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

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.

Teenage pregnancy in the United States

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

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

Proportion of high school students who have had sex

Proportion of sexually active high school students who use condoms

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. 34-35. Pregnancies (6.3 million)

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 15-44 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)

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

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

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

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

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.

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.

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

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.

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.

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.

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

Surgical vs. Medical Abortion Mortality from Surgical vs. Medical Abortion Mortality Procedures Mortality Rate Surgical Procedures: Worldwide 70,000 a 36-53,000,000 1/514 - 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

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%

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

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

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

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

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

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”)

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.

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

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

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.

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

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.

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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