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Induced Abortion: An Overview for Internists
David A. Grimes, MD, and Mitchell D. Creinin, MD
Internists care for many women who have had abortions and
death per 100 000 procedures. Infection, hemorrhage, acute he-
many who will seek abortions in the future. Each year, about 2%
matometra, and retained tissue are among the more common
of all women of reproductive age have an abortion. Women hav-
complications. Referral back to the original abortion provider for
ing abortions tend to be young, white, unmarried, and early in
management is advisable. Overall, induced abortion does not lead
pregnancy. Most abortions are done by suction curettage under
to late sequelae, either medical or psychiatric. Of importance, no
local anesthesia in a freestanding clinic. However, medical abor-
link exists between induced abortion and later breast cancer. For
tion is growing in popularity as a nonsurgical alternative. The
physicians who are asked to help with a referral, the National
regimen approved by the U.S. Food and Drug Administration
Abortion Federation and Planned Parenthood Federation of Amer-
specifies mifepristone, 600 mg orally, followed 2 days later by
ica have helpful Web sites and networks of high-quality clinics.
misoprostol, 400 ␮g orally (within 49 days from last menses).
The cost of abortion (currently about $372 at 10 weeks) has
Recent studies have recommended alternative approaches, such as
decreased in recent decades. Provision of ongoing contraception
mifepristone, 200 mg orally, followed in 1 to 3 days by misopros-
and encouragement of emergency contraception can reduce unin-
tol, 800 ␮g vaginally (up to 63 days). Medical abortion can be
tended pregnancies and the need for abortion.
provided by a broader variety of physicians than can surgical
Ann Intern Med. 2004;140:620-626.
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abortion. The overall case-fatality rate for abortion is less than 1
For author affiliations, see end of text.
Most internists' practices include large numbers of pa- abortions, for example, specifying that abortions must take
tients who have had or will seek induced abortion.
place in a hospital. However, pregnancy should be consid- Although abortion rates are declining, were they to remain ered a continuum, with no clear demarcations once embry- stable, an estimated 43% of all U.S. women would have had one or more induced abortions during their reproduc- Two terms describe abortion frequency: the annual tive years (1). More than 30 million U.S. women now rate (number of abortions per women of reproductive age) and ratio (number of abortions per live births). The abor- Because surgical abortion is one of the most common tion rate in 1999 was 17 abortions per 1000 women age 15 operations in contemporary practice and new technologies to 44 years; stated alternatively, about 2% of all women of have emerged over the past decade, this article will provide reproductive age have an abortion each year. The corre- a primer for internists. We describe the numbers and char- sponding abortion ratio was 256 abortions per 1000 live acteristics of women having abortions, review the methods births, about 1 induced abortion for every 4 live births (3).
used, summarize safety data, explain how internists canhelp patients with referrals to abortion providers if re-quested, and describe costs. We focus on early induced WHO HAS AN ABORTION?
abortion, which dominates practice in the United States.
Women who have abortions tend to be young, white, Our sources were textbooks, review articles, and a search unmarried, and early in pregnancy (Table 1) (3). In 1999,
through PubMed using the Medical Subject Heading more than half of abortions (58%) were obtained at 8 or terms abortion, induced; abortion, legal; and abortion, ther- fewer weeks of gestation (counted from the first day of the last menstrual period), and 88% were performed before 13weeks. Suction curettage (also called vacuum aspiration)accounted for nearly all abortions.
WHAT IS AN ABORTION?
Several important demographic and medical trends are Abortion is the removal of a fetus or embryo from the evident over the past 3 decades (Table 1). The proportion
uterus before the stage of viability, further defined as "20 of teenage patients having abortions has declined, as has weeks' gestation or fetal weight Ͻ 500 g" (2). The latter the proportion of married women. Women have been ob- descriptors are misleading, however, because fetal viability taining abortions at progressively earlier gestational ages has not been reported at 20 weeks and weight alone is a and by suction, rather than sharp, curettage (4). As of poor predictor of viability. The terminology of timing is 1999, over half of all women having abortions were moth- also confusing. The notion of pregnancy "trimesters" was ers of one or more children. A nationwide survey by the adopted by the U.S. Supreme Court in the Roe v. Wade Alan Guttmacher Institute indicated that in 2000 and decision of 1973, which legalized abortion nationwide. Re- 2001, most women older than 17 years of age reported a grettably, this obstetrical convention has no basis in biol- religious affiliation: 43% Protestant, 27% Catholic, 8% ogy, and the distinction between first- and second-trimes- other, and 22% no religious affiliation (5). Forty-six per- ter abortion remains blurred after 3 decades. The practical cent of women had not used a contraceptive method in the importance is that states may regulate second-trimester month in which they conceived; inconsistent use of con- 620 2004 American College of Physicians
traceptive method was the main cause of pregnancy amongthose using contraception (6).
Key Summary Points
Each year, about 2% of all women of reproductive age in the United States have an induced abortion.
OW IS A FIRST-TRIMESTER ABORTION PROVIDED?
When women inquire about abortion, physicians Most abortions are performed by vacuum aspiration under should review all the options for the pregnancy as part of local anesthesia in freestanding clinics.
informed consent. These include carrying the pregnancy to Use of medical abortion with mifepristone plus misopros- delivery and keeping the baby, delivering the baby and tol, methotrexate plus misoprostol, or misoprostol alone is giving it up for adoption, or abortion. If abortion is cho- sen, counseling can then focus on the procedures available; Abortion remains one of the safest procedures in contem- this discussion needs to include the efficacy, benefits, risks, porary practice, with a case-fatality rate less than 1 death and side effects of surgical abortion and, for women at 9 or fewer weeks of gestation, the alternative of medical abor- Abortion does not lead to an increased risk for breast can- tion. The National Abortion Federation (www.prochoice cer or other late psychiatric or medical sequelae.
.org) and Planned Parenthood Federation of America (www The National Abortion Federation and Planned Parenthood .ppfa.org) Web sites provide information about pregnancy Federation of America have helpful Web sites and net- options and providers. Physicians need to understand all local and federal regulations related to abortion provision.
Abortion can be accomplished by surgical or medical techniques. Surgical abortion entails evacuation of the the case in surgery, surprises are unwelcome. Therefore, products of conception through the cervix. The phrase most National Abortion Federation clinics surveyed (66%) "medical" abortion refers to early abortion effected by use ultrasonography to confirm gestational age before sur- drugs (usually before 9 weeks of gestation) (7).
Suction curettage dominates practice in the United SURGICAL ABORTION
States. This technique evacuates the uterine contents with Accurate determination of the duration of the preg- negative pressure; the source of vacuum is commonly an nancy is an important prerequisite to abortion; as is often electrical pump or a hand-held syringe. The process in-volves cervical dilation to a diameter less than 12 mm,followed by evacuation of the uterine contents. Physicians Table 1. Characteristics of Women Who Obtained Legal
have traditionally inserted a series of progressively larger Abortions, United States, 1972 and 1999*
metal or plastic dilators for dilation. In recent years, use of Characteristic
Distribution, %†
vaginal or oral misoprostol, a prostaglandin E1 derivative,has grown in popularity. Administration of misoprostol, 400 ␮g (2 tablets) vaginally, for 2 to 3 hours before the (n ؍ 586 760)
(n ؍ 861 789)
abortion softens and opens the cervix (9), although whether this decreases complication rates or improves pa- After the cervix is dilated, a plastic cannula is intro- duced into the uterine cavity and connected to the suction source to perform the abortion. Cannulas range in diame- ter from 4 to 14 mm. Suction curettage is safer, faster, and Marital status
more comfortable than its predecessor, sharp curettage (also termed D & C for dilation and curettage). Procedure Live births
time is usually less than 5 minutes.
Local anesthesia is the most common approach to pain control. In a recent survey of providers, 58% used para- Gestational age
cervical block with or without oral premedication, 32% combined paracervical block with intravenous sedation, and 10% used general anesthesia (8). Local anesthesia is both safer and less expensive than general anesthesia, al- Type of procedure
though pain relief is not complete. With local anesthesia, most women have discomfort similar to bad menstrual cramps during the operation; this resolves soon after theoperation is finished. Most women are comfortable at the * Source: Centers for Disease Control and Prevention (3).
† Totals may not add to 100% because of rounding.
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20 April 2004 Annals of Internal Medicine Volume 140 • Number 8 621
Figure 1. Mean plasma concentrations of misoprostol acid over
ing methotrexate and misoprostol and misoprostol alone time with oral and vaginal administration.
Mifepristone, a derivative of the progestin norethin- drone, binds strongly to the progesterone receptor withoutactivation, thereby acting as an "antiprogestin." Mifepris-tone results in separation of the trophoblast from the en-dometrial wall; it also increases endogenous prostaglandinrelease and sensitizes the myometrium to exogenous pros-taglandins. In addition, mifepristone softens the cervix toallow expulsion. Initial studies of mifepristone attemptedto find the optimal regimen to achieve acceptable rates ofexpulsion. However, not until investigators began follow-ing mifepristone with small doses of a prostaglandin ana-logue did the efficacy approach 100% (13).
Misoprostol is the prostaglandin analogue most com- monly used with mifepristone because of its safety, lowcost, and stability at room temperatures. Misoprostol canalso be placed in the vagina, which leads to slower absorp-tion and a lower peak serum level (14). However, the area Error bars represent 1 SD. (Reprinted from Zieman M, Fong SK, Be- under the curve following vaginal misoprostol is greater nowitz NL, Bansketer D, Darney PD. Absorption kinetics of misoprostol (Figure 1). In addition, vaginal administration may have
with oral or vaginal administration. Obstet Gynecol. 1997;90:88-92,with permission from The American College of Obstetricians and Gy- direct cervical and uterine effects. Clinically, vaginal ad- ministration of misoprostol results in greater efficacy andlower rates of continuing pregnancy (15, 16).
The mifepristone and prostaglandin analogue regimen After the abortion, the woman is monitored in a re- for medical abortion, approved by the U.S. Food and Drug covery room for about 30 minutes. Before discharge, she Administration (FDA), involves a single 600-mg oral dose of receives information about warning signs of common com- mifepristone followed approximately 48 hours later by miso- plications, and most women leave the clinic with their cho- prostol, 400 ␮g orally, in women up to 49 days of gestation.
sen method of contraception. Standard practice is for the This results in complete abortion in 92% to 99% of women physician or a designee to inspect the aspirated tissue to (11, 17, 18). Between 2% and 5% of women will abort before confirm successful completion of the abortion and to ex- misoprostol administration (16 -18).
clude an unsuspected ectopic pregnancy. Formal patho- Gestational age and location of the pregnancy are con- logic examination of the products of conception is unnec- firmed before mifepristone administration. In the United essary (10). Women who are Rh negative receive Rh States, vaginal ultrasonography is commonly performed for immunoglobulin. Many women resume their usual activi- these purposes. The patient then takes the mifepristone ties the same day as the abortion, although some prefer to under observation by a health care provider. The FDA wait another day before returning to routine daily activity.
guidelines for mifepristone regimens for medical abortion A follow-up visit is usually scheduled in 2 or 3 weeks, stipulate that the patient should return in 2 days for an but evidence supporting the benefit of this visit is lacking.
evaluation before misoprostol administration. Once she Moreover, only about half of women opt to return. The swallows the misoprostol, the patient has the option of principal use of the follow-up visit may be management of staying in the office for observation or returning home.
contraception. If an internist sees an asymptomatic woman Some clinicians administer additional doses of misoprostol for follow-up after abortion, a pelvic examination is typi- if abortion has not occurred. A follow-up examination is cally performed but is unnecessary. Likewise, no laboratory performed 2 weeks later to confirm expulsion, which is tests are indicated. Most important, the patient should be based on the patient's history of events after misoprostol asked how she is doing with her chosen contraceptive.
use and pelvic examination. Suction curettage is performedif complete expulsion has not occurred.
MEDICAL ABORTION
The FDA-approved dose of mifepristone is excessive.
The most commonly used medical abortion regimen A 200-mg dose is as effective as the 600-mg dose when throughout the world is mifepristone followed by a pros- combined with a prostaglandin analogue (18 -21). Because taglandin analogue, usually misoprostol. However, in areas mifepristone is the more expensive of the medications, lower- without access to mifepristone, methotrexate and miso- prostol or misoprostol alone are acceptable alternatives.
Women can administer misoprostol themselves, elim- Mifepristone regimens result in higher rates of complete inating a trip back to the provider (15, 21-24). In the 3 abortion and cause expulsion more rapidly than those us- largest trials using mifepristone, 200 mg, and misoprostol, 622 20 April 2004 Annals of Internal Medicine Volume 140 • Number 8
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800 ␮g vaginally (21, 22, 24), 90% of women in all studies vider is advisable. Management at that point should reflect found home use of misoprostol acceptable regardless of the patient's physical and emotional comfort and baseline previous abortion experience (22), gestational age (21), or hemoglobin level as well as whether the bleeding is slow- time between mifepristone and misoprostol use (24). Four ing. Transportation time to emergency care, if necessary, (0.1%) participants in 2 studies totaling almost 4500 women experienced adverse events soon after misoprostol The duration of bleeding after a medical abortion us- administration (21, 22). Only one of these events could ing mifepristone varies among studies. Three studies, in- have been avoided with observation of the woman in an cluding 2 from France, found an average duration of bleed- ing of 9 days (16, 17, 28), with a range of 1 to 32 days (16, Misoprostol can be used sooner after mifepristone 17). However, the remainder of studies, including those than the time interval recommended by the FDA. Regi- from the United States, report a mean duration of bleeding mens with a shorter interval between mifepristone and mi- of 14 to 17 days (22, 23, 29), with a range of 1 to 69 days soprostol administration, if effective, might reduce abor- (18, 23, 30). Davis and colleagues (31) followed women by tion times and increase acceptability (24). In addition, using bleeding diaries to document bleeding patterns after because approximately half of women bleed during the 48 administration of mifepristone and vaginal misoprostol.
hours after mifepristone is given (18, 22), administering They reported bleeding for a mean of 14 days and spotting the misoprostol sooner would decrease such an undesirable for a mean of 10 days. Overall, women had bleeding or side effect. The standard regimen with an interval of only 6 spotting for an average of 24 days, longer than what is to 8 hours is ineffective. However, Schaff and colleagues typically reported in efficacy studies. Twenty percent of (15, 24) demonstrated in 2 multicenter, randomized trials women had bleeding or spotting that lasted more than 35 that the regimen of mifepristone, 200 mg, followed be- tween 24 and 72 hours later by misoprostol, 800 ␮g vag-inally, is more effective than regimens with oral WHO CAN PROVIDE MEDICAL ABORTION?
Although gynecologists provide most surgical abor- Follow-up sooner than 2 weeks can accurately predict tions, a broader variety of physicians may be able to pro- successful abortion when vaginal ultrasonography is rou- vide medical abortions. These include family physicians, tinely used to confirm expulsion (15, 21, 22, 24). Without internists, and pediatricians. If the physician providing ultrasonography, whether the patient or physician can ac- medical abortion does not have the skills or equipment for curately assess outcome in these situations is unknown.
suction curettage, referral to other physicians can meet this The main goal of the ultrasonography is to determine the occasional need. Physicians interested in obtaining mi- presence or absence of the gestational sac. Harwood and fepristone for medical abortion need to apply to the dis- colleagues (25) demonstrated that clot and debris are nor- tributor (Danco Laboratories, New York, New York; www mally seen in the uterus when transvaginal ultrasonography .earlyoptionpill.com). Training is available from the is used after medical abortion; the thickness of the endo- National Abortion Federation and other organizations.
metrial lining does not predict abortion success.
Current evidence supports use of regimens with mi- fepristone, 200 mg, followed 24 to 72 hours later by mi- HOW SAFE IS ABORTION?
soprostol, 800 ␮g (up to 63 days of gestation). The miso- Abortion is one of the safest procedures in contempo- prostol can be administered by the patient at home at a rary practice. However, in some developing countries convenient time. A follow-up evaluation can be performed where safe, legal abortion is not available, 50 000 to by physical examination at 2 weeks or sooner if transvagi- 70 000 women die of unsafe abortion each year. Refine- nal ultrasonography is used to assess the uterine cavity.
ments in abortion technology, improvements in prevention Pain management typically includes use of ibuprofen and management of complications, and earlier abortions or acetaminophen initially, with oral narcotics if necessary.
have all contributed to the impressive safety record (4) The use of a nonsteroidal anti-inflammatory drug, such as (Figure 2). The case-fatality rate from abortion today is less
ibuprofen, is not contraindicated and does not decrease the than 1 death per 100 000 abortions (32, 33). By compar- likelihood of abortion after administration of a prostaglan- ison, the risk for death from anaphylaxis after parenteral din analogue (26). Some clinics provide patients with a administration of penicillin is about 2 per 100 000 events.
prescription for 20 plain codeine tablets with instructions The risk for complications is also low. In a recent large case to use 1 to 3 tablets as needed should the nonsteroidal series report, the risk for a complication requiring hospi- anti-inflammatory drugs provide inadequate relief. Bleed- talization was 0.7 per 1000 abortions; less serious compli- ing typically begins within 3 hours of misoprostol admin- cations occurred in 8 per 1000 abortions (34).
istration. Even though heavy bleeding is expected, patients Both gestational age and abortion method influence are typically fine unless they are soaking 2 thick sanitary abortion safety; in general, the earlier the abortion, the pads per hour for 2 consecutive hours (27). While inter- safer (Table 2). In terms of mortality risk, suction curet-
vention may not be necessary, consultation with the pro- tage early in pregnancy is the safest method that has been www.annals.org
20 April 2004 Annals of Internal Medicine Volume 140 • Number 8 623
Figure 2. Case-fatality rate for legal abortions, United States,
side of abortion practice, and gynecologists who do not selected years, 1975 to 1995.
perform abortions may have little experience with it. More-over, clinics often provide care of complications at no ad-ditional charge to the woman.
DOES ABORTION HAVE LATE SEQUELAE?
Extensive literature has documented the long-term safety of abortion. Induced abortion does not harm a wom-an's reproductive capacity. Premature birth, infertility, ec-topic pregnancy, spontaneous abortion, and adverse preg-nancy outcomes are not increased in frequency afterabortion. The question of placenta previa is unsettled;some reports have found an increased risk for this abnor-mal placental attachment in later pregnancies, whereas oth-ers have not (37).
Induced abortion does not harm women's emotional Source: Centers for Disease Control and Prevention (32).
health; for most women, it allows an overall improvementin quality of life (38, 39). Indeed, the most common reac- widely used. Delays in obtaining services, regardless of the tion to abortion is a profound sense of relief. In some cause, tend to increase both the risk and cost of abortions.
studies, abortion has been linked with improved psycho- Suction curettage is safer than sharp curettage; medical logical health because the abortion resolved an intense cri- abortion also has low complication rates.
sis in the woman's life. The alleged "postabortion trauma Infection, hemorrhage, acute hematometra, and re- tained tissue are among the more common complications Abortion does not increase a woman's risk for cancer.
(27). The low risk for infection is further reduced by ad- Flawed epidemiologic studies led to claims that abortion ministration of prophylactic antibiotics, a practice that is elevates a woman's risk for breast cancer in later life. How- evidence-based (35) and widely used (8). A common anti- ever, recall bias among controls in case-control studies ac- biotic is doxycycline. Some surgeons send patients home counts for this association; large cohort studies from Scan- with a short course of methylergonovine maleate to mini- dinavia have found either no association or a protective mize uterine atony and bleeding, although evidence does effect of abortion (41). After review of the evidence, both not support any benefit of this treatment (36). The risk for the World Health Organization and the National Cancer hemorrhage severe enough to require blood transfusion is Institute have concurred that no credible evidence supports remote. Hematometra occurs when the uterine cavity fills a link between abortion and breast cancer.
with clotted and liquid blood in the postoperative period.
Little or no vaginal bleeding accompanied by increasinglower abdominal cramping and an enlarged uterus suggest WHERE CAN A WOMAN GET AN ABORTION?
the diagnosis; prompt repeated aspiration of the uterus is Most surgical abortions (93% in 2000) are provided in both diagnostic and therapeutic. Repeated aspiration is also freestanding abortion clinics (42). Comparable data are un- diagnostic and therapeutic for retained tissue, which causes available for medical abortion. Clinics typically feature continued or increasing bleeding after the procedure.
high-quality care in attractive surroundings. Most women When primary care physicians are consulted by pa- receive services during a single visit. Because of economies tients who are having complications after abortion, prompt of scale, clinics can provide services at lower costs than referral back to the abortion provider is usually indicated.
hospitals and most physicians' offices. Because clinics limit Some problems, such as hematometra, are uncommon out- their clientele to healthy patients and because their sur- Table 2. Case-Fatality Rates for Legal Abortion, by Procedure and Gestational Age, United States, 1972 to 1987*
Procedure
Gestational Age
9-10 wk
11-12 wk
13-15 wk
16-20 wk
>21 wk
* Deaths per 100 000 abortions. Data obtained from Lawson et al. (33).
† Dilation and evacuation is instrumental abortion through the cervix at 13 or more weeks of gestation.
‡ Includes deaths from other rare procedures, such as hysterotomy or hysterectomy.
624 20 April 2004 Annals of Internal Medicine Volume 140 • Number 8
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geons are so experienced, complication rates are low (34).
raphy has been performed, a copy of the report should be Paradoxically, abortions performed in hospitals have higher complication rates than do clinic abortions, in part becauseof higher-risk patients, residents in training, and less expe- HOW MUCH DOES AN ABORTION COST?
rienced surgeons than in freestanding clinics (43).
Access to abortion clinics remains a problem: Clinics Unlike most other operations, the cost of abortion has cluster in metropolitan areas. About one third of women of dropped dramatically over the past 3 decades (48). The reproductive age live in the 87% of U.S. counties without current charges are below market value for several reasons.
an abortion provider (42). Among the nation's 276 metro- First, the Hyde Amendment cut off federal payment ofnearly all abortions for poor women in 1977, and clinics politan areas, 86 have no provider. About a quarter of have intentionally tried to keep the price within reach of women have to travel 50 miles or more to reach a clinic women of limited means. Seventeen states, including Cal- (44); this geographic barrier hinders both service provision ifornia and New York, currently use state funds to pay for (45) and follow-up in case of complications.
medically necessary abortions; 33 states and the District ofColumbia prohibit funding of medically necessary abor-tions, except in extraordinary cases (49). Nationwide, only HOW DO I LOCATE A PROVIDER AND MAKE A
a quarter of women receive services billed directly to public REFERRAL?
or private insurance (44). Second, competition between Making an appropriate referral for an abortion is an clinics in cities has kept costs low. In 2001 and 2002, the important role for internists. Most urban areas have both average self-paying woman was charged $372 for a surgical clinics and private physicians who provide abortion services abortion at 10 weeks. Adjusted for the increase in the con- as part of general gynecologic practice. Clinics in the com- sumer price index over the past 3 decades, the charge munity tend to advertise in the yellow pages of the local should be several times higher (48). In general, clinics set medical and surgical abortion prices to be similar so as to Referring physicians and their patients can identify eliminate financial reasons for women to choose between reputable providers of abortion services through the Na- tional Abortion Federation, the professional association of Induced abortion represents secondary prevention of abortion providers in the United States and Canada. The an unintended pregnancy. Primary prevention, through National Abortion Federation operates a hotline with fac- ongoing and emergency contraception, deserves more at- tual information about abortion and pregnancy options in tention from all physicians. Contraception is especially im- both English and Spanish. Information about member portant for women with serious illnesses, for whom un- physicians and clinics can be obtained by calling 800-772- intended pregnancy may pose special risks. Provision of 9100, and more information about the hotline is available contraception and encouragement of emergency contracep- at www.prochoice.org. In addition, many clinics of the tion, as needed, can further reduce the burden of suffering Planned Parenthood Federation of America provide abor- from unintended pregnancies nationwide.
tions. Its Web site (www.ppfa.org) enables users to findhealth centers near their ZIP code.
From University of North Carolina School of Medicine, Chapel Hill,North Carolina, and University of Pittsburgh School of Medicine, Clinicians and women need to be wary of fake clinics, Magee-Womens Research Institute, Pittsburgh, Pennsylvania.
biased counseling centers (numbering over 3000 nation-wide), and misleading Web sites. Some telephone directory Potential Financial Conflicts of Interest: Employment: D.A. Grimes,
yellow pages include "crisis pregnancy counseling" facili- M.D. Creinin; Consultancies: M.D. Creinin (Danco Laboratories); Expert ties, which provide only directive counseling against abor- tion. This commonly includes misleading and deceptivemessages (46). For example, the Web site www.prochoice Requests for Single Reprints: David A. Grimes, MD, Department of
.com, similar to the National Abortion Federation's Web Obstetrics and Gynecology, CB #7570, University of North CarolinaSchool of Medicine, Chapel Hill, NC 27599-7570.
address, lists "Developing breast cancer" as an abortion riskand warns that abortion "is a rip off with little concern forthe patient, it's a business." Links from this Web site con- References
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www.annals.org
Current Author Addresses: Dr. Grimes: Department of Obstetrics and
Dr. Creinin: Department of Obstetrics, Gynecology and Reproductive Gynecology, CB #7570, University of North Carolina School of Medi- Sciences, University of Pittsburgh School of Medicine, Magee-Womens Research Institute, 300 Halket Street, Pittsburgh, PA 15213-3108.
American College of Physicians E-627

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