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Abortion is the termination of a pregnancy by removal or expulsion of an embryo or fetus.[nb 1] An abortion that occurs without intervention is known as a miscarriage or "spontaneous abortion"; these occur in approximately 30% to 40% of all pregnancies.[2][3] When deliberate steps are taken to end a pregnancy, it is called an induced abortion, or less frequently "induced miscarriage". The unmodified word abortion generally refers to an induced abortion.[4][5] The most common reasons women give for having an abortion are for birth-timing and limiting family size.[6][7][8] Other reasons reported include maternal health, an inability to afford a child, domestic violence, lack of support, feeling they are too young, wishing to complete education or advance a career, and not being able or willing to raise a child conceived as a result of rape or incest.[6][8][9]



When done legally in industrialized societies, induced abortion is one of the safest procedures in medicine.[10]: 1 [11] Unsafe abortions—those performed by people lacking the necessary skills, or in inadequately resourced settings—are responsible for between 5–13% of maternal deaths, especially in the developing world.[12] However, medication abortions that are self-managed are highly effective and safe throughout the first trimester.[13][14][15] Public health data shows that making safe abortion legal and accessible reduces maternal deaths.[16][17]



Modern methods use medication or surgery for abortions.[18] The drug mifepristone in combination with prostaglandin appears to be as safe and effective as surgery during the first and second trimesters of pregnancy.[18][19] The most common surgical technique involves dilating the cervix and using a suction device.[20] Birth control, such as the pill or intrauterine devices, can be used immediately following abortion.[19] When performed legally and safely on a woman who desires it, induced abortions do not increase the risk of long-term mental or physical problems.[21] In contrast, unsafe abortions performed by unskilled individuals, with hazardous equipment, or in unsanitary facilities cause between 22,000 and 44,000 deaths and 6.9 million hospital admissions each year.[22] The World Health Organization states that "access to legal, safe and comprehensive abortion care, including post-abortion care, is essential for the attainment of the highest possible level of sexual and reproductive health".[23] Historically, abortions have been attempted using herbal medicines, sharp tools, forceful massage, or other traditional methods.[24]



Around 73 million abortions are performed each year in the world,[25] with about 45% done unsafely.[26] Abortion rates changed little between 2003 and 2008,[27] before which they decreased for at least two decades as access to family planning and birth control increased.[28] As of 2018, 37% of the world”s women had access to legal abortions without limits as to reason.[29] Countries that permit abortions have different limits on how late in pregnancy abortion is allowed.[30] Abortion rates are similar between countries that restrict abortion and countries that broadly allow it, though this is partly because countries which restrict abortion tend to have higher unintended pregnancy rates.[31]



Globally, there has been a widespread trend towards greater legal access to abortion since 1973,[32] but there remains debate with regard to moral, religious, ethical, and legal issues.[33][34] Those who oppose abortion often argue that an embryo or fetus is a person with a right to life, and thus equate abortion with murder.[35][36] Those who support abortion”s legality often argue that it is a woman”s reproductive right.[37] Others favor legal and accessible abortion as a public health measure.[38] Abortion laws and views of the procedure are different around the world. In some countries abortion is legal and women have the right to make the choice about abortion.[39] In some areas, abortion is legal only in specific cases such as rape, incest, fetal defects, poverty, and risk to a woman”s health.[40]



Types

Induced

An induced abortion is a medical procedure to end a pregnancy.[41] In modern English, the term abortion, when used without further qualification, generally refers to induced abortion.[5]



A pregnancy can be intentionally aborted in several ways. The abortion method depends upon the gestational age of the embryo or fetus, which gains mass as the pregnancy progresses.[42][43] Abortion laws, regional availability, and the personal preference of the women and her doctor may inform the women”s choice of a specific abortion procedure.



Abortions can be characterized as either therapeutic or elective. When an abortion is performed for medical reasons, the procedure is referred to as a therapeutic abortion. Medical reasons for therapeutic abortion include saving the life of the pregnant woman, preventing harm to the woman”s physical or mental health, preventing the birth of a child who will have a significantly increased chance of mortality or morbidity, and reducing the number of fetuses to lessen health risks associated with multiple pregnancy.[44][45] An abortion is referred to as elective or voluntary when it is performed at the request of the woman for non-medical reasons.[45] Confusion sometimes arises over the term elective because "elective surgery" generally refers to all scheduled surgery, whether medically necessary or not.[46]



About one in five pregnancies worldwide ends with an induced abortion.[27] Most abortions result from unintended pregnancies.[6][47] In the United Kingdom, 1 to 2% of abortions are done because of genetic problems in the fetus.[21]



Spontaneous

Main article: Miscarriage

Miscarriage, also known as spontaneous abortion, is the unintentional expulsion of an embryo or fetus before the 24th week of gestation.[48] A pregnancy that ends before 37 weeks of gestation resulting in a live-born infant is a "premature birth" or a "preterm birth".[49] When a fetus dies in utero after viability, or during delivery, it is usually termed "stillborn".[50] Premature births and stillbirths are generally not considered to be miscarriages, although usage of these terms can sometimes overlap.[51]



Studies of pregnant women in the US and China have shown that between 40% and 60% of embryos do not progress to birth.[52][53][54] The vast majority of miscarriages occur before the woman is aware that she is pregnant,[45] and many pregnancies spontaneously abort before medical practitioners can detect an embryo.[55] Between 15% and 30% of known pregnancies end in clinically apparent miscarriage, depending upon the age and health of the pregnant woman.[56] 80% of these spontaneous abortions happen in the first trimester.[57]



The most common cause of spontaneous abortion during the first trimester is chromosomal abnormalities of the embryo or fetus,[45][58] accounting for at least 50% of sampled early pregnancy losses.[59] Other causes include vascular disease (such as lupus), diabetes, other hormonal problems, infection, and abnormalities of the uterus.[58] Advancing maternal age and a woman”s history of previous spontaneous abortions are the two leading factors associated with a greater risk of spontaneous abortion.[59] A spontaneous abortion can also be caused by accidental trauma; intentional trauma or stress to cause miscarriage is considered induced abortion or feticide.[60]



Methods

Medical

Main article: Medical abortion

Practice of Induced Abortion MethodsMVAD&EEVAHyst.D&CIntact D&XMifepr.Induced Miscarr.0–12 wks12–28 weeks28–40 wks

Gestational age may determine which abortion methods are practiced.

Medical abortions are those induced by abortifacient pharmaceuticals. Medical abortion became an alternative method of abortion with the availability of prostaglandin analogs in the 1970s and the antiprogestogen mifepristone (also known as RU-486) in the 1980s.[19][18][61][62]



The most common early first trimester medical abortion regimens use mifepristone in combination with misoprostol (or sometimes another prostaglandin analog, gemeprost) up to 10 weeks (70 days) gestational age,[63][64] methotrexate in combination with a prostaglandin analog up to 7 weeks gestation, or a prostaglandin analog alone.[18] Mifepristone–misoprostol combination regimens work faster and are more effective at later gestational ages than methotrexate–misoprostol combination regimens, and combination regimens are more effective than misoprostol alone, particularly in the second trimester.[61][65] Medical abortion regimens involving mifepristone followed by misoprostol in the cheek between 24 and 48 hours later are effective when performed before 70 days” gestation.[64][63]





Shown here is the typical regimen for early medical abortions (200 mg mifepristone and 800 μg misoprostol).

In very early abortions, up to 7 weeks gestation, medical abortion using a mifepristone–misoprostol combination regimen is considered to be more effective than surgical abortion (vacuum aspiration), especially when clinical practice does not include detailed inspection of aspirated tissue.[66] Early medical abortion regimens using mifepristone, followed 24–48 hours later by buccal or vaginal misoprostol are 98% effective up to 9 weeks gestational age; from 9 to 10 weeks efficacy decreases modestly to 94%.[63][67] If medical abortion fails, surgical abortion must be used to complete the procedure.[68]



Early medical abortions account for the majority of abortions before 9 weeks gestation in Britain,[69] France,[70] Switzerland,[71] United States,[72] and the Nordic countries.[73]



Medical abortion regimens using mifepristone in combination with a prostaglandin analog are the most common methods used for second trimester abortions in Canada, most of Europe, China and India,[62] in contrast to the United States where 96% of second trimester abortions are performed surgically by dilation and evacuation.[74]



A 2020 Cochrane Systematic Review concluded that providing women with medications to take home to complete the second stage of the procedure for an early medical abortion results in an effective abortion.[75] Further research is required to determine if self-administered medical abortion is as safe as provider-administered medical abortion, where a health care professional is present to help manage the medical abortion.[75] Safely permitting women to self-administer abortion medication has the potential to improve access to abortion.[75] The review also noted a research gap concerning methods to support women who take medication at home for a self-administered abortion.[75]



Surgical



A vacuum aspiration abortion at eight weeks gestational age (six weeks after fertilization).

1: Amniotic sac

2: Embryo

3: Uterine lining

4: Speculum

5: Vacurette

6: Attached to a suction pump

Up to 15 weeks” gestation, suction-aspiration or vacuum aspiration are the most common surgical methods of induced abortion.[76] Manual vacuum aspiration (MVA) consists of removing the fetus or embryo, placenta, and membranes by suction using a manual syringe, while electric vacuum aspiration (EVA) uses an electric pump. Both techniques can be used very early in pregnancy. MVA can be used up to 14 weeks but is more often used earlier in the U.S. EVA can be used later.[74]



MVA, also known as "mini-suction" and "menstrual extraction", or EVA can be used in very early pregnancy when cervical dilation may not be required. Dilation and curettage (D&C) refers to opening the cervix (dilation) and removing tissue (curettage) via suction or sharp instruments. D&C is a standard gynecological procedure performed for a variety of reasons, including examination of the uterine lining for possible malignancy, investigation of abnormal bleeding, and abortion. The World Health Organization recommends sharp curettage only when suction aspiration is unavailable.[77]



Dilation and evacuation (D&E), used after 12 to 16 weeks, consists of opening the cervix and emptying the uterus using surgical instruments and suction. D&E is performed vaginally and does not require an incision. Intact dilation and extraction (D&X) refers to a variant of D&E sometimes used after 18 to 20 weeks when removal of an intact fetus improves surgical safety or for other reasons.[78]



Abortion may also be performed surgically by hysterotomy or gravid hysterectomy. Hysterotomy abortion is a procedure similar to a caesarean section and is performed under general anesthesia. It requires a smaller incision than a caesarean section and can be used during later stages of pregnancy. Gravid hysterectomy refers to removal of the whole uterus while still containing the pregnancy. Hysterotomy and hysterectomy are associated with much higher rates of maternal morbidity and mortality than D&E or induction abortion.[79]



First trimester procedures can generally be performed using local anesthesia, while second trimester methods may require deep sedation or general anesthesia.[80][81][82]




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