Chapter 1: Research on Post-Abortion Complications: An Overview

• Limitations exist in the available literature on physical after-effects of abortion.
• There are no standard reporting procedures of complications after abortions in Canada, the United States, or by WHO (the World Health Organization), and those complications which are reported, are only short term.
• The abortion question in North America is very politicized, which may explain why reported negative sequelae are significantly fewer than in medical reports from other countries.
• Since the 1970s, there has been a marked increase in North America in the number of abortions and repeat abortions, which may explain the significant increases in pelvic inflammatory disease (PID), uterine hemorrhage, sepsis, pain due to endometritis, retained fetal or placental tissue, and the increasing evidence of an abortion-breast cancer link.
• What accounts for the significantly lower reporting of negative sequelae after abortion in North America? Are its abortion services more efficient, or are they missing complications as a result of relying on short-term follow up and incomplete coding?
• This study will examine long-term effects of abortion on women's health and the importance of "informed consent" for women considering abortion.

Chapter 1 contains fourteen endnotes including:
12 Royal College of Obstetricians and Gynaecologists (UK). The care of women requesting induced abortion: 4. information for women. 2000.www.rcog.org.uk/guidelines/induced_abortion.html.

Chapter 2: Induced Abortion and Breast Cancer

• Abortion increases a woman's overall risk of breast cancer by 30 per cent.
• The risk is likely much higher in women who have a first abortion at a young age, or who have a family history of breast cancer.
• Since 1957, 23 of 37 worldwide studies show an increased breast cancer risk with abortion, a risk as high as 310 per cent.
• Ten of fifteen U.S. studies confirm the abortion-breast cancer link.
• The biological rationale for breast cancer development is related to the woman's unprotected internal exposure to estrogen when a pregnancy is abruptly terminated early in gestation.
• The magnitude of the risk has, until recently, been hidden by studies of poor quality, many of which have failed to separate induced abortion from low-risk spontaneous miscarriage.
• The medical establishment is often slow to accept and respond to emerging data, slowed further, in this case, by the conflicting politics of abortion.

Chapter 2 contains 25 endnotes including:
Daling JR, Malone KE, Voigt LF, White E, Weiss NS. Risk of breast cancer among young women: relationship to induced abortion. Journal of the National Cancer Institute 1994 Nov(2);86(21):1584-92.

Chapter 3: Induced Abortion and Other Cancers

• A history of previous induced abortion(s) may play a role in cancers of the reproductive system and rectal cancers.
• Inconsistencies between studies and countries where the studies are done, in addition to the fact that in the literature, spontaneous and induced abortions are often not separated, make it difficult to draw definitive conclusions.
• Recent studies have connected a higher risk of cervical and ovarian cancers to previous abortions, though the degree of risk varies from study to study.
• A consistent finding has been the protective effect of full-term pregnancies against the onset of cancers of the reproductive system.
• Researchers have found a connection between abortion and rectal cancer.
• With reproductive and rectal cancers on the increase in women, more studies are needed, specifically to examine the connection between abortion and cancer.

Chapter 3 contains twelve endnotes including:
Kvale G, Heuch I. Is the incidence of colorectal cancer related to reproduction? A prospective study of 63,000 women. International Journal of Cancer 1991 February 1;47(3):390-5, p. 392.

Chapter 4: Impact on Subsequent Pregnancies

• Subsequent pregnancies are negatively affected by induced abortion.
• The main complications are: cervical incompetence leading to future miscarriages; uterine perforations and placenta previa with serious implications to the health of the woman and her child(ren) in later pregnancies; and ectopic pregnancies which, if undiagnosed and not treated, can lead to a woman's death.
• Forty-nine studies of preterm or premature births from Europe and North America found increased risks ranging from 30 per cent to 510 per cent.
• The consequence of this significantly increased risk of prematurity after abortion is that the rate of cerebral palsy among premature infants weighing less than 1500 grams at birth is 38 times greater than among the general population. Induced abortion, in other words, is directly responsible for many thousands of cases of cerebral palsy - in North America alone - that otherwise would not have occurred.
• Despite the data which point to the link between induced abortion and future serious health risks, many North-American research studies fail to point these out.
• Numerical data should be carefully compared to research abstracts and conclusions because they often do not correlate; in other words, where data clearly indicate increased health risks, they are often minimized in the abstracts and conclusions of medical articles.
• In light of the growing knowledge of the impact of abortion on the rate of prematurity, abortion providers soon incur greatly increased liability for obtaining informed consent for women contemplating abortion.

Chapter 4 contains 34 endnotes including:
Luke, B. Every Pregnant Woman's Guide to Preventing Premature Birth.1995 [foreword by Emile Papiernik], New York: Times Books; p.32.

Chapter 5: Future Fertility

• No previous births and an earlier abortion put a woman at significant risk of post-abortion complications leading to possible infertility.
• Coding systems at hospitals often make it difficult to link abortion with medical sequelae.
• Much larger numbers of women than previously suspected are negatively affected by induced abortion with PID and ectopic pregnancies at much higher levels than ever before in North America and Europe.
• Other serious sequelae also on the rise are uterine perforations, endometriosis, Chlamydia trachomatis, endometrial ossification (bone fragments left in the uterus), all of which compromise future fertility.
• Many of these medical problems go undetected at the time of abortion and are only discovered years later when women are treated for infertility.

Chapter 5 contains 50 endnotes including:
Ruiz-Velasco V, Gonzalez Alfani G, Pliego Sanchez L, Alamillo Vera M. Endometrial pathology and infertility. Fertility and Sterility 1997 April;67(4):687-92 p. 692.

Chapter 6: Maternal Mortality

• Women die from abortion-related problems but, owing to irregular and biased reporting, it is difficult to know how many.
• Reasons for maternal mortality related to abortion are many, including hemorrhage, infection, embolism, ectopic pregnancy, and cardiomyopathy.
• Coding deaths in hospitals and reasons for death on death certificates frequently record only the presenting problem as the cause of death, which results in many abortion-related deaths going unreported.
• The American Medical Association (AMA) relies on the Centers for Disease Control (CDC) for its statistics concerning abortion-related deaths and, given that the CDC uses hospital and clinic records (which underreport maternal deaths from abortion) for its data, the AMA does not recognize the full extent of abortion-related deaths.
• At most risk of abortion-related deaths are African-American and other minority women.
• A large-scale, authoritative Scandinavian study establishes post-pregnancy death rates within one year that are nearly four times greater among women who abort their pregnancies than among women who bear their babies. The suicide rate is nearly six times greater among aborting women than among women who give birth. These findings refute the oft-heard claim that induced abortion is safer than childbirth.
• There is an urgent need for independent studies of maternal mortality related to abortion, and medical facilities should be required to keep more accurate and informative records so that women may be better served in this area.

Chapter 6 contains 24 endnotes including:
18 Gissler M, Hemminki E and Lonnqvist J. Suicides after pregnancy in Finland, 1987-94: register linkage study. British Medical Journal 1996 December 7;313(7070):1431-4.

Chapter 7: Repeat Abortion

• There have been no attempts to study the effects of repeat abortion on women's future fertility.
• Women's reproductive histories when being treated for gynecological problems such as Asherman's Syndrome, PID, and cervical incompetence, often reveal one or more past abortions.
• A significant number of women who experience pregnancy loss have had multiple induced abortions.
• Many women are not aware of the connection between repeat abortion and their future ability to have children.
• There is a need for studies that focus directly on the connection between multiple abortions and pregnancy loss and that inform women of the risks of repeat abortion to their future health.

Chapter 7 contains seven endnotes including:
Koonin LM, Strauss LT, Chrisman CE, Parker WY. Abortion surveillance--United States, 1997. Morbidity and Mortality Weekly Report, Centers for Disease Control, Surveillance Summaries 2000 December 8;49(SS-11):1-43, p.39 (Table 13).

Chapter 8: Drug-induced or "Medical" Abortion

• With the introduction of RU-486 and other similar drugs women can now avoid surgical abortion to terminate a pregnancy.
• There are no long-term, follow-up studies of the consequences of drug-induced or "medical" abortion.
• Studies show that some women choose drug-induced abortion because they consider it "more natural."
• Drugs, however, are not always effective in expelling the fetus. This can lead to a second, surgical, abortion.
• There are a number of unpleasant side effects, including nausea, various gastrointestinal discomforts, prolonged bleeding, and infections sometimes leading to subsequent surgical abortion.
• Pain is an issue for many women and needs further study.
• Many of these unpleasant sequelae are understated in the North-American literature on abortion, leading to the question: Are women in Canada and the United States being fully informed of the medical risks of the procedure?

Chapter 8 contains 22 endnotes including:
Christin-Maitre S, Bouchard P, Spitz IM. Medical termination of pregnancy. New England Journal of Medicine 2000 March 30;342(13):946-956, p.954.

Chapter 9: Pain

• Pain during and after abortion has been inadequately studied.
• Women report pain levels that are usually much worse than suggested in pre-abortion counseling.
• Severe pain after abortion is strongly linked to depression before and after abortion.
• Pain can be a key indicator of serious medical complications, a fact not often told to women.
• Pain levels reported by women may be dismissed or minimized in surveys conducted by abortion practitioners.
• There need to be more independent studies on the connection of abortion to pain.

Chapter 9 contains thirteen endnotes including:
Holt VL, Daling JR, Voigt LF, McKnight B, Stergachis A, Chu J, et al. Induced abortion and the risk of subsequent ectopic pregnancy. American Journal of Public Health 1989 September;79(9):1234-8.

Chapter 10: When Abortion Fails

• Failure of abortion, though infrequent, is a complication of the procedure.
• The woman can decide to attempt another abortion or to continue her pregnancy.
• Children born after a failed abortion may have limb or digit abnormalities and other congenital problems, though a number of infants with no defects are born.
• Drug-induced abortions are more likely to fail than surgical abortions partly because drug dosages which would ensure that the fetus is stillborn would yield in the mother "unacceptably high levels of side effects". (See note 9.)
• Maternal grief and guilt are concerns after a failed abortion.
• More research is needed in this area.

Chapter 10 contains twelve endnotes including:
Grimes D. Medical abortion in early pregnancy: A review of the evidence [Review]. Obstetrics & Gynecology 1997 May;89(5 Pt 1):790-6, p. 793.

Chapter 11: Psychological Risk Factors

• Women who have abortions are at risk of emotional difficulties after the procedure, especially those with pre-existing factors such as relationship problems, ambivalence about their abortion, adolescence, previous psychiatric or emotional problems, pressure by others into making a decision to abort, or religious or philosophical values that are at odds with aborting a pregnancy.
• The prevailing interpretation of post-abortion grief, depression, guilt, anger, and anxiety in abortion clinics and research studies in North America is that they are due, not to the procedure, but to a woman's pre-existing disposition to psychological problems.
• Where support through counseling is offered (for example, in Sweden) to pregnant women who are not sure if they should or can carry their pregnancy to term, they are more likely not to abort.
• Given the evidence that women in certain risk groups are more emotionally vulnerable after an abortion, should abortion clinics and medical facilities consider recommending against abortion in their cases? This question has become crucial given recent findings that women who abort are much likelier to commit suicide.
• Informed consent for the psychological well-being of women, post-abortion, is an issue which health care professionals should address.

Chapter 11 contains 53 endnotes including:
The Emotional Effects of Induced Abortion. Fact Sheet. New York: Planned Parenthood Federation of America, May 2000.

Chapter 12: Abortion after Prenatal Testing

• Prenatal diagnosis is increasingly seen as a routine part of prenatal care, yet in the minds of pregnant women and their partners it is rarely linked explicitly to abortion.
• The growing amount of available genetic information about individual fetuses over the past decade has increased the likelihood that a woman will opt for abortion, perhaps at a late stage in her pregnancy.
• When testing reveals a fetal anomaly the pregnant woman and her partner are usually urged to make the decision to terminate quickly.
• Terminating a pregnancy because of a major fetal malformation is often a shattering experience for women. The grief, guilt, and depression experienced after a genetic abortion can come as a complete surprise to many couples.
• These negative experiences occur whether the pregnancy has been planned or unplanned.
• The decision to abort for genetic reasons can also have a negative impact on living children.
• Positive information needs to be given about the choice of parenting a child with special needs resulting from physical or mental handicaps.

Chapter 12 contains 80 endnotes including:
Brown D, Elkins TE, Larson DB. Prolonged grieving after abortion: A descriptive study. The Journal of Clinical Ethics 1993 (4):118-123.

Chapter 13: Multifetal Pregnancy Reduction

• For couples who cannot conceive a child, there is a very strong motivation to do whatever is medically recommended in order to have a child, whether using in vitro fertilization (IVF) or multifetal pregnancy reduction (MFPR). With either method there is the possibility of coercion by medical personnel.
• IVF is often used in cases of long-term infertility, and sometimes as many as nine cycles of treatment are needed for conception to take place, often resulting in three or more implanted fetuses.
• An approach doctors currently recommend to ensure a living birth in multifetal pregnancies is MFPR, a form of abortion (a needle stab to the heart) to reduce the number of fetuses. This procedure does not guarantee that the remaining fetuses will remain healthy, but it usually results in at least one live birth.
• Parents' reactions to the loss of some of the fetuses conceived are similar to those experienced after abortion for genetic reasons: sadness, guilt, and depression.
• Too often MFPR is assumed by the medical and research community to be what the parents want without obtaining true informed consent or giving them a choice about the number of fetuses to be kept alive.
• More research needs to be done into the effects of MFPR on couples and on their future family life with the surviving babies. This research should be carried out by investigators not already involved in performing and advocating this procedure.

Chapter 13 contains 29 endnotes including:
Schreiner-Engel P, Walther VN, Mindes J, Lynch L, Berkowitz RL. First-trimester multifetal pregnancy reduction: acute and persistent psychologic reactions. American Journal of Obstetrics and Gynecology 1995 February;172(2 Pt 1):541-7; pp. 545, 546.

Chapter 14: Behavioral Outcomes, Suicide, Healing

• It is becoming clear, as women who have had abortions present themselves for therapy, that previous abuse sometimes leads to the decision to abort.
• After an abortion, women are more likely to display self-destructive behaviors including suicide and attempts at suicide; mutilation and various forms of punishment (including repeat abortions and sterilization); drug, alcohol and tobacco abuse; and eating disorders as a way of denying or minimizing the guilt, pain and numbness they feel.
• Women who abort often have trouble bonding with the children of future pregnancies and have a higher chance of eventually abusing them, which leads to a cyclical pattern of abuse-abortion- abuse.
• It seems clear, given the frequency of negative behavioral outcomes for women after abortion, that more thought needs to be given to appropriate therapy for women (and their children) who are at risk.
• Many women seek support in recovering from post-abortion distress, often years after the abortion. Project Rachel, The Healing Choice, and The National Office for Reconciliation and Healing are among the many therapeutic options that have evolved in the wake of widely- practised abortion.

Chapter 14 contains 70 endnotes including:
Lauzon P et al. Emotional distress in couples involved in first-trimester induced abortions. Canadian Family Physician 2000 October:46;2033-2040.

Chapter 15: Abortion and Interpersonal Relationships

• Women's marital or partner or family relationships can be significantly affected by abortion.
• After abortion, many relationships come to an end, and if the woman stays with her partner or husband, sexual dysfunction often results as does difficulty bonding with children born later on.
• When a woman or adolescent girl has been coerced into having an abortion, typical reactions include feelings of betrayal (by partners or family members), anger, depression, sadness, and breakdown of trust and intimacy in relationships.
• Some men are negatively affected and sense a loss of control and pride, especially when their partner has had an abortion without their being consulted
• "Suppressed mourning" has very negative outcomes, often leading to feelings of numbness and/or hostility and anger, and to difficulties in forming future relationships and in bonding with later-born children; in some instances, post-abortion trauma can lead to actual abuse of later children.
• Already-born children are affected by the abortion of a sibling, often demonstrating feelings of sadness, fear, confusion, and anxiety; parent-child trust is damaged.

Chapter 15 contains 39 endnotes including:
Coleman PK, Reardon DC, Cougle JR. Child developmental outcomes associated with maternal history of abortion using the NLSY data. Archives of Women's Mental Health 2001;3(4)Supp.2:104.

Chapter 16: Abortion: Its Effect on Men

• There is not much literature on the effects of abortion on men, but what there is clearly demonstrates that many men suffer after an abortion.
• Symptoms include depression, guilt, anger, grief, and feelings of powerlessness.
• In Canada and the United States, men have no legal rights in the decision to abort a child they have helped to conceive, which often leads to frustration at their legal disenfranchisement.
• Post-abortion, self-defeating behavior patterns emerge in some men, including abuse of alcohol, drugs, and sex.
• Unmarried relationships often do not remain intact after an abortion.
• Future relationships and fatherhood can be adversely affected by past abortion(s).
• There are few programs for men in which they can express their feelings of ambivalence, grief, or anger after a partner has had an abortion. Many researchers are calling for more studies on the effects of abortion on men and therapeutic counseling for them.

Chapter 16 contains 38 endnotes including:
Buchanan M, Robbins C. Early adult psychological consequences for males of adolescent pregnancy and its resolution. Journal of Youth and Adolescence 1990;19(4):413-24.

Chapter 17: Methodology and Bias: Problems with the Way Post-Abortion Research is Done

• Post-abortion research in North America is often hindered by methodological problems which make it difficult to ascertain accurately the actual effects of abortion on women's future health and fertility.
• Post-abortion follow up tends to be short-term, to suffer from inadequate sample size, no control group, or incomplete information; consequently, many complications are not attributed to the procedure.
• Vested interests in North America do not want the public to hear any bad news about abortion, hence, there is a great deal of underreporting in the literature about the negative sequelae of abortion and their possible connection to a number of medical problems, including low fertility, prematurity, and breast cancer.
• Irregular coding in hospitals and by the Centers for Disease Control does not connect many reproductive problems, such as infertility, pelvic inflammatory disease, Asherman's Syndrome, complications of failed drug-induced and repeat abortions, and ectopic pregnancies to previous abortion(s) when, in fact, abortion is often the trigger cause. Deaths are inaccurately attributed.
• Women deserve a more accountable system of risk assessment where research data accurately reflect the true risks of abortion to their future health and fertility.

Chapter 17 contains sixteen endnotes including:
13 Rogers JL, Stoms GB, Phifer JL. Psychological impact of abortion: methodological and outcomes summary of empirical research between 1966 and 1988. Health Care for Women International 1989;10(4):347-76.

Chapter 18: Informed Consent and Abortion: A Woman's Right to Know

• The concept of informed consent has been clarified and broadened by the Supreme Courts of the United States and Canada, as well as by courts in other western countries.
• The courts have ruled that doctors have a "continuing duty" to be familiar with up-to-date information about potential and developing risks of treatments or procedures in order to inform patients properly.
• The standard of disclosure has shifted to what a "reasonable or prudent" patient might want to know about a procedure, rather than what a "reasonable" doctor might disclose.
• Common but minor risks must be disclosed, while rare risks must be disclosed if the consequences are potentially serious or fatal.
• The doctor must also ensure that the patient has understood what he or she has been told.
• Doctors who fail to inform their patients about the documented risks associated with induced abortion may be liable to prosecution in the courts.

Chapter 18 contains seven endnotes including:
Dickens, BM. "Informed Consent: The Doctor's Duty of Disclosure" Chapter 5 in Downie, J. and Caulfield, T. Canadian Health Law and Policy. Toronto: Butterworths, 1999, p. 137.