ABORTION! FOR ME??

by William F. Harrison, MD, FACOG

September 2, 2002

How does one answer this question? Years ago, the U. S. Supreme Court ruled in Roe v. Wade that until the 24th week of pregnancy, usually about 26 weeks after the last menstrual period (LMP), every woman or girl who becomes pregnant through ignorance, naivety, carelessness, poverty, or just plain bad luck may decide for herself whether to continue a pregnancy or to abort. A majority of Americans believe that safe, legal abortion should be available as an option for those who choose to end a pregnancy. This freedom to choose whether, when and by whom you will have a baby is, however, in extreme jeopardy so long as 'Republicans (the national Republican Party has long been committed to reversing Roe v. Wade) and so-called "Pro-Life" politicians dominate our political process.

First, you must settle in your own mind ho you feel about abortion. If you believe abortion to be wrong in your case, a sin or "against the will of God," if you believe that in having an abortion that you are killing a baby, then for you, the answer is simple: You should not have an abortion. The guilt and psychological pain you may suffer from having an abortion may be far more damaging to your long-term well being than having a child, no matter what difficulties that may imply.

Most women, when considering abortion, have both positive and negative feelings and this is perfectly normal. On one side is the fear of pain from the abortion itself, the shame of being pregnant and not wanting to have a child at this particular time and circumstance or with this partner. You may also fear that friends and loved ones may know, or find out, and think less of you. And then there is the fear of injury, infertility or even death. You may be concerned that the "baby" you are carrying may suffer pain or terror at being so treated by its mother. There may be anger toward and resentment of your sexual partner and disgust with yourself. You may wonder at your own ignorance, carelessness or bad luck. On the other hand, there is the sense of relief that you don't have to continue this pregnancy, that your plans, hopes and dreams will not be shattered by the misfortune of an unwanted child, that there is this birth control of last resort. For that is exactly what abortion is in the final analysis - a method of birth control. It prevents the birth of a child when you are not ready, for whatever reason, to raise one. Abortion is certainly not the best method of birth control, but since contraception has failed you at this time, you still have abortion as an option.

Those who are anti-abortion - almost always for sectarian religious reasons (There is, by the way, no monolithic Christian, Muslim or Jewish „position" on abortion. Well meaning and thoughtful people of all faiths on both sides of the issue differ with others in their own tradition) - have advanced certain ideas and notions which may have raised questions in the minds of even those of you who already consider yourselves "Pro-Choice" and think that abortion is your best course. What follows are answers to some of those questions. If you have others, we will be happy to try to answer them for you.

QUESTION: Is it dangerous to have an abortion?
ANSWER: There are no medical or surgical procedures without risk. What you have to do when considering abortion's risks is to compare them with the risks of not having an abortion but carrying the baby to term and delivering. You have no other options once you are pregnant. If you choose to abort before the 10th week after your last menstrual period (LMP), the risk of your dying from an abortion is about I in 200,000. If you choose to carry the pregnancy to term and deliver, your risk of dying from complications of that is about I in 10,000, or possibly even greater depending on your age, health and social status. A second thing that you may be worried about is the possibility of infertility or sterility caused by having an abortion. Abortion done by a qualified and experienced physician carries no greater risk of these complications than does carrying a baby to term and delivering, and in fact, the risks are considerably smaller. The risks of infection and injury during the abortion are minimal but increase as your pregnancy advances while the risks of these in term pregnancy are very real. The risk of having to have major surgery following an abortion in the first ten weeks of pregnancy is probably considerably less than I in 10,000, while the risk of major surgery with carrying a baby to term is about 1in 5 at this time.

QUESTION: Is there a relationship between abortion and breast cancer?
ANSWER: This is one of the crueler hoaxes perpetuated by the Pro-Life side. While there are a few studies which seem to suggest that there may be an association, most of those who have studied this feel that there is no credible evidence which confirms such a relationship. In fact, there is much more credible evidence that abstinence causes breast cancer since the incidence of this disease is much, much higher in nuns than any study has ever suggested might be the case among women who have had abortions.

QUESTION: Will I get Post Abortion Syndrome from having an abortion?
ANSWER: "Post abortion syndrome" is something that exists only in the mind of anti-abortion zealots. If you choose abortion of your own free will, do not feel that family, spouse, boyfriend or parent is forcing the choice on you, and if you don't have extremely strong religious feelings, or very strong moral prejudices against abortion, then the answer for you is, No, you will not get "post abortion syndrome." There is no generally recognized psychological diagnosis associated with freely chosen abortion. However, if you feel that abortion is not your choice, but is being forced on you by others even though you feel that abortion is wrong and sinful or that by having an abortion you are killing a baby, then the answer for you might be that you may have significant sadness and regret after an abortion, even severe depression, and you should probably not have an abortion without extensive counseling and very serious consideration of your options if you choose to have the baby.

QUESTION: Am I killing a baby if I have an abortion?
ANSWER: No! Nor are we in the baby killing business! Every person begins as a chance meeting between an egg and a sperm. Over the period of a few months, the conceptus - that living thing which results from the joining of two living things, the egg and sperm - will develop all, or at least most, of those structures, functions and attributes which we associate with a baby, a person. Scientists have divided the various stages in the development of an adult human, being, which flow one into the other in a smooth continuum, into categories based on the conceptus' anatomical development and functional capacities. The fertilized egg has none of the functional capacities or physical architecture that we identify as a baby. There obviously does come a time when, unless it is electively or spontaneously aborted, the conceptus becomes a baby. There is every good scientific reason to believe that a less than 26 weeks LMP fetus should not be identified as a "baby." Prior to the 24th week of intrauterine life (26 weeks after the IMP) there is very good evidence that the fetus cannot feel pain, that it has no thoughts, no consciousness, no hopes, no fear, no sadness, no elation, love, hate or even indifference. A baby has the capacity to do a minimum of these things. So the answer is, No! You will not be killing a baby, and neither will we who do your abortion.

QUESTION: Will I feel any pain with the abortion?
ANSWER: Yes. There is always some pain with abortion, even if it may be no more than the pain of the shots to dull the pain. In this clinic, when we do abortions at ten weeks or beyond, we may insert some tablets called misoprostol to ripen your cervix so that later we can easily dilate it without injury. We may have you put them between your cheek and gum, or we may insert them deep into the vagina. At other times, we may insert a small piece of water absorbing (hydrophilic) material called laminaria into the cervix. Both these methods may make you cramp and bleed a little, sometimes a lot. Then after waiting an appropriate length of time, we complete the abortion. Depending on the results of the first series of pills or laminaria, we may do this again or wait overnight to do the abortion. Generally, almost all abortions are performed on the same day we start them, but rarely, a visit to complete the abortion may be required the next day. Also, in very early pregnancies, under the right circumstances, you may be a candidate for a "medical abortion." We will discuss these options with you when it is appropriate to do so, if you wish.

QUESTION: When is it safe to have an abortion?
ANSWER: Probably the safest time to have an abortion is between 6 and 8 weeks after your LMP. However, with certain restrictions, we provide abortions here in the clinic from the time you first discover the pregnancy (which is in rare instances even before a woman has missed a period) and decide on abortion and 18 weeks after the LMP. As pregnancy progresses beyond 10 weeks, the risk of major complications nearly doubles every two weeks. This continues up to 26 weeks after which abortion is not generally available. We rarely provide abortions in hospital after 18 weeks, but as Dr. George Tiller's clinic in Wichita, Kansas has had extensive experience with late second trimester abortions and even some third trimester abortions for severe fetal anomalies, we almost always refer the later patients to him. In-clinic abortion is available in Little Rock up to 20 weeks and we also refer patients there to Dr. Jerry Edwards for those more than 18 and less than 20 weeks.

QUESTION: How can I schedule an abortion?
ANSWER: At Fayetteville Women's Clinic we usually see you a day or a few days before the abortion (state law mandates that we provide you with certain information at least one day prior to the abortion which sometimes may be done by phone) for examination and discussion of your options, concerns and fears, and then schedule the abortion at a mutually convenient time. During this first visit, we will collect a medical history, do a limited physical exam to determine if you really are pregnant, how far your pregnancy has progressed and if you are physically fit for outpatient minor surgery. We will also discuss with you the option of medical abortion if you meet our guidelines for this procedure and are interested in this route. You will be given this booklet, ABORTION! For me? to read which is as accurate and truthful as we can make it, plus the state mandated information booklets which we are required by law to provide you but which contain some minimal misinformation. You may read the state booklets or discard them, as you decide. We will do an ultrasound examination to determine exactly how far the pregnancy has advanced, the shape and position of the uterus and any abnormalities of the pelvic structures that might affect the technique of the abortion. Sometimes we obtain a hematocrit prior to the abortion and always a blood typing unless you already have that available. If you are under 18 years old, and a dependent, you are a minor in the eyes of the state and Arkansas law concerning parental notification must be followed. I, or your counselor, will discuss this with you. Then, if all circumstances are appropriate, we will get your informed consent signed after you have read and understood it, and we will schedule the abortion.

QUESTION: What has been your experience with complications at Fayetteville Women's Clinic?
ANSWER: Our experience here has been very good so far as significant complications are concerned. In 1974, we had a patient who had a post¹abortal infection that led to infertility. Perhaps I in 100 patients will have to undergo a second D&C because of excessive bleeding or cramping. There have been a few patients who were discovered to have ectopic pregnancies (a pregnancy outside the uterus that may require an abdominal operative procedure, either a full scale laprotomy or a laproscopic procedure) before, during or after the abortion. We always make every attempt to diagnose this before an abortion, but in rare instances these efforts fail. About 1 in 30 patients has heavier bleeding or more pain than anticipated requiring additional visits to ensure that no significant complications are developing. The cost of these visits to the clinic is included in your payment for the abortion. There may, however, be additional lab work necessary, which is not included in the original fee. In our practice so far, our only major complications have been the post operative infection in 1974, and in 2002 we had a patient with an abnormal placenta called a placenta accreta which required a visit to the hospital operating room for safe removal under a general anesthesia by minor surgery. This does not mean that other complications may never happen. These other major complications are listed on the informed consent and we will be happy to discuss them with you.

QUESTION: How are abortions done here?
ANSWER: In very early pregnancy, medical abortion with either methotrexate (a very old anti-cancer drug which is now used for multiple indications) or mifepristone (widely known as RU486), plus Cytotec are used to induce a miscarriage. Not every early pregnant patient is a candidate for these procedures and we have very strict criteria for choosing those patients who are offered these options. For those who are candidates for these medications, there is a special informed consent that contains material pertinent to these. Most abortions done here are by suction D&C. D&C is usually considered a "minor operation," however, as a pregnancy advances, a much higher level of skill is required than that which may suffice for most D&Cs. Since the difficulty and complication rates of abortion rise as pregnancy advances, it is always best to abort as soon as possible. When a surgical abortion is done, the surgeon cannot see into the uterus, the organ within which the surgery is being performed. Immediately prior to doing the abortion, we will do an ultrasound to determine the size and position of the uterus. (We may use the ultrasound to guide the abortion instruments within the, uterus and we will do a post¹operative ultrasound to ensure that the uterus appears empty.) Either the nurse or I will start an IV after which this will be used to administer Valium and midazolam for relaxation and amnesia. Most patients remember nothing about the procedure once the midazolam is started. The perineum and vagina are then prepared with an antiseptic solution to reduce the chance of infection, the cervix is injected with a local anesthetic and the abortion completed by either suction D&C or a procedure called D&E, depending on the term of your pregnancy. You will be here about an hour or so, depending on multiple factors, including how soon you are awake and conscious. Very early pregnancies can be very difficult to locate, and it is extremely important that if you have an abortion prior to the fourth week of pregnancy that you return for a two-week post-operative visit and that you contact us if you develop fever, excessive bleeding or more pain than you anticipated. Very early pregnancies may present confusing pictures and if you have a surgical abortion prior to 4 weeks, we may miss an ectopic pregnancy and may even miss an intrauterine pregnancy on rare occasions. Undetected ectopic pregnancies can be very dangerous unless properly treated and the above symptoms might be indicators of just such a pregnancy. For pregnancies that are beyond 10 weeks, we prepare the cervix for mechanical dilatation with either vaginal or buccal (this means between the cheek and the gum) Cytotec tablets, or one or more small water absorbing sticks inserted into the cervix. This is usually done from one and a half hours or so before the abortion, or the day before for those pregnancies beyond 16 weeks.

For those who are having surgical abortions, we recommend that you have a friend or relative with you who can provide comfort in the operating room and drive you home afterward. You should plan to sleep and rest for several hours after the abortion, and you should avoid driving or operating dangerous equipment for 24 hours after the procedure.

It is perfectly natural for you to be afraid, however surgical abortions done by someone who is expert in the surgery carries no greater risk than having a tooth pulled and is almost certainly less painful.

Once you are pregnant, your choices are limited to having a baby, or having an abortion. Obviously your being here and reading this means that you are considering abortion. If you have already chosen, or if you choose, abortion, we are aware that this may be or may have been a difficult and painful decision for you, involving many factors. We strongly support your decision, whatever that decision may ultimately be. If you should decide that abortion is not for you at this time even after you have scheduled the procedure, you should cancel your appointment and arrange for obstetrical care.

In the past, our clinic has sometimes been picketed by persons opposed to your freedom to make your own reproductive choices. It is important that if demonstrators should be here when you come, that you be aware that there is no way that these people can know why you are here. We usually see anywhere from 20 to 40 or more patients a day here and only a small number of you will be here for an abortion. If you feel that you are harassed, intimidated, or had your entry into the clinic blocked by these people, please notify us, the Fayetteville police, the prosecuting attorney and the local office of the FBI. There are local and federal laws that protect your unhindered entry into this clinic, but both you and we must make the complaint.

We are here to serve you, to make what is probably a very bad time better, and as easy and as painless as possible. Every person who works here is on your side, here to help you make the right choice for you.

We wish you well.

QUESTION: How can I prevent unintended pregnancies in the future?
ANSWER: If you never have intercourse again, you will never again get pregnant. However, once you have become sexually active, this is not a very realistic and may not be even a desirable goal. Nearly every young woman who tells us, "Oh, I won't need anything for birth control because I'm not going to have sex again," we see for a second and even sometimes a third abortion. It is much better to be prepared with contraceptive knowledge and methods and not need them, than to need them and not be prepared. However, when you have intercourse with out proper preparation, you still can use the morning after pill, also called emergency contraception (emergency contraception, or EC, is not an emergency and I will be very grumpy if I am waked in the middle of the night for a non-emergency) if you get in touch with us within 72 hours after exposure. This can also be used if a condom slips off or breaks, but it is important that you call as soon as possible during clinic hours. EC is not a substitute for the regular use of an effective method of contraception and should not be used as such.

Birth control methods

1. Abstinence.
If you are very young, there is no doubt that this is the most desirable option for you. Also, one who is sexually abstinent does not get sexually transmitted diseases. But remember, just saying you're going to be abstinent does not prevent pregnancy. You have to practice it.

2. Avoiding coitus.
Coitus is the act of sexual intercourse involving the penis making contact with the vagina. However, vaginal penetration is not necessary for pregnancy to occur if your partner ejaculates, or "cums," in the vicinity of your vulva. If you avoid coitus while engaging in other forms of sexual activity - oral sex, mutual masturbation and other non-genital contact sexual relations, you will not get pregnant. However, these activities almost always lead to coitus and should probably be avoided unless you are using something for birth control, except for the very rare individual.

3. Hormonal and other methods.
A. The single most effective methods of birth control currently available are injectable or implantable progestins called Depo¹Provera and Norplant. We no longer use Norplant in this clinic, and I am unsure where you might obtain this. We do use Depo-Provera, which has a pregnancy rate of about 1 in 200 or so when it is properly used. Used in combination with condoms, the odds against an unintended pregnancy are about 1 in 2,000, and using a condom also helps prevent sexually transmitted diseases for you who are not married to, and living with, your partner.

B. There are now multiple routes by which the hormones in the birth control pill may be delivered. There is the pill itself -several different name brand and generic preparations - which is absorbed in the intestinal tract. Anything that interferes with the gut's motility (that is, the speed that substances move through the bowel) or rate of absorption may alter the effectiveness of the pill. There are now two products available which deliver the hormones through the mucus membranes of the vagina or through the skin: one is a patch, sort of like a band-aid, the other a vaginal ring. These are touted as being as effective as the pill, but because of relatively steady absorption rates, they may prove to be even more effective. About I in 50 women who use the pill will get pregnant and this is improved to about one in 2-300 if your partner wears a condom every time.

C. The IUD. There are at least three IUDs on the market. At one time, it was assumed that wearing an IUD might increase the probability of pelvic infections. This may or may not be true according to the latest data. Using an IUD makes the rate of unwanted pregnancies about 1 in 50, and again, having a partner use a condom as well will reduce that probability to about I in 2-300.

D. Sterilization. Sterilization is a permanent method of insuring that you won't become pregnant again. It should be considered only by mature women who are certain that they never want any more babies under any circumstances. The odds of a pregnancy after sterilization are about I in 200 or so.

E. Spermicides plus condoms. The odds are about 1 in 50 of becoming pregnant if you use both every time.

F. Spermacide or condom alone. About 1 in 8 pregnancy rate.

G. Diaphragm with a spermicide. About 1 in 5.

H. Rhythm method. About 1 in 2.

I. Douching. Probably not much better than using nothing.

J. No method. About 8 of 10 women will get pregnant in any one year.

QUESTION: Do you take care of problems other than abortion here at Fayetteville Women's Clinic?
ANSWER: Yes. Dr. William Harrison practices all phases of women's health care except Obstetrics. Should you like to know what the embryo or fetus looks like at various stages of pregnancy there are photographic representations in the state mandated materials that we give you. You need not look at these illustrations unless you want to. These are only for those who wish to know.


William F Harrison, MD, FACO