David A. Grimes, MD; Mitchell D. Creinin, MD
Internists care for many women who have had abortions and many who will seek abortions in the future. Each year, about 2% of all women of reproductive age have an abortion. Women having abortions tend to be young, white, unmarried, and early in pregnancy. Most abortions are done by suction curettage under local anesthesia in a freestanding clinic. However, medical abortion is growing in popularity as a nonsurgical alternative. The regimen approved by the U.S. Food and Drug Administration specifies mifepristone, 600 mg orally, followed 2 days later by misoprostol, 400 Âµg orally (within 49 days from last menses). Recent studies have recommended alternative approaches, such as mifepristone, 200 mg orally, followed in 1 to 3 days by misoprostol, 800 Âµg vaginally (up to 63 days). Medical abortion can be provided by a broader variety of physicians than can surgical abortion. The overall case-fatality rate for abortion is less than 1 death per 100â€‰000 procedures. Infection, hemorrhage, acute hematometra, and retained tissue are among the more common complications. Referral back to the original abortion provider for management is advisable. Overall, induced abortion does not lead to late sequelae, either medical or psychiatric. Of importance, no link exists between induced abortion and later breast cancer. For physicians who are asked to help with a referral, the National Abortion Federation and Planned Parenthood Federation of America have helpful Web sites and networks of high-quality clinics. The cost of abortion (currently about $372 at 10 weeks) has decreased in recent decades. Provision of ongoing contraception and encouragement of emergency contraception can reduce unintended pregnancies and the need for abortion.
Error bars represent 1 SD. (Reprinted from Zieman M, Fong SK, Benowitz NL, Bansketer D, Darney PD. Absorption kinetics of misoprostol with oral or vaginal administration. Obstet Gynecol. 1997;90:88-92, with permission from The American College of Obstetricians and Gynecologists ).
Source: Centers for Disease Control and Prevention (32).
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Jon A Sherrod
April 28, 2004
Abortion is safe? For whom?
I find ludicrous many of the assertions made in Grimes and Creinin's review, which should have been titled, "Promoting the Involvement of Internists in Abortion". Calling an abortion "secondary prevention" of pregnancy represents a sad and twisted view of what can never be viewed as a "safe" procedure for the unborn child. The case- fatality rate for induced abortion would be more accurately portrayed as approximately 100,001 per 100,000 abortions, unless one chooses to disregard the life of the "fetus". I have personally seen the tears and listened to the painful stories of women who carry the scars of the "alleged 'postabortion trauma syndrome' [which] does not exist". The article is filled with numerous other glaring examples of blatant pro- abortion (sorry--"pro-choice") bias.
I am terribly disappointed in the one-sided approach 'Annals' has chosen in publishing this review; the complete lack of discussion of alternate views on the ethics of this issue is appalling. I am discontinuing my 'Annals' subscription and withdrawing from the ACP effective immediately; I have no desire to be represented by an organization or publication promoting an activity which is solely intended to end ("terminate") a human life.
Jon A Sherrod
Gerald P. Bodey
April 30, 2004
I would take issue with the statement made by Grimes and Creinen in their review entitled, "Induced Abortion: An Overview for Internists"(1). They state: "The case-fatality rate from abortion today is less than 1 death per 100,000 abortions". In actual fact the fatality rate for this procedure is 100%. No aborted human beings survive this procedure. Every physician knows that nearly all fetuses left alone in the womb will survive as human beings.
I strongly object to the statement that, "Making an appropriate referral for an abortion is an important role for internists". The authors do not even mention the alternatives! I studied medicine to save lives and alleviate suffering, not to assist in killing babies. In my practice I have done everything possible to discourage abortion.
May 3, 2004
Timing of The Abortion Reviw Article
The timing of your review article on abortion coincided with the abortion parade in Washington DC.This raises quetions regarding the political motivation in publishing what seems to be a totally one sided account of the abortion issue.
As internists,whenever we treat a young woman in childbearing age,we go out of our way to assertain that the patient is not pregnant, before ordering X-rays, nuclear scans,or before prescribing potentially teratogenic medications to the prospective mother.We give nutrition advice, lifestyle councel to avoid harming the fetus.We keep the mother's AND the fetus's well being and best interest in mind.
It is disappointing to see that your authors totally disregarded the significant OTHER in pregnancy,namely the fetus!The unseen elephant in the room.
Even a toddler if presented with pictures of modern fetal ultrasounds in their "abortable age",they will unmistakably identify them as human babies, full with life, movement and limbs.
When our children one day reflect on these pictures, and contemplate the 1973 Supreme Court decision, they certainly will recognise the intentional and ideological hemianopsia that has prevented the single minded proponents of abortion to notice the unseen truth, life before birth,which they have chosen to keep in the dark.
Harold C. Sox
May 6, 2004
Response from Editor
Several of our correspondents have criticized the editors for publishing an article on induced abortion. We published the article because we believe that physicians should know about medical and surgical procedures that patients often use and should therefore be prepared to provide accurate information when a patient asks them about induced abortion.
To respond to Dr. Apelia, we did not time the date of publication to coincide with the demonstration in Washington, D.C.
Warren W. Furey
Mercy Hospital and Medical Center
May 10, 2004
Abortion As Secondary Prevention
The review of Induced Abortion: An Overview for Internists, paints a very favorable picture of abortion. It is common, "43% of all women would have had one or more abortions during their reproductive years, more than 30 million U.S. women now share this experience". Abortion is one of the "safest procedures in contemporary practice", there are "no harmful sequelae" and "for most women abortion allows an overall improvement in quality of life". Abortion is reasonably priced because "clinics have intentionally tried to keep the price within reach of women with limiteed means". And now a "broader variety of physicians, including family practitioners, pediatricians and internists may be able to provide medical abortion". "Induced abortion represents secondary prevention of pregnancy".
Maybe the terminology is correct, but it fails to clearly state that this particular secondary prevention is done with the sacrifice of a living, totally dependent human fetus. I remember pre Roe vs. Wade septic problems that desperate women suffered at the hands of unskilled abortionists or at their own ill-conceived effort to be rid of a pregnancy. The abortion issue is impossible to discuss without arousing passionate opinions from opposite ends of the spectrum. I don't know how many women really like the idea of abortion, but many people feel that the woman who is pregnant should be able to make a decision whether she will deliver the baby she has conceived. I do not agree with that position but they have a right to their opinion.
Many people, including many women and physicians, feel abortion is intrinsically wrong because it is the destruction of innocent life and much more than a "secondary prevention of pregnancy". The tragedy is that such a large number, "one for every four live births", result in abortion. Physicians should address the problems of unwanted pregnancy through education, primary prevention and adoption.
Eleanor B Schwarz
University of California, San Francisco
May 21, 2004
Abortion, Skin Biopsy, Cataract Removal, and Cardiac Catheterization
I greatly appreciated Annals recent review on Abortion. As vacuum aspiration is one of the most common surgical procedures American women undergo, it is indeed important for internists to know as much about a patient's experience with abortion as they do about skin biopsy, cataract removal, and cardiac cathaterization (procedures performed with similar frequency per Owings MF,Kozak LJ. "Ambulatory and inpatient procedures in the United States, 1996" National Center for Health Statistics. Vital Health Stat(139).1998. page 15. (PHS) 98-1798. GPO stock number 017-022-01438-6.) Unfortunately, many internists complete their medical training without receiving any formal didactics on abortion or pregnancy options counseling. As challenging as abortion can be to discuss, refusing to acknowledge its profound public health implications is a disservice to the families and communities we serve.
David N. Layer
January 22, 2005
Grief from abortion
TO THE EDITOR: Grimes and Creinin (1) state that: overall, induced abortion does not lead to psychiatric late sequelae and that an alleged "postabortion trauma syndrome" does not exist. The article read like a "how to abort" article for providers. We are in a profession that calls us to do no harm, and we are reading a "primer for internist" on how to kill.
My wife Susan is post-abortive and has experienced PAG (Post-Abortion Grief). She has been open in talking about her experience and has facilitated many groups of females with similar experiences. Her research thesis for her master's in clinical Social Work led to the following research article: Post Abortion Grief: Evaluating the Possible Efficacy of a Spiritual Group Intervention (2). This study measured efficacy of a spiritually based grief group intervention for women grieving an abortion. Thirty-five women completed the Impact of Event Scale-Revised (IES-R) and the Internalized Shame Scale (ISS) pre and post intervention. The results showed significant decrease in shame (p<.000) and PTSD symptoms (<.002). Psychiatric sequalae of a real syndrome is showing benefit from a useful treatment. When providers deny impact of this event on a woman's life, they miss an opportunity to heal. Other literature, not quoted in the article, also identifies a range of PAG symptoms with some exhibiting acute stress or post traumatic stress disorder (PTSD) (3,4,5).
Grimes and Creinin do point out the large number of females that experience an abortion in the U.S. (43%). As a provider it is important to realize this life event can be a source of trauma for many females. I work as an internist in the VA and have discovered significant PAG a few times in the minimal female Veterans population that is under my care. Just like treating unresolved grief, PTSD, or past rape, discussing how a PAG woman feels about her abortion experience provides key opportunities for validation and compassion for her grief. The PAG groups are only provided by faith based agencies such as Care Net (www.care-net.org) and Project Rachel (www.ggw.org/~projectrachel) and both offer informative web-sites about post abortion grief. To locate a faith-based PAG group in your area contact Care Net (non-denominational) at 1-800-395-HELP or Project Rachel (Catholic) at 1-800-5WECARE. Furthermore, these PAG groups are provided for the woman at a nominal cost with most agencies providing free services if needed. The PAG group setting is effective in creating a safe, accepting environment where women share about their abortions, which eventually lead to a reduction in shame and isolation, and eventual grief resolution. It is sad that the longstanding heated debate over abortion has created for some an intractable barrier in recognizing that some women do experience grief from an abortion and consequently remain silent and unsupported in their loss. I encourage you to inquire in all females if they have had an abortion, and if they are struggling with that decision to make a referral for an appropriate intervention. (6,7)
1. Grimes DA, Creinin MD. Induced Abortion: An overview for Internists. Ann Intern Medicine. 2004;140:620-6. 2. Dyer-Layer S, Roberts C, Wild K, Walters J. Post Abortion Grief: Evaluating the Possible Efficacy of a Spiritual Group Intervention. Research on Social Work Practice. 2004;14:344-50. 3. Rosenfeld JA. Emotional responses to therapeutic abortion. American Family Physician. 1992;45:137-40. 4. Speckhard AC, Rue VM. Complicated mourning: Dynamics of impacted post abortion grief. Pre- and Perinatal Psychology Journal. 1993;8:5-32. 5. Donnai P and Harris C. Attitudes of patients after genetic termination of pregnancy. British Medical Journal. 1981;282:621-2.
David A. Grimes, Mitchell D. Creinin. Induced Abortion: An Overview for Internists. Ann Intern Med. 2004;140:620–626. doi: 10.7326/0003-4819-140-8-200404200-00009
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Published: Ann Intern Med. 2004;140(8):620-626.
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