At the core of reproductive rights is the principle that a woman has the right to decide whether and when to have a child.
- Centre for Reproductive Rights.

How can anyone claim they have the 'freedom' or 'right' to kill an innocent baby? The only 'choice' in abortion is between a dead baby and a live baby.
- ProLife America Website.

The subject of abortion is a highly sensitive and controversial one, which persists even in our age of science and enlightenment. To call it necessary would be to violate the beliefs of people and the foundations of religion; to say it is wrong would be to turn our backs on the rights of women.

Whatever the opinion, abortion much remains very much an issue in today's society. About 210 million pregnancies occur worldwide every year. Of these, 38% are unplanned, and about 22% will end in abortion. In developed nations that have little or no restriction as to the reason for an abortion, termination is relatively safe and effective; however, 40% of the 50 million abortions performed annually around the world are unsafe, and about 90% of these take place in developing countries where contraceptives are unavailable and abortion is banned, or at least severely restricted. This means that roughly 78,000 thousand pregnancy-related deaths every year are due to complications from unsafe (usually illegal) abortions.

Is abortion the answer to every unwanted pregnancy? Is it a woman's right to choose the fate of her embryo or foetus, or is it a question of morality and human rights?

What Is An abortion?

An abortion, by medical definition, is the termination of a pregnancy due to the loss or destruction of the embryo or foetus before birth.

Spontaneous abortions (or miscarriages) occur frequently in pregnancy. It has been estimated that between 20% and 75% of known pregnancies fail¹. This can happen as a result of:

• The fertilised ovum (egg) failing to implant in the endometrium².
• The embryo failing to develop
• Complete or incomplete expulsion of the products of conception
• Death of the foetus prior to 20 weeks from the woman's last menstrual period (LMP)

Because many of these spontaneous abortions occur very early into the pregnancy (prior to six weeks after LMP), they hardly affect the menstrual cycle and consequently the woman does not realise that a pregnancy has even occurred.

Induced abortion refers to the medical procedure performed upon a pregnant woman to remove, or induce the expulsion of, the embryo or foetus, and forms the basis of this article's discussion.

A Brief Guide to Foetal Development in Pregnancy

1. First trimester (after fertilised ovum is implanted in the endometrium)
• 4 weeks: the heart begins beating.
• 8 weeks: male and female reproductive systems have differentiated; the eyes, ears, nose, mouth, fingers and toes are easily recognisable.
• 12 weeks: all recognisable organs have developed.

For the first eight weeks of gestation³, the developing organism is called an embryo. After it has developed sexual organs - after eight weeks - it is known as a foetus.

2. Second trimester
• Organs begin functioning, bone marrow starts making blood, subcutaneous (under the skin) fat increases, bones begin to harden.
• Thin-walled skin develops, scalp hair appears.
• 20 weeks: foetus begins moving.
3. Third trimester
• The foetus begins gaining weight rapidly.
• Cartilage develops in earlobes, nails begin growing, creases develop over the soles of the feet.
• In males, testes begin descending into the scrotum.
• Foetus begins demonstrating coordinated patterns of behaviour similar to the cycles of sleep and activity of a newborn.

Types of Abortion Procedures

Many abortion procedures are being practised today - the methods vary from place to place and depend on the social/religious/ethical climate of the country. There is a general trend towards safer abortion procedures (especially those involving the administration of abortion-inducing medicine) in countries that do not impose restrictions regarding the reasons for abortion; in places where abortion law is severely restrictive, back-door abortion clinics practising dubious and often dangerous procedures thrive on the clientele of desperate women.

The types of abortion procedures, therapeutic or illegal, are listed below according to category.

Instrumentation

1. Suction abortion: This method is used during the first three months of pregnancy, before the embryo develops a functioning heart. A suction tube is introduced into the womb, where the powerful suction draws the embryo out along with the placenta. The embryonic remains are deposited into an attached waste bottle.
2. Dilation and curettage (D&C): In this procedure, the cervix is dilated, and ring forceps are inserted into the womb to withdraw the foetus. A curette⁴ is then used to scrape away any of the foetus or placenta that remains in the womb. Profuse bleeding usually follows. This procedure is used at the end of the first trimester (approximately 12 weeks).
3. Dilation and evacuation: This method is used if the pregnancy has been allowed to progress to 13 weeks or later. The cervix is dilated and the foetus is removed with plier-like forceps. The foetus and placenta are then reassembled outside the womb to make sure that they have been completely removed and so avoid complications.
4. Dilation and extraction⁵ (D&X): This is a procedure used for late-term abortions, and is carried out from the fourth to the ninth month of pregnancy. An ultrasound is first used to locate the legs of the foetus, which are then drawn through the birth canal with a pair of forceps. Scissors are then used to puncture the base of the back of the head so that the brain may be removed by suction. This serves to collapse the skull to facilitate removal of the entire foetus.

Local Interference

This type of procedure involves the injection of fluid containing salt or hormones into the amniotic sac⁶, and is usually postponed until after the 16th week to reduce the risk of injection outside the amniotic cavity.

1. Saline amniocentesis involves in introduction of a concentrated salt solution into the amniotic fluid via an amniocentesis needle. This is inhaled and swallowed by the foetus, which subsequently dies of acute salt poisoning.
2. Alternatively, a hormone called prostaglandin is injected into the amniotic sac. This causes premature labour and delivery of a stillborn.
3. Another injection method is inter-cardiac injection abortion whereby poison is injected into the chest or heart of the foetus via a long needle inserted through the mother's abdomen. This method is sometimes used for 'pregnancy reduction' in multi-foetal pregnancies.
4. Application of potassium permanganate crystals to the upper vagina and cervix causes chemical burns and death of the foetus from absorption of permanganate.
5. Some illegal abortion procedures use legitimate substances such as 'utus paste' (which contains soap, thymol and potassium iodide) or 'interruptin' (which contains iodine). These substances are injected through a cannula into the cervical canal and through irritant action causes the chorionic⁷ sac to break open.

Medicinal

Medicinal abortion procedures are currently among the safest and most popular methods available. These involve the termination of early pregnancy using certain medications taken orally or administered by injection. Two methods of medical abortion currently exist: mifepristone (formerly known as RU-486) and methotrexate.

Mifepristone is a synthetic chemical that blocks progesterone, which is required to continue pregnancy, and thus causes the uterus to shed its lining as in normal menstruation. An early embryo attached to this lining will be shed along with it. This method is effective for up to 63 days of pregnancy, although the FDA⁸ has only approved it up to 49 days. Methotrexate terminates pregnancy by preventing cells from dividing and multiplying, and is effective for up to 49 days. Both of these drugs are used in combination with misoprostol, which is administered after 48 hours to stimulate uterine contractions and expels the fertilized egg. Abortion can occur within four hours to two weeks following this dose, although the reported success rate for Mifepristone is only 92-95%, and Methotrexate is only effective about 90% of the time.

In developing countries where there is little or no access to these FDA-approved drugs, folk remedy may recommend more drastic chemicals and toxins in an attempt to terminate pregnancy. These include vegetable compounds of dubious efficacy such as juniper, pennyroyal and pineapple. Most of these substances have little or no effect on the uterus or the product of conception; others, such as ergot and lead, do have a contractile effect on smooth muscle, but usually end up doing more harm than good.

Certain hormonal contraceptives are also capable of terminating early⁹ pregnancy. Although most modern contraceptive pills are designed to prevent pregnancy in the first place, they sometimes allow ovulation to occur in certain women¹⁰; however, the hormone progestin (which prevents implantation by thickening the cervical mucous) contained in the pill can prevent or disrupt implantation early into the pregnancy if a woman who has recently become pregnant (and is not yet aware of it) continues to take the contraceptive. Emergency contraceptives, or 'morning-after pills', have the same potential as regular hormonal contraceptives to terminate pregnancies, only they are more likely to do so due to the higher dose of hormones.

General Violence

Horrifying as it may sound, these desperate measures may still be encountered occasionally. These usually take the form of blunt injury to the abdominal wall (which includes punching and kicking) and self-inflicted trauma. Countless women have subjected themselves to very hot baths and violent exercise only to discover that the embryo or foetus is very persistent in clinging on to the uterus.

The Risk Involved in Abortion

There are no medical procedures that come risk-free, even the safest ones. In the case of abortions, risk varies from the failure to terminate pregnancy to risk of damaging the mother's health (and sometimes that of the persistent foetus). Relatively harmless folk remedies involving the consumption of traditional herbs (as previously discussed) are usually useless in inducing abortion, as are general violence methods. The more potent substances sometimes score higher on the success chart, but are usually harmful to the mother's health ('anything which is likely to kill the foetus is just as likely to kill the mother' - Bernard Knight).

Surgical procedures have the highest risk of causing harm to the mother, especially if they are performed illegally by people who do not possess sufficient medical knowledge to carry out the procedure. Among the things they are capable of causing are:

• Haemorrhage - caused by perforation of the uterus or adjacent organs, due to the inept handling of instruments;
• Sepsis - due to unsterile instruments and technique. This frequently happens in the case of illegal abortions, where surgical instruments of dubious hygienic quality are used. In most illegal abortion cases, adequate antibiotic cover is not provided, causing the damaged area to become infected. On the other hand, overuse of strong antiseptic or disinfectant substances may also cause necrosis¹¹ of the uterine lining and subsequent secondary infection. Retention of products of conception (if the uterus is not completely evacuated) will provide a hospitable breeding ground for micro-organisms, especially those that thrive in non-oxygen, or anaerobic, conditions. This causes the uterus to become swollen and brownish, with a foul-smelling necrotic endometrium. In extreme cases, sepsis may cause death; in less severe cases, it may lead to future illness and gynaecological problems such as sterility and pelvic inflammatory disease.
• Shock - a disorder resulting from ineffective circulation of the blood, characterised by a marked decrease in blood pressure, rapid pulse, and decreased kidney function. This results from haemorrhage or perforation of the vagina, uterus or adjacent organs. The onset of shock may be immediate if the woman is not anaesthetised when the cervix is dilated.
• Air embolism - the obstruction of blood vessels because of air bubbles, due to the introduction of air bubbles into the circulatory system. This was a common complication of the Higginson syringe method of abortion, where a Higginson syringe was used to inject fluid into the uterus to separate the chorionic membrane and deciduae; however, this procedure is no longer in use, and air embolism is only rarely seen in syringe aspiration cases.
• Leg vein or pelvic vein thrombosis - where the veins of these body areas are clogged by blood clots. This may be followed by fatal pulmonary embolism.
• Renal failure and septicaemia (blood poisoning) - are also possible complications of unsafe abortions. Others may include chronic pelvic pain, pelvic inflammatory disease, tubal blockage and secondary infertility.

Statistics have shown that between 10-50% of all women who undergo unsafe abortions will suffer these complications. A smaller percentage of women undergoing legal abortions may also suffer from the same, although with trained medical personnel and better hygiene standards, the risk is not as high.

As with many medicinal treatments, there are certain side-effects associated with medicinal abortion (using mifepristone and methotrexate); however, many of these are self-limiting and not severe, and so do not usually require medical intervention. These include pain and bleeding, which are associated with the process of aborting, and medicinal side effects such as nausea and vomiting. It was reported that between 2% and 10% of women who undergo this method of abortion require surgical aspiration to remove retained tissues or heavy/persistent bleeding. However, complications such as haemorrhaging rarely occur in the case of medicinal abortion. Sustained fever may also be an indication of endometritis.

Psychological side effects may also result from abortion, although studies on the psychological impact of abortion are harder to assess than physical impact because they are more subjective in nature and depend greatly on the people carrying out the study¹². However, there have been some associations made between abortion and later psychological or psychiatric problems such as suicide attempts, substance abuse and depression, although it has not been determined if abortion was directly responsible, or if other predisposing psychological problems also had a part to play in all this.

Where Does the Doctor Stand?

The foetus is unexpelled, the uterus is punctured. She has acute peritonitis. There's a foreign object - I think it's a crochet hook... If she had come to you four months ago for a simple D&C, what would you have done? Nothing! This is what doing nothing gets you. It means that somebody else is going to do the job, some moron who doesn't know how.
- Dr. Wilbur Larch, The Cider House Rules.

In the award-winning movie The Cider House Rules we see a wartime doctor who violates the Hippocratic Oath by providing illegal abortion services and euthanasia to desperate young women, feeling obligated to help them out because they had nowhere else to go. Although many countries today have legalised abortion, numerous laws still control the process of abortion itself, and a doctor should remember that to go against the law and the Hippocratic Oath for the sake of compassion and helping someone is to risk criminal conviction and probable loss of medical licence. On the other hand, a physician may refuse to carry out an abortion procedure if he has strong religious or moral objections to abortion.

In the event that a physician learns that criminal abortion has taken place, certain dilemmas may arise as to the course of action to be taken. If it is the woman herself who has performed the procedure, the doctor should generally restrict himself to providing the necessary medical care. He is not obliged to report to any authorities unless the patient dies, in which case the coroner or other forensic authorities may be called in to investigate.

If the abortion was performed by someone else, a physician may be obliged to report it to the authorities if he or she gains the knowledge that it was done by a professional abortionist, particularly if the said abortionist is known to use dirty and dangerous methods. However, the British Medical Association and the Royal College of Physicians have decreed that A medical practitioner should not under any circumstances disclose voluntarily, without the patient's consent, information obtained from that patient in the course of professional duties, and a doctor should not compromise his patient's confidentiality unless he feels that his duty to the public overrides this breach of confidentiality.

Abortion Laws and Legal Issues

Restrictiveness of Abortion Law

The laws permitting or prohibiting abortion vary not only from country to country, but also sometimes within the country itself¹³. There are five categories of abortion law restrictiveness:

1. Without restriction as to reason (50 nations): Currently, about 62% of the world's population resides in countries where there are relaxed laws or no restrictions at all as to the reason for an abortion. These nations include China (which has turned its one-child policy into law to control its population growth), a number of European countries, Canada and certain states in the USA.
2. Permitted on socio-economic grounds (14 nations): In these countries, consideration is given to a woman's economic background, age, marital status and household size where abortion is concerned. These nations include the United Kingdom, India, Japan and Australia.
3. Permitted on the grounds of mental health (20 nations): Women in these countries are permitted to undergo abortion if the pregnancy threatens her mental or physical health, or her life. This includes women who have suffered psychological distress such as rape and incest, or who have socio-economic problems. The twenty nations include New Zealand, Switzerland, Spain and Malaysia.
4. Permitted on the grounds of physical health (33 nations): The law in the countries that fall into this category permit abortion only to protect a woman's life and physical health. In some countries, the law requires that the threatened injury be either serious or permanent. Thailand, Ecuador and a number of countries in Africa and the Middle East practice this policy.
5. Permitted only to save the woman's life or prohibited altogether (74 nations): The nations in this category only allow abortion to save a woman's life, or disallow it completely. Brazil, Nigeria and Indonesia are countries that explicitly state that abortion is only to be carried out if the pregnancy threatens the mother's life.

Target Regulation of Abortion Providers (TRAP) Laws

These laws, found in countries such as the USA, single out abortion facilities and subject them to regulations that do not apply to healthcare facilities of any other sort. These TRAP laws vary from place to place with regard to the facilities and types of abortion performed in these places. Some places requires that the abortion facilities become licensed and open for inspection by the state (such as in North Carolina), and comply with a whole list of schemes and guidelines with regard to staffing, patient testing and stages of abortion; other places may be more lenient and only require compliance with general guidelines. However, it is to be noted that the majority of these laws do not apply to private physician offices in which only first-trimester abortions are performed.

In many places, the abortion providers are also required to keep records of certain information for inspection, such as the number and type of procedures done and the demographics of the patients, so long as they do not compromise patient confidentiality.

Food and Drug Administration Regulations

These regulations apply to medical abortion, where the drug mifepristone must be provided by or supervised by a doctor who can accurately assess the stage of pregnancy and is able to diagnose ectopic pregnancies. These physicians must also be able to deal with complications such as incomplete abortion or severe bleeding, or arrange for other qualified physicians to provide such surgical intervention, and must be able to provide or arrange for the patient to have access to fully-equipped medical facilities. In addition, the patients are also to receive a complete explanation of the medical procedure, and are given the opportunity to discuss it with their physician; subsequently, the patients are to sign the patient agreement, which the physicians are to sign as well. Any serious complications, including the need to resort to surgical abortion in case of medical abortion failure, are also to be reported by the physicians.

Physician-only Laws

Some countries have restrictive laws whereby only licensed physicians are permitted to perform abortion; however, this does not prevent non-physician health care workers from assisting the doctor in the process. In some parts of the world, physician assistants may also be allowed to perform abortions, and other non-physician health care providers such as midwives and advanced registered nurses are authorised to perform medical abortion.

Foetal Tissue Examination and Disposal Laws

Many countries around the world have laws requiring foetal tissue to be submitted to a physician or pathologist for examination following an abortion. Some places also have laws regulating the disposal of said tissue. For example, the foetal disposal laws in California allow the disposal of the tissue down the toilet. However, in North Dakota, the foetal tissue must be disposed of by incineration, burial or cremation. Such laws may be considered irrational and burdensome under certain circumstances, for example, if the woman aborts the tissue at home following medical abortion.

Waiting Periods/Informed Consent Laws

In some places, there must be a waiting period (usually 24-48 hours) between the time the physicians provide their patients with state-scripted information regarding the abortion and the time the patient consents to the abortion. The patient must be informed about the abortion procedure, the stage of pregnancy, the characteristics of the foetus at that stage, alternatives to abortion and possible medical assistance and child support available. Alternatively, in some parts of the world, the consent of the husband must be obtained before a woman can undergo abortion. Certain places allow this information to be handed over by a delegate, or to be made available to the patient ahead of time.

If the patient requesting the abortion is a minor, parental consent or notice is sometimes required before the abortion can be performed¹⁴. Alternatively, some laws allow the notification of another adult family member besides the parents. However, a minor who chooses not to notify or obtain the consent of the said adults in these parts of the world may still be permitted to undergo the procedure if she is able to obtain court authorisation.

Religion and Abortion

The restrictiveness of abortion laws tend to depend, in certain parts of the world, on the dominant religion practiced there. For example, in places such as Latin America and Europe where the religion is predominantly Catholicism the condemnation of abortion has led to greatly more stringent abortion laws. However, the 1994 International Conference on Population and Development in Cairo and the 1995 Fourth World Conference on Women in Beijing saw religious leaders worldwide supporting women's reproductive choice.

From a survey of several major religions in the world, it has been found that on the whole different religions take different stands with regard to abortion, but many agree that abortion should be permitted on the grounds of saving the mother's life.

Catholicism

The Catholic Church has been firmly opposed to abortion, especially in Europe and Latin America. However, for most of its history, the belief of 'delayed hominisation' - the belief that a foetus is only human when it has fully developed into a human form; a less than fully human body is incapable of receiving a soul, and therefore is not fully human - had dominated Catholic teaching, which meant that early-pregnancy abortions did not constitute killing a human being. However, the current Catholic catechism is that life begins at conception¹⁵:

From the time that the ovum is fertilised, a life is begun which is neither that of the father nor the mother; it is rather the life of a new human being with his own growth. It would never be made human if it were not human already.

Thus abortion is considered a violation of the commandment Thou shalt not kill and is considered a mortal sin.

However, contrary to the myth that women who have obtained an abortion are subsequently expelled from the Catholic church forever, the modern Catholic church actually has a programme called 'Project Rachel' (which has the support of Pope John Paul II) that offers help and healing to these women. The network is made up of trained priests and professional counsellors who help men and women cope emotionally and spiritually following their difficult decision to opt for abortion.

Hinduism

Several authorities in ancient Hindu medicine were of the opinion that abortion, no matter how undesirable, was the proper thing to do under certain circumstances. Susruta, whose medical writings date from approximately the 5th Century BC, believed that abortion was necessary if an early pregnancy threatened a mother's health. Hindu scripture (Kaushitaki Upanishad, 3.1 UpR, 774; Atharva Veda, 6.113.2 HE, 43 etc) generally condemns abortion unless the mother's life is in danger.

Today, Hinduism generally leaves it to the individual to decide whether or not abortion is the right thing to do, although it is usually considered bad karma. India adopted a liberal abortion law in 1971, following the frighteningly high rates of maternal mortality and morbidity. On the other hand, Nepal, the only official Hindu state in the world, severely prohibits abortion, causing the rate of maternal mortality to reach as high as 1,500 maternal deaths per 100,000 live births as determined women oppose the law by seeking unsafe, illegal abortions.

Buddhism

There are currently differing opinions regarding abortion within Buddhism. It is generally observed that practitioners of the Theravaadin tradition tend to prohibit abortion. By contrast, the Mahaayaanan tradition and Japanese Buddhism are rather tolerant towards abortion. However, self-serving reasons such as 'concealing extramarital affairs, preventing inheritances, and domestic rivalry between co-wives' are unacceptable as grounds for abortion, as stated in Buddhagosa's commentaries.

Islam

Islamic scripture dictates:

Kill not your children for fear of want; it is We who provide sustenance for them as well as for you; for verily killing them is a great sin.
- (Chapter 17, Verse 31)

However, Islam jurists have agreed that abortion within 120 days of conception is acceptable if a pregnant woman is in poor health, is still nursing an infant, is at risk of difficult labour, or is under fifteen years of age, since a foetus is not 'ensouled' until about 40-120 days after conception (based on an interpretation of Chapter 22, Verse 4 and Chapter 23, Verses 12-14). Some also permit abortion if the woman suffers from stress or other mental health conditions; others believe that socio-economic factors are acceptable reasons for abortion. All schools of Islam allow abortion even after the 'ensoulment' of a foetus occurs, if the mother's life is at risk.

Judaism

It is clearly stated in Jewish text when a foetus becomes human. The Babylonian Talmud Yevamot 69b states that 'the embryo is considered to be mere water until the fortieth day'. And then, according to the Jewish law (Halacha), '...a baby ...becomes a full-fledged human being when the head emerges from the womb. Before then, the foetus is considered a 'partial life'.' A Jewish legal text from the second century CE, describing a situation in which a woman's life is endangered during childbirth, states that the foetus must be aborted using the D&X method; however, if the greater part of the foetus has been delivered, then the foetus could not be killed, as the foetus would only become human after most of its body emerged from the birth canal.

However, different branches of Judaism have different opinions regarding the permissibility of abortion. Generally, the modern-day consensus is that abortion is permitted to save a woman's life, and with the exception of some Orthodox authorities, Judaism generally supports abortion access for women; however, it is not permitted on the grounds of genetic imperfection, economic reasons, avoidance of career inconveniences, or because the woman is unmarried. In Israel, abortion is allowed if a woman's life or health is in danger, if the woman is under 17 or over 40, and if the pregnancy is caused by rape, incest or extra-marital relationships. If the foetus is likely to be physically or mentally impaired, then abortion is also permissible. Even among Orthodox Jews, there is a general consensus that abortion is a religious duty if a pregnant woman's life is at risk.

Conclusion

The issue of abortion continues to be a contentious issue even today, chiefly because safe and legal forms of abortion are still unavailable in many parts of the world. Just as an ostrich is said to bury its head in the sand, making abortion illegal will not cause the problem to evaporate. The very act of prohibiting abortion and restricting access to contraceptives and sexual education only serves to irritate the problem as women resort to dangerous means to cope with their unwanted pregnancies.

References

Bergstrom, S. 1999. Safer illegal abortion - an ethical challenge. Written for Q Webs discussions group about sexuality and reproduction.

Brodsky, B. 1992. Aaron: Channelled through Barbara Brodsky. Deep Spring Center for Meditation and Spiritual Inquiry, Ann Arbor, USA.

Grimes DA. 1997. Medical abortion in early pregnancy: a review of the evidence. Obstet Gynecol. 89:790-796.

Ioannes Paulus PP. II. 1995. Evangelium vitae to the Bishops, Priests and Deacons, Men and Women religious lay Faithful and all People of Good Will on the Value and Inviolability of Human Life.

Jones, BS and S Heller. 2000. Providing Medical Abortion: Legal Issues of Relevance to Providers. The Journal of the American Medical Women's Association, Vol. 55 (3).

Keown, D (ed). 1998. Buddhism and abortion: A western approach. IN Buddhism and abortion. University of Hawaii Press

Knight, B. 1997. Pregnancy and abortion. IN Simpson's forensic medicine, 11th edition. Arnold Press.

Webster's New World Dictionary, 3rd College edition. Simon & Schuster, New York.