B. BASIC TYPES OF ABORTION PROCEDURES

An important first step in advocating for APCs as abortion providers involves education about the abortion procedure itself. Politicians and regulators as well as clinicians are often unaware of the basic training that is required to become a provider of medication or early aspiration abortion. This lack of understanding can lead to misinformed decisions that unduly restrict training and access.

Although there are multiple types of abortion procedures, this APC Toolkit focuses on the two methods most commonly used during the first trimester of pregnancy: aspiration and medication.5 (See Figure I.3 for a discussion of why the language used to describe these procedures is important.) The vast majority of women seeking abortion care do so in the first trimester,

Medication Abortion

Medication abortion is a method of pharmacologic termination of the early first trimester of pregnancy. Depending on the agent(s), the regimen, and the provider, medication abortion may be initiated as soon as a woman finds out she is pregnant, through 7–9 weeks (49–63 days) of gestation (via menstrual dating). Together, these methods account for 13% of all abortions in the United States (Jones et al., 2008).

In the United States, three medications are available for use as abortifacients: (1) mifepristone, (2) methotrexate, and (3) misoprostol. Both mifepristone and methotrexate are only acceptably effective in terminating intrauterine pregnancy when used in combination with misoprostol (Creinin, 2000; Pymar & Creinin, 2000). Mifepristone is the only one of these agents that has been specifically labeled by the FDA for use as an abortifacient. It blocks the uptake of progesterone by receptor cells in the uterus. Without this essential hormone, the lining of the uterus begins to break down, and the cervix softens. Methotrexate, by contrast, interferes with the DNA synthesis of rapidly dividing cells—in this case, the developing embryo. Misoprostol is a prostaglandin analogue that stimulates uterine contractions and softens the cervix, facilitating uterine emptying. It is most effective when used following either mifepristone or methotrexate. Where neither methotrexate nor mifepristone is available, regimens for misoprostol alone may be used, although efficacy is lower, and the risk of side effects is higher (Carbonell et.al. 2003; Singh et.al. 2003)

FIGURE I.4

Abortion Method Terminology

Medication abortion refers to termination of pregnancy using one or more of the pharmacologic agents mifepristone, methotrexate, and/or misoprostol. Medication abortion may sometimes be referred to as RU486 (its original European name), “the abortion pill,” or as “medical” abortion.

Aspiration (or suction, or surgical) abortion refers to procedures that terminate a pregnancy by using manual or electric suction to empty the uterus. These procedures are also known as manual vacuum aspiration (MVA) or electric vacuum aspiration (EVA).

Dilation and evacuation (D&E) and dilation and extraction (D&X) describe abortion procedures performed with instrumentation of the uterus and fetus. These procedures are generally used in second trimester abortion care.

Medication Abortion Regimens

Medication abortion regimens are based on the most current clinical research evidence. The World Health Organization (WHO), the American College of Obstetricians and Gynecologists (ACOG), and several other general and specialty health organizations have described safe and effective regimens of early medication abortion (American College of Obstetricians and Gynecologists, 2005; Cheng, 2008; Chien & Thomson, 2006; Grossman 2004; Odusoga & Olatunji, 2002).

As professional organizations that together represent the majority of abortion providers in the United States, the National Abortion Federation (NAF) and the Planned Parenthood Federation of America (PPFA) offer their members continuously revised protocols for safe and effective administration of abortifacients in the first 9 weeks of pregnancy (National Abortion Federation, 2008a). Figure I.5 summarizes the most common regimens (NAF, 2008a).

Early Aspiration Abortion in the U.S.

In the first trimester, abortion can be performed as a simple office procedure using a vacuum aspirator. The designator aspiration abortion more accurately describes this procedure (see Figure I.3) than the traditional appellation surgical abortion. In aspiration abortion, the cervix usually is gradually stretched with tapered rods. After the cervix is dilated sufficiently, a plastic cannula attached to the suction apparatus is inserted into the uterus. Gentle suction (<60 mmHg) is applied to empty the contents of the uterus. Local anesthesia by means of paracervical and/or intracervical injection is almost universally used, and many clinics offer various other medications for relief of anxiety and pain management. General anesthesia is less commonly used in early abortion but may be offered in some facilities that have specialized equipment and dedicated anesthesia services.

FIGURE I.5

from NAF (2008a): Comparison of FDA-Approved and Other Evidence-Based Regimens

Efficacy and Safety of Early Abortion

Aspiration abortion is highly effective, with success rates (complete abortion) at 99% (National Abortion Federation, 2009). It is also extremely safe. Both major and minor risks are lowest when women receive abortion care in the first trimester (Boonstra, 2006). One communitybased study of 1,132 aspiration abortions reported that 88% of patients had been less than 13 weeks pregnant (Paul, Mitchell, Rogers, Fox, & Lackie, 2002). Of these women, 97% reported no complications, 2.5% had minor complications (e.g., infection, bleeding, incomplete abortion) that were handled at a medical office or abortion facility, and less than 0.5% had more serious complications that required some additional surgical procedure and/or hospitalization. No deaths were reported.

Medication abortion is also an extremely safe procedure, with complications occurring in less than 0.5% of cases when evidence-based mifepristone/misoprostol regimens are used (Grimes, 2005). In less than 2% of medication abortions (using evidence-based regimens), the medications do not successfully terminate the pregnancy and an aspiration procedure is necessary.

Both major and minor risks are lowest when women receive abortion care in the first trimester (Boonstra, 2006). Rarely, excessive bleeding or uterine infection may occur (ACOG, 2005; Soper, 2007; Paul, Lichtenberg, Borgatta et al, 2009). Figure I.6 compares aspiration and medication abortion, describing how each works and the advantages and disadvantages of each method.

FIGURE I.6

First Trimester Abortion: A Comparison of Procedures


5 See Janet Singer’s article—Share with women. Early termination of pregnancy. J Midwifery Womens Health 2009;54:93-4—which provides evidence-based information on early termination of pregnancy that can be used during the essential clinician–patient options counseling for a woman with an unintended pregnancy who is considering abortion or pre-abortion counseling for a woman who has chosen that option.