Philippa Taylor

Abortion and preterm births: what women need to know but are not told

Philippa Taylor was Head of Public Policy at CMF until September 2019 and now works with CARE. She has an MA in Bioethics from St Mary’s University College and a background in policy work on bioethics and family issues.
The views expressed do not necessarily reflect those of CMF.

 

prematurePrematurity – a birth prior to 37 weeks gestational age – has recently been described as: ‘the biggest challenge in western obstetrics, with severe neonatal morbidity (and a need for intensive care treatment for infant respiratory distress syndrome, feeding problems, neonatal jaundice and cerebral palsy) and infant mortality.’

In the UK 7.8% of babies are born prematurely, 60,000 per year, a number that is on the rise.

90% of the NHS costs of this are focused around neonatal care, and total costs to the NHS are £2.9 billion a year, comparable to those of smoking, alcohol and obesity, about which we hear far more.

Perhaps this is partly because preterm birth does not have a single identifiable cause on which to focus efforts?  It has been associated with a number of accepted risk factors such as prior history, being underweight, obesity, diabetes, hypertension, smoking, infection, maternal age, genetics and multi-fetal pregnancy.

However the existence of a link between abortion and preterm birth is news to many – and no doubt controversial to many.

Yet there is actually a well established link between abortion and premature birth, which has been consistently underplayed by British authorities, including the Royal College of Obstetricians and Gynaecologists (RCOG).

New research on preterm births

New research, using a database of two million women, not only confirms this link but sheds more light on the cause of it.

In June a research paper was presented to the prestigious European Society of Human Reproduction and Embryology Annual Meeting in Lisbon, linking surgical abortions to prematurity in subsequent pregnancies:

‘Dilatation and curettage (D&C) is one of the most common minor surgical procedures in obstetrics and gynaecology, used mainly for miscarriage or terminations…Now, an analysis of 21 cohort studies which included almost 2 million women has found that a D&C performed in cases of miscarriage or induced abortion increases the chance of preterm birth (under 37 weeks) in a subsequent pregnancy by 29%, and of very preterm birth (under 32 weeks) by 69%.

The risks were even higher in women with a history of multiple D&Cs.

The results, says Dr Ankum, ‘warrant caution in the use of D&C after miscarriage and induced abortion and add further weight to the case for less invasive procedures in such circumstances.’

Warnings of the higher risk for women who have multiple abortions is important as the latest national statistics reveal that 37% of women in England and Wales had repeat abortions in 2014.

What are the possible causes?

The authors suggest some reasons behind the increased risk from D&C:

‘…dilatation of the cervix may cause permanent damage which affects cervical tightness, with premature opening of the cervix and subsequent premature birth a consequence. Other intra-cervical procedures, such as cervical biopsy or cauterization, may also cause an increased risk of subsequent preterm birth. Cervical damage might also impair the anti-microbial defence mechanism in the cervix, which could lead to ascending genital tract infection, a known cause of preterm birth.’

Not surprisingly, the authors suggest that the use of D&C should be ‘restrained’, which is already happening as latest abortion statistics for the UK show for the first time that more medical abortions were carried out in the UK than surgical (just). The surgical procedure vacuum aspiration was used for 44% of all abortions in 2014 and D&E alone in about 4%.

Nevertheless, surgical procedures still account for thousands of abortions a year (over 88,000) in England and Wales, since the total number of all abortions was 184,571.

Vacuum, or suction, aspiration was introduced into clinical practice in 1958 when two Shanghai doctors published an article in the Chinese Journal of Obstetrics and Gynaecology in 1958 on the use of a new technique requiring a new device, suction abortion, which they had performed on 300 Chinese women. The procedure spread rapidly by word of mouth throughout China, then into Russia and throughout the Communist world before being taken up by the Western world. It has become the most commonly performed abortion procedure, although this is changing now with the increased use of chemical abortion.

Is the alternative, medical abortion, really so safe?

It has been found that ‘medical’ (ie. chemical) abortions have devastating effects on mice, as this research shows:

‘Mice subjected to two previous medical abortions experienced spontaneous abortions in subsequent pregnancies. Medical abortion caused reduced reproductive capacity and affected placental dysfunction…The impact of repeated abortions on the offspring of subsequent pregnancies was also noteworthy and deserves further exploration.’

Medical abortion also has a higher failure rate than surgical. Finnish research on 40,000 women found the incidence of adverse events was four times higher for medical compared with surgical abortion (20% compared to 5.6%). Grossman and colleagues (2008) reported a 29% rate of adverse effects after medical abortion in the 2nd trimester compared to 4% for surgical abortion. A 2011 FDA report accounts for at least 2,207 cases of severe adverse events after chemical abortion, including haemorrhaging, blood loss requiring transfusions, serious infection, and death. UK statistics for 2014 report over twice as many complications for medical than surgical abortion, of those reported up to the time of discharge from the abortion clinic (table 8).

Back to the specific link between abortion and pre-term births:

What does other research find?

Just last year a study of 112,500 Chinese women found that: ‘Women with a history of recurrent induced abortion were at high risk of preterm premature rupture of membranes (PPROM) before 33 weeks. This finding is in accordance with a previous report from Eastern Europe.’

Interestingly, the authors found that:

‘Among the participants who had PPROM in the present study, approximately 44% had a history of induced abortion (24% had had one and 13% two).’

So if this were replicated elsewhere, it would suggest that nearly half of preterm births could be linked to prior abortion(s)! This deserves further investigation, at the very least given the significant cost implications of premature births for Government that I have noted above.

The authors offer a possible explanation for the association, suggesting that there: ‘…could be a tendency for increased systemic inflammation and stimulation of the infection pathway in women who have had an induced abortion.’

This short briefing here notes several other robust studies that similarly demonstrate an increase in the risk of preterm delivery after abortion, a risk that increases with the number of abortions that a woman has. There are now over 100 studies in the medical literature confirming the association.

What women need to know

Preterm labour and birth leads to hospitalisations of days or weeks for mothers. In the case of a very preterm birth – a birth prior to 32 weeks gestation – hospitalisations from 4-16 weeks can be expected. Preterm infants who survive are at risk for lifelong complications, including breathing problems, cerebral palsy, autism, blindness and mental retardation.

As I said at the beginning, the existence of the link between abortion and preterm birth will be news to many. The new research received almost no coverage outside the conference.  It is down-played and dismissed.

Yet the author of a major study in 2009 on the link specifically highlights the importance of informed consent for women:

More than a million abortions are performed in the US per year. Of these, more than 75% of women wish to or get pregnant again. These women should know the risks associated with induced abortion not only for their health but also for their future reproductive potential. A properly obtained consent legally mandates explanation of these risks to women and ensuring their understanding.’

This, he suggests, should include education of girls and women at schools and colleges, during routine visits to family doctors or specialists and finally when counselling women seeking abortion.

Six years later, and with ever more research to back this up, his advice has still not been put into practice.

I wonder if it is only a matter of time before a mother with a prior abortion brings a case against a doctor or health authority for not being informed that she was at increased risk of having a premature baby in a subsequent pregnancy?

If so, it would at least give the link the publicity it deserves.

Posted by Philippa Taylor
CMF Head of Public Policy

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