10 Facts for Hospitalists About Abortion

The U.S. Supreme Court’s decision to overturn Roe versus Wade is expected to result in a wave of state laws limiting access to reproductive health. This highlights why clinicians should stay current on topics at the intersection of medicine and politics. Unfortunately, however, clinicians can be a source of misinformation or disinformation, even if unintentionally. Hospitalists are not exempt from this and deserve to have available medical facts about reproductive health in order to have honest and accurate conversations about the expected consequences of limiting abortion access.

Most hospitalists are internal medicine trained, and these residencies do not require training on abortion and in general only superficially on reproductive health. Regardless of our training, we have many opportunities to learn reproductive health so we can advocate for the best care for our patients.

Here are 10 facts about abortion and reproductive health you can use when talking with patients, peers, and learners, and the references to support them.

1. Unintended pregnancies are common and most people seeking an abortion are using contraception.

A 2016 study identified that unintended pregnancies had fallen to the lowest known rate in the U.S.to 45% from 51%. Per the authors, the most likely cause of this change was “a change in the frequency and type of contraceptive use over time.”¹ In 2014, 51% of abortion patients were using a contraceptive method in the month they became pregnant, most commonly condoms (24%) or a short-acting hormonal method (13%).²

2. Abortion is common, including among physicians, and the reasons for seeking abortion are complex and varied.

Nearly a quarter of U.S. women will have an abortion by age 45.³ In a 2021 study surveying 3,104 physicians, there was an 11.2% abortion rate in the 1,556 who had been pregnant.⁴ This is similar to the national abortion rate of 11.4% per 1,000 women in 2017.⁵ A  longitudinal study conducted from 2008 to 2010 of 954 women found the dominant reasons for seeking an abortion were financial, timing, partner-related, and the need to focus on other children. Most women (64%) cited multiple reasons for seeking an abortion.⁶

3. Most abortions occur during the first trimester.

The Morbidity and Mortality Weekly Report shows that 65.5% of abortions were performed at <8 weeks’ gestation, 91% at <13 weeks’ gestation, 7.7 at 14-20 weeks’ gestation, and 1.2% at >21 weeks’ gestation.⁷

4. Legal abortions are safe.

The risk of having a major complication (one that requires further surgery, hospital admission, or blood transfusion) in the first trimester of pregnancy is <0.1% and also low in the second trimester (0.41%).^8,9 Notably, the rate of mortality related to abortion occurring anytime during pregnancy in the U.S. is similar to the mortality rate of outpatient plastic surgery procedures and the mortality rate of running a marathon.¹⁰ Legal abortion is also much safer than childbirth, with the risk of death associated with childbirth being approximately 14 times higher than that with abortion. ¹¹

5. Pregnancy and childbirth pose a well-defined (and higher in the U.S.) health risk.

According to the Commonwealth Fund, the U.S. is ranked last among industrialized countries in maternal mortality, with a rate of 17.4 per 100,000. There are significant inequities in care during pregnancy. In a study examining the prevalence and case-fatality rates for pregnancy-related complications of pre-eclampsia, eclampsia, abruptio placenta, placenta previa, and postpartum hemorrhage, Black women had similar prevalence but two to three times higher case fatality from these complications than white women in the U.S.¹² Non-Hispanic Black people experience a 3.4 times higher maternal mortality ratio than non-Hispanic white people.¹³ This disparity remained after adjustment for co-morbidities and in at least one study and was attributed to access to care.¹⁴

6. Limiting access to abortion does not stop people from seeking an abortion.

There isn’t any evidence that abortion rates are lower when abortion access is restricted. According to a Lancet article, this suggests that some women with restricted access to abortion must take legal and physical risks to receive care.¹⁵

7. Having an abortion does not increase one’s risk of cancer or mental health issues.

There is a common misperception that abortion can increase the risk for breast cancer or other cancers but this has been extensively studied and is not evidence-based.¹⁶ There are also similar misperceptions about mental health worsening after abortion, but this is not accurate either.¹⁷

8. Denying abortion can have negative effects on physical health, emotional health, and economic wellbeing.

According to research at the University of California, San Francisco, women who are denied an abortion and give birth, experience more life-threatening complications such as eclampsia and postpartum hemorrhage than those who received an abortion. They also experienced more chronic health concerns.¹⁸  The same research team also found that women denied abortion who gave birth experienced household poverty lasting at least four years, increased debt, increased bankruptcies, and evictions.¹⁹ From a mental health perspective, people denied abortion experience more regret and anger, and less relief and happiness, and they also experience more adverse psychological outcomes such as anxiety and stress in the short term.^19,20

9. Not all people who seek abortion care are women.

According to a study in the journal Contraception, approximately  862,000 abortions were performed in the U.S.in 2017, of these an estimated 462-530 were performed on transgender and gender non-binary people. Hospitalists are more patient-centered when we provide gender-affirming care.²¹

10. Hospitalists should embrace reproductive health, including family planning and abortion access, as part of our role.

Hospitalists care about patients, see a lot of people who can’t easily access reproductive health, and personally benefit from access to reproductive health services. As with many other important interventions, hospitalization is a prime opportunity to discuss and provide treatment for reproductive health.

In conclusion, hospitalists have a role in taking care of people who may be seeking abortion and should be familiar with facts, as well as common misperceptions. These 10 facts can help hospitalists facilitate accurate conversations and advocate for patients. All hospitalists should recognize abortion as a commonly performed, safe, and often life-saving procedure.

Additional reading from the Journal of Hospital Medicine:

Reproductive rights. It’s complicated

Abortion bans and implications for physician-patient trust

References:

1. Finer LB, Zolna MR. Declines in unintended pregnancy in the United States 2008-2011. N Engl J Med. 2016;374(9):843-52. doi:10.1056/NEJMsa150657
2. Jones RK. Reported contraceptive Suse in the month of becoming pregnant among U.S. abortion patients in 2000 and 2014. Contraception. 2018;97(4):309-312. doi:10.1016/j. contraception.2017.12.018.
3. Jones RK, Jerman J. Population group abortion rates and lifetime incidence of abortion: United States, 2008-2014. American Journal of Public Health. 2017;107:1904-1909. doi:10.2105/AJPH.2017.304042
4. Levy, Morgan S, et al. Abortion among physicians. [Research Letter] Obstetrics & Gynecology. 2022;00:00. doi: 10.1097/AOG.0000000000004724. Published online April 7, 2022. Accessed July 18, 2022.
5. Kortsmit K, et al. Abortion Surveillance—United States, 2019. MMWR Surveill Summ 2021;70(No. SS-9):1-29. doi: 10.15585/mmwr.ss7009a1
6. Biggs MA, et al. Understanding why women seek abortions in the US. BMC Women’s Health. 2013;13:29. doi: 10.1186/1472-6874-13-29
7. Jatlaoui TC, et al. Abortion Surveillance—United States, 2016. MMWR Surveill Summ. 2019;68(No. SS-11):1-41. DOI: 10.15585/mmwr.ss6811a1.
8. Jones RK, Kooistra K. Abortion incidence and access to services in the United States, 2008. Perspect Sex Reprod Health. 2011;43(1):41-50. doi: 10.1363/4304111.
9. Lichtenberg ES, et al. Abortion complications—prevention and management. In: Paul M, Lichtenberg ES, Borgatta L, et al., eds. A Clinician’s Guide to Medical and Surgical Abortion. New York: Churchill Livingstone, 1999.
10. Raymond EG, et al. Mortality of induced abortion, other outpatient surgical procedures and common activities in the United States. Contraception. 2014;90(5):476-9. doi: 10.1016/j.contraception.2014.07.012.
11. Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol. 2012;119 (2 Pt 1):215-219. doi: 10.1097/AOG.0b013e31823fe923
12. Howell EA, et al. Site of delivery contribution to black-white severe maternal morbidity disparity. Am J Obstet Gynecol. 2016;215(2):143-52. doi: 10.1016/j. ajog.2016.05.007.
13. Verma N, Shainker SA. Maternal mortality, abortion access, and optimizing care in an increasingly restrictive United States: A review of the current climate. Semin Perinatol. 2020;44(5):151269. doi: 10.1016/j.semperi.2020.15
14. Declercq E, Zephyrin L. Maternal Mortality in the United States: A Primer. Commonwealth Fund. Available at: https://www.commonwealthfund.org/publications/issue-brief-report/2020/dec/maternal-mortality-united-states-primer. Published online December 16, 2020. Accessed July 18, 2022.
15. Bearak J, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019. Lancet Glob Health. 2020;8(9):e1152-e1161. doi: 10.1016/S2214- 109X(20)30315-6.
16. Boonstra HD, et al. Abortion in Women’s Lives. Guttmacher Institute, 2006. Available online at: https://www.guttmacher.org/sites/default/files/report_pdf/aiwl.pdf. Published online 2006. Accessed July 18, 2022.
17. van Ditzhuijzen J, et al. Correlates of common mental disorders among Dutch women who have had an abortion: A longitudinal cohort study. Perspect Sex Reprod Health. 2017;49(2):123-131. Doi: 10.1363/psrh.12028.
18. Advancing New Standards in Reproductive Health. The harms of denying a woman a wanted abortion: Findings from the Turnaway Study. University of California, San Francisco. Available at: https://www.ansirh.org/sites/default/files/publications/files/the_harms_of_denying_a_woman_a_wanted_abortion_4-16-2020.pdf. Published online April 16, 2020. Last accessed July 18, 2022.
19. Foster DG, Biggs MA. The mental health impact of receiving vs. being denied a wanted abortion. Advancing New Standards in Reproductive Health. [Issue Brief] July 2018. https://www.ansirh.org/sites/default/files/publications/files/mental_health_issue_brief_7-24-2018.pdf2020. Published online July 22, 2018. Last accessed July 18, 2022.
20. Rocca CH, et al. Women’s emotions one week after receiving or being denied an abortion in the United States. Perspect Sex Reprod Health. 2013;45(3):122-31. doi: 10.1363/4512213.
21. Jones RK, et al. Transgender abortion patients and the provision of transgender-specific care at non-hospital facilities that provide abortions. Contracept X. 2020;2:100019. doi: 10.1016/j.conx.2020.100019.