Abortion Care Varies Highly Across the US, New Report Says

Troy Brown, RN

March 19, 2018

An updated consensus study report from the National Academies of Sciences, Engineering, and Medicine found the quality of abortion care in the United States varies greatly depending on where a woman lives, and this disparity is largely the result of differences in state regulations.

The report on the safety and quality of abortion care in the United States was released on March 16, with an accompanying media teleconference.

It updates the last report, published in 1975, just 2 years after the US Supreme Court decision Roe v Wade legalized abortion. Nationwide data collection was just beginning at that time.

"There is a great deal of related scientific research, including well-designed randomized controlled trials...systematic reviews, and epidemiological studies examining the relative safety of abortion methods and the appropriateness of methods for different clinical circumstances. With this growing body of research, medical and surgical abortion methods have been refined or discontinued, and new techniques have been developed," the report authors write.

Commenting on the scope of the report, committee member Eva K. Pressman, MD, Henry A. Thiede Professor of Obstetrics and Gynecology and chair, Department of Obstetrics and Gynecology, University of Rochester, New York, noted: "We were able to look at studies that involve hundreds of thousands of patients, which really makes abortion in some cases better studied than almost any procedure that is done in the medical profession."

Too Many Regulations Compromise Quality of Abortion Care on Offer

Abortion is one of the most regulated procedures in the United States, Helene D. Gayle, MD, president and chief executive officer, Chicago Community Trust, Illinois, and cochair of the committee that wrote the report, said during the teleconference.

Regulations vary from aspects that relate to timeliness, things such as mandated waiting periods, required in-person counseling visits, or the detail about what is necessary in facilities, she noted. There are also "limitations on private and public health insurance, and the provision of information that is not medically accurate as a part of counseling for women," Gayle said.

These upshot of all of these regulations is that they limit the availability and quality of abortion services for women.

"[I]t was really striking that so many of the regulations really have an effect of potentially compromising quality for women. I don't think that's the intention of the regulations, but that is the impact in many cases," committee member Alina Salganicoff, PhD, vice president and director of Women's Health Policy, the Kaiser Family Foundation, San Francisco, California, noted during the teleconference.

There are cases where women are given incorrect information around long-term effects of abortion, such as concerns about the future potential for breast cancer or effect on fertility.

"That is an issue that really violates the accepted standards of informed consent," Salganicoff stressed.

Moving on to discuss the specific issue of medical abortions, the researchers noted that mifepristone is used, and medical abortions are performed up to 10 weeks of gestation. The US Food and Drug Administration restricts the distribution of mifepristone to patients in clinics, hospitals, or medical offices, and only under the supervision of a certified prescriber.

It "cannot be sold in retail pharmacies," the authors write.

The committee could find no evidence about the effect of this restriction on the safety or quality of abortions.

The committee also found no evidence that clinicians who provide abortions require hospital privileges to provide safe services, but they should have a plan in place to arrange for patient transfer to medical facilities that can provide surgical intervention and critical care, if necessary, the report states.

Serious Complications Rare

There are four types of abortions, and the type of termination a woman receives depends largely on how far along she is in the pregnancy.

The advent of highly sensitive home pregnancy tests that allow women to detect pregnancy early and the availability of medical abortion have made it possible for women to obtain abortions early in pregnancy: Half of all abortions are performed during the first 7 weeks, and 90% occur during the first 12 weeks.

Medication and aspiration abortions are the most frequently used methods, and together constitute about 90% of all terminations performed in the United States.

"[A]s with all medical interventions, abortion care has continued to evolve and improve in terms of having a greater safety and additional options. The advent of medication abortions is a great example of how things have really changed, providing services that are extremely safe and can be provided early in pregnancy," committee cochair B. Ned Calonge, MD, associate professor of family medicine and epidemiology, University of Colorado, Denver, said during the telebriefing.

Dilation and evacuation and induction abortions occur later in pregnancy. Even with these methods, serious complications are rare and are lowest the earlier in gestation they are performed, "and most of these procedures can be safely provided in office-based settings," he said.

Calonge added that trained nurse practitioners, midwives, and physician assistants can safely provide medication and aspiration abortions, although they require "more specialized surgical skills and experience." Facility requirements and safeguards are similar to those for other office-based procedures.

The biggest driving factor in the need for additional equipment is when there are deeper levels of sedation used for pain management, he explained.

No Long-term Risks, Other Than With Multiple Abortions

Committee member Carol J. Rowland Hogue, PhD, professor of epidemiology and Jules and Uldeen Terry Chair of Maternal and Child Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, said one of the concerns in the 1975 report was on long-term effects of abortion.

The studies performed to examine this aspect, fairly consistently and in hundreds of thousands of women, "show that there is no increased risk of breast cancer or of mental health conditions or of [future] preterm birth (ie, under 37 weeks' gestation), which has been controversial until very recently," she explained.

The committee also found no evidence of an association with difficulties in future childbearing, including fertility issues, abnormal implantation, abnormal attachment of the placenta, ectopic pregnancy, or hypertensive disorders of pregnancy, Calonge said.

He added, "We did find that two or more abortions prior to first birth was associated with an increased risk of very premature birth; that is, less than 27 weeks. That risk seemed to increase with the number of abortions above two."

Abortions Fall, and There Are Fewer Clinics Now, Which Limits Access

The report details the fact that abortion rate in the United States fell from 29 per thousand in 1980 to about 14 per thousand in 2014. Reasons for this include increased use of contraception and regulatory changes, although the extent to which each of these factors is responsible for the drop is unclear.

From 2011 to 2014, the number of abortion clinics fell by 17%, and 39% of women of reproductive age lived in a county with no abortion provider.

In 2017, half of the states had five or fewer abortion clinics and five had only one clinic. Approximately 17% of women must travel more than 50 miles to receive an abortion.

Most women who obtain abortions are younger than 30 years of age (72%), are unmarried (86%), and are poor (75%).

The reason for this "seems to be because women who have limited resources also have higher rates of unintended pregnancy. Given an unintended pregnancy, they're no more likely to have an abortion, but...they do have higher rates of unintended pregnancy," Hogue said.

The committee also investigated whether or not low-income women receive support as needed for seeking abortion care.

In conclusion, Gayle observed that is up to individual practitioners to decide how they will use the information in the report: "This is a report that hopefully will give people the evidence base that is helpful to them depending on whether they're a policy maker or a practitioner."

The committee members will hold a public webinar at noon EDT on Friday, March 23, to present their findings and recommendations and to answer questions.

National Academies of Sciences, Engineering, and Medicine. "The Safety and Quality of Abortion Care in the United States." Full text

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