Safe abortion saves women’s lives
The Swedish Abortion Act came into force in 1974, giving women the right to decide for themselves whether they wanted to end a pregnancy in the first eighteen weeks. Since then, abortion procedures have become more effective, safe, accepted and accessible.
Text: Karin Söderlund-Leifler, first published in the magazine Medicinsk Vetenskap, no 3, 2015
The fact that a prestigious university such as Karolinska Institutet is conducting research on abortion is very important from a global perspective according to Kristina Gemzell Danielsson, Professor of Obstetrics and Gynaecology at Karolinska Institutet, Senior Consultant at the Women's Clinic at Karolinska University Hospital as well as Head of the WHO Collaborating Centre for Research in Human Reproduction.
“It shows that this is an important medical issue, and that there is an academic interest in it. What we do matters to women in Sweden, but it also matters to women in low-resource countries, where the consequences of the lack of safe methods are worsening,” she says.
Unsafe abortion methods take the lives of approximately 47,000 women around the world each year, according to the World Health Organization (WHO). This makes unsafe abortions one of the major causes of death among women, globally speaking. Women’s access to and possibilities of having a safe abortion differ enormously between different countries.
While some countries have legislation that gives a woman the right to decide over her own body and have an abortion during part of the pregnancy, abortion is illegal in many places around the world. However, abortions are still carried out, and often in an unsafe manner. Globally, approximately 21 million women go through unsafe abortions every year, primarily in countries with fewer resources. According to the WHO, unsafe abortions constitute nearly half of all the abortions carried out in the world.
“We know that it is not possible to reduce the number of abortions by making abortion laws more restrictive or by denying women the possibility of having an abortion. The only thing that happens is that women will still have abortions, but they may be carried out at a later stage and using unsafe methods. The only way to reduce complications and mortality rates in connection to abortions is to increase the access to safe methods and to promote the use of effective contraceptives,” says Kristina Gemzell Danielsson.
Over the 40 years that have passed since the introduction of the Swedish Abortion Act, the number of abortions in Sweden has remained stable at a relatively even level, between 18 and 21 abortions per 1,000 women of fertile age (15–44 years old). But this is not to say that nothing has changed. The proportion of early abortions, which are carried out in the first nine weeks of pregnancy, has increased from 45 per cent in the early 1980s to 80 per cent today.
Development of medical abortion
One important explanation for the increased proportion of early abortions is the development of medical abortion. The procedure mimics what happens in the body when the foetus is expelled during a miscarriage. The medical abortion is founded to a great extent in research conducted at Karolinska Institutet. It is based on the realisation that a group of substances called prostaglandins have a number of effects on the body. It was later discovered that prostaglandins could stimulate the uterus to contract and thus be used as an abortion method. The first abortion procedure using prostaglandin is as old as the first moon landing and was carried out at Karolinska Institutet in 1969.
“In the 1960s, before the introduction of medical abortions, the average duration of the pregnancy at the time of the abortion was 17 weeks,” says Kristina Gemzell Danielsson.
Her research team has gradually been working on simplifying the procedure. Now, the substance used is the prostaglandin analogue misoprostol, which was originally developed to prevent ulcers, but which has turned out to have a wide range of applications.
“We have shown that it is possible to use misoprostol not only for abortions, but also to treat an incomplete miscarriage or abortion, to induce labour, to treat bleeding after the birth or to dilate the cervix. We have found that several of the indications counteracted by misoprostol are ones that contribute to maternal mortality,” says Kristina Gemzell Danielsson.
Misoprostol is on WHO’s list of essential medicines for basic medical care, and it can be obtained in most countries. Medical abortion has been particularly significant in low-resource countries where surgical abortion is both inaccessible, due to a lack of physicians, and risky. The development of the method is propelled by research that looks at how it can be made easier and more accessible, and by extension save lives.
“The motto in our research is ‘from bench to bed to roadside’, to give women the possibility of self-treatment,” says Kristina Gemzell Danielsson.
Her research team recently published two articles in The Lancet, of which one concerned the treatment of an incomplete abortion or an incomplete miscarriage in the Ugandan countryside.
“We showed that misoprostol treatment is as effective as surgical treatment, but easier. We also showed that midwives in the Ugandan countryside, where there are few doctors, could implement this treatment. Since this is a very large problem around the world, this study becomes very important and has contributed to new WHO guidelines,” says Kristina Gemzell Danielsson.
Research is also conducted at home in order to simplify the medical abortion procedure. Today, the woman is recommended to come back for a check-up to ensure that the pregnancy has been terminated. The second study that was published in The Lancet showed that it is possible to switch the check-up for a special pregnancy test, which the woman can take in the comfort of her own home.
“We see that the majority fails to show up for the check-up. These are healthy women who have undergone treatment and see no reason to come back when they are feeling fine. The women greatly appreciated the possibility of evaluating the treatment by taking the test at home and thereby save themselves another trip to the doctor’s. We feel that it is important to have choices, and now you can choose to do this at home if you prefer,” says Kristina Gemzell Danielsson.
Regardless of where you live in the world, an unwanted pregnancy can trigger strong and sometimes contradictory feelings. Several studies have shown that it is the time before the actual abortion that is perceived as the most difficult by the woman seeking an abortion.
“Research has shown that this is not black and white, but that the experience of a pregnancy as well as an abortion can entail a range of different emotions. The unwanted pregnancy may trigger a crisis, while the abortion, when you have a choice, can be a solution to a problem. And many also feel a sadness that their life situation is not what they would want,” says Kristina Gemzell Danielsson.
Both Swedish and international research has shown that the abortion procedure is seen as a necessity and is perceived as a relief by the majority of women who undergo it.
“In Sweden, we have an abortion law that trusts the woman to be the best judge when it comes to decisions about her body and her life, and she doesn’t have to explain herself. Women’s reasons for having an abortion can be summed up as mainly being founded in a desire for a planned parenthood. Abortion is one of the most common medical procedures. Nearly half of all women will have an abortion at some point,” says Kristina Gemzell Danielsson.
Abortion is an emotianlly charged subject, and debates regarding issues relating to abortion will flare up on a regular basis. One issue that midwives, physicians and gynaecologists have raised is the matter of a quality register for abortion procedures. Today, the National Board of Health and Welfare compiles statistics, but only on age intervals and with no possibility of connecting a procedure to the clinic where it was performed. One argument that has been voiced against the registration of personal data has been that it should not be possible to identify the women who have had an abortion.
“In the Swedish healthcare system, we have health and medical records for everything but abortion, including information that could be considered sensitive, for example referring to psychiatric care and substance abuse. It is currently not possible for us to monitor what happens after an abortion in terms of complications and side effects, or whether certain drugs lead to deformations when used during pregnancy. If we want to find something out, it has to be done in the form of large prospective research studies, where we monitor the women over time, as we currently don’t have any way of conducting studies where we compare records,” says Kristina Gemzell Danielsson.
In countries that unlike Sweden have quality registers for abortion, such as Denmark, researchers have been able to conduct register studies to look at supposed links between abortion and negative consequences for the woman. Coherent studies have for example shown that abortion does not increase the risk of mental ill-health or breast cancer. Physicians and researchers have also been involved in the debate regarding the abortion limit for late abortions.
Abortion after week 18
Medical developments have made it possible to save a small proportion of children born in week 22. In accordance with the Swedish Abortion Act, the Legal Council of the National Board of Health and Welfare can grant an abortion after week 18 of a pregnancy if there are special grounds to do so, but not if the foetus is deemed to be viable outside of the uterus. Today, the limit applied in terms of viability is 21 weeks + 6 days.
“There is no absolute upper limit in the Swedish Abortion Act, and that has been done specifically so that this can be adjusted as new developments occur. When the Abortion Act was adopted, the limit for when in the pregnancy it was possible to save prematurely born children was significantly later, so a higher practical limit was set, which has then been gradually adjusted downwards,” says Kristina Gemzell Danielsson.
Statistics show that less than one per cent of all abortions in Sweden are done after week 18. Most of these are carried out due to birth defects. One of the factors that led to Sweden adopting the law of free abortion 40 years ago was that Swedish women would go to Poland, where abortion was allowed. Since then, the Catholic church has increased its power in Poland. In the same country that Swedish women would go to for an abortion in the 1960s, abortion is now more or less forbidden. And in many countries, including Sweden, repeated attempts are made to restrict the abortion laws.
“We don’t see an increased opposition to abortion in Europe, but a more strategic one. Those who oppose abortion are adapting their strategies to what they think is possible, so instead of propagating for a complete abortion ban, they are trying to pass restrictions little by little. Anti-abortion activists in the USA and Europe are coordinating their efforts in a way that we have not seen before, and they operate on the EU level to attempt to pass restrictions to abortion rights,” says Kristina Ljungros, Secretary General of the Swedish Association for Sexuality Education (RFSU).
In Spain last year, the government had to back away from a proposal that would have made the country’s abortion laws some of the most restrictive in Europe. But new proposals to limit Spanish women’s right to abortion were presented only a few months later.
“All restrictions of abortion rights entail a risk of guilting and shaming women, which leads to abortions that are clandestine, delayed and carried out under greater medical risks. For this reason, restricting women’s right to free abortion can have incredibly serious consequences,” says Kristina Ljungros.
Text: Karin Söderlund-Leifler, first published in the magazine Medicinsk Vetenskap, no 3, 2015
Facts about abortion
A medical abortion is done with a combination of two drugs. The woman is first given tablets with mifepriston, which in accordance with the Abortion Act must be taken at the hospital/clinic. This drug inhibits the effect of the hormone progesterone and increases the uterus’s sensitivity to prostaglandin analogues such as misoprostol. After a few days, the woman is given misoprostol, which causes the uterus to contract and dilates the cervix so that the foetus is expelled. A check-up or an at-home test verifies that the abortion is complete.
Abortion in Sweden
How many? In 2013, approximately 36,600 abortions were carried out in Sweden. That figure corresponds to 20.3 abortions per 1,000 women.
When? The majority of abortions are carried out early in the pregnancy. 79 per cent of the abortions are carried out up until week 8. 14 per cent are carried out in weeks 9–11, 6 per cent in week 12–17 and one per cent in week 18 or later (when authorisation is required).
How? The method used is influenced by when in the pregnancy the abortion is carried out: In week 6 or earlier, the medical method is used in as much as 97 per cent of abortions. The other 3 per cent are carried out using the surgical method. However, at week 12 or later, the surgical method is used in most, 91 per cent, of the cases.
Sources: Skåne University Hospital, Kristina Gemzell Danielsson, National Board of Health and Welfare.