“Abortion”: The word that’s been on everyone’s minds (and social media threads) since last summer. This word has led to heated discussions around the dining room table. It has inspired protests and marches. It has turned brother against brother and sister against sister as we have fought over the place that abortion should have in today’s America. But at least we know what we’re fighting about – right?
As it turns out, maybe we don’t. In the medical community, the word “abortion” encompasses a wide variety of conditions, only some of which involve the willful termination of a pregnancy. This is in stark contrast to the way most people use the word, which leads to the question:
What actually is abortion?
Editor’s Note: Please read with discretion, as this article contains discussion and descriptions of pregnancy loss.
How Doctors Define “Abortion”
As alluded to above, the answer seems to depend on the source. According to Wikipedia, abortion is simply “the termination of a pregnancy by removal or expulsion of an embryo or fetus.” In the legal source Wex Law (powered by Cornell University), however, abortion is defined as “the voluntary termination of a pregnancy.”
In medicine, the picture is even more complex. Abortion can be separated into two broad categories: induced and spontaneous.
Induced abortions are elective, making them the primary subject of current abortion discourse. When the word “abortion” comes up in conversation, this is what usually comes to mind. Some terms falling under the umbrella of induced abortion include elective abortion, termination of pregnancy, pregnancy interruption, and therapeutic abortion.
The spontaneous abortion category covers all other situations in which a pregnancy loss has occurred, might occur, or is in progress. Anything under this category is usually called a “miscarriage” in layman’s terms.
When a pregnancy loss has occurred, it is called a “missed abortion” in medical literature. This is the phrase that is usually recorded in a patient’s medical history following diagnosis. According to the Merck Manual – a widely used resource for medical professionals – a missed abortion is the “death of an embryo or a fetus that is not expelled and that causes no bleeding or cervical dilation.” It often exhibits little or no symptoms. A woman might have gone in for an appointment one week and the baby had a steady heartbeat; but the next week, a heartbeat can’t be detected. Per standard medical protocols, a doctor would record this event as a “missed abortion.”
If a spontaneous abortion (miscarriage) might occur, but the pregnancy is still currently progressing, the medical term used is a “threatened abortion.” Per Medline Plus – an online resource for patients run by the National Library of Medicine (NLM) – the initial sign of a threatened abortion is often cramping, and may or may not be accompanied by abdominal bleeding. In these cases, the pregnancy is somewhat in danger, but may still go to term. Someone experiencing this during her pregnancy might be considered “on watch,” but no medical intervention would be necessary just yet.
Once intervention is needed, the medical term used is an “incomplete abortion.” In this situation, a miscarriage is actively underway, but has not yet been completed. The woman would likely experience cramping and moderate to heavy bleeding, and she might be in need of immediate medical care. According to the NLM, “saturating more than one pad an hour suggests heavy bleeding and requires emergent attention.”
Medical Interventions for “Missed” or “Incomplete” Abortions
For a missed abortion or an incomplete abortion, medical intervention might be necessary. The available tools to care for women experiencing these losses include both medical and surgical approaches. From a medical perspective, a patient might choose to take the drug Misoprostol (which induces cramping) to help to remove any remaining uterine contents, with or without the assistance of the drug Mifepristone. A patient might also undergo a surgical procedure such as a Dilation and Curettage (D&C), during which the patient goes under general anesthesia and the doctor removes the remaining uterine contents.
These care practices are essential for the physical health of the mother if the miscarriage is not completed naturally, as they help prevent infection and sepsis. However, they are also contributors to the patient’s emotional health, as the physical process of resolving the pregnancy helps give closure to grieving parents.
Critically, these procedures are the same ones used during elective abortions.
Precise Definitions of “Abortion” Are Even More Important When the Same Medical Interventions Are Used
The commonality of these medical protocols across varying clinical contexts – combined with the disconnect between the medical, legal, and general understandings of “abortion” – leads to several potential consequences for both patients and physicians.
Clinical trials of medical management for miscarriages indicate that Mifepristone and Misoprostol are more effective than Misoprostol alone. However, despite studies demonstrating its benefit outside of an elective abortion context, because of Mifepristone’s association with (and FDA approval for) elective abortion, procuring the medication for any other medical purpose is difficult. Additionally, the current precarity of Mifepristone’s FDA approval status, as well as state-by-state legislation differences, might further challenge access to the medication. Walgreens’ recent decision to not distribute the drug in certain states is a prime example. As the legal battle over elective abortion continues, the way states distinguish (or don’t) the use of Mifepristone in different medical contexts could have a broad-reaching impact for women who have suffered miscarriages. This has the potential to greatly increase a patient’s potential health risks and emotional distress.
Confusion over terminology among medical professionals and laymen might also impact patients after their pregnancy losses. When a physician sees a patient, they indicate the patient’s diagnosis and treatment using internationally standardized codes called “ICD 10 codes.” These codes might appear on a patient's bill; because “abortion” in medical language encompasses both elective and spontaneous events, the word “abortion” will appear on that bill. For someone who is already experiencing grief after loss, seeing their experience connected with such a charged word may only add to their suffering. If physicians clarify the distinction between “abortion” terms with their patients, this might help bring them peace.
Without a Precise Definition of “Abortion,” Providing Good Medical Care Gets Complicated
Physicians might also find themselves in the crosshairs when the medical, legal, and general worlds collide over the topic of abortion. A woman might be suffering an incomplete miscarriage. She has an open cervix, is bleeding heavily, and is in need of immediate medical care. However, an ultrasound detects the fetus’s heartbeat. The baby is still alive for the moment, but will in all probability not survive. This situation is sometimes referred to as an “inevitable abortion.”
In this scenario, because the woman’s life is in critical, immediate danger, the physician has to make a decision about what to do. A D & C may be performed, saving the life of the mother but, unfortunately, leading to the loss of the child. The doctor’s action in this example is not an elective abortion (and is morally acceptable in the eyes of the Catholic Church). However, because of the case’s similarity to an elective abortion, a physician might still land in complicated legal ground as a result.
Affirmative defense – a law requiring physicians to prove in court that they had to perform an abortion to save a woman’s life – is in effect in Tennessee. This means that a physician would potentially need to defend their actions during the clinical example given above in a court of law. Because of the muddiness that can exist in this kind of scenario, it might be difficult for physicians to make that defense clear. Doctors who treat inevitable abortions in states where elective abortion is illegal may fall under similar legal fire.
Nuance, Clarity, and Precision Are Essential When We Talk about “Abortion”
The United States is still responding to the overturn of Roe v. Wade. Discussions are still being had. Votes are still being cast. Laws are still being written. Amid this ongoing process, nuance, clarity, and precision have important roles to play.
Remembering the many definitions of the word “abortion” is critical to moving forward. With so many implications, moral undertones, and implicit emotional reactions associated with the term, forgetting important distinctions can lead to equivocating what are actually different experiences. By going back to these precise terms, perhaps we can re-enter the abortion discourse in an intelligent, educated, and more compassionate way.
Abortion is a difficult topic. There are so many hearts, minds, and souls tangled up in it because the related legal decisions affect medical care for all women, beyond those seeking elective abortions. Starting a dialogue about these decisions and what their consequences could be is challenging, and making them better won’t happen overnight. But, maybe understanding what we mean (and don’t) when we talk about abortion is a good place to start.