Presentation on theme: "Contraception and Abortion"— Presentation transcript:
1 Contraception and Abortion Chapter ThirteenContraception and Abortion
2 Agenda Discuss History and Considerations Associated with Methods Discuss Contraception MethodsDiscuss Abortion
3 Class Exercise: Contraception Values Clarification Complete the handout entitled “Contraception Values Clarification.After you have completed the handout, discuss your response in small groups.
4 IntroductionMajority of U.S. pregnancies are not planned and most are a result of not using contraceptionFactors increasing motivation to use contraception:good communication with partner,lower cost,effectiveness rates,frequency of intercourse,motivation to avoid pregnancy,side effects,openness about sexuality
5 Contraception: History Contraception in Ancient TimesContraception in the U.S.: 1800s and Early 1900sContraception Outside the U.S.
6 Contraception in Ancient Times Ancient Greeks: magic, superstition, herbsEgyptians: fumigating female genitalia, tampon soaked in herbal liquid & honey, inserting a mixture of crocodile feces, sour milk, & honeySouth Africa: insert vegetable seed podsAfrica: insert a grassy cervical plugPersia: insert alcohol soaked spongesGreece: insert empty pomegranate halves
7 Contraception in the U.S.: 1800s and Early 1900s Concern in early 1800s was to curb poverty by controlling fertility1873 Comstock laws prohibited dispersing information about contraceptives, including by doctors
8 Contraception use is affected by Social issues – e.g. desired family sizeEconomic issuesKnowledge & misinformationReligionGender roles & power – in some areas, men make the contraceptive decisions; for some it is the responsibility of both
9 Choosing a Method of Contraception FDA Approval ProcessLifestyle Issues
10 FDA Approval ProcessThe U.S. Food and Drug Administration (FDA) must formally approve the method10-14 year process to develop a new contraceptive drugDrug company submits a new drug application demonstrating safety in animal tests & a desire to conduct human trials
11 FDA Approval Process 3 phases Phase 1: volunteers to test effectivenessPhase 2: several hundred to test effectiveness, side effects, risksPhase 3: hundreds to thousands are tested for generalizationAnimal trials are conducted throughout the process
12 Class Discussion: Lifestyle Issues Associated with Contraceptive The following factors seem to be associated with choosing a contraceptive method:Own health & risksNumber of sexual partnersFrequency of intercourseRisk of acquiring a STIResponsibility levelMethod costAdvantages & disadvantages of the methodDiscuss influence of each.
14 Barrier Methods: Condoms and Caps Prevent sperm from entering the uterusBarrier Methods:CondomsThe DiaphragmThe Contraceptive SpongeThe Cervical Barriers
15 Condoms 1850 – latex condoms available in the U.S. $10-$15/dozen Non-expired condom is rolled onto an erect penis (foreskin pulled back), ½-inch empty space at the tipWater-based lubricants for latex condomsCondom grasped at base when withdrawingLatex condoms have lower rates of slippage & breakage, and offer better STI protection
16 Condoms In 1994, female polyurethane/nonlatex condoms were available $2 each7 inches long with 2 flexible ringsInner ring squeezed and inserted close to the cervixOuter ring lies outside the vaginaAdequate lubrication is necessary
17 Condoms Effectiveness rates Latex condoms: 85-98% Female condoms: 79-95%Latex & polyurethane protect against STI transmissionLambskin condoms block sperm, but contain holes large enough for viruses to pass throughHeat can damage condoms
18 Condoms Advantages: STI protection Encourages male participation InexpensiveNo prescription necessaryCan reduce premature ejaculationCan reduce postcoital dripNo medical side effects
19 Condoms Disadvantages: Reduces spontaneity Can reduce sensation Female condoms can be difficult to use, uncomfortable, noisyFemale & male condoms should never be used togetherPopular in some countries, not used in others
20 The Diaphragm Not widely used, almost 0% in 2002 Made of latex or siliconeMany sizes and shapes; a fitting by a health care provider is necessary$20-$35 diaphragm, $13 spermicidal jelly/cream, office visit chargeThey can last for many years
21 Diaphragms come in a variety of different shapes and sizes and must be fitted by a health-care provider.
22 The DiaphragmDiaphragm rim is covered in spermicidal jelly & a tablespoon of jelly is placed in the dome; it is folded in half and inserted into the vagina with the front rim tucked under the pubic boneIt should not be felt & should cover the cervixIt can be inserted up to 6 hours prior to intercourseLeft in for at least 6-8 hours, no more than 24After use it is washed with soap & water
23 Instructions for proper insertion of a diaphragm.
24 The Diaphragm 84-94% effective, lower for those who have given birth Advantages:Increases spontaneitySome STI & PID protectionReduces risk of cervical dysplasia & cancerDoes not affect hormonal levelsRelatively inexpensive
25 The Diaphragm Disadvantages: Physician fitting and prescription Insertion & removal involves touching the genitalsIncreased risk of toxic shock syndrome and urinary tract infectionPostcoital dripLow usage outside the U.S.
26 The Contraceptive Sponge The Today contraceptive sponge was taken off the market for a decade due to issues with the manufacturing plant; reintroduced in 2005Available over the counter in one sizeThe sponge covers the cervix & contains spermicide; it blocks, absorbs, & deactivates spermOne box of 3 sponges is $13
27 The Today contraceptive sponge was back on the market in late 2005 in the United States.
28 The DiaphragmSponge is moistened with water to activate the spermicide, folded in half, & inserted to cover the cervixCan be inserted up to 24 hours in advance, with intercourse occurring as many times as desirable in that time periodMust be left in at least 6 hours after intercourse75-89% effectiveness rates
29 Instructions for proper insertion of a contraceptive sponge.
30 The Diaphragm Advantages: No prescription necessary Can have intercourse several times within 24 hoursIncrease sexual spontaneityDo not affect hormonal levelsDisposable
31 The Diaphragm Disadvantages: Increased risk of toxic shock syndrome & urinary tract infectionCannot be used while menstruatingRequires touching of the genitalsHigh expense if frequently usedSome men can feel itLow usage rates in other cultures
32 The Cervical BarriersThimble-shaped, silicone barriers that fit over the cervixBlock entrance to the uterus & deactivate sperm with the spermicideFitting by a health care provider is necessaryTwo types:FemCapLea’s Shield
33 The FemCap is a silicone cup shaped like a sailor’s hat that fits securely over the cervix.
34 Lea’s Shield is a silicone cup with a one-way valve and a loop for easier removal.
35 The Cervical Barriers $15-75 plus cost of spermicide Left in place for 8 hours after intercourseAfter use, it is washed with soap & waterNot to be used during menstruation86% effectiveness rate, lower for those who have had children
36 The Cervical Barriers Advantages: Left in place for up to 48 hours Do not affect hormonal levelsImmediately effectiveNot permanentOne-way release valve in Lea’s Shield reduces risk of toxic shock syndrome
37 The Cervical Barriers Disadvantages: Abnormal Pap smears Increased risk of urinary tract infectionsIncreased vaginal odorsCervical damageIncreased postcoital dripFitting is necessarySome male partners feel it & may dislodge it
38 The Cervical Barriers Widely used in England Lea’s Shield is available over the counter in Germany, Austria, Switzerland, & Canada
39 Hormonal Methods for Women: The Pill, the Patch, and More Changing hormonal levels can deter production of ova, fertilization, and implantation
40 Hormonal Methods for Women: The Pill, the Patch, and More Combined-Hormone MethodsBirth Control PillsHormonal RingHormonal PatchProgestin-Only MethodsSubdermal ImplantsHormonal Injectibles
41 Combined-Hormone Methods Combination of estrogen & progesteroneCan repress ovulation and thicken cervical mucus
42 Birth Control Pills Federally approved in 1960 Most popular contraceptive in the U.S. and around the worldMost studied type of medicationCombination birth control pills are $12-25 per monthDesigned to mimic a menstrual cycle, with 21 days of hormones and one off weekBleeding is medically induced
43 Birth Control PillsSome take 2 to 3 packs of active pills in a row to reduce the number of menstrual periodsSeasonale – 84-day active pill with 7-day placeboReducing periods can help those with heavy bleeding and cramping60% of women prefer to not have a period
44 Birth Control PillsIncrease in estrogen & progesterone prevent the pituitary from sending hormones to ripen the ovariesCervical mucus thickens & endometrium buildup is minimalThe body is tricked into thinking it is pregnantMay experience other signs of pregnancy that usually disappear within a few months
45 Birth Control PillsInitially prescribed a low-dose estrogen pill; increased if breakthrough bleeding occursMonophasic pills contain the same dose of hormones in each pillMultiphasic pills vary in hormone amountTriphasil pills have 3 sets, each week the hormonal dosage increases% effectiveNeed to take it each day at the same time
46 Birth Control Pills Advantages: High effectiveness rate Doesn’t interfere with spontaneityReduced menstrual flow, cramps, & PMSIncreased menstrual regularityReduced risk of ovarian cysts, uterine & breast fibroids, facial acne, ovarian & endometrial cancers, PID, benign breast disease
47 Birth Control Pills Disadvantages: No STI protection Female’s responsibility; taken dailyCan be expensiveLower effectiveness if overweightNot appropriate for smokersUsed throughout the world, although not popular everywhere; some places have it over the counter
48 Hormonal Ring NuvaRing introduced in 2003 Plastic ring inserted into the vagina once a month for 3 weeks, removed for 1 weekAffects the body as combination pills doBody heat & moisture activate a constant dose of estrogen & progesterone; lower dose than pills$30-35 per month99.7% effective
49 The NuvaRing is inserted deep into the vagina; moisture and heat cause it to time-release hormones that inhibit ovulation.
50 Hormonal Ring Advantages: High effectiveness Doesn’t interfere with spontaneityReduces menstrual flow, cramps, PMSIncreases menstrual regularityProtection from ovarian & endometrial cancer and ovarian cystsFertility restored upon removal
51 Hormonal Ring Disadvantages: Comfortable touching genitals No STI protectionSide effects that typically disappear with regular use: breakthrough bleeding, weight change, breast tenderness, nausea, mood changes, changes in sexual desire, increased vaginal irritation & dischargeNo data on cross-cultural use
52 Hormonal PatchOrtho Evra patch is a thin, peach colored sticker attached to the skin with time-released hormonesPlaced on buttock, stomach, or upper torso for 3 weeks, no patch for the 4th weekAffects the body as combination pills do$30-35 per month99.7% effective, lower if weigh more than 198 pounds
53 The Ortho Evra patch is worn on the buttock, abdomen, or upper torso for three weeks each month.
54 Hormonal Patch Advantages: High effectiveness Doesn’t interfere with spontaneityReduces menstrual flow, cramps, PMSIncreases menstrual regularityProtection from ovarian & endometrial cancer and ovarian cysts
55 Hormonal Patch Disadvantages: No STI protection Side effects similar to hormonal ringSkin irritationChange in vision, discomfort to contact wearersCollects lintNearly impossible to conceal from partnerNo data on cross-cultural use
56 Progestin-Only Methods Do not contain estrogen and can be used by women that cannot take estrogen, such as those who are breastfeeding & smokersOver time, may eliminate periodsMay cause slight weight gain, bloatedness, & breast tenderness
57 Progestin-Only Methods Minipill/POPs (progestin-only pills)Inhibit ovulation and thicken mucusFewer side effects than combination pills% effectiveMore expensive than combination pillsCan cause irregular bleedingHigher rate of ectopic pregnancies if get pregnant while taking the minipill
58 Subdermal ImplantsConstant dose of progestin is time released for up to 5 yearsNorplant is no longer availableJadelle is FDA approved but not marketed in the U.S.2 silicone cylinders implanted in the forearm in a 10 minute procedure; $500+Implanon is a single-rod approved in 2004Fertility restored upon removal
59 Subdermal ImplantsSuppresses ovulation, thickens cervical mucus, unreceptive endometrium99.95% effective, decreases after the 3rd yearLower effectiveness rates if over 154 poundsAdvantages:Effective, long-lasting, reversibleSimple implantation procedureNo estrogen side effectsDecreased menstrual flow, cramping
60 Subdermal Implants Disadvantages: Expensive implantation fees, arm pain, painful removal, possible scarringIrregular bleeding, crampingHeadaches, nausea, dizziness, weight change, rash, acne, hair growth or lossVision problemsPopular in South Africa
61 Hormonal InjectiblesDepo-medroxyprogesterone acetate (Depo-Provera) – synthetic progesteroneMost popular non-oral contraceptiveInjected into the arm or buttock muscle every 3 months$ per injectionWorks within 24 hoursFertility resumes 10 months after last injection
62 Hormonal Injectibles 97-99.7% effective Advantages: Long lasting injectionModerately expensiveNo estrogenDecreased menstrual flow & crampingDecreased risk of endometrial & ovarian cancersAllows for spontaneity
63 Hormonal Injectibles Disadvantages: Office visits every 3 months Irregular bleedingFatigue, dizziness, weakness, headachesAppetite increasesDecrease in bone densityRisk of liver, cervical, and breast cancersLong return to fertilityLow usage rates in many countries
64 Chemical Methods for Women: Spermicides Spermicides come as foams, gels, suppositories, creams, foaming tablets, films, and capsulesInserted into vagina with applicator or finger minutes prior to intercourse$5-10 over the counterCan also help reduce STIsLikely to see microbicides introduced that will protect from HIV & other STIs
65 Chemical Methods for Women: Spermicides 71-82% effectiveEffectiveness is reduced if tampons or douches are used within 6-8 hoursFoam is more effective than other varietiesAdvantages:Over the counterProvide lubricationSome protection from STIsNo serious side effects
66 Chemical Methods for Women: Spermicides Disadvantages:Used each timeIncreased postcoital dripMay produce allergic reactions, skin irritationsIncreased risk of urinary tract infectionsUnpleasant tasteWidely used in some countries, and not used much in other countries
67 Intrauterine Methods for Women: IUDs and IUSs Intrauterine Device (IUD)ParaGard Copper T – can be left in for 12 yearsIntrauterine System (IUS)Mirena – IUD that contains time-released progestin; can be left in for 5 yearsMost IUD & IUS users are 35 or older$ plus office visit
68 Intrauterine Methods for Women: IUDs and IUSs IUDs & IUSs create a slight infection in the uterus that obstructs sperm mobilityProgesterone from the IUS also affects the endometrium, hampering implantationHealth care providers insert the IUDEach month the woman must check for the string to assure it is still in place% effective, lower if never pregnant
70 Intrauterine Methods for Women: IUDs and IUSs Advantages:Least expensive method over timeAllows for spontaneityDecreases menstrual flow (Mirena)Long lasting effects
71 Intrauterine Methods for Women: IUDs and IUSs Disadvantages:No STI protectionRisk of uterine perforation and PIDIrregular bleedingPainful insertion & removalIncreased menstrual flow and crampingMay be expelled from uterusMay cause discomfort to the partnerWidely used through most of the world
72 Natural Methods for Women and Men Natural Family Planning and Fertility AwarenessWithdrawalAbstinence
73 Natural Family Planning and Fertility Awareness Involves a woman charting her menstrual periods and determining ovulation by daily monitoring of basal body temperature and checking cervical mucusBody temperature rises °F before ovulation & remains elevated until menstruationCervical mucus is thin, stretchy during ovulation
74 Natural Family Planning and Fertility Awareness Abstinence is practiced during ovulationOr a form of birth control is used during ovulation (fertility awareness)Mostly used by women spacing pregnancies that are not as concerned about preventionOvulation kits can also be used75-99% effective
75 Natural Family Planning and Fertility Awareness Advantages:Useful if other methods are not acceptable for religious reasonsInexpensiveEducates about the menstrual cycleEncourages partner communicationNo side effects
76 Natural Family Planning and Fertility Awareness Disadvantages:No STI protectionRestricts spontaneityLow effectivenessTakes time & commitmentSeveral cycles need to be recorded before it is reliableWidely used in many countries, particularly Catholic countries
77 Withdrawal Also called coitus interruptus Just before ejaculation, the male withdraws his penis and ejaculates outside of the woman73-96% effectiveSperm may remain in urethra from previous ejaculations & impregnate without the male ejaculating inside of the woman
78 Withdrawal Advantages: Useful if other methods are not acceptable for religious reasonsNo costsGood if couples aren’t concerned about prevention
79 Withdrawal Disadvantages: No STI protection Low effectiveness May lead to premature ejaculationMay be stressfulRequires trust & restraintWidely used in many countries
80 Abstinence Refraining from sexual intercourse 100% effective Protects against STIs
81 Permanent (Surgical) Methods A woman may be fertile until yearsA man may be fertile most of his lifeSterilization in one of the safest & most effective contraceptive methodsSurgery that is typically irreversibleTwo types:Female SterilizationMale Sterilization
82 Female SterilizationAlso called tubal sterilization or getting “tubes tied”A small incision is made under the navel or lower in the abdomenBoth Fallopian tubes are blocked through cauterization, rings, bands, clips, plugs, or clamps, or the tubes may be cutThis procedure uses general anesthesia as outpatient surgery or after childbirth
84 Female SterilizationA woman still ovulates, but the egg can’t enter the uterus$Risks: anesthesia side effects, bleeding, infection, injury to other organsReduces risk of ovarian cancerMost widely used birth control method in the world
85 Male SterilizationA vasectomy impedes the travel of sperm through the vas deferensCheaper, safer, & simpler than tubal sterilizationTwo ¼ to ½ inch incisions are made in the scrotum and the vas deferens is snipped, clipped, or cauterized under local anesthesia20 minute procedureThe man ejaculates semen without sperm
86 In a vasectomy, each vas deferens is clipped, cut, or cauterized In a vasectomy, each vas deferens is clipped, cut, or cauterized. A vasclip uses a flexible plastic clip to block the vas deferens.
87 Male SterilizationAfter surgery, sperm for 20 more ejaculations remainsSperm counts are checked 2-3 months later to check sterility$Risks: swelling, bruising, internal bleeding, infection% effective
88 Permanent (Surgical) Methods Advantages:High effectivenessPermanentAllows for spontaneityDisadvantages:Expensive, irreversible surgeryNo STI protectionWidely used throughout the world
89 Abortion The Abortion Debate Why Do Women Have Abortions? Abortion ProceduresReactions to AbortionTeens and AbortionCross-Cultural Aspects of Abortion
90 Class Exercise: Abortion A fertilized egg is a human being from the moment the sperm and egg unite.The rights of the fetus always take precedence over the rights of the mother.Parental consent should be required for teenagers seeking abortion.Spousal consent should be required for married women seeking abortion.I support a woman’s right to choose in any and all circumstances.I support a woman’s right to choose if the pregnancy resulted from a rape.I support a woman’s right to choose if the pregnancy resulted from contraceptive failure.Abortion is a controversial topic. Stand if you agree with a statement; sit if you disagree.
91 Exercise (cont.)I believe abortion is justified if the woman feels that she is not ready for this child.I believe abortion is justified if a serious birth defect has been detected via amniocentesis.I believe abortion is justified if the couple already has 5 children and the woman unexpectedly becomes pregnant again.I believe abortion is justified if parents of two boys discover they are pregnant again with a third boy, and they were really hoping for a girl.I believe abortion should be legal.There should be a mandatory 24-hour waiting period for all women seeking an abortion.Adoption could solve the problem of “unwanted children.”
92 The Abortion Debate Pro-Life versus Pro-Choice Historical Perspectives Legal versus Illegal Abortions
93 Pro-Life versus Pro-Choice Pro-life supporters: an embryo at any stage of development is a person and aborting a fetus is murderPro-choice supporters: it is a woman’s choice and the government should not control her bodyNo gender differences in abortion attitudes
94 Historical Perspectives Abortion has been practiced throughout time in many societiesReligion has determined attitudes for most of western historyIn 1965, all U.S. states banned abortion with some exceptionsIllegal (back-alley) abortions were often performed in unsanitary conditions and produced many complications, even death
95 Historical Perspectives In 1973, Roe v. Wade protected a woman’s right to have an abortion in the 1st trimester2nd trimester abortions regulated by states3rd trimester abortions can be limited or banned by states, unless a woman is at riskIn 1992, the Supreme Court gave states the right to restrict abortions through waiting periods, mandatory counseling, parental consent, public funding limitations
96 Historical Perspectives In 1994, Supreme Court barred anti-abortion demonstrators from getting within 36 feet of an abortion clinicLouisiana has the most restrictionsNew York, California, & Washington state have been most protective of their abortion laws
97 Legal versus Illegal Abortions Since legalization in 1973, deaths from abortion decreased significantly
99 Why Do Women Have Abortions? Baby would interfere with life goalsLack financial resourcesPoor relationship with the fatherDon't want others to know they had sexPartner and/or family pressureFetal deformity or risk to mother’s healthRape54% of women who had an abortion used contraception when they became pregnant
100 Abortion ProceduresOne of the most common surgical procedures in the U.S.; most performed in abortion clinicsSurgery involves risksMost serious risks are uterine perforation, hemorrhaging, cervical laceration, infection, complications with anesthesia, deathRisks increase with the use of general anesthesia and the further along the pregnancy is
102 First-Trimester Surgical Abortion Vacuum aspiration – before 14 weeks gestationUsually an outpatient surgery with local anesthesia88% of abortionsWoman lies on examining table, feet in stirrupsSpeculum is placed in the vagina, cervix is anesthetized, & dilation rods open the cervix
103 First-Trimester Surgical Abortion A cannula that is attached to a vacuum aspirator is put into the cervix, the content of the uterus is emptiedTakes 4-6 minutes, with a few hour stay afterAfter she needs to rest, bleeding and cramping is likelyRisks: excessive bleeding, infection, uterine perforation
104 Second-Trimester Surgical Abortion Between weeks11% of abortionsReasons for a late abortion: medical complications, fetal deformity, divorce/marital problems, miscalculation of due date, financial or geographic problems
105 Second-Trimester Surgical Abortion Dilation & evacuation procedure: weeksSimilar to vacuum aspiration, but in a hospital under general anesthesia15-30 minute procedureMore complicated than 1st trimester, with more pain, blood loss, & cervical trauma
106 Second-Trimester Surgical Abortion Induced labor procedure used in late 2nd trimesterNeedle inserted into amniotic sac and drains the fluid; the sac is injected with saline or prostaglandinFetus is delivered hours laterCan be painful emotionally & physicallyRisks: nausea, diarrhea, cervical problems, uterine rupture, risk of death
107 Second-Trimester Surgical Abortion Hysterotomy – used in emergency situationsAbdomen is opened to remove the fetusSimilar to a cesarean section, with a 5-7 day hospital stayHysterectomy – removal of the fetus and uterusRarely used
108 Medical Abortion Two drugs: Mifepristone (RU-486) Methotrexate They are used with a prostaglandin to produce contractions and expel the contents2-3 office visits are required; $Advantages over surgical abortion: no anesthesia; it seems more like a miscarriageIncreased risk of bacterial infection
109 RU-486An antiprogestin that inhibits progesterone production, breaking down the uterine lining3 RU-486 pills are taken; 2 days later the prostaglandin is taken, which produces uterine contractions95-97% effectiveCan be used up to 9 weeks gestationMifepristone produces bleeding within 4-5 hours, and it continues for up to 13 days
110 MethotrexateMethotrexate produces bleeding that may last 1 month or moreIt is injected and ceases the development of the zygote cellsThe prostaglandin produces contractions and expels the uterine contentsCan be used up to 9 weeks gestation
112 Women’s Reactions Physiological symptoms: Surgeon General’s report found physiological health consequences (infertility, miscarriage, premature birth, low birth weight) no more common in women who have had abortions compared to the general population of womenImmediately following the procedure: cramping, heavy bleeding, nausea
113 Women’s Reactions Psychological symptoms: A woman’s feelings are often correlated with her society’s views on abortionThere is little known about reactions to medical abortionsMany women cycle through feelings of relief, happiness, shame, guilt, fear of disapproval, regret, anxiety, depression, doubt, anger, sense of loss, sadness
114 Women’s Reactions 10% of cases a woman has severe feelings Factors in severe psychological symptoms:YoungLack family or partner supportPersuaded to have an abortion or difficult time making the decisionStrong religious & moral backgroundMedical or genetic reasons for abortionHistory of psychiatric problems
115 Men’s ReactionsAbortion may cause couples to break up or may increase communication in a relationship and strengthen itSupportive partners are more positive following the procedureMen can feel sadness, a sense of loss, fear for partner’s well being, isolated, angryMen lack counseling services to help them through this time
116 Teens and AbortionSome states require parental notification or consentIn lieu of that, they may request a judicial bypass optionIn states without mandatory parental involvement, 75% of minors involve at least one parent in the process
117 Cross-Cultural Aspects of Abortion About 40% of worldwide pregnancies are unplanned20% are abortedLowest abortion rates are in Ireland, Netherlands, Belgium, & SpainHighest abortion rates are in Cuba, Vietnam, Romania, & India1.3 million abortions each year in the U.S.
118 Cross-Cultural Aspects of Abortion 25% of countries have strong restrictions on abortion20 million unsafe abortions occur each year by taking drugs, inserting objects into the vagina or flushing it with liquids, or forcefully massaging the abdomenMedical abortion is widely used outside the U.S.