Transcript Conference holding slides

Dr Sam Rowlands
Visiting Senior Lecturer
Warwick Medical School
Is repeat abortion a
problem?
Is repeat abortion a
problem?
Sam Rowlands
MD FRCGP FFSRH
Future of Abortion 26 June 2008
Context
• Abortion is as old as humanity and
probably occurs in all cultures
• Throughout recorded history women
have resorted to abortion, regardless of
religious or legal sanction and often at
considerable risk
David HP, 1981
Definition
• More than one abortion ever?
• Rapid repeat pregnancy (teenagers):
within 12 – 24 months?
Terminology
• Recidivists
– Rovinsky J. Obstet Gynecol 1972; 39: 649
– Novaes SB. Revue Francaises de Sociologie
1982; 23: 473
• Repeat aborters
– Jacobsson L. Social Psychiatry 1976; 11: 75
– Schneider SM. AmJOG 1976; 126: 316
• Habitual therapeutic aborters
– Freeman EW. In Perspectives on abortion, 1985.
Biological perspective
• Women experience around 450
menstrual cycles in their reproductive
careers
• Time to pregnancy: probability of
conceiving within 12 months is 0.84
• Contraceptive: an agent which extends
the length of time taken to conceive
Having sex does not often end
in abortion
Acts of heterosexual
coitus in women
Conceptions
Number of daily events
(England & Wales)
2 million
2,290
Abortions
510
Births
1,780
Simplistic notions
• ‘Proper’ use of contraception will
eliminate abortions
• Women need to be targeted - WHAT
ABOUT THE MEN?!
Factors behind abortion
•
•
•
•
•
•
Unconscious desire for pregnancy
Risk-taking behaviour
Forced sex: coercion, threats and abuse
Substance excess/abuse
Mental health problems
Peer pressure
Factors relating to
contraception
• Ignorance due to lack of sex education
• Cultural/religious opposition to
contraception
• Contraceptive scares
• Relationship changes
Reactions of health
professionals
• Moralising
• Judgement
• Punishment
• Self-blame
(perceived
deficiency in
contraceptive
services) ? leading
to over-zealous
promotion of
products
Moralising
“To agree to a second abortion would only
encourage immorality or at least
carelessness”.
Aitken-Swan J, 1973
Service level agreements
• “Consultants are reluctant to undertake
repeated terminations”.
• “If a doctor perceives that the patient regards
termination of pregnancy as a form of
contraception by virtue of the number of
previous procedures had” then abortion will
not be offered within the service contract.
Survey of Primary Care Trusts, 2004
Threats of sterilisation
Doctors have threatened women with
sterilisation if they attend for
subsequent abortions
Wolf B. Zentralbl Gynakol 1991;113: 21
Neamatalia GS. EngenderHealth 1995
Sterilisation with abortion
• In England and Wales sterilisation was
performed with abortion in 1969 in 22%
of cases; this had decreased to 7% by
1980
• Now, with the advent of long-acting
reversible contraceptives, concurrent
sterilisation is performed rarely
(statistics no longer presented)
Existing data is an
underestimate anyway
• Previous abortions in Great Britain
defined as legal abortions in that
jurisdiction
• Underreporting in the early days of
legalisation likely to approach 100%
• General underreporting due to recall
bias (true numbers only from record
linkage systems e.g. Scandinavia)
Tietze C: numerous
publications in the 70s/80s
• As the number of women in the population
who have had an abortion increases, the
number at risk of having a repeat procedure
rises
• About 30 years after legalisation, when all
women of childbearing age have had access
to legal abortion, the proportion of repeat
abortion reaches a steady state
Hungary 1
• Abortion on request from 1956
• In 1958, 17% of women relied
exclusively on abortion for fertility
control
• Stabilisation of repeat abortion by late
1960s, then a drop in the 1970s and
1980s
• Sterilisation legalised in 1990
Hungary 2
1968
Proportion of
repeat
abortions
58%
1975
54%
1987
49%
Hungary 3 Proportion of
women who had had previous
abortions, 1968
45
40
35
30
%
25
20
15
10
5
0
0
1
2
3+
Tietze C
The proportion of abortions that are
repeat procedures is affected by the
abortion rate; the higher the rate the
more likely it is that a woman in the
population will have had an abortion
Data for 1987
England &
Wales
Abortion rate
14
per 1000
women 15 - 44
% repeat
18%
abortions
Former
Czechoslovakia
47
42%
Norway 1981 (Skjeldestad &
Bakketeig 1986)
Abortion rate /
1000 women
aged 15-44
Proportion of
abortions
which are
repeat
Three counties
with higher
abortion rate
18
Three counties
with lower
abortion rate
13
18%
11%
2007
2005
2003
2001
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
1973
1971
1969
Abortion rate per 1000 women
aged 15-44 (E&W )
20
18
16
14
12
10
8
6
4
2
0
Proportion of women having TOP
who had had one or more previous
abortions
E&W
Sweden
Finland
Scotland
USA
Canada
60
50
40
% 30
20
10
2005
2002
1999
1996
1993
1990
1987
1984
1981
1978
1975
1972
1969
0
Millar et al, 1997
A woman who has had one or more
abortion is more likely to have another
one in a given year than a woman who
has never had an abortion is to have a
first
Canada 1993
Abortion First
rate
abortion
rate
All ages 15
13
Repeat
abortion
rate
27
15 - 19
81
22
19
Millar et al, 1997
The higher rate of repeat abortions
compared to first abortions occurs in
spite of evidence that contraceptive use
improves after an abortion (Henshaw
SK, 1984)
Danish record linkage study
(Somers, 1977)
• Fifteen months immediately after the
introduction of abortion on demand to 12
weeks’ gestation
• 27,695 abortions between Oct 1973 and Dec
1974
• 97.1% had one abortion, 2.9% had 2
abortions and 0.05% had 3 abortions
• Mathematical modelling assuming a monthly
probability of conception of 20% suggests
that these women were using contraception
to an effectiveness level of 98%
Greater chance of repeat for
women who have already had
one abortion
• More likely to be in the higher fertility
20-29 age group
• More likely to be sexually active
• By definition not infertile
• More likely to consider abortion as a
method of fertility control
• More likely to have problems practising
contraception
Proportion of women who had
had previous abortions E & W
2007
80
70
60
%
50
40
30
20
1.3%
10
0.4%
0.1%
0
0
1
2
3
4
5+
Proportion of women who had
had previous abortions 2006
(USA 2004)
70
60
50
40
Finland
E&W
USA
%
30
20
10
0
0
1
2
3+
Is abortion being used as a
method of fertility control?
• These data suggest that abortion is not
widely used as a primary method of
fertility control
• Abortion is almost entirely used an
adjunct to contraception
Women having subsequent
abortions compared to those
having a first 1
• They are more likely to:
– present with less delay (one study)
– have had an earlier sexual debut (2
studies)
– have a higher coital frequency (3 studies)
– have had a larger number of sexual
partners (one study)
– have had an STI in the past (one study)
Women having subsequent
abortions compared to those
having a first 2
• They are more likely to:
– have low socio-economic status (4 studies)
– have suffered intimate partner violence (2
studies)
– be immigrants (3 studies)
– have no religious affiliation (one study)
Women having subsequent
abortions compared to those
having a first 3
• Four ‘softer’ studies show tendencies to:
– have been neglected
– have had difficulties at school
– conflicts with current partner
– be immature, dependent and impulsive
– have sexual problems
Use of contraception in those
undergoing subsequent abortions
compared to women having first
abortions
• No lesser use of contraception (ten
studies)
• Better use of contraception (eight of the
above studies)
• Greater use of coitus-independent
methods (two studies)
• More consistent use of contraception
(one study)
Use of emergency contraception
(Garg et al, 2001)
Repeat n = 50 First time n = 83
Did not use EC
29 (88%)
54 (90%)
Did not know about 6 (21%)
EC
7 (13%)
Could not obtain
EC
2 (7%)
3 (5%)
Did not know
1 (3%)
where to obtain EC
1 (2%)
Did not think about 20 (69%)
EC at the time
43 (79%)
England & Wales 2007
Region
North East
Proportion of previous
abortions in under 25s
undergoing abortion
19%
London
30%
What do the DH figures for the
under 25s mean?
• different types of population?
• varying access to abortion?
Possible interventions
(Schunmann & Glasier, 2006)
• Randomisation to specialist
contraceptive advice and enhanced
provision or standard care
• Short-lived beneficial effect on
contraceptive uptake and use of LARC
seen in intervention group
• No difference in repeat abortions
between the groups
Conclusions
• There is no cause for alarm and
despondency about our statistics for repeat
abortion; they were predicted
• The proportion of repeat abortions is
stabilising
• Abortion alone is not being used in the West
as a means of fertility control
• Women having repeat abortions do not differ
from those having their first and should be
treated no differently
Data sources
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•
•
•
•
www.dh.gov.uk/publichealthstatistics
www.isdscotland.org/isd/1916.html
www.cdc.gov/mmwr
www.stakes.fi
www.sos.se
www.stats.govt.nz
Review article
Rowlands S. More than one abortion.
JFPRHC 2007; 33: 155