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Medical abortion: Taking first tablet at home after 12 weeks of pregnancy is safe, study reports

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• Gareth Iacobucci

Women who began the process of medical abortion at home after 12 weeks of pregnancy were more likely to complete their care in hospital without an overnight stay than those who started in hospital, a study published in the Lancet has reported. 1

The randomised controlled trial of 435 women found that 71% (156 of 220) of patients who took the first dose of misoprostol at home spent fewer than nine hours in hospital (the cut off for day case procedures) compared with 46% (99 of 215) of patients who took the first dose of misoprostol at hospital (difference 24.9%; 95% confidence interval 15.4 to 34.3; …

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Managing early stages of abortion care at home after 12 weeks is safe and reduces time spent in hospital, study finds

A randomized controlled trial of 435 women having a medical abortion after 12 weeks of pregnancy found 71% of patients who took the first dose of misoprostol at home spent fewer than 9 hours in hospital, compared to 46% of patients who took the first dose of misoprostol at hospital. There was no difference in safety outcomes observed between the two groups. However, of the women who took the first dose of misoprostol at home, 1% (2/220) completed the abortion before admission to hospital.

In a survey after the abortion, more participants in the home group (78%) said they preferred their allocated treatment compared with the hospital group (49%). The authors say the option of taking the first dose of misoprostol at home would give women having abortions after 12 weeks greater autonomy and reduce the need for overnight hospital stays.

Pregnant people who took the first dose of misoprostol (a pill given as part of the procedure for medical abortions) at home had a 71% chance of completing their care in hospital within 9 hours with no overnight stay when having an abortion after 12 weeks of pregnancy, compared to 46% of those who took the first dose of misoprostol at hospital, finds a randomized controlled trial published in The Lancet .

A medical abortion (also known as abortion with pills) involves taking two types of pills to end a pregnancy: mifepristone, which blocks the hormone progesterone therefore causing the lining of the uterus to break down, and misoprostol, which makes the womb contract. For abortions after 12 weeks of pregnancy, mifepristone is often given at a clinic to which the patient returns one to two days later to receive a first dose of misoprostol followed by additional doses of misoprostol every few hours until the abortion is complete.

In this trial, all patients received the first dose of mifepristone in the clinic as usual, but some patients then took the first dose of misoprostol at home. Previous studies indicate that most medical abortions after 12 weeks of pregnancy are completed within eight to 12 hours after the first misoprostol dose and require an average of two to three misoprostol doses, with some patients needing to stay overnight in hospital.

"Currently, most abortions after 12 weeks of pregnancy take place in hospitals and may require an overnight stay, which some women find stressful and isolating. Our trial results show that taking the first dose of misoprostol at home decreases the average time women spent in hospital, enabling them to leave the hospital within nine hours after admission and without an overnight stay.

"Offering the choice to take the first dose of misoprostol at home provides a safe and effective alternative to taking all misoprostol doses at hospital and enables women to self-manage some of the process, potentially leading to feelings of autonomy during a time where women can feel extremely vulnerable," says author Dr. Johanna Rydelius, Sahlgrenska Academy, University of Gothenburg, Sweden.

She adds, "Our study found 1% of the women who took misoprostol at home completed the abortion before attending hospital for the next dose. Previous studies suggest a 1% complete abortion rate within two hours after the misoprostol first dose, and women who took misoprostol at home were made aware of this risk when choosing to take part in the trial and provided with a number to call if they had any concerns. It's extremely important that women who are given the choice to take the first dose of misoprostol at home are clearly informed about the very small risk of the abortion occurring before attending the hospital."

The study took place at six hospitals in Sweden between January 2019 and December 2022. All participants were given mifepristone oral pills at an outpatient clinic and provided with a time to return. Women between 12 to 22 weeks pregnant planning to undergo a medical abortion and who chose to take part in the trial were randomized to either receive their first dose of misoprostol at home or at the hospital.

Women in the home treatment group administered the first dose of misoprostol vaginally at home and returned to hospital two hours later for the remaining treatment. Women in the hospital group self-administered the first dose of misoprostol upon arrival at the hospital. All participants then took repeated doses of misoprostol under the tongue every three hours until the abortion occurred.

Of the patients in the home treatment group, 71% (156/220) spent fewer than nine hours at hospital, compared to 46% (99/215) of those in the hospital treatment group. There was no difference in the average pain score, types and number of side effects, or rates of admittance to hospital earlier than planned between the two groups. Two patients in the home treatment group (1%) had the abortion on the way to the hospital, between one to two hours after taking the first dose of misoprostol.

The patients were asked to complete a follow-up survey two to four weeks after the abortion. Five out of six participants in both trial arms (171/200 of those in the home treatment group and 152/188 of those in the hospital treatment group) said they were very satisfied with the care they received.

When asked "if you were to choose, where would you prefer to take the first dose of misoprostol?" 78% of women in the home group and 51% of women in the hospital group said they'd prefer to take the first dose of misoprostol at home.

The authors acknowledge some limitations of the study, including that the researchers were advised by the Data and Safety Monitoring Board to end the trial early due to a lower-than-expected enrollment and slow progress towards the trial's target of 784 participants. However, trial site feedback suggests the lower-than-expected enrollment rate was not due to reluctance to take misoprostol at home, but rather due to patients feeling overwhelmed by the overall situation.

"Every patient who seeks abortion care must navigate a unique set of personal and medical circumstances. The choice of self-administering the first dose of misoprostol at home may provide some patients with a sense of autonomy and comfort during what can be a very overwhelming time in their lives.

"In addition, providing the option of the first dose of misoprostol at home would enable more abortion clinics with no overnight facilities to provide medical abortions for women who are over 12 weeks pregnant, something particularly important for locations where access to abortion care is limited," says author Prof Kristina Gemzell Danielsson, The Karolinska Institutet, Sweden.

Writing in a linked Comment, Heidi Moseson and Caitlin Gerdts, Ibis Reproductive Health, U.S., who were not involved in the study, said, "Increasing access to abortion later in pregnancy is a crucial component of the struggle for reproductive autonomy; it requires innovation, and evidence, and a willingness to listen to the needs and experiences of people having abortions. Judging from the overwhelming preference for at-home administration of misoprostol in the PRIMA Trial, moving towards a less clinically supervised model of medical abortion care later in pregnancy is an important first step."

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• Case report
• Open access
• Published: 14 June 2019

“Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua

• Samantha M. Luffy 1 ,
• Dabney P. Evans   ORCID: orcid.org/0000-0002-2201-5655 1 &
• Roger W. Rochat 1  

BMC Women's Health volume  19 , Article number:  76 ( 2019 ) Cite this article

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Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014.

Case presentation

This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience.

Conclusions

Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion.

Peer Review reports

Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, however, the international community, States, and advocates have made great strides to advance our understanding of sexual and reproductive rights and how they can be protected at the national and international levels. The 1994 Cairo Declaration began this process by including sexual health under the umbrella of reproductive health and recognized the impact of violence on an individual’s sexual and reproductive health (SRH) decision-making. [ 1 ] One year later, the 1995 Beijing Platform for Action specifically addressed the issues of unintended pregnancy and abortion by emphasizing that improved family planning services should be the main method by which unintended pregnancies and unsafe abortions are prevented. [ 2 ]

A recent World Health Organization (WHO) report on the relationships between sexual health, human rights, and State’s laws sets the foundation for our contemporary understanding of these issues. The 2015 report describes sexual health as, “a state of physical, emotional, mental and social well-being in relation to sexuality.” [ 3 ] That state includes control over one’s fertility via access to health services such as abortion; it also includes the right to enjoy sexual experiences free from coercion, discrimination, and violence. [ 3 ] Whether experienced alone or in combination, rape, unintended pregnancy, and abortion are important SRH issues on which public health can and should intervene.

In the public health field, case studies provide a useful lens through which to examine individual women’s sexual and reproductive health experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; an in-depth analysis of these personal experiences can identify contextual risk factors and missed opportunities for public health rights-based  intervention. This type of analysis is especially cogent when legal policies and social factors, such as gender inequality, may influence one’s SRH decision-making process. On an individual level, bearing witness to women’s stories through in-depth interviews helps document their lived experience; surveying these experiences within the context of laws related to SRH provides important evidence for the impact of such policies on women’s well-being.

We present the case of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her complex experience of violence, unintended pregnancy, and unsafe abortion represent a series of contextual factors and missed opportunities for public health and human rights intervention. Ana Maria’s story, told through the use of a pseudonym, takes place in a city located in North Central Nicaragua – a country that presents unique challenges related to its citizens’ fulfillment of their sexual and reproductive health and rights.

Violence against women in Nicaragua

Along with 189 States, Nicaragua is a party to the United Nations (UN) Convention on the Elimination of All Forms of Discrimination against Women, which includes State obligations to protect and promote the health and well-being of Nicaraguan women. [ 4 ] As defined by human rights documents, the right to health includes access to health care services, as well as provisions for the underlying social determinants of health, such as personal experiences of structural violence. [ 5 ]

In the Nicaraguan context, political and sociocultural institutions support unequal power relations between genders. [ 6 ] Machismo is one such form of structural violence that perpetuates gender inequality and has been identified as a barrier to SRH promotion in Nicaragua. [ 7 , 8 ] The term ‘ machismo ’ is most commonly used to describe male behaviors that are sexist, hyper masculine, chauvinistic, or violent towards women. [ 9 ] These behaviors often legitimize the patriarchy, reinforce traditional gender roles, and are used to limit or control the actions of women, who are often perceived as inferior. [ 10 ]

The vast majority (89.7%) of Nicaraguan women have experienced some form of gender-based violence  during their lifetime, which poses a serious public health problem. The latest population-based Demographic and Health Survey showed that at least 50% of Nicaraguan women surveyed had experienced either verbal/psychological, physical, or sexual violenceduring their lifetime. An additional 29.3% of women reported having experienced both physical and sexual violence at least once, while another 10.4% reported having experienced all three types of violence. [ 11 ]

In 2012, Nicaragua joined a host of other Central and South American countries that have implemented laws to eliminate all forms of violence against women VAW, including rape and femicide. [ 12 ] Nicaragua’s federal law against VAW, Law 779, intends to eradicate such violence in both public and private spheres. [ 13 ] On paper, Law 779 guarantees women freedom from violence and discrimination, but it is unclear if the law is being adequately enforced; it has been reported that some women believe VAW has increased since the law’s implementation. [ 14 ]

Before Law 779, violent acts like rape, particularly of young women ages 15–24, were endemic in Nicaragua. Approximately two-thirds of rapes reported in Nicaragua between 1998 and 2008 were committed against girls under 17 years of age; most of these acts were committed by a known acquaintance. [ 15 ] Due to a lack of reporting and to culturally propagated stigma regarding rape, no reliable data suggest that Law 779 has been effective in reducing the incidence of rape in Nicaragua. For women who wish to terminate a pregnancy that resulted from rape, access to abortion services is vital, yet completely illegal. [ 16 ] In contrast, technical guidance from the WHO recommends that health systems include access to safe abortion services for women who experience unintended pregnancy or become pregnant as a result of rape. [ 17 ]

Family planning and unintended pregnancy in Nicaragua

Like violence, unintended pregnancies -- not only those that result from rape -- pose a widespread public health problem in Nicaragua. National data suggest that 65% of pregnancies among women ages 15–29 were unintended. [ 11 ] Oftentimes, unintended pregnancy results from a complex combination of social determinants of health including: low socioeconomic status (SES), low education level, lack of access to adequate reproductive health care, and restrictive reproductive rights laws. [ 18 , 19 , 20 ] Nicaraguan women of low SES with limited access to family planning services are at an increased risk of depression, violence, and unemployment due to an unintended pregnancy. [ 19 , 20 ]

The UN Committee on the Elimination of all forms of Discrimination Against Women (CEDAW) has expressed concern regarding the lack of comprehensive sexual education programs, as well as inadequate family planning services, and high rates of unintended pregnancy throughout Nicaragua. [ 21 ] Due to a lack of sexual education, Nicaraguan adolescents, if they use contraceptives like male condoms or oral contraceptive pills, often do so inconsistently or incorrectly. [ 22 ]

Deeply rooted cultural stigma surrounding unmarried women’s sexual behavior contributes to the harsh criticism of young women in Nicaragua that use a method of family planning or engage in sexual relationships outside of a committed union. [ 18 , 22 ] Also, young women who are not in a formal union may experience unplanned sex (consensual or nonconsensual) and are unlikely to be using contraception, which further increases the risk of unintended pregnancy. [ 22 ] These social and cultural factors, in conjunction with restrictive reproductive rights laws, may contribute to a high incidence of unintended pregnancy among young Nicaraguan women.

The total ban on abortion in Nicaragua

Compounding the economic, social, and emotional burden of unintended pregnancy on women’s lives is the current prohibition of abortion in Nicaragua. In 2006, the National Assembly unanimously passed a law to criminalize abortion, which had been legal in Nicaragua since the late 1800s. [ 20 ] Researchers often refer to this law as the “total ban” on abortion. [ 20 , 23 ] The total ban prohibits the termination of a pregnancy in all cases, including incest, rape, fetal anomaly, and danger to the life of the woman. Laws that prohibit medical procedures are, by definition, barriers to access; equitable access to safe medical services is a critical element of the right to health. [ 3 , 5 ] The UN Committee on Civil and Political Rights (CCPR) has also recognized the discriminatory and harmful nature of criminalizing medical procedures that only women undergo. [ 24 ]

Nicaragua is one of the few countries in the world to completely ban abortion in all circumstances. In States where illegal, abortion does not stop. Instead, women are forced to obtain abortions from unskilled providers in conditions that are often unsafe and unhygienic. [ 25 ] Unsafe abortions are among the main preventable causes of maternal morbidity and mortality worldwide and can be avoided through decriminalization of such services. [ 26 ]

The Nicaraguan ban includes serious legal penalties for women who obtain illegal abortions, as well as for the medical professionals who perform them, which can have profound negative effects on women’s health. [ 20 , 23 ] Women who need or want an abortion face not only the health risks that accompany an unsafe procedure, but additional criminal penalties. The total ban on abortion violates the human rights of both health care providers and women nationwide, as well as the confidentiality inherent in the patient-provider relationship. [ 20 ] It also results in a ‘chilling effect’ where health care providers are unwilling to provide both abortion and postabortion care (PAC) services for fear of prosecution. [ 20 ]

In response to the negative impacts of the total ban on maternal morbidity and mortality in Nicaragua, as well as detrimental effects on women’s physical, mental, and emotional health, CEDAW has recommended that the Nicaraguan government review the total ban and remove the punitive measures imposed on women who have abortions. [ 21 ] While the Nicaraguan government may not view abortion as a human right per se, women should not face morbidity or mortality as a result of illegal or unsafe abortion. [ 27 ]

Criminalizing abortion also increases stigma around this issue and significantly reduces people’s willingness to speak openly about abortion and related SRH services. Qualitative research conducted in Nicaragua suggests that women who have had unsafe abortions rarely discuss their experiences openly due to the illegal and highly stigmatized nature of such procedures. [ 18 ] Therefore, the overall aim of the study was to better understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua from June to July 2014. This private method of data collection allowed for the detailed exploration of each young woman’s personal experience with an unintended pregnancy, including the decision-making process she went through regarding how to respond to the pregnancy. Given the personal nature of this experience – including the criminalization and stigmatization of women who obtain abortions – IDIs allowed the participants to share intimate details and information that would be inappropriate or dangerous to share in a group setting. One case, presented here, emerged as salient for understanding the intersections of violence, unintended pregnancy, and abortion – and the missed opportunities for rights-based public health intervention.

Emory University’s Institutional Review Board ruled the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. Nevertheless, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. The first author reviewed the informed consent form in Spanish with each participant and then acquired each participant’s signature and verbal informed consent before the IDIs were conducted. The investigators developed a semi-structured interview guide with open-ended questions and piloted the guide twice to improve the cultural appropriateness of the script (Additional file 1 ). The investigators also collaborated with local partners to design and implement the research according to local cultural and social norms. Due to the contentious topics discussed in this study, these collaborators prefer to not be mentioned by name. Interviews were conducted in Spanish in a private location and audio taped to protect the participants’ privacy. Recordings were transcribed verbatim and transcripts were coded and analyzed using MAXQDA11 software (VERBI GmbH, Berlin, Germany).

Initially, participants were recruited for interviews through purposive sampling of individuals who had disclosed a personal experience with unintended pregnancy during focus group discussions (FGDs) conducted in a larger parent study. At the end of each interview, participants were asked to refer other young women they knew who may have experienced an unintended pregnancy to participate in an interview. This form of respondent-driven sampling created a network of participants with a wide variety of experiences with unintended pregnancy. Of the ten interviewees, two had experienced unintended pregnancy as a result of rape, though both used the phrase “ sexo no consensual ” or “nonconsensual sex” in lieu of “ violación, ” the Spanish word for rape. One of these women shared her personal experience receiving an unsafe abortion to terminate an unintended pregnancy that had resulted from rape. Her story, shared under the use of the pseudonym Ana Maria, is presented here in order to:

Illustrate the harmful impact of restrictive abortion laws on the health and well-being of women – especially those who do not have access to abortion in the case of rape; and

Exemplify the nexus of contextual risk factors that impact women’s SRH decision-making, such as conservative social norms and restrictive legal policies.

Through thorough analysis, we examine the impact of these contextual factors that impacted Ana Maria’s experience.

When she was 19, Ana Maria was raped by her godfather, a close friend of her family.

In an in-depth interview, Ana Maria described enduring incessant verbal harassment from her godfather – her elder brother’s best friend – in the months before the assault. He constantly called and texted her cell phone in order to interrogate her about platonic relationships with other men in town and to convince her to spend time alone with him. Even though he was married with children and she repeatedly dismissed his advances, he continued to engage in this form of psychological violence with his goddaughter. Ana Maria described eventually “giving in” and meeting him – not knowing that this encounter would result in her forcible rape.

The disclosure of Ana Maria’s rape during her interview was spontaneous and unexpected. Ana Maria was unwilling to disclose explicit details of the sexual assault. Instead, she stated multiple times that the sexual contact was nonconsensual and she did not want to have sex with him. When asked if she told anyone about this experience, she said no because she did not want others to judge her for what had happened.

Approximately a month of scared silence after she was raped, Ana Maria noticed that her period had not come. Nervous, she bought a pregnancy test from a local pharmacy. To her dismay, the test was positive. In order to confirm the pregnancy, she traveled alone to the nearby health center in her town to obtain a blood test. Again, the test was positive. She had never been pregnant before and she was terrified. In the midst of her fear, she shared the results with her rapist, her godfather.

His response: get an abortion. He did not want to lose his wife and children if they found out about the pregnancy.

Other than their illegal nature, Ana Maria knew nothing about abortions – where to get one, how it was done, what it felt like. She asked her neighbors to explain it to her. They said “it was worse than having a baby and [experiencing] childbirth.”

Though Ana Maria did not want to get the abortion, her godfather continued to pressure her to get the procedure saying, “Regardless, you must get the abortion… you are not the first woman to have ever had one.” Similar to the emotional violence before he raped her, he called and texted Ana Maria every day telling her to, “do it as fast as you can.” He forbade her from telling anyone about the pregnancy and Ana Maria didn’t feel like she had anyone to confide in about the situation. She worried about people judging her for getting pregnant outside of a committed relationship – even though she was raped. Ana Maria described this difficult time:

“When he started to pressure me [to get the abortion], I felt alone. I did not have enough trust in anyone to tell them [what had happened] because… if I had had enough trust in someone, I know that they would not have let me do it. If I had been given advice, they would have said, ‘No, do not do it,’ but I did not have anyone and I felt so depressed. What made it worse, I couldn’t sleep; I could not sleep [because I was] thinking of everything he had told me. At night, I would remember how it all started and I do not know what he did to find that money, but he gave me the money to get the abortion.”

Her godfather gave her 3000 Córdobas (approximately USD112 at the time) and put her on a public bus, alone. He had arranged for her to receive the abortion from an older woman that practiced “natural medicine” in a nearby city. When Ana Maria arrived at the woman’s home, she was instructed to remove her pants and underwear and lie on a bed. Ana Maria did not receive any medication before the woman inserted a “device like the one used for a Papanicolau… and then another device like an iron rod” into her vagina.

After describing these devices, Ana Maria made a jerking motion back and forth with her arm to imitate the movement the woman used to perform the abortion.

Once it was over, the woman gave Ana Maria an injection of an unknown substance and told her that she would pass a few blood clots over the next few days. That night, however, Ana Maria’s condition worsened; she became feverish, felt disoriented, and began to pass dark, fetid clots of blood. She described the pain she experienced throughout the ordeal:

“I felt so much pain when they took her out of me. I felt pain when the blood was leaving my body and when I had the fever. I felt a terrible pain that only I suffered. I am [a] different [person] now because of those pains.”

Ana Maria was too afraid to tell her family about the assault or the abortion because she was uncertain how they would react. She was even more terrified of the potential legal repercussions that she could face for violating the total ban on abortion. Within a few days of the abortion, though, Ana Maria’s brother heard rumors of his sister’s situation from neighbors “in the street” and confronted her about what had happened. At first, Ana Maria denied that she had had an abortion, but her brother continued to ask for the truth. Though she was nervous, Ana Maria eventually told her brother everything that had happened – from her godfather’s incessant verbal harassment, to the rape, to the unsafe abortion she was forced to get.

Afraid for his sister’s life, Ana Maria’s brother contacted a local nurse who discreetly provides postabortion care (PAC) to women experiencing complications from unsafe abortion and other obstetric emergencies. This nurse is locally known to be one of the few health care providers who provide PAC despite many other providers’ fear of prosecution under the total ban. The nurse recommended that Ana Maria come to the hospital immediately.

Ana Maria spent almost two weeks as an inpatient at the only hospital in the region. She had become septic as a result of what she described as a “perforated uterus,” a common complication from unsafe abortion. [ 28 ] Upon her initial examination, the nurse was afraid that her uterus could not be repaired because the infection was so severe. Fortunately, the medical team administered an ultrasound, removed infected blood clots, and completed uterine surgery to repair the damage from the unsafe abortion. At the request of the gynecologist taking care of her, Ana Maria received the one-month contraceptive hormonal injection before being discharged. At the time of the interview, Ana Maria had not received the next month’s injection because she “didn’t have any use for a man.”

As a result of this experience, Ana Maria reported feelings of depression, isolation, and recurring dreams about a little girl, which she described in this way:

“After I was discharged, I always dreamt of a little girl and that she was mine, standing in my doorway and when I awoke, I couldn’t find her. I looked for her in my bed but she wasn’t there. And this has tormented me because, it’s true: I am the girl that committed this error, but the little girl was not at fault. He pressured me so strongly to get the abortion, so I did.”

Ana Maria had the same recurring dream every night for more than two weeks and she continued to feel depressed weeks after leaving the hospital. One of the sources of her depression was the isolation she felt because there was no one with whom she could share this experience.

According to Ana Maria, she longs to have other people to talk to about her experience – particularly those who may have had similar experiences. She also expressed a desire to pursue a law degree so that she can have a career in local government.

Discussion and conclusions

Ana Maria’s case provides insight into the contextual factors effecting her ability to realize her sexual and reproductive health and rights in Nicaragua where restrictive legal policies and conservative cultural norms around sexuality abound. These contextual risk factors include social norms related to sexual health, laws targeting VAW, and the criminalization of abortion.

Social norms related to sexual health

The fundamental relationship between structural inequality and sexual and reproductive rights has been duly noted; gender inequality, in particular, must be addressed in order to fulfill sexual rights for women. [ 29 ] As in many cases in Nicaragua, the fact that Ana Maria’s first sexual experience was nonconsensual and was initiated by an older male and trusted family friend highlights the uneven power relations between men and women in Nicaraguan culture, which propagate high instances of VAW and sexual assault. In a patriarchal society where machismo and gender inequality run rampant, women’s sexuality is further constrained by the stigmatization of sexual health and a culture of violence that limits women’s autonomy. The compound stigma surrounding sexual health in general, and rape in particular, negatively impacted Ana Maria’s knowledge and ability to access mental health and SRH services, including emergency contraception and post-rape care, which may have assisted her immediately following her assault. Before her brother intervened, Ana Maria’s fear of judgment and legal repercussions also prevented her from seeking PAC, which was necessary to save her life.

Comprehensive sexual education is a primary way to challenge these social norms and widespread stigma surrounding sexuality and SRH services, such as contraception and PAC, at the population level. Such education might have mitigated Ana Maria’s experience of unintended pregnancy through the provision of advance knowledge of emergency contraception and medical options in the event of pregnancy. CEDAW has recognized this missed opportunity for public health intervention in Nicaragua, and recommends sexual education as a means of addressing stigma related to sexuality, decreasing unintended pregnancy, and increasing the acceptability and use of family planning services throughout the country. [ 21 ] Furthermore, the lack of adolescent-friendly sexual education and SRH services symbolizes a social reluctance to acknowledge the reality that young people have sex. [ 30 ] Such ignorance results in a lack of information on healthy relationships and human reproduction, as well as experiences of unintended pregnancy, early motherhood, and unsafe abortion. Exposure to this type of information may have improved Ana Maria’s ability to protect herself, mitigated the impact of Nicaragua’s pervasive misogyny on her decision making, and lessened the influence of her godfather’s coercion before her experiences of rape and unsafe abortion.

Individual and structural violence against women

Though we do not know explicit details of Ana Maria’s rape, the act of rape is inherently violent. The assault violated her right to enjoy sexual experiences free from coercion and violence. [ 3 ] To further constrain her sexual and reproductive rights, Ana Maria’s experience of rape resulted in an unintended pregnancy and an unsafe abortion that she was pressured into undergoing. Along with physical sequelae as a result of the procedure, she also expressed feelings of depression and isolation, which are common symptoms of post-traumatic stress disorder (PTSD). [ 31 ] These mental health consequences are forms of emotional violence that Ana Maria continued to experience long after the initial insult of physical violence. We can’t distinguish whether her mental health symptoms were a pre-existing condition or a result of the traumatic experience presented here. It is likely, however, that all parts of this experience impacted her mental and physical health. As reported elsewhere, perceived social criticism and a lack of social support are barriers to the fulfillment of sexual and reproductive health among young Nicaraguan women. [ 18 ] These contextual risk factors undoubtedly played a role in Ana Maria’s ability to navigate the circumstances surrounding her assault and its aftermath.

What legal recourse was feasibly available to Ana Maria for the crime of her sexual assault? To our knowledge, Ana Maria did not report the rape to authorities nor did her godfather ever face criminal charges for his actions. Yet Ana Maria’s own fear of prosecution for undergoing the unsafe abortion, as well as shame and fear of being stigmatized by others in her community, strongly influenced her decision not to report the rape -- even though Law 779 contains sanctions specific to those who commit rape.

In the event she had reported the crime, however, it is unclear if Law 779 would have provided justice. There are no data to suggest that Law 779 has led to an increase in the reporting or prosecution of rape at the national level. To the contrary, qualitative work in Nicaragua found a perceived increase in VAW following the passage of the law. [ 14 ] In Nicaragua, the inconsistent or ineffective enforcement of Law 779 is another factor worthy of consideration in cases like Ana Maria’s where individuals do not report such crimes. Documents like the UN Women Model Protocol have recently been released to improve the enforcement of laws like Law 779 in Latin American countries, presenting an opportunity for the effective operationalization of the law in Nicaragua. [ 32 ] If Law 779 is not adequately enforced, women like Ana Maria face the potential for re-victimization through the structural violence of impuity and continued exposure to VAW. To our knowledge, Ana Maria’s perpetrator faced no consequences for his perpetration of harassment, coercion and rape of Ana Maria. Moreover, in countries where abortion is criminalized, such as El Salvador, it is most often women who face criminal sanctions. [ 33 ] Indeed, it was Ana Maria herself who bore the physical and mental burden that resulted from her assault, unintended pregnancy, and unsafe abortion.

The criminalization of abortion

The criminalization of health services is a strategy that governments use to regulate people’s sexuality and sexual activity. [ 34 ] The criminalization of services such as abortion limits women’s ability to make autonomous decisions about their SRH. By definition, laws that restrict access to health services exclude people from receiving the information and services necessary to realize the highest level of SRH possible. [ 5 ] The criminalization of abortion puts the health and well-being of individuals and communities at risk. Beyond the individual level, complications from unsafe abortion often put unnecessary and immeasurable financial burdens on health systems that are already stretched [ 28 ].

Ana Maria did not have a choice when it came to her abortion; the man who raped her coerced her to undergo an unsafe and illegal procedure. The criminalization of abortion in Nicaragua put Ana Maria’s health at risk in two ways: first, it prevented her from obtaining a safe abortion and second, it limited her access to comprehensive sexual health information that could have helped her address her unintended pregnancy, through emergency contraception. After the unsafe abortion procedure, her access to PAC was likely constrained by her own fear of the possible legal repercussions of undergoing an abortion, and was compounded by her inability to trust that a health care provider would maintain patient confidentiality and provide adequate PAC.

In Nicaragua, the total ban on abortion directly contradicts strategic objectives outlined in the Beijing Declaration, which guarantees women’s rights to comprehensive SRH care, including family planning and PAC services. Though providing PAC is not considered illegal under the total ban, many Nicaraguan health care providers refuse to treat women who have had unsafe abortions, which results in a ‘chilling effect’; providers do not want to be accused of being complicit in providing abortions so they refuse to provide PAC services. The ‘chilling effect’ put Ana Maria at risk of morbidity or mortality as a result of the complications that resulted from her unsafe abortion.

Equally troubling is the use of criminal law against individuals like Ana Maria as well as health care professionals that provide PAC. By requiring health care providers to report to the police women who have had abortions, the total ban violates the privacy inherent in the patient-provider relationship. Health care providers are faced with a dual loyalty to both the State’s laws and the confidentiality of their patients, which makes it difficult for providers to fulfill their professional obligations. It also makes health care professionals complicit in a discriminatory practice, one where women face legal sanctions in ways that men do not. The criminalization of abortion in Nicaragua therefore resulted in the fear, stigma, discrimination, and negative health outcomes observed in Ana Maria’s case.

The contextual risk factors that contributed to Ana Maria’s experience of rape, unintended pregnancy, and unsafe abortion are as follows: sexual assault, impunity for violence, gender inequality, restrictive social norms around SRH, stigma resulting from unintended pregnancy and abortion, harmful health impacts from an unsafe abortion, and fear of prosecution due to the total ban. Her first sexual experience was forced and nonconsensual and preceded by months of harassment. Social norms made taboo any discussion of the harassment and sexual violence she experienced at the hands of her godfather; without social support, she was coerced into undergoing an unsafe abortion that resulted in serious mental and physical health sequelae. The illegal nature of abortion in Nicaragua placed Ana Maria at risk for social stigma as well as criminal prosecution. Her subsequent underutilization of family planning services at the time of the interview also placed Ana Maria at risk for an unintended pregnancy in the future; other long-term physical and mental health effects of her experience remain unknown.

The realization of one’s sexual and reproductive rights guarantees autonomous decision-making over one’s fertility and sexual experiences. However, Ana Maria’s story demonstrates that an individual’s SRH decisions are not made in isolation, free from the influence of social norms and national laws. Far too many women experience their sexuality in the context of individual and structural violence, such as VAW and gender inequality. This case highlights the contextual risk factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion; we must continue to critically investigate these factors to ensure that experiences like Ana Maria’s do not become further normalized in Nicaragua. Due to restrictive social norms around SRH, Ana Maria grew up experiencing stigma and taboo associated with sex, sexuality, contraceptive use and abortion. She also lacked access to information regarding SRH, healthy relationships, and how to respond to VAW before she was assaulted. After her assault, she did not have access to post-rape care, emergency contraception, safe abortion services, or mental health services to help her process this trauma. Shame and fear of stigma also prevented Ana Maria from reaching out for social support from family, friends, or the health or legal system. From the legal perspective, inadequate enforcement of VAW laws and the criminalization of abortion further exacerbated the trauma Ana Maria experienced.

It would require active engagement from the Nicaraguan government to address the contextual risk factors identified herein to protect their citizens’ right to health and prevent future experiences like Ana Maria’s. These efforts are particularly relevant given recent political unrest throughout Nicaragua including anti-government protests demanding the president’s resignation. [ 35 ] Nicaraguans’ right to health is at risk not only due to the widespread violence, but also because health care workers are being dismissed and persecuted nationwide. [ 36 ] Sexual and reproductive health researchers, advocates, and the public will continue to monitor Nicaragua’s response to the immediate demands and needs of its citizens -- including the demand that Nicaraguan women like Ana Maria are able to fully exercise their sexual and reproductive rights in times of both conflict and peace.

Availability of data and materials

Deidentified data are available upon reasonable request.

Abbreviations

Committee on Civil and Political Rights

Committee on the Elimination of all forms of Discrimination Against Women

In-Depth Interviews

Postabortion Care

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United Nations

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Acknowledgements

The authors thank the research team and in-country collaborators from Proyecto Paz y Amistad, as well as the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund for financially supporting this project. We are also grateful to Ellen Chiang for her editorial support.

This study was funded with support from the Emory University Global Field Experience (GFE) Fund and the Global Elimination of Maternal Mortality from Abortion (GEMMA) Fund. The funders did not play any direct role in the design of the study; the collection, analysis, and interpretation of data; or the writing of the manuscript.

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All authors contributed extensively to the work presented in this manuscript. SML, DPE, and RWR jointly designed the study. SML performed data collection and data analysis. SML and DPE wrote the manuscript with significant input from RWR. DPE and RWR also provided support and supervision throughout the study. All authors read and approved the final manuscript.

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Emory University’s Institutional Review Board found the study exempt from review because it did not meet the definition of “research” with human subjects as set forth in Emory policies and procedures and federal rules. The authors partnered with Proyecto Paz y Amistad, a local organization to design and implement this study. Proyecto Paz y Amistad deferred to the Emory University IRB’s determination. Nicaragua is notably absent from the US Department of Health and Human Services, International Compilation of Human Research Standards ( https://www.hhs.gov/ohrp/sites/default/files/2018-International-Compilation-of-Human-Research-Standards.pdf ). To our knowledge, there were no existing national level human subjects requirements or exemptions at the time of data collection.

Though the project was exempt from full review by Emory University’s Institutional Review Board, procedural steps were taken to protect the rights of participants and ensure confidentiality throughout data collection, management, and analysis. Verbal informed consent was acquired from all participants before the IDIs were conducted and each participant signed a waiver to participate.

Due to the sensitive nature of this work, individual partners at Proyeto Paz y Amistad have asked not be named publicly as authors on this work, although their partnership was instrumental in the implementation of this study.

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Luffy, S.M., Evans, D.P. & Rochat, R.W. “Regardless, you are not the first woman”: an illustrative case study of contextual risk factors impacting sexual and reproductive health and rights in Nicaragua. BMC Women's Health 19 , 76 (2019). https://doi.org/10.1186/s12905-019-0771-9

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Addressing a Crisis in Abortion Access

A case study in advocacy.

Lynch, Beatrice BS; Mallow, Michaela MPH; Bodde, Katharine E. S. MEd, JD; Castaldi-Micca, Danielle BA; Yanow, Susan MSW; Nádas, Marisa MD, MPH

Albert Einstein College of Medicine, The Bronx, New York; NYC Health + Hospitals; the New York Civil Liberties Union; the National Institute for Reproductive Health, New York, New York; the Later Abortion Initiative, Ibis Reproductive Health, Cambridge, Massachusetts.

Corresponding author: Marisa Nádas, MD, MPH, NYC Health + Hospitals, Jacobi Medical Center, The Bronx, New York; email: [email protected] .

Financial Disclosure The authors did not report any potential conflicts of interest.

The authors acknowledge the continuous efforts of clinicians who provide abortion and their supporters in New York.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at https://links.lww.com/AOG/C746 .

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND) , where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

As restrictions on abortion increase nationwide, it is critical to ensure ongoing access to abortion care throughout pregnancy. People may seek abortions later in pregnancy as a result of financial or legal barriers that delay care or because of changing circumstances, such as the status of their partner, the health of other children, employment, or a new fetal diagnosis. New York State has been a beacon for abortion access since 1970. Yet, after Roe v Wade was decided, New York State abortion law was not in compliance with federal law, and risk-averse medical institutions hesitated to provide later abortions, forcing patients out of state for care. After years of advocacy, the Reproductive Health Act was passed in 2019. Clinicians and advocates collaborated to translate policy into expanded practice at NYC Health + Hospitals, the largest public health care system in the United States. NYC Health + Hospitals conducted an internal review, identified barriers to abortion care, and addressed these through improvements in public and internal communication, strengthening of procedural skills, and a better referral system. As a result, abortion services have become visible and the system’s capacity and gestational age limit have expanded. The example of NYC Health + Hospitals is an instructive model to ensure that abortion care is provided to the most vulnerable patients, including those who need care later in pregnancy. Given the ongoing threat to reproductive rights, this example of expanded access is particularly timely.

Health care systems can ensure that high-quality abortion care is available to all by identifying and removing barriers to services in collaboration with local advocates.

On December 1, 2021, the U.S. Supreme Court heard arguments in a Mississippi case, Dobbs v Jackson . 1 Experts who listened to the arguments and questions from the Justices agree that the current federal protections for abortion established by Roe v Wade (hereinafter “ Roe ”) 2 will be significantly weakened. Access will be particularly restricted for people who need abortions later in pregnancy. 3 In 2021 alone, there have been 108 abortion restrictions enacted in 19 states, the highest total in any year since the 1973 Roe decision, 4 most of which dramatically reduce the upper gestational age for abortion care.

Prohibiting abortion does not remove the need for abortion, but instead exacerbates the economic stratification between who can and cannot access care. 5 People need later abortions for many of the same reasons people need abortions earlier in pregnancy. Studies show that many of those who seek abortion care after 20 weeks of gestation wanted an earlier abortion but faced financial hurdles and legal barriers, including the need to travel for care. 6 For others, new information such as a fetal diagnosis may arise later in pregnancy. 7 And for others still, circumstances change and a wanted pregnancy becomes untenable, for example when a partner leaves or dies, a young child develops a serious illness, or someone in the family loses their job or health insurance. In all of these circumstances, the ability to access later care is essential and yet has constricted over the past decade. 8 It is anticipated that at least 22 states will quickly restrict abortion if the Supreme Court weakens federal protections, either following Texas’ example of banning abortion after an early point in pregnancy or falling in step with a currently enjoined Alabama law banning all abortions. These bans will result in people from these states traveling long distances to access services and will place a burden on clinicians who provide abortion in neighboring states, particularly for later abortion care. 9

It is critical that facilities expand their capacity to provide abortion care to those who will travel for care wherever possible. This article highlights the effort of the public health care system in New York City to expand access to later abortion care.

New York State has historically been considered a beacon for abortion access. New York State permitted abortion in 1970, 3 years before Roe . However, after Roe was decided in 1973, New York State law fell short of constitutional protections with respect to later care. The 1970 state law criminalized care after 24 weeks from the commencement of pregnancy unless a person’s life was at risk. 10 This meant that, even though Roe and subsequent cases protected care later in pregnancy when a pregnant person’s health or life is at risk or a fetus is not viable, risk-averse medical institutions in New York State were reluctant to provide later care in those instances. As a result, pregnant people and their families were forced to travel to distant states such as New Mexico and Colorado to seek later abortion care, far from the support of family, friends, and familiar physicians and at great financial cost, stress, and additional health risks. 11

Despite the legal challenges, over the past decades, advocates and health care professionals in New York City and New York State worked to expand access to care. This included interviewing health care professionals to better understand access points and needs, convening physician roundtables, and strengthening referral networks. Furthermore, attention was given to creating residency training initiatives, 12 seeking legal opinions from the New York State Attorney General to clarify health care professionals’ scope, and creating the first-in-the-nation direct municipal funding to individuals for abortion care. 13 However, access to later care did not improve, as evidenced in an informal New York City physician survey done by advocates in 2015, which revealed that hospitals were not providing care after 24 weeks of gestation, except for specific maternal or fetal indications, and only one ambulatory facility was providing care up to 26 weeks of gestation. Finally, after more than a decade of advocacy, in 2019, New York State passed the Reproductive Health Act. 14

The Reproductive Health Act made three principal changes to New York State’s abortion law. It 1) removed abortion from the criminal code; 2) clarified that advanced practice clinicians such as physician assistants, nurse practitioners, and licensed midwives may provide abortion care within their scope of practice; and 3) created protections that allow for abortion up to 24 weeks from the commencement of pregnancy and throughout pregnancy when the patient’s life or health is at risk or in cases of fetal nonviability. Advocates and clinicians have been working with the New York State Department of Health to create guidance interpreting the Reproductive Health Act’s parameters. The guidance was newly released on May 6, 2022 in the form of a letter from the Commissioner of Health, and it aligns with federal policy (eg, 45 CFR § 46.102) and the “ReVITALize: Gynecology Data Definitions” endorsed by the American College of Obstetricians and Gynecologists and numerous other respected national organizations, placing the “commencement of pregnancy” at implantation of a fertilized egg. 15 This will have a significant effect on clinical practice, placing “24 weeks from the commencement of pregnancy” at 27–28 weeks from the last menstrual period, as opposed to the previous interpretation of 26 weeks from the last menstrual period. Furthermore, this guidance aligns with the Supreme Court’s broad definition of health, 16 which supports individualized decision making between patient and health care team throughout pregnancy.

However, policy and legal changes do not automatically result in changes to medical practice. Determined New York City advocates worked closely with hospital and ambulatory clinicians who provide abortion to mobilize expanded services allowed under the Reproductive Health Act. One example of this successful collaboration is the expansion of abortion care within NYC Health + Hospitals.

CASE STUDY: NYC HEALTH + HOSPITALS

NYC Health + Hospitals is the largest public health care system in the United States, comprised of 11 hospitals (see Box 1), five long-term care facilities, a certified home health agency, and more than 100 community health centers. Its mission is to deliver high-quality comprehensive health care services to all with compassion, dignity, and respect. The health care system provides essential inpatient, outpatient, and home-based services to more than 1 million New Yorkers annually. NYC Health + Hospitals recognizes abortion as an essential and necessary component of comprehensive care, and abortion care is available at all of the hospitals; however, these services have expanded and contracted over the years, largely as a result of staffing changes, loss of institutional knowledge, competing priorities, and the evolving political landscape. Interpretations of New York State’s previous abortion law allowed for abortion care for any indication up to 26 weeks of gestation; yet, by 2019, when the Reproductive Health Act was passed, many staff were unaware of the existing legal parameters that regulated abortion, and few health care professionals had the clinical experience to provide care beyond 24 weeks of gestation, leaving a gap in care beyond that point. Furthermore, each hospital had its own organizational politics related to historical practices, unique patient communities, and current leadership views. However, NYC Health + Hospitals clinician–advocates identified strong supporters of reproductive rights at the systemwide leadership level and, with their endorsement, moved forward on expanding abortion access. Supported by policy advocates, these clinicians assessed existing barriers to care and created a strategic plan around communication, skill-building, and accessibility to expand abortion services to more fully align with the Reproductive Health Act.

NYC Health + Hospitals Acute Care Facilities

•  NYC Health + Hospitals/Jacobi
•  NYC Health + Hospitals/Lincoln
•  NYC Health + Hospitals/North Central Bronx
•  NYC Health + Hospitals/Coney Island
•  NYC Health + Hospitals/Kings County
•  NYC Health + Hospitals/Woodhull
•  NYC Health + Hospitals/Bellevue
•  NYC Health + Hospitals/Harlem
•  NYC Health + Hospitals/Metropolitan
•  NYC Health + Hospitals/Elmhurst
•  NYC Health + Hospitals/Queens

COMMUNICATION

The first critical barrier identified was a lack of knowledge among patients and physicians about the abortion care NYC Health + Hospitals provided. Patients often went elsewhere for abortion care. Owing to communication challenges within the vast health care system, there was also low clinician awareness about abortion services. To improve patient awareness, clinician–advocates worked with the hospital communications team to edit patient materials to provide clear and accessible information about abortion on all websites, social media, and printed materials. To target awareness on the provider side, clinician–advocates provide ongoing presentations to give real-time clarification to clinicians and staff regarding what the Reproductive Health Act means for patient care. Additionally, the systemwide policy on abortion later in pregnancy, which was first written in 2003, was revised by a working group comprised of family planning directors from several hospitals. It was updated to align with the Reproductive Health Act and then approved by hospital legal counsel. It is being circulated to physician and nursing leadership to bring people up to date on current New York State law.

ENHANCING PROCEDURAL SKILLS

NYC Health + Hospitals clinicians also identified gaps in procedural skills that needed to be filled to expand services. Training for later abortion care is limited by the small volume of cases, the narrow specialization of care, and the misinformation and stigma about these services that exists within the medical community. To build clinician skills and participation, two educational projects are underway. The first is the development and implementation of training for physicians on administering feticidal injections. Although inducing fetal death is part of the clinical process for abortions after 24 weeks of gestation in NYC Health + Hospitals, the injection procedure is not a standard part of obstetrics and gynecology residency or family planning fellowship training. Abortion services historically have relied on maternal–fetal medicine specialists to perform this procedure; however, this depends on these specialists being comfortable participating in later abortion care. Training physicians who provide abortion services in the injection procedure will reduce the reliance on outside specialists. The second project focuses on the expansion of surgical skills needed to provide later abortion care. To facilitate training, physicians have been credentialed at multiple sites, allowing practitioners who are the sole providers of later abortion care at their facilities to find support for skill expansion outside their home institutions. Building a cadre of trained clinicians who provide abortion services who are able to administer injections and perform abortions across the pregnancy spectrum will solidify access to later abortion care within the health care system.

ACCESSIBILITY

Abortion is a time-sensitive service that requires appropriate and timely referral. The clinician–advocate team identified several obstacles within the existing referral network. There was no effective communication pathway to support timely referrals, nor a central, identifiable referral pathway for external health care professionals. In addition, because care can be cost-prohibitive for patients, seamless connections to sources of financial support such as abortion funds are a critical part of the referral system, but they were absent. To improve accessibility, NYC Health + Hospitals created a new, nimble referral system that can reduce logistical barriers to care. This referral system was built by a team comprised of physicians, administrators, members of the electronic medical record team, and data analysts. This new system integrates a patient’s geographic preference and gestational age to ensure an appropriate and timely referral. The health care system is also liaising with abortion funds to facilitate financial support for patients who face financial barriers to care.

Additionally, NYC Health + Hospitals created a new position of “Client Navigator,” following a successful model that was created in Massachusetts. 17 The Client Navigator’s primary role will be to accompany patients who need logistic or financial support through their abortion care experience, linking them to necessary resources and ensuring timely access to care. The Client Navigator will also support health care professionals both inside and outside the public health care system who are seeking referrals for their patients. This position has been filled and onboarding is underway.

In the past 6 years, NYC Health + Hospitals has successfully made abortion services more visible to the public by citing them in public speeches, clearly explaining them on their website, and adding information about these services in patient materials. The health care system added two institutions to the list of hospitals providing abortions at more than 20 weeks of gestation and expanded systemwide capacity to provide abortion care up to 26 weeks of gestation. The number of clinicians who provide abortion care has grown with internal training and changes in hiring priorities, resulting in 10 new providers. Further, there is now a strong network of health care professionals across institutions involved in a systemwide Reproductive Health Working Group, which creates policies and cross-institutional support. This working group consists of family planning leaders from several institutions within the system and serves as a team of experts that sets medical standards for the system and liaises with individual institutions. The group has created systemwide guidance for medication abortion, later abortion, and long-acting reversible contraception. Each institution has expanded access in an individualized way depending on local politics. Future systemwide goals include expansion of abortion services to include the option of induction termination and expanding beyond 26 weeks of gestation. With this measurable progress, NYC Health + Hospitals is increasing access to abortion care for people in New York City who need this critical service.

Replication of this model in other hospital systems where allowed by law is urgent. Given the ongoing threat to abortion access stemming from the Supreme Court and state legislatures that continue to pass restrictions aiming to eliminate care, it will take a national movement of health care professionals to create sustainable abortion access. The internal advocacy by NYC Health + Hospitals clinicians, supported by state-based advocates who helped to clear legislative and regulatory barriers, is a clear example of how to provide and expand abortion care for the most vulnerable patients, including those in need of care later in pregnancy. To ensure that the right to abortion does not become a hollow promise, health care systems must evaluate and address barriers, review and expand policies, and build coalitions with local advocates, supportive lawmakers, and abortion funds so that high-quality abortion care is a reality for all our communities.

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• 28 June 2022

The US Supreme Court abortion verdict is a tragedy. This is how research organizations can help

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The Jackson Women’s Health Organization in Mississippi now faces closure. Credit: Rory Doyle/Reuters

The consequences of the US Supreme Court’s 24 June decision to overturn Roe v. Wade , the court’s own landmark 1973 decision that enshrined the constitutional right to abortion for nearly 50 years, are already being felt. By striking down Roe , the court has put abortion rights in the hands of US state legislators. They have already responded.

Abortion is now either severely restricted or banned in 9 states, a figure that is expected to rise to at least 26. This is a shocking and unacceptable denial of human rights. The American Medical Association, which represents physicians, rightly describes it as “a brazen violation of patients’ rights to evidence-based reproductive health services” .

The Association of American Medical Colleges (AAMC), which represents the medical-education community, says the decision will ultimately put more women’s lives at risk . This is, in part, because legal abortion procedures have a lower risk of death than do pregnancy and childbirth. Overall, the United States had a maternal mortality rate of 24 deaths per 100,000 live births in 2020 (compared with just 3.3 deaths per 100,000 live births in the European Union in the same year). Maternal deaths due to abortion in the United States constitute only a small fraction of this number — between 2013 and 2018, there were fewer than 0.5 deaths from abortion per 100,000 live births 1 .

After Roe v. Wade: US researchers warn of what’s to come

The court’s decision to overturn Roe was not unexpected — a draft was leaked to the news outlet Politico nearly two months ago. University faculties of medicine and public health, as well as clinicians’ and researchers’ organizations, have a grave responsibility to try to temper the disastrous impact this will have on health and research. There are several things they must do.

First, they must provide support to students, researchers and other staff members who are affected by the decision — and to whom institutions have a duty of care. In 2019, more than half (57%) of those who had an abortion were women in their twenties 1 . Many people in university communities fall into this age group, so campus reproductive health-care advisory services need to have strategies to protect their staff and students from harm while following the law.

Second, universities must take steps to ensure that researchers who work in reproductive health, especially those involved in the study of abortion, can continue to do this work. Their work will come under more scrutiny from lawmakers and campaigners opposed to abortion as a result of the Supreme Court’s verdict, but it is essential that their research and scholarship continues.

Why hundreds of scientists are weighing in on a high-stakes US abortion case

Third, medical education and training in abortion must continue. In its statement, the AAMC rightly says that physicians need to have “comprehensive training in the full spectrum of reproductive health care”. But the statement also says that the association will “evaluate the court’s decision and its implications for medical education and health care”. Institutions must avoid pulling back on training or research on abortions so that physicians can safely support people seeking abortions where they are legal.

Fourth, scientists must advocate for an abortion policy based on evidence and expert consensus. Researchers submitted 50 years’ worth of evidence to the Supreme Court ahead of the ruling that revealed, among other things, that access to abortion contributes to both improved health-care outcomes and equality. Although the court seems to have disregarded these findings, scientists should continue such evidence-based advocacy at every opportunity.

Researchers can push for policies to counter the rise in maternal mortality rates expected to occur as a result of Roe ’s demise, and they can advocate for policies that will help to ease any further burdens on new parents. For example, last month researchers showed that targeting cash transfers (universal child benefit) to new mothers in Spain improved health outcomes for their children 2 . Research shows that when people are denied an abortion, they often struggle financially and can be forced into poverty, making it hard for them to care for their children.

The United States’ research, education and training communities can and must act to temper the impacts of the Supreme Court’s decision. The verdict cannot be undone, but every opportunity must be taken to mitigate the worst of its effects.

Nature 606 , 839-840 (2022)

doi: https://doi.org/10.1038/d41586-022-01760-6

Kortsmit, K. et al. MMWR Surveill. Summ. 70 , 1–29 (2021).

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González, L. & Trommlerová, S. J. Health Econ. 83 , 102622 (2022).

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The Most Important Study in the Abortion Debate

Researchers rigorously tested the persistent notion that abortion wounds the women who seek it.

The demographer Diana Greene Foster was in Orlando last month, preparing for the end of Roe v. Wade , when Politico published a leaked draft of a majority Supreme Court opinion striking down the landmark ruling. The opinion, written by Justice Samuel Alito, would revoke the constitutional right to abortion and thus give states the ability to ban the medical procedure.

Foster, the director of the Bixby Population Sciences Research Unit at UC San Francisco, was at a meeting of abortion providers, seeking their help recruiting people for a new study . And she was racing against time. She wanted to look, she told me, “at the last person served in, say, Nebraska, compared to the first person turned away in Nebraska.” Nearly two dozen red and purple states are expected to enact stringent limits or even bans on abortion as soon as the Supreme Court strikes down Roe v. Wade , as it is poised to do. Foster intends to study women with unwanted pregnancies just before and just after the right to an abortion vanishes.

Read: When a right becomes a privilege

When Alito’s draft surfaced, Foster told me, “I was struck by how little it considered the people who would be affected. The experience of someone who’s pregnant when they do not want to be and what happens to their life is absolutely not considered in that document.” Foster’s earlier work provides detailed insight into what does happen. The landmark Turnaway Study , which she led, is a crystal ball into our post- Roe future and, I would argue, the single most important piece of academic research in American life at this moment.

The legal and political debate about abortion in recent decades has tended to focus more on the rights and experience of embryos and fetuses than the people who gestate them. And some commentators—including ones seated on the Supreme Court—have speculated that termination is not just a cruel convenience, but one that harms women too . Foster and her colleagues rigorously tested that notion. Their research demonstrates that, in general, abortion does not wound women physically, psychologically, or financially. Carrying an unwanted pregnancy to term does.

In a 2007 decision , Gonzales v. Carhart , the Supreme Court upheld a ban on one specific, uncommon abortion procedure. In his majority opinion , Justice Anthony Kennedy ventured a guess about abortion’s effect on women’s lives: “While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained,” he wrote. “Severe depression and loss of esteem can follow.”

Was that really true? Activists insisted so, but social scientists were not sure . Indeed, they were not sure about a lot of things when it came to the effect of the termination of a pregnancy on a person’s life. Many papers compared individuals who had an abortion with people who carried a pregnancy to term. The problem is that those are two different groups of people; to state the obvious, most people seeking an abortion are experiencing an unplanned pregnancy, while a majority of people carrying to term intended to get pregnant.

Foster and her co-authors figured out a way to isolate the impact of abortion itself. Nearly all states bar the procedure after a certain gestational age or after the point that a fetus is considered viable outside the womb . The researchers could compare people who were “turned away” by a provider because they were too far along with people who had an abortion at the same clinics. (They did not include people who ended a pregnancy for medical reasons.) The women who got an abortion would be similar, in terms of demographics and socioeconomics, to those who were turned away; what would separate the two groups was only that some women got to the clinic on time, and some didn’t.

In time, 30 abortion providers—ones that had the latest gestational limit of any clinic within 150 miles, meaning that a person could not easily access an abortion if they were turned away—agreed to work with the researchers. They recruited nearly 1,000 women to be interviewed every six months for five years. The findings were voluminous, resulting in 50 publications and counting. They were also clear. Kennedy’s speculation was wrong: Women, as a general point, do not regret having an abortion at all.

Researchers found, among other things, that women who were denied abortions were more likely to end up living in poverty. They had worse credit scores and, even years later, were more likely to not have enough money for the basics, such as food and gas. They were more likely to be unemployed. They were more likely to go through bankruptcy or eviction. “The two groups were economically the same when they sought an abortion,” Foster told me. “One became poorer.”

Read: The calamity of unwanted motherhood

In addition, those denied a termination were more likely to be with a partner who abused them. They were more likely to end up as a single parent. They had more trouble bonding with their infants, were less likely to agree with the statement “I feel happy when my child laughs or smiles,” and were more likely to say they “feel trapped as a mother.” They experienced more anxiety and had lower self-esteem, though those effects faded in time. They were half as likely to be in a “very good” romantic relationship at two years. They were less likely to have “aspirational” life plans.

Their bodies were different too. The ones denied an abortion were in worse health, experiencing more hypertension and chronic pain. None of the women who had an abortion died from it. This is unsurprising; other research shows that the procedure has extremely low complication rates , as well as no known negative health or fertility effects . Yet in the Turnaway sample, pregnancy ended up killing two of the women who wanted a termination and did not get one.

The Turnaway Study also showed that abortion is a choice that women often make in order to take care of their family. Most of the women seeking an abortion were already mothers. In the years after they terminated a pregnancy, their kids were better off; they were more likely to hit their developmental milestones and less likely to live in poverty. Moreover, many women who had an abortion went on to have more children. Those pregnancies were much more likely to be planned, and those kids had better outcomes too.

The interviews made clear that women, far from taking a casual view of abortion, took the decision seriously. Most reported using contraception when they got pregnant, and most of the people who sought an abortion after their state’s limit simply did not realize they were pregnant until it was too late. (Many women have irregular periods, do not experience morning sickness, and do not feel fetal movement until late in the second trimester.) The women gave nuanced, compelling reasons for wanting to end their pregnancies.

Afterward, nearly all said that termination had been the right decision. At five years, only 14 percent felt any sadness about having an abortion; two in three ended up having no or very few emotions about it at all. “Relief” was the most common feeling, and an abiding one.

From the May 2022 issue: The future of abortion in a post- Roe America

The policy impact of the Turnaway research has been significant, even though it was published during a period when states have been restricting abortion access. In 2018, the Iowa Supreme Court struck down a law requiring a 72-hour waiting period between when a person seeks and has an abortion, noting that “the vast majority of abortion patients do not regret the procedure, even years later, and instead feel relief and acceptance”—a Turnaway finding. That same finding was cited by members of Chile’s constitutional court  as they allowed for the decriminalization of abortion in certain circumstances.

Yet the research has not swayed many people who advocate for abortion bans, believing that life begins at conception and that the law must prioritize the needs of the fetus. Other activists have argued that Turnaway is methodologically flawed; some women approached in the clinic waiting room declined to participate, and not all participating women completed all interviews . “The women who anticipate and experience the most negative reactions to abortion are the least likely to want to participate in interviews,” the activist David Reardon argued in a 2018 article in a Catholic Medical Association journal.

Still, four dozen papers analyzing the Turnaway Study’s findings have been published in peer-reviewed journals; the research is “the gold standard,” Emily M. Johnston, an Urban Institute health-policy expert who wasn’t involved with the project, told me. In the trajectories of women who received an abortion and those who were denied one, “we can understand the impact of abortion on women’s lives,” Foster told me. “They don’t have to represent all women seeking abortion for the findings to be valid.” And her work has been buttressed by other surveys, showing that women fear the repercussions of unplanned pregnancies for good reason and do not tend to regret having a termination. “Among the women we spoke with, they did not regret either choice,” whether that was having an abortion or carrying to term, Johnston told me. “These women were thinking about their desires for themselves, but also were thinking very thoughtfully about what kind of life they could provide for a child.”

The Turnaway study , for Foster, underscored that nobody needs the government to decide whether they need an abortion. If and when America’s highest court overturns Roe , though, an estimated 34 million women of reproductive age will lose some or all access to the procedure in the state where they live. Some people will travel to an out-of-state clinic to terminate a pregnancy; some will get pills by mail to manage their abortions at home; some will “try and do things that are less safe,” as Foster put it. Many will carry to term: The Guttmacher Institute has estimated that there will be roughly 100,000 fewer legal abortions per year post- Roe . “The question now is who is able to circumvent the law, what that costs, and who suffers from these bans,” Foster told me. “The burden of this will be disproportionately put on people who are least able to support a pregnancy and to support a child.”

Ellen Gruber Garvey: I helped women get abortions in pre- Roe America

Foster said that there is a lot we still do not know about how the end of Roe might alter the course of people’s lives—the topic of her new research. “In the Turnaway Study, people were too late to get an abortion, but they didn’t have to feel like the police were going to knock on their door,” she told me. “Now, if you’re able to find an abortion somewhere and you have a complication, do you get health care? Do you seek health care out if you’re having a miscarriage, or are you too scared? If you’re going to travel across state lines, can you tell your mother or your boss what you’re doing?”

In addition, she said that she was uncertain about the role that abortion funds —local, on-the-ground organizations that help people find, travel to, and pay for terminations—might play. “We really don’t know who is calling these hotlines,” she said. “When people call, what support do they need? What is enough, and who falls through the cracks?” She added that many people are unaware that such services exist, and might have trouble accessing them.

People are resourceful when seeking a termination and resilient when denied an abortion, Foster told me. But looking into the post- Roe future, she predicted, “There’s going to be some widespread and scary consequences just from the fact that we’ve made this common health-care practice against the law.” Foster, to her dismay, is about to have a lot more research to do.

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The Most Important Abortion Case You Never Heard About

How we got to this week’s abortion showdown — and how Justice Scalia’s views could help shape the outcome.

by Nina Martin

Everyone considers Roe v. Wade, the 1973 decision that established a woman’s right to an abortion, to be the most important ruling ever on the issue by the Supreme Court. But this year, a lesser-known progeny of Roe occupies center stage in potentially the most momentous abortion case confronting the justices in a generation. After Roe established abortion rights, Planned Parenthood v. Casey reined them in, creating a new legal standard that gave states greater leeway to regulate the procedure. Many conservative legislatures took advantage to enact a series of increasingly tough laws that reproductive rights advocates argue have made it more difficult — and sometimes impossible — for women to obtain abortions.

One of those states was Texas, which in 2013 enacted H.B. 2, an omnibus bill whose multiple provisions include restrictions, known as TRAP laws , targeting abortion providers. Now the Supreme Court is being asked to decide the constitutionality of two of these laws — one requiring clinics to meet the same building codes as other types of outpatient surgical centers, the other requiring abortion doctors to have admitting privileges at a hospital within 30 miles — that have already shut down more than half of the state’s 41 clinics and could close 8 more. When the court holds oral arguments in Whole Woman’s Health v. Hellerstedt this week, the signs that protesters wave and the chants they chant will likely focus on Roe , but the outcome of the case will hinge on how justices interpret PP v. Casey .

Abortion rights advocates contend the Texas rules are “sham” laws that pretend to protect women’s health while erecting so many hurdles — what PP v. Casey calls an “undue burden” — that abortion becomes “an abstract right that doesn’t have any meaning,” in the words of Stephanie Toti, a Center for Reproductive Rights attorney representing the clinics. Abortion foes insist that TRAP laws have a genuine medical purpose. They want the court to abandon the “undue burden” standard and allow lawmakers to pass abortion regulations as long as they have a “rational basis,” without having to prove that the laws actually benefit women. If the court goes along, it could have a sweeping impact on access to abortion across the country, but especially in conservative states in the South and Midwest, triggering not just a new wave of TRAP laws but other types of restrictions as well.

PP v. Casey was decided in 1992, a time of many political parallels to today. Here is the background to the most important abortion decision you may never have heard about.

The Rise of Incrementalism

In the period immediately following Roe , abortion opponents mobilized and pushed for a federal constitutional amendment declaring that a fetus was a “person” entitled to “equal protection” under the 14th Amendment. But those efforts stalled. Abortion opponents began arguing for a new, pragmatic strategy known as “incrementalism.” Instead of attempting to overturn Roe outright, “you would argue that certain abortion restrictions and regulations were compatible with Roe ,” said Mary Ziegler, a law professor at Florida State University and author of “After Roe: The Lost History of the Abortion Debate” . The idea was “to chip away at abortion rights until Roe was so incoherent and so full of holes that courts would finally get rid of it.”

The approach required “an accurate understanding of political power, an assessment of what is politically achievable, [and] recognition of the imperfect world in which we live,” Clarke Forsythe, senior counsel for Americans United for Life , a key of architect of anti-abortion strategies, wrote in a law review article around that time. That translated into retail politics on the state level, the election of anti-abortion candidates, the passage of model legislation and the defense of those new laws in court. The approach was extremely effective: By the late 1980s, states had enacted dozens of restrictions. Moreover, the political makeup of the Supreme Court had turned more conservative, and the court’s jurisprudence on abortion had become splintered and, to some, confused. Forsythe, though, could read the tea leaves: The justices seemed ready to show “greater deference to state abortion laws — quite a contrast from the Roe decision.”

The Pennsylvania Law

The battles over the Pennsylvania Abortion Control Act were a prime example of incrementalism in action. A version of the law passed in 1982 was largely struck down by the U.S. Supreme Court four years later. But instead of giving up on the law, legislators amended it; the version signed by Gov. Robert Casey Sr. in 1989 included a 24-hour waiting period, informed consent rules for women seeking abortions, parental consent rules for minors and a requirement that married women notify their husbands before terminating a pregnancy. Planned Parenthood and other abortion providers challenged these rules, too. But this time, the Third U.S. Circuit Court of Appeals upheld all the provisions except spousal notification. Planned Parenthood appealed the case to the high court.

Another Nasty Fight for the Supreme Court

Consider the events of 1991–1992. A presidential election loomed; the first war in Iraq was over; racial unrest after the acquittal of four white police officers in the videotaped beating of Rodney King left Los Angeles in flames. Massive job layoffs led to widespread economic resentment, and a blunt-talking billionaire emerged out of nowhere to become a populist hero and presidential spoiler (this one’s name was Ross Perot ). On the abortion front, groups such as Operation Rescue were using aggressive, sometimes violent tactics to block access to abortion clinics. Then, in June 1991, an ailing Justice Thurgood Marshall resigned, touching off an epically ugly Supreme Court fight (although the one to replace Justice Antonin Scalia could make it seem like a model of decorum).

Clarence Thomas’s confirmation in October 1991 meant Republican appointees now clearly held the fate of abortion rights in their hands. “Our concern was that when the [Pennsylvania] case went before the Supreme Court, the majority would use this opportunity to go much further [than the Third Circuit appeals court] and say that any law that was rational, including the complete banning of abortion, would be constitutional,” said Kathryn Kolbert, the lead ACLU attorney challenging the Pennsylvania law, who is now director of the Athena Center for Leadership Studies at Barnard College. That was what many abortion opponents were urging : Indeed, they had been lobbying for the “rational basis” standard since Roe .

Figuring that they were going to lose anyway, Kolbert and her allies embarked on what author and legal analyst Jeffrey Toobin has called “ one of the most audacious litigation strategies in Supreme Court history. ” Instead of dragging the case out, they opted to “lose fast”: to push the case onto an exceptionally fast track in the hope it would be decided in the middle of the 1992 elections. And instead of making it a fight about Pennsylvania’s incremental law, they cast it as the ultimate showdown over Roe. This would let them take political advantage of the backlash that would ensue if abortion rights were gutted. According to Toobin, the conservative chief justice, William Rehnquist, resented this “transparent” ploy, but the court’s two liberal justices, Roe ’s author Harry Blackmun and John Paul Stevens, supported it and Rehnquist’s hand was forced. The case was argued on the last possible day of the 1991–92 term.

Justice Kennedy’s Compromise

A central question facing the justices was whether the state could comply with Roe v. Wade while requiring women to go through additional hoops before getting an abortion. Oral arguments left both sides convinced that abortion rights were in peril; when Blackmun’s papers became public years later, they showed that Rehnquist had drafted an opinion overruling Roe . But then the trio of Republican-appointed moderates — Anthony Kennedy, Sandra Day O’Connor and David Souter — had second thoughts. Instead of joining Rehnquist, they made a secret deal to thwart him .

The PP v. Casey decision, announced in June 1992, was stunning. By a 5–4 vote, the court reaffirmed Roe ’s “essential holding” that the right to abortion was protected by the Constitution. Not only that, the opinion embraced women’s equality as central to the abortion right in a way that Roe had not. With abortion, the liberty of the woman is at stake “in a sense unique to the human condition and so unique to the law,” the decision read. “Her suffering is too intimate and personal for the State to insist … upon its own vision of the woman’s role, however dominant that vision has been in the course of our history and of our culture.”

The structure of the ruling was also highly unusual: It was a “plurality” opinion by the three moderates — Kennedy, O’Connor and Souter — with the court’s two liberals agreeing with some parts and disagreeing with others. Kolbert notes that the plurality’s emphasis on “stare decisis,” the principle that courts must follow precedent, was a sign that the justices had understood “the challenge to the institutional integrity of the court was real.” Justice Kennedy in particular “did not want the court to be perceived as changing course” on abortion, Kolbert said, simply because the majority’s ideological balance had shifted.

But abortion foes like Paul Linton, later special counsel to the Thomas More Society , noted that a “moral ambiguity” about abortion pervaded the joint opinion, as well as “the nagging sense” that the three justices thought Roe had been wrongly decided but upheld it anyway: “That … does not promote respect for the judiciary, especially in a case where the stakes were so high.” Abortion opponents felt especially betrayed by Kennedy, a dismay that has only grown deeper over the years, as he has authored landmark opinions on gay rights and marriage equality. That’s one reason conservative expectations for the Texas abortion case are much more cautious today than they were for Casey . Kennedy “doesn’t have any clearly defined principles that allow you to predict what he’s going to do in any case, in any area,” said Lynn Wardle, a law professor at Brigham Young University who has written often about same-sex marriage and abortion. “The best test for being able to predict what he will do is to lick your finger and hold it out to the wind.”

A Clouded Victory for Abortion Rights

Even as PP v. Casey upheld the right to abortion, the plurality opinion took Roe v. Wade apart, starting with its foundation, the trimester framework. Under Roe , states were almost completely banned from regulating abortion during the first trimester. They had more flexibility to pass laws protecting a woman’s health in the second trimester, and they could prohibit most abortions in the third. In contrast, Casey declared, “[T]he State has legitimate interests from the outset of the pregnancy in protecting the health of the woman and the life of the fetus that may become a child.” Instead of the trimester approach, Casey established viability — the point at which the fetus can survive outside the womb — as the new dividing line for determining whether an abortion law was valid or not. (When Roe was decided, fetuses weren’t considered viable until 28 weeks, or the third trimester; by 1992, medical advances had pushed the line to around 24 weeks.) Before viability, Casey said, states could only try to persuade a woman not to have an abortion; laws that made it difficult or impossible for her to act on her decision did not pass muster. After viability, though, states could restrict abortions pretty much however they liked.

More significantly, Casey also rejected Roe ’s “strict scrutiny” test for evaluating abortion restrictions — a test that had stymied most state efforts to regulate the procedure — replacing it with the looser “undue burden” standard, which Justice O’Connor had proposed in dissents to earlier abortion rulings. An undue burden was defined as any law that had “the purpose or effect of placing a substantial obstacle in the path of a woman seeking an abortion.” Importantly for the pending Texas abortion case, this reasoning applied to medical rules as well as other restrictions: Although “the State may enact regulations to further the health or safety of a woman seeking an abortion,” the court held, “unnecessary health regulations that have the purpose or effect of presenting a substantial obstacle to a woman seeking an abortion impose an undue burden.” Still, the court reiterated, just because a law had “the incidental effect of making it more difficult or more expensive to procure an abortion” wasn’t enough to invalidate it.

Under the new standard, the Pennsylvania rules aimed at giving women more information and time to reflect on their decisions were valid. Only the spousal notification provision was deemed to be an undue burden and thus unconstitutional: “A state may not give to a man the kind of dominion over his wife that parents exercise over their children.”

Scalia’s Dissent: “Hopelessly Unworkable”

Casey prompted one of Antonin Scalia’s most famous and blistering dissents: The plurality’s reasoning, he fumed, was “really more than one should have to bear.” Much as he disliked Roe , at least the trimester framework laid down clear guidelines, he wrote. In contrast, Casey ’s “undue burden” standard was “created largely out of whole cloth,” “inherently manipulable,” and “hopelessly unworkable,” giving individual judges much more power to inject their own private beliefs into the abortion debate. “Its authors believe they are bringing to an end a troublesome era in the history of our Nation and of our Court,” Scalia scoffed. But he said the abortion wars would only be stoked by “this jurisprudence of confusion” — a view that would help frame the conversation about Casey for the next two decades. More recently, abortion rights advocates have fought back, arguing that Casey ’s reputation as “squishy law” is undeserved and part of a long effort to delegitimitize the undue burden standard, much as critics have sought to undermine Roe . “Excuse me for simplifying, but there’s a there there,” said Reva Siegel, a Yale Law professor who has written extensively on abortion and gender equity. One reason Casey may be so misunderstood: It gave each side half a loaf, so neither embraced it, even though it reflected how most ordinary people felt. The decision “speaks to an America divided by conflict over abortion,” Siegel said. “It’s summoning each side to engage respectfully with the other.”

Reshaping the Debate: “Partial Birth”

The 18 months or so immediately following Casey “were probably a low point in the history of the pro-life movement,” said Michael New, a conservative pundit and visiting assistant professor at Ave Maria University who has written often about abortion. At first most new restrictions introduced in the states were modeled closely on the Pennsylvania law. Then abortion opponents hit upon the mid–1990s version of last year’s Planned Parenthood videos: the rare but gruesome technique for third-trimester abortions that they dubbed “partial-birth abortion.”A flurry of bans on the procedure re-energized the incrementalists, providing new opportunities " to slowly convince [average] Americans that they're just as uncomfortable about abortion as pro-life folks are ," Jack Balkin, a professor of constitutional law at Yale University, told PBS' Frontline in 2005. That meant more chances to challenge not just Roe , but also Casey . Said Forsythe, of Americans United for Life: "The procedure served to humanize the unborn and produced a sea change in American public opinion on the issue."

Ultimately, it was the sea change on the Supreme Court during the administration of George W. Bush that mattered most. In 2007, the court upheld the federal ban on partial-birth abortion; Kennedy wrote the majority opinion using language suggesting he might be open to tighter abortion restrictions despite the undue burden standard, especially in areas of “medical uncertainty.” Abortion, he said, was “a decision … fraught with emotional consequence,” one in which women would “struggle with grief more anguished and sorrow more profound” if they really understood what this particular procedure involved. Conservative strategists saw the ruling as a victory not just against partial-birth abortion but against Casey .

How Big a Burden?

It took the huge Tea Party wave of 2010 for abortion opponents to gain the political clout to push through laws like Texas’ H.B. 2. Since 2011, states in the South and Midwest have passed more than 300 abortion restrictions — TRAP laws, rules for how medication abortions may be performed, bans on abortion after 20 weeks (and sometimes earlier), longer waiting periods and greater impediments to teenagers seeking abortions without parental approval. The central question raised by many of these laws goes directly to the 24-year-old ruling in Casey : How undue must a restriction become before it renders the right to abortion meaningless?

Even before Scalia’s death, the outcome of the Texas case was anyone’s guess; his demise makes it even more uncertain. The biggest question has always been whether Kennedy, the last remaining PP v. Casey co-author on the Supreme Court, will see that decision as an important part of his legacy that he wants to defend, or whether he will be inclined to give states more leeway to restrict the abortion right.

As Casey itself shows, all kinds of court alliances and plurality rulings are possible.

What is clear: The Texas case, whatever its outcome, probably won’t settle the abortion issue any more than Casey did.

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Reproductive rights in America

A landmark study tracks the lasting effect of having an abortion — or being denied one.

Megan Burbank

Emily Kwong

With Roe v. Wade primed to be overruled, people seeking abortions could soon face new barriers in many states. Researcher Diana Greene Foster documented what happens when someone is denied an abortion in The Turnaway Study. Malte Mueller/Getty Images hide caption

With Roe v. Wade primed to be overruled, people seeking abortions could soon face new barriers in many states. Researcher Diana Greene Foster documented what happens when someone is denied an abortion in The Turnaway Study.

Though it's impossible to know exactly what will happen to abortion access if Roe v. Wade is overturned, demographer Diana Greene Foster does know what happens when someone is denied an abortion. She documented it in her groundbreaking yearslong research project, The Turnaway Study and her findings provide insight into the ways getting an abortion – or being denied one – affects a person's mental health and economic wellbeing.

For over 10 years, Dr. Foster and her team of researchers tracked the experiences of women who'd received abortions or who had been denied them because of clinic policies on gestational age limits.

The research team regularly interviewed each of nearly 1,000 women for five years and found those who'd been denied abortion experienced worse economic and mental health outcomes than the cohort that received care. And 95% of study participants who received an abortion said they made the right decision.

The idea for the Turnaway Study emerged from a 2007 Supreme Court abortion case, Gonzales v. Carhart . In the majority opinion upholding a ban on a specific procedure used rarely in later abortions, Justice Anthony Kennedy speculated that abortions led to poor mental health. "While we find no reliable data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained," he wrote. "Severe depression and loss of esteem can follow."

Dr. Diana Greene Foster is the lead researcher on the interdisciplinary team behind The Turnaway Study. Simon & Schuster hide caption

Kennedy's speculation — and admitted lack of evidence — captured Foster's attention, "because you can't make policy based on assumptions of what seems reasonable without talking to a representative sample of people who actually wanted an abortion," she said. The Turnaway Study fact-checked the justice's guess, finding that not having a wanted abortion was more likely to lead to the mental health outcomes he'd described than having one.

The study concluded in 2016, and didn't assess the effects of existing abortion restrictions on patients, or anticipate a future in which Roe v. Wade is overturned. It also didn't address the experiences of transgender and nonbinary people seeking abortion care, who Foster suspects may face even more significant access barriers than the women who were turned away.

Foster spoke with NPR's Short Wave about the study and its relevance today.

This interview has been edited for length and clarity.

Who participated in The Turnaway Study? How did the women in the study compare to people who typically seek abortions?

The sample ended up looking very closely like the population of people who seek abortions nationally. So 60% of the women were already mothers. About half were in their 20s, which is typical. About three-quarters were already below the federal poverty level at the time they were seeking an abortion.

The only real difference is that they tended to be later in pregnancy because we recruited them right up near the gestational limit. And I think I had an idea before I started this study, that people seeking abortion later in pregnancy would somehow be different... And that turned out to be completely false. The people who seek abortions later in pregnancy were not substantively different from the people seeking abortion earlier, with the exception that they tended to have been a lot later in realizing they were pregnant....

The Turnaway Study: What The Research Says About Abortion

What did you learn about the lives of women who were denied abortions after five years of follow-up conversations?

We see a couple of areas where their lives dramatically diverge in outcomes [from women who got abortions]. The first is health. Consistent with the medical literature, carrying a pregnancy to term and delivering a child is much more physically risky than having an abortion, even a later abortion. We see much more severe physical health complications from birth, including most tragically, two women who died after delivery — one died of an infection and one died of a very common pregnancy complication.

The other area that we see big differences is in socioeconomic well-being. This is not just about poverty, although we see that people who are denied abortions are more likely to live in households where there just isn't enough money for basic living needs... And they're more likely to be raising children alone if they are denied the abortion than if they receive one. They're equally likely to be in a relationship, whether they received or were denied an abortion.

But those who receive the abortion report that their relationship is higher quality. So it's changing fundamental aspects of people's lives, including their chance at having children later under better circumstances.

And what did you find for those women who were able to get an abortion?

We see better mental health initially for the people who receive an abortion compared to those who are denied it and for both groups, improving mental health over time. And I think that's because the experience of having an unwanted pregnancy is associated with serious anxiety and distress. And over time, people improve...

Abortion doesn't cause depression or anxiety, but people could have an emotional reaction to having had an abortion. And so we asked people about six emotions... happiness, sadness, regret, relief, anger and guilt... And what we learned is that positive emotions outweigh negative emotions, but a substantial number of people do have negative emotions about it.

People can experience the emotion regret and still feel like they made the right decision about having an abortion. So: "I regret that I was in the position where I needed an abortion. But given that I was, I'm glad I had it." And they can feel sad, and sad is different than depressed. So people have a range of emotional responses, and over time, people say that having strong positive emotions and strong negative emotions, both of those reduce over time, and people tell us that they stop thinking about abortion. One woman told us "I only think about it when you call me for these interviews."

So this idea that somehow this event is disrupting people's lives forever — that is not accurate for the vast majority of people. This is something that people say they needed to do, and they did it and moved on with their lives.

Did you see any differences among women who had the support of their family, friends or community in their decision?

My colleague, social psychologist Antonia Biggs, analyzed the mental health data ... to narrow in on who actually is experiencing some mental health distress over time, and it's disproportionately those who report that they experience a lot of stigma around abortion. But I should note it's rare, and the much bigger predictor of poor mental health is a history of childhood abuse and neglect.

What impact did being denied an abortion have on families who already had children?

I think it's often surprising to people who don't think about abortion very much that people who seek abortions are often already parents. Sixty percent of people nationally who have abortions are already mothers, and they give as a reason for wanting to have an abortion that they need to take care of the kids they already have. And when we look at the well-being of those existing children, we see differences based on whether their mom received or was denied an abortion for their subsequent pregnancy. So those kids whose mothers were denied abortions are less likely to achieve developmental milestones such as language and gross motor, fine motor skills.

What does this research add to the discussion of Roe v. Wade ?

The Turnaway Study was not designed with this moment in mind, because in my worst nightmares, I did not imagine that we would see an end of Roe so quickly. But what The Turnaway Study shows is that people who become pregnant and are unable to get a safe, legal abortion in their state, those that carry the pregnancy to term will experience long-term physical health and economic harm. We haven't become a more generous country that supports low-income mothers. And so those outcomes are still the outcomes that that people will experience when they are denied a wanted abortion.

What The Turnaway Study doesn't answer about the current time is that many people will manage to circumvent their state laws and they won't carry that pregnancy to term and they'll travel to nearby or faraway states or they'll order medication abortion pills online and they'll manage to get an abortion. And some people will try dangerous things and potentially harm themselves. And so we really don't know the full effect of this decision.

NPR's Rebecca Ramirez produced the audio version of this interview for Short Wave.

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Up next for Supreme Court on abortion: Idaho

Justices to hear case on near-complete ban amid shifting legal landscape after overturn of Roe

Christina Pazzanese

Harvard Staff Writer

Since the Supreme Court overturned Roe v. Wade in June 2022, 21 states have enacted laws that strictly limit abortion.

Next week, justices will hear arguments over the first and among the most restrictive of those new laws. Idaho’s statute calls for a near-complete ban on abortion and prohibits anyone from performing or assisting one except when the pregnancy is ectopic or molar; a result of rape or incest; or a risk to the life of the mother.

The U.S. Department of Justice argues those restrictions conflict with a 1986 federal law requiring hospitals that participate in Medicare to provide stabilizing treatment to emergency room patients regardless of their ability to pay. Both the federal District Court and U.S. Court of Appeals in Idaho sided with the federal government and had blocked the state ban from going into effect. The Supreme Court lifted the injunction in January when it agreed to hear the case.

Several other abortion cases are moving through federal and state courts. Notably, Arizona’s top court upheld a Civil War-era law last week criminalizing abortion in all circumstances except to save a pregnant woman’s life.

The Gazette spoke with I. Glenn Cohen , James A. Attwood and Leslie Williams Professor of Law at  Harvard Law School  and faculty director of the Petrie-Flom Center  for Health Law Policy, Biotechnology, and Bioethics at HLS, about the legal landscape after the Dobbs v. Jackson Women’s Health Organization ruling that overturned Roe and what a decision for Idaho might mean for other states. The interview has been edited for clarity and length.

There has been a flurry of abortion-related legal challenges since the overturning of Roe. Can you describe some recent developments?

On April 1, the Florida Supreme Court upheld the state’s 15-week ban, which, because of the way the law is written, means the state’s six-week ban will go into effect in 30 days. The Court also allowed a ballot initiative to go forward, so Florida voters will get to vote on abortion.

Last week, the Arizona State Supreme Court cleared an 1864 abortion law in the state to go into effect — a law that predates Arizona’s statehood that prohibits abortion without exceptions for rape or incest. An attempt by Democrats in Arizona’s legislature to repeal that 1864 law failed.

The state’s attorney general, Kris Mayes, and some county attorneys have said they will not prosecute abortion cases under the law, but it is not clear whether providers will be willing to perform abortions even with those assurances.

Moreover, such assurances can change with changes in who is in charge. There is a proposed ballot initiative in Arizona that would enshrine some abortion rights protections in Arizona’s state constitution, so, as in Florida, voters will be able to have their say.

“When does federal law pre-empt state law? There are multiple types of pre-emption arguably raised in this case. The key question is whether any of those apply.”

In terms of what’s before the Supreme Court or making its way to the Supreme Court, I’d say there are three main cases to keep an eye on.

One is the mifepristone litigation, where oral argument happened on March 26, which is about whether FDA appropriately altered the drug’s Risk Evaluation and Mitigation Strategies in 2016 and 2021. REMS are potential restrictions on the use of that drug that has been approved. That case is really about medical abortion.

We’ve got this case in Idaho, which is about states, in the wake of Dobbs, that have more narrowly limited their abortion laws such that there are now questions about emergencies and questions about exceptions for life and health of the pregnant person. This case presents that question squarely.

And then, floating in the background, but not yet squarely before the U.S. Supreme Court, is the Comstock Act. The question the Court may eventually have to answer is whether this very old act, more than 100 years old, restricts sending in the mail drugs used for abortion or even tools that could be used for surgical abortion.

We are seeing all these cases now in part because while these questions were always in theory there, there was a constitutional protection of abortion that restricted states from going below a certain minimum, such that very few such restrictive measures were active and had legal questions that needed to be resolved.

But now, in the wake of Dobbs, we’ve got states that have more or less completely limited abortion except under very narrow circumstances. What’s so interesting about the Idaho case is that the Emergency Medical Treatment and Active Labor Act is a general law about emergency treatment and stabilization. And so, we’re talking about how it intersects with what Idaho and other states may have done.

What’s the legal question at issue in this Idaho case?

Part of what makes the case complicated is the parties have slightly different views about what the state of play is. The federal government puts the question presented as “whether EMTALA pre-empts Idaho law in the narrow but important circumstance where terminating a pregnancy is required to stabilize an emergency medical condition that would otherwise threaten serious harm to pregnant women’s health, but the state prohibits an emergency room physician from providing that care.”

Idaho frames it as “whether EMTALA pre-empts state abortion regulations and requires hospitals to perform abortions disallowed by state law.”

One of the pieces of wrangling that has occurred throughout litigation is exactly what is prohibited by the Idaho Defense of Life Act. Questions about pregnancy termination related to ectopic pregnancies, pre-eclampsia, and stuff like that. So, the parties, I don’t think, are in complete agreement over the question about what the act prohibits or doesn’t prohibit.

What is there for the Supreme Court to consider? Doesn’t the Constitution already say that when federal law conflicts with state law, federal law prevails?

Exactly right. Under the Supremacy Clause of the Constitution, federal law trumps state law where they conflict. But what it means for the laws to conflict is a nuanced question. So, the question is: When does federal law pre-empt state law? There are multiple types of pre-emption arguably raised in this case — express, implied, and obstacle. The key question is whether any of those apply, which, in turn, depends on understanding what EMTALA requires.

On Idaho’s side of the case, their argument is there isn’t a conflict with EMTALA because EMTALA doesn’t reach this particular question. And on the other side, the federal government argues it definitely does apply here. So, part of this is an interpretation of what EMTALA does and does not require.

Has EMTALA been challenged before in other contexts?

There have been some EMTALA cases. There’s a famous case called the Baby K case from many years ago. Baby K was a Fourth Circuit case from 1994 about a baby born with anencephaly — missing a major part of the brain that is necessary for conscious thought — and whether a hospital could decline to provide a ventilator to the newborn if the newborn came to the ER.

There was a Fifth Circuit case from 1991, Burditt v. U.S. Department of Health and Human Services, unsuccessfully challenging EMTALA as unconstitutional. In the Supreme Court certainly, EMTALA cases been relatively few and far between.

The justices referenced EMTALA quite a bit during oral arguments in the recent mifepristone case, FDA v. Alliance for Hippocratic Medicine. Why do you think that is?

There was a lot of shadowboxing around the Idaho case in the mifepristone oral argument .

In particular, two things to highlight: One is this question about so-called “conscience clauses” and whether EMTALA could ever overcome legal protections for conscience and thus, require a physician to perform an abortion against her or his conscience.

Solicitor General Elizabeth Prelogar gave, I think, the correct answer, which is that EMTALA obligations sit on a hospital, not on a physician. And typically, hospitals have systems in place that if they have a physician who is conscientiously objecting to abortion and protections for that under law, it’s up to the hospital to find a substitute, which is, I think, a correct statement of the law, but one I’m sure there’s going to be some pushback on.

Second, there was some sniping at the mifepristone argument about whether the government has changed its position on the conscience question and whether they’ve changed their position and given different answers to this question at different stages of the litigation.

On the flip side, in the Idaho case, the federal government argues the state of Idaho keeps changing their position about what their theory of pre-emption is. So, I think there’ll be some nasty questioning — “has this always been your position, has your position changed” and the like. I don’t think it’ll actually make a difference to the outcome, but that’s something that I expect that we’ll hear at argument.

“In a state like Massachusetts, we’re not going to get the conflict we saw in this case. Elsewhere it looks different.”

A Supreme Court decision in Idaho’s favor could impact people in many other states. How might that unfold?

I wouldn’t say every state because many states have robust protections. In those states there may be some fairly robust protections regarding emergency exceptions for the health and life of the mother.

In a state like Massachusetts, we’re not going to get the conflict we saw in this case. Elsewhere it looks different. There was a parallel EMTALA case in Texas, and Texas won that one. So currently, the court in Texas has allowed Texas’s law to go into effect.

The Solicitor General, in her brief in the Idaho case, had a footnote listing the states they think this is going to be most relevant to. Texas is certainly one of them. Footnote 11 in the Solicitor General’s briefs says seven states, including Idaho, have laws that lack a health exception. They name Arizona, Arkansas, Mississippi, Oklahoma, South Dakota, and Wisconsin. But it says several of those laws are in flux. So at least in those seven states directly relevant.

But there are some other states that have restrictions on health exceptions for abortion that are not as firm as the ones in Idaho but are narrower than what the federal government understands to be required by EMTALA, where this decision will also be relevant. Moreover, there may be some states that might see a win for Idaho in this case and learn and rewrite their statute to be narrower than it is now.

Does the federal government have any recourse if Idaho prevails? Could the government withhold Medicare reimbursements to those states, for example?

I think the answer is probably no, in part because the Supreme Court is giving the definitive reading about what EMTALA means.

If the government, under EMTALA, threatened to remove Medicare and Medicaid funding from the hospitals in a state that allegedly violated EMTALA, they would now say, “We’re not violating EMTALA. See the decision in this case.”

What would have to happen would be congressional action to change the language if Idaho wins. In such legislation, Congress could just say EMTALA requires that the health of the mother be considered in a particular way as a requirement of the statute.

Congress could also pass a freestanding statute that said the same thing. This sometimes happens — the Supreme Court gives an interpretation of a statute; Congress doesn’t like the interpretation; and Congress changes the statute.

In theory, that could happen here. In reality, the politics would require Democrats to have a majority in both houses and unless the filibuster is going to go away, would require a filibuster-proof majority in the Senate, and that’s quite unlikely.

The other thing that’s possible is, and this is going to be even more unlikely, is forget EMTALA. If there’s federal protection provided to abortion in general [through legislation], some federal backstop that says, “States have power to do some things, but not this. This is too far,” then the federal government could also include more protections for health and life of the mother exceptions.

One more thing that’s in play here: the interpretation of what does Idaho state law mean or what does Texas state law mean in terms of the breadth of the exceptions is typically not for the U.S. Supreme Court to decide because they’ve said when a decision rests on an independent adequate state ground, the Supreme Court will not review the case.

But there is a question under state law, what does the exception mean. Texas right now is having litigation in the Texas state courts about what its emergency exception for abortion covers. So, another possibility is the people of Idaho change their law, or the Idaho Supreme Court interprets the law in a way that is more friendly to abortion access. Those are also possibilities. Though as the failure of legislation to protect abortion in Arizona I mentioned before shows, in many states changing abortion law via ordinary legislation will be an uphill battle. 

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Women are bearers of life. Nurturing human inside the womb for nine months is no small feat, that is why when a woman and her significant others learns about her pregnancy, they always go the extra mile just to make sure that the health and the safety of both the mother and the baby are intact. Abortion is a complex and sensitive topic that lies at the intersection of healthcare, ethics, and women’s rights. As healthcare professionals, nurses play a crucial role in providing compassionate, non-judgmental, and patient-centered care to individuals seeking abortion services. Understanding the diverse reasons for seeking abortion, the medical procedures involved, and the ethical dilemmas surrounding this issue is essential for nurses to navigate this field with empathy and professionalism.

This article aims to offer a comprehensive nursing perspective on abortion, addressing the various aspects of patient care , informed consent, and the ethical principles guiding this practice. We, as nurses, also have this primary responsibility to be informed about the dangers to a pregnant woman so we could educate them and protect them too. As part of our holistic care , let us take a peek on how abortion or miscarriage affects a pregnant woman and what we can do to reduce these cases.

Table of Contents

What is abortion, pathophysiology, risk factors, signs and symptoms, diagnostic tests.

• Medical Management

Surgical Management

Nursing assessment, nursing diagnosis, nursing interventions.

• Abortion is a medical term for the disruption of a pregnancy before the fetus reaches its viable age of more than 20 to 24 weeks of gestation or weighs at least 500g.
• The most common cause of an abortion is abnormal fetal development , which is either due to a chromosomal aberration or a teratogenic factor.
• Another common cause is the abnormal implantation of the zygote, where there is inadequate endometrial formation or the zygote was implanted on an inappropriate site.
• This would cause inadequate development of the placental circulation, leading to poor nutrition of the fetus and eventually, to an abortion.

There are always precipitating factors for every condition. Here are the risk factors that concerns abortion:

• Congenital Structural Defect. This structural defect may be due to chromosomal aberration or a serious physical defect.
• Low Progesterone . Progesterone maintains the decidua basalis. If the corpus luteum fails to produce enough progesterone, it would risk the life of the fetus inside the uterus.
• Rh Incompatibility . The fetus could get rejected from a mother’s body if they have an incompatible Rh.
• Undernutrition. Lack of nutrients would cause undernourishment to both the mother and the fetus, leading to abortion.
• Drugs. There are drugs which are contraindicated for pregnant women. Ingestion might compromise the fetus and lead to abortion.
• Infection . In infection, the fetus would fail to grow and estrogen and progesterone production would fall. This would lead to endometrial sloughing, then prostaglandins would be released leading to uterine contractions and cervical dilatation along with expulsion of the products of pregnancy.

Several types of abortion are used to classify every case for a pregnant woman. Once a thorough assessment is done, that would be the time that the type of abortion that occurred could be established.

• Threatened abortion. The embryo is already viable. The products of conception are still intact and the cervix is closed, but there is vaginal bleeding present.
• Inevitable/Imminent abortion. The embryo is dead with the products of conception either intact or expelled. The cervix is already dilated and there is presence of vaginal bleeding .
• Complete abortion. All products of conception are expelled and the embryo is dead. The cervix is dilated, and there is mild bleeding.
• Incomplete abortion. The embryo is dead but some products of conception are still intact. The cervix is already dilated and there is severe vaginal bleeding.
• Missed abortion. The embryo is already dead while inside the uterus. The products of conception are still intact and the cervix is closed. There are brown vaginal discharges present.
• Recurrent/Habitual abortion. Abortion becomes recurrent once the woman has had 3 consecutive miscarriages at the same gestational age.

As nurses, we are tasked with assessing our patient to provide baseline and accurate information to other caregivers . The signs and symptoms of abortion must be identified first before ruling out any other relative causes.

• Vaginal spotting. Vaginal spotting appears as small brownish to reddish spots of blood coming out of the woman’s vaginal opening. This usually occurs when the cervix slightly dilates because the woman may have tried to lift heavy objects or mild trauma to the abdomen occurred.
• Vaginal bleeding. Bleeding is a serious occurrence during pregnancy because it might indicate that the cervix has opened and products of conception might be expelled.
• Cramping/sharp/dull pain in the symphysis pubis. This could occur on both sides and could be caused by trauma or premature contractions that might cause cervical dilation.
• Uterine contractions felt by the mother. Uterine contractions can be false or true, but either of the two could be alarming during the early stages of pregnancy because it could expel the contents of the uterus thereby leading to abortion.
• Pregnancy test. This is to confirm the pregnancy first if vaginal bleeding occurs. If test turns out negative, then the woman would be subjected to other diagnostic tests that could confirm the nature and cause of the vaginal bleeding. If it is positive, then abortion would be considered and it would be classified according to the presenting signs and symptoms.
• Ultrasound. The safest and confirmatory test for pregnancy, the ultrasound would be able to confirm if the pregnancy is positive, and also confirm if the products of conception are still intact.

Medical Management

Medical interventions should also be incorporated in the patient’s care plan to reinforce his treatment. These are physician’s orders wherein nurses and other caregivers would assist or take into action, thus ensuring the recovery of the patient.

• Aside from our own nursing management , physicians would also have to order a series of therapeutic management for the pregnant woman.
• Administration of intravenous fluids . Such as Lactated Ringer’s, IV therapy should be anticipated by the nurse as well as administration of oxygen regulated at 6-10L/minute by a face mask to replace intravascular fluid loss and provide adequate fetal oxygenation .
• Avoid vaginal examinations. The physician would also avoid further vaginal examinations to avoid disturbing the products of conception or triggering cervical dilatation.
• The physician might also order an ultrasound examination to glean more information about the fetal and also maternal well-being.

Our role as nurses in these medical interventions would be to assist in every aspect possible, and ensure the wellbeing of both the mother and the fetus. Through our nursing interventions , we could initiate care without needing to run after the physicians and ask for their orders. We should be able to function independently as caregivers and promote their wellness in our own way as nurses. The most vital pieces of information are always handed to us first, so it would be up to us to initiate the first intervention to make or break the condition of the client before a doctor arrives. Nurses are the first line of defense of every hospital, and we should live up to that expectation.

Aside from the medical interventions ordered by physician, incidences might occur which would lead to a surgical operation .

• Dilatation and evacuation . This is to make sure that all products of conception would be removed from the uterus. However, before undergoing this intervention, the physician must be sure that no fetal heart sounds could be heard anymore and the ultrasound must show an empty uterus.
• Dilation and curettage . This is most commonly performed for incomplete abortions to remove the remainder of the products of conception from the uterus. Since the uterus would not be able to contract effectively, the contents might be trapped inside and could cause serious bleeding and infection.

Nursing Management

Nurses must also have their own independent functions to ensure the safety and well-being of the patient. The following are measures that would allow the nurse to act independently.

• The presenting symptom of an abortion is always vaginal spotting, and once this is noticed by the pregnant woman, she should immediately notify her healthcare provider
• As nurses, we are always the first to receive the initial information so we should be aware of the guidelines in assessing bleeding during pregnancy.
• Ask of the pregnant woman’s actions before the spotting or bleeding occurred and identifies the measures she did when she first noticed the bleeding.
• Inquire of the duration and intensity of the bleeding or pain felt. Lastly, identify the client’s blood type for cases of Rh incompatibility.
• Risk for deficient fluid volume related to bleeding during pregnancy
• If bleeding is profuse, place the woman flat in bed on her side and monitor uterine contractions and fetal heart rate through an external monitor.
• Also measure intake and output to establish renal function and assess the woman’s vital signs to establish maternal response to blood loss .
• Measure the maternal blood loss by saving and weighing the used pads.
• Save any tissue found in the pads because this might be a part of the products of conception.
• The aim for evaluation is inclined towards restoring the maternal blood volume and stopping the source of the bleeding.
• The client’s blood pressure must be maintained above 100/60 mmHg.
• The pulse rate should be below 100 beats per minute and the fetal heart rate must be at a normal level of 120-160 beats per minute.
• The client’s urine output should be more than 30 mL/hr, and only minimal bleeding should be apparent for not more than 24 hours.

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Study shows benefits of taking misoprostol at home during medical abortions after 12 weeks

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Pregnant people who took the first dose of misoprostol (a pill given as part of the procedure for medical abortions) at home had a 71% chance of completing their care in hospital within 9 hours with no overnight stay when having an abortion after 12 weeks of pregnancy, compared to 46% of those who took the first dose of misoprostol at hospital, finds a randomized controlled trial published in The Lancet . A medical abortion (also known as abortion with pills) involves taking two types of pills to end a pregnancy: mifepristone, which blocks the hormone progesterone therefore causing the lining of the uterus to break down, and misoprostol, which makes the womb contract. For abortions after 12 weeks of pregnancy, mifepristone is often given at a clinic to which the patient returns one to two days later to receive a first dose of misoprostol followed by additional doses of misoprostol every few hours until the abortion is complete. In this trial, all patients received the first dose of mifepristone in the clinic as usual, but some patients then took the first dose of misoprostol at home. Previous studies indicate that most medical abortions after 12 weeks of pregnancy are completed within eight to 12 hours after the first misoprostol dose and require an average of two to three misoprostol doses, with some patients needing to stay overnight in hospital.

Currently, most abortions after 12 weeks of pregnancy take place in hospitals and may require an overnight stay, which some women find stressful and isolating. Our trial results show that taking the first dose of misoprostol at home decreases the average time women spent in hospital, enabling them to leave the hospital within nine hours after admission and without an overnight stay. Offering the choice to take the first dose of misoprostol at home provides a safe and effective alternative to taking all misoprostol doses at hospital and enables women to self-manage some of the process, potentially leading to feelings of autonomy during a time where women can feel extremely vulnerable." Dr. Johanna Rydelius, Author, Sahlgrenska Academy, University of Gothenburg, Sweden

She adds, "Our study found 1% of the women who took misoprostol at home completed the abortion before attending hospital for the next dose. Previous studies suggest a 1% complete abortion rate within two hours after the misoprostol first dose, and women who took misoprostol at home were made aware of this risk when choosing to take part in the trial and provided with a number to call if they had any concerns. It's extremely important that women who are given the choice to take the first dose of misoprostol at home are clearly informed about the very small risk of the abortion occurring before attending the hospital." The study took place at six hospitals in Sweden between January 2019 and December 2022. All participants were given mifepristone oral pills at an outpatient clinic and provided with a time to return. Women between 12 to 22 weeks pregnant planning to undergo a medical abortion and who chose to take part in the trial were randomised to either receive their first dose of misoprostol at home or at the hospital. Women in the home treatment group administered the first dose of misoprostol vaginally at home and returned to hospital two hours later for the remaining treatment. Women in the hospital group self-administered the first dose of misoprostol upon arrival at the hospital. All participants then took repeated doses of misoprostol under the tongue every three hours until the abortion occurred. Of the patients in the home treatment group, 71% (156/220) spent fewer than nine hours at hospital, compared to 46% (99/215) of those in the hospital treatment group. There was no difference in the average pain score, types and number of side effects, or rates of admittance to hospital earlier than planned between the two groups. Two patients in the home treatment group (1%) had the abortion on the way to the hospital, between one to two hours after taking the first dose of misoprostol. The patients were asked to complete a follow up survey two to four weeks after the abortion. Five out of six participants in both trial arms (171/200 of those in the home treatment group and 152/188 of those in the hospital treatment group) said they were very satisfied with the care they received. When asked 'if you were to choose, where would you prefer to take the first dose of misoprostol?', 78% of women in the home group and 51% of women in the hospital group said they'd prefer to take the first dose of misoprostol at home. The authors acknowledge some limitations of the study, including that the researchers were advised by the Data and Safety Monitoring Board to end the trial early due to a lower-than-expected enrolment and slow progress towards the trial's target of 784 participants. However, trial site feedback suggests the lower-than-expected enrolment rate was not due to reluctance to take misoprostol at home but rather due to patients feeling overwhelmed by the overall situation.

Every patient who seeks abortion care must navigate a unique set of personal and medical circumstances. The choice of self-administering the first dose of misoprostol at home may provide some patients with a sense of autonomy and comfort during what can be a very overwhelming time in their lives. In addition, providing the option of the first dose of misoprostol at home would enable more abortion clinics with no overnight facilities to provide medical abortions for women who are over 12 weeks pregnant, something particularly important for locations where access to abortion care is limited." Prof. Kristina Gemzell Danielsson, The Karolinska Institutet, Sweden

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Writing in a linked Comment, Heidi Moseson and Caitlin Gerdts, Ibis Reproductive Health, USA, who were not involved in the study, said: "Increasing access to abortion later in pregnancy is a crucial component of the struggle for reproductive autonomy; it requires innovation, and evidence, and a willingness to listen to the needs and experiences of people having abortions. Judging from the overwhelming preference for at-home administration of misoprostol in the PRIMA Trial, moving towards a less clinically supervised model of medical abortion care later in pregnancy is an important first step."

Rydelius, J.,  et al.  (2024) First dose of misoprostol administration at home or in hospital for medical abortion between 12–22 gestational weeks in Sweden (PRIMA): a multicentre, open-label, randomised controlled trial . The Lancet . doi.org/10.1016/S0140-6736(24)01079-1 .

Posted in: Drug Trial News | Women's Health News | Pharmaceutical News

Tags: Abortion , Hormone , Hospital , Pain , Pregnancy , Progesterone , Reproductive Health , Tongue , Uterus , Womb

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• Case report
• Open access
• Published: 02 May 2018

A case report of spontaneous abortion caused by Brucella melitensis biovar 3

• Hong-Xia Yang 1 , 3 ,
• Jun-Jun Feng 2 ,
• Qiu-Xiang Zhang 1 ,
• Rui-E Hao 1 ,
• Su-Xia Yao 1 ,
• Rong Zhao 1 ,
• Dong-Ri Piao 3 ,
• Bu-Yun Cui 3 &
• Hai Jiang 3  

Infectious Diseases of Poverty volume  7 , Article number:  31 ( 2018 ) Cite this article

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Brucellosis is a worldwide zoonotic disease caused by Brucella spp. Brucella invades the body through the skin mucosa, digestive tract, and respiratory tract. However, only a few studies on human spontaneous abortion attributable to Brucella have been reported. In this work, the patient living in Shanxi Province in China who had suffered a spontaneous abortion was underwent pathogen detection and Brucella melitensis biovar 3 was identified.

Case presentation

The patient in this study was 22 years old. On July 16, 2015, she was admitted to Shanxi Grand Hospital, Shanxi Province, China because of one day of vaginal bleeding and three days of abdominal distension accompanied by fever after five months of amenorrhea. A serum tube agglutination test for brucellosis and blood culture were positive. At the time of discharge, she was prescribed oral doxycycline (100 mg/dose, twice a day) and rifampicin (600 mg/dose, once daily) for 6 weeks as recommended by the World Health Organization (WHO). No recurrence was observed during the six months of follow-up after the cessation of antibiotic treatment.

Conclusions

This is the first reported case of miscarriage resulting from Brucella melitensis biovar 3 isolated from a pregnant woman who was infected through unpasteurized milk in China. Brucellosis infection was overlooked in the Maternity Hospital because of physician unawareness. Early recognition and prompt treatment of brucellosis infection are crucial for a successful outcome in pregnancy.

Multilingual abstract

Please see Additional file  1 for translation of the abstract into the five official working languages of the United Nations.

Brucellosis is a worldwide zoonotic disease caused by Brucella spp. The Law of the People’s Republic of China on Prevention and Treatment of Infectious Diseases classifies it as a Class B infection. Brucella invades the body through the skin mucosa, digestive tract, and respiratory tract. Livestock infected with Brucella often undergo spontaneous abortion and infertility, and have low reproductive and survival rates. Humans infected with Brucella mainly manifest fever, sweating, fatigue, and arthralgia, and can also suffer damages to the nervous, circulatory, and reproductive systems [ 1 ]. However, only few studies on spontaneous abortion attributable to Brucella have been reported. In this work, a patient living in Shanxi Province in China who had suffered a spontaneous abortion underwent pathogen detection to analyse the genetic characteristics of the spontaneous abortion-related Brucella strain. This helps to provide a scientific basis for the prevention and control of Brucella infection in pregnant women.

The patient in this study was 22 years old. She was admitted to Shanxi Grand Hospital, Shanxi Province, China, on July 16, 2015 because of one day of vaginal bleeding and three days of abdominal distension accompanied by fever after five months of amenorrhea. This patient had a history of regular menstruation, and her last menstrual period had been on February 20, 2015. An immunoassay showed her urine to be positive for human chronic gonadotrophin. The patient had no fever during early pregnancy and did not have a history of exposure to toxic, harmful, or radioactive materials. Down’s syndrome screening performed as part of a regular second-semester prenatal checkup showed no obvious fetal abnormality. The patient had abdominal distension with fever and received anti-infective treatment at a local hospital three days before coming to Shanxi Grand Hospital. One day before coming to Shanxi Grand Hospital, she suffered vaginal bleeding. She was given conventional tocolytic treatment, but the outcome was poor. The patient was examined after hospital admission and had a body temperature of 39 °C, pulse rate of 120 beats/min, breath rate of 21 breaths/min, and blood pressure of 90/53 mmHg, but no cardiopulmonary or abdominal abnormalities. Specialist examinations showed minor abdominal swelling, irregular contraction of the uterus palpable at two fingers under the uterus and umbilicus, and a small amount of vaginal bleeding. The fetal membrane was slightly ruptured, and the fetal heart rate was 170–180 beats/min. A complete blood count showed 16.6 × 10 9 /L white blood cells, 78.4% neutrophils, 16.5% lymphocytes, 4.9% monocytes, 3.63 × 10 12 /L erythrocytes, 106 g/L hemoglobin, 202.1 × 10 9  g/L platelets, and 102.16 mg/L C reaction protein. Intravenous ceftriaxone (2 g/d), 25% magnesium sulfate, and antipyretic treatments were administered to the patient after her admission to Shanxi Grand Hospital, but the patient had a miscarriage and vaginal delivery of a female fetus on July 19. Her body temperature continued to fluctuate after admission, increasing to 39.3 °C the afternoon of July 19. Further questions about the patient’s medical history showed that this patient had sheep at home but never came into direct contact with them. However, she had begun to drink unpasteurized goat milk during her fourth month of pregnancy and was thus suspected of having Brucella infection. A serum tube agglutination test (SAT) for brucellosis and blood culture were immediately performed. The SAT result was 1:800, confirming brucellosis. This patient was given antibiotic treatment for three consecutive days. She was discharged from the hospital on July 24 because the fever stopped. At the time of discharge, she was prescribed oral doxycycline (100 mg/dose, twice a day) and rifampicin (600 mg/dose, once daily) for 6 weeks as recommended by the World Health Organization (WHO). No recurrence was observed during the six months of follow-up after the cessation of antibiotic treatment. The onset, diagnosis, and treatment of the disease in this patient are shown in Fig.  1 .

The onset and outcome of disease, diagnosis, and treatment

Serological testing

The diagnosis of brucellosis was based on the serum standard tube agglutination test (SAT). The SAT result was 1:800.

Pathogen detection

Five milliliters of venous blood from the patient were collected and injected into a two-phase culture flask for culture. After detecting bacterial growth in the culture, traditional biological methods were used for the isolation and identification of the bacteria [ 2 ]. With the reference to the standard strain B. melitensis 16 M, colony morphology, Gram stain reaction, CO 2 requirements, H 2 S production, inhibition of growth by basic Fuchsin and Thionin, agglutination with monospecific antisera, and phage lysis testing were performed. Serum and bacteriophage were provided by the Brucellosis Laboratory, National Institute for Communicable Disease Control and Prevention, and the Chinese Center for Disease Control and Prevention.

Specific sequences of the 16 MLVA primers are described in previous work [ 3 ]. The reaction system for genotyping included 10 μl 2 ×  Taq PCR Mastermix, 0.4 μl each of the 10 pmol/μl primers, and 1 μl DNA template, with sterile distilled water to a total volume of 20 μl. The amplification conditions were: 95 °C denaturation; 40 cycles of denaturation at 95 °C for 30 s, annealing at 60 °C for 30 s, and elongation at 72 °C for 30 s. Amplification products were analysed by microsatellite sequencing to convert the repeated unit according to the size of the PCR products. BioNumerics (Version 5.0) software was used for cluster analysis to perform an online comparison between the typing and the Brucella database. Nucleic acid extraction was performed using a bacterial whole genome nucleic acid extraction kit [Tiangen Biotech (Beijing) Co., Ltd., Beijing, China]. MLVA primers were synthesized by Sangon Biotech (Shanghai) Co., Ltd. (Shanghai, China), and STR microsatellite sequencing was performed by Tianyi HuiYuan Biotech Co., Ltd. (Beijing, China).

Seven housekeeper genes ( dnaK , gyrB , trpE , aroA , cobQ , gap , and glk ), one outer membrane protein gene ( omp25 ), and one intergenic region int-hyp were used as the target genes of MLST for synthesis of the corresponding primers and for PCR [ 4 ]. PCR products were purified and subjected to bidirectional sequencing. The sequencing was completed by Tianyi HuiYuan Biotech Co., Ltd.. The tested sequences were compared to the sequences of allelic genotypes of the corresponding genes. The MLST online tool ( http://pubmlst.org/perl/mlstanalyse/mlstan-alyse.=pubmlst ) was used to analyse the alleles in the sequence.

Five milliliters of whole blood were extracted from the patient on July 20 and were found to have bacterial growth on July 26. The colonies were collarless and transparent, round in shape, and with smooth surfaces. Conventional identification by microscopy showed colonies to be gram-negative short bacilli that did not produce hydrogen sulfide and had positive monospecific antisera agglutination. The basic Fuchsin and Thionin tests and the bacteriophage Bk test were positive, while the Tb and Wb tests were negative, indicating that the colony was B. melitensis biovar 3, commonly found in sheep and goats. For MLVA-16 typing (Additional file 2 : Table S1), panel 1 showed the sample to be a type 42 (1–5–3-13-2-2-3-2), belonging to the Eastern Mediterranean type; panel 2 typing showed the sample to be a 4–40–8-4-4-3-8-5, which was completely identical to the goat type 3 Brucella (2012167) strain in MLVA genotyping [ 5 ]. For MLST, the ST allele spectrum was 3–2–3-2-1-5-3-8-2, and MLST sequence typing was ST8 (Additional file 3 ) , which is a common sequence type found in China [ 6 ].

Discussion and conclusions

Spontaneous abortion is a common complication of brucellosis in animals. The infection tends to localize to the placenta, which is associated with erythritol (a bovine growth stimulant). Although erythritol is not present in human placental tissues, brucellosis can lead to spontaneous abortion in human, especially in early pregnancy [ 7 ]. Khan et al. studied 92 cases of brucellosis during pregnancy in a hospital in Saudi Arabia during 1983–1995 and found a rate of spontaneous abortion in the first and second trimesters of 43% [ 8 ]. Roushan et al. studied 19 cases of brucellosis during pregnancy in the Babol region in Iran and observed 10 cases of spontaneous abortion, accounting for 53% of all cases [ 9 ]. Al-Tawfiq et al. reviewed the literature covering brucellosis during pregnancy from 1954 to 2011 and found that the incidence of spontaneous abortion and stillbirth among 430 cases ranged from 31 to 46%, which was much higher than in other pregnant women [ 10 ]. However, Gulsun et al. conducted a case-control study on brucellosis during pregnancy from 2003 to 2010 and showed no significant differences in fetal congenital malformations and/or mortality between patients infected with Brucella and the control group, but Brucella did cause premature birth and low birth weight [ 11 ]. The present case study of brucellosis-induced spontaneous abortion in the second trimester provides clinical evidence for miscarriage caused by Brucella infection. The B. melitensis biovar 3 isolated from the blood culture belonged to the dominant strain found in Shanxi Province. Further study of the mechanism underlying miscarriage caused by Brucella will be necessary, and genome sequencing is in progress.

Milk from cattle, goats, and other animals with brucellosis contains large numbers of Brucella . It is possible to acquire brucellosis through the consumption of unpasteurized milk and dairy products [ 12 ]. The symptoms of brucellosis are atypical, and cases are easily misdiagnosed. In this study, the patient was treated in our hospital due to miscarriage and atypical symptoms of brucellosis. However, during her hospitalization, the patient did not immediately mention consuming goat’s milk. Although our staff had been actively looking for the cause of the fever, we only suspected Brucella infection after the patient’s miscarriage. We confirmed the diagnosis five days after her admission to the hospital.

It is difficult for antibiotics and antibodies to enter cells, so single-drug therapy cannot completely eliminate the bacteria. The WHO Expert Committee recommends brucellosis be treated using a combination of doxycycline (200 mg oral admission daily) and rifampicin (600–900 mg oral admission daily) for six weeks [ 7 ]. In this study, the patient was given combination therapy of doxycycline and rifampicin for six weeks and showed no recurrence during follow-up. The basic factor in the treatment of brucellosis is to ensure the effectiveness and adequate course of antibiotic treatment. Patients are urged to complete their full course.

In summary, this is the first reported case of miscarriage resulted from Brucella melitensis biovar 3 isolated from a pregnant woman who was infected through unpasteurized milk in China. Brucellosis infection was easily overlooked in the Maternity Hospital because of physician unawareness. The early recognition and prompt treatment of brucellosis infection are crucial for a successful outcome in pregnancy.

Abbreviations

Multilocus sequencing typing

Multiple-locus variable number tandem repeat analysis

Sequencing typing

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Acknowledgements

We are grateful to Hong-Yan Zhao and Guo-Zhong Tian for experimental guidance.

This study was supported by the Science and Technology Project of the Shanxi Province Health and Family Planning Commission (No. 2011077) and the National Natural Science Foundation of China (No. 81271900). The funders contributed to the study design and data collection.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

Author information

Authors and affiliations.

Disease Inspection Laboratory, Shanxi Center for Disease Control and Prevention, Taiyuan, China

Hong-Xia Yang, Qiu-Xiang Zhang, Rui-E Hao, Su-Xia Yao & Rong Zhao

Clinical Laboratory, Shanxi Dayi Hospital, Taiyuan, China

Jun-Jun Feng

State Key Laboratory for Infectious Disease Prevention and Control, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China

Hong-Xia Yang, Dong-Ri Piao, Bu-Yun Cui & Hai Jiang

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H-X Y performed the majority of the pathogen detection testing, coordinated all work related to the study, performed data analysis, drafted the manuscript, and participated in the design of the study; J-J F collected the case clinical data; R-E H, S-X Y, R Z, and D-R P performed MLVA and MLST and participated in data analysis; B-Y C participated in the design of the study and critically reviewed the manuscript. H J participated in the design of the study and managed the project. All of the authors read and approved the final manuscript.

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Correspondence to Hai Jiang .

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This research was carried out according to the principles of the Declaration of Helsinki and was approved by the Ethics Committees of the National Institute for Communicable Disease Control and Prevention and the Chinese Center for Disease Control and Prevention (No.: ICDC-2014005). No animal work was carried out as part of this study.

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Yang, HX., Feng, JJ., Zhang, QX. et al. A case report of spontaneous abortion caused by Brucella melitensis biovar 3. Infect Dis Poverty 7 , 31 (2018). https://doi.org/10.1186/s40249-018-0411-x

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DOI : https://doi.org/10.1186/s40249-018-0411-x

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The horror of unsafe abortion: case report of a life threatening complication in a 29-year old woman

Kaniz zehra naqvi.

1 Liaquat National Hospital and Medical Collage, 402, Al jannat plaza, M.A.Jinnah road, Karachi, Pakistan

Muhammad Muzzammil Edhi

Every year 42 million women with unintended pregnancies choose abortion, and fifty percent of these procedures, 20 million are unsafe. An unsafe abortion is defined as a procedure for terminating an unintended pregnancy carried out either by person lacking the necessary skills or in an environment that does not conform to minimal medical standards or both.

Pakistan is the one of the six countries where more than 50% of the world’s all maternal deaths occur. It is estimated that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1000 women aged 15-49.

Case presentation

Here we present a case report of a 29-year old woman who underwent an unsafe abortion for unintended pregnancy resulting in uterine perforation. The unskilled provider pulled out her bowel through vagina after perforating the uterus, as a result she lost major portion of her small intestine resulting in short bowel syndrome.

The law of Pakistan only allows abortion during early stages of pregnancy for purpose of saving the life of a mother but does not cater for cases of rape, incest and fetal abnormalities or social reasons.

Only legalization of abortion is not sufficient, preventing unintended pregnancy should be the priority of all the nations and for this reason contraception should be widely accessible.

Practitioners need to become better trained in safer abortion methods and be to able transfer the patient to health facility when complications occur.

Pakistan is the one of the six countries where more than 50% of the world’s all maternal deaths occur [ 1 ].

It is estimated that 890,000 induced abortions are performed annually in Pakistan, and estimate an annual abortion rate of 29 per 1000 women aged 15-49 [ 2 ].

According to World Health Organization, every 8 minutes a women in a developing nations will die of complications arising from an unsafe abortion [ 3 ]. The fifth United Nations Millennium Development Goal recommends 75% reduction in maternal mortality by 2015. WHO deems unsafe abortion one of easiest preventable causes of maternal mortality and a public health issue.

Throughout Europe, except for Ireland and Poland, abortion is broadly legal, widely available and safe. Even United States legalized abortion nationwide and this is because of the realization that restrictive policies were instead of ending abortion were putting pressure on public health especially on those who could not afford to pay for safe abortion. Today, 60% of the world’s 1.55 billion women of reproductive age(15-44) live in countries where abortion is legal, the remaining 40% live where abortion is highly restricted, virtually all of them in developing countries [ 4 ]. Data suggests that even as the overall abortion rate has declined, the proportion of unsafe abortions is on the rise, especially in the developing nations [ 5 ]. It is clear that in those countries where contraceptive use increased the most, abortion rate dropped significantly but in countries like Pakistan which has 25% unmet need of contraception the incidence of unsafe abortion is still high 29 per 1000 women aged 15-49 [ 2 ].

Approximately 1 in 10 pregnancies end in an unsafe abortion, giving a ratio of 1 unsafe abortion to about 7 live births [ 6 ]. Approximately eighty million more women per year suffer post abortion complications that can lead to short or long term consequences [ 4 ].

Highest incidence of unsafe abortion takes place in Latin America, Africa and South East Asia [ 3 ]. According to Pakistan demographic survey 2006–7 with total fertility rate at 4.1%, stagnant contraception prevalence rate 29.6% and high 25% unmet need for contraception, and 1 out of every 4 birth unwanted, prospects of achieving MDG 4and 5 by 2015 look bleak [ 7 ].

It should not therefore come as a surprise that unwanted pregnancies are the leading cause of induced abortion in Pakistan [ 8 ].

40% of these abortions are performed by unskilled workers in back street clinics.

It is seen that in countries with restrictive laws, the women who are determined to end an unwanted pregnancy will seek out clandestine means. In Pakistan where average earnings of a person are less than $2 per day and fee for doctor assisted abortion is around $50-104, the services provided by untrained persons thrive. The shaming, blaming and the judgemental or punitive attitude of the staff are another factor which prevents these females from seeking post abortion medical care. So changing the laws is no guarantee that unsafe abortion will not take place. In Zambia a study findings revealed, high ratio of induced abortion mortality and more than half of those deaths were of schoolgirls. Although abortion is legal in Zambia on social and medical grounds but most females choose illegal abortion because of being expelled from school, unwillingness to reveal relationship, to protect the health of their previous baby [ 9 ].

The main causes of death or morbidity from unsafe abortion is due to haemorrhage, sepsis, genital trauma and bowel injury. Here we are presenting a case report of unsafe abortion in a young woman which resulted not only in unrecognized perforation of uterus, but also the removal of a significant portion of her small intestines via the uterine perforation and introitus causing severely shortened intestines and infection. The procedure was performed by an unskilled worker in one of the back street clinic of the city.

Case report

At 9 pm a ‘29-year old female’ Para 0 +0 was admitted via Accident and Emergency department of our hospital complaining of severe abdominal pain starting earlier in the afternoon. She reported recent attempts at termination of a 10 weeks unplanned and undesired pregnancy at an outside clinic. According to the patient about three to four weeks earlier as a part of workup done for fever revealed pregnancy of about 10 weeks duration. She took some abortificient to abort this unintended pregnancy. She developed bleeding per vagina following that, for which she had uterine evacuation at some small clinic. After that she came home, but next day she started to bleed heavily per vagina, so she went back to the same place and was prescribed tablet misoprostol twice daily. According to her she took this tablet for 1 week but as she continued to bleed so she again visited the same clinic and second uterine evacuation was performed on her. After 2 or 3 days she returned to the same clinic because her bleeding had not yet subsided. A third attempt on uterine evacuation was made but this time there was lots of pain which was unbearable, so the person attempting the evacuation gave her some intravenous sedation and completed her job. After returning home, the patient almost collapsed due to severe pain, so her family brought her to hospital.

On presentation to our hospital she was conscious, pale and in obvious discomfort, her BP was 115/77 mm Hg, pulse 99/min, temperature was 99.2°F. Abdominal examination revealed generalized tenderness and guarding all over the abdomen. Bowel sounds were absent. On per vagina examination, there was no active bleeding but vagina was hot, uterus was about 10–12 weeks size, mobile and cervical os was closed. Her blood investigation showed Hb 7 gm/dl, white cell count 9.6 × 10 9 /l, platelets were 278 × 10 9 /l. urea, creatinine and electrolytes were all within normal limits. Ultrasound pelvis showed fluid with echoes in pelvis, an empty uterus and normal looking ovaries. Suspecting uterine/bowel injury we also asked for x-ray abdomen both erect and supine and it showed gas under the diaphragm. A clinical diagnosis of uterine perforation leading to bowel injury was made and laparotomy planned after resuscitation of patient.

During the exploratory laparotomy, hemoperitoneum of about 500–800 ml was noted, additionally two separate segments of small bowel were identified lying at a distance from each other and in between mesentery was all bruised and necrosed (Figure  1 ).

Cut ends of small bowel.

When the bowel was run, we found that only about one and half feet of small bowel from duodeno-jejunal flexure and about 6 inches from ilieo-caecal junction intact, rest of the small bowel was missing completely. It transpired that while doing the evacuation the person had removed the whole of small gut except for those two small pieces. We also found a 2.5 cm perforation in the anterior wall of uterus close to cervical canal (Figure  2 ).

Perforation in anterior wall of uterus.

After resecting the nonviable portion of intestines an end to end anastomosis was performed. Primary repair of uterine perforation was done. Abdominal cavity washed and closed leaving a drain behind. Post operatively she was kept in high dependency unit. 3 units of packed red cells were transfused, broad spectrum antibiotics and intravenous fluids were given. She responded well to the treatment, on third post-operative day the intra-abdomen drain was removed and she was discharged on tenth post-operative day.

At the time of discharge the patient and her family was counselled regarding the implications of losing a major portion of her small bowel. They were told that she will suffer from repeated bouts of diarrhoea which may cause dehydration and malnutrition. Advice regarding small frequent meals, fluid in the form of ORS, nutritional supplements and medication to control diarrhoea was given. She was also referred to psychologist for support and therapy.

She was admitted twice through accident and emergency for treatment of dehydration because of diarrhoea. She has been under regular follow up and though has lost weight but her diarrhoea has improved.

Psychological support in the form of counselling of both the family and the patient was carried out but since there are no established support groups so whatever was done was on individual basis.

Uterine perforation and bowel injuries are the major complications after unsafe abortion. The reason for these complications is that most abortions are done by untrained personals i.e. unskilled workers in very unhygienic conditions [ 10 , 11 ]. The same happened with this unfortunate woman, the person doing the evacuation did not recognise that she had perforated the uterus and what she was pulling out was intestines and as a result this woman ended up with only one and half to two feet of small intestine. In one study 11.2% had bowel injury and most of the abortions were performed by unskilled workers [ 12 ]. In another study done at Khyber medical college and hospital in Peshawar Pakistan the incidence of gut injury after induced abortion was about 42% [ 13 ]. Despite the adverse outcome of abortions, the low socio-economic status of these women compels them to resort to abortion rather than practicing contraception as it entails a ‘one time’ cost compared to recurrent cost of buying contraception [ 8 ]. These unqualified providers are easily accessible to the clients in countries such as Pakistan.

Even safe abortions in the developing countries are still risky because it depends on the health facility, the training of the provider and the gestational age of the fetus. With unsafe abortion the risk of maternal morbidity and mortality depends on method of abortion and the willingness of the women to seek post abortion care [ 14 ].

Data on nonfatal long term health consequences are poor, but those documented are infertility, stool or urinary incontinence due to bowel or bladder injury and bowel resection along with psychological trauma.

There is a relationship between unsafe abortion and restrictive abortion laws. The median rate of unsafe abortions in the 82 countries with the most restrictive abortion laws is up to 23 of 1000 women compared with 2 of 1000 in nations that allow abortion [ 15 ].

Less restrictive abortion laws do not appear to increase the abortion rate overall. The world’s lowest rate is in Europe, where abortion is legal and easily available because the contraception use is high. Compared to Latin America, Africa and south east Asia where abortion laws are more restrictive and contraception use is low the rates ranges from mid 20 s to 39 per 1000 women [ 16 ].

In developing countries, two third of unintended pregnancies occur in women who are not using any contraception.

Complications due to unsafe abortion account for an estimated 13% of maternal deaths world over or 70,000 deaths per year [ 17 ].

Unsafe abortion is a significant problem both medical and social worldwide. It is seen that in developing countries most unsafe abortions are carried out by untrained persons resulting in high morbidity and mortality [ 18 ].

To reduce the morbidity and mortality associated with unsafe abortions, intensive dissemination of information and commitment at all levels is required. Use of various contraceptive methods should be promoted in order to prevent unintended pregnancies. Governments and non government organizations should find ways and means to overcome cultural and social misconceptions which restrict women from receiving health care.

Regular training courses for traditional birth attendants, nurses and doctors under the supervision of expert obstetrician should be carried out. All those facilities which provide such services should have appropriate equipment and trained staff and the service is provided at a reasonable cost. Post abortion family planning counselling should be the part of the service.

There is evidence that liberalizing abortion laws results in reduction in abortion related morbidities and mortalities but here the role of socio-political and religious organization comes into play.

By preventing 5 million abortions related complications and deaths worldwide we can save 220,000 children from becoming motherless.

Written informed consent was obtained from the patient for publication of this Case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interest

The authors declare that they have no competing interests.

Authors’ contributions

MME did manuscript drafting and KZN did critically review the manuscript. Both authors approved the final document of manuscript.

Acknowledgement

We great fully acknowledge all the staff member of obstetrics and gynaecology department of Liaquat National Hospital, Karachi, Pakistan for their help and cooperation.

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