Abortion, Health, and the Law
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Greene and Ecker's interesting exploration of difficulties in risk–benefit analyses with regard to therapeutic abortions (Jan. 8 issue)1 is, unfortunately, flawed by the use of disparate comparisons. For example, they cite sources that use dissimilar definitions, populations, and means of case identification to calculate comparative death rates for abortion and childbirth. This approach is problematic, since efforts to track deaths associated with pregnancy and abortion are hampered by inaccurate death certificates and inconsistent definitions.2 Citing the only two record-based, case–control studies that directly compared death rates associated with abortion and childbirth would have been more informative.2,3 Both reveal significantly higher mortality rates associated with abortion than with other outcomes of pregnancy. The one-year age-adjusted odds ratio for death among pregnant women as compared with nonpregnant women was 0.50 for those who gave birth, 0.87 for those who had a miscarriage, and 1.76 for those who had an abortion.2
The authors also fail to note that couples in which the woman undergoes a therapeutic abortion have high rates of psychiatric sequelae and divorce.4 Although it is known that elective abortion is more strongly associated with subsequent psychiatric hospitalization than is childbirth,5 there have been no comparative studies of therapeutic abortion. Therefore, case–control studies are required to support the authors' risk–benefit analysis.
David C. Reardon, Ph.D.
Elliot Institute
Springfield, IL 62791-7348
References
Greene MF, Ecker JL. Abortion, health, and the law. N Engl J Med 2004;350:184-186.
Gissler M, Kauppila R, Meril?inen J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland 1987-1994 -- definition problems and benefits of record linkage. Acta Obstet Gynecol Scand 1997;76:651-657.
Reardon DC, Ney PG, Scheuren F, Cougle J, Coleman PK, Strahan TW. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002;95:834-841.
Lloyd J, Laurence KM. Sequelae and support after termination of pregnancy for fetal malformation. Br Med J (Clin Red Ed) 1985;290:907-9.
Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 2003;168:1253-1256.
To the Editor: Greene and Ecker present scenarios in which induced abortion might be considered for medical reasons. In one, a woman at 18 weeks of gestation learns that she is carrying an aneuploid fetus. The authors compare the mortality rate associated with abortion (0.6 per 100,000) and the mortality rate among pregnant women 35 to 39 years old (21 per 100,000), yielding a 35-fold risk of death associated with continuing the pregnancy. However, the abortion-related mortality was derived from a population in which more than 90 percent of abortions were performed at less than 16 weeks of gestation and more than 80 percent of procedures were performed in women less than 35 years of age.1 A more appropriate approach would involve a comparison of women aborting a pregnancy at 18 weeks with women carrying a pregnancy to term. The mortality rate associated with abortion at 16 to 20 weeks of gestation is 9.3 per 100,000,2 and the maternal mortality rate during this period is approximately 10 per 100,000.3 There are no data indicating that mortality rates differ according to maternal age between those aborting a pregnancy at 16 to 20 weeks and those carrying a pregnancy to term. Therefore, at 18 weeks of gestation, there is no evidence of a difference between the mortality associated with induced abortion and the mortality associated with the attempt to carry a pregnancy to term.
Nathan J. Hoeldtke, M.D.
Tripler Army Medical Center
Honolulu, HI 96859
References
Elam-Evans LD, Strauss LT, Herndon J, Parker WY, Whitehead S, Berg CJ. Abortion surveillance -- United States, 1999. MMWR Surveill Summ 2002;51:1-9, 11.
Lawson HW, Frye A, Atrash HK, Smith JC, Shulman HB, Ramick M. Abortion mortality, United States, 1972 through 1987. Am J Obstet Gynecol 1994;171:1365-1372.
Maternal mortality -- United States, 1982-1996. MMWR Morb Mortal Wkly Rep 1998;47:705-707.
To the Editor: Both the Sounding Board article by Greene and Ecker and the accompanying editorial by Drazen1 argue that the Partial-Birth Abortion Ban Act infringes on liberty and medical practice. But if dilation and evacuation is the standard procedure for removing the contents of the uterus between 20 and 24 weeks of gestation, why is it not used in the case of a fetal death? A fetus that dies a natural death in utero is not destroyed before removal, but a living fetus is. If a fetus has no rights or is no different from a cancer, why should it matter whether it is delivered dead or alive? Could it be that watching a 20-to-24-week-old fetus die ex utero, in sight, as opposed to in utero and out of sight, is too much like watching another person die? If so, then we need to rethink the appropriateness of the procedure. For, as John Stuart Mill said, "The only part of the conduct of any one, for which he is amenable to society, is that which concerns others."2
Pennie Marchetti, M.D.
Primary Care Physicians of Stow
Stow, OH 44224
pmarchetti@ameritech.net
References
Drazen JM. Inserting government between patient and physician. N Engl J Med 2004;350:178-179.
Mill JS. On liberty. 1869. (Accessed April 8, 2004, at http://www.bartleby.com/130/1.html.)
The authors reply: Drs. Reardon and Hoeldtke both object to our assessment that induced abortion at 18 to 24 weeks of gestation is associated with a lower risk of maternal death than a continuing pregnancy. Both refer to studies that have found risks of maternal death associated with induced abortion to be approximately the same as or greater than the risk associated with the attempt to carry a pregnancy to term. Their objections point out several problems in trying to make these comparisons, including problems of confounding by indication, the notion of causality, and the thankfully small numbers of events available to study. According to Dr. Reardon and colleagues' own data from California,1 the risk of maternal death from AIDS during the eight-year period after a first pregnancy that ended in induced abortion was nearly three times as great as that after a first pregnancy that ended with a delivery. Given the amount of time that elapses between human immunodeficiency virus (HIV) infection and death from AIDS, it is likely that the women who chose to terminate their pregnancy did so at least in part because they knew they had HIV infection and were ill. It is also likely that they were sicker than the women with HIV infection or AIDS who chose to continue their pregnancy to term.
We would also like to suggest that death up to eight years after an induced abortion stretches the notion of "causality." The women in Dr. Reardon and colleagues' study also had significantly higher rates of death due to homicide or suicide in the eight years after an induced abortion than after a term delivery. Were these deaths caused by the abortions, or were they associated with risk-taking behaviors that are also associated with undesired pregnancies and acquisition of HIV infection? The Finnish data that Dr. Reardon cites similarly show an increased risk of death due to an accident, suicide, or homicide in association with induced abortion but no increase in the risk of "natural death."2
Dr. Hoeldtke points out that the low risk of death associated with abortion that we cite in our article is for all procedures at all gestational ages, and he suggests that such group reporting masks a higher risk associated with late-term procedures. In 1999, nearly 862,000 induced abortions were reported to the Centers for Disease Control and Prevention, approximately 5.7 percent of which had been performed after 16 weeks of gestation. Four maternal deaths were reported, but no information was given on the gestational ages of the fetuses in those cases. Even if all four deaths occurred among the minority of women in whom procedures were performed after 16 weeks, the risk of death would still be half that associated with childbirth between the ages of 35 and 39 years. From 1991 through 1999, nearly a third of all recognized pregnancies ended in abortion, either induced or spontaneous, yet only 4 percent of all maternal deaths during that time were associated with any type of abortion.3
Dr. Marchetti asks why dilatation and evacuation is not used to evacuate the uterus in the case of fetal death. In fact, the procedure is routinely used for that purpose. She also points out that the difference between the death of a fetus in utero, out of sight, and in full view during a destructive procedure is the degree to which the event offends our sensibilities. We agree.
Michael F. Greene, M.D.
Jeffrey L. Ecker, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
Reardon DC, Ney PG, Scheuren F, Cougle J, Coleman PK, Strahan TW. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002;95:834-841.
Gissler M, Kauppila R, Meril?inen J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland 1987-1994 -- definition problems and benefits of record linkage. Acta Obstet Gynecol Scand 1997;76:651-657.
Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance -- United States, 1991-1999. MMWR Surveill Summ 2003;52:1-8.
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David C. Reardon, Ph.D.
Elliot Institute
Springfield, IL 62791-7348
References
Greene MF, Ecker JL. Abortion, health, and the law. N Engl J Med 2004;350:184-186.
Gissler M, Kauppila R, Meril?inen J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland 1987-1994 -- definition problems and benefits of record linkage. Acta Obstet Gynecol Scand 1997;76:651-657.
Reardon DC, Ney PG, Scheuren F, Cougle J, Coleman PK, Strahan TW. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002;95:834-841.
Lloyd J, Laurence KM. Sequelae and support after termination of pregnancy for fetal malformation. Br Med J (Clin Red Ed) 1985;290:907-9.
Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 2003;168:1253-1256.
To the Editor: Greene and Ecker present scenarios in which induced abortion might be considered for medical reasons. In one, a woman at 18 weeks of gestation learns that she is carrying an aneuploid fetus. The authors compare the mortality rate associated with abortion (0.6 per 100,000) and the mortality rate among pregnant women 35 to 39 years old (21 per 100,000), yielding a 35-fold risk of death associated with continuing the pregnancy. However, the abortion-related mortality was derived from a population in which more than 90 percent of abortions were performed at less than 16 weeks of gestation and more than 80 percent of procedures were performed in women less than 35 years of age.1 A more appropriate approach would involve a comparison of women aborting a pregnancy at 18 weeks with women carrying a pregnancy to term. The mortality rate associated with abortion at 16 to 20 weeks of gestation is 9.3 per 100,000,2 and the maternal mortality rate during this period is approximately 10 per 100,000.3 There are no data indicating that mortality rates differ according to maternal age between those aborting a pregnancy at 16 to 20 weeks and those carrying a pregnancy to term. Therefore, at 18 weeks of gestation, there is no evidence of a difference between the mortality associated with induced abortion and the mortality associated with the attempt to carry a pregnancy to term.
Nathan J. Hoeldtke, M.D.
Tripler Army Medical Center
Honolulu, HI 96859
References
Elam-Evans LD, Strauss LT, Herndon J, Parker WY, Whitehead S, Berg CJ. Abortion surveillance -- United States, 1999. MMWR Surveill Summ 2002;51:1-9, 11.
Lawson HW, Frye A, Atrash HK, Smith JC, Shulman HB, Ramick M. Abortion mortality, United States, 1972 through 1987. Am J Obstet Gynecol 1994;171:1365-1372.
Maternal mortality -- United States, 1982-1996. MMWR Morb Mortal Wkly Rep 1998;47:705-707.
To the Editor: Both the Sounding Board article by Greene and Ecker and the accompanying editorial by Drazen1 argue that the Partial-Birth Abortion Ban Act infringes on liberty and medical practice. But if dilation and evacuation is the standard procedure for removing the contents of the uterus between 20 and 24 weeks of gestation, why is it not used in the case of a fetal death? A fetus that dies a natural death in utero is not destroyed before removal, but a living fetus is. If a fetus has no rights or is no different from a cancer, why should it matter whether it is delivered dead or alive? Could it be that watching a 20-to-24-week-old fetus die ex utero, in sight, as opposed to in utero and out of sight, is too much like watching another person die? If so, then we need to rethink the appropriateness of the procedure. For, as John Stuart Mill said, "The only part of the conduct of any one, for which he is amenable to society, is that which concerns others."2
Pennie Marchetti, M.D.
Primary Care Physicians of Stow
Stow, OH 44224
pmarchetti@ameritech.net
References
Drazen JM. Inserting government between patient and physician. N Engl J Med 2004;350:178-179.
Mill JS. On liberty. 1869. (Accessed April 8, 2004, at http://www.bartleby.com/130/1.html.)
The authors reply: Drs. Reardon and Hoeldtke both object to our assessment that induced abortion at 18 to 24 weeks of gestation is associated with a lower risk of maternal death than a continuing pregnancy. Both refer to studies that have found risks of maternal death associated with induced abortion to be approximately the same as or greater than the risk associated with the attempt to carry a pregnancy to term. Their objections point out several problems in trying to make these comparisons, including problems of confounding by indication, the notion of causality, and the thankfully small numbers of events available to study. According to Dr. Reardon and colleagues' own data from California,1 the risk of maternal death from AIDS during the eight-year period after a first pregnancy that ended in induced abortion was nearly three times as great as that after a first pregnancy that ended with a delivery. Given the amount of time that elapses between human immunodeficiency virus (HIV) infection and death from AIDS, it is likely that the women who chose to terminate their pregnancy did so at least in part because they knew they had HIV infection and were ill. It is also likely that they were sicker than the women with HIV infection or AIDS who chose to continue their pregnancy to term.
We would also like to suggest that death up to eight years after an induced abortion stretches the notion of "causality." The women in Dr. Reardon and colleagues' study also had significantly higher rates of death due to homicide or suicide in the eight years after an induced abortion than after a term delivery. Were these deaths caused by the abortions, or were they associated with risk-taking behaviors that are also associated with undesired pregnancies and acquisition of HIV infection? The Finnish data that Dr. Reardon cites similarly show an increased risk of death due to an accident, suicide, or homicide in association with induced abortion but no increase in the risk of "natural death."2
Dr. Hoeldtke points out that the low risk of death associated with abortion that we cite in our article is for all procedures at all gestational ages, and he suggests that such group reporting masks a higher risk associated with late-term procedures. In 1999, nearly 862,000 induced abortions were reported to the Centers for Disease Control and Prevention, approximately 5.7 percent of which had been performed after 16 weeks of gestation. Four maternal deaths were reported, but no information was given on the gestational ages of the fetuses in those cases. Even if all four deaths occurred among the minority of women in whom procedures were performed after 16 weeks, the risk of death would still be half that associated with childbirth between the ages of 35 and 39 years. From 1991 through 1999, nearly a third of all recognized pregnancies ended in abortion, either induced or spontaneous, yet only 4 percent of all maternal deaths during that time were associated with any type of abortion.3
Dr. Marchetti asks why dilatation and evacuation is not used to evacuate the uterus in the case of fetal death. In fact, the procedure is routinely used for that purpose. She also points out that the difference between the death of a fetus in utero, out of sight, and in full view during a destructive procedure is the degree to which the event offends our sensibilities. We agree.
Michael F. Greene, M.D.
Jeffrey L. Ecker, M.D.
Massachusetts General Hospital
Boston, MA 02114
References
Reardon DC, Ney PG, Scheuren F, Cougle J, Coleman PK, Strahan TW. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002;95:834-841.
Gissler M, Kauppila R, Meril?inen J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland 1987-1994 -- definition problems and benefits of record linkage. Acta Obstet Gynecol Scand 1997;76:651-657.
Chang J, Elam-Evans LD, Berg CJ, et al. Pregnancy-related mortality surveillance -- United States, 1991-1999. MMWR Surveill Summ 2003;52:1-8.