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SURGICAL ABORTION/History and Overview


Abortion and Medicine

The history of the relationship between the medical profession and abortion is an unusual saga of a seeming rediscovery, from the eighteenth century onward, of the main elements of abortion practice which, in fact, were known to medical practitioners in antiquity. Although dilators, curettes, and even a rudimentary suction apparatus existed in the ancient world, "modern" abortion techniques - especially dilation and curettage - did not come into prominence until developments within the larger field of gynecology occurred during the mid nineteenth century.

Dilation and Curettage

The modern curette (from the French verb, curer, "to cleanse") was developed in France in 1723 for general surgical use. Its specific application to the uterus is believed to have been developed in 1842 by J. Recamier, who is also credited with reintroducing the vaginal speculum into gynecology. During the 1870s the German physician Alfred Hegar created the dilator that bears his name, and dilation and curettage (D&C) became widely practiced during the last quarter of the nineteenth century.1,2

Although eventually the use of D&C for abortion proved more effective and safe than many of the herbal and other folk remedies in use in the nineteenth century, this method may have been more dangerous to women when performed by unskilled abortionists or without adherence to proper antiseptic techniques. As one writer has put it, "Puerperal (childbed) fever was the scourge of nineteenth century obstetrics and abortion." 1,3

Vacuum Aspiration Abortions

Perhaps the most significant development in modern abortion technology was the introduction and widespread dissemination of the vacuum suction machine. In the modern era it was first described by the nineteenth century gynecologist James young Simpson2,4 and most significantly by the Russian physician S.G. Bykov in 1927. After falling into disuse in the Soviet Union, it was refined in subsequent years in China and Japan, reintroduced in Eastern Europe, and by the late 1960s became known to British and U.S. physicians.

The medical community in the United States was directly educated about the vacuum suction method at a landmark conference on abortion in 1968 sponsored by the Association for the Study of Abortion, one of the first medical abortion rights groups. The presentation on vacuum suction given by Franc Novak, an obstetrician-gynecologist from Yugoslavia, was enthusiastically received owing to the method's obvious superiority over D&C in terms of safety and ease. As Novak stated, "When the gynecologist who knows only the conventional D&C method first sees the apparatus in action, he is impressed by the cleanness, apparent bloodlessness, speed, and simplicity of the operation. While a D&C gives the impression of crude artisan's work, an abortion provided with suction gives the impression of a simple mechanical procedure."5 Novak went on to report the lessened blood loss experienced by the patient and the dramatically lowered risk of uterine perforation compared to D&C.5 By the early 1970s vacuum aspiration had become the dominant method of first trimester abortion in North America and eventually in the rest of the developed world. Because of a lack of training and appropriate equipment, however, abortions in developing nations are still often done by sharp curettage, leading to higher injury rates.6

Three other significant innovations during the 1960s and 1970s were the use of local anesthesia (paracervical block) for abortion, development of the Karman cannula, and introduction of manual vacuum aspiration (MVA). The paracervical block, initially refined for abortion use by a father and son team of Yugoslavian physicians (M. and B. Beric), allowed suction abortion to be provided under local anesthesia.2 This advance dramatically affected abortion services offered in outpatient settings, including those provided in freestanding facilities.

The Karman cannula was developed by Harvey Karman, a California psychologist who became involved in illegal abortion provision during the 1960s. Composed of plastic rather than metal, which had been the standard, this soft, flexible cannula made early suction abortions possible with local or no anesthesia and made perforation far less likely.2.7 The Karman cannula became a crucial component of abortion services in the developing world and was adapted to the standard suction machines in the United States and elsewhere. Widespread adoption of the Karman cannula is perhaps the most vivid example of a larger phenomenon - the extent to which, as abortion rapidly became legalized during the late 1960s and early 1970s, the medical profession was compelled to seek the advice of a number of illegal abortion providers, both lay and physician.8

Manual vacuum aspiration was the key to the widespread practice of "menstrual extraction" or "menstrual regulation" starting during the late 1960s. Although there are slight differences between the "Del-Em" developed by U.S. feminist health activists and the "menstrual regulation kits" that continue to be manufactured and distributed by Ipas, both rely on a handheld vacuum syringe, a Karman or similar soft cannula, and a valve that prevents air from entering the uterus. In the United States menstrual extraction was used as a method of fertility regulation and a means of hygiene (i.e., to remove a woman's monthly period at one instance).2,9 When abortion became legal in the United States, menstrual extraction became far less common.

In the developing world menstrual regulation persists as a crucial strategy to circumvent anti-abortion laws. In Bangladesh, for example, although abortion is illegal the government has long supported a network of menstrual regulation clinics. Some other countries allow menstrual regulation because it presumably takes place without a technical verification of pregnancy.10

The technology of MVA is particularly suited for the developing world because it does not depend on the availability of electricity or anesthetics. Furthermore, with proper supervision and training, many public health officials assert that health care workers below the rank of physician can provide these procedures safely. Until anti-abortion politicians in the United States put a stop to the practice in 1973, the U.S. Agency for International Development (USAID) supplied thousands of menstrual regulation kits to developing countries.11

During the mid-1990s in the United States the medical community showed renewed interest in MVA as a method of early surgical abortion. This resurgence is due to technological advances that permit early pregnancy detection and a growing popular demand for safe, effective early abortion options, both surgical and medical. An innovator in the development of early surgical abortion services is Jerry Edwards, a physician, who developed a protocol in which women are offered an abortion using a handheld vacuum syringe as soon as a positive pregnancy test is received.12

The development of the vacuum aspiration method and the paracerical block made possible the creation of the freestanding abortion clinic, which was pioneered in the United States. Washington, DC and New York City had liberalized their abortion laws several years before the Roe v. Wade decision, and clinics in these cities attracted women from all over the country. A prime rationale for these clinics was that they were able to offer safe outpatient abortion services at lower cost, and in a more supportive manner, than hospital-based services. The creation of the role of the "abortion counselor" - someone whose job it was to discuss the abortion decision with the patient, explain the procedure, and accompany her throughout the process - was a distinctive and lasting contribution of this early period in legal abortion.13,14 These clinics were also instrumental in pioneering a model of ambulatory surgery that became widely adopted by the medical profession.

Freestanding clinics remain the dominant form of abortion delivery in the United States, whereas in Europe and Canada abortions are more evenly apportioned between clinics and hospitals.6 Notwithstanding the many benefits of the freestanding clinic system in the United States, it has contributed to the marginalization of abortion services from the rest of the medical establishment and has been vulnerable to attacks from anti-abortion extremists.8 In contrast, in European countries where abortions are delivered as part of national health care systems, there has been less difficulty finding abortion providers and far less anti-abortion activity at sites of abortion provision.

Reprinted from "Abortion in Historical Perspective" C Joffe in A Clinician's Guide to Medical and Surgical Abortion, Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG (Eds). Philadelphia: Churchill Livingstone, 1999 with permission from Elsevier.

References

  1. Luker K. Abortion and the politics of motherhood. Berkeley: University of California. 1984
  2. Potts M, Diggory P, Peel J. Abortion. Cambridge (UK): Cambridge University. 1977
  3. Wertz R, Wertz D. Lying-in: a history of childbirth in America. New York: Oxford University Press. 1977
  4. David H. Abortion policies. In: Hodgson JE, ed. Abortion and sterilization: medical and social aspects. London: Academic Press. 1981:1-38
  5. Novak F. Experience with suction curettage. In: Hall R, ed. Abortion in a changing world. Vol. 1. New York: Columbia University. 1970:74-84
  6. Henshaw SK. Induced abortion: a world review, 1990. In: Butler JD, Walbert DF. Abortion, medicine, and the law. New York: Facts on File. 1992:406-436
  7. Karman H. The paramedic abortionist. Clin Obstet Gynecol 1972; 15:379-387
  8. Joffe C. Doctors of conscience: the struggle to provide abortion before and after Roe v. Wade. Boston: Beacon Press. 1995
  9. Chalker R, Downer, C. A woman's book of choices: abortion, menstruation, RU 486. New York: Four Walls, Eight Windows. 1992
  10. Dixon-Mueller R. Innovations in reproductive health care: menstrual regulation policies and programs in Bangladesh. Stud Fam Plann 1988;19:129-140
  11. Dixon-Mueller R. Population policy and women's rights: Transforming reproductive choice. Westport: Praeger. 1993
  12. Creinin MD, Edwards J. Early abortion: Surgical and medical options. Curr Probl Obstet Gynecol Fertil 1997;20:1-32
  13. Joffe C. The regulation of sexuality: Experiences of family planning workers. Philadelphia: Temple University. 1986
  14. Preterm Institute. Counselor's manual: Individual and group techniques. Newton: Preterm. 1973

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