Abortion

Abortion
Specialty	Obstetrics

Abortion is the termination of a pregnancy by the removal or expulsion of a fetus or embryo from the uterus, caused by or resulting in its death.^{[note 1]} An abortion can occur spontaneously due to complications during pregnancy, or can be induced, in humans and in other species. In the context of human pregnancies, an induced abortion may be referred to as either^{[disputed – discuss]} therapeutic or elective. The term abortion most commonly refers to the induced abortion of a human pregnancy; spontaneous abortions are usually termed miscarriages.

Abortion, when performed in the developed world in jurisdictions where the procedure is legal, is among the safest procedures in medicine.^[1] However, unsafe abortions (those performed by persons without proper training or outside of a medical environment) result in approximately 70 thousand maternal deaths and 5 million disabilities per year globally.^[2] An estimated 42 million abortions are performed globally each year, with 20 million of those performed unsafely.^[2] Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits.^[3]

Induced abortion has a long history and has been facilitated by various methods including herbal abortifacients, the use of sharpened tools, physical trauma, and other traditional methods. Contemporary medicine utilizes medications and surgical procedures to induce abortion. The legality, prevalence, cultural status, and religious status of abortion vary substantially around the world. In many parts of the world there is prominent and divisive public controversy over the ethical and legal issues of abortion. Abortion and abortion-related issues feature prominently in the national politics in many nations, often involving the opposing pro-life and pro-choice worldwide social movements (both self-named). The incidence of abortion has declined worldwide as access to family planning education and contraceptive services has increased.^[4]

Approximately 205 million pregnancies occur each year worldwide. Over a third are unintended and about a fifth end in induced abortion.^[5] A pregnancy can be intentionally aborted in several ways. The manner selected often depends upon the gestational age of the embryo or fetus,^[6] which increases in size as the pregnancy progresses.^[7] Specific procedures may also be selected due to legality, regional availability, and doctor or patient preference.

Reasons for procuring induced abortions are typically characterized as either therapeutic or elective. An abortion is medically referred to as a therapeutic abortion when it is performed to save the life of the pregnant woman; prevent harm to the woman's physical or mental health; terminate a pregnancy where indications are that the child will have a significantly increased chance of premature morbidity or mortality or be otherwise disabled; or to selectively reduce the number of fetuses to lessen health risks associated with multiple pregnancy.^[8][9] An abortion is referred to as an elective or voluntary abortion when it is performed at the request of the woman for non-medical reasons.^[9]

Spontaneous abortion, also known as miscarriage, is the unintentional expulsion of an embryo or fetus before the 20th to 22nd week of gestation.^{[note 2]} A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is known as a "premature birth" or a "preterm birth".^[10] When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".^[11] Premature births and stillbirths are generally not considered to be miscarriages although usage of these terms can sometimes overlap.^{[citation needed]}

Only 30 to 50% of conceptions progress past the first trimester.^[12] The vast majority of those that do not progress are lost before the woman is aware of the conception,^[9] and many pregnancies are lost before medical practitioners have the ability to detect the presence of an embryo.^[13] Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman.^[14]

The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo/fetus,^[9][15] accounting for at least 50% of sampled early pregnancy losses.^[16] Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus.^[15] Advancing maternal age and a patient history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion.^[16] A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.^[17]

"Medical abortions" are non-surgical abortions that use pharmaceutical drugs, categorically called abortifacients. In 2005, medical abortions constituted 13% of all abortions in the United States;^[18] in 2010 the figure increased to 17%.^[19] Combined regimens include methotrexate or mifepristone, followed by a prostaglandin (either misoprostol or gemeprost: misoprostol is used in the U.S.; gemeprost is used in the UK and Sweden.) When used within 49 days gestation, approximately 92% of women undergoing medical abortion with a combined regimen completed it without surgical intervention.^[20] Misoprostol can be used alone, but has a lower efficacy rate than combined regimens. In cases of failure of medical abortion, surgical abortion must be use to complete the procedure.^[21]

In the first 12 weeks, suction-aspiration or vacuum abortion is the most common method.^[22] Manual vacuum aspiration (MVA) abortion consists of removing the fetus or embryo, placenta and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) abortion uses an electric pump. These techniques are comparable, and differ in the mechanism used to apply suction, how early in pregnancy they can be used, and whether cervical dilation is necessary. MVA, also known as "mini-suction" and "menstrual extraction", can be used in very early pregnancy, and does not require cervical dilation. Surgical techniques are sometimes referred to as 'Suction (or surgical) Termination Of Pregnancy' (STOP). From the 15th week until approximately the 26th, dilation and evacuation (D&E) is used. D&E consists of opening the cervix of the uterus and emptying it using surgical instruments and suction.

Dilation and curettage (D&C), the second most common method of surgical abortion, is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. Curettage refers to cleaning the walls of the uterus with a curette. The World Health Organization recommends this procedure, also called sharp curettage, only when MVA is unavailable.^[23]

Other techniques must be used to induce abortion in the second trimester. Premature delivery can be induced with prostaglandin; this can be coupled with injecting the amniotic fluid with hypertonic solutions containing saline or urea. After the 16th week of gestation, abortions can be induced by intact dilation and extraction (IDX) (also called intrauterine cranial decompression), which requires surgical decompression of the fetus's head before evacuation. IDX is sometimes called "partial-birth abortion," which has been federally banned in the United States. A hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and is used during later stages of pregnancy.^[24]

The Royal College of Obstetricians and Gynaecologists has recommended that an injection be used to stop the fetal heart during the first phase of the surgical abortion procedure to ensure that the fetus is not born alive.^[25]

Historically, a number of herbs reputed to possess abortifacient properties have been used in folk medicine: tansy, pennyroyal, black cohosh, and the now-extinct silphium (see history of abortion).^[27] The use of herbs in such a manner can cause serious—even lethal—side effects, such as multiple organ failure, and is not recommended by physicians.^[28]

Abortion is sometimes attempted by causing trauma to the abdomen. The degree of force, if severe, can cause serious internal injuries without necessarily succeeding in inducing miscarriage.^[29] Both accidental and deliberate abortions of this kind can be subject to criminal liability in many countries.^{[citation needed]} In Southeast Asia, there is an ancient tradition of attempting abortion through forceful abdominal massage.^[30] One of the bas reliefs decorating the temple of Angkor Wat in Cambodia depicts a demon performing such an abortion upon a woman who has been sent to the underworld.^[30]

Reported methods of unsafe, self-induced abortion include misuse of misoprostol, and insertion of non-surgical implements such as knitting needles and clothes hangers into the uterus. These methods are rarely seen in developed countries where surgical abortion is legal and available.^[31]

The health risks of abortion depend on whether the procedure is performed safely or unsafely. The World Health Organization defines unsafe abortions as those performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities.^[32]

Abortion, when performed in the developed world in countries where abortion is legal, is among the safest procedures in medicine.^[1][33] In the US, the risk of maternal death from abortion is 0.567 per 100,000 procedures, making abortion approximately 14 times safer than childbirth (7.06 maternal deaths per 100,000 live births).^[34] The risk of abortion-related mortality increases with increasing gestational age, but remains lower than that of childbirth through at least 21 weeks' gestation.^[35][36]

Vacuum aspiration in the first trimester is the safest method of surgical abortion, and can be performed in a primary care office, abortion clinic, or hospital. Complications are rare and can include uterine perforation, pelvic infection, and retained products of conception requiring a second procedure to evacuate.^[37] Preventive antibiotics (such as doxycycline or metronidazole) are typically given before elective abortion,^[38] as they are believed to substantially reduce the risk of postoperative uterine infection.^[39] Complications after second-trimester abortion are similar to those after first-trimester abortion, and depend somewhat on the method chosen. A 2008 Cochrane Library review found that dilation and evacuation was safer than other means of second-trimester abortion.^[40]

Medical abortion with mifepristone and misoprostol is effective through 49 days of gestational age.^[41] It has been used in women up to 63 days of gestational age, albeit with an increased risk of failure (requiring surgical abortion).^[42] Medical abortion is generally considered as safe as surgical abortion in the first trimester, but is associated with more pain and a lower success rate (requiring surgical abortion).^[43] Overall, the risk of uterine infection is lower with medical than with surgical abortion,^[41] although in 2005 four deaths after medical abortion were reported due to infection with Clostridium sordellii.^[44] As a result, some abortion providers have begun using preventive antibiotics with medical abortion.^[45]

In contrast, unsafe abortion is a major cause of injury and death among women worldwide. Although data are imprecise, it is estimated that approximately 20 million unsafe abortions are performed annually, with 97% taking place in developing countries.^[1] Unsafe abortion is believed to result in approximately 68,000 deaths and millions of injuries annually.^[1] The legal status of abortion is believed to play a major role in the frequency of unsafe abortion.^[46][47] For example, the 1996 legalization of abortion in South Africa had an immediate positive impact on the frequency of abortion-related complications,^[48] with abortion-related deaths dropping by more than 90%.^[49] Groups such as the World Health Organization have advocated a public-health approach to addressing unsafe abortion, emphasizing the legalization of abortion, the training of medical personnel, and ensuring access to reproductive-health services.^[47]

Although some studies have postulated an association between abortion and breast cancer, the best available evidence at present does not support such a link. Major medical bodies, including the World Health Organization,^[50] the U.S. National Cancer Institute,^[51] the American Cancer Society,^[52] and the Royal College of Obstetricians and Gynaecologists,^[53] have concluded on the basis of existing evidence that abortion does not cause breast cancer.^[54][55] Currently, the concept of a link between induced abortion and breast cancer is promoted primarily by pro-life groups.^[54]

No scientific research has demonstrated that abortion is a cause of poor mental health in the general population. However there are groups of women who may be at higher risk of coping with problems and distress following abortion.^[56] Some factors in a woman's life, such as emotional attachment to the pregnancy, lack of social support, pre-existing psychiatric illness, and conservative views on abortion increase the likelihood of experiencing negative feelings after an abortion.^[57] The American Psychological Association (APA) concluded that first trimester abortion does not lead to increased mental health problems,^[58] and further research has concluded that later abortions are no different.^[59]

Some proposed negative psychological effects of abortion have been referred to by pro-life advocates as a separate condition called "post-abortion syndrome". However, the existence of "post-abortion syndrome" is not recognized by any medical or psychological organization.^[60][61][62]

There are two commonly used methods of measuring the incidence of abortion:

• Abortion rate - number of abortions per 1000 women between 15 and 44 years of age
• Abortion ratio - number of abortions out of 100 known pregnancies (excluding miscarriages and stillbirths)

The number of abortions performed worldwide has decreased between 1995 and 2003 from 45.6 million to 41.6 million, which means a decrease in abortion rate from 35 to 29 per 1000 women. The greatest decrease has occurred in the developed world with a drop from 39 to 26 per 1000 women in comparison to the developing world, which had a decrease from 34 to 29 per 1000 women. Out of a total of about 42 million abortions 22 million occurred safely and 20 million unsafely.^[2]

On average, the frequency of abortions is similar in developing countries (where abortion is generally restricted) to the frequency in developed countries (where abortion is generally much less restricted).^[3][63] Abortion rates are very difficult to measure in locations where those abortions are illegal,^[64] and pro-life groups have criticized researchers for allegedly jumping to conclusions about those numbers.^[65] According to the Guttmacher Institute and the United Nations Population Fund, the abortion rate in developing countries is largely attributable to lack of access to modern contraceptives; assuming no change in abortion laws, providing that access to contraceptives would result in about 25 million fewer abortions annually, including almost 15 million fewer unsafe abortions.^[66]

The incidence of induced abortion varies regionally. Some countries, such as Belgium (11.2 out of 100 known pregnancies) and the Netherlands (10.6 per 100), had a comparatively low ratio of induced abortion. Others like Russia (62.6 out of 100), Romania (63 out of 100)^[67] and Vietnam (43.7 out of 100) had a high ratio (data for last three countries of unknown completeness). The estimated world ratio was 26%, the world rate - 35 per 1000 women.^[68]

Abortion rates also vary depending on the stage of pregnancy and the method practiced. In 2003, data from the CDC reports that overall 26% of abortions were known to have been obtained at <6 weeks' gestation, 18% at 7 weeks, 15% at 8 weeks, 4.1% at 16 through 20 weeks and 1.4% at >21 weeks. 90.9% of these were classified as having been done by "curettage" (suction-aspiration, Dilation and curettage, Dilation and evacuation), 7.7% by "medical" means (mifepristone), 0.4% by "intrauterine instillation" (saline or prostaglandin), and 1.0% by "other" (including hysterotomy and hysterectomy).^[69] According to the CDC, due to data collection difficulties the data must be viewed as tentative and some fetal deaths reported beyond 20 weeks may be natural deaths erroneously classified as abortions if the removal of the fetus is accomplished by the same procedure as an induced abortion.^[70] The Guttmacher Institute estimated there were 2,200 intact dilation and extraction procedures in the U.S. during 2000; this accounts for 0.17% of the total number of abortions performed that year.^[71] Similarly, in England and Wales in 2006, 89% of terminations occurred at or under 12 weeks, 9% between 13 to 19 weeks, and 1.5% at or over 20 weeks. 64% of those reported were by vacuum aspiration, 6% by D&E, and 30% were medical.^[72] In 2009 in Scotland, 62.1% of all terminations were performed at less than 9 weeks, with medical termination accounting for nearly 70%.^[73]

Later abortions are more common in China, India, and other developing countries than in developed countries.^[74]

A 1998 study from 27 countries on the reasons women seek to terminate their pregnancies concluded that the most common reason women cited for having an abortion was to postpone childbearing to a more suitable time or to focus energies and resources on existing children. The most commonly reported reasons were socioeconomic factors such as being unable to afford a child either in terms of the direct costs of raising a child or the loss of income while she is caring for the child, lack of support from the father, inability to afford additional children, desire to provide schooling for existing children, disruption of education, relationship problems with a husband or partner, the perception that she is too young, and unemployment. ^[75] A 2004 study in which American women at clinics answered a questionnaire yielded similar results.^[76] A 1998 survey found risk to maternal health cited as the main reason by 5-10% in seven countries and by 20-38% in three (Kenya, Bangladesh and India).^[75] A 1997 U.S. report cited maternal health the "most important reason" for their decision by 3% of women and another 3% cited concern that the fetus had a health problem.^[70] In a 2004 survey-based U.S. study, 1% of women having abortions became pregnant as a result of rape and 0.5% as a result of incest.^[76] Another American study in 2002 concluded that 54% of women who had an abortion were using a form of contraception at the time of becoming pregnant while 46% were not. Inconsistent use was reported by 49% of those using condoms and 76% of those using the combined oral contraceptive pill; 42% of those using condoms reported failure through slipping or breakage.^[77] The Guttmacher Institute estimated that "most abortions in the United States are obtained by minority women" because minority women "have much higher rates of unintended pregnancy."^[78]

Some abortions are undergone as the result of societal pressures. These might include the stigmatization of disabled people, preference for children of a specific sex, disapproval of single motherhood, insufficient economic support for families, lack of access to or rejection of contraceptive methods, or efforts toward population control (such as China's one-child policy). These factors can sometimes result in compulsory abortion or sex-selective abortion.

Women seeking to terminate their pregnancies sometimes resort to unsafe methods, particularly when access to legal abortion is restricted. About one in eight pregnancy-related deaths worldwide are associated with unsafe abortion.^[79]

The World Health Organization (WHO) defines an unsafe abortion as being "a procedure ... carried out by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both."^[80] They may be performed by the woman herself, by another person without medical training, or by a healthcare professional operating in sub-standard conditions. Unsafe abortion remains a public health concern due to the higher incidence and severity of its associated complications, such as incomplete abortion, sepsis, hemorrhage, and damage to internal organs.

The legality of abortion is one of the main determinants of its safety. Restrictive abortion laws are associated with a high rate of unsafe abortions.^[2][81][82] In addition, a lack of access to safe and effective contraception contributes to unsafe abortion. It has been estimated that the incidence of unsafe abortion could be reduced by as much as 73% without any change in abortion laws if modern family planning and maternal health services were readily available globally.^[83]

Forty percent of the world's women are able to access therapeutic and elective abortions within gestational limits.^[3] While maternal mortality seldom results from safe abortions, unsafe abortions result in 70,000 deaths and 5 million disabilities per year.^[2] Complications of unsafe abortion account for approximately 12% of maternal mortalities in Asia, 25% in Latin America, and 13% in sub-Saharan Africa.^[84] Secondary infertility caused by an unsafe abortion affects an estimated 24 million women.^[82] Although the global rate of abortion declined from 45.6 million in 1995 to 41.6 million in 2003, unsafe procedures still accounted for 48% of all abortions performed in 2003.^[81] Health education, access to family planning, and improvements in health care during and after abortion have been proposed to address this phenomenon.^[85]

Induced abortion has long history, and can be traced back to civilizations as varied as China under Shennong (c. 2700 BCE), Ancient Egypt with its Ebers Papyrus (c. 1550 BCE), and the Roman Empire in the time of Juvenal (c. 200 CE).^[86] There is evidence to suggest that pregnancies were terminated through a number of methods, including the administration of abortifacient herbs, the use of sharpened implements, the application of abdominal pressure, and other techniques.

Some medical scholars and abortion opponents have suggested that the Hippocratic Oath forbade Ancient Greek physicians from performing abortions.^[86] However, other modern scholars disagree with this interpretation,^[86] and the the medical texts of Hippocratic Corpus contain descriptions of abortive techniques and notes on the risks they posed to a woman's health.^[87] In Christianity, Pope Sixtus V (1585–90) is noted as the first Pope to declare that abortion is homicide regardless of the stage of pregnancy;^[88] the Church had previously been divided on whether if believed that abortion was murder, and did not begin vigorously opposing abortion until the 1800s.^[86] Islamic tradition has traditionally permitted abortion up until a point in time when Muslims believe the soul enters the fetus,^[86] considered by various theologians to be at conception, at 40 days after conception, at 120 days after conception, or at quickening.^[89] However, abortion is largely heavily restricted or forbidden in areas of high Islamic faith such as the Middle East and North Africa.^[90]

In Europe and North America, abortion techniques advanced starting in the 1600s. However, conservatism by most physicians with regards to sexual matters prevented the wide expansion of safe abortion techniques.^[86] Other medical practitioners in addition to some physicians advertised their services, and they were not widely regulated until the mid-1800s, when the practice was banned in both the United States and the United Kingdom,^[86] among other countries.^{[citation needed]} Church groups as well as physicians were highly influential in anti-abortion movements.^[86] The Soviet Union (1919), Iceland (1935) and Sweden (1938) were among the first countries to legalize certain or all forms of abortion.^[91] In 1935 Nazi Germany, a law was passed permitting abortions for those deemed "hereditarily ill," while women considered of German stock were specifically prohibited from having abortions.^{[92][93][94][95]}

However, the procedure remained relatively rare until the late 1960s.^{[citation needed]} In late 1960s and early 1970s, due to a confluence of factors, the number of abortions increased worldwide. In West Germany, the number of reported abortions increased from 2,800 in 1968 to 87,702 in 1980.^[96] In the United States, some sources show an even greater increase, from 4,600 in 1968 to 1.5 million in 1980.^{[citation needed]} However, the fact that abortion remained illegal in many states prior to the landmark 1973 decision of Roe v. Wade may have affected the number of reported abortions prior to 1973.

In the history of abortion, induced abortion has been the source of considerable debate, controversy, and activism. An individual's position on the complex ethical, moral, philosophical, biological, and legal issues is often related to his or her value system. The main positions are one that argues in favor of access to abortion and one argues against access to abortion. Opinions of abortion may be described as being a combination of beliefs on its morality, and beliefs on the responsibility, ethical scope, and proper extent of governmental authorities in public policy. Religious ethics also has an influence upon both personal opinion and the greater debate over abortion (see religion and abortion).

Abortion debates, especially pertaining to abortion laws, are often spearheaded by groups advocating one of these two positions. In the United States, those in favor of greater legal restrictions on, or even complete prohibition of abortion, most often describe themselves as pro-life while those against legal restrictions on abortion describe themselves as pro-choice. Generally, the former position argues that a human fetus is a human being with a right to live making abortion tantamount to murder. The latter position argues that a woman has certain reproductive rights, especially the choice whether or not to carry a pregnancy to term.

In both public and private debate, arguments presented in favor of or against abortion access focus on either the moral permissibility of an induced abortion, or justification of laws permitting or restricting abortion.

Debate also focuses on whether the pregnant woman should have to notify and/or have the consent of others in distinct cases: for a minor, her parents; for a legally married or common-law wife, her husband; or, for any case, the biological father. In a 2003 Gallup poll in the United States, 79% of male and 67% of female respondents were in favor of legalized mandatory spousal notification; overall support was 72% with 26% opposed.^[97]

The earliest secular laws regulating abortion reflect a concern with class and caste purity and preservation of male prerogatives. Abortion as such was not outlawed, but wives who procured abortions without their husband's knowledge could be severely punished, as could slaves who induced abortions in highborn women. Generally, abortions prior to quickening were treated as minor crimes, if at all.

The new philosophies of the Axial Age, which began discussing the nature and value of human life in abstract terms, had little impact on existing abortion laws. Even the Christian ecclesiastical courts of the Middle Ages imposed penance and no corporal punishment for abortion, and retained the pre- and post-quickening distinction from the ancient philosophies.

With the sole exception of Bracton,^[98] commentators on the English common law formulated the born alive rule, excluding feticide from homicide law, using language dating back to the Leges Henrici Primi.^[99]

In the late 18th century, it was claimed that scientific knowledge of human development beginning at fertilization justified stricter abortion laws.^[100] This was part of a larger struggle on the part of the medical profession to distinguish scientifically based medicine from "traditional" medicine, including midwifery and herbalism.^[101]

Both pre- and post-quickening abortions were criminalized by Lord Ellenborough's Act in 1803.^[102] In 1861, the Parliament of the United Kingdom passed the Offences against the Person Act 1861, which continued to outlaw abortion and served as a model for similar prohibitions in some other nations.^[103]

The Soviet Union, with legislation in 1920, and Iceland, with legislation in 1935, were two of the first countries to generally allow abortion. The second half of the 20th century saw the liberalization of abortion laws in other countries as well. The Abortion Act 1967 allowed abortion for limited reasons in the United Kingdom (except Northern Ireland). In the 1973 case, Roe v. Wade, the United States Supreme Court struck down state laws banning abortion, ruling that such laws violated an implied right to privacy in the United States Constitution. The Supreme Court of Canada, similarly, in the case of R. v. Morgentaler, discarded its criminal code regarding abortion in 1988, after ruling that such restrictions violated the security of person guaranteed to women under the Canadian Charter of Rights and Freedoms.^[104] Canada later struck down provincial regulations of abortion in the case of R. v. Morgentaler (1993). By contrast, abortion in Ireland was affected by the addition of an amendment to the Irish Constitution in 1983 by popular referendum, recognizing "the right to life of the unborn".

Current laws pertaining to abortion are diverse. Religious, moral, and cultural sensibilities continue to influence abortion laws throughout the world. The right to life, the right to liberty, the right to security of person, and the right to reproductive health are major issues of human rights that are sometimes used as justification for the existence or absence of laws controlling abortion. Many countries in which abortion is legal require that certain criteria be met in order for an abortion to be obtained, often, but not always, using a trimester-based system to regulate the window of legality:

• In the United States, some states impose a 24-hour waiting period before the procedure, prescribe the distribution of information on fetal development, or require that parents be contacted if their minor daughter requests an abortion.^[105]
• In the United Kingdom, as in some other countries, two doctors must first certify that an abortion is medically or socially necessary before it can be performed.^{[citation needed]}

Other countries, in which abortion is normally illegal, will allow one to be performed in the case of rape, incest, or danger to the pregnant woman's life or health.

• A few nations ban abortion entirely: Chile, El Salvador, Malta, and Nicaragua. In Nicaragua, rises in maternal death directly and indirectly due to pregnancy have been noted.^[106][107] However, in 2006, the Chilean government began the free distribution of emergency contraception.^[108][109]
• In Bangladesh, abortion is illegal, but the government has long supported a network of "menstrual regulation clinics", where menstrual extraction (manual vacuum aspiration) can be performed as menstrual hygiene.^[110]

In places where abortion is illegal or carries heavy social stigma, pregnant women may engage in medical tourism and travel to countries where they can terminate their pregnancies. Women without the means to travel can resort to providers of illegal abortions or try to do it themselves. ^[111]

In the US, about 8% of abortions are performed on women who travel from another state.^[112] However, that is driven at least partly by differing limits on abortion according to gestational age or the scarcity of doctors trained and willing to do later abortions.^[113] Thousands of women every year travel from Northern Ireland, the Republic of Ireland, Poland, and other countries where elective abortion is illegal, to Britain or other countries with less restrictive laws, in order to obtain abortions.^[114][115]

In the United States and some Canadian localities, it is a legal offense to obstruct access to a clinic or doctor's office where abortions are performed. "Buffer zones," regulating how close protesters can come to the clinic or to the patients, may exist.

Mandatory spousal notification was ruled unconstitutional in the United States by the Supreme Court in Planned Parenthood v. Casey.^[116][117]

Other issues in abortion law may include the requirement that a minor obtain the consent of one or both parents to the abortion or that she notify one or both parents, the requirement that a woman obtain the consent of her husband to the abortion and the question of whether the fetus's father can prohibit an abortion, the requirement that abortion providers inform patients of the supposed health risks of the procedure, and wrongful birth laws.

Sonography and amniocentesis allow parents to determine sex before childbirth. The development of this technology has led to sex-selective abortion, or the termination of a fetus based on sex. The selective termination of a female fetus is most common.

It is suggested that sex-selective abortion might be partially responsible for the noticeable disparities between the birth rates of male and female children in some places. The preference for male children is reported in many areas of Asia, and abortion used to limit female births has been reported in China, Taiwan, South Korea, and India.^[118]

In India, the economic role of men, the costs associated with dowries, and a common Indian tradition which dictates that funeral rites must be performed by a male relative have led to a cultural preference for sons.^[119] The widespread availability of diagnostic testing, during the 1970s and '80s, led to advertisements for services which read, "Invest 500 rupees [for a sex test] now, save 50,000 rupees [for a dowry] later."^[120] In 1991, the male-to-female sex ratio in India was skewed from its biological norm of 105 to 100, to an average of 108 to 100.^[121] Researchers have asserted that between 1985 and 2005 as many as 10 million female fetuses may have been selectively aborted.^[122] The Indian government passed an official ban of pre-natal sex screening in 1994 and moved to pass a complete ban of sex-selective abortion in 2002.^[123]

In the People's Republic of China, there is also a historic son preference. The implementation of the one-child policy in 1979, in response to population concerns, led to an increased disparity in the sex ratio as parents attempted to circumvent the law through sex-selective abortion or the abandonment of unwanted daughters.^[124] Sex-selective abortion might be an influence on the shift from the baseline male-to-female birth rate to an elevated national rate of 117:100 reported in 2002. The trend was more pronounced in rural regions: as high as 130:100 in Guangdong and 135:100 in Hainan.^[125] A ban upon the practice of sex-selective abortion was enacted in 2003.^[126]

Doctors and facilities that provide abortion have been subjected to various forms of violence, including murder, attempted murder, kidnapping, stalking, assault, arson, and bombing. Anti-abortion violence has been classified by governmental and scholarly sources as terrorism.^[127][128] Only a small fraction of those opposed to abortion commit violence, often rationalizing their actions as justifiable homicide or defense of others, committed in order to protect the lives of fetuses.

In the United States, four abortion providers—Drs. David Gunn, John Britton, Barnett Slepian, and George Tiller—have been assassinated. Attempted assassinations have also taken place in the United States and Canada, and other personnel at abortion clinics, including receptionists and security guards, have been killed in the United States and Australia. Hundreds of bombings, arsons, acid attacks, invasions, and incidents of vandalism against abortion providers have also occurred.^[129][130] Notable perpetrators of anti-abortion violence include Eric Robert Rudolph, Scott Roeder, Shelley Shannon, and Paul Jennings Hill, the first person to be executed in the United States for murdering an abortion provider.^[131]

Art serves to humanize the abortion issue and illustrates the myriad of decisions and consequences it has. One of the earliest known representations of abortion is in a bas relief at Angkor Wat (c. 1150). Pro-life activist Børre Knudsen was linked to a 1994 art theft as part of a pro-life drive in Norway surrounding the 1994 Winter Olympics.^[132] A Swiss gallery removed a piece from a Chinese art collection in 2005, that had the head of a fetus attached to the body of a bird.^[133] In 2008, a Yale student proposed using aborted excretions and the induced abortion itself as a performance art project.^[134]

The Cider House Rules (novel 1985, film 1999) follows the story of Dr. Larch an orphanage director who is a reluctant abortionist after seeing the consequences of back-alley abortions, and his orphan medical assistant Homer who is against abortion.^[135] Feminist novels such as Braided Lives (1997) by Marge Piercy emphasize the struggles women had in dealing with unsafe abortion in various circumstances prior to legalization.^[136] Doctor Susan Wicklund wrote This Common Secret (2007) about how a personal traumatic abortion experience hardened her resolve to provide compassionate care to women who decide to have an abortion. As Wicklund crisscrosses the West to provide abortion services to remote clinics, she tells the stories of women she's treated and the sacrifices she and her loved ones made.^[137] In 2009, Irene Vilar revealed her past abuse and addiction to abortion in Impossible Motherhood, where she aborted 15 pregnancies in 17 years. According to Vilar it was the result of a dark psychological cycle of power, rebellion and societal expectations.^[138] In Annie Finch's mythic epic poem and opera libretto Among the Goddesses (2010), the heroine's abortion is contextualized spiritually by the goddesses Demeter, Kali, and Inanna. ^[139]

Various options and realities of abortion have been dramatized in film. In Riding in Cars with Boys (2001) an underage woman carries her pregnancy to term as abortion is not an affordable option, moves in with the father and finds herself involved with drugs, has no opportunities, and questioning if she loves her child. While in Juno (2007) a 16-year-old initially goes to have an abortion but decides to bear the child and allow a wealthy couple to adopt it. Other films Dirty Dancing (1987) and If These Walls Could Talk (1996) explore the availability, affordability and dangers of illegal abortions. The emotional impact of dealing with an unwanted pregnancy alone is the focus of Things You Can Tell Just By Looking At Her (2000) and Circle of Friends (1995). As a marriage was in trouble in the The Godfather Part II (1974) Kay knew the relationship was over when she aborted "a son" in secret.^[140] On the abortion debate, an irresponsible drug addict is used as a pawn in a power struggle between pro-choice and pro-life groups in Citizen Ruth (1996).^[141]

Spontaneous abortion occurs in various animals. For example, in sheep, it may be caused by crowding through doors, or being chased by dogs.^[142] In cows, abortion may be caused by contagious disease, such as Brucellosis or Campylobacter, but can often be controlled by vaccination.^[143]

Abortion may also be induced in animals, in the context of animal husbandry. For example, abortion may be induced in mares that have been mated improperly, or that have been purchased by owners who did not realize the mares were pregnant, or that are pregnant with twin foals.^[144]

Feticide can occur in horses and zebras due to male harassment of pregnant mares or forced copulation,^{[145][146][147]} although the frequency in the wild has been questioned.^[148] Male Gray langur monkeys may attack females following male takeover, causing miscarriage.^[149]

• Template:Dmoz
• Abortion Policies: A Global Review
• MedlinePlus Medical Encyclopedia: Abortion
• The Guttmacher Institute, the official website of The Guttmacher Institute, a sexual and reproductive health research organization.

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