State Medicaid Coverage of Medically Necessary Abortions and Severe Maternal Morbidity and Maternal Mortality.

OBJECTIVE: To estimate the association between state Medicaid coverage of medically necessary abortion and severe maternal morbidity and in-hospital maternal mortality in the United States. METHODS: We used data on pregnancy-related hospitalizations from the Nationwide Inpatient Sample from 2000 to 2011 (weighted n=38,016,845). State-level Medicaid coverage of medically necessary abortion for each year was determined from Guttmacher Institute reports. We used multivariable logistic regression to examine the association between state Medicaid coverage of abortion and severe maternal morbidity and in-hospital maternal mortality, overall and stratified by payer. RESULTS: The unadjusted rate of severe maternal morbidity was lower among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion relative to those in states without such coverage (62.4 compared with 69.3 per 10,000). Among Medicaid-paid hospitalizations in states with Medicaid coverage of medically necessary abortion, there were 8.5 per 10,000 fewer cases (95% confidence interval [CI] 4.0-16.5) of severe maternal morbidity in adjusted analyses relative to those in states without such Medicaid coverage. Similarly, there were 10.3 per 10,000 fewer cases (95% CI 3.5-17.2) of severe maternal morbidity in adjusted analyses among private insurance-paid hospitalizations in states with Medicaid coverage of medically necessary abortion relative to those in states without such Medicaid coverage. The adjusted rate of in-hospital maternal mortality was not different for Medicaid-paid hospitalizations in states with and without Medicaid coverage of medically necessary abortion (9.2 and 9.0 per 100,000, respectively) nor for private insurance-paid hospitalizations (5.6 and 6.1 per 100,000, respectively). CONCLUSION: State Medicaid coverage of medically necessary abortion was associated with an average 16% decreased risk of severe maternal morbidity. An association between state Medicaid coverage of medically necessary abortion and a reduced risk of severe maternal morbidity was observed in women covered by both Medicaid and private insurance. Results suggest that Medicaid coverage of medically necessary abortion is not harmful to maternal health.

Aborto inducido, séptico y shock séptico / Induced abortion, septic abortion and septic shock

El aborto provocado séptico en Chile estuvo por varias décadas dentro de las primeras causas de mortalidad materna, y en 1960 la tasa de mortalidad materna por aborto era de 107/100.000 NV. El desarrollo y progreso en diversas áreas de nuestro país, sumado a las políticas sanitarias implementadas gubernamentalmente, han logrado disminuir la mortalidad materna por aborto de manera muy significativa, siendo ésta de 0.8/100.000 NV en 2005 y manteniéndose estable y por debajo de 1.5/100.000 NV desde el 2001 en adelante. En el presente artículo se revisa y compara el perfil epidemiológico de la mujer que actualmente se realiza un aborto y además se aborda el diagnóstico y tratamiento médico desde la perspectiva gineco-obstétrica.

In Chile induced septic abortion was one of main causes of maternal death for several decades. In 1960 maternal mortality ratio (MMR) associated to abortion was 107 per 100.000 live births. Development an progress in a wide range of areas in addition to government’s family planning policies in our country have reduced the MMR associated to abortion significatively to 0.8 /100.000 live births in 2005 and have kept it under 1.5/100.000 live births since 2001. In this article we review and compare the epidemiologic profile of women who undergo an induced abortion and we approach to diagnosis and medical treatment from de gyneco-obstetric perspective.

RU-486=Preguntas y respuestas / RU-486 Question and answer

Los fármacos con antiprogestina constituyen un nuevo método prometedor para el control de la natalidad. El RU-486, también conocido con el nombre de mifepristone, es el primer fármaco con antiprogestina disponible en el mercado. Hasta ahora se ha aprobado en Francia y China como alternativa no quirúrgica para terminar los embarazos en su etapa inicial. Siguen investigándose las distintas aplicaciones anticonceptivas del RU-486, que también parece tener varios otros usos terapéuticos. El RU-486 y otros fármacos parecidos pueden contribuir a eliminar las complicaciones relacionadas con las actuales técnicas quirúrgicas del aborto. Estos fármacos son potencialmente menos costosos y más aceptables para muchas mujeres que el aborto quirúrgico. Hoy en día, los expertos en medicina recomiendan usar el RU-486 dentro de un período de tres semanas después de producido el atraso menstrual y administrarlo junto con otro fármaco, la prostaglandina, la cual aumenta mucho su efectividad. En vista de que a veces se presentan problemas de hemorragias y abortos incompletos, el RU-486 debe tomarse bajo supervisión médica. El RU-486 podría reducir enormemente las defunciones por abortos practicados en condiciones deficientes en los países en desarrollo. Pero como este fármaco se ha convertido en objeto de considerables controversias, es probable que en muchos países su disponibilidad dependa de factores políticos

Therapeutic abortions, Canada, 1970-1988.

A total of 66,251 therapeutic abortions were performed in hospitals in Canada in 1988, an increase of 4.1% from the 63,662 performed in 1987. The abortion rate per 1,000 women 15-44 years was 10.6% in 1988, up from 10.2% in 1987. The number of therapeutic abortions performed annually peaked at 66,319 in 1982. The abortion rate peaked at 11.6% in 1979. Looking at marital status at the time of abortion in 1988, 67% of the women were single, 22% were married and 11% were widowed, divorced, separated, or living common law. About 22% of the women were under 20 years of age, 54.4% were between 20-29 years, 21.5% were between 30-39 years and 2.2% were over 39 years of age. At the time of pregnancy termination, the gestation period was under 13 weeks for 89.6% of abortion cases. The gestation period was 13 weeks or more for 10.4% of abortion cases. The trend towards abortions performed in the early stages of pregnancy may be one of the reasons for a 50% drop in the abortion complication rate to 1.6% of abortions in 1988 from 3.2% of abortions in 1975.

Abortion hysterectomy for gynecologic pathology.

Abortion hysterectomy has been discredited as the method of performing simultaneous pregnancy termination and elective sterilization for women with undesired pregnancies who simultaneously wish to end their child-bearing potential. The procedure continues to be advocated, however, for cases in which there is an underlying gynecologic pathologic condition. The morbidity of this procedure has not been directly compared with that for indicated hysterectomy in nonpregnant women. Between January 1976 and January 1987, 50 patients underwent abortion hysterectomy at The University of Chicago. The morbidity and mortality rates of these patients were compared with those of 50 premenopausal nonpregnant women undergoing abdominal hysterectomy for gynecologic pathologic status. There was no statistically significant different between the groups in the duration of surgery, estimated blood loss, or infectious morbidity. No operative site infections or other adverse sequelae were noted at the time of final postoperative examination. These data support the relative safety of abdominal abortion hysterectomy for women with undesired pregnancy in whom hysterectomy is indicated for an underlying gynecologic pathologic condition.

[Melanoma of the skin and pregnancy]. / Melanoma kozhi i beremennost'.

Out of 2018 patients, skin melanoma occurred in IO2 (5%) cases during pregnancy. Three-, five- and ten year survival was analysed in the latter cases versus term of pregnancy, abortion and the stage of the disease. Also comparison was made between the said group, another 42 females who developed tumors during lactation period and 599 normally-cycling females of reproductive age who were not pregnant when melanoma appeared (controls). Significantly lower 10-year survival was observed in pregnant patients, as compared with those who were not pregnant (p less than 0.05). Five- and ten-year survivals were significantly lower in cases of stage I tumor during the latter half of pregnancy than in skin melanoma patients who were not pregnant (p less than 0.05). Abortion during the first half of pregnancy was found to produce an adverse effect on prognosis in stage I tumor patients while this effect was reversed in stage II tumor. No significant differences were found between 3-, 5- and 10-year survival in melanoma patients who had pregnancies before the disease and those who had not (p greater than 0.05).

Therapeutic abortion: the medical argument.

PIP: This document analyzes all cases of maternal death between 1970-79 at the National Maternity Hospital, Dublin, Ireland, and speculates as to the number of lives which might have been saved by therapeutic abortion. 74,317 births were considered; there were 21 deaths, or a mortality rate of 0.28/1000. 7 women died for reasons that had nothing to do with pregnancy: 3 cases of malignant disease, 2 of cerebrovascular accident, 1 of road accident, and 1 of Weil's disease. Therapeutic abortion would not have altered the outcome of pregnancy in these cases. 11 women died of pregnancy complications, 4 of infection, 3 of embolism, 2 of hemorrhage, 1 of eclampsia, and 1 of liver rupture. These deaths, however, could not have been prevented by therapeutic abortion, since these complications could not have been foreseen. 3 women died of diseases which could be said to have made pregnancy more dangerous. However, in the 1st case no disease was suspected until necropsy demonstrated the lesion; in the 2nd case the fatal outcome was interpreted as the terminal state of a chronic process which would have occurred whether or not the woman had been pregnant. Only in the 3rd instance a reasonable case could have been made in favor of therapeutic abortion. However, the woman in question had purposely sought pregnancy for the 2nd time in 2 years, fully aware of the risk involved; she would not have accepted a therapeutic abortion. Thus, the conclusion seems to be that, in the series presented, therapeutic abortion would not have saved a single life. The most recent publication on therapeutic abortion, bearing on 57,228 deliveries at the Mount Sinai Hospital in New York between 1953-64, indicates that in over 69 cases of therapeutic abortion the degree of risk to the mother's life was debatable.^ieng

The risk of death from combined abortion-sterilization procedures: can hysterotomy or hysterectomy be justified?

Clinicians have debated whether women who request permanent sterilization when they undergo elective abortion should have the two operations done concurrently. Moreover, if the procedures are performed concurrently, the appropriate surgical approach is unknown. To evaluate the latter issue, we identified all concurrent abortion-sterilization deaths in the United States in the period 1972 to 1978 from the Centers for Disease Control's nationwide surveillance of abortion mortality and divided them into two groups: those who had hysterotomy with tubal ligation or hysterectomy (H/H) and those who had curettage or instillation procedures, with tubal ligation by laparoscopy or laparotomy (other procedures). We then used data from the Joint Program for the Study of Abortion (JPSA/CDC) to estimate the number of procedures done in the United States in the period 1972 to 1978 and calculated death-to-case rates for each group. We found that the risk of dying from a concurrent abortion-sterilization procedure was 3.3 times higher if done by H/H. The relative risk for this group was highest during the first 12 weeks of gestation (4.6) and lowest at 13 weeks or later (1.3), regardless of the presence or absence of preexisting medical conditions. Except in the rare instances where the woman has an indication for hysterectomy other than fertility control, the performance of hysterectomy or hysterectomy for concurrent abortion-sterilization, particularly at less than 13 weeks' gestation, does not appear justified.

Criminal abortion. Fact or fiction?

This is a review of the current status of legal and illicit abortions in England as related to the changes brought on by the United Kingdom Abortion Act or 1968. The controversy surrounding the Act is discussed, and a review of mortality statistics is also included.

A maternal death associated with prostaglandin E2.

A maternal death following prostaglandin E2 (PGE2) administration is reported. It is suggested that prostaglandin may not be safer than other methods of uterine evacuation for late abortion and fetal death.

Therapeutic abortion in Maryland, 1968-1970.

PIP: The effect of reporting therapeutic abortions in Maryland from 1968-1970 to assess the impact of the new abortion law, which was a liberalization of the previous law, is discussed. All hospitals in the state were required to report on all abortions performed. In fiscal year 1969, 2134 abortions were performed, while 5530 were performed in fiscal year 1970. Of the state's 39 non-federal hospitals only 2 did more than 100 abortions. The ratio of abortions to live births was 40.1/1000 live births in 1969 and 101.6/1000 live births in 1970. 2/3 of all abortions were performed on patients recommended by a private physician or by a member of the hospital staff. 91.6% of all abortions performed in 1969 were for mental health reasons, while in 1971 96.1% fell into this category during the first 6 months. The most common method of abortion was suction curettage whose use increased from 20.9 to 45% during the period 1969-1970. Morbidity (defined to include fever in excess of 100.4 degrees F, transfusion and other complications) occurred in 0.4 to 1.8% of all suction curettage patients, and in 2.9 to 8.1% of all saline amniotic fluid exchange patients. Hysterotomy and hysterectomy had rates of 8.6 to 24.4%. The proportion of out of state women declined from 15.0% to 2.8% during 1969-1970. Blacks had higher ratios (132.8/1000 live births) than did whites (76.5/1000 live births). The median age was 22. 49% had no children. The law had its greatest impact in large urban areas during the first year, while smaller urban areas were affected during the second year.^ieng

In-hospital care and post-hospital followup.

PIP: Guidelines are given for nurses and social workers involved in abortion care before and after the in-hospital procedure. The California Nurses' Association Maternity Conference Group established guidelines for such care in October, 1970 as follows. The nurse should keep the patient informed of all aspects of the procedure, provide a supportive presence, perform standard physical monitoring during the operation and afterwards, provide contraceptive counseling, and act as a sounding board for discussion of interpersonal relationships and future plans. High quality nursing requires understanding the physical and psychosocial aspects of abortion reflecting the nurse's recognition of the cultural, religious, and socioeconomic factors involved. This requires a nurse who is fully aware of her own feelings and can adapt or defer them to the patient's needs. In cases of suction or dilation abortions, these actions are particularly important, since the patient is in the hospital only a short time and can be easily ignored. In cases of saline infusion, the nurse should be fully aware of possible complications, including retained placentae, hemorrhage, infection, or uterine perforation. If the patient is readmitted for any of these complications, the nurse should continue to play the informative, supportive role. The nurse and social worker should also be aware of the possible psychological sequelae of abortion and watch for mental health problems. It is concluded that postabortion counseling is the best time for contraceptive counseling. Conscientious professional support along these guidelines should insure a positive experience for the abortion patient.^ieng