Induced abortion in Sri Lanka: who goes to providers for pregnancy termination?

The sociodemographic characteristics of abortion seekers and the reasons they give for procuring termination were studied in 356 clients selected from two abortion clinics in the city of Colombo. Nearly 80% were Buddhists and about 10% were Christians. Almost all had some formal education but only 20% were employed outside the home. Over 95% were currently married and at the peak of their childbearing age. More than one-half were aged 30 years or over, while adolescents only constituted about 3%. Fourteen per cent were nulliparous and about two-thirds had one or two living children at the time of obtaining the abortion. A significantly high proportion also had a very young child. In total, the 356 women had had 1130 pregnancies, and the mean rate of abortion was 42 per 100 pregnancies. Over one-quarter had had more than one abortion and about 10% had had three or more. Almost all abortions were performed within the first trimester with a mean gestation period of 6 weeks. About one-third of the clients were using some method of contraception at the time they became pregnant. The most common reasons cited for the present abortion were 'pregnancy too soon after previous delivery', 'no more children desired' or 'curtailment of opportunity for foreign employment'. Unmarried women constitute a special group of abortion seekers who have different needs and behave differently from married women. Their needs are not currently being met by reproductive health programmes in Sri Lanka, and it is important that they should be given special attention in the future. An interesting finding is that a significant minority of the abortion seekers answered negatively to the question regarding providing medical facilities for abortions without difficulty. This underscores the ambivalence many people have to abortion.     

Therapeutic abortion and its psychological implications: the Canadian experience.

Approximately 9 months after a legal therapeutic abortion, 188 Canadian women were interviewed. One half were single and the rest were married, separated or divorced. They were matched closely for a number of demographic variables with control women who had not had abortions. Neurotic disturbance in several areas of personality functioning was assessed from questionnaire responses. Out of 27 psychological scales, differences between the abortion and control groups were found on only 3: in general, women who had had abortions were more rebellious than control women, abortion tended to be associated with somewhat greater depression in married women, and single women who had had abortions scored higher on the shallow-affect scale. However, all the personality scores were well within the normal range. Perceived social support was strongly associated with favourable psychological reactions after abortion. Use of contraceptives improved greatly after the abortion, when over 90% of women reported using contraceptives regularly.     

Legal abortions among teenagers in Canada, 1974 through 1978.

Between August 1969, when the amendment to the Criminal Code went into effect, and December 1978 about 397 000 legal abortions were performed in hospitals with therapeutic abortion committees in Canada. During the 5-year period 1974-78 abortions in females under 20 years of age accounted for 30.9% of all the legal abortions performed in Canada on Canadian residents, and the abortion rate per 1000 women aged 15 to 19 years increased from 13.6 to 16.3. During 1974-77 the proportion of women in whom the gestation period was more than 12 weeks at the time of abortion was 25.3% for teenagers (females under 20 years of age) but only 14.6% for women aged 20 years or over. In 1976 the teenage abortion rate was lower in Canada (14.5) than in the United States (36.2%), Sweden (28.5), Hungary (26.4), Denmark (26.0), Norway (22.7), Finland (20.3), and England and Wales (15.4).     

Therapeutic Abortion in a Canadian City

In a city of 200,000, 119 therapeutic abortions were performed during the period 1962 to 1968. Multiple grounds were commonly given for abortion; these often included depression. Very frequently the absence of support from other people was a factor in deciding to perform abortion. Only five psychiatrists were involved in 82 cases seen in psychiatric consultation. Abortions carried out for more conventional medical reasons, including rubella, decreased in 1967 and 1968 but there was an overall increase beginning in 1967. In the later years of the study (1967-68) a higher proportion of patients were single, younger, had had no previous pregnancy and were aborted later in pregnancy; more were sterilized.A marked increase in abortion rate related particularly to the activity of one of the psychiatrists.One hundred and sixty-six abortions were performed in 1969; a comparable figure (179) was obtained from one other Canadian centre; another centre had performed more (291); two others, 109 and 63; the combined total for 27 other centres from whom replies were obtained was 186.     

No evidence of fetal DNA persistence in maternal plasma after pregnancy

Short- and long-term persistence of fetal DNA in maternal plasma has been investigated. Short-term persistence at very low concentration was detected in 47 out of 105 women within two days after delivery. Twelve out of 13 samples re-tested within three days scored negative. No long-term persistence was detected in 172 women who had previous sons or abortions. Molecular microchimerism due to circulating fetal DNA persisting from previous pregnancies should not hamper non-invasive plasma-based prenatal testing.     

ABO incompatibility and reproductive failure. I. Prenatal selection

An analysis of previous spontaneous abortions and the frequencies of blood-group combinations in mother-child pairs was carried out in 500 gravidae. The rate of previous spontaneous abortions in blood-group-O women whose latest child has blood group B is significantly higher than in all other women. On the other hand, the combination mother B/child AB is rarer than expected, but no increase in the rate of previous spontaneous abortions is obvious among these women. These discrepancies are interpreted as an indication that prenatal selection associated with ABO incompatibility may operate at various stages from fertilization through pregnancy, and that different incompatible combinations may be subject to selection at different stages.     

Immunologic abortion and its treatment by immunotherapy

Recurrent spontaneous abortions in most cases, can be explained by classical abnormalities; but for some cases without etiology and consequently without appropriate therapy until a few years ago, there is hope a successful treatment, thanks to recent advances. Contrary to what was suspected in the past, during pregnancy, the mother is immunologically competent against the paternal antigens of the fetus; this competence is necessary for her to respond to the trophoblast paternal antigen stimulations and develop her immune tolerance. If, because of insufficient stimulation, the woman does not succeed in producing this tolerance, it is now possible to help her by vaccination with paternal lymphocytes, before she becomes pregnant. Our results confirm these data: Again, we observe a greater frequency of HLA antigen sharing in couples with recurrent spontaneous abortions (RSAs), especially at the DR locus, Women with three or more RSAs, produce fewer antibodies against their husbands HLA antigens than regular normal fertile women (none out of the 50 cases studied), Anti-paternal antibodies the specificity of which cannot be determined at the moment, are shown by means of the microlymphocytotoxicity test at 37 degrees C carried out on the paternal B lymphocytes. They appear with the cure of the abortive illness after treatment by paternal lymphocyte injections. In the control women who did not receive any immunotherapy, those who developed anti-paternal antibodies spontaneously had a new normal pregnancy; 57.2 of those who did not produce any anti-paternal antibodies aborted once more.     

Prenatal diagnosis of genetic disease in Canada: report of a collaborative study.

A study of 1223 amniocenteses carried out during 1020 pregnancies in 990 women showed that 2nd-trimester amniocentesis at about 16 weeks'' gestation is a safe, accurate and reliable procedure for the diagnosis of certain classes of genetic disease when it is monitored by ultrasound, performed by a trained obstetrician and carried out in a major health sciences centre. The percentage of fetal losses (4.7%) and neonatal deaths (0.5%) during the study was not greater than in control samples for women 35 years of age and older. The best results were obtained when needles of gauge 20 or 21 were used. The use of needles of gauge 19 or larger and more than two insertions during a single amniocentesis were associated with a significantly greater frequency of fetal loss than a second or even a third amniocentesis during the same pregnancy. For 39 fetuses (3.8%) a diagnosis of a genetic abnormality was made and 23 male fetuses were found to be potentially hemizygous for an X-linked gene. There were 51 therapeutic abortions as a result of the diagnosis. Sixty-six tests (5.4%) gave an inconclusive result and seven (0.6%) gave an erroneous diagnosis; five of the latter (two false-positives and three false-negatives) resulted from the alpha1-fetoprotein test for neural-tube defects and in two cases the sex was incorrectly determined. The frequency of all chromosome abnormalities was 1:20 when the mother''s age was 40 years or more and 1:60 when the mother''s age was between 35 and 39 years. When a mother had previously had a child with a chromosome abnormality the risk of recurrence of such an abnormality was 1:100 when the age of the mother was 35 years or more.     

Pregnancy and the risk of autoimmune disease

Autoimmune diseases (AID) predominantly affect women of reproductive age. While basic molecular studies have implicated persisting fetal cells in the mother in some AID, supportive epidemiological evidence is limited. We investigated the effect of vaginal delivery, caesarean section (CS) and induced abortion on the risk of subsequent maternal AID. Using the Danish Civil Registration System (CRS) we identified women who were born between 1960 and1992. We performed data linkage between the CRS other Danish national registers to identify women who had a pregnancy and those who developed AID. Women were categorised into 4 groups; nulligravida (control group), women who had 1st child by vaginal delivery, whose 1st delivery was by CS and who had abortions. Log-linear Poisson regression with person-years was used for data analysis adjusting for several potential confounders. There were 1,035,639 women aged >14 years and 25,570 developed AID: 43.4% nulligravida, 44.3% had their first pregnancy delivered vaginally, 7.6% CS and 4.1% abortions. The risk of AID was significantly higher in the 1st year after vaginal delivery (RR = 1.1[1.0, 1.2]) and CS (RR = 1.3[1.1, 1.5]) but significantly lower in the 1st year following abortion (RR = 0.7[0.6, 0.9]). These results suggest an association between pregnancy and the risk of subsequent maternal AID. Increased risks of AID after CS may be explained by amplified fetal cell traffic at delivery, while decreased risks after abortion may be due to the transfer of more primitive fetal stem cells. The increased risk of AID in the first year after delivery may also be related to greater testing during pregnancy.     

Ten-minute abortions.

A service performing very early abortions in a district general hospital uses menstrual aspiration, which enables abortion to be carried out early, easily, safely, and simply. Menstrual aspiration avoids interference with routine gynaecological work and permits an operator to widen his criteria for accepting patients for termination. From September 1975 to April 1977 123 cases were referred and 104 aspirations were performed. Termination of pregnancy failed in only two cases, through inexperience, and infection occurred in only one case. Menstrual aspiration should be performed within 10-18 days of missing a period.     

Recurrent spontaneous abortion and polycystic ovarian disease: comparison of two regimens to induce ovulation.

OBJECTIVE--To determine whether pituitary suppression before induction of ovulation reduces the rate of spontaneous abortion in women with polycystic ovarian disease and primary recurrent spontaneous abortions. DESIGN--Closed, randomised, sequential trial. Pairs of women were allocated to each treatment by the toss of a coin. SETTING--Supraregional clinic for women who had had recurrent spontaneous abortions. SUBJECTS--Forty two women with polycystic ovarian disease and primary recurrent spontaneous abortions. INTERVENTIONS--Ovulation was induced by clomiphene or pituitary suppression with buserelin followed by pure follicle stimulating hormone. MAIN OUTCOME MEASURES--Preference for a particular treatment was noted. A preference occurred when one woman in a pair had a successful pregnancy (defined as one of over 12 weeks'' gestation) and one had a spontaneous abortion; the preference was for the treatment resulting in the successful pregnancy. RESULTS--Spontaneous abortions occurred in 11 of 20 women given clomiphene compared with two of 20 who had pituitary suppression. Eleven preferences were found for buserelin and two for clomiphene. In seven pairs both women had successful pregnancies. One pair was discarded because one of the women did not become pregnant. The ratio of luteinising hormone concentration to follicular diameter was found to be a possible diagnostic indicator of spontaneous abortion. CONCLUSION--Pituitary suppression before induction of ovulation significantly reduces the risk of spontaneous abortion in women with polycystic ovarian disease and primary recurrent spontaneous abortions.     

Career pathways and destinations 18 years on among doctors who qualified in the United Kingdom in 1977: postal questionnaire survey

ObjectiveTo determine the career destinations, by 1995, of doctors who qualified in the United Kingdom in 1977; the relation between their destinations and early career choice; and their intentions regarding retirement age.DesignPostal questionnaire.SettingUnited Kingdom.SubjectsAll (n=3135) medical qualifiers of 1977.ResultsAfter about 12 years the distribution of respondents by type of employment, and, for women, the percentage of doctors in part time rather than full time medical work, had stabilised. Of all 2997 qualifiers from medical schools in Great Britain, 2399 (80.0% (95% confidence interval 79.5% to 80.6%)) were working in medicine in the NHS in Great Britain 18 years after qualifying. Almost half the women (318/656) worked in the NHS part time. Of 1714 doctors in the NHS, 1125 intended to work in the NHS until normal retirement age, 392 did not, and 197 were undecided. Of the 1548 doctors for whom we had sufficient information, career destinations at 18 years matched the choices made at 1, 3, and 5 years in 58.9% (912), 78.2% (1211), and 86.6% (1341) of cases respectively.ConclusionsPlanning for the medical workforce needs to be supported by information about doctors’ career plans, destinations, and whole time equivalent years of work. Postgraduate training needs to take account of doctors’ eventual choice of specialty (and the timing of this choice).

Key messages

• A large scale national study in the United Kingdom followed doctors from qualification to mid-career and beyond
• Most doctors had made their choice of eventual career—at least in terms of broadly defined specialty—within 5 years of qualifying
• Eighteen years on, 80% of the doctors were working in the NHS and nearly half of women doctors were working part time
• Almost a quarter of NHS doctors planned to retire early

     

Results of cytogenetic examinations in 255 married couples with a history of infertility]

The results of cytogenetic examination carried out in 255 couples with a history of infertility have been analysed. Chromosomal aberrations have been detected in 15 examinations (6.7%) with predominance of translocations (mutual - 3.6%; Robertson' - 1.3%). Identified aberrations have been noted in 9 women and 6 men. The obtained results have been analysed in relation to the number of abortions, dead and live newborn babies with inherited abnormalities. It was found that the incidence of chromosomal aberrations increases with the number of the spontaneous abortions in anamnesis. Such aberrations have also been more frequent in the families in which spontaneous abortions have been accompanied by other fertility disorders.     

Analysis of lifestyle data and cytologic findings in a pilot cervical screening project in rural Vietnam.

OBJECTIVE: To evaluate the possibilities of a cervical cytology screening program and the importance of lifestyle parameters in women living in rural Vietnam. STUDY DESIGN: Screening took place in Quangninh province in the north of Vietnam. From 700 women screened for the first time, smears were prepared and read by a cytotechnologist. The number of children and abortions (some women having had 10 abortions) allowed us to study the relationship of these life-style parameters with disturbed vaginal ecology (defined as the presence of Candida, trichomonads or cocci in the smear). RESULTS: The smears from farmers showed the greatest ecologic disturbances in vaginal flora. Water supply turned out to be important for coccoid overgrowth. Scores for both fungal infection and coccoid overgrowth were related to profession. Candidosis proved to be very prominent in cytologically negative smears: the organisms were found (often in abundance) in 95 of 661 negative smears but were absent from cytologically positive smears. CONCLUSION: Since only two cases of CIN 3 were found and no cases of invasive carcinoma, cervical screening for cancer ought not to be the first priority for rural Vietnam.     

Risks and costs of illegally induced abortion in Bangladesh

This article reports on women admitted to Dhaka Medical College Hospital for incomplete, illegally induced abortion. Women with low complication rates more often had abortions induced by medical practitioners. These women were younger, of lower parity and better educated than women having abortions initiated by other practitioners. Poorly educated women from slum areas almost always had an abortion induced by a nonmedical practitioner through the insertion of a solid object. These women experienced high complication rates and often required hysterectomies. This group also had high mortality rates. The drain on hospital resources needed to treat these abortion patients was great.     

The use of screening episodes linked to CIN3 and invasive cancer registrations to study outcomes from the NHS Cervical Screening Programme

Objective: To examine how NHS cervical screening data can be collected and analysed in order to evaluate women’s screening histories as episodes rather than as individual smears. Design: Analysis of routine cervical screening data grouped into screening episodes for a cohort of women regarding episodes starting in a given year. Setting: NHS Cervical Screening Programme. Population: Data from four Health Authorities (now eight Primary Care Trusts) from the NHS Cervical Screening Programme with primary smears (first in an episode) taken between 1 April 1999 and 31 March 2000. Methods: Cytology information obtained from the call/recall (‘Exeter’) computer system was linked to cervical intraepithelial neoplasia (CIN) 3 and invasive cancer outcome information obtained from cancer registries. Screening histories were divided into episodes, each starting with a primary smear that was followed up to episode closure or, for episodes still open followed for an average 4.25 years, from the primary smear. The episode was divided into two parts (up to referral to colposcopy and following the referral). The outcomes of the episodes are described including referral rate to colposcopy and CIN3 and invasive cancer rates by factors such as age. Main outcome measures: Episode histories and rates of referral to colposcopy, CIN3 and invasive cancer. Results: There were 176 923 episodes from 176 319 women (1.003 episodes per woman) followed up to March 2004, the date at which the first phase of information accrual ceased. Of these episodes, 172 100 (97.3%) were closed either by a negative smear referring the woman back to routine recall or by default (defined as no smear recorded within 21 months following a smear requiring an action of repeat or refer to colposcopy). The remaining 4823 (2.7%) of episodes were still open, of which in 3121 (1.8%) the woman had been referred to colposcopy and in 1702 (1.0%) no referral decision had been made. Referral rates to colposcopy varied by age from 5.7% in women aged 20–24 years down to 0.9% in women aged 60–64 years. The overall efficiency of screening was highest for woman aged about 30 years, with a CIN3 detection rate of eight per 1000 women and a positive predictive value (for CIN3 or worse) of referral to colposcopy of 21%. Conclusion: The study has shown that routinely collected NHS cervical screening data can be combined to give information on complete episodes, allowing important performance measures to be studied. We suggest that in future information in the NHS screening system should be structured to facilitate such analysis and to allow cytology and histology information to be readily linked.     

Multiple miscarriages are associated with the risk of ovarian cancer: results from the European Prospective Investigation into Cancer and Nutrition

While the risk of ovarian cancer clearly reduces with each full-term pregnancy, the effect of incomplete pregnancies is unclear. We investigated whether incomplete pregnancies (miscarriages and induced abortions) are associated with risk of epithelial ovarian cancer. This observational study was carried out in female participants of the European Prospective Investigation into Cancer and Nutrition (EPIC). A total of 274,442 women were followed from 1992 until 2010. The baseline questionnaire elicited information on miscarriages and induced abortions, reproductive history, and lifestyle-related factors. During a median follow-up of 11.5 years, 1,035 women were diagnosed with incident epithelial ovarian cancer. Despite the lack of an overall association (ever vs. never), risk of ovarian cancer was higher among women with multiple incomplete pregnancies (HR(≥4vs.0): 1.74, 95% CI: 1.20-2.70; number of cases in this category: n?=?23). This association was particularly evident for multiple miscarriages (HR(≥4vs.0): 1.99, 95% CI: 1.06-3.73; number of cases in this category: n?=?10), with no significant association for multiple induced abortions (HR(≥4vs.0): 1.46, 95% CI: 0.68-3.14; number of cases in this category: n?=?7). Our findings suggest that multiple miscarriages are associated with an increased risk of epithelial ovarian cancer, possibly through a shared cluster of etiological factors or a common underlying pathology. These findings should be interpreted with caution as this is the first study to show this association and given the small number of cases in the highest exposure categories.     

The prevalent use of contraception among teenagers in Denmark and the corresponding low pregnancy rate

In Denmark the number of births and induced abortions among teenagers has reduced and teenage parenthood is now rare. This paper evaluates the correlation between this observed fertility and reported sexual and contraceptive behaviour. In 1989 a sample of 16-20-year-olds in Denmark was selected at random and personally interviewed about sexual and contraceptive behaviour. Ninety-five per cent of the young women who had experienced sexual intercourse used contraception at the most recent sexual intercourse. In order to support the validity of this finding a model was developed to estimate an expected number of conceptions in the age groups concerned. The model included both the information on coital frequency and use of contraception from the questionnaire and available efficacy rates on contraception. The estimates derived by the model were compared with the registered number of births and induced abortions derived from public registers. The analysis revealed a high accordance between the estimated number of conceptions and the registered number of births and induced abortions for each age group. This underlines the validity of the data on sexual and contraceptive behaviour sampled among teenagers in Denmark. The findings indicate that contraceptive failure is a much greater problem than non-use of contraception for teenagers in Denmark.     

Are women sufficiently well informed to provide valid consent for the cervical smear test?

Three hundred women attending colposcopy for the first time, following an abnormal cervical smear, were invited to fill in a questionnaire. This covered aspects of their understanding of the cervical smear test and the NHS Cervical Screening Programme (NHSCSP). In addition, it covered aspects of consent to the test. The response rate was 83%. Seventy percent thought that the NHSCSP is working well and 72% were aware that probably over 3000 cases of cervical cancer per year are being saved by the NHSCSP. However, 55% did not know that the death rate from cervical cancer is decreasing. 96% were aware that the main reason for a cervical smear is to prevent the development of cervical cancer, by finding early treatable abnormalities. Similarly, 94% were aware that the presence of abnormal cells on a cervical smear indicated a possible but not definitive indication of cervical precancer or cancer. Disappointingly, only 5 had seen the new NHSCSP information poster on the cervical smear test and only 44% had been given written information about the test. Consent for the test in 59% of women had been implied rather than expressed and 30% of women providing expressed consent had signed to that effect. In 42% of women, the smear taker or a doctor had failed to discuss the reason for having a cervical smear and had not explained about its advantages and limitations. In 72%, the smear taker or doctor had not explained that the cervical smear test can never be 100% accurate and that some laboratory errors are unavoidable. It is likely that women attending for colposcopy are a highly motivated cohort in relation to their understanding of the cervical smear test and the NHSCSP. Accordingly, understanding in the more general female population is likely to be considerably less. It would appear that women are often suboptimally informed to provide valid consent for the cervical smear test.     

Q-banding of chromosomes in human spontaneous abortions

Chromosome studies of 242 spontaneous abortions were carried out by Q-banding technique. The abortuses were selected for study because they were phenotypically abnormal, had not progressed beyond 12 weeks development or were from women with repeated abortions. Chromosome anomalies were found in 126 (52%) of the abortuses. Of these, 71 (56%) were trisomies. Trisomies were found for all the autosomes except Nos. 1, 3, 5, 11, 17 and 18. Triploidy was the second commonest anomaly in this series, making up 26 (21%) of the total anomalies. About 70% of these had an XXY sex chromosome complement. Only 16 (13%) of the abortuses had X monosomy, a lower frequency than would be expected in an unselected study. Tetraploidy was found in 8 abortuses and the 5 remaining specimens had various anomalies. These included 3 translocations, a trisomy 21,X monosomy and a ring chromosome 13. Except for the greater frequency of XXY than XXX sex chromosomes in the triploids, there was no evidence of a distortion of the sex ratio, either among the trisomic or among the chromosomally normal abortuses.