In February 2001 the British Medical Journal published my letter identifying an elective medical procedure that elevates a woman's risk of subsequent preterm birth; at the time I wrote the letter I was aware of ten studies finding significantly increased risk.35 My current count is twenty-seven (27).1-25,37,38 Patients and medical doctors both benefit if the "prudent practice of medicine" produces results that render the desire to resort to malpractice law suits extremely unlikely. Very specifically, gynecologists must seriously consider "abstaining" from any elective medical procedure with credible odds of increasing a woman's risk of a subsequent preterm birth. Consider just one malady that preterm birth renders more likely: Cerebral Palsy.29 In Britain there was "a threefold rise in litigation for negligence leading to brain damage to infants between 1984 and 1989, and that the average award had increased almost threefold in a similar period."30 If the birth is so preterm that the birth weight falls below 1500 grams, the risk of cerebral palsy is approximately thirty-eight times that of a full-term normal weight newborn infant.32 Is there an elective procedure with a credible prematurity risk?
If there was one statistically significant report in a peer reviewed medical journal finding that an elective medical treatment raised the risk of a subsequent preterm birth, then women must be warned of this possible risk. There are, at least, twenty-seven studies in peer reviewed medical journals finding (with statistical significance) that previous induced abortions increase the risk of a subsequent preterm birth; twenty-seven exceeds 1 by 2,600 percent. How many have reported a statistically significant reduction in preterm birth risk via previous induced abortions? None, to your
author's knowledge. By themselves, these twenty-seven reports certainly make the induced abortion/prematurity risk a more than merely credible one and one that legally must be included on consent forms, at least at the level of "possible risk". The rest of this article will present arguments that will convince "objective gynecologists" that the purported risk has very high credibility.
Three world renowned experts find elevated PB risk
What if three world renowned preterm birth experts identified an elective medical procedure as boosting subsequent preterm birth risk? Would that make the risk very plausible? The only answer to that question can only be "YES". The three renowned experts:
Barbara Luke (ScD, MPH; Dept. of Obstetrics and Gynecology, University of Michigan)
Judith Lumley (PhD; Centre for the Study of Mothers' and Children's Health, Victoria, Australia)
Emile Papiernik (MD, Professor of Obstetrics and Gynecology, Maternite Port Royal)
Professor Barbara Luke in her classic book wrote, "If you have had one or more induced abortions, your risk of prematurity with this pregnancy increases by about 30 percent."
(Every Pregnant Woman's Guide to Preventing Premature Birth, 1995) In that same book Luke identifies both previous spontaneous abortions and previous induced abortions as risk factors for later preterm births. Judith Lumley in 1998 reported both as risk factors with induced abortions having approximately the same prematurity risk as spontaneous abortions.10
How credible is Luke's 1995 book? "This complete and accurate book should have great appeal to the discriminating woman who is pregnant or planning pregnancy, as a means of maximizing her chances for a successful pregnancy." So wrote the editor of the medical journal Obstetrics & Gynecology, Roy M. Pitkin (M.D.).28
Who is Emile Papiernik? Dr. Papiernik was director of a national program in France that lowered the prematurity rate by 31.5 percent in its first ten years!! Compare this magnificent accomplishment with the U.S. situation where the prematurity rate has risen steadily over the last 20 years and is now approximately 11%. In 1999 Papiernik, et al., reported:
86% increased risk of very preterm birth (less than 33 weeks' gestation) for women with previous first trimester abortions
267% increased risk of very preterm birth for women with previous second trimester abortions19
So what, if induced abortions boost preterm birth risk?
Preterm birth (under 37 week's gestation) is universally recognized as the number one cause of infant death before age one year. Those "preemies" who do not die are at much higher risk for physical and mental handicaps. One such handicap is cerebral palsy.29 Is it biologically plausible that abortions can increase the risk of a subsequent preterm birth?
Highly regarded obstetric expert, Barbara Luke, has identified one mechanism that explains why abortion raises prematurity risk. "The procedures for first-trimester abortion involve dilating the cervix slightly and suctioning the contents of the uterus (see Figure 3). The procedures for second-trimester abortion are more involved, including dilating the cervix wider and for longer periods, and scraping the inside of the uterus. Women who had had several second-trimester abortions may have a higher incidence of incompetent cervix, a premature spontaneous dilation of the cervix, because the cervix has been artificially dilated several times before this pregnancy."28 Is there a second biological risk that helps to explain higher prematurity risk? Yes, infection risk. "Our findings indicate that an abortion in a woman's first pregnancy does not have the same protective effect of lowering the risk for intrapartum infection in the following pregnancy as does a live birth." So wrote researchers (1996) from the University of Washington in the respected medical journal Epidemiology.26 Infection is a leading cause of death from induced abortion (if one ignores breast cancer and suicide from abortion). Infection is often mentioned as a risk factor for premature birth. In 1992 Dr. Janet Daling and colleagues reported that if the previous pregnancy ended in induced abortion, the risk of intraamniotic infection [i.e. infection of the amniotic sac] increased by 140% (95% CI=1.7-3.4).27 "One possible mechanism is that cervical instrumentation can facilitate the passage of organisms into the upper part of the uterus, increasing the probability of inapparent infection and subsequent preterm birth", wrote Australian researcher Judith Lumley in 1998.10
The PB risk in brief
Most abortion clinic consent forms list infection as a risk and some list "incompetent cervix" (e.g. "lacerated cervix") but NO form lists a very serious consequence of these risks: elevated risk of a future preterm birth. In brief what makes the abortion/preterm
birth risk very credible is:
Three world experts (Luke, Lumley, Papiernik) report that induced abortion boosts prematurity risk
ONE HUNDRED percent of TWENTY-SEVEN statistically significant medical studies find higher prematurity risk
Dose/response - most of the studies that looked for it, found that the more the number of previous induced abortions, the higher the prematurity risk.
1,2,3,7,8,10,15,16,17,18,19,20,37,38 Two evacuation abortions increases prematurity risk by 1155% (95% CI 5.14-30.64).1
Biological Plausibility - incompetent cervix and infection are risks of induced abortion and risks for preterm birth.10,26,27,28,33
Consent forms list infection and/or incompetent cervix as risk factors of induced abortion
In 1967 in Eugenics Review Dr. Malcolm Potts conceded that induced abortion increased prematurity risk.36 "there seems little doubt that there is a true relationship between the high incidence of therapeutic abortion and prematurity. The interruption of pregnancy in the young (under seventeen) is more dangerous than in other cases."36 "Birth before 32 weeks [gestation] is ten times more likely with the diagnosis of incompetent cervix", wrote Professor Barbara
Luke.28 Since black American women have about triple the rate of induced abortion as Caucasian women, this helps to explain their tripled risk of very preterm birth relative to Caucasian women.34,35
A medical doctor has a legal duty to protect a woman patient's health. To severely threaten a woman's reproductive health is a direct and potentially expensive violation of this duty. Defenders of "terminations" will trot out the old "Joe Camel" defense of "not conclusively proven" and thus, no warning of risk should be given. Only one report in a peer reviewed medical journal finding increased prematurity risk from previous induced abortions need be provided for a warning of possible preterm birth to be issued. TWENTY-SEVEN reports is 2600 percent more than one report. The warning was a must in 1980, not to mention 2001. To protect themselves from potentially huge legal liabilities, medical doctors should refrain from performing elective (!) induced abortions.
Final Words belong to a Pediatrician
In a 'recent' (1998) book pediatrician Dr. Elliot Gersh included the following risk factor for cerebral palsy:
"Incompetent cervix (premature dilation) leading to premature delivery" 29 Incompetent cervix is a known risk of induced abortion surgery.28,33