How Abortion Works


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All women, when they become pregnant, must consider a wide variety of options. For some women, these options are along the lines of baby names, nursery décor themes and childcare choices. Other women, however, don't view a positive pregnancy test as such a joyous occasion, and these women begin considering options that include giving the baby up for adoption or terminating the pregnancy with an abortion. Depending on where the woman lives, that last option is legal, or it may be pursued underground.

In the United States alone, half of the 6 million pregnancies that occur each year are unplanned; about 1.3 million of those 3 million unplanned pregnancies end in abortion [source: Bazelon]. If these rates continue, then about one-third of women in the U.S. will have had an abortion by age 45 [source: Guttmacher Institute]. Worldwide, about 2 percent of all women of reproductive age will have an abortion each year [source: Grimes, Creinin]. (These numbers don't include the number of women who suffer spontaneous abortions, the medical term for miscarriages.)

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The Guttmacher Institute, a nonprofit organization that studies abortion, provides the statistics that give us an idea of the type of women who pursue an abortion. In the United States, that woman is likely to be young (50 percent of U.S. women obtaining abortion are under the age of 25), unmarried (unwed women obtain two-thirds of all abortions) and lower class (the abortion rate for poor women is four times higher than that of women living above the poverty line). She's also likely to have at least one child already (60 percent of abortions are performed on women who are already mothers) and to report not using contraceptives properly, if at all. Of the abortions performed in the United States, 37 percent are attributed to black women, 34 percent to white women and 22 percent to Hispanic women.

­Despite the fact that abortion is one of the most common surgical procedures for women, we don't hear much about the actual process very often. The topic of abortion has become one of the most contentious ethical and legal issues of our time, wrapped up in phrases like "right to life" and images of coat hangers. Regardless of how you feel about the subject, the numbers above indicate that many women make the choice to terminate a pregnancy. But the choice doesn't end there. On the next page, we'll consider the many options for how the procedure is carried out.

Medical Abortion

There are two methods for performing an abortion: medical and surgical. In medical abortions, the fetus is expelled when an abortifacient, or abortion-inducing substance, is administered. Abortifacients have a long history; since the time of Ancient Greece, women have tried to induce an abortion by swallowing a mix of herbs or plants. However, the drugs used to induce to induce a medical abortion are fairly new, having only been approved by the Food and Drug Administration (FDA) in 2000.

The regimen approved by the FDA is 600 milligrams of mifepristone followed by 400 micrograms of misoprostol. The administration of mifepristone, which is taken orally, takes place in a clinic under medical supervision. Mifepristone, also known as RU-486, blocks the hormone progesterone, which is essential to the buildup of the uterine lining that will support the embryo in the womb. The dose of this drug causes the lining to break down, and bleeding similar to a menstrual period occurs.

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About three or four days later, once the lining is weakened, misoprostol is administered. Some doctors require that patients return to the clinic for the misoprostol dose, while others allow women to take misoprostol in their own homes. The FDA approved oral use of misoprostol, though some women have been advised to administer the dose as a vaginal suppository. The vaginal method has been linked with several deaths because the delivery method suppresses some of the body's natural immune responses [source: University of Michigan]. Misoprostol causes uterine contractions to begin, and the contents of the uterus are expelled in a process very similar to that of miscarriage. Bleeding can last up to two weeks.

Because a medical abortion ends much like a miscarriage, the possible side effects are very similar; the woman may experience nausea, vomiting or diarrhea. There are more serious complications. Excessive bleeding can occur if a uterine muscle ruptures, or the cervix could become blocked if all of the tissue and blood is not expelled. However, medical abortions are effective 95 to 98 percent of the time when done in the first nine weeks of pregnancy [source: WebMD].

If the medical abortion fails, or if a woman is past the ninth week of pregnancy, then a surgical abortion will be performed. We'll cover that procedure on the next page.

Vacuum Extraction Abortion

There are several surgical methods for performing an abortion; which method is chosen largely depends how far along the pregnancy is. The most common method is vacuum extraction, also known as aspiration, which can be performed for 12 weeks after a woman's last period. The fetus is extracted either manually, with a handheld suction device, or with a machine vacuum.

A manual vacuum extraction is one of the earliest surgical options available to a woman; the procedure can be done within the first six to seven weeks of pregnancy. In this method, a speculum is inserted into the woman's vagina. The ­cervix may be slightly numbed, and depending on the woman, the cervix may need to be stretched with dilators. Dilation isn't common with manual extraction, however. A tube is inserted through the cervix and into the uterus, and the doctor applies suction with a special handheld device, extracting the contents of the uterus through the tube. The process takes only a few minutes; women report cramps, nausea and feeling faint.

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Those symptoms are slightly more severe with a machine vacuum extraction. This method is used in the first six to 12 weeks of pregnancy. With this approach, the woman's cervix will need to be dilated, which is accomplished either with absorbent dilators inserted a day beforehand, or by inserting rods that gradually increase in size on the day of the procedure. The rest of the procedure is similar to that of a manual extraction, except a machine applies the suction that pulls out the uterine contents through the tube.

There are a few more methods of surgical abortion, which we'll cover on the next page.

Surgical Abortion

Rep. Charles Canady of Florida stands next to a poster illustrating the dilation and extraction method in 1995.
Rep. Charles Canady of Florida stands next to a poster illustrating the dilation and extraction method in 1995.
Associated Press/Greg Gibson

Sometimes, after completing a vacuum extraction, the person performing the abortion may need to use a curette to scrape the remaining fetal tissue from the uterus. A curette is a long, thin instrument with a serrated spoon at one end. When a curette is used, the procedure is typically referred to as dilation and curettage, or D&C (D&C is also used therapeutically to resolve issues such as abnormal vaginal or uterine bleeding). Vacuum extractions can usually be performed up to 16 weeks after a woman's last period when combined with D&C.

Statistically, abortions carried out more than 16 weeks after a woman's last period are rare, but they may be performed with a method known as dilation and evacuation, or D&E. This technique combines all the methods that went before, including aspiration and curettage, but it requires additional surgical instruments since the fetus is more developed. Often, the person performing the abortion will administer a shot to the fetus through abdominal tissue to ensure that the fetus is dead. Then medication is given to the woman, and, as with the other methods, the woman's cervix is stretched with dilators.

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The fetal tissue is extracted to the degree possible with vacuum extraction and curettage, but since the fetus is likely too large at this point to be completely removed in this way, the person providing the abortion will insert forceps into the woman's vagina and crush the fetus's head. This allows the fetus to be broken down into pieces that allow for easy removal. The person administering the abortion then examines the fetal tissues and fragments to ensure that the entire fetus was removed.

Dilation and evacuation is different from a method known as dilation and extraction because the fetus is dead before leaving the woman's body. In the dilation and extraction method, also known as a partial birth abortion, the fetus is partially delivered vaginally in a feet-first position. When the fetus is partially expelled, the abortion provider makes a hole at the base of the fetal skull, inserts tubing, and uses suction to pull out the brain of the fetus. When the skull collapses, the fetus can be fully expelled. In the U.S., this method has been banned except for purposes of protecting a woman's health, such as in the case of an infected uterus or a heart condition [source: Gawande].

Very rarely, an induction abortion may be used to end a late-term pregnancy. In this instance, a saline solution is administered to start early labor. The fetus is delivered intact. This method might be used in the case of abnormal fetal development or antenatal diagnosis of a genetic disorder, so that an autopsy can be performed on the fetus.

On the next page, we'll look at the recovery process after an abortion.

Post-abortion Recovery

Women are encouraged to rest after an abortion procedure.
Women are encouraged to rest after an abortion procedure.
© iStockphoto.com/Spauln

After an abortion, women are kept in a recovery room for a few hours and then sent home with follow-up instructions and emergency contact information. Women will continue to bleed for several days, perhaps even passing blood clots the size of a quarter. However, women may return to regular activities, including work or class, as early as the day after the procedure. The exceptions to that rule include strenuous exercise and vaginal sexual intercourse, which should be put on hold for about a week. When women do resume having sex, they should use birth control; because abortion begins a new menstrual cycle, women can get pregnant again shortly after the procedure.

Abortions are generally very safe -- in fact, a woman has 11 times the chance of dying in childbirth as she does of dying from an abortion performed in the first 20 weeks of pregnancy [source: Planned Parenthood]. Less than 1 percent of women experience a serious complication that requires further hospitalization, but there are a few symptoms of complications:

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  • Extremely heavy bleeding, to the point that more than two sanitary pads are used in an hour
  • Blood clots larger than a lemon
  • Incessant pain or vomiting
  • Pungent vaginal odors

These signs may indicate an infection, an injury to the uterine lining or the cervix, or an incomplete abortion, with fetal tissue remaining in the uterus.

There appear to be few, if any, long-term physical effects to a woman who's had an abortion. Some doctors have theorized that an abortion heightens the risk for breast cancer, largely because of studies in which women who were diagnosed with breast cancer offered up the fact that they had an abortion, as if to provide a reason. In these types of retrospective studies, it's unlikely that a healthy woman would offer up that she had an abortion [source: Bakalar]. However, in a study published in 2007, researchers followed a control group of women who didn't have abortions against a group of women that did have abortions; the incidence of breast cancer was about the same in both groups [source: Bakalar].

Abortion doesn't affect future fertility; however, abortions with curettage involve a sharp tool that could create scar tissue in the uterus. Though it's rare for this scar tissue to form, it could affect a woman's chances of getting pregnant or increase the risk of pregnancy complications [source: WebMD].

The emotional response to an abortion is different for each woman. Several sources claim that many women feel relief after the procedure is over [sources: Bazelon; Grimes, Creinin; Planned Parenthood]. There is no medical evidence that abortion has any negative effect on mental health, but some anti-abortion groups claim that abortion leads to serious mental problems known collectively as post-abortion syndrome (PAS). While PAS isn't recognized by any medical or psychological association, some claim that depression, drug abuse or self-destructive behaviors may follow an abortion. Currently, doctors suggest that those women who d­o become seriously depressed after an abortion may have been emotionally unstable to begin with [source: Bazelon].

PAS has been cited by some groups as a reason to outlaw abortions. On the next page, we'll take a look at both sides of the abortion issue.

Ethics of Abortion

An anti-abortion protestor showing the development of a fetus at 8 weeks.
An anti-abortion protestor showing the development of a fetus at 8 weeks.
Associated Press/Steve Miller

Some anti-abortion groups cite post-abortion syndrome as one reason why abortion should be outlawed; these groups claim that the procedure harms women mentally and emotionally. This argument is slightly different from the argument that most of these groups make, which revolve around the rights of the fetus. It may be a response to groups that support abortion rights, which often frame their argument as an issue of women's rights.

In essence, the issue of fetal rights versus a woman's rights sum up the current argument about whether abortion should be legal. The key question that doctors, lawyers, philosophers and theologians have spent much time debating is at what point a fetus becomes a human being, and at what point that fetus is entitled to the legal rights that a fully developed and grown person is.

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International polls show that there are many different beliefs about when human life begins. Some people believe that life begins at the moment of conception, when the male's sperm fertilizes the female's egg. Others say that life begins when that fertilized embryo is implanted in the womb, while the highest percentage of people in a 2008 poll claimed that life didn't begin until a fetal heartbeat could be detected [source: Coghlan].

Historically, abortion was deemed acceptable and legal until the woman felt the "quickening," or the first movements of the fetus. At that point, most believed, the fetus was a person with rights. This may also be discussed in terms of the "viability" of the fetus, or a measure of whether the fetus could conceivably survive outside the womb. Some look for markers that the baby is attaining the means for consciousness. For example, some anti-abortion groups believe that a woman should be told that an abortion will cause the baby pain. The understanding that a being is capable of pain is in some ways a recognition that the fetus is cognizant and aware of its surroundings, and thus in some ways conscious. While there's a lack of consensus about when a fetus feels pain, many researchers believe that it's unlikely until the 28th week of gestation [source: Tanner].

In ancient Greece and Rome, abortion was considered a reasonable method of family planning; it was even endorsed by Aristotle because he believed the fetus lacked a soul. However, as time went on, the practice became shaped by cultural shifts, particularly influenced by religious viewpoints on the practice. For example, the intent of a woman seeking an abortion was questioned, because many found the practice more tolerable when done to save the mother's life or in the case of rape or incest. However, while Aristotle once believed abortion could be a family planning tool, many today believe that abortion is the equivalent of murder. On the next page, we'll explore how this changing worldview has affected the legality of abortion.

Legality of Abortion

Coat hanger imagery is often used by abortion rights groups to demonstrate the danger of illegal abortions.
Coat hanger imagery is often used by abortion rights groups to demonstrate the danger of illegal abortions.
Associated Press/David Duprey

Traditionally, abortifacient herbs and mixtures have been the most common way to procure an abortion, along with brutal injury to the abdominal region. In the United States, some of the first rules that criminalized abortion were meant to protect women who were dying after swallowing poisons to bring on an abortion, rather than to protect the fetus from termination. Even early feminists supported making abortion illegal because of the threat of violence or abandonment to the woman from a man who didn't want the responsibility of parenthood [source: Schroedel].

However, one of the main factors in criminalizing abortion in the U.S. was the newly formed American Medical Association and its member doctors. Doctors had economic motivations for advocating against abortion; they lost a significant amount of income to the midwives and private individuals who performed abortions, and the AMA served as an effective legal lobby to block the procedure [source: Schroedel].

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Though abortion was illegal in many states beginning the mid to late 1800s, there were many loopholes in the states' laws, particularly for wealthy women. Poor women were more likely to seek out back-alley abortions performed with knitting needles, coat hangers or lye. In the time in which abortions were illegal in the U.S., as many as 1.2 million abortions were performed each year, seemingly indicating that criminalizing the act may not reduce the number of procedures that take place [source: Gold].

­By the early to mid 1900s, however, Western countries were repealing laws that criminalized abortion, or at least widening the circumstances in which a woman could procure the procedure. In the U.S., individual states were creating laws which relaxed or restricted regulations, but in 1973, abortion became a national matter with the Roe v. Wade ruling. In Roe v. Wade, the U.S. Supreme Court established that any legal restriction to an abortion violated the right to privacy guaranteed by the 14th amendment. Rather, the decision to perform an abortion was up to a woman and her doctor, and not the government, until the point at which the fetus became viable, which was generally agreed to be at the end of the second trimester.

With each presidential election, the possibility of overturning Roe is a major issue for both sides of the abortion debate. Even some of those who support abortion rights worry that Roe is a poorly worded decision, but they continue to fight any legal measure that would restrict abortion or a woman's right to choose it. Anti-abortion groups continue to campaign for measures that would outlaw abortion or make it more difficult for a woman to receive the procedure through measures such as parental or spousal notification laws.

So what's the future of abortion?

The Future of Abortion

Abortion rights and anti-abortion advocates express opposing viewpoints during a demonstration in Washington, D.C.
Abortion rights and anti-abortion advocates express opposing viewpoints during a demonstration in Washington, D.C.
Associated Press/Joe Marquette

­It's impossible to know what the future will hold for the legality of abortion. Anti-abortion groups remain convinced that a fetus is a viable person with the same legal rights as a newborn infant, while abortion rights groups believe that a woman should be able to make decisions about her body without governmental interference.

However, abortion is such a controversial topic that it already affects our medical providers. The generation of doctors that saw women suffering in the aftermath of an illegal, unsafe abortion is now mostly retired from medical practice. In their place is a generation that saw abortion clinics bombed or abortion providers shot in their own homes. In fact, abortion training is not covered at many medical schools or in many hospital residencies unless the student asks for the opportunity to learn [source: Meisol]. Already, there are shortages of medical professionals that can perform the procedure in many areas. Some medical professionals exercise a right of conscience and refuse to do the procedure for personal reasons.

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If abortion were to be outlawed or largely unavailable due to a lack of providers, it seems unlikely that we would return to the days of coat hangers. Rather, some doctors think women will turn to the same abortifacients that are used in medical abortions today [source: Leland]. When misoprostol is used as part of a medical abortion, that actually constitutes an off-label use; the drug was approved by the FDA for treatment of ulcers and is more commonly known as Cytotec. The drug isn't intended to be used in doses necessary to induce an abortion, so its safety hasn't been widely tested for that purpose. It's also not as effective without the prior dosage of mifepristone, and it could lead to severe birth defects. It is, however, cheap, and is already used in many countries and communities where abortion is illegal or considered immoral [sources: Lee, Buckley; Leland].

For more on women's health issues, please see the links on the next page.

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Sources

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