Abortion

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• Introduction to abortion in Australia
• Issues to consider before having an abortion
• Surgical termination procedures
  • Manual vacuum evacuation
  • Vacuum aspiration (dilation and suction curretage)
  • Dilation and evacuation
  • Issues to consider after surgical termination
• Pharmacological termination procedures
  • Mifepristone (RU-486)
  • Method of action of mifepristone
  • Side effects of mifepristone
  • Viewpoints concerning mifepristone
• Complications associated with abortions
• Commonly experienced emotions after an abortion
• My experience:
  • Michelle reflects upon her abortion experience
  • Jackie opens up about her late-stage abortion

Introduction to abortion in Australia

Abortions are usually carried out to avoid unwanted or unplanned pregnancies, or pregnancies that are dangerous to the mother. Abortions can be achieved by a variety of surgical methods in Australia, including vacuum evacuation, vacuum aspiration and dilation, and curettage (These processes are explained below). Abortions can also be carried out with the use of the abortion drug mifepristone, although this is not available in Australia.

An abortion is the termination of a pregnancy, resulting in the removal or expulsion of the contents of the uterus (i.e. the embryo or foetus). There have been many abortions performed. It is estimated that one in every three women will undergo an abortion at some stage in their lives. The moral and legal issues surrounding abortion are under constant debate and scrutiny throughout the world.

Abortion is a very controversial issue. The purpose of this article is not to determine what is right or wrong, but rather provide you with in an insight and overview regarding the many issues that surround this topic. Different practices exist in different parts of the world. Here in Australia, abortions are able to be carried out under various circumstances, depending on the State or Territory that you live in.

Victoria

In Victoria, the Menhennitt ruling of 1969 established that an abortion is lawful if the doctor holds an honest belief, on reasonable grounds, that the abortion is ‘necessary to preserve the life of the woman from a serious danger to her life or health which the continuance of the pregnancy would entail’ and ‘proportionate’ to the danger averted. The ruling includes both mental and physical risks to the mother.

New South Wales

In New South Wales, the Levine ruling in 1971 established that an abortion is lawful in that State if there is ‘any economic, social or medical ground or reason’ upon which a doctor can base an honest and reasonable belief that an abortion is required to avoid a ‘serious danger to the pregnant woman’s life or to her physical or mental health’.

Australian Capital Territory

In the Australian Capital Territory, there are no criminal laws relating to abortion. It is generally assumed that the legal position in the Australian Capital Territory is the same as the legal position established at any given time by case law in New South Wales. The Medical Practitioners (Maternal Health) Act of 2002 specified that abortions could only be carried out by a registered medical practitioner in an approved medical facility.

Queensland

In Queensland, the McGuire ruling of 1986 confirmed that the law offered in Victoria in the Menhennitt ruling also applies in Queensland. However, the law in Queensland remains unclear.

Tasmania

An amendment to the law in 2001 provided that abortion in Tasmania is lawful if two medical practitioners agree that the continuation of the pregnancy would put the mental and physical health of the mother at greater risk than if the pregnancy was terminated, and if the mother has given informed consent.

South Australia

In South Australia, an abortion can be performed within 28 weeks of pregnancy if two medical practitioners agree in good faith that there is substantial risk to the life or mental or physical health of the mother, or if there is substantial risk that the child would be seriously physically or mentally handicapped. A woman must live in South Australia for two months before an abortion can be performed, and medical practitioners may elect not to participate on conscientious grounds.

Northern Territory

In the Northern Territory, the legislation permits abortion within 14 weeks of pregnancy if two medical practitioners agree in good faith that there is substantial risk to the life or mental or physical health of the mother, or if there is substantial risk that the child would be seriously physically or mentally handicapped. An abortion may be carried out within 23 weeks of pregnancy if a medical practitioner believes in good faith that it is immediately necessary to prevent grave injury to the mother’s physical or mental health. An abortion may be carried out at any stage if the medical practitioner believes in good faith that it is necessary for preserving the mother’s life.

Western Australia

In Western Australia, abortion remains unlawful unless it is justified under the (amended) health legislation in that State, which now permits abortion within 20 weeks of pregnancy if it is performed by a medical practitioner in good faith, the mother has given informed consent, and if there are serious physical, mental, personal, family or social consequences if the abortion is not performed. Abortions after 20 weeks of pregnancy require approval from a government-appointed medical panel on the basis of a serious medical condition in the mother or the child.

Issues to consider before having an abortion

Counselling

If you or someone you know is facing the choice of considering a termination, it is important that the involved person undergoes counselling prior to the procedure. You need to talk to someone about the issues influencing your decision, and any problems that you may have, before making a decision. Other possible options apart from an abortion should also be explored. You may present for advice regarding an abortion after you have been told that you are pregnant, either through a home pregnancy test or through a pregnancy test performed by your local doctor. In other cases, discussion on pregnancy options and potential termination of pregnancy occurs before a pregnancy test. If you are seeking advice regarding a potential pregnancy, you should not suppress any concerns or worries that you may have.

There are support groups and personnel that exist to help a woman through her decision to terminate a pregnancy, if she chooses to do so. It is common for a woman to feel many mixed emotions about her choice. Some women may enter a state of denial for a period of time while the information sinks in. Others will request available options immediately. In these circumstances, it is important to ensure that you are making the best informed decision possible. It is important that you are aware of the details of the procedure itself and the risks and complications associated with the procedure. A discussion about the alternative options (i.e. continuing pregnancy and adoption) is also important. In addition, your doctor should discuss common emotions and psychological consequences associated with these procedures with you. Support systems that you could turn to should be considered and explored – many women often find it an invaluable resource to have someone who is available to support her through her termination and help her deal with the emotions commonly experienced afterwards.

History and examination

Before you undergo any abortion, your doctor will obtain a comprehensive history from you, and conduct a full physical examination to assess your and your baby’s health. The presence and duration of your pregnancy should be confirmed with appropriate investigations, including measuring blood levels of serum human chorionic gonadotrophin (a hormone secreted by the developing embryo) and ultrasound examination. The age of the baby can be determined by both menstrual history (i.e. the date of your last period) and an examination, depending on your estimated date of gestation. If there is any uncertainty regarding the gestational age, an ultrasound should be performed. If there is any doubt about your last period (e.g. it was lighter or more scant than usual), you should bring this up with your doctor and it should be investigated further. To help accurately determine the estimated date of pregnancy, you may also be asked about the average length of your menstrual cycles. A history of any past pregnancies, terminations or miscarriages may also be enquired about.

It is imperative that you report any abnormal bleeding which has occurred since your last menstrual period, and any abdominal discomfort you feel. These symptoms may indicate the possibility of an ectopic pregnancy or miscarriage. If these conditions are missed, they can be life threatening. If there are any doubts as to whether there is a viable pregnancy, appropriate investigations should be carried out.

When you are discussing possible termination of pregnancy with your doctor, your beliefs and reasons leading to such a decision should be addressed. Some women may be strongly opposed to undergoing a termination, but due to unforeseen circumstances (medical, financial, family or relationship issues) have no other choice. In some cases of termination for medical reasons, these women may find the decision to terminate the pregnancy much more stressful and difficult, especially if it was a planned and originally wanted pregnancy. These women are more likely to experience a greater degree of grief and loss issues. If you are a victim of sexual abuse or assault, you may choose to raise the issue during a counselling session. In these circumstances, you may be experiencing much emotional trauma and your doctor will ensure further counselling and ongoing treatment to fully assess the situation, and address any ongoing issues.

 

Investigations

Before any termination procedure is carried out, initial baseline investigations such as a blood test for your haemoglobin levels and Rhesus status should be performed. An abnormally low blood haemoglobin level or Rhesus negative status requires treatment before undergoing a termination procedure. Depending on your Rhesus status, you may need anti D immunoglobulin.

Additional investigations may be necessary, depending on your past medical, surgical and pregnancy history. Imaging procedures such as ultrasonography should be considered if either you or your doctor are unsure about the size of the uterus, age of the baby, state that the baby is in, or if the diagnosis has not been confirmed yet and is in doubt (e.g. possible ectopic pregnancy, hydatiform mole). It is also important to determine the age of your baby to ensure that the termination procedure can be performed in accordance with State guidelines. It is often part of standard protocol that all women who undergo an abortion should also be screened for sexually transmitted infections and offered antibiotic treatment if required.

Some doctors give antibiotics to you to reduce the risk of any complications occurring from infections, regardless of whether or not you have any infection. Antibiotic treatment for the termination procedure itself is recommended, as complications after the termination procedure (e.g. endometritis) occur in 5-20% of patients who have not received antibiotic treatment. A study performed in a group of pregnant women found that, if they were all given antibiotics to prevent infection, cases of endometritis were reduced by as much as 50% in all subgroups of women undergoing abortion. The choice of antibiotic varies according to hospital/clinic protocols.

You should also return to your doctor after you have had the termination procedure to address any questions or concerns that you may have. A discussion about possible contraception choices may also benefit you, preventing another termination procedure, if you do not want to have any more children in the near future.

Surgical termination procedures

Surgical termination procedures can be performed under many types of sedation and pain relief methods, including local anaesthetic, general anaesthetic or intravenous sedation.

Intravenous sedation refers to injection of agents such as midazolam (an agent that helps put you at ease, decreases your anxiety and fear about the procedure, and induces a drowsy state) into the veins. This method of sedation is becoming more popular in Australia.

Manual vacuum evacuation

This procedure is not often performed in Australia due to a higher chance of failure and reports of increased levels of discomfort from the procedure. Manual vacuum evacuation involves the use of a handheld plastic tube-like device to suck out the uterine contents, including the embryo and lining of the uterus. This procedure is only performed in very early pregnancies, often before eight weeks.

Vacuum aspiration (dilation and suction curretage)

Vacuum aspiration is the most commonly used method of abortion in Australia. The muscle surrounding the neck of the cervix is relaxed and stretched open a number of millimeters to allow the insertion of a small plastic tube. The contents of the uterus are then suctioned out. In the earlier stages of pregnancy (i.e. less than seven weeks) dilation may not be required. A loop-shaped instrument called a curette may be used afterwards to scrape the inside of the uterus, ensuring that it is completely empty.

Dilation and evacuation

Dilation and evacuation is a variation of the above procedure, and can be used to terminate a pregnancy in its later stages. It can be performed in a uterus of almost any size. The cervix is dilated and a plier-like instrument is inserted into the uterus. This allows the removal of parts of the developing foetus, until the uterus is fully empty.

Issues to consider after surgical termination

After you undergo a termination procedure, you are usually monitored and observed for at least 30-60 minutes to ensure that you remain in a stable state. If there are any symptoms suggesting bleeding in the abdomen or any other compromise, you can be treated straight away. Women who are Rhesus negative should also receive their RhD immunoglobulin in this period.

You should be informed about what to expect after procedure (e.g. passage of small amounts of tissue and blood, a cramping feeling in the lower abdomen, and some bleeding from the vagina). If these symptoms do not settle or are more severe than can be tolerated, you should seek immediate medical attention. Also contact your doctor if:

• You develop a fever or become unwell
• Pregnancy symptoms have not resolved within one week of termination
• Your period has not returned by six weeks after the procedure

It is recommended that intercourse and use of tampons be avoided for two weeks after the procedure to reduce the risk of infection. Depending on your circumstances, it is best to discuss this issue with your doctor before commencing these activities.

Pharmacological termination procedures

Mifepristone (RU-486)

Mifepristone (RU-486) is a medical drug that works to produce abortion. It has been used in combination with a second drug which stimulates contraction of the uterus to expel the foetus. It is primarily used in the early stages of pregnancy as an alternative method of non-surgical termination.

Pharmacological abortion with mifepristone is not yet available in Australia, but has been widely accepted and practiced in other parts of the world, including the United Kingdom, Western Europe, North America and New Zealand. There have been over 1.5 million termination procedures performed all over the world using mifepristone. There is growing literature and evidence on the effectiveness, action, side effects and risks associated with medical termination using mifepristone.

Method of action of mifepristone

Mifepristone acts to block the actions of progesterone, an important hormone during pregnancy. Progesterone acts to maintain the lining of the uterus, and to provide nutrients and oxygen to the developing baby. Blocking this hormone stops the pregnancy from continuing and causes the foetus and placenta to separate from the uterus wall.

Mifepristone is combined with a second drug called a prostaglandin analogue (e.g. misoprostol or gemeprost) to cause contraction and expulsion of the uterine contents. In 93-98% of cases, complete abortion occurs after administration of these drugs. In the remaining cases, the termination requires further surgical intervention. It is most commonly used in early terminations (less than 9 weeks), but can also be effective for second trimester terminations.

Side effects of mifepristone

In a small number of cases, women who used mifepristone for a termination procedure experienced heavy vaginal bleeding that required hospitalisation and, occasionally, a blood transfusion. In addition, if any products remain inside the uterus, infection is a possibility.

Viewpoints concerning mifepristone

There are many mixed emotions concerning the controversial issue of abortion, and women within Australia will continue to seek methods of termination, whether it be pharmacological or surgical. In other countries where mifepristone has been available and tested, there has been no documented increase in the overall abortion rate. The number of abortions performed at earlier gestations has increased. The earlier that an abortion occurs, the safer the overall process is for the woman involved.

There is a growing opinion that pharmacological abortion could and should be incorporated into the abortion choices available for women in Australia. This is particularly for women in rural and remote areas. For these women, the availability of pharmacological abortion could help overcome many barriers and issues of limited access to clinics/hospitals.

Complications associated with abortions

Early complications following an abortion include:

• Bleeding
• Perforation of the uterus
• Potential damage to other body organs
• Laceration/tears to the cervix
• Infection

There is a very small failure rate associated with all procedures. The rate depends on the type of procedure and the staff involved.

Late complications of abortion include:

• Infertility
• Inability of the cervix to function properly
• Development of antibodies to different blood components
• Psychiatric/emotional conditions

To try and minimise the mental complications associated with terminations, your doctor should thoroughly explain any procedures and provide appropriate counselling.

Commonly experienced emotions after an abortion

Each woman will experience different feelings and emotions when undergoing an abortion. This is a natural reaction and it is important to acknowledge this when you have such a procedure. A lot of the time, women may try and suppress their feelings, trivialising the process that has occurred. This can result in aftereffects and complications in the long term. Women commonly report feelings such as fear, guilt, embarrassment, anxiety, and grief or sadness. They may also feel angry, confused and resentful. The procedure itself may bring back nightmares or bad memories, resulting in depression and sleeping disorders.

In the longer term, low self-esteem and avoidance of all issues relating to pregnancy and small babies may occur. Delayed reactions are common and may be triggered by various events, such as being in contact with a pregnant woman, the birth of a child, or any other significant life events. It is important that you seek help if this occurs.

In one study of women eight weeks after their abortion, 44% experienced nervous disorders, 36% had sleep disturbances, 31% reported regrets about their choice, and 11% required medications to calm them down.

The major types of nervous disorders and psychological complications seen include:

• Post traumatic stress disorder
• Suicidal ideas and attempts
• Alcohol and drug abuse
• Eating disorders
• Child neglect or abuse
• Relationship problems

It has also been shown that women who have had one abortion are at an increased risk of having another abortion in the future. This increased risk may be due to confusion regarding future pregnancies, decreased self-esteem, or an unconscious desire for a replacement pregnancy. This data shows that it is very important to address any underlying emotions and issues after an abortion to avoid unnecessary abortions in the future.

You may find it helpful to talk to your GP, counsellors or psychiatrists about your feelings before and after you have an abortion.

My experience

Abortion is a safe and simple operation, performed to terminate a pregnancy. Women who have an abortion often don’t want to talk about it for fear that others will judge them. Many women have an abortion not really knowing what to expect, and feeling a little embarrassed. In Michelle’s experience, fear and embarrassment were much more difficult to cope with than the abortion surgery itself even though she was sure she wanted to terminate her pregnancy.

To read Michelle’s story, see Abortion: Michelle reflects upon her abortion experience.

Choosing to terminate a pregnancy is difficult in any situation. But what if you were stuck in a foreign country with no doctor to help you, no one to talk to and no way home? Jackie says she wants to talk about the emotional trauma and the physical exhaustion of a delayed abortion so that other women wrestling their demons know there is light at the end of the tunnel.

To read Jackie’s story, see Abortion in late first trimester: Jackie opens up for other women.

More information

For information on different types of contraception, male and female anatomy and related health issues, see Contraception.

For more information about pregnancy, including preconception advice, stages of pregnancy, investigations, complications, living with pregnancy and birth, see Pregnancy.

 

References

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5. Foran T. Issues surrounding the termination of pregnancy. Current Therapeutics. 2001; 42(3): 37-41.
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9. Symmonds EM, Symmonds IM. Essential Obstetrics & Gynaecology. Spain: Churchill.
10. Australian abortion law and practice [online]. Children By Choice. 2007 [cited 30 July 2008]. Available from URL: http://www.childrenbychoice.org.au/ nwww/ auslawprac.htm
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