The issue of unwanted pregnancy among teenagers has received widespread national attention (eg, Time, December 9, 1985). This paper will examine the process by which a teenager decides to continue or terminate the pregnancy as well as the acute and long-term medical and psychosocial sequelae of abortion at adolescence.
The majority of adolescent pregnancies are unintended. In 1981, there were 1,343,200 pregnancies among women under 20 years of age. In the same year, there were 448,570 legal abortions for women under the age of 20.' Legal abortion is a safe surgical procedure, with a serious complication rate of 0.4%. 2 The abortion ratio (number of abortions per 1,000 live births) increased slightly from 1979 to 1981 in the youngest adolescent age group (under 15 years of age), and this group continued to have the highest abortion ratio 1,397 abortions per 1,000 live births).3 The highest abortion rate of any group is in the 18- to 19year-old age group (61.8 per 1,000). The rate for nonwhites is higher than the rate for whites at all ages, but because of higher birth rates in nonwhites, the abortion ratios are similar.1
Abortion is a less than optimal solution for a somber situation, and most pro-choice advocates would rather avoid unplanned pregnancy among teenagers than have to recommend an abortion. Although public opinion has become somewhat more conservative regarding abortion, the majority of Americans surveyed in a 1985 Harris poll (56%) still felt that an unmarried teenager should be able to obtain an abortion if she felt her future life might be seriously affected.4 In the same study, Americans affirmed the belief that abortion is a woman's right and that there are many circumstances which legitimize abortion. This is despite the finding that many felt abortion
PERCENT OF ABORTIONS OBTAINED AT EACH GESTATIONAL AGE BY AGE GROUP
eliminates a fetus' life. Adolescents reflect this ambivalence to an even greater extent.
Adolescents are less likely than older women to approve of abortion. 5 Despite this feet, the vast majority of adolescents who have undergone an abortion felt it was a positive and maturing influence on their life.6,7 However, the experience of the procedure itself is considered by many teens to be stressful and associated with feelings of guilt, depression, and a sense of isolation.6-8,9 These feelings are especially negative with abortifacient instillations6 in which the teenager undergoes labor and delivers a dead fetus, often in isolation. Parental involvement with the adolescent who undergoes an abortion has a mixed influence, although the younger teen does better with parental support. The negative consequences are short-term and are mitigated with support from the partner before, during, and after the procedure.9
When compared to adult women, adolescents tend to obtain abortions at later gestational ages, and younger adolescents delay more than other teens (Table). This is especially significant when one considers that the medical complications of abortion increase with the gestational age.
A major factor responsible for delayed presentation of abortion is failure to suspect pregnancy. Adolescents frequently have irregular cycles and are unfamiliar with reproductive physiology and symptoms of pregnancy. Therefore, when the adolescent encounters a missed cycle, her sense of invulnerability allows her to deny the possibility of pregnancy. Typical adolescent experimentation and risk-taking behavior, contributing to delay in seeking effective contraception, place her at high risk for pregnancy. An additional factor that results in delay includes the failure to confide the suspicion of pregnancy to another person. Fear was more frequently stated by adolescents as a reason for delay. 10 The potential impact of parental notification and consent requirements may potentially lead to delay or actual avoidance of abortion.1
In evaluating the decision-making process regarding continuation of pregnancy, Olson described four stages: acknowledgment of the pregnancy, formulation of alternative outcomes, consideration of relative merits of options, and commitment to chosen outcomes.11,12 The first step is to establish the reality of the pregnancy. After working through the denial, the available alternatives must be considered. In recent years, fewer adolescents have chosen adoption as a possibility. The adolescent must be reminded that prolonging the decision-making process may be a passive decision to carry to term.
Ambivalence among these pregnancy-related choices is common. Adolescents are more likely than adults to consider the effect of their decision on significant others.13 In a study comparing teens choosing termination with those continuing the pregnancy, those choosing termination were more independent, had a more realistic view of pregnancy, had fewer sexual partners since initiating intercourse, and began intercourse at a later age. The subjects choosing to continue the pregnancy had more frequent intercourse, were more likely to have had contraceptive failures, were more submissive, and had their choices strongly influenced by significant others. They perceived their decision as externally determined.14 Another study evaluated several psychological factors (eg, ego and moral development, locus of control, future orientation) among successful contraceptors, those currently pregnant, adolescent mothers, and adolescent abortees. Adolescents who had undergone abortion had the most developed future time perspective and lowest need for external approval. The teen mothers had the least developed conceptualization of the future and highest levels of anxiety and external locus of control.15 An important long-term consequence of adolescent childbearing is that teen mothers were less likely to complete high school than teens who had terminated their pregnancy.11
Reviewing the issues with the pregnant girl allows her to explore the positive and negative aspects of her options; the counselor should attempt to maintain a neutral position. If the adolescent chooses abortion, counseling is important both before and after the procedure. The teenagers especially at risk for psychological sequelae are those with pre-existing mental illness, strong religious beliefs, limited coping skills, limited support (family, friends, or partner), or abortions at later gestational ages.16 If the adolescent feels pressured by her family to terminate her pregnancy, she is also at higher risk for psychological sequelae11 and repeat pregnancy soon after abortion.13 Teens who have obtained abortions are more effective contrae eptors.17,18
The two primary factors that influence the morbidity of an abortion include gestational age at time of the procedure and abortion technique, which is related to gestational age. The risk of abortion morbidity and mortality increases with each increasing week of gesrational age.19 Thus, delay in recognition of pregnancy or physician delay in suspecting the diagnosis, both of which are common when dealing with adolescents, may contribute to a higher potential risk for the procedure.
In the recent past, patients presenting from 12 weeks to 16 weeks had their abortions postponed because of technical difficulties with amniocentesis with instillation of utea, hypertonic saline, and prostaglandins. With an increasing use of second trimester curettage procedures (curettage in this paper will represent both dilatation and curettage as well as dilatation and extraction) there is no longer a gray zone from 13 to 15 weeks.20 As a result, abortions are performed at earlier gestational ages, and second trimester abortions are done by the safer curettage rather than instillation methods. Eighty-eight percent of all procedures done in the 13- to 15-week interval were curettage procedures in 1981. 21 In 1980, curettage became, for the first time, the most commonly performed method of abortion (49%) between 16 and 20 weeks of gestation.
Other factors affecting the potential risks include the choice of anesthetic. Use of general anesthesia for abortions at 12 weeks of gestation or less is associated with a two- to four-fold increased risk of death from abortion,22 although there was no statistically significant difference in the rate of major complications.23 Local anesthesia for second trimester curettage is associated with a lower risk of morbidity than general anesthesia.24
Abortion complications can be divided into immediate (occurring or developing within 3 hours of the procedure), delayed (after 3 hours and up to 28 days), and late (occurring past 28 days).25 The Centers for Disease Control's (CDC) definition of serious complication includes: 1) fever of 380C for 3 or more days; 2) unintended major surgical procedures; 3) transfusions; or 4) death.
An immediate complication is hemorrhage. Transfusion requirements are low, with rates of 0.06 per 100 first trimester suction procedures, 0.19 per 100 second trimester curettage, and 0.96 to 1.53 per 100 instillation procedures.25 General anesthetic for first and second trimester curettage procedures is associated with higher rates of hemorrhage.23 Uterine perforation is reported to occur in only 0.9 cases per 1000 abortions. 21 Treatment for perforation may range from no treatment other than observation to laparotomy for intra-abdominal bleeding. Injury or trauma to the cervix has been reported to occur in 1.03 per 100 first trimester curettage procedures.21 The extent of cervical injury may range from minor tenaculum tears requiring no treatment to major lacerations from dilators that may injure the uterus or uterine blood vessels. Concern has been raised that mechanically dilating the cervix will result in injury to the internal cervical os with resultant risk of cervical incompetence. In an effort to prevent these problems, many physicians are now using laminaria or synthetic osmotic dilators which soften and dilate the cervix slowly over time. Instillation procedures may rarely lead to the complication of a cervicovaginal fistula if cervical dilation does not occur and strong uterine contractions force the fetus to be expelled through a posterior sacculation of the cervix. A number of problems have been associated with instillation abortion procedures, and the type of complication is related to the abortifacient used. Morbidity is increased with hypertonic saline instillation. Amniotic fluid, clot, or air embolism occur rarely enough that no reliable incidence figures are available. A live-bom fetus is an undesired complication of second trimester abortion, which can be minimized through the use of ultrasonography to accurately assess gestational age and the use of fetocidal abortifacients.
Retained products of conception after an abortion procedure result in abnormal bleeding or uterine infection, and thus will necessitate repeat curettage. Untreated cervical gonorrhea markedly increases the risk for postabortion infection, while the role of untreated cervical chlamydia has not been clarified. Prophylactic antibiotics such as tetracycline, which treats both gonorrhea and chlamydia, may reduce the risk of postabortion infection.
Many studies attempting to document the rare occurrence of late abortion complications reach conflicting conclusions and suffer from methodologic flaw. Available data suggest that there is no effect on the regularity or duration of menstrual pattern subsequent to an abortion. There is no convincing evidence that legal abortion produces a higher risk of infertility. Although an individual who develops a severe postabortion infection may develop tubai adhesions and subsequently be unable to conceive, population studies indicate that this is not a major problem. U.S. data, including a prospective cohort study27 have concluded that secondary infertility is not increased by a previous induced abortion. A recent paper28 deals with the impact of curettage procedures on future childbearing. Based on a review of 10 studies it concluded that women who aborted their first pregnancy were at no greater risk of premature delivery or subsequent spontaneous abortions than women carrying their first pregnancy to term. No definite conclusion could be reached about the impact of multiple induced abortions. Other long-term risks from induced abortion include the risk of Rh sensitization for Rh-negative women if immunoglobulin is omitted.
Death related to an abortion procedure is particularly tragic in that women obtaining abortions are generally young and healthy. The most important factor in preventing death from abortion procedures has been the availability of safe, legal abortions. Illegal abortions and abortion-related deaths are still occurring in the U.S., and would almost certainly increase if the 1973 Supreme Court decision legalizing abortion were reversed. The risk of death from abortion is lower than that of any other surgical procedure. Abortionrelated deaths reported to the CDC were 0.5 per 100,000 procedures.21 The birth related mortality in the U.S. was 7.5 reported deaths per 100,000 live births in 1980. 29 Thus, the risks of dying from pregnancy are much greater than the risks of dying from a legal abortion procedure.
Risks for Adolescents
Few studies have emphasized the issue of abortion risks for adolescents. Teenagers have been shown to have the lowest risk of all age groups for abortionrelated mortality.30 When serious complications were examined, women under 19 years of age had a risk comparable to other age groups for abortions under 12 weeks.31 For abortions after 12 weeks of gestation, fewer adolescents experienced a serious abortion complication. However, younger women obtain abortions later in pregnancy than older women (see Table). Data from 1981 indicated 15% of all abortions for women 19 years of age or younger were beyond 12 weeks gestation, compared to 8.5% in older women. Because of the clearly documented increase in risk of complications with increasing gestational age, a greater percentage of adolescents are exposed to a higher risk of complications.
One recent study assessing abortion morbidity risk concluded that adolescents are more likely than older women to develop a postabortal endometritis. i2 These authors also noted a trend toward a greater risk of cervical laceration, which had been shown in another study to be twice as likely to occur in women 17 years old and younger. 33 The nulliparous cervix is more rigid and less easily dilated. Burkman's study32 also demonstrated higher rates of positive cervical gonorrhea cultures and urinary tract infections among adolescents. These women were treated prior to the abortion procedure and none developed endometritis. However, the authors speculate that these younger women may have been more likely to harbor Chiamydia or Mycoplasma, for which no screening was accomplished. Prophylactic antibiotics for abortion procedures may therefore be of particular value in adolescents.
Other factors related to the technical performance of the abortion may result in some increased risk for adolescents. Curettage under local anesthesia is contraindtcated if the patient is unable to remain quiet and cooperative during the examination. Adolescents are more likely to fall into this category and require general anesthesia with its resultant increased risk of hemorrhage, cervical injury, and uterine perforation.
Overall, the medical hazards and risks of abortion procedures are extremely low, particularly when the abortion is performed early in the first trimester by curettage under local anesthesia. Attention should be addressed to avoiding delay: delay by the patient in suspecting pregnancy, or reporting her suspicions because of fear of reprisal, and delay by the physician in suspecting or diagnosing pregnancy. Once the diagnosis of pregnancy is made, a decision about the options for the pregnancy (continued pregnancy and keeping the child or placing the baby for adoption versus pregnancy termination) should be made as expeditiously as possible. To delay is to increase the potential risks of the abortion.
Adolescent pregnancy continues to be a major problem in this country. It is estimated that 40% of teenage girls now 14 years old will become pregnant by age 19. Adolescents are becoming sexually active at earlier ages, and with an increasing age for the first planned pregnancy, there is a growing population at risk for unplanned pregnancy. More teens are using contraception at the time of first intercourse, but less effective methods are being used increasingly,34 and the abortion ratio for adolescents continues to increase, although at a slower rate than in recent years.21 Women will continue to have abortions, whether legal or not. Abortion is not a solution to the problem of unplanned pregnancy. If there are no future plans or possibilities that are attainable or worth attaining, motherhood may be the best alternative available. 15 More effective sex education that includes values clarification,35 dissemination of more realistic information regarding oral contraceptives, more widely available confidential and low-cost contraceptive care, and a relaxation on the restrictions of nonprescription contraceptives36 may help address the issue of unwanted adolescent pregnancy.
1 . Henshaw SK, Binkins N]. Blaine E, et al: A portrait of American women who obtain abortions, Fam Plann ftrspeci 1985; 17(2):90-96.
2. Joint Program for Study of Abortions III.
3. Centers for Disease Control: Abortion SunxJIance 1981, issued November 1985.
4. Harris foil. #854005. August-September 1985: Public Attitudes About Sex Education, Family Planning, and Abortion in the United Slates.
5. Cales W: Atorrion and Sreritionon - Medical and Social Aipecu, Hod)jsonJE(ed). New York. Grune and Stratton, 1981.
6. Perez-Reyes MG, Falk R: Follow-up after therapeutic abortion in early adolescence. Arch Gen Psychiary, 1973; 28:120-126.
7. Greet HS, Lal S. Lewis, et al: Psfchosocial consequences of thrapeutic abortion. Br J Psychiatry 1976; 128:74-79.
8. Freeman EW: Influence of personality attributes on abortion experiences. ?t? Orifioplyduaaj 1977; 47(3):503-513.
9. Robbins JM, deLamater JD: Support from significant others and loneliness following induced abortion. Set Psychiatry 1985; 20:92-99.
10. Fielding JE: Adolescent pregnancy revisited. N Engf } Med 1973; 299:893-896.
11. Olson L: Social and psychological correlates of pregnancy resolution among adolescent women. Am } On/mpsjciiiarrj 1980; 50(3):432-455.
12. Bracken MD1 (German LV1 Bracken M: Coping with pregnancy resolution among never-married women. Am ] OrAopsychiarry 1978; 48(2):320-334.
13. Lewis CC: A comparison of minors and adults - Pregnancy decisions. Am ] Orifiopsydiary 1980; 50(3):446-453.
14- Morin-Gomhier M, Lottie G: The significance of pregnancy among adolescents choosing abortion as compared to those continuing pregnancy. J Reptad Med [984; 29(4):255-259.
15. Blum RW, Resnick MD: Adolescent sexual decision-making: Contraception, pregnancy, abortion, motherhood, ftdàwr Ann 1982; ll(10):797-805.
16. Greydanus DE: Premature Adolescent Pregnancy ana Riremhood. New York, Gruñe and Stratton. 1983.
17. Abrami M: Birth control use by teenagers. Ì Adbiest Health Care 1985; 6:196-200.
18. Cvejic H, Lippev 1, Ki neh RA, étal: Follow-up of 50 adolescent girls two years after abonion. CMA journal 1977; 116:44-46.
19. Cates W, Schulz KF. Grimes DA, et al: Effect of delay and method choiceon the risk of abortion morbidity, fam Plann ftrsfwct 1977; <6):266-276.
20. Grimes EW, Cates W: Gesrational age limit of twelve weeks for abortion by curettage. Am J Obswt G-rnecol 1978; 132:207-210.
21. Centers fin Disease Control·. AboitHnv S\nveiBonce (98!, issued Nurtmbet, 19&5.
22. Petterson HB. Grimes DA. Cates W, et al: Comparative risk of death from induced abortion at 'S 12 weeks gestation performed with local vs. general anesthesia. Am J Ofotei Gynecal 1981; 141:763-768.
23. Grimes DA, Schulz KF, Cates W, et al: Local vs. general anesthesia: Which is safer for performing suction cureitage abortions. Am J BM1 Gjnecol 1979;, 135:1030-1035.
24. Mac Ii ay HT, Schulz KF, Grimes DA: Safety of local vs. general anesthesia for second trimester dilation and evacuation abortion· Obstet Gynecol 1995; 66:661-665, 25. Grimes DA, Cates W: Complications from legali ?- induced abortions: A review. Obstet Gynecol Sun 1979; 34:177-191.
26. Grimes EM, Schuh KF: Morbidity and mortality from second-trimester abortions. } ffcprad Mai 1985; 30:505-514.
27. StubHefield PG, Monson RR. Schoenbauni SC. étal: Fertility after induced abortion: A perspective follow-up study. Obstet Gyntcol 1984; 63:186-193.
28. Hogue CJR, Cates W, Tiene C: Impact of vacuum aspiration abortion on future childbearing: A review. Fam Plann Permea 1983; 15:119-125.
29. Tiene C: The public heakh effects of legal abonion in the United States. Fam Plann ftrjpeci 1984; 16:26-28.
30. Ory HW: Mortality associated with fertility and fertility control: 1983. fitm Plann Perpect 1983; 15:57-63.
31. Buehler JW, Schult KF. Grimes DA, et al: The risk of serious complications from induced abortion: Do personal characteristics make a difference? AmJ Otniet Gynecal 1985; 153:14-20.
32. Burkman RT, A tierna MF, King TM: Morbidity risks among young adolescents undergoing elective abortion. Contraceprkm 1964; 30:99-105
33. Schuh KF, Grimes DA. Cares W: Measures to prevent cervical injury during suction curettaee abortion. Lancet 1983; 5:1182-1185.
34. Alan GunrnacKei Institute: Teenage Pregnancy. The Problem thai Ham'iGone Avw> New York, Alan Guttmacher, 1980.
35. Howard M; ftetponing sexual involvement among adolescents. J Adolese Health Care 1985; 6(4):271-277.
36. Jones EF, Rsrrest DH, Goldman N, ei al: Teenage pregnancy in developed countries: Determinants and polity implications. Fam Plann Perspea 1985; 17(2). 53-63.
PERCENT OF ABORTIONS OBTAINED AT EACH GESTATIONAL AGE BY AGE GROUP