1. CONTRACEPTION, STERILIZATION AND ABORTION
Mark Nichols, MD
Professor, Ob/Gyn, OHSU

2. Teenage pregnancy is more common in the United States than in most other industrialized countries
In addition, while the pregnancy rate among U.S. teenagers declined by 17% from its peak in 1990 to 1996, it is still one of the highest among industrialized nations.
Source: AGI, Fulfilling the Promise, p. 35.

3. Teenage pregnancy in the United States

4. Teenage pregnancy in the United States
Decline explained by:
25% by increased abstinence
75% by more effective contraceptive use

5. Use of contraception by teens at first sex
1982 to 1995 teens using no contraceptive at first sex fell from 52% to 23%
1982 to 1995 teen use of a condom at first sex rose from 23% to 54%
1991 to 2001 condom use by teens at last sex from 54% to 65 for women
But, the trend appears to be slowing

6. Proportion of high school students who have had sex

7. Proportion of sexually active high school students who use condoms

8. Half of all pregnancies in the United States each year are unintended
Even as clinics work to broaden their public health focus, much work remains to be done to achieve their goal of eliminating unintended pregnancy. Each year, half of all pregnancies in the United States are unintended, and half of unintended pregnancies - or one in four pregnancies overall - end in abortion.
Rates of unintended pregnancy remain highest among young and low-income women -- the groups the publicly funded family planning clinic network serves.
Source: AGI, Fulfilling the Promise, pp
Pregnancies
(6.3 million)

9. The small proportion of women who do not use contraceptives . . .
. . . account for roughly half of all unintended pregnancies
In fact, the likelihood of pregnancy in the absence of contraceptive use is so great that the 7% of American women aged using no method while at risk of unintended pregnancy account for nearly half (47%) of all unintended pregnancies.
Source: AGI, Fulfilling the Promise, p. 10.
Women at risk of
unintended pregnancy
(42 million)
Women experiencing unintended pregnancies
(3 million)

10. Any contraceptive method is better than none, . . .
. . . but choice of method makes a difference
Contraception is key to helping women and their partners realize their family-size goals. Some of the most widely used contraceptive methods reduce the risk of unintended pregnancy by more than 90%.
Source: AGI, Fulfilling the Promise, p. 10.
% of users becoming pregnant within one year

11. Abortion Worldwide 46 million abortions
26 million safe, legal abortions
20 million clandestine abortions (generally unsafe)
68,000 deaths from unsafe abortion
3% of world’s abortions occur in the U.S.
Abortion rates:
U.S.: 23 per 1000 women per year
Worldwide 35 per 1000 women per year

12. Abortion United States
Over half of all pregnancies in the U.S. are undesired, half of these are terminated.
Approximately 1.1 million elective abortions are done in the US each year.
90% of abortions are performed before the second trimester using a suction technique.
38% of women in the USA will have an abortion at some time in their life
Between 1980 and 2000, decline in rate from 30 to 23 per 1000 women per year overall

13. FAMILY PLANNING EXPERIENCE
OB/GYN RESIDENTS
FAMILY PLANNING EXPERIENCE
Topic
No instruction (%)
No experience
(%)
Experience > 10 cases
(%)
OC management 7 5 95
IUD insertion 25 38 29
Norplant insertion 14 25 31
Diaphragm fitting 18 11 46
First trimester abortion 29 47 45
Dilation & Evacuation 31 43 19
Postpartum tubal ligation 9 9 89
Laparoscopic tubal ligation 9 6 92
Obstet Gynecol 1993;81:311-4

14. ABORTION Legal Aspects
Abortion is protected by the U. S. Supreme Court decision Roe v. Wade decided in 1973.
Protects the right to abortion prior to viability
Decision made in privacy with a women and her physician.
Based on the principle of maternal rights superseding the rights of the fetus.

15. ABORTION Legal Aspects
Viability = gestational age at which a fetus will survive outside of the womb albeit with artificial support.
Physicians have an ethical responsibility to provide information and appropriate referral for abortion or contraceptive services that a patient might request.

16. ABORTION Technique
Discussion of the alternatives. Informed consent. Careful pelvic exam.
Ultrasound assessment of gestational age. Not yet the standard of care. Most large volume providers include as part of the abortion package.
Procedure depends on gestational age (stated from the first day of the last menstrual period)
Same technique used for managing unsuccessful pregnancies

17. Suction abortion technique: <14 weeks gestational age
Anesthetic choices:
Paracervical block with local anesthetic. Oral or IV sedation may be used in addition.
General anesthetic used in more difficult 1st trimester procedures
Dilation of the cervix to allow passage of a suction cannula into the uterine cavity.

18. Suction abortion technique: <14 weeks gestational age
Direct dilation with dilator <10 weeks,
Laminaria or misoprostol for pregnancies >11 weeks gestation.
Laminaria absorb moisture and swell to dilate the cervix.
Sterilized pieces of the seaweed Laminaria japonicum.

19. Suction abortion technique: <14 weeks gestational age
Size of canulas in mm. diameter used equals the gestational age in weeks or
G. A. minus 1.
Suction is applied with an electric pump and the pregnancy is removed from the uterus.
Suctioning continues until uterus feels empty
Tissue carefully inspected to assure that the entire pregnancy has been removed.

23. Manual vacuum aspiration abortion
Syringe used to generate suction
No electricity needed
Reusable syringes
Can be done as soon as gestational sac seen in uterus, 4½ weeks from the LMP

26. Surgical vs. Medical Abortion
Mortality from
Surgical vs. Medical Abortion
Mortality
Procedures
Mortality
Rate
Surgical Procedures:
Worldwide
70,000 a
36-53,000,000
1/ /757
Surgical Procedures:
United States
10 b
1,200,000
1/120,000
Medical Procedures
1 c
2,000,000
1/2,000,000
a=WHO data, b=CDC reports, c=Estimated 500,000 in Europe, 2,000,000 in China

28. Medical abortion with mifepristone or methotrexate and misoprostol
Mifepristone formerly called RU-486
≤9 weeks gestational age
Induces a miscarriage
95-98% successful (no suction used)
Side effects = nausea 30%, vomiting 15%, diarrhea 10%

29. Population Council trial (mifepristone with misoprostol)
2100 women in 17 sites across USA
Data submitted to FDA led to mifepristone approval
Protocol
Day 1: H & P, Ultrasound Exam, Informed consent, 600 mg mifepristone
Day 3: 400 μg misoprostol orally
Stay in clinic four hours
Day 15: Follow-up visit

30. Mifepristone/Misoprostol Abortion
Failures of
Mifepristone/Misoprostol Abortion
Group I
Group II
Group III
Total
Total
7.7
16.8
22.5
14.2
Medically Indicated
1.6
3.8
4.1
3.0
Patient Request
0.6
1.9
2.4
1.5
Incomplete Abortion
4.6
7.4
7.1
6.2
Ongoing Pregnancy
1.0
3.7
9.0
3.9

31. U. S. Mifepristone Clinical Trials vs. French Data (<49 days)
Outcomes (%)
USA
France
Total Success
92.3%
95.5%
Medically Indicated
1.6
0.4
Patient Request
0.6
N/A
Incomplete Abortion
4.6
2.9
Ongoing Pregnancy
1.0
1.3

32. Population Council trial Side Effects
Pain 98%
(management:
66% Acetaminophen alone
29% Codeine)
Nausea 65%
Vomiting 30%
Diarrhea 20%
Bleeding 60% at 15 days

33. U. S. Mifepristone Clinical Trials Patient Acceptance
Degree of Satisfaction
Total
Success
Surgery
Very Satisfied 72 79 31
Moderately Satisfied 15 14 19
Fair 7 5 18
Moderately Unsatisfied 2 1 10
Very Unsatisfied 4 1 22

34. Dilation and Evacuation (D & E)
>14 weeks gestational age
Fetus and placenta extracted through the cervix.
Anesthetic choices: Same as <14 weeks gestational age suction procedures.
This is not the procedure used in intact dilation and extraction (“partial birth abortions”)

35. Induction of labor Oxytocin or prostaglandin used to induce labor
Labor lasts from 12 to 36 hours.
Epidural anesthetic is often used
Often chosen in pregnancies where a fetal abnormality has been diagnosed.

36. Psychologic reactions
Most women have a short lived grief reaction
Most feel relieved that they no longer face the crisis of an undesired pregnancy
Incidence of major psychologic illness is no greater than in carrying an undesired pregnancy to term
Some women feel empowered by controlling their future by terminating an undesired pregnancy

37. Complications
Risk of complications increases with increasing gestational age
Reporting of all complications required to state health department

38. Perforation of the uterus
Approximately 1 in 1000 first trimester suction abortions
Managed by observation in the hospital or clinic
Risk of bowel injury or significant internal bleeding is <1%.
Approximately 1 in 300 D & E's.
Immediate laparotomy is usually indicated.

39. Incomplete abortion
Defined as a need to have another suction procedure to complete the abortion
Incidence is approximately 1 in 250 abortions

40. Infection The incidence of infection is about 1 in 200.
Almost always successfully treated as an outpatient.
Risk of infection leading to infertility extremely rare.

41. Death Risk 1st trimester abortion = 0.5 per 100,000 procedures.
2nd trimester D & E = 2 per 100,000
2nd trimester labor induction = 4 per 100,000
Term pregnancy and birth = 10 per 100,000.
Ectopic pregnancy = 50 per 100,000 cases.

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