Maternal Mortality in California

During the period August 1957 to December 1966, the Committee on Maternal and Child Care of the California Medical Association and the State Department of Public Health studied 1,219 deaths of women who died during or within 90 days of termination of pregnancy. Twenty-two percent of the deaths reviewed were considered unavoidable. Seventy percent had one or more avoidable factors; of these, 46 percent were attributed to errors in professional judgment, and 16 percent to inadequate prenatal care by the patient herself.Nearly one-third (383) of the 1,219 cases reviewed were deaths from non-obstetric causes. Of the 836 deaths from obstetric causes, 260 were attributed to abortion. Preliminary figures suggest a reduction in criminal abortion deaths corresponding to the increase in therapeutic abortions since 1968.Over one-third of the deaths occurred in Mexican and Negro mothers. Death rate for Negro was triple that for white mothers. Despite the presence of four medical schools in District II (Los Angeles County), maternal death rates were 30 to 50 percent higher than in other districts due to the large urban black and Chicano population. One rural district with a large migratory agricultural population also had high rates.     

Abortion-seeking behaviour among Nigerian women

This study used data from a community-based survey to examine women's experiences of abortion in Nigeria. Fourteen percent of respondents reported that they had ever tried to terminate a pregnancy, and 10% had obtained an abortion. The majority of women who sought an abortion did so early in the pregnancy. Forty-two percent of women who obtained an abortion used the services of a non-professional provider, a quarter experienced complications and 9% sought treatment for complications from their abortions. Roughly half of the women who obtained an abortion used a method other than D&C or MVA. The abortion prevalence and conditions under which women sought abortions varied by women's socio-demographic characteristics. Because abortion is illegal in Nigeria except to save the woman's life, many women take significant risks to terminate unwanted pregnancies. Reducing the incidence of unwanted pregnancy and unsafe abortion can significantly impact the reproductive health of women in Nigeria.     

Increase in the occurrence of abortions associated with exposure to the Bluetongue virus serotype 8 in naïve dairy herds

The transplacental transmission capacity demonstrated for Bluetongue virus serotype 8 (BTV-8) in cattle probably is associated with an increased occurrence of abortions. The objectives of this study were to quantify the effect of BTV-8 exposure on the occurrence of abortions in previously naive dairy cow herds under natural infection conditions, and to determine a possible risk period during pregnancy associated with this increase. Two criteria were considered in order to estimate the occurrence of abortion: late return-to-service after a first artificial insemination (AI), and short gestations. A late return-to-service was defined as a return taking place 90 to 200 days after a first AI. These criteria were compared between cows in herds exposed during the 2007 epizootic in France and cows in herds that were not exposed. To determine the risk period during a pregnancy, variations in the occurrence of abortions were quantified according to the stage of the pregnancy during which the exposure took place. Survival analyses were used to estimate the risk of increased occurrence of abortion associated with BTV-8 exposure, adjusted by the principal factors known to influence the risk of abortion. Exposure to the BTV-8 virus under natural conditions in previously naive dairy herds notified after clinical suspicion during the 2007 epizootic was associated with an increase in the occurrence of abortions, regardless of the stage of pregnancy. The at-risk gestation period depended on the criteria used to detect abortions. The mean effect of BTV-8 exposure in the ensemble of detected outbreaks corresponded to an increase of 6.7% in late return-to-service. BTV-8 exposure during the first 3 mo of gestation was associated with a 15% increase in late return-to-service for cows with no return-to-service at 90 days, while this increase was 6% for exposure starting from the third month of gestation (in outbreaks detected in September). BTV-8 exposure from the third month of gestation was associated with a 1.9% increase of short gestations. The effect of exposure was more pronounced for outbreaks detected early in the epizootic compared with those detected later.     

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.     

The relationship between legal abortion and marriage.

A study using the abortion-birth ratios for residents of each U.S. state for the second half of 1970 and for all of 1971 was done to determine if legal abortions reduced marriages. Data showed that trends were consistent with the hypothesis that a relationship exists between l egalized abortion-birth ratios and trends in crude marriage rates among states between 1967 and 1971 with reduction in crude marriage rates in the states with the relatively high abortion-birth ratios. Change in po licy on induced abortions may be responsible for the increased trend in the U.S. crude marriage rate from 1959-1970 and for its levelling off in 1971 and 1972. Analysis of data also suggested that there is a relation ship between less restrictive abortion policies and a decline in crude marriage rates. An estimation of the number of marriages postponed for at least one year following legal abortion indicated that about 1 abortion in 10 delays a marriage when all the decline in marriage rates were caused by increased abortions and when no legal abortions were subs titutes for illegal abortions. Results were obtained employing general measures for variables, but stronger relationships might be produced if more refined measures which consider race, age, parity, and marital status were introduced.     

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.     

Incidence of Induced Abortion in Uganda, 2013: New Estimates Since 2003

BackgroundIn Uganda, abortion is permitted only when the life of a woman is in danger. This restriction compels the perpetuation of the practice in secrecy and often under unsafe conditions. In 2003, 294,000 induced abortions were estimated to occur each year in Uganda. Since then, no other research on abortion incidence has been conducted in the country.MethodsData from 418 health facilities were used to estimate the number and rate of induced abortion in 2013. An indirect estimation methodology was used to calculate the annual incidence of induced abortions ─ nationally and by major regions. The use of a comparable methodology in an earlier study permits assessment of trends between 2003 and 2013.ResultsIn 2013, an estimated 128,682 women were treated for abortion complications and an estimated 314,304 induced abortions occurred, both slightly up from 110,000 and 294,000 in 2003, respectively. The national abortion rate was 39 abortions per 1,000 women aged 15–49, down from 51 in 2003. Regional variation in abortion rates is very large, from as high as an estimated 77 per 1,000 women 15–49 in Kampala region, to as low as 18 per 1,000 women in Western region. The overall pregnancy rate also declined from 326 to 288; however the proportion of pregnancies that were unintended increased slightly, from 49% to 52%.ConclusionUnsafe abortion remains a major problem confronting Ugandan women. Although the overall pregnancy rate and the abortion rate declined in the past decade, the majority of pregnancies to Ugandan women are still unintended. These findings reflect the increase in the use of modern contraception but also suggest that a large proportion of women are still having difficulty practicing contraception effectively. Improved access to contraceptive services and abortion-related care are still needed.     

Effects of legal termination on subsequent pregnancy.

Two hundred and eleven patients who had undergone vaginal termination and were pregnant again were investigated; 43-2% had become pregnant within one year of termination. The overall fetal loss in the 211 patients was 17-5% compared with 7-5% in a group matched for parity but consisting of patients who were pregnant after a spontaneous abortion. Altogether 4-3% of pregnancies after legal abortion ended as first trimester abortions, 8-5% as second trimester abortions, and 13-7% in premature delivery. Among 11 women whose cervices had been lacerated at the time of legal termination the fetal loss in subsequent pregnancy was 45-5%, and only one pregnancy went beyond 36 weeks. Routine Shirodkar suture may be beneficial when the cervix is known to have been damaged at legal abortion. Several patients had asked that their general practitioner should not be told of their termination, and such patients may not admit their termination during a subsequent pregnancy, which could thus be jeopardised. No evidence was found to suggest that infants of patients with a history of legal termination are small for dates.     

Neospora caninum infection does not affect early pregnancy in dairy cattle

This study was designed to evaluate the relationship between Neospora caninum infection prior to pregnancy, as determined through maternal serology, and the subsequent occurrence of abortion in dairy cattle. Special emphasis was placed on pregnancy losses in the first trimester of pregnancy. Neospora caninum antibodies were analyzed by commercial ELISA in 2773 pregnant animals (2022 parous cows and 751 heifers) from six herds. The mean seroprevalence of antibodies to N. caninum in the herds was 15.1% (n = 419). From gestation Day 34 to the 90th day of pregnancy, there were 183 abortions (6.6% of all pregnancies) (23 in Neospora positive animals). After 90 days of pregnancy, the number of abortions was 146 (5.3%); 126 occurring during the second and 20 during the third trimester of pregnancy (105 in Neospora positive animals). Multiple logistic regression analyses were performed on data from each animal using abortion before or after 90 days of pregnancy as the dependent variable, and Neospora positivity, herd, pregnancy season, and parity (parous or nonparous) as independent factors. No significant effects of Neospora positivity and herd were found on the abortion rate before 90 days of pregnancy. Based on the odds ratio, the abortion rate was 4 times higher (P < 0.0001) in animals that became pregnant in the warm than in the cool period, and 3.7 times higher (P < 0.0001) in parous than in nonparous animals. Neospora positivity was the only variable included in the logistic regression model for abortions occurring after 90 days of pregnancy. Seropositivity in an animal increased the probability of abortion by an odds ratio of 18.9 (P < 0.0001; 95% confidence interval 12.9-27.8). Season, parity, and herd showed no effect. The results of the present study suggest that chronic N. caninum infection prior to pregnancy appears not to affect the early fetal period, but does have a significant abortive effect after 90 days of gestation.     

Epigenetic status of imprinted genes in placenta during recurrent pregnancy loss

An analysis of differential methylation of 47 imprinted genes in placenta tissues of spontaneous abortions at the first trimester of pregnancy from women with recurrent pregnancy loss or with one sporadic abortion was performed using the DNA-microarray approach. We showed that epimutations of the imprinted genes were registered significantly more often in abortions from women with recurrent miscarriage in contrast to the embryos from women with sporadic pregnancy loss with frequency of 6.2 and 3.7% per locus, respectively (p < 0.01). The predominant type of epimutation appeared to be a postzygotic hypomethylation of the imprinted genes on chromosomes of maternal origin, which was observed in the examined samples in 5.1 and 2.89% of cases, respectively. Replicative study of the methylation status of seven imprinted genes (DLK1, PEG10, PLAGL1, KCNQ1OT1, PEG3, GRB10, and PEG1/MEST) in the enlarged embryo samples supported the results of microarray analysis in respect to both epimutation frequency and predominance of somatic hypomethylation of maternal alleles. It was also demonstrated that pregnancy loss was associated with multilocus methylation defects of imprinted genes, the frequency of which was also significantly increased in the placental tissues of spontaneous abortions in women with recurrent miscarriage.     

Attitudes towards abortion in the Danish population

This article reports the results of a survey, by mailed questionnaire, of the attitudes among a sample of the Danish population towards abortion for social and genetic reasons. Of 1080 questionnaires sent to a random sample of persons between 18 and 45 years, 731 (68%) were completed and returned.
A great majority of the respondents were liberal towards early abortion both for social reasons and in case of minor disease. In contrast, there was controversy about late abortions for social reasons and in the case of Down syndrome. Further there was strong reluctance to accept late abortion in case of minor disease.
An analysis of the response patterns showed that most of the respondents had gradualist views on abortion, i.e. they would allow all early abortions, but only abortions for some reasons later in pregnancy. It was also found that the number who would find an early abortion acceptable in general was much higher than the number who would accept it in their own case. These findings suggest that a great part of the resistance towards abortion does not rest on a concern for the rights and interests for the fetus. Instead it may be explained on a view according to which fetal life is ascribed intrinsic moral value.     

CMA abortion survey.

Responses to the question as to whether abortions should be performed at the woman''s request during the first trimester of pregnancy were evenly divided. There was support for abortion on socioeconomic grounds, during the first trimester, from 61.5% of the respondents. Termination of pregnancy beyond the first trimester was supported by a majority of the respondents only in cases in which the woman''s life is in danger (73.9%) or in which there is evidence of a severe physical abnormality in the fetus (70.6%) or in cases in which the woman''s physical health is in danger (55.5%). Those who said they would not support abortion under any circumstances constitute, at most, 5.1% of the respondents. Support for the maintenance or the elimination of therapeutic abortion committees was addressed in two questions and in both cases the respondents were evenly divided. The responses to these two questions were compared and found to be logically consistent. Only physicians should perform abortions, and they should be performed in hospitals with the woman either as an inpatient or, during the first trimester, as an outpatient. The performance of first-trimester abortions in provincially approved abortion clinics was supported by 47.3% of the respondents. Of the 885 respondents who wished to see some amendment to the Criminal Code, 409 stated that the term "health" as used in the Criminal Code relative to the legal grounds for therapeutic abortion should be defined.     

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.     

Incidence of resistance to tetracycline,chloramphenicol and ampicillin amongSalmonella species isolated in the Netherlands in 1967 and 1968

In 1967 and 1968 respectively 10450 and 8665Salmonella strains were screened for resistance to ampicillin, chloramphenicol and tetracycline. It was found that in 1967, 17.8% and in 1968, 14.6% of the isolated strains were resistant to one or more antibiotics. Most strains appeared to be only tetracycline-resistant. Strains from human sources that were only ampicillin-resistant increased from 0.8 % in 1965 to 3.2% in 1967, and then decreased in 1968 to 1.3%. Resistance to chloramphenicol remained low (1.4% and lower).     

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.     

Factors associated with immediate abortion complications.

OBJECTIVE: To identify factors associated with increased risk of immediate complications from induced abortion. DESIGN: Retrospective analysis of a provincial database. SETTING: All Ontario general hospitals in which abortions are performed and all free-standing abortion clinics in Ontario. POPULATION: Women in Ontario aged 15 to 44 years who underwent an induced abortion in the province (without concurrent sterilization) between Jan. 1, 1992, and Dec. 31, 1993. OUTCOME MEASURES: Recording of complications at the time of the procedure, gestational age, type of procedure, place of abortion (hospital or clinic), and patient''s age, parity and history of previous abortion (spontaneous or induced). RESULTS: During the study period 83 469 abortions were performed that met our inclusion criteria. Immediate complications were reported in 571 cases (0.7%). Multivariate logistic regression analysis revealed that, after other variables were controlled for, the patient''s age, parity and history of previous abortions (spontaneous or induced) were not significant risk factors for immediate complications; however, gestational age, method of abortion and place of abortion were significant risk factors (p < 0.001). The odds ratio (OR) for having a complication from abortion was 1.3 (95% confidence interval [CI] 1.02 to 1.63) between 9 and 12 weeks, compared with having one after abortion at 9 weeks or earlier, and increased to 3.3 (95% CI 2.23 to 5.00) after abortion between 17 and 20 weeks. Compared with surgical dilatation and curettage (D&C), instillation of saline and instillation of prostaglandins were more likely to be associated with immediate complications (OR 24.0, 95% CI 13.22 to 43.70, and OR 11.7, 95% CI 6.43 to 21.18, respectively), whereas both suction D&C and insertion of a laminaria tent were less likely to be associated with immediate complications (OR 0.4, 95% CI 0.26 to 0.67, and OR 0.3, 95% CI 0.19 to 0.52, respectively). Compared with women who had an abortion in a free-standing clinic, the risk for immediate complications was greater among those who had an abortion in a hospital, especially a teaching hospital (OR 1.9, 95% CI 1.38 to 2.58), a nonteaching hospital with 200 to 399 acute care beds (OR 3.1, 95% CI 2.27 to 4.21) and a nonteaching hospital with fewer than 200 acute care beds (OR 5.9, 95% CI 4.04 to 8.64). CONCLUSION: The risk of immediate complications from induced abortion is very low. Unlike in previous studies, the woman''s age, parity and history of previous spontaneous or induced abortions were not found to be risk factors. However, advancing gestational age and procedures involving instillation of saline or prostaglandins were predictive factors of immediate complications.     

Effectiveness of abortion as birth control.

Several models used to study the effectiveness of abortion in population limitation are examined. The Keyfitz model, based on the probability that an individual woman will conceive in a given month, is extended and public implications of legal abortions are discussed. A model more appropriate for a population of women rather than a single woman can be developed by relating the probability of conception and the sterile intervals to the number of birth and the number of women in the population. The effectiveness of abortion as a birth control method is studied using this model and includes: 1) abortion effectiveness combined with efficient contraception (95% effective); 2) the sensitivity of abortion to gestation when a contraceptive of lower efficiency is used; 3) these effects modified for prolonged lactation; 4) the effect of changing the monthly probability of conception and the monthly efficiency of contraception. Abortion later in pregnancy is advantageous when efficient contraception is absent. The effectiveness of abortion to gestation is approximately the same whether lactation is included or absent, although abortion is more effective at all gestations and for all contraceptives efficiencies in the absence of lactation. The sensitivity of the effectiveness of abortion to the probability of conception decreases as monthly effectiveness of contraception increases. The probability of conception and the monthly effectiveness of contraception are difficult parameters to measure in the population. The effect of abortion averaged over the entire population at risk of pregnancy is different from its effect on certain subgroups. For U.S. females the probability of conception may be between .06 and .16, and from the model it is indicated that the effectiveness of abortion would be from 1 to 1.13 abortions per live birth. The application of the model suggests that the expenditures for abortion services in this population are a reasonable investment, although investment for efficient contraception is also suggested.     

Decidual lymphocytes of human spontaneous abortions induce apoptosis but not necrosis in JEG-3 extravillous trophoblast cells

The human decidua contains an unusually high proportion of lymphocytes, mainly NK and T cells, which are potentially cytotoxic to the trophoblast when they are stimulated with certain cytokines. Given the high incidence of spontaneous abortion in humans and other species, our working hypothesis is that decidual lymphocytes are involved in immunological mechanisms that attack the trophoblast and induce abortion when any gestational problem arises. To test this hypothesis, flow cytometry was used to compare decidual lymphocyte populations in first-trimester spontaneous abortions and elective terminations of first-trimester pregnancy. We found significantly higher proportions of decidual lymphocytes that expressed activation markers, and of T cells (mainly T helper cells) in spontaneous abortions than in elective terminations of pregnancy. Decidual lymphocytes from spontaneous abortion, like decidual lymphocytes from elective termination of pregnancy and peripheral blood lymphocytes, were however, unable to lyse the JEG-3 extravillous cytotrophoblast cell line in a (51)Cr-release assay. Nevertheless, decidual lymphocytes from spontaneous abortion, unlike decidual lymphocytes from elective termination of pregnancy and peripheral blood lymphocytes, induced apoptosis in JEG-3 cells as determined by DNA fragment-release assay. Hematoxylin and eosin staining showed a significantly higher proportion of apoptotic JEG-3 cells when these cells were treated with decidual lymphocytes from spontaneous abortion than when JEG-3 cells were cultured with decidual lymphocytes from elective termination of pregnancy. The ultrastructural signs of apoptosis were confirmed by electron microscopy. These data support the hypothesis that activated decidual lymphocytes participate in human spontaneous abortion by inducing apoptosis but not necrosis of the trophoblast.