Thursday, 30 October 2014

Multiple Abortions May Increase Risk Of Prematurity And Low Birth Weight In Future Pregnancies

One of the largest studies to look at the effect of induced abortions on a subsequent first birth has found that women who have had three or more abortions have a higher risk of some adverse birth outcomes, such as delivering a baby prematurely and with a low birth weight.

The research, which is published online in Europe's leading reproductive medicine journal Human Reproduction [1] , found that among 300,858 Finnish mothers, 31,083 (10.3%) had had one induced abortion between 1996-2008, 4,417 (1.5%) had two, and 942 (0.3%) had three or more induced abortions before a first birth (excluding twins and triplets). Those who had had three or more induced abortions had a small, but statistically significant increased risk of having a baby with very low birth weight (less than 1500g), low birth weight (less than 2500g), or of a preterm birth (before 37 weeks), or very preterm birth (before 28 weeks), compared to women who had had no abortions. There was a slightly increased risk of a very preterm birth for women who had had two induced abortions.

Dr Reija Klemetti, an associate professor and senior researcher in public health at the National Institute for Health and Welfare in Helsinki, Finland, who led the research, said: "Our results suggest that induced abortions before the first birth, particularly three or more abortions, are associated with a marginally increased risk during the first birth. However, the increased risk is very small, particularly after only one or even two abortions, and women should not be alarmed by our findings."

Most of the induced abortions (88%) were surgically performed and nearly all (91%) were performed before 12 weeks gestation. The researchers adjusted their findings to take account of various factors that could affect birth outcomes, such as social background, marital status, age, smoking, previous ectopic pregnancies and miscarriages. Multiple births (twins and triplets) were excluded.

The risk of having a baby born very preterm appeared to increase slightly with each induced abortion, but only the risk from two abortions or more was statistically significant.

"To put these risks into perspective, for every 1000 women, three who have had no abortion will have a baby born under 28 weeks," said Dr Klemetti. "This rises to four women among those who have had one abortion, six women who have had two abortions, and 11 women who have had three or more."

Among women who had had three or more abortions, there was a statistically significant increased risk of a third (35%) of having a baby born preterm (before 37 weeks), a two-fold (225%) increased risk of very low birth weight, and a two-fifths (43%) increased risk of low birth weight.

The study also showed a small increased risk of a baby's death around the time of birth. However, the numbers for this finding were very low (1498 births or five per 1000 babies) and so should be treated with caution. In addition, the authors say they might not have been able to fully adjust for all the factors that could affect this result and perinatal deaths are sensitive to social factors such as poverty.

"Our study is the first large study to look at a broad set of perinatal outcomes and to control, at least partly, for the most important confounding factors such as smoking and socioeconomic position," said Dr Klemetti. "However, it is important to say that even though we adjusted for these factors, and also ectopic pregnancies and miscarriages, there might be some confounding for social class that we could not control for. Most probably, this may be related to women's (or some of these women's) way of life, life habits, and sexual and reproductive health.

"Furthermore, this is an observational study and, however large and well-controlled, it only shows there is a link between abortion and some adverse birth outcomes - it cannot prove that abortions are the cause.

"Finland has one of the lowest rates of induced abortion in Europe [2], but even so, a large number are carried out every year. In addition, Finland has good quality abortion and maternity care, and in other contexts, particularly in poorer countries, the situation may be different. For these reasons, even a very small increase in the risk of poor birth outcomes could have significant health implications, as preterm births and low birth weight can have serious, adverse effects on the health and well-being of both babies and mothers.

"We suggest that the potential for increased risks for subsequent births should be included in sex education, especially as there are other, good reasons to avoid induced abortions. Health professionals should also be informed about the potential risks of repeat abortions."


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Tuesday, 28 October 2014

Advanced Practice Nurses And Physician Assistants Can Safely Perform Abortions

First trimester abortions are just as safe when performed by trained nurse practitioners, physician assistants and certified nurse midwives as when conducted by physicians, according to a new six-year study led by UCSF.

The study posted online in the American Journal of Public Health in advance of the print edition.

The publication comes a week before the 40th anniversary of the Roe vs. Wade, the landmark Supreme Court decision that made abortion legal in the United States.

Currently in the United States, a patchwork of state regulations determines who can provide abortions, with several states specifically prohibiting non-physician clinicians from performing the procedure.

The new study was designed to evaluate the safety of early aspiration abortions when performed by nurse practitioners, physician assistants and certified nurse midwives trained in the procedure. The study was conducted under a legal waiver from the Health Workforce Pilot Projects Program, a division of the California Office of Statewide Health Planning and Development. California law requires a legal clarification about who can perform aspiration abortions.

The researchers report in their study that the results show the pool of abortion providers could be safely expanded beyond physicians to include other trained health care professionals. They found that:

Nurse practitioners, certified nurse midwives and physician assistants can provide early abortion care that is clinically as safe as physicians;

Outpatient abortion is very safe, whether it is provided by physicians or by nurse practitioners, certified nurse midwives or physician assistants.

Nationally, 92 percent of abortions take place in the first trimester but studies find that black, uninsured and low-income women continue to have less access to this care, according to the researchers.

In California, 13 percent of women using state Medicaid insurance obtain abortions after the first trimester. Because the average cost of a second trimester abortion is substantially higher than a first trimester procedure and abortion complications increase as the pregnancy advances, shifting the population distribution of abortions to earlier gestations may result in safer, less costly care, according to the research team.

"Increasing the types of health care professionals who can provide early aspiration abortion care is one way to reduce this health care disparity,'' said lead author Tracy Weitz, PhD, MPA, a UCSF associate professor and director of Advancing New Standards in Reproductive Health at the UCSF Bixby Center for Global Reproductive Health. "Policy makers can now feel confident that expanding access to care in this way is evidence-based and will promote women's health.''

Currently, non-physicians are allowed to perform aspiration abortions in four states: Montana, Oregon, New Hampshire and Vermont. In other states, non-physician clinicians are permitted to perform medication but not aspiration abortions. In recent years, in an effort to limit abortion availability, several states have put laws on the books to prohibit non-physician clinicians from performing abortions.

In the study, 40 nurse practitioners, certified nurse midwives and physician assistants from four Planned Parenthood affiliates and from Kaiser Permanente of Northern California were trained to perform aspiration abortions. They were compared to a group of nearly 100 physicians, who had a mean of 14 years of experience providing abortions.

Altogether, 5,675 abortions were performed in the study by nurse practitioners, certified nurse midwives and physician assistants, compared to 5,812 abortions by physicians. The abortions were performed between August 2007 and August 2011 at 22 clinical facilities in California.

The researchers found that both groups of abortion providers had few complications -- less than 2 percent, including incomplete abortions, minor infection and pain. Statistically, according to the researchers, the complication rates were not different between the two groups of providers.

"The value of this study extends beyond the question of who can safely perform aspiration abortion services in California because it provides an example of how research can be used to answer relevant health care policy issues,'' said study co-author Diana Taylor, PhD, RNP, professor emeritus in the UCSF School of Nursing. "As the U.S. demand for cost-effective health care increases, workforce development has become a key component of health care reform. All qualified health professionals should perform clinical care to the fullest extent of their education and competency.''


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Monday, 27 October 2014

Modern Methods Of Abortion Are Not Linked With An Increased Risk Of Preterm Birth

The link between previous termination of pregnancy (abortion) and preterm delivery in a subsequent pregnancy has disappeared over the last 20-30 years, according to a study of data from Scotland published in this week's PLOS Medicine. The study, led by Gordon Smith from the University of Cambridge, found that abortion was a strong risk factor for subsequent preterm birth in the 1980s but over the next 20 years, the link progressively weakened and was no longer present among women giving birth from 2000 onwards.

These findings are important as the current recommendations to discuss a possible increased risk of preterm birth if a woman has an abortion were based on studies before 2000. The current analysis indicates that there is no link between abortion and the subsequent risk of preterm birth in modern practice and so current guidelines may have to be revised.

By using a large dataset from Scotland, the authors found that out of 757,060 live first births (excluding twins) between 1980 and 2008, 56,816 women reported one previous termination, 5,790 women reported two previous terminations, and 822 women reported three or more previous terminations. After adjusting for maternal characteristics, the authors found that there was a strong link between spontaneous preterm birth and previous abortion in 1980-1983, with a >30% increase in the risk of preterm birth with each previous procedure. However, this link progressively weakened, with a 10-20% increase in risk for preterm births in the 1990s, and no link at all from 2000 onwards.

The likely explanation for these findings is changes in methods of abortion. Over the period 1992 to 2008, the authors found that the procedure thought most likely to be lead to an increased risk of preterm birth (purely surgical abortion without the use of any drugs) decreased from 31% in 1992 to 0.4% in 2008. Furthermore, the proportion of medical terminations (procedures that avoided the use of surgery altogether) increased from 18% to 68%.

These findings suggest that use of purely surgical termination may have been responsible for the increased risk of spontaneous preterm birth and so, the phasing out of this procedure in Scotland in the 1980s and 1990s may have led to the subsequent disappearance of the established link between previous termination and preterm delivery from 2000 onwards. However, the authors could not directly test whether the two trends were related because they did not have information on the method of previous termination linked to subsequent birth outcome for individual women.

The authors say: "We have shown that previous abortion was a risk factor for preterm birth among nulliparous women in Scotland prior to 2000. However, increased use of medical methods of abortion and of cervical pre-treatment prior to surgical abortion has been paralleled by a disappearance in the association."

The authors add: "We believe that it is plausible that modernising methods of termination of pregnancy worldwide may be an effective long-term strategy to reduce future rates of preterm birth."

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Sunday, 26 October 2014

Medications Used To Treat Rheumatoid Arthritis May Affect Abortion Rate In Women

A new study published in the American College of Rheumatology (ACR) journal, Arthritis Care & Research, reveals that women with rheumatoid arthritis (RA) who were on methotrexate (MTX), a drug commonly used to reduce inflammation caused by RA, had lower rates of induced abortions compared to women with RA who were not exposed to the medication. Findings indicate that women with RA exposed to anti-tumor necrosis factor (anti-TNF) drugs may have increased abortion rates compared to unexposed women.

Experts estimate that 1.3 million U.S. adults have RA - an inflammatory disease where the immune system attacks the lining of the joints causing pain, swelling, stiffness, and ultimately may lead to loss of joint function. RA can affect women during their reproductive years, placing them at risk for unplanned pregnancies. In fact, one study has shown that up to half of pregnancies in North America are unplanned, and nearly half of these unintended pregnancies are terminated.

A 2003 study by Chakravarty et al. found that while 96% of rheumatologists in the U.S. had recommended birth control to female RA patients of childbearing age who were starting MTX, only 55% followed-up with patients regarding their use of contraceptives. "Women with RA who become pregnant may have disease-specific reasons which might influence their decision to end a pregnancy. Exposure to teratogenic drugs, such as MTX, which can affect the development of the fetus, is one such reason women with RA may choose an induced abortion," explains lead author, Dr. √Čvelyne Vinet, from the Montreal General Hospital of the McGill University Health Centre (MUHC) in Canada.

To expand evidence of induced abortion rates in women with RA exposed to MTX, the team performed a nested case-control study using Quebec's physician billing and hospitalization databases from 1996 to 2008. Women with RA who were between the ages of 15 and 45 were identified, with cases classified as women who had an induced abortion. MTX exposure was defined as filling a prescription for the drug less than 16 weeks prior to the date of abortion.

The team identified 112 women with RA who had an induced abortion (cases) and 5855 RA controls. Close to 11% of cases and 22% of controls were exposed to MTX. Compared to the unexposed controls, women with RA who were exposed to MTX had a lower rate of induced abortions. Further analysis found a potential increase in the rate of induced abortions among women exposed to anti-TNF drugs, such as Enbrel, Humira, and Remicade.

"Our study shows that women with RA who were on MTX had lower rates of induced abortions, while those exposed to anti-TNF medications had potentially higher abortion rates" concludes Dr. Vinet. "These findings highlight the importance of research on reducing the number of unplanned pregnancies in women with RA taking MTX or TNF inhibitors. Further examination of counseling practices and contraceptive use is warranted to further reduce the need for abortions in women with RA."


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Friday, 24 October 2014

Kids Less Sexually Active Than People Think

Contrary to popular belief, the vast majority of young American adolescents are not sexually active, researchers from the Guttmacher Institute reported in the journal Pediatrics.

The authors explained that things change when adolescents reach the ages of 16 to 18.

Lawrence B Finer and Jesse M Philbin gathered and examined newly available public data on sexual initiation, contraceptive use and pregnancy among American adolescents from the 2006-2010 National Survey of Family Growth, issued by the U.S. National Center for Health Statistics. The data involved children and teenagers aged from 10 to 19 years.

They found that very few boys and girls had sex before the age of 13 years. According to their study, the following shows the percentages of young adolescents who had had sex: 0.6% of 10-year olds1.1% of 11-year olds2.4% of 12-year oldsThey added that the percentage of girls aged up to 12 years who became pregnant was "miniscule". By the time children reached the second half of their teenage years, things started changing rapidly. 33% of 16-year-olds were sexually active48% had become sexually active by the age of 1761% at 18 years71% at 19 yearsThese percentages and ages - when things change - have prevailed for several decades, the researchers found. Low sexual activity during the early years of adolescence has been the norm for a long time, while losing their virginity has been, and remains, a normal part of a teenager's development process.

However, the authors observed that more recently, teenagers appear to be waiting longer to become sexually active. The likelihood of being sexually active at any teenage year is currently the lowest it has been for the last twenty-five years.

Lead author, Finer, said:

"Policymakers and the media often sensationalize teen sexual behavior, suggesting that adolescents as young as 10 or 11 are increasingly sexually active. But the data just don't support that concern.

Rather, we are seeing teens waiting longer to have sex, using contraceptives more frequently when they start having sex, and being less likely to become pregnant than their peers of past decades."

The majority of teenagers used some kind of contraceptive once they started having sex. They said their main reason was to avoid pregnancy and sexually transmitted diseases (STDs).

The researchers found that 15-year-old girls were as careful about using contraceptives as their older counterparts. Over 80% of 16-year-olds used a contraceptive method during their first sexual experienceBy 12 months following their first sex, 95% of teenagers had used contraceptivesAdolescents who became sexually active at 14 years or younger were less likely to use contraceptives initially. They also took longer to start using a contraceptive method.Children who became sexually active at a much younger age were more often than not coerced into sex, the authors discovered. 62% of girls who had sex by the time they were 10 reported that their first sex was coerced50% of girls who had sex by 11 said they were coerced the first timeCoerced sex is an area that "warrants attention in and of itself", the authors argued.

Adolescent health professionals, including pediatricians, are ideally placed to teach adolescents about contraception before they start becoming sexually active.

Contraceptive methods should be made available to patients before their first sexual encounter. This would help improve teen health outcomes. Health professionals are also in an ideal position to screen for unwanted sexual activity among patients of all age groups.

In an abstract in the journal, the investigators wrote:

"Sexual activity and pregnancy are rare among the youngest adolescents, whose behavior represents a different public health concern than the broader issue of pregnancies to older teens. Health professionals can improve outcomes for teenagers by recognizing the higher likelihood of nonconsensual sex among younger teens and by teaching and making contraceptive methods available to teen patients before they become sexually active."

In 2007, researchers from the Division of Reproductive Health at the US Centers for Disease Control and Prevention, reported in the Journal of Adolescent Health that the sexual behavior of teenagers is linked to whether they have had formal sex education at school. In 2009, "Advocates for Youth" published some startling figures comparing adolescent sexual and reproductive health in the USA, France, Germany and the Netherlands.

The report found that: The teenage birth rate is nine times higher in the USA than in the Netherlands, and four times higher than in France and GermanyThe American teen abortion rate is twice that of the Netherlands and GermanyThe teenage gonorrhea rate is 28 times higher in the USA than in the NetherlandsIf the American teen birth rate were the same as that of the Netherlands, there would be 617,000 fewer teenage pregnancies in America each yearOne of the main reasons America lags behind other developed nations regarding teenage sexual and reproductive health is its failure to invest in comprehensive, age-appropriate sex education.

Written by Christian Nordqvist


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Thursday, 23 October 2014

New Study On Post-War Romanian Abortion Policy Demonstrates That Restrictions Result In Maternal Mortality

A unique study published in today's edition of the Journal of Family Planning and Reproductive Health Care1, provides new evidence about the causal links between restrictions to abortion policy and maternal mortality. The study demonstrates that limiting abortion does not prevent women from seeking pregnancy terminations but simply increases the risks they face.

The study reveals women's fertility rate and abortion rates before, during and after the Romanian dictator Nicolae Ceausescu outlawed abortion in 1966 until his death in 1989. Prior to Nicolae Ceausescu's rise to power, access to surgical abortions had been easily available under the Soviet regime. Within days of the dictator's fall, the anti-abortion law was abolished and abortion was made available again on request.

The report's authors point out that the country's dramatic shifts in family planning policy offer a rare opportunity to study causal links between access to contraception and abortion and changes in reproductive outcomes. The two causal links that authors were able to surmise provide important lessons for all policy makers today: Restricting access to safe abortion in Romania caused a dramatic increase in maternal mortality driven solely by unsafe abortion-related deathIncreased access to modern contraception in Romania has not reduced fertility, but instead has reduced the need for women to resort to abortionProfessor Malcolm Potts, one of three authors and British director of the Bixby Centre for Population, Health and Sustainability at the University of California, Berkeley said:

"Countries that increasingly seek to restrict access to abortion and contraception should look and learn from Romania's example... All legislators in Britain and elsewhere who really care about women's safety - and, indeed, women's lives - need to pay attention to these findings,"

Key findings from the study reveal: Nicolae Ceausescu outlawed abortion in order to increase Romania's fertility rate. However, after nearly doubling initially, it soon fell back to the level before abortion was outlawed as women gradually found solutions for regulating their fertility either through contraceptives procured illegally or through illegal abortionsFor the 30 years abortion was outlawed, maternal mortality from unsafe abortion rocketed to an incredible 147 per 100 000 live births (see graph below and attached) before falling rapidly following the fall of Ceausescu's regime to 5.2 per 100 000 live births in 2010Following the fall of Ceausescu's regime, the rise in contraceptive use has been accompanied by a decisive fall in the abortion rate from 163 per 1000 women in 1990 to 10.1 in 2010  

Ann Furedi, Chief Executive of the British Pregnancy Advisory Service (bpas) said: 'When women cannot obtain abortion legally in their own country, they either travel to countries where they can, or they risk their health by resorting to unlawful means at home.'  

Kate Guthrie, spokesperson for the Faculty of Sexual and Reproductive Healthcare said: "This study starkly demonstrates the risks, often with fatal consequences, that women will take to avoid unwanted pregnancy. Equally it shows the dramatic impact that easy access to contraception had on abortion."

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Tuesday, 21 October 2014

Intimate partner violence and termination of pregnancy linked

Intimate partner violence in women (sometimes referred to as domestic violence) is linked to termination of pregnancy, according to a study by UK researchers published in this week's PLOS Medicine. The study, led by Susan Bewley from Kings College London, also found that intimate partner violence was linked to a women's partner not knowing about the termination of pregnancy.

The authors reached these conclusions by reviewing 74 published studies that provided information about experiences of intimate partner violence (which could be physical, sexual, or emotional/ psychological) among women who had had a termination. From the information in these studies, the authors found that worldwide, intimate partner violence rates among women undergoing termination of pregnancy ranged from 2.5% to 30% in the preceding year and from 14% to 40% over their lifetime. When combining relevant information from a selection of appropriate studies, the authors found that in women seeking a termination of pregnancy, the lifetime rate of intimate partner violence was 25%. Furthermore, the authors found some evidence that intimate partner violence was associated with single and repeat termination of pregnancy.

The authors also found that women undergoing terminations of pregnancy welcomed the opportunity to disclose their experiences of intimate partner violence and to be offered help, suggesting that termination services may represent an appropriate setting in which to test interventions designed to reduce intimate partner violence.

Among factors that may limit the conclusiveness of these finding are variability among the included studies, the likelihood of under-reporting of both intimate partner violence and termination of pregnancy in the included studies, and the lack of validation of reports of violence through, for example, police reports.

The authors conclude: "Intimate partner violence is associated with pregnancy termination. Novel public health approaches are required to address violence against women and repeat termination. Termination services provide an opportune health-based setting in which to design and test interventions at the individual level."

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