Risk Factors for Legal Induced Abortion–Related Mortality in the United States

Bartlett, Linda A. MD, MHSc^*; Berg, Cynthia J. MD, MPH^*; Shulman, Holly B. MS^*†‡; Zane, Suzanne B. DVM^*; Green, Clarice A. MD, MPH^*; Whitehead, Sara MD, MPH^*§; Atrash, Hani K. MD, MPH^*

Author Information

From the *Maternal and Infant Health Branch, †Information Technology, Statistics, and Surveillance Branch, and ‡Applied Sciences Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia; and §Epidemic Intelligence Service, Division of Applied Public Health Training, Epidemiology Program Office, Atlanta, Georgia. Dr. Green is now with Epidemiology and Drug Safety, Drug Safety and Surveillance, Solvay Pharmaceuticals, Inc. Dr. Whitehead is currently with the Division of STD Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, on station in Chiang Rai, Thailand; and Disease Outbreak and Control Division, Hawaii Department of Health. Dr. Atrash is currently with the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia.

The authors thank Lisa Koonin for leading the collection and maintenance of all abortion-procedure data during 1987–2000, Lisa Flowers for providing assistance with data entry and SAS programming for numerator analyses, and Joy Herndon for providing assistance by coordinating the abortion surveillance system from 2000 through the present.

Address reprint requests to: L. Bartlett MD, MHSc, Division of Reproductive Health, 4770 Buford Highway NE, MS-K-23, Atlanta, GA 30341; e-mail:[email protected].

Received August 25, 2003. Received in revised form December 3, 2003. Accepted December 19, 2003.

Obstetrics & Gynecology103(4):p 729-737, April 2004. |DOI:10.1097/01.AOG.0000116260.81570.60

OBJECTIVE:

To assess risk factors for legal induced abortion–related deaths.

METHODS:

This is a descriptive epidemiologic study of women dying of complications of induced abortions. Numerator data are from the Abortion Mortality Surveillance System. Denominator data are from the Abortion Surveillance System, which monitors the number and characteristics of women who have legal induced abortions in the United States. Risk factors examined include age of the woman, gestational length of pregnancy at the time of termination, race, and procedure. Main outcome measures include crude, adjusted, and risk factor–specific mortality rates.

RESULTS:

During 1988–1997, the overall death rate for women obtaining legally induced abortions was 0.7 per 100,000 legal induced abortions. The risk of death increased exponentially by 38% for each additional week of gestation. Compared with women whose abortions were performed at or before 8 weeks of gestation, women whose abortions were performed in the second trimester were significantly more likely to die of abortion-related causes. The relative risk (unadjusted) of abortion-related mortality was 14.7 at 13–15 weeks of gestation (95% confidence interval [CI] 6.2, 34.7), 29.5 at 16–20 weeks (95% CI 12.9, 67.4), and 76.6 at or after 21 weeks (95% CI 32.5, 180.8). Up to 87% of deaths in women who chose to terminate their pregnancies after 8 weeks of gestation may have been avoidable if these women had accessed abortion services before 8 weeks of gestation.

CONCLUSION:

Although primary prevention of unintended pregnancy is optimal, among women who choose to terminate their pregnancies, increased access to surgical and nonsurgical abortion services may increase the proportion of abortions performed at lower-risk, early gestational ages and help further decrease deaths.