CONTRACEPTION, CONTRACEPTION, STERILIZATION AND STERILIZATION AND

ABORTIONABORTION

Mark Nichols, MDMark Nichols, MD

Professor, Ob/Gyn, OHSUProfessor, Ob/Gyn, OHSU

0 10 20 30 40 50 60 70 80 90 100 110 120

United States

Bulgaria

HungaryEngland and Wales

Canada

Sweden

France

SpainNetherlands

Japan

Pregnancies per 1,000 women aged 15-19

Births

Abortions

Miscarriages

Teenage pregnancy is more common in the United Teenage pregnancy is more common in the United States than in most other industrialized countriesStates than in most other industrialized countries

Teenage pregnancy in the Teenage pregnancy in the United StatesUnited States

0

20

40

60

80

100

120

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Teenage pregnancy in the Teenage pregnancy in the United StatesUnited States

Decline explained by:Decline explained by:• 25% by increased abstinence25% by increased abstinence• 75% by more effective contraceptive 75% by more effective contraceptive

useuse

Use of contraception by teens Use of contraception by teens at first sexat first sex

1982 to 1995 teens using no 1982 to 1995 teens using no contraceptive at first sex fell from contraceptive at first sex fell from 52% to 23%52% to 23%

1982 to 1995 teen use of a condom 1982 to 1995 teen use of a condom at first sex rose from 23% to 54%at first sex rose from 23% to 54%

1991 to 2001 condom use by teens 1991 to 2001 condom use by teens at last sex from 54% to 65 for at last sex from 54% to 65 for womenwomen

But, the trend appears to be slowingBut, the trend appears to be slowing

Proportion of high school students Proportion of high school students who have had sexwho have had sex

0

10

20

30

40

50

60

Male Female

1991

2001

Proportion of sexually active high Proportion of sexually active high school students who use condomsschool students who use condoms

0

10

20

30

40

50

60

70

Male Female

1991

2001

Abortion23%

Miscarriage6%

Birth19%

Half of all pregnancies in the United States Half of all pregnancies in the United States each year are unintendedeach year are unintended

Miscarriage9%

Birth43%

Pregnancies(6.3 million)

Unintendedpregnancies

Intendedpregnancies

The small proportion of The small proportion of women who do not use women who do not use

contraceptives . . .contraceptives . . .

Not using7%

Using93%

Using53%

Not using47%

Women at risk of unintended pregnancy

(42 million)

Women experiencing unintended pregnancies

(3 million)

. . . account for roughly . . . account for roughly half of all unintended half of all unintended

pregnanciespregnancies

Any contraceptive method is better than none, . . .Any contraceptive method is better than none, . . .

7.3

85.0

12.5

All reversible methods plus sterilization

All reversible methods

No method

% of users becoming pregnant within one year

27.6

22.9

13.1

3.5

0.2

0.5

7.5

13.7

24.5

0 10 20 30 40 50 60 70 80 90 100

Spermicides

Withdrawal

Periodic abstinence

Male condom

Diaphragm

Pill

Long-acting reversible methods

Female sterilization

Male sterilization

. . . but choice of method makes a difference

AbortionAbortion Worldwide Worldwide

46 million abortions46 million abortions 26 million safe, legal abortions26 million safe, legal abortions 20 million clandestine abortions (generally 20 million clandestine abortions (generally

unsafe)unsafe) 68,000 deaths from unsafe abortion68,000 deaths from unsafe abortion 3% of world’s abortions occur in the U.S.3% of world’s abortions occur in the U.S. Abortion rates:Abortion rates:

• U.S.: 23 per 1000 women per yearU.S.: 23 per 1000 women per year• Worldwide 35 per 1000 women per yearWorldwide 35 per 1000 women per year

AbortionAbortionUnited StatesUnited States

Over half of all pregnancies in the U.S. are Over half of all pregnancies in the U.S. are undesired, half of these are terminated. undesired, half of these are terminated.

Approximately 1.1 million elective Approximately 1.1 million elective abortions are done in the US each year.abortions are done in the US each year.

90% of abortions are performed before the 90% of abortions are performed before the second trimester using a suction second trimester using a suction technique.technique.

38% of women in the USA will have an 38% of women in the USA will have an abortion at some time in their lifeabortion at some time in their life

Between 1980 and 2000, decline in rate Between 1980 and 2000, decline in rate from 30 to 23 per 1000 women per year from 30 to 23 per 1000 women per year overalloverall

OB/GYN RESIDENTS OB/GYN RESIDENTS FAMILY PLANNING EXPERIENCEFAMILY PLANNING EXPERIENCE

TopicNo 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

ABORTIONABORTIONLegal AspectsLegal Aspects

Abortion is protected by the U. S. Supreme Abortion is protected by the U. S. Supreme Court decision Roe v. Wade decided in Court decision Roe v. Wade decided in 1973. 1973.

Protects the right to abortion prior to Protects the right to abortion prior to viabilityviability

Decision made in privacy with a women Decision made in privacy with a women and her physician. and her physician.

Based on the principle of maternal rights Based on the principle of maternal rights superseding the rights of the fetus.superseding the rights of the fetus.

ABORTIONABORTIONLegal AspectsLegal Aspects

Viability = gestational age at which a Viability = gestational age at which a fetus will survive outside of the fetus will survive outside of the womb albeit with artificial support. womb albeit with artificial support.

Physicians have an ethical Physicians have an ethical responsibility to provide information responsibility to provide information and appropriate referral for abortion and appropriate referral for abortion or contraceptive services that a or contraceptive services that a patient might request. patient might request.

ABORTIONABORTION Technique Technique

Discussion of the alternatives. Informed Discussion of the alternatives. Informed consent. Careful pelvic exam. consent. Careful pelvic exam.

Ultrasound assessment of gestational age. Ultrasound assessment of gestational age. Not yet the standard of care. Most large Not yet the standard of care. Most large volume providers include as part of the volume providers include as part of the abortion package. abortion package.

Procedure depends on gestational age Procedure depends on gestational age (stated from the first day of the last (stated from the first day of the last menstrual period)menstrual period)

Same technique used for managing Same technique used for managing unsuccessful pregnanciesunsuccessful pregnancies

Suction abortion technique: Suction abortion technique: <14 weeks gestational age<14 weeks gestational age

Anesthetic choices:Anesthetic choices:• Paracervical block with local anesthetic. Paracervical block with local anesthetic.

Oral or IV sedation may be used in Oral or IV sedation may be used in addition. addition.

• General anesthetic used in more difficult General anesthetic used in more difficult 1st trimester procedures1st trimester procedures

Dilation of the cervix to allow Dilation of the cervix to allow passage of a suction cannula into the passage of a suction cannula into the uterine cavity. uterine cavity.

Suction abortion technique: Suction abortion technique: <14 weeks gestational age<14 weeks gestational age

Direct dilation with dilator <10 Direct dilation with dilator <10 weeks, weeks,

Laminaria or misoprostol for Laminaria or misoprostol for pregnancies >11 weeks gestation.pregnancies >11 weeks gestation.• Laminaria absorb moisture and swell to Laminaria absorb moisture and swell to

dilate the cervix. dilate the cervix. • Sterilized pieces of the seaweedSterilized pieces of the seaweed

Laminaria japonicumLaminaria japonicum. .

Suction abortion technique: Suction abortion technique: <14 weeks gestational age<14 weeks gestational age

Size of canulas in mm. diameter used Size of canulas in mm. diameter used equals the gestational age in weeks or equals the gestational age in weeks or

G. A. minus 1.G. A. minus 1. Suction is applied with an electric pump Suction is applied with an electric pump

and the pregnancy is removed from the and the pregnancy is removed from the uterus. uterus.

Suctioning continues until uterus feels Suctioning continues until uterus feels emptyempty

Tissue carefully inspected to assure that Tissue carefully inspected to assure that the entire pregnancy has been removed.the entire pregnancy has been removed.

Manual vacuum aspiration abortionManual vacuum aspiration abortion

Syringe used to generate suctionSyringe used to generate suction No electricity neededNo electricity needed Reusable syringesReusable syringes Can be done as soon as gestational Can be done as soon as gestational

sac seen in uterus, 4sac seen in uterus, 4½½ weeks from weeks from the LMPthe LMP

Mortality ProceduresMortality

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

Mortality from Surgical vs. Medical Abortion

a=WHO data, b=CDC reports, c=Estimated 500,000 in Europe, 2,000,000 in China

Medical abortion with mifepristone Medical abortion with mifepristone or methotrexate and misoprostolor methotrexate and misoprostol

Mifepristone formerly called RU-486Mifepristone formerly called RU-486 ≤≤9 weeks gestational age9 weeks gestational age Induces a miscarriageInduces a miscarriage 95-98% successful (no suction used)95-98% successful (no suction used) Side effects = nausea 30%, vomiting Side effects = nausea 30%, vomiting

15%, diarrhea 10%15%, diarrhea 10%

Population Council trial Population Council trial (mifepristone with misoprostol)(mifepristone with misoprostol)

2100 women in 17 sites across USA2100 women in 17 sites across USA Data submitted to FDA led to Data submitted to FDA led to

mifepristone approvalmifepristone approval ProtocolProtocol

• Day 1: H & P, Ultrasound Exam, Day 1: H & P, Ultrasound Exam, Informed consent, 600 mg mifepristoneInformed consent, 600 mg mifepristone

• Day 3: 400 μg misoprostol orallyDay 3: 400 μg misoprostol orally Stay in clinic four hoursStay in clinic four hours

• Day 15: Follow-up visitDay 15: Follow-up visit

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 TrialsU. S. Mifepristone Clinical Trialsvs. French Data (<49 days)vs. French Data (<49 days)

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

Outcomes (%)

Population Council trial Population Council trial Side EffectsSide Effects

Pain 98% Pain 98% • (management: (management:

66% Acetaminophen alone66% Acetaminophen alone 29% Codeine)29% Codeine)

Nausea 65%Nausea 65% Vomiting 30%Vomiting 30% Diarrhea 20%Diarrhea 20% Bleeding 60% at 15 daysBleeding 60% at 15 days

U. S. Mifepristone Clinical TrialsPatient Acceptance

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

Degree of Satisfaction

Dilation and Evacuation (D & E)Dilation and Evacuation (D & E)

>14 weeks gestational age>14 weeks gestational age Fetus and placenta extracted Fetus and placenta extracted

through the cervix. through the cervix. Anesthetic choices: Same as <14 Anesthetic choices: Same as <14

weeks gestational age suction weeks gestational age suction procedures.procedures.

This is not the procedure used in This is not the procedure used in intact dilation and extraction intact dilation and extraction (“partial birth abortions”)(“partial birth abortions”)

Induction of laborInduction of labor

Oxytocin or prostaglandin used to Oxytocin or prostaglandin used to induce labor induce labor

Labor lasts from 12 to 36 hours.Labor lasts from 12 to 36 hours. Epidural anesthetic is often usedEpidural anesthetic is often used Often chosen in pregnancies where a Often chosen in pregnancies where a

fetal abnormality has been fetal abnormality has been diagnosed.diagnosed.

Psychologic reactionsPsychologic reactions

Most women have a short lived grief Most women have a short lived grief reactionreaction

Most feel relieved that they no longer face Most feel relieved that they no longer face the crisis of an undesired pregnancythe crisis of an undesired pregnancy

Incidence of major psychologic illness is Incidence of major psychologic illness is no greater than in carrying an undesired no greater than in carrying an undesired pregnancy to termpregnancy to term

Some women feel empowered by Some women feel empowered by controlling their future by terminating an controlling their future by terminating an undesired pregnancyundesired pregnancy

ComplicationsComplications

Risk of complications increases with Risk of complications increases with increasing gestational ageincreasing gestational age

Reporting of all complications Reporting of all complications required to state health departmentrequired to state health department

Perforation of the uterus Perforation of the uterus

Approximately 1 in 1000 first Approximately 1 in 1000 first trimester suction abortions trimester suction abortions • Managed by observation in the hospital Managed by observation in the hospital

or clinic or clinic • Risk of bowel injury or significant Risk of bowel injury or significant

internal bleeding is <1%.internal bleeding is <1%. Approximately 1 in 300 D & E's. Approximately 1 in 300 D & E's.

• Immediate laparotomy is usually Immediate laparotomy is usually indicated. indicated.

Incomplete abortionIncomplete abortion

Defined as a need to have another Defined as a need to have another suction procedure to complete the suction procedure to complete the abortionabortion

Incidence is approximately 1 in 250 Incidence is approximately 1 in 250 abortionsabortions

InfectionInfection

The incidence of infection is about 1 The incidence of infection is about 1 in 200. in 200.

Almost always successfully treated Almost always successfully treated as an outpatient. as an outpatient.

Risk of infection leading to infertility Risk of infection leading to infertility extremely rare. extremely rare.

Death RiskDeath Risk

1st trimester abortion = 0.5 per 1st trimester abortion = 0.5 per 100,000 procedures. 100,000 procedures.

2nd trimester D & E = 2 per 100,0002nd trimester D & E = 2 per 100,000 2nd trimester labor induction = 4 per 2nd trimester labor induction = 4 per

100,000100,000 Term pregnancy and birth = 10 per Term pregnancy and birth = 10 per

100,000.100,000. Ectopic pregnancy = 50 per 100,000 Ectopic pregnancy = 50 per 100,000

cases.cases.

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