Abortion: what is it? and Risk factors

Abortion is the loss of an embryo or fetus during pregnancy.

It can be spontaneous, that is to say occur without having been researched (health problem, genetics, etc.), or provoked and therefore voluntary.

  • Spontaneous abortion. We also talk about miscarriage. By definition, it is the death or expulsion from the maternal body of an embryo or fetus weighing less than 500 grams or less than 22 weeks of amenorrhea or without menstruation (= 20 weeks of pregnancy). If the miscarriage occurs later in pregnancy, it is called “fetal death in utero”.
  • induced abortion , also called “abortion” can be triggered in several ways, including taking medication “abortifacients” or the aspiration of the fetus. Laws governing access to (or prohibition of) abortion differ from country to country.
  • Medical termination of pregnancy (IMG) is an induced abortion, performed for medical reasons, often due to an abnormality or disease of the fetus that is life-threatening after birth or causes serious health problems, or when the mother’s life is in danger.
Whether psychologically or medically, induced abortion is very different from spontaneous miscarriage, although there are many commonalities. This sheet will therefore treat these two subjects separately.

Spontaneous abortion: prevalence and causes

Miscarriages are a very common occurrence. They are, for the most part, linked to a genetic or chromosomal anomaly in the embryo, which is then expelled naturally by the mother.

We distinguish :

  • early miscarriages, occurring during the first trimester of pregnancy (less than 12 weeks of gestation). They affect 15 to 20% of pregnancies but sometimes go unnoticed when they occur in the very first weeks because they are sometimes confused with the rules.
  • late miscarriages, occurring during the second trimester, between about 12 and 24 weeks of gestation. They occur in about 0.5% of pregnancies 1 .
  • fetal death in utero, in the third trimester.

There are many, many causes that can lead to miscarriage or even repeated miscarriages.

Among these causes, we find in the first place genetic or chromosomal abnormalities of the embryo, involved in 30 to 80% of early miscarriages 2 .

Other possible causes of spontaneous abortion are:

  • an abnormality of the uterus (eg partitioned uterus, open cervix, uterine fibroids, uterine synechiae, etc.), or DES syndrome in women who have been exposed in utero to distilbene (born between 1950 and 1977).
  • hormonal disorders, which prevent the pregnancy from being carried to term (thyroid disorders, metabolic disorders, etc.).
  • multiple pregnancies which increase the risk of miscarriages.
  • the occurrence of infection during pregnancy. Many infectious or parasitic diseases can indeed cause miscarriage, in particular malaria, toxoplasmosis, listeriosis, brucellosis, measles, rubella, mumps, etc.
  • some medical tests, such as amniocentesis or trophoblast biopsy, can cause a miscarriage.
  • the presence of an IUD in the uterus during pregnancy.
  • Certain environmental factors (consumption of drugs, alcohol, tobacco, medication, etc.).
  • Immunological disorders (of the immune system), especially involved in repeated miscarriages.
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Induced abortion: inventory

Statistics on induced abortion around the world

The World Health Organization (WHO) regularly publishes reports on induced abortions around the world. In 2008, around one in five pregnancies was reportedly terminated voluntarily.

In total, nearly 44 million abortions were performed in 2008. The rate is higher in developing countries than in industrialized countries (29 abortions per 1,000 women aged 15 to 44 compared to 24 per 1,000, respectively).

According to a study published in 2012 3 , the global abortion rate fell from 35 to 29 per 1,000 women between 1995 and 2003. Today, there are an average of 28 abortions per 1,000 women.

Abortion is not legal everywhere in the world. According to the organization Center for Reproductive Rights , more than 60% of the world’s population live in countries where abortion is permitted with or without restrictions. On the contrary, around 26% of the population lives in states where this act is prohibited (although it is sometimes authorized if the woman’s life is in danger for medical reasons) 4 .

Who is affected by induced abortions?

Induced abortions affect all age groups among women of childbearing age, and all social backgrounds.

In France and Quebec, the abortion rate is higher among women aged 20 to 24. Four-fifths of abortions performed there concern women between 20 and 40 years old.

In two thirds of cases, in France, abortions are performed in women who use a contraceptive method.

Pregnancy occurs due to method failure in 19% of cases and due to its incorrect use in 46% of cases. For women on oral contraception, forgetting the pill is involved in more than 90% of cases 8 .

In developing countries, more than contraceptive failures, it is above all the total lack of contraception that leads to unwanted pregnancies.

Possible complications of abortion

According to the WHO, a woman dies every 8 minutes worldwide due to complications from an abortion.

Of the 44 million abortions performed each year worldwide, half are performed in unsafe conditions, by a person “who does not have the necessary skills or in an environment that does not meet minimum medical standards. , or both “.

We deplore about 47,000 deaths directly linked to these abortions, 5 million women suffering from complications after the act, such as hemorrhages or septicemia.

Thus, unsafe abortions are one of the most easily preventable causes of maternal mortality (they were responsible for 13% of maternal deaths in 2008) 9 .

The main causes of death related to abortions are:

  • hemorrhages
  • infections and sepsis
  • poisonings (due to the consumption of plants or abortive drugs)
  • genital and internal injuries (perforated intestine or uterus).

Non-fatal sequelae include healing problems, infertility, urinary or fecal incontinence (related to physical trauma during the procedure), etc.

Almost all clandestine or unsafe abortions (97%) are performed in developing countries. The African continent alone accounts for half of the mortality attributable to these abortions.

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According to the WHO, “these deaths and disabilities could have been avoided if these induced abortions had been performed within a legal framework and in good safety conditions, or if their complications had been properly taken care of upstream, if the patients had access to sexuality education and family planning services ”.

 In countries where abortion is performed safely, the associated mortality is around three deaths for a million abortions, which is a very low risk. The main complications are, when the abortion is done by surgery:

  • uterine perforation (1 to 4 ‰)
  • a tear in the cervix (less than 1%) 10 .
Contrary to some beliefs, in the long term, abortion does not increase the risk of miscarriage, nor that of fetal death in utero, ectopic pregnancy, or infertility.

Abortion: risk factors and people at risk

Symptoms of spontaneous abortion

Depending on the case, spontaneous abortion can result in:

  • stopping the progress of the pregnancy without expulsion (often marked by disappearance or attenuation of signs of pregnancy such as nausea or breast pain);
  • expulsion of the embryo or fetus.

The symptoms are usually:

  • more or less abundant vaginal bleeding. However, bleeding during pregnancy is not always linked to a miscarriage, far from it.
  • abdominal cramps, stomach pain or lower back pain.
  • vaginal loss of fluid, blood clots, or debris from the uterus.

After a voluntary termination of pregnancy , abdominal cramps and bleeding may occur, with varying intensity, for a few days. Symptoms related to pregnancy gradually disappear as the amount of pregnancy hormones decreases in the blood.

Risk factors for spontaneous abortion

In the first trimester of pregnancy, premature miscarriages are frequent and should not be of great concern. The vast majority of these are sporadic events that correspond to a natural process of elimination of non-viable embryos. Having had a single miscarriage does not increase the risk of having more in subsequent pregnancies.

For about 1 to 2% of couples desiring a child, however, miscarriages occur repeatedly (at least three pregnancies terminated spontaneously before 12 weeks gestation, by definition).

The higher the number of miscarriages, the greater the risk in subsequent pregnancies. Thus, this risk is:

  • 17 to 35% after 2 spontaneous miscarriages
  • 25-46% after 3 miscarriages
  • greater than 50% after 6 miscarriages 11 .

Factors that may increase the risk of a natural miscarriage are 12  :

  • age (35 years and over)
  • health problems (infections, blood clotting problems, endocrine diseases, autoimmunes, uterine or ovarian problems, etc.)
  • the consumption of alcohol, drugs or tobacco.
  • exposure to certain chemicals, such as pesticides
  • taking certain medications or herbal remedies

Risk factors for voluntary termination of pregnancy

Although abortions affect all women, of all ages and all social classes, certain factors are associated with an increased risk of having an abortion:

  • lack of easy access to contraception
  • lack of sex education programs
  • the fact of having already undergone an abortion, which is a risk factor to have it a second time, or several other times 13 .
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Getting informed about abortion

Can we prevent?
Obviously, preventing voluntary terminations of pregnancy means preventing unwanted pregnancies, through adequate contraception and through information and sex education.As for miscarriages and terminations of pregnancy linked to a medical problem, concerning either the fetus or the mother, their prevention is rarely possible, except when the cause is clearly identified and a treatment exists.

Worldwide, according to INED, 63% of couples use a contraceptive method.
The most used method is sterilization (37% worldwide). 
The other most common contraceptive methods are the IUD (23%), the pill (14%), the condom (10%) and withdrawal (4%)  .
According to the WHO, however, 215 million women living in developing countries do not have access to modern contraception despite the desire to limit births. 
For example, 82% of unwanted pregnancies in developing countries occur in women whose contraceptive needs are not met .
There are still many fears (of side effects, in particular), beliefs, pressures from family or from the husband, in addition to difficult and sometimes expensive access to contraceptives, which hinder women’s access to contraception. .

Intervention procedures during an abortion

Two techniques are used to perform a voluntary termination of pregnancy:

  • drug technique
  • surgical technique
Whenever possible, women should be able to choose the technique, medical or surgical, as well as the mode of anesthesia, local or general.

Medication technique

The medical abortion is based on the taking of drugs allowing to cause the termination of the pregnancy and the expulsion of the embryo or the fetus. It can be used up to 9 weeks of amenorrhea. 

There are several “abortion” drugs, but the most common method is to administer:

  • an anti-progestogen (mifepristone or RU-486), which inhibits progesterone, the hormone that allows pregnancy to continue;
  • in combination with a drug of the prostaglandin family (misoprostol), which triggers contractions of the uterus and allows the evacuation of the fetus.

Thus, the WHO recommends, for pregnancies of gestational age up to 9 weeks (63 days) the intake of mifepristone followed 1 to 2 days later by misoprostol.

Mifepristone is taken by mouth. The recommended dose is 200 mg. Administration of misoprostol is recommended 1 to 2 days (24 to 48 hours) after taking mifepristone. It can be done by vaginal, buccal or sublingual route up to 7 weeks of amenorrhea (5 weeks of pregnancy).

The effects are mostly related to misoprostol, which can cause bleeding, headache, nausea, vomiting, diarrhea and painful abdominal cramps.
In practice, medical abortion can be performed until the 5 th week of pregnancy without hospitalization ( home ) until the 7 th week of pregnancy with a few hours of hospitalization.

From 10 weeks of amenorrhea, the drug technique is no longer recommended.

The surgical technique of abortion 

Most abortions in the world are performed by a surgical technique, generally aspiration of the contents of the uterus, after dilation of the cervix (either mechanically, by inserting increasingly large dilators, or medicinally). It can be performed regardless of the term of pregnancy, either by local anesthesia or by general anesthesia. The intervention usually takes place during the day. Aspiration is the recommended technique for surgical abortion up to a gestational age of 12 to 14 weeks gestation, according to the WHO.

Another procedure is sometimes used in some countries, dilation of the cervix followed by curettage (which involves “scraping” the lining of the uterus to remove debris). WHO recommends that this method be replaced by aspiration, which is safer and more reliable.

When gestational age is greater than 12-14 weeks, both dilation and evacuation and medication can be recommended, according to the WHO.

Abortion procedures

In all countries that authorize abortion, its performance is framed by a well-defined protocol.

It is therefore necessary to find out about the procedures, the deadlines, the places of intervention, the legal age of access, the terms of reimbursement.

You should know that the procedures take time and that there are often waiting times. It is therefore important to quickly consult a doctor or go to a facility performing abortions as soon as the decision is made, so as not to delay the date of the act and risk arriving at a pregnancy date when it is necessary. will be more complex.