Ep 134: Answering Questions About Abortion

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Today’s episode is about abortion. To be honest, I debated whether or not I should cover this topic because I know it’s polarizing and there are a lot of strong emotions involved. There’s also the real fear for my safety. However, there is a lot of disinformation on this subject and, just like always, I want to be a source of factual, evidence-based information.

There are many reasons for choosing an abortion. Maybe you don’t want to have children or do not want more children. Perhaps there are medical reasons to choose abortion or maybe there is a reason you cannot parent a child at the time. Whatever the reason is, it is a largely personal choice (I say largely because I do think that gestational age limits are reasonable). Abortion is more common than you might think - chances are you know someone who has had one. I encourage you to listen to the entire episode regardless of where you stand on this issue.

In this Episode, You’ll Learn About:

  • How many women have abortions and at what point in pregnancy
  • What are some of the reasons women might choose abortion
  • What is the procedure itself and what are the procedure options
  • Whether or not a fetus can feel pain
  • What are some of the potential complications from abortion and how common are they
  • Whether abortion has an effect on women’s mental health
  • What is the definition of an unsafe abortion
  • What is the public opinion of abortion

Links Mentioned in the Episode

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Ep 134: Answering Questions About Abortion

Nicole: In this episode, you are going to learn about abortion. I know this is a controversial topic and I encourage you to listen to the entire episode, regardless of where you stand on the issue. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello. Hello. Welcome to another episode of the podcast. This is episode number 134. Thank you for being here with me today. So today's episode is about abortion and to be honest, I debated for quite some time about whether or not I should even talk about this topic because I know it is very polarizing and I know that there are a lot of strong emotions involved. I'll be honest. There's also the real fear for my safety. However, there is a lot of disinformation on this topic and just like I always do. I want to be a source of factual evidence-based information about all topics related to pregnancy and birth, including this one. So in this episode, you are going to learn about the epidemiology of abortion. So that's how many women have abortions, at what point in pregnancy does it typically happen, why women choose abortion?

Nicole: I'll talk about the procedure itself, including partial birth, so-called partial birth abortions, the research behind a fetus feeling pain, complications from abortion, including mental health outcomes. Uh, I'll tell you what unsafe abortion is. We'll go over the public opinion about abortion that has remained pretty consistent actually over time. And then finally, I'll end with my opinion about abortion. Also throughout the episode, I'm going to answer questions that folks asked me about abortion through Instagram. I posted an Instagram story that gave folks the opportunity to ask questions there in anticipation of this episode. And there were quite a few, so I'll address them throughout the episode. Now, if you don't already follow me on Instagram, this is a great reason to do so because it's a lovely way for us to connect in between episodes and interact in between episodes. And it influences what I bring to the show.

Nicole: I do fun stuff there like polls and question boxes, post behind the scenes from my life. And then of course there's great additional pregnancy and birth content there as well. So head on over to Instagram, follow me at Dr. Nicole Rankins there. Okay. So first up, let's talk about the epidemiology of abortion. So, and I'm going to focus specifically on the United States for the most part of the conversation. So in the US, close to one in four women will have an abortion in their reproductive lifetime. So by about age 45, when you break that down a little bit further by age 20, about 4.6% of women will have had an abortion. And by age 30, about 19% of women will have had an abortion. And again, by 45, that's almost about one in four. I will add that anecdotally in my clinical practice, abortion is very common to see that that women have had a prior abortion.

Nicole: So chances are that you probably know someone who's had an abortion. And if you don't know someone, then you know, you're not that far removed from someone who has, when we look at data more specifically, or look at the CDC data in terms of the numbers and rates. So overall, the rate of pregnancy termination is wa and this was a 2017 data. So it was 11.3 per 1000 women between ages 15 to 44. So that's about 189 per 1000 live births. Okay? And this is voluntary reported data. That's reported to state health agency. So it may not be complete, but it's the best data that we have. And when we look at abortion rates by groups, um, it's highest in women who are 20 to 24, followed by women who are 25 to 29. Most pregnancy terminations happen in women who are unmarried about 85% and have one or more children, about 59% have one or more children.

Nicole: 40% of abortions happen in women who had a prior abortion. There are also some slight racial and ethnic differences. Abortion rates per 1000 women by racial group are 38.7 for non-Hispanic white women, 33.6 for non-Hispanic black women, 24 Hispanic women, and then 7.7 for other races. Um, this dispels kind of a common misperception or lie really that's perpetuated sometimes in the black community about abortion, that it's used as a form of population control and like getting rid of the black race. And that is not true. The abortion, as I just mentioned, is not more common, uh, among black communities in any other communities. And then we look at gestational age, the vast majority of pregnancy terminations are performed in the first trimester. So within the first 14 weeks of pregnancy, and in fact, 77, almost 78% are performed at less than nine weeks. 92% are done at less than 13 weeks.

Nicole: This is why new laws about abortion are aggressively targeting very early gestational ages because the data shows that most pregnancy terminations happen at these very early gestational ages. When we look at later gestational ages about 7% are performed between 14 and 20 weeks and only 1% after 21 weeks. Now, one of the things that someone asked me on Instagram is where would someone find a place to have an abortion procedure if needed, especially if it was in a later stage in pregnancy. And the truth is that can be challenging. Planned Parenthood is going to be your best resource for finding abortion care. So, um, definitely Planned Parenthood is, is a great place to start, but in the United States, at least in 2014, for data that we have available, roughly 90% of counties had no abortion providers. So it can be difficult. And that's also a strategy for people who want to limit access to abortion is, um, doing things that limit it in certain areas or make it difficult, um, for providers to get established in the area as a provider.

Nicole: So not necessarily targeting the procedure itself, but targeting the provider or making, um, things difficult for folks to be able to perform the procedure. So let's talk about why do women choose abortion? And there are a lot of reasons that women choose abortion. Here are some of the common reasons when women are surveyed. They don't want to have children ever, or they don't want to have more children. Some don't want to be pregnant at that moment because it's not a good time to be pregnant, um, or, or parent, um, maybe it interferes with schoo,l work, family or other responsibilities, maybe, um, they can't afford to raise a child. Uh, the current situation makes it difficult to be pregnant or parent. Maybe the relationship with the partner is not good. Um, or you don't have a partner and you don't want to parent a child by yourself sometimes it's because, um, and this is not as common, although I've had a couple of podcast episodes talking about this is, um, the baby has a, a problem or a birth defect.

Nicole: Um, or sometimes the pregnancy is a result of sexual assault. There might also be cases where the mom has health problems that make pregnancy difficult or risky. This was a question I got a few times of like, what's a medical reason to terminate pregnancy or a medically necessary abortion. And, um, medically necessary is not really the right term. Abortion is always the choice of the woman. So it's not that it's ever like that it has to be done. It should be the woman's choice, or at least it should be her choice about whether or not she has it. But in terms of like medical indications, there are instances where it might be lifesaving because pregnancy and continuing the pregnancy would be more dangerous. This isn't common that this happens, but it does happen. An example of this is when, if a woman has like severe heart disease, the, a pregnancy can be an incredibly stress at not can be pregnancy is an incredibly stressful event on the heart in terms of the demands and the increased blood flow.

Nicole: It puts the, the heart requires a lot of extra work during pregnancy. So if a woman has an underlying heart condition and then pregnancy can make that worse than as a life threatening measure for her, the abortion may be suggested or, or even recommended, or sometimes kidney disease is another one where that may be the case in terms of if there's an issue with the baby, there's rarely that that's considered, I would say medically necessary as an abortion or medically, um, recommended, but it is certainly an option. So there's the, the medical necessary abortion centers around whether or not it would be a life saving measure for the mother. All right. So let's talk about the procedure itself. So there are two types of the procedure there's medical, where medications are used and then surgical where the contents of the pregnancy are removed from the uterus.

Nicole: So as far as numbers go for procedures that are nine weeks or less medication abortion is a happens in about 39% of abortions in the United States. I think that number is, is starting to increase. That was from 2018 and, uh, for pregnancies greater than 14 weeks. Most of them are surgical. Then I'm going to talk about those surgical techniques as well. In general, across pregnancy termination of pregnancy by a surgical method. And that's called uterine aspiration. And that can be suction, curettage. So basically using the suction machine to suck out the contents of the pregnancy. Dilation and curettage, that's DNC dilating, the cervix and curettaging, or, um, curettage is a way of, as a way of, um, just removing the contents of the uterus ,more dilation and evacuation is the second trimester procedure. I'm going to talk about that. But termination of pregnancy by some sort of surgical procedures is most the most common form of abortion in the United States.

Nicole: And as far as where they are done, the vast majority of first trimesters abortion, first trimester abortions in the U S are performed in an outpatient clinic. Um, hospital termination is rare for a first trimester unless the mother is sick. The most will happen in an outpatient setting for second trimester, actually surgical. Most of those will also happen in an outpatient setting. So it's only a tiny portion, like if an abortion is induced with medication later in pregnancy, that it's going to happen in the hospital. Now let's talk about which choice of procedure. Um, and it really just depends on gestational age, patient preferences, um, the experience of the clinician and then availability of medications, equipment, and that kind of thing.

Nicole: And I'm going to break it down again by trimester here. So in the first trimester, um, the FDA has approved Mifepristone for medication abortion for up to 10 weeks of pregnancy. Planned Parenthood will extend that a little bit for Mifepristone and Mifeprostol, uh, medication abortion to about 11 weeks. Um, so after that point in pregnancy, you are not eligible for a medication abortion, then you would have to, um, or I should say between 12 and 14 weeks, you're not eligible for a medication abortion in an outpatient setting. You would have to go to an inside the hospital or do a surgical procedure. Now, the other option is aspiration and aspiration is essentially, like I said, is removing the contents of the uterus with a surgical procedure. Usually it's something called a suction curettage, they're both safe and effective procedures.

Nicole: And again, the choice is dependent upon the stage in pregnancy, patient preferences, of the availability of resources. So the main difference between them is really the experience of the procedure. The surgical procedure aspiration procedure takes place in a facility. It usually takes less than 15 minutes. It can be done under local anesthesia or moderate sedation. You don't have to be completely asleep. 99% of the time. You can leave the facility knowing that the abortion is complete. Medication abortion, on the other hand allows for the avoidance of a surgical procedure. If that's something that's important to you, the avoidance of anesthesia, um, some people feel like the process feels more natural, so to speak. They also can manage things privately and at home, it will take longer. And you're going to be more aware of blood loss. You're also going to be more aware of passage of pregnancy tissue, especially the further along that you get.

Nicole: So for some reason, especially being aware of pregnancy tissue, some people choose the surgical abortion instead, but as long as you know that going into it, then, um, either option is, is perfectly fine. And patients report that they appreciate the choice of having both options, okay. When they're allowed to choose or have that option about 35, even up to 80% will choose a medication abortion, and most who selected a medication abortion report that they would opt for it again, up to 60 to 90% do so. Now, as far as the effectiveness, the surgical or aspiration abortion is slightly more effective because it's going to result in termination of the pregnancy and over 99% of procedures, the success of medication abortion with mifepristone and misoprostol is very close to that 95 to 98% is still a very very very high likelihood of success. And then with an additional two to 5% needing further intervention with either repeating medication or having to need a DNC for tissue that didn't come out.

Nicole: And then finally, overall complications are more common in medication abortion than in surgical abortion. Mostly because if there is ongoing retained pregnancy tissue or the, the pregnancy continues and, um, it didn't work, then there's a higher need to have a surgery after the medication. Okay. So let's talk about second trimester abortion. So that's 14 to 28 weeks or beyond into third trimester abortion is exceptionally rare. So I'm really focusing on second trimester abortion and including partial birth abortion. So, as I mentioned earlier, this does not happen very common in the United States. About 8% of abortions were performed between 14 and 20 weeks. 1% are after 21 weeks. So very, very few are performed after, after 21 weeks at later stages in pregnancy, second trimester abortion is associated with increased morbidity and mortality. Actually the mortality risk increases by 38% for each successive week after eight weeks abortion is performed, but overall abortion is still very, very safe with a low risk of death.

Nicole: The CDC reported between 2013 and 2017 that there were 20 deaths associated with abortion in the United States. So over four year period, 20 deaths and abortion always remains significantly safer than childbirth. Now, as far as why women may have pregnancy termination in the second trimester, sometimes it's because of or I should say often, it's just because of a delay in diagnosis of pregnancy, or it's a difficulty in finding a provider who can perform an abortion. Also sometimes fetal anomalies or problems just aren't recognized until later in the pregnancy. Now I said second trimester abortion, 14 to 28 weeks, but actually most states restrict abortion after fetal viability, which is a little bit defined differently depending on the state, but that's roughly going to be anywhere from 23 to 24 weeks. Some will be in a little bit earlier 20, 21 weeks, although no babies were, or very, very rarely babies will survive at 20 or 21 weeks viability.

Nicole: Meaning when a baby can survive outside of mom, based on the technologies and things that we have is around 23 to 24 weeks. So the vast majority of states have some restrictions around not being able to do abortion after viability. There are eight states that have no restrictions on gestational age for abortion, Arkansas, Arkansas, Colorado, DC, which technically isn't a state, but DC, New Hampshire, New Jersey, New Mexico, Oregon, and Vermont. Now similar to first trimester abortion. Second trimester procedures can be performed surgically with dilation and evacuation or with induction with medication. Um, it's similar. The medications that are used are similar, but induction medication has to be done in the hospital just because there's a higher risk of bleeding. Both methods are safe. The choice really depends upon patient preferences. The availability of a clinician who is experienced enough to provide either approach. Um, most second trimester pregnancy terminations are done with D&E.

Nicole: The C the CDC reports that, um, dilation and extraction is used in 94 to 98% of abortions at 10 to 20 weeks and 92% greater than 21 weeks. So by far, most folks have a surgical termination of pregnancy in the second trimester. Okay. So let's talk about that procedure. That's called D&E dilation and evacuation or dilation and extraction. It's also referred to and D the dilation is dilating the cervix, and that usually takes one or two days before the procedure actually happens. So getting the cervix open enough so that the pregnancy can be removed. And then the procedure itself, E evacuation or extraction is evacuation of the uterus with suction or using extraction forceps to remove the fetus. And then curettage. Curettage is essentially scraping out the inside of the uterus. Now I am going to admit that this can be a difficult procedure to watch.

Nicole: Okay. Regardless of the reason why the pregnancy is being ended, whether it's for an unknown, lethal anomaly for the baby, whether it's because there was a fetal demise it's 16 or 18 weeks, it's a difficult procedure to watch because, uh, it's, what's called a destructive procedure. And what that means, and I'm just going to say it is that the fetus is removed in parts or pieces, and you can see the parts or pieces as, as the fetus is being removed as the procedure is being done. So I'm just going to be honest from my own personal perspective is that D&E can be difficult, difficult to see. Now, there is a variation of dilation and evacuation called an intact dilation and evacuation, and that is where the term partial birth abortion comes from. And with this technique, and I'm going to describe it, and this is going to be a little bit graphic.

Nicole: So just, you know, brace yourself if this is going to bother you. So what happens is that the fetus is removed intact, or nearly intact through the cervix, unlike a traditional D and E, which is a destructive procedure. So what happens is after the cervix is sufficiently dilated, then the surgeon uses extraction forceps to deliver the baby either breech or head first. Okay. If, if, if the fetus delivers in breech presentation, the head is the largest part at that point. All right. So the head is the largest part, so the body will come out, but the head will still be inside the cervix. And then what happens is that the head has to be decompressed. And that is often done by suctioning out the contents of the brain. Okay. The, or I should say the intracranial contents. So the contents inside the skull, if the fetus is head down, then, and the head comes first, then, um, an incision can be made into the skull.

Nicole: And then the, the brain contents suctioned out to decompress the skull, and then the remainder of the fetus will then deliver intact. So that is what a partial birth abortion is. I personally have never seen that. I have seen D&Es done when I was in residency training, but I haven't seen an intact D&E. Now, the partial birth abortion act of 2003, actually criminalizes some variants of D&E and doesn't provide any legal exception for cases to perform, to protect more maternal health. But in practicality, this doesn't really reduce the, the access to having the procedure, because most of the time, uh, an intact D&E is not done. All right. Now I know that that sounded graphic. And one of the things that that often brings up is can a fetus feel pain? Well, the data shows in rigorous scientific rigorous scientific studies actually have found that a human fetus does not have the capacity to experience pain until after viability.

Nicole: So till until after 23 weeks at the earliest, the connections that are necessary to transmit signals from the periphery nerves to the brain. So from the nerve, say, for instance, in the skin to the brain, as well as the brain structures that are necessary to process those signals, that infrastructure, that system in our bodies doesn't develop until at least 24 weeks of gestation. So because the fetus lacks connections, lacks the structures, they don't have the physiologic capacity to perceive pain until at least 24 weeks. And in fact, the perception of pain requires more than just that mechanical transmission of signals. Okay. Pain is actually considered an emotional and psychological experience. It requires a conscious recognition of some sort of stimulus, all right? And that capacities is not developed until the third trimester at the earliest, even, you know, well, past 20, 24 weeks, the neural pathways that are necessary to distinguish just touch from painful touch, don't develop until late in the third trimester.

Nicole: So the occurrence of movement or a baby moving inside of the uterus is not an indication that they can feel pain. Now, one of the arguments that's often used is a fetus's response to a stimuli and saying that that is an indication that they can feel pain. For example, during an amniocentesis, if they are in inadvertently pricked with the needle. And then they recoil from that, then that is interpreted as pain, similar to how an adult would recoil or pull back from a painful pinprick. However, this is different. And studies show that that pulling back is more of a reflex that's controlled by the lower brain. The part of our brain that does the things that are unconscious, that we don't have to think about, like our heart beating, or breathing, those kinds of things. And it doesn't reflect an experience of pain. In fact, you can see that same response in anacephalic infants and anencephaly is a condition where the vast majority of the brain is missing and they will recoil as well.

Nicole: Okay. So just to kind of put a, put a pen in it is that the experience that pain is different than the experience of touch and pain requires a deeper level of connection and brain development. And that doesn't happen until after 24 weeks of pregnancy at the earliest. Okay. Now, circling back to those two procedures, the D&E versus the medical induction, just real quickly, the advantages and disadvantages of each. So the advantage of the D&E is that the procedure is shorter. Um, they use, you usually undergo one to two days of cervical preparation, and the procedure itself is about 30 minutes. Whereas induced abortion in the second trimester can take 24 hours or longer. A D&E is cheaper than an induced abortion because D&E is going to happen in an outpatient facility. Disadvantages of D&E are that there is a risk of uterine perforation, which is when a hole is poked through the uterus, and that's going to require for local surgical intervention.

Nicole: Also, um, an advantage of induction is that if you want an intact fetus, for some people, that's important to have something to bury or something to, um, to hold. Then an induction will, will give you that. Whereas a D&E is a destructive destructive procedure. Like I mentioned before, a disadvantage of induction is that you are going to have, um, or that there's going to be an increased experience of the procedure. All right, you're going to experience more of the uncomfortable effects, like bleeding, cramping, nausea, vomiting, and they're going to occur over a longer period of time than a D&E. And there's also a greater awareness of the process of terminating the pregnancy. And that can be emotionally difficult for some people. And then finally, there's a higher risk of hemorrhage after second trimester induction, as well as retained placenta, which then necessitates surgical removal of the placenta.

Nicole: Now, one of the things that someone asked me on Instagram is what happens with the tissue after, after surgical, um, abortion or a termination of pregnancy. And it gets disposed of like medical waste. It's not used in any particular studies or research things or things like that, unless there's explicit consent, attain obtained ahead of time in order to do that. But it gets disposed of as, as medical waste. Um, if people desire, like if the pregnancy is further along and they desire some sort of burial or, or ceremony than, uh, an induced abortion is going to give you the opportunity for that, if you want some physical remains. And also, um, something, one of the nurses that I worked with shared with me is that for an earlier stages of pregnancy, if you do the medication abortion at home, you can place a, a strainer in, in the toilet.

Nicole: And it's not going to look like a form, um, human. But if you want to have something that is, is, is meaningful for you to hold on to, to bury or dispose of later, then you can do that. Okay. And then the final thing I'll say is as about the cost, the cost can vary depending on the area, but it can be in the $750 range in terms of abortion, maybe even a little bit higher or a little bit lower. Okay. So I'm going to quickly go through some of the complications from abortion in general, the rate of complications associated with pregnancy termination is very low. Okay. So in the first trimester, the risk of major complications is 0.16%. Minor complications is 1.1%. That's what the surgical abortion, medication abortion major complications 0.31% minor complications, 4.88%. All right. So overall it is very, very safe.

Nicole: And the risk of complications depends on how far along the pregnancy is, the method. As I just talked about, um, the clinician skill and experience with the procedure, as far as what the potential complications are, the most common complication is going to be hemorrhage or bleeding and similar to vaginal birth uterine perforation, which is poking a hole through the uterus during the surgical procedure, um, is also a risk or a possibility. Infection is a possibility as well as is retained products of conception, meaning all of the pregnancy tissue was removed and, um, infection, I should say back up and say, the infection can be mild. And in very rare cases can be severe where, uh, it goes throughout the body, which is in sepsis. Death is a possibility as well, but it's very, very, very low it's lowest before eight weeks and then increases after 18 weeks. So, um, is less than 0.3 per 100,000 abortions it lists at eight weeks weeks, and then seven per 100,000 at 16 to 20 weeks, 11 per 100,000 at greater than 21 weeks. So overall elective abortion at any gestational age is safer than carrying a pregnancy to term.

Nicole: And then as far as the effects on future pregnancies, there are conflicting results, whether or not prior abortion is a risk factor for preterm delivery or low birth weight. That data is conflicting, but the evidence overall suggests that abortion actually has no effects on subsequent pregnancy. Some of that differs based on the method, a surgical abortion may slightly increase the risk of preterm delivery, low birth weight, and small for gestational age babies, but the absolute risk remained small. So these aren't the exact numbers. For example, like without an abortion, it may be one in a thousand and then with an abortion, it's two in a thousand. So it's higher, but still overall, very low.

Nicole: Now that's contrasted to medication abortion, which doesn't have any surgical procedure instruments. The outcomes are same for the same for a medication abortion that doesn't appear to increase the risk of any pregnancy complications. And then for second trimester, a surgical procedure may have a slightly increased risk of preterm birth, lower birth weight, small babies, but again, the overall or absolute risk is still very small. Okay. Let's talk a little more specifically about psychiatric outcomes after abortion. So most reviews, including the turn away study, the turn away study is the largest and longest study that looked at the psychological effects of abortion versus childbirth. So most reviews have concluded that abortion does not harm a woman's mental health. Okay, does not harm her when a woman, a woman's mental health. And I'm going to get into a little bit more of the details. And some of the nuances of that.

Nicole: Now it's difficult to draw conclusions because some of the evidence is not great about psychiatric effects. It's low quality. The study designs are inconsistent. They don't use validated instruments. They also don't take into account other factors that can lead to emotional distress, like impaired relationships or financial difficulties. So it's really hard to make generalizations about it, but in general, most studies show that abortion is not associated with an increased risk, increased risk of mental health disorders. Okay. So I'm going to dig into the data or more specific conditions, a little bit more closely. And I want to be clear than I am focusing specifically on people who have unintended pregnancy, okay. Who have unintended pregnancy. And the reason that I'm focusing on that is that most people who terminate pregnancy or terminate a wanted pregnancy. And in that instance, I'm thinking specifically like terminating a pregnancy due to fetal abnormalities are going to have some level of depression, anxiety, stress afterwards.

Nicole: Um, so that is almost a given. So I'm specifically talking about health outcomes, following pregnancy termination for an unintended or unwanted pregnancy. So again, when you look at mental health disorders in aggregate, most studies show that there is not an increased risk of mental health disorders. Um, as in relation to abortion, when you break it down by more specific conditions. So when you look at depression, um, there is conflicting data regarding the association of pregnancy termination with the long-term risk of depression, but the higher quality studies, studies that are prospective studies that are well controlled for other factors that may influence depression. They have generally found that abortion is not associated with an increased risk of depression symptoms. As for anxiety, many women, maybe even most women will experience anxiety before pregnancy termination. Um, but the short-term risk of anxiety is worse in women who are denied an abortion compared with women who have an abortion and the long-term risk of anxiety after abortion does not appear to be elevated. When we look at post-traumatic stress disorder, pregnancy termination does not appear to be associated with post-traumatic stress disorder.

Nicole: Now there is, are, there are some studies that have found an elevated risk of PTSD after pregnancy termination, but that study has been, those studies have been, um, criticized for having methodological flaws. So they don't carry as much weight, don't take into account some of the confounding factors and things like, um, history of mental illness or financial difficulties, social difficulties. So the higher quality studies do not show a risk of PTSD after abortion. Best evidence also suggests that induced abortion does not increase the risk of suicidal ideation or behavior, induced abortion does not increase the risk of psychosis, although that hasn't been studied very often, it's also not associated with an increased risk of subsequent substance use disorders. Now, some people will have regret after having an abortion, but it is usually paired with feelings of relief. Okay. So this is a difficult thing to study.

Nicole: And one of the things that was pointed out when I was doing the research for this is that they don't always clarify. The question is if you could go back in time with what you know now, would you make a different decision? So very clearly I'm articulating would they have done something different? So yes, there may be feelings of regret, but the overall or overwhelming feeling is relief. Also, when we look at self-esteem, self-esteem doesn't appear to be effected in the longterm with abortion and neither does life satisfaction. And then finally, let me say a word about stigma. Concern about social stigma is a really common aspect and something that women worry about with pregnancy termination and, and fear of stigma. Um, and one study that looked at women for two years after pregnancy termination, this was about 400 women, 47, 47% reported that they felt others would disapprove of them as a result of their abortion. And 44% felt that they needed to keep the abortion a secret from family or friends. The stigma can be made worse by having difficulty in obtaining an abortion.

Nicole: And stigma will also actually increase the risk of feeling negative emotions, feeling regret, guilt, sadness, or anger following an abortion. So another one of the questions that I got on Instagram was essentially like, how can you help someone in the mental health space or help support them with an abortion? Like if you have a friend or family member. And I would say the biggest thing is, is, is reducing the stigma and not making people or imposing guilt on people about their choices. So just supporting people in their choices and where they are and not giving them guilt about that. And I know that that can be done regardless of your feelings about the procedure itself. In fact, there are some, some folks who are against the abortion procedure who speak out about being supportive of women themselves, and not stigmatizing them for the choices that they made.

Nicole: So I think one of the most important things to support someone who's had an abortion is to help remove that stigma. All right, now, some factors that may increase the risk of having post abortion, psychiatric problems. One of the biggest ones is having mental disorders prior to abortion. That is the most important risk factor for psychiatric symptoms after an induced abortion. So, you know, if you have depression or anxiety beforehand, then you're more likely to have depression or anxiety afterwards. Okay. Same thing with substance abuse disorders, um, mood disorders, all of those things, having a lack of social support will also increase your risk of having post-abortion psychiatric problems. So if, um, your partner is not supportive, if your relationship isn't healthy and this isn't marital status, this is a relationship health. So if your relationship is not in a good place, then that can increase the risk of mental health disorders. Afterwards.

Nicole: Also, if you feel pressure from a partner or friends to terminate a pregnancy that can increase the risk of feeling distress afterwards, including post traumatic stress disorder, a current or past history of having been a victim of violence, um, childhood physical or sexual abuse, partner violence, rape, all of those things are associated with mental health disorders. Afterwards that the pregnancy was if you've had a pregnancy termination and then as might be expected, if you have negative attitudes towards abortion before the procedure, then that's going to be associated with negative emotional responses. After the procedure, some women feel compelled to terminate an unintended pregnancy. Um, even if they themselves have a negative attitude towards, uh, or, or an unfavorable or don't, don't believe in abortion, they may feel compelled to terminate it. And then that can make it difficult for her to accept her decision without having some distress. Also religious factors can factor into that as well. And then finally, actually women who have more children actually have more positive attitudes towards abortion and better psychological responses after the procedure than women who have fewer or no children.

Nicole: Now, some factors that don't appear related to post abortion mental health are how far along the pregnancy is. Um, having a history of prior pregnancy termination doesn't seem to affect it. The technique doesn't seem to affect mental health after abortion, socio economic status or being an adolescent. Okay, so let's finish up by talking about unsafe abortion public opinion, in my opinion. So unsafe abortion is the World Health Organization defines let's start with safe abortion, which is abortion where abortion laws are not restrictive, or if abortion laws exist, access to safe abortion is available. Unsafe abortion is defined, however, is when it's performed by people who lack the necessary skills, they use hazardous techniques or do so in an environment that does not meet minimum medical safety standards. Unsafe abortion is not, does not happen very often in the United States. It did before abortion was legal, but it doesn't happen very much these days, but in general, unsafe abortion worldwide, it can be performed by trained medical providers like physicians, nurses, midwives, even pharmacists.

Nicole: It can be performed by lay practitioner. Sometimes individuals will self induce abortions. Okay. Um, often in places where abortion has been illegal and unsafe, someone may attempt instrumentation of the uterus. So put something inside the uterus, like a coat hanger, and that's not an exaggeration in order to induce bleeding or get bleeding started. And then it's diagnosed as a miscarriage and process or a spontaneous abortion. And then they get appropriate medical care. Also in some large urban settings, individuals who can afford to, there are some physicians who do abortions in their office, kind of under the table where they will do it discreetly with dilation and curettage, or what's called vacuum aspiration for early pregnancy termination, or some physicians will offer misoprostol to kind of start the process and make it look like an abortion or a miscarriage is happening. And then people present to the hospital for completion of, of that miscarriage.

Nicole: This can also be unsafe, um, even if it's done by medical providers, because if there's a lack of adequate training or instruments or sterile technique being used, that can be a difficulty as well. And then lay practitioners or patients. There's been lots of history of people, inducing abortion with a wide range of things, oral and injectable treatments, um, things that are placed in the cervix, the vagina, even the rectum, um, placing things in, um, inside the uterus or even trauma to the abdomen, like literally beating on the abdomen. And this is really just a reflection that people can be very desperate when they're faced with an unplanned pregnancy and they are willing to endure sometimes very, very risky things in order to end that pregnancy. I don't think that these are decisions that people come to lightly. People are, are often desperate and sometimes they'll resort to a combination of, of, of approaches in order to induce an abortion. Now complications of unsafe abortion.

Nicole: And then this was also something that someone asked me on Instagram as well. So, uh, some of the complications include him and there's similar to, to, um, to birth in general, but just, but just higher numbers for sure. So hemorrhage, uh, severe can be three present, 3% non severe as high as 44%. And a lot of these is in, is in resource limited countries. It's kind of hard to extrapolate to the U S because it's been quite some time since we've had unsafe abortion, but hemorrhage, infection both severe and non severe, trauma from inserting foreign objects or using chemical burns, um, anemia, which is low blood count, kidney failure, even mortality is an issue. And most people will have one or more complications. If they have a complication, some factors that increase morbidity and mortality of unsafe abortion, or lack of provider skill, poor technique, unsanitary conditions, um, lack of appropriate equipment, um, increasing gestational age. So further along in pregnancy, and then lack of access to post abortion care. Sometimes also social stigma, legal threats, or even fear will prevent people who undergo unsafe abortion from accessing good post-abortion care. And that post-abortion care is a critical aspect of reducing problems as a result of unsafe abortion.

Nicole: Okay. So the last two things I'll talk about are public opinion. In my opinion, public opinion has actually been very remarkably consistent for quite some time about abortion. It varies some, but for the most part, it has remained pretty consistent. And what the public opinion is, is that roughly about 25% of folks say that abortion should be legal under any circumstances with no restrictions about 20%, say the opposite that it should be illegal in all circumstances with no restrictions. And then there's a, every most other folks are in the middle where they believe that it should be legal under some circumstances. And what those circumstances are very, the vast majority of people favor exceptions, um, to have abortion for rape incest or a fetus that has a lethal anomaly. So most people favor those types of exceptions. And then some people favor abortion in the earlier stages of pregnancy or favor access in the earlier stages of pregnancy, but not in the later stages stages of pregnancy.

Nicole: So when we look at very restrictive laws that ban abortion early, like the six week law in Texas, and provide no exceptions from maternal health or rape or incest or anything like that, I should also add that most people favor abortion available to save the mother's life as well. But those very restrictive laws are actually not in step with the vast majority of public opinion. And then my opinion is that abortion is a personal choice, or I should say largely a personal choice between a woman and her healthcare provider. It's not something that should have very much legal influence at all. Now I say largely because I do think a gestational age, age limit is reasonable. Once a baby is at a gestational age, that it can survive outside of a mom, then they deserve legal protection. So after viability of 24 weeks, then no, I don't think you should be able to end a pregnancy because you don't want to be pregnant at 26 weeks because that, um, baby could survive.

Nicole: That baby could be adopted. So I don't think abortion should be available in those circumstances, but in the early part of pregnancy before viability, before the baby can survive outside of the mom's body, then I believe it is solely the mother's decision to decide what she wants to do with that pregnancy and what happens in her body. Now, some other things that I think about abortion in my opinion, are that when we talk about abortion, we have to talk about providing contraception. Okay? Sex is a normal and natural part of being human being and just telling people not to do that does not work. And it makes sense, okay. That's not how human beings were designed. So we have to talk about providing safe, reliable, affordable contraception. Study after study has shown worldwide that when you do that, that will decrease the rate of abortion.

Nicole: So if you care about reducing abortion, I believe you should care about providing access to contraception. I also believe it's incredibly HIPAA hypocritical when people are against abortion, but then criticized the social support programs that are put in place to help support moms and the children of these vulnerable situations in pregnancies. It's very baffling to me, how you can say, no, you can't end that pregnancy and then turn around and you do it in the, the, the guise of, you know, the life needs to be protected. But then when the life is actually here, don't want to do anything and actively criticized social support government programs that are in place to help support these vulnerable, vulnerable populations. That makes no sense to me.

Nicole: And then the final thing that I will say is I definitely, definitely am opposed to the pro-life pro-choice terminology around the dis the abortion discussion. It is offensive for you to tell me that I am not pro-life okay. Just because I believe that a woman has a choice about what happens in her body does not mean that I am not pro-life. Of course I am. Pro-life, I'm an obstetrician for God's sakes. I help bring life into this world all of the time. So it is not an either or, I believe that choice can be there and should be there under certain circumstances. And I am also here to support life, not just inside the uterus, but throughout the life span and after people are born as well, that is equally as important. All right. So just to recap, abortion is very common. About one in four women will have an abortion throughout the reproductive lifetime. Abortion has a low risk of complications. It's actually safer than continuing a pregnancy overall. It does not appear to increase the risk of future problems in, um, future pregnancies or psychiatric problems. That favor the public actually favors some access to abortion, how much varies. And then I believe abortion should be legal for everyone, um, before viability, and then not legal after viability. Unless of course there are circumstances where it may be necessary to save the mom's life, or it's a lethal anomaly. That's diagnosed later if that's a woman's choice, and then she wants to do that. But in general, my opinion is that it should be legal before the age of viability. All right. So there you have it, be sure to subscribe to the podcast in Apple Podcast or wherever you're listening to me right now and do come on over and follow me on Instagram.

Nicole: I'm there @drnicolerankins and we can connect in-between the show. So that is it for this episode. I know it's a longer one, but do come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the All About Pregnancy & Birth podcast. Head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information or my free online class on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, the Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.