South Dakota Task Force to Study Abortion Pierre, South Dakota September 21, 2005

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1 South Dakota Task Force to Study Abortion Pierre, South Dakota September 21, 2005 Section III. : The review and exposition of the body of medical, psychological, and sociological knowledge that has accumulated since 1973 concerning the physical and mental health of women who have undergone abortions and their subsequent life, health, and socioeconomic experiences. Reviewing the Medical Evidence: Short and Long-Term Physical Consequences of Induced Abortion Elizabeth M. Shadigian, M.D. Clinical Associate Professor of Obstetrics and Gynecology University of Michigan Medical School Thank you, legislators and committee members, for the opportunity to address this group. I am a medical expert on abortion complications, gender issues in obstetrics and gynecology and violence against women. I am not here to argue a pro-life or pro-choice political stand. I am here as a medical expert advocating for accurate and accessible medical information for women, and society in general, on the short and long-term health effects of abortion. I am a clinician who must explain to women the complications and risks of surgical procedures, such as induced abortion, and get their permission for procedures. This is called informed consent. I also co-authored a compilation of research articles, called a systematic review, evaluating the long-term physical and psychological health consequences of induced abortion (1). In addition, I co- authored an article on pregnancy-associated death, specifically death from homicide and suicide during pregnancy and in the year after pregnancy (2). I have testified in the United States Senate and in the House of Representatives in similar matters. Approximately 25% of all pregnancies are terminated in the United States and 43% of all women undergo an abortion at some time in their lives. Therefore, if there is a small positive or negative effect of induced abortion on subsequent health, a large number of women will be affected. As physicians, we generally divide complications or effects from an intervention or procedure into 1) short-term effects, which are up to six weeks after the procedure and 2) long-term effects, which are seen as persistent effects after the six week window has ended. Approximately 10% of women undergoing induced abortion will suffer immediate complications, of which approximately one fifth (or 2%) is considered life threatening. Complication rates increase with greater gestational age of the pregnancy. Immediate complications include: infection, fever, abdominal pain and cramping, bleeding, hemorrhage, blood transfusion with its subsequent risks, deep vein thromboses, pulmonary or amniotic fluid embolism, injury to the cervix, vagina, uterus, Fallopian tubes and ovaries, bowel, bladder, and other internal organs, anesthesia complications (which are higher with general anesthesia), failure to remove all the contents of the uterus

2 (leaving behind parts of the fetus/baby or placenta), need to repeat the surgery, possible hospitalization, risk of more surgery such as laparoscopy or exploratory laparotomy, possible hysterectomy (loss of the uterus and subsequent infertility), allergic reactions to medicines, misdiagnosis of an intrauterine pregnancy with a tubal or abdominal pregnancy being present (which necessitates different treatment with medicines or more extensive surgery), possible molar pregnancy with the need for further work-up and treatment), emotional reactions (including but not limited to depression, guilt, relief, anxiety, etc.) death of the woman, risk of a live or live and injured fetus/baby. All these short-term risks should appear on abortion consent forms. In addition, the long-term risks that should also appear on abortion consent forms, but usually do not in this country, include increased risks of: breast cancer, placenta previa (a condition that necessitates a c-section and has higher rates of complications), preterm birth in subsequent pregnancies (births before 37 weeks gestation, many of which require neonatal intensive care unit stays for babies and higher rates of death), depression, suicidal ideation and attempt, deaths from all causes including suicide, medical diseases, accidents and homicide. My study (1) concluded that increased long-term risks of the following were found to be associated with induced abortion enough to warrant disclosure: breast cancer (from the loss of protective effect that a full-term delivery would have given a woman and a possible independent effect of induced abortion on breast cancer risk), placenta previa, pre-term birth, and maternal suicide. Three other reproductive outcomes that were studied, but we concluded were not found to be associated with induced abortion were: subsequent spontaneous abortion (miscarriage), ectopic pregnancy, and infertility. The Centers for Disease Control (CDC) reports approximately one death for every 100,000 abortion procedures performed in the United States. However, this only includes short-term risks (only those deaths in the six-week period following abortion) and is based on those states that require reporting. A recent study by Horon showed that the number of maternal deaths is substantially underestimated if death certificates alone are used to identify deaths (3), as is usually the case in reporting to the CDC. Deaths of women that occur after the six-week window following pregnancy should be considered long-term risks. Compared to women who give birth, women who have an induced abortion have an elevated risk of death: approximately three times greater than the risk associated with childbirth (4, 5, and 6). This elevated risk of death associated with induced abortion persists for at least eight years (7). Most prominent is the higher risk of death from homicide, suicide and accidents, although deaths from natural causes are also elevated (8). Excluding these long-term deaths underestimates the number of deaths associated with induced abortion by thousands each year. In the most recent edition of medical opinions set forth by the American College of Obstetricians and Gynecologists (Compendium of Selected Publications, 2005, Practice Bulletin #26), ACOG inexplicably states: Long-term risks sometimes attributed to surgical abortion include potential effects on reproductive functions, cancer incidence, and psychological sequelae. However, the medical literature, when carefully evaluated, clearly demonstrates no significant negative impact on any of these factors with surgical abortion. I am a proud member and fellow of ACOG. Because of groups like ACOG American women enjoy some of the best health, and health care, in the world. However,

3 I am deeply troubled that ACOG makes assurances to their membership, and to women everywhere, claiming a lack of long-term health consequences of induced abortion. Instead, ACOG should be insisting that these long-term health consequences appear on abortion consent forms. Why doesn t ACOG insist that long-term health consequences of induced abortion be included? ACOG seems to claim that they have adequately evaluated the medical literature, but they do not consider our study or the many other studies we evaluated. This situation is akin to the early studies that indicated that cigarette smoking was linked to heart disease and lung cancer in the 1950 s and 1960 s, but that those medical establishments initially denied. Eventually, larger, improved studies were funded that could thoroughly assess the health effects of smoking and medical organizations had to change their positions. We are at a similar crossroads for women and induced abortion today just as we were regarding smoking and long-term health effects in the 1950 s and 1960 s. A clear and overwhelming need exists to study a large group of women with unintended pregnancies who choose - and do not choose - abortion. If done properly, a dramatic advance in knowledge will be afforded to women and their health care providers - regardless of the study s outcome. A commitment to such long-term research concerning the health effects of abortion including maternal mortality would seem to be the morally neutral common ground upon which both sides of the abortion/choice debate could agree. In the meantime, there is enough medical evidence to inform women about the long-term health consequences of induced abortion, specifically breast cancer, placenta previa, pre-term birth, maternal suicide and maternal death from all causes, including homicide. Physicians, policy makers, medical governing bodies and society in general should also be informed of the inadequate manner in which maternal death and pregnancy-associated death is reported on death certificates and to the government, thus grossly underestimating the risk of death from abortion. I applaud this South Dakota Task Force to Study Abortion for looking critically at these issues and inviting me to participate in the forum.

4 Bibliography 1) Thorp JM, Hartmann KE, Shadigian EM: Long-Term Physical and Psychological Health Consequences of Induced Abortion: A Review of the Evidence, Obstetrical and Gynecological Survey, 58(1), ) Shadigian EM and Bauer ST: Pregnancy-Associated Death: A Qualitative Systematic Review of Homicide and Suicide, Obstetrical and Gynecological Survey, 60 (3), ) Horon IL: Underreporting of Maternal Deaths on Death Certificates and the Magnitude of the Problem of Maternal Mortality, American Journal of Public Health, 95(3), ) Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion or induced abortion in Finland, American Journal of Obstetrics and Gynecology 2004; 190: ) Gissler M, Kauppila R, Merilainen J, Toukomaa H, Hemminki E. Pregnancyassociated deaths in Finland definition problems and benefits of record linkage. Acta Obstet Gynecol Scand 1997; 76(7): ) Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Methods for identifying pregnancy-associated deaths: population-based data from Finland Paediatr Perinat Epidemiol Nov; 18(6): ) Reardon DC, Ney PG, Scheuren FJ,, Cougle JR, Coleman, PK, Strahan T. Deaths associated with pregnancy outcome: a record linkage study of low income women. Southern Medical Journal. 95(8): , ) Reardon DC, Strahan TW, Thorp JM and Shuping, MW: Deaths Associated with Abortion Compared To Childbirth A Review Of New And Old Data And The Medical And Legal Implications, The Journal of Contemporary Health Law & Policy, 20(2): , 2004.

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