between the fourth and sixth months, at which the woman first senses movement in her womb. Until 1869, abortion until quickening was legal in most of Europe. In that year, however, Roman Catholic pope Pius IX declared abortion at any point to be murder. This position has been upheld by all subsequent popes.

In many European countries without dominant Catholic populations, the principle of legality until quickening held true until around 1860. In that year, the British Parliament declared abortion a felony; that law remained on the books for more than one hundred years. In 1968, the Abortion Act passed by Parliament radically reduced the restrictions, allowing abortions in cases in which doctors determined that the pregnancy threatened the physical or mental health of the woman.

In the United States, abortion before quickening was legal until the 1840s. By 1841, ten states had declared abortion to be a criminal act, but punishments were weak and the laws frequently ignored. The movement against abortion was led by the American Medical Association (AMA), founded in 1847. In 1859, the AMA passed a resolution condemning abortion as a criminal act. Within a few years, every state declared abortion a felony. Not until 1950 did the AMA reverse its position, when it began a new campaign to liberalize abortion laws. Many doctors were concerned about the thousands of women suffering from complications and even death from illegal abortions. Consequently, seventeen states, including California, passed laws providing for legal abortions under certain conditions. The remaining states, however, continued to prohibit abortions. In 1973, the US Supreme Court ruled in Roe v. Wade that abortions in all states were generally legal. This ruling made abortions in the United States available on the request of the pregnant woman. However, conservative states tested the limits of the ruling whenever possible, and activists consistently pushed for the appointment of conservative justices to the Supreme Court in hopes of one day getting Roe overturned. This goal came to fruition in June 2022 when the Supreme Court released its decision on Dobbs v. Jackson Women's Health Organization, which overturned Roe by arguing that the US Constitution does not provide a right to abortion.

Abortion around the World

In the early 2020s about 25 percent of the world's population lived in countries with very restrictive abortion laws. Most other nations authorized abortions under various conditions. In 2023 the Guttmacher Institute estimated that there were approximately seventy-three million abortions conducted worldwide per year between 2015 and 2019. According to the World Health Organization (WHO), tens of millions of these are performed unsafely, leading to the deaths of thousands of women. The Guttmacher Institute reported 930,160 abortions in the US in 2020, an increase of 8 percent over figures from 2017; this figure is also larger than the 620,327 legal induced abortions reported to the Centers for Disease Control and Prevention (CDC) from 49 reporting areas.

Many national approaches to abortion legislation are informed by religious tradition, and as social conditions have changed, so too have views on abortion. Ireland, which traditionally had some of the most stringent abortion laws, passed legislation in 2013 allowing for abortion in cases in which the mother's life is threatened. In 2018 a referendum in Ireland saw the population vote by a wide measure to completely remove its long-standing abortion ban. The new law that went into effect in early 2019 allowed for abortions to be conducted without restrictions up to three months into a pregnancy. Also in 2019, a law was passed and came into force decriminalizing abortion in Northern Ireland. Eastern European countries tend to have abortion rates three to four times higher than Western European countries, with more abortions than live births. According to the Guttmacher Institute in 2018, from the beginning of the twenty-first century to 2017, thirty-three countries had expanded legally permissible conditions for abortion. The early 2020s saw further developments worldwide as multiple countries, including Argentina and Thailand, legalized or decriminalized abortion. In September 2023 the supreme court of Mexico decriminalized abortion throughout the entire country. Meanwhile, other countries, including Honduras and the US, moved to restrict the procedure.

Before 1970, statistics on abortions in the United States were generally not kept or reported, and they can only be estimated. In the nineteenth century, it is believed that there was one abortion for every four live births, a rate only slightly lower than that in the latter part of the twentieth century. The number of abortions in any year varied from five hundred thousand to one million, most of them illegal. In 1969, the Centers for Disease Control (CDC), a branch of the US Department of Health and Human Services, began an annual abortion count. Legal abortions in 1970 numbered about two hundred thousand. The number of illegal abortions is unknown. Ten years later, legal abortions reached 1.2 million, and by 1990, they had increased to 1.6 million; they have dropped slightly but steadily since 1990. The CDC estimated that there were about 325 abortions for every one thousand live births in the 1980s, a number consistent with findings for the 1990s. For 2010, the CDC estimated there were 228 abortions for every one thousand live births. In 2023 the CDC reported a ratio of 198 abortions for every one thousand live births in 2020.

In Roe v. Wade the Supreme Court ruled that abortions were legal under certain conditions. These conditions include the welfare of the woman and the viability of the fetus. During the first three months of pregnancy, according to the Supreme Court, the government had no legitimate interest in regulating abortions—with one exception: states can require that abortions be performed by a licensed physician in a “medical setting.” These physician-only statutes, enacted by some states, made it more difficult for nurse practitioners and certified nurse midwives to expand their role to surgical abortion, but in many states these individuals could provide medication which causes abortion. In all other circumstances, until 2022 the Court held that the decision to abort was strictly that of the pregnant woman as a constitutional right of privacy.

During the second trimester, abortions were more restricted. They were legal only if the woman's health needs to be protected, and they require the consent of a doctor. The interest of the fetus was protected during the third trimester, when it becomes able to survive on its own outside the woman's body, with or without artificial life support. At this point, states were allowed to prohibit abortions except in cases where the life or health of the mother was threatened. In a companion case, Doe v. Bolton, “health” was defined as “all factors—physical, emotional, psychological, familial, and the woman's age.” This broad definition of health effectively made it possible for a woman to have an abortion at any time during her pregnancy, circumventing state restrictions. The determination of viability was to be made by doctors, not by legal authorities. This ruling effectively struck down all antiabortion laws across the United States.

In the aftermath of Roe v. Wade, abortion became an intensely emotional political issue in the United States. The Hyde Amendment of 1976 eliminated federal funding for abortions, and other legislation blocked foreign aid to family planning programs, which members of Congress who were opposed to abortion saw as “pro-abortion.” In Webster v. Reproductive Health Services (1989), the Supreme Court upheld its ruling in Roe v. Wade, but it also sustained a rule forbidding the use of public facilities or public employees for carrying out abortions. The court also supported a requirement that a test for viability be done before any late-term abortion and ruled that states could ban funding for abortion counseling. The issue continued to divide North Americans, with opponents arguing that abortion at any point during the pregnancy constituted murder.

A 2017 survey of women who had abortions in fourteen different countries, published in the journal Contraception, revealed the most common reasons for making that decision. While the main reason for having an abortion differed across different countries, financial concerns were the most common reason for getting an abortion in six of the countries analyzed, and a common reason in all other countries. Other commonly cited concerns included wanting to limit childbearing, concerns from partners or family opposition, wanted to postpone having children until a later date (especially among young women), and maternal health.

Religion appears to be a factor in the decision to seek an abortion: in an earlier survey of US women from 2004, the Guttmacher Institute found the percentage of Catholic women having abortions was 29 percent higher than the percentage of Protestant women. The lowest percentage of abortions was found among evangelical, “born-again” Christians. Nonreligious women had abortions at four times the rate of religious women. Teenagers under the age of fifteen and women over the age of forty had the highest rates of abortion of any age group. Thirty-three percent of all abortions occur before the fetal period of development. Fifty-five percent of abortions were performed between eight and twelve weeks into the pregnancy. The risk of death associated with abortion increases from one death for every 530,000 abortions at eight weeks or fewer to one death per six thousand abortions performed at twenty-one or more weeks of gestation.

Techniques and Procedures

A variety of techniques can be used to perform abortions. They vary according to the length of the pregnancy, which is usually measured by the number of weeks since the last menstrual period (LMP). Instrumental techniques are usually used very early in a pregnancy. They include a procedure called menstrual extraction, in which the entire contents of the uterus are removed. It can be done as early as fourteen days after the expected onset of a period. A major problem with this method is a high risk of error; the human embryo may still be so small at this age that it can be missed. It is also true that a high proportion of women undergoing this procedure are in fact not pregnant. Nevertheless, this method is easy and very safe. Death rates from this technique average less than one in one hundred thousand.

Vacuum aspiration, or suction curettage, is the most common type of in-clinic procedural abortion. This technique can be used up to about fourteen weeks after the LMP. It can be performed with local anesthesia and follows several steps. First, the cervix is expanded with metal rods that are inserted one at a time, with each rod being slightly larger than the previous one. When the cervix is expanded to the right size, a transparent, hollow tube called the vacuum cannula is placed into the uterine cavity. This instrument is attached to a suction device, which looks something like a drinking straw. An electric or hand-operated vacuum pump then empties the uterus of its contents. Finally, a spoon-shaped device called a curette is used to check for any leftover tissue in the uterus. The entire procedure takes less than five minutes. This method, first used in China in 1958, is among the safest procedures in medicine. There are about six times more maternal deaths during regular birth than during vacuum aspiration.

An older method, dilation and curettage (D&C), was common up to the 1970s, but it has largely been replaced by vacuum aspiration. In a D&C, the cervix is expanded or dilated and a curette is used to scrape out the contents of the uterus. The biggest difference is the use of general anesthesia during the process. Since most abortion-related deaths result from complications from anesthesia, a method that requires only local anesthesia, such as aspiration, greatly reduces the dangers of the procedure.

For the period from thirteen to twenty weeks, a method called dilation and evacuation (D&E) is usually preferred. The cervix is expanded with tubes of laminaria (a type of seaweed), and the fetus is removed with the placenta, the part of the uterus by which the fetus is nourished. Forceps, suction, or a sharp curette is sometimes used. The procedure is usually safe, but sometimes if the fetus is large, it must be crushed and dismembered to remove it through the cervix. One variation of this procedure involves delivering the fetus breech, except for the head, and then inserting a suction tube through an incision made in the head. The brain is then sucked out, which collapses the skull, and the fetus is then easily removed. In 2003, legislation banning this procedure, called the Partial-Birth Abortion Ban Act of 2003, was passed by Congress and signed into law by President George W. Bush. The act's constitutionality, which had been challenged, was upheld by the Supreme Court in 2007. By the end of the second decade of the twenty-first century, antiabortion activists had begun targeting the D&E method at the state level in further efforts to restrict abortion, with several states introducing or even passing D&E bans.

Along with these methods of menstrual extraction, physicians can use “medical induction” techniques when required. Amnioinfusion is an old example of this method that was used on fetuses from sixteen to twenty weeks old. This process has largely been replaced by D&E, which has proven far less dangerous.

Amnioinfusion usually requires hospitalization, local anesthesia, and the insertion of a large needle into the uterus. Between 100 and 200 milliliters of fluid is withdrawn and a similar amount of hypertonic saline solution infused into the uterine cavity. Within ninety minutes, the fetal heart stops. The woman then goes into labor and delivers a dead fetus within twenty-four to seventy-two hours. These kinds of abortions generally have much higher risk of complications than did D&E. On rare occasions, a fetus has been born alive, but the main risks are infection, hemorrhage, and cervical injuries to the woman. The psychological difficulties associated with this procedure can be severe, especially the knowledge that the fetus delivered would be dead.

Another method uses prostaglandins, naturally occurring hormones that cause uterine contractions and expulsion of the fetus, rather than a saline solution. The hormones can be given to the patient in several different ways: intravenously, intramuscularly, through vaginal suppositories, or directly into the amniotic sac. Prostaglandins are used for inducing second-trimester abortions and are as safe as saline solutions. Their major advantage is to reduce the duration of the abortion, but they also have severe side effects. They cause intense stomach cramps and other gastrointestinal discomfort, and about 7 percent of the fetuses expelled show some sign of life.

Surgical techniques for abortion are very rare, although sometimes they prove necessary in special cases. Hysterotomy resembles a cesarean section. An incision is made in the abdomen, and the fetus is removed. Hysterotomy is usually used in the second trimester, but only in cases where other methods have failed. The risk of death is much higher in this procedure than in most others. Even more rare is a hysterectomy, the removal of the uterus. This is done only in cases in which a malignant tumor threatens the life of the pregnant woman.

In the late 1980s, the French “abortion pill,” RU-486, was approved for use in many parts of Europe. By the mid-1990s, it had been safely and effectively used in more than fifty thousand abortions. Progesterone is a hormone that causes the uterus to develop the lining that houses a fertilized egg. If the egg is not fertilized, the production of progesterone stops, and the uterine lining is discarded during menstruation. RU-486 contains an antiprogesterone; it prevents the production of progesterone.

The antiprogesterone mifepristone was approved for legal use in the United States in 2000. It is usually used in a regimen in conjunction with misoprostol, which augments the effect of mifepristone by causing the uterus to contract. The regimen begins with the oral administration of mifepristone, followed by at-home administration of misoprostol. It has proved to be highly safe and effective, although a few serious side effects can sometimes occur, the major one being sustained bleeding. Because of this, women are carefully screened to determine if they are candidates for mifepristone use; women with low blood counts are not offered the procedure. Cramps and nausea are also reported in a number of cases, and women are provided medication to relieve these symptoms. There is apparently no effect on subsequent pregnancies.

The drug is administered in the United States mostly under protocols that involve an ultrasound or the testing of serum hormone levels to determine that the pregnancy is in an appropriately early stage. Next comes follow-up care with a physical examination, an ultrasound or test for hormone levels, and contraceptive counseling and provision that meets the woman's needs. Properly done, medication abortion may be up to 95 to 97 percent effective, but women must return for follow-up care to ensure that the procedure was successful.

Because the abortion will take place at home, there is sufficient privacy. To be a candidate for the procedure, however, a woman must be capable of managing her medication and the passage of the fetus, with associated side effects. Various evidence-based protocols are employed in respect to timing the administration of the drug and the number of days of gestation at which the drug will be provided. The drug is intended only for termination of early first-trimester pregnancies. In many states, medication abortion is provided by nurse practitioners and certified nurse midwives, while surgical abortion is provided by physicians.

Perspective and Prospects

Abortion is among the most frequently performed surgical procedures in the United States. Experts suggest that as long as women have restricted access to contraceptive choice and experience unwanted pregnancies, that will continue to be the case. Medically, abortion is considered a very safe procedure, although there can be complications. Generally, the earlier the procedure is performed, the less severe the risk. The lowest chance of medical complications occurs during the first eight weeks of pregnancy. After eight weeks, the risk of complications increases by 30 percent for each week of delay. Nevertheless, the death rate per case is very low, about half that for tonsillectomy. These statistics apply only to those areas of the world where abortion is legal, since women in those places tend to have earlier abortions.

In parts of the world where it remains against the law, abortion is a leading cause of death for women due to lack of medical oversight. In 2021, the WHO estimated that as many as thirty women die per one hundred thousand unsafe abortions in developed countries while 220 women die per one hundred thousand abortions performed in unsafe conditions in developing countries. Before the Roe v. Wade decision, it was estimated that anywhere from a few hundred to several thousand American women died every year from the procedure. The best estimate was that in the 1960s about 290 women died every year as a result of complications from abortions. In the 1980s, the average was twelve per year, mostly from anesthesia complications. By the 2020s there was less than one death per one hundred thousand legal induced abortion procedures. Based on such statistics, advocates argue that safe and legal abortion is an important component of women's health and reproductive freedom.

Despite such evidence, abortion remains highly controversial and there is considerable political pressure to restrict the practice or even overturn its legality. In 2015, several states, including Oklahoma and Florida, began enacting bills that instituted a waiting period—often two or three days—between the time that a woman decides to have an abortion and the actual procedure. Supporters of the policy defended it as a way to give pregnant people more time to reach the most appropriate decision regarding the pregnancy, while opponents criticized the policy for the potential to increase the cost of the procedure through additional loss of wages and travel expenses.

Conservative efforts against Planned Parenthood specifically and against safe and legal abortions in general continued, however. The future of abortion in the United States was widely questioned after Republican Donald Trump was elected US president in 2016, with former Indiana governor Mike Pence as vice president. Both men made clear their opposition to abortion, with Pence in particular stating his support for a total ban on the practice. Many opponents of abortion considered it a prime opportunity to defund Planned Parenthood and even reverse Roe v. Wade. In January 2017, Trump signed an order that ended all US funding to any foreign non-government health organization that offered abortion counseling or that advocated for the right to seek an abortion.

In 2018, Trump's second Supreme Court appointment, Brett Kavanaugh, solidified the court's conservative majority and futher raised speculation that the court would overturn Roe v. Wade. A number of states, anticipating the overturn of Roe, began passing laws limiting abortion. These states restricted legal abortions by banning them after a certain gestational age or after a fetal heartbeat was detectable, banning abortion procedures, and/or eliminating exceptions for cases of rape or incest. Though the enforcement of such restrictive laws was challenged and even, in many cases, at least temporarily halted by courts as of the end of 2019, including the blocking of Alabama's particularly restrictive law in late October, antiabortion activists argued that their existence would hopefully spark renewed legal consideration of abortion overall. Even as challenges continued into 2020, with many rights activists calling for temporary blocks to be made permanent, some states continued to consider similar changes to their abortion laws. In June 2020, Tennessee's legislature passed a heartbeat bill that was halted from implementation by a federal temporary restraining order shortly after being signed by the governor in July. Similarly, Texas became the country's biggest state to sign this type of heartbeat bill into law in May 2021.

In February 2019, the Trump administration established a rule that any clinic receiving funds from Title X, a federal grant program for family planning aimed at low-income citizens, could not administer abortions in the same physical space in which other patients were seen. The policy was criticized by many supporters of reproductive rights as targeting Planned Parenthood clinics and shifting federal funds to faith-based organizations. Twenty states soon filed suit against the rule, setting up another legal battle in the ongoing controversy around abortion. As the new rule also meant that clinics would be prohibited from referring patients for abortions, which was also challenged, Planned Parenthood announced in August 2019 that they were withdrawing from the Title X funding program. While cases against the rules continued in lower courts, in February 2020 a federal appeals court upheld the block against referrals.

In early 2020, a new side to the abortion debate was introduced by the ongoing impact of the spread of the novel coronavirus disease 2019 (COVID-19), which was declared a worldwide pandemic by March 2020. As states implemented stay-at-home orders and other policies such as practicing social distancing, some states controversially attempted to limit or deny access to abortions based on the argument that they were “nonessential.” While some states, such as New York and Washington, ensured that abortions would not be canceled, other states, such as Mississippi and Texas, attempted to order clinics to stop abortion services, deemed “elective,” unless there was a risk to the woman's health.

The contentious confirmation of Trump's third Supreme Court nominee, Justice Amy Coney Barrett, to the Supreme Court in October 2020 further increased the court's conservative majority and spurred the passage of dozens of state-level abortion restrictions by the end of April 2021. At the same time, Democrat Joe Biden, who had campaigned in favor of women's rights and won the November 2020 presidential election, issued an executive order in January 2021 that reinstated the ability for international nongovernmental organizations that perform or provide referrals for abortions to receive federal funding from the United States; meanwhile, it additionally ordered a review and potential reversal of the domestic Title X policy also instituted under the Trump administration.

On September 1, 2021, Texas lawmakers succeeded in passing new legislation that restricted most abortions in the state after six weeks, becoming the most restrictive abortion measure in the United States. The law was unusual in that it was to be enforced by citizens, not the state, making it harder to challenge in court, and it also did not provide for exceptions for pregnancies resulting from rape or incest. Many abortion rights activists protested the law and called for the Supreme Court to block it shortly after it went into effect. The Supreme Court voted 5 to 4 to allow the Texas law to stand, however, prompting the Biden administration to investigate. In early December 2021, the court ruled that while the Texas law would remain in effect, abortion providers would have a limited ability to challenge it in federal court. In January 2022, the court rejected another request for interference on behalf of providers.

In May 2022, a draft opinion was leaked that showed conservative Supreme Court justices planned to overturn Roe v. Wade in their decision on Dobbs v. Jackson Women's Health Organization. Antiabortion supporters praised the court's ruling, while abortion rights supporters across the country protested the pending decision. Despite public opposition, in June 2022 the Court released its opinion on Dobbs. In a 6–3 vote, the Court found that the US Constitution did not provide a right to abortion, effectively overturning Roe v. Wade. This decision once again brought abortion to the forefront of political debate in the US, with different states taking drastically different approaches in response to Dobbs.

After Dobbs, some states passed laws protecting abortion access at the state level, while other states, empowered by the Dobbs decision, moved to further dismantle abortion access, with some enacting bans in almost all circumstances. In addition to banning the procedure, some states moved to establish severe legal penalties for anyone who performed an abortion. During the 2022 midterm elections, abortion protections and restrictions appeared as ballot questions in a number of states. In April 2023, Florida's six-week abortion ban went into effect, although the state's limit remained at fifteen weeks while the Florida Supreme Court reviewed the constitutionality of the state's abortion laws. In Texas, which already had some of the strictest laws in the US by that point, local lawmakers increasingly worked to criminalize efforts to receive out-of-state abortion care in places such as New Mexico. These new statutes made it illegal to drive through certain cities or counties while traveling for the purposes of obtaining an abortion. By September 2023 two cities and counties in Texas had already passed such measures, with other municipalities considering similar legislation.

By 2023, the majority of abortions in the United States were medication abortions rather than procedural abortions. According to the Guttmacher Institute, medication abortions accounted for about 63 percent of legal abortions in the US formal health care system that year.

By mid-2024, public health researchers found that although the number of in-person abortions decreased in states that had banned them, the overall number of abortions per month in the United States had increased rather than declined between 2022 and 2023. Researchers attributed the overall increase in abortions to the increased accessibility and use of telehealth services allowed during and following the COVID-19 pandemic.

Since Dobbs, some states have passed shield laws to protect telehealth providers from prosecution for providing medication abortions to people from states that had banned or restricted the procedure. At the same time, the number of primary care and family doctors offering medication abortions and other forms of reproductive care was also trending upward, increasing access. Opponents of abortion brought lawsuits to restrict, criminalize, and or limit mail access to mifepristone, the most commonly used drug for medication abortion in the US.

In June 2024, the Supreme Court allowed emergency abortions in cases where the mother's health (not just her life) was endangered in Idaho to continue, at least while the state's strict abortion law was being challenged. The court dismissed Moyle v. United States without ruling on the merits of the case, which centered on whether a federal law ensuring emergency care outweighed Idaho's ban on abortion except in cases where the mother's life was at risk. By dismissing the case, the court returned it to lower courts and reinstated a lower court's temporary injunction against the Idaho law.

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