Abortion

What is an abortion?

Abortion is the early ending of a pregnancy.

• A spontaneous abortion, or miscarriage, occurs when a natural cause ends a pregnancy. If you have had or may be having a miscarriage, see the topic Miscarriage.
• A therapeutic or induced abortion is one resulting from measures taken to intentionally end a pregnancy, using medicines (medical abortion) or surgery.

Surgical abortion is most commonly used to end a pregnancy, but medical abortion is becoming more widely used since RU-486 (mifepristone) was approved for use in the United States in 2000.¹ Both medical and surgical methods of abortion require follow-up visits that include a physical and pelvic examination to make sure recovery is going well, as well as birth control planning.

When should I see a doctor?

If you have had unprotected sex in the last 5 days and don't want to become pregnant, see a health professional about emergency contraception. This is most commonly in the form of hormone pills (Plan B, also referred to as the morning-after pill) to help prevent pregnancy. If you are 18 or older, you can get Plan B at a pharmacy, with proof of age. If you are younger than 18, you can get Plan B with a prescription. If you have had unprotected sex in the past 5 to 7 days, you may be able to use a copper intrauterine device (IUD) for emergency contraception. This will also work for long-term birth control.

If you think you may be pregnant, see a health professional for a pregnancy test and examination as soon as possible. If you are pregnant, this is an important time for learning as much as you can about your options. If you are considering abortion, the earlier you are in your pregnancy, the more options you are likely to have and the lower your risk of complications.

How do I know what decision is right for me?

For your own future well-being, it's important that you make a well-informed decision when you are considering an abortion. Early pregnancy counseling helps you reach a positive outcome, regardless of whether you continue with the pregnancy or choose an abortion. Family planning clinics offer pregnancy counseling. You may also want to discuss your decision with a trusted person close to you who has a realistic view of how a pregnancy and parenthood would impact your life. Take time to think through your choices, which are to:

• Have an abortion.
• Have a baby and dedicate yourself to supporting and raising your child to adulthood.
• Have a baby and place the baby for adoption.

When can an abortion be done?

Depending on how many weeks pregnant you are, you may have a choice between two or more types of abortion procedures. Medical and surgical methods available differ at each stage of pregnancy. As a pregnancy progresses into the second trimester, only surgical abortion can be used. Risks of second-trimester surgical abortion are higher than risks for first-trimester abortion.

Options include the use of medicines, manual or mechanical vacuum aspiration, dilation and curettage (D&C), dilation and evacuation (D&E), or using medicine to start labor and delivery (induction).

How safe is abortion?

Abortion procedures done by health professionals are very safe. Less than 1 in 100 women has a serious complication after an abortion.¹ In countries where abortion is legal and safe, women very rarely die after an abortion—less than 1 in 100,000 women. To put abortion risk into perspective, childbirth in the United States is at least 7 times more likely to result in a woman's death than having an abortion. If abortion were legal worldwide, post-abortion deaths per year would drop from 150,000 to 250.²

The safest timing for an abortion is between 3 and 10 weeks after your last menstrual period.¹ This is when a low-risk medicine or vacuum aspiration procedure can be used, the placenta is still developing, and the embryo is very small. (Medicine becomes less effective after 7 weeks.)

As a pregnancy progresses into the second trimester and only surgical abortion can be used, risks increase. Complications of second-trimester surgical abortion can include heavy blood loss, infection, and moderate to severe pain. Cramping pain is more common during a medical abortion than after a surgical abortion.¹

In the past, there has been concern that an abortion might increase a woman's risk of breast cancer. However, more recent, carefully done studies show that there is no link between having an abortion and getting breast cancer later in life.^{3, 1}

Who should I see for an abortion?

Early manual vacuum aspiration and medical abortion are offered by specially trained medical professionals, including medical doctors (such as family medicine doctors and gynecologists), and some nurse-midwives, nurse practitioners, and physician assistants. Typically, only medical doctors offer machine vacuum aspiration and other types of surgical abortion. Abortion services are most likely to be available in university hospitals and family planning clinics. However, depending on where you live, you may have to travel a long distance to see an abortion specialist.

If you choose to have a medical abortion, make sure that your health professional can also perform a vacuum aspiration (or can refer you to a health professional who does). This is important in case medicine doesn't completely remove the pregnancy, which happens after 2% to 5% of medical abortions.^{4, 1}

What exams or tests will I need to have?

Your health professional will ask about your medical history and will do a physical examination, including a pelvic examination. Lab tests will be done to confirm your pregnancy. An ultrasound may also be done.

Whether you are a teenager or an adult, rest assured that the law protects your privacy. Your gynecological exam and test results are your private information. Your health professional will not share your private information with anyone but you unless you give permission to do so.

Who can have an abortion?

An abortion is legal, with some restrictions, in the United States. Contact your closest Planned Parenthood or other family planning clinic for more information about restrictions in your state, as well as neighboring states.

• Many states require women to wait 24 hours or longer after a first informational appointment.
• Some states require a parent's consent for women under the age of 18 before they can have an abortion. In these states, however, a minor has the right to seek a court order allowing an abortion without a parent's consent. (Over half of women under the age of 18 who have an abortion have their decision supported by at least one of their parents.⁵)

Abortions are rarely done after 24 weeks of pregnancy (during the late second trimester and entire third trimester). Many states in the U.S. have restrictions on abortions after 24 weeks.

Will I be able to have children in the future?

The most widely used methods for abortion do not affect a woman's future ability to become pregnant.¹ In fact, it is possible to become pregnant in the weeks right after an abortion procedure. This is a good time to start a highly effective birth control method that fits your lifestyle. After taking 1 to 3 weeks to recover from an abortion, be sure to also use condoms (to prevent infection) when you start having intercourse again. Continue with this practice for several weeks, or as long as your health professional advises. For more information on birth control choices, see the topic Birth Control.

Having two or more abortions using a sharp instrument (such as dilation and curettage, or D&C, which is rarely used during the first trimester) could create enough scar tissue to affect your future ability to become pregnant as well as your risk of infertility or pregnancy complications. Such complications include implantation of a fertilized egg outside of the uterus (ectopic pregnancy), miscarriage, or growth of the placenta over the cervix (placenta previa).⁶

Frequently Asked Questions

In the United States, about 6 million women become pregnant per year.⁷ Half of all pregnancies are unintended, and of all births, about 1 in 10 newborns have been reported as "unwanted."⁸

Each year, nearly 1.3 million American women have an abortion to end a pregnancy.⁹ This number reflects a declining abortion rate, in part because more women are using emergency contraception to prevent unintended pregnancy in the first days after unprotected sex.

The most common reasons women consider abortion are:

• Birth control (contraceptive) failure. Over half of all women who have an abortion used a contraceptive method during the month they became pregnant.⁹
• Inability to support or care for a child.
• To end an unwanted pregnancy.
• To prevent the birth of a child with birth defects or severe medical problems. Such defects are often unknown until routine second-trimester tests are done.
• Pregnancy resulting from rape or incest.
• Physical or mental conditions that endanger the woman's health if the pregnancy is continued.

In the United States, 9 out of 10 abortions are performed in the first 12 weeks (first trimester) of pregnancy. The majority of these are done within the first 8 weeks of pregnancy.⁹

Very few abortions are done after 16 weeks of pregnancy. Of those abortions that are done after the first trimester, almost half have been delayed by trouble with affording, finding, or traveling to an abortion specialist.^{8, 9}

Illegal abortion

An abortion is legal, with some restrictions, in the United States (up to 24 weeks of pregnancy). Many states require women to wait 24 hours or longer after a first informational appointment. Contact your closest Planned Parenthood or other family planning clinic for more information about restrictions in your state, as well as neighboring states.

An abortion performed without professional medical care (illegally) has a much greater risk of complications than one performed legally with good medical care.

Teen pregnancy

About 30% of pregnant teens choose to have an abortion.⁵ About 60% of women under age 18 having an abortion have a parent who knows of the abortion; the majority of these parents support their daughters' decision.⁵ (In the United States, some states require a parent's consent for women under the age of 18 before they can have an abortion. In these states, however, a minor has the right to seek a court order allowing an abortion without a parent's consent. For more information, contact your closest Planned Parenthood or other family planning clinic.)

The most common reasons that teens and young women choose to have an abortion include:⁵

• Awareness that they are not mature enough to have a child.
• Knowledge that they are financially not able to support or care for a child.
• Concern that having a baby would change their lives and compromise their (and a child's) future—many young mothers don't ever manage to get the education and employment necessary to raise their child above the poverty line.

Examinations and tests are used to diagnose a pregnancy and to check for any health conditions you may have that need special consideration. Regardless of whether you know that you would continue a pregnancy or have an abortion, your evaluation will include a medical history, a physical exam, and some laboratory tests.

Whether you are a teenager or an adult, rest assured that the law protects your privacy. Your gynecological exam and test results are your private information. Your health professional will not share your private information with anyone but you unless you give permission to do so.

A physical exam before an abortion includes:

• Taking your vital signs, such as blood pressure and heart rate.
• Listening to your heart and lungs.
• Performing a pelvic exam to determine the size and shape of your uterus. The size of the uterus can help estimate the number of weeks you are pregnant. A pelvic exam also allows your health professional to check the ovaries and fallopian tubes for a possible tubal (ectopic) pregnancy, which would feel like an abnormal mass in the pelvis.

Laboratory tests before an abortion include:

• A urine pregnancy test to determine that you are pregnant. (You may have missed a menstrual cycle for another reason, such as stress, and not because you are pregnant.)
• A blood test to determine:
  • Whether you have low blood iron (anemia). If you have anemia, your health professional may want you to take some iron supplements before and after an abortion.
  • Your blood type and whether you are Rh-negative. If you are Rh-negative, you should receive a vaccine called Rh immune globulin after an abortion. For more information, see the topic Rh Sensitization During Pregnancy.
• A urine test, which may be done to make sure you do not have a urinary infection.
• Screening for sexually transmitted diseases (STDs), if you are at high risk for an STD. This is not a routine test before an abortion but may be done to reduce the risk of complications, such as an infection, after the procedure.
• A Pap smear to check for cervical cell abnormalities (dysplasia), if you are due for one (not a routine test before an abortion).

An ultrasound may be done to check your uterus size and shape and to make sure the pregnancy is in the uterus. A transvaginal ultrasound done in the first trimester is the most accurate method of learning how long you have been pregnant.

Medical abortion, the use of medicines to end an early pregnancy, is up to 98% effective within the first 9 weeks of pregnancy.¹⁰ As a pregnancy progresses into the late first trimester, medicines are less likely to fully induce an abortion. When this happens, a follow-up surgical abortion becomes necessary to make sure that the uterus is completely clear of tissue.

• A typical treatment schedule for a medical abortion includes a first medical visit and medicine, followed 3 to 4 days later by a second medical check and medicine (another common schedule allows the second medicine to be taken at home¹¹). Moderate to heavy vaginal bleeding lasts about 14 days. About 2 weeks after the second medical visit, a follow-up examination is necessary to see if you are recovering well and to make sure the procedure worked.
• Medical care before and after a medical abortion includes physical exams and lab tests, education about what to expect, self-care instructions, information on when to call your health professional, and birth control planning.

Medicines currently available in the United States for inducing abortion are:

• Misoprostol. This hormone softens and opens (dilates) the cervix and triggers uterine contractions. Misoprostol used alone may end a pregnancy but is much more effective when used with other medicines, such as mifepristone or methotrexate, in first-trimester abortions.⁴
• Mifepristone and misoprostol. Mifepristone, also known as Mifeprex or RU-486, blocks the effects of the hormone progesterone. This stops the placenta's growth, softens the cervix, and makes the uterus ready for labor. Misoprostol is then used to start contractions to clear the uterus of all tissue. This is effective 95% to 98% of the time among women 9 weeks pregnant or less.^{4, 1}
• Methotrexate and misoprostol. Methotrexate interferes with the placenta's growth; it is not as effective as mifepristone and takes longer to abort a pregnancy.¹⁰ Misoprostol is then used to start contractions to clear the uterus of all tissue. This is effective 95% to 99% of the time when completed before 7 weeks of pregnancy.¹⁰

See the section What to Think About for a comparison of medical abortion and surgical abortion.

A surgical abortion ends a pregnancy by surgically removing the contents of the uterus. Different procedures are used for surgical abortion, depending on how many weeks of pregnancy have passed.

Care before and after a surgical abortion includes a physical exam and lab tests, education about what to expect, self-care instructions, symptoms that indicate you should call your health professional, and birth control planning.

Surgical methods in the first trimester (3 to 12 weeks)

• Manual vacuum aspiration (MVA) or machine vacuum aspiration uses suction through a small tube to empty the uterus of all tissue.
• Dilation and curettage (D&C), which is more "surgical" than aspiration, uses a sharp instrument to clear the uterus. It is usually reserved for following up on medical or vacuum aspiration procedures that have not completely emptied the uterus.

Surgical method in the second trimester

• Dilation and evacuation (D&E) is typically done when an abortion occurs in the second 12 weeks (second trimester) of pregnancy. It usually includes a combination of vacuum aspiration, dilation and curettage (D&C), and the use of surgical instruments (such as forceps) to clear the uterus of fetal and placental tissue.

A D&E is most commonly used during the second trimester because it has a lower complication risk than induction abortion.

Nonsurgical method in the second trimester

• Induction abortion ends a second-trimester pregnancy by using medicines to start (induce) contractions, which expel (push) the fetus from the uterus. If the fetus has severe medical problems, a woman may choose to have an induction abortion. This method is used to minimize risk to the woman and so an autopsy can be performed to find out what is wrong with the fetus.

See the section What to Think About for a comparison between medical abortion and surgical abortion.

If you have had unprotected sex in the last 5 days and don't want to become pregnant, see a health professional about emergency contraception in the form of hormone pills (Plan B—also referred to as the morning-after pill). If you have had unprotected sex in the past 5 to 7 days, you may be able to use a copper intrauterine device (IUD) for emergency contraception. This will also work for long-term birth control.

Your abortion options are affected by your medical history, how many weeks pregnant you are, and what options are available in your region. Not all medical or surgical choices for an abortion are available in all parts of the United States or around the world. In the U.S., individual states have restrictions on abortion, such as requiring a waiting period, requiring parental consent for young women under a certain age, or limiting options for pregnancies between 13 and 24 weeks (second trimester).

The following table lists some of the differences between the most commonly used medical and surgical abortion procedures.

Pain associated with a medical or surgical abortion ranges from mild to severe and depends on each woman's physical and emotional condition.

Some fetal birth defects or medical problems are not commonly diagnosed until the second trimester, when most routine screening tests are done. There are fewer abortion options during the second trimester.

Right after surgery, you will be taken to a recovery area where nurses will care for and observe you. You will probably stay in the recovery area for 1 to 4 hours. You will then be moved to a hospital room or you will go home. In addition to any special instructions from your doctor, your nurse will explain information to help you in your recovery. You will go home with a page of care instructions including who to contact if a problem arises.

Abortion and breast cancer

Research suggests that the hormonal changes during pregnancy may be protective and reduce the risk of breast cancer. In the past, there has been concern that an abortion might interrupt these protective hormonal changes and possibly increase the risk of breast cancer. However, more recent, carefully done studies have led experts to conclude that there is no link between having an abortion and breast cancer.^{3, 1}

If you think you may be pregnant, see a health professional for a pregnancy test, examination, and pregnancy counseling as soon as possible. If you are considering ending the pregnancy, this is an important time for learning as much as you can about your options. The earlier you take measures to end a pregnancy, the more medical choices you are likely to have and the less your risk of complications will be.

If you have had unprotected sex in the past 72 hours, a pregnancy test is not necessary before using emergency contraception medicine to prevent pregnancy. A copper intrauterine device (IUD) can also be used as emergency contraception and can be inserted as late as 5 to 7 days after unprotected intercourse.

Who to see

Surgical abortions are minor surgeries that require a health professional with specialized training. If a medical abortion is not successful, a surgical abortion must be done as follow-up. This is necessary to prevent infection and blood loss and to end the pregnancy, because medical abortion medicines cause birth defects. The following health professionals can perform abortions:

• Gynecologist
• Family medicine doctor who has special training
• Certified nurse-midwife
• Nurse-practitioner with special training
• Physician assistant with special training

Some health professionals offer medical abortion only and recommend another health professional if a vacuum aspiration becomes necessary. Other health professionals offer medical abortion and manual vacuum extraction (MVA) if necessary, which is a simple and effective procedure. Fewer health professionals offer medical, MVA, and surgical abortion services.

Your health professional will give you information about what to expect after an abortion. Normal symptoms that most women experience include:

• Irregular bleeding or spotting for as long as the first 3 weeks.
• Cramping for the first 2 weeks. Some women have menstrual-like cramping for as long as 6 weeks.
• Emotional reactions for 2 to 3 weeks.

The hospital or surgery center may send you instructions on how to get ready for your surgery or a nurse may call you with instructions before your surgery.

Right after surgery, you will be taken to a recovery area where nurses will care for and observe you. You can expect to stay in the recovery area for 1 to 4 hours, and then you will be moved to a hospital room or you will go home. In addition to any special instructions from your doctor, your nurse will explain information to help you in your recovery. You will go home with a page of care instructions including who to contact if a problem arises.

Signs of complications

Less than 1% of all women who have an abortion have serious problems afterward.⁹

Call your health professional immediately if you have any of these symptoms after an abortion:

• Severe bleeding. Both medical and surgical abortions usually cause bleeding that is different from a normal menstrual period. Severe bleeding can mean:
  • Passing clots that are bigger than a golf ball, lasting 2 or more hours.
  • Soaking more than 2 large sanitary pads in an hour, for 2 hours in a row.
  • Bleeding heavily for 12 hours in a row.
• Signs of infection in your whole body, such as headache, muscle aches, dizziness, or a general feeling of illness. Severe infection is possible without fever.
• Severe pain in the abdomen that is not relieved by pain medicine, rest, or heat
• Hot flushes or a fever of 100.4°F (38°C) or higher that lasts longer than 4 hours
• Vomiting lasting more than 4 to 6 hours
• Sudden abdominal swelling or rapid heart rate
• Vaginal discharge that has increased in amount or smells bad
• Pain, swelling, or redness in the genital area

Call your health professional for an appointment if you have had any of these symptoms after a recent abortion:

• Bleeding (not spotting) for longer than 2 weeks.
• New, unexplained symptoms that may be caused by medicines used in your treatment.
• No menstrual period within 6 weeks after the procedure.
• Signs and symptoms of depression. Hormonal changes after a pregnancy can cause postpartum depression that requires treatment.

Your ability to become pregnant in the future

Medical abortion and vacuum aspiration do not affect your ability to become pregnant in the future.¹ It is possible to become pregnant in the weeks right after an abortion procedure.

• Avoid sexual intercourse until your body has fully recovered, for at least 1 to 3 weeks.
• To prevent infection and pregnancy, it is important to use condoms as directed by your health professional when you start to have intercourse again. This is a good time to also start a highly effective birth control method that fits your lifestyle. For more information, see the topic Birth Control.

Having several abortions using dilation and curettage (D&C) may create enough scar tissue to reduce a woman's ability to become pregnant and raises the risk of pregnancy complications, including ectopic pregnancy, miscarriage, and placenta previa.⁶ However, this method is rarely used.

Online Resource

Organizations

• Birth Control
• Miscarriage
• Postpartum Depression
• Pregnancy

Citations

1. Trupin SR (2003). Induced abortion. In JR Scott et al., eds., Danforth's Obstetrics and Gynecology, 9th ed., pp. 561–580. Philadelphia: Lippincott Williams and Wilkins.

2. Ketting E (1993). Global overview of abortion. Planned Parenthood Challenges, 1: 27–29.

3. American College of Obstetricians and Gynecologists (2003). Induced abortion and breast cancer risk. ACOG Committee Opinion No. 285. Obstetrics and Gynecology, 102(2): 433–435.

4. Goldberg AB, et al. (2001). Misoprostol and pregnancy. New England Journal of Medicine, 344(1): 3845.

5. Facts on American teens' sexual and reproductive health (2006). In Brief. New York: Alan Guttmacher Institute. Also available online: http://www.guttmacher.org/pubs/fb_ATSRH.html.

6. Johnson LG, et al. (2003). The relationship of placenta previa and history of induced abortion. International Journal of Gynaecology and Obstetrics, 81(2): 191–198.

7. Vernture SJ, et al. (2001). Trends in pregnancy rates for the United States, 1976–1997: An update. National Vital Statistics Reports, Centers for Disease Control, 49(4): 1–10.

8. Centers for Disease Control and Prevention (2003). Abortion surveillance—United States, 2000. MMWR, 52(SS–12): 1–32.

9. Facts on induced abortion in the United States (2006). In Brief. New York: Alan Guttmacher Institute. Also available online: http://www.guttmacher.org/pubs/fb_induced_abortion.html.

10. Trupin SR, Moreno C (2002). Medical abortion: Overview and management. Medscape General Medicine, 4(1). Also available online: http://www.medscape.com/viewarticle/429755_1.

11. Prine L, et al. (2003). Medical abortion in family practice: A case series. Journal of the American Board of Family Practice, 16(4): 290–295.

12. American College of Obstetricians and Gynecologists (2005). Medical management of abortion. ACOG Practice Bulletin No. 67. Obstetrics and Gynecology, 106(4): 871–882.