Medical Concerns of Induced Abortion and Contraception

After the introduction of the abortion prohibition law in 1953 in Korea, the Constitutional Court ruled a constitutional inconsistency with respect to the abortion prohibition law on April 11, 2019. This decision was made after 66 years. If the abortion prohibition law provisions are not amended before December 31, 2020, the abortion law is automatically abolished. Based on the problem of abortion prohibition law, which was regarded as almost indefinite law, the “Pro-Life Physicians” who were opposed to abortion accused four-obstetrics and gynecology doctors who performed abortion surgery in 2009. Eventually the accused obstetricians were sentenced guilty and punished in 2010. After that event, hospitals that provide abortion surgery have been rapidly reduced and the surgery costs increased significantly. Therefore in the 2010s, some women went to overseas for abortion surgery. In the meantime, a teenager died of excessive bleeding during the abortion procedure in November 2012. On September 22, 2016, the Ministry of Health and Welfare (MOHW) prescribed that abortion surgery was defined as ‘immoral medical practice’ and foretold the amendments to the “Enforcement Decree of the Medical Law and the Enforcement Regulations” to disqualify doctors for up to 12 months for infractions. In response to the MOHW prescription, women's organizations and other civil groups rebelled strongly. On September 30, 2017, a petition for abolishment of the abortion prohibition law was issued to the Blue House; 230,000 people agreed within one month.

It is difficult to find a country that allows unrestricted abortion because it is a matter of life. In most countries, abortion is allowed limitedly if the period of pregnancy and specific requirements are met. In Germany, abortion is legal within 12 weeks, and the surgery for medical reasons is allowed regardless of the period. Finland allows abortion if pregnancy causes social, socio-medical or socioeconomic risks to maternal health within 12 weeks, or rape or other reasons, and approval is required for 13–20 weeks. In the UK, if two doctors agree, abortion is possible for up to 24 weeks of pregnancy on the basis of the physical and mental health of pregnant women. Artificial abortion is possible without any limit of time if serious disability of the fetus is concerned or if there is a concern about permanent or fatal damage to the life of the pregnant woman. Canada allows artificial abortion without any restrictions for the whole duration of the pregnancy.

Induced abortion describes pregnancy termination of a live fetus that has not reached viability. The pregnancy termination can be performed either medically or surgically. Induced abortions are performed safely before 8 weeks' gestation with medications such as mifepristone, methotrexate, and misoprostol. Contraindications to medical abortion include current intrauterine device, severe anemia, coagulopathy, or anticoagulant use, long-term systemic corticosteroid therapy, and severe diseases of the liver, kidney, lungs, or cardiovascular system. Within 14 weeks of gestation, it can be performed relatively safely by suction dilatation and curettage (D & C). After 14 weeks, however, dilatation and evacuation rather than suction D & C is dictated because of fetal size and bony structure. Because of the large size of fetus, cervical dilatation is required, and the fetus must be crushed and removed. At that time, the uterine wall becomes thinner, which leads to a high risk of complications.1 Complications include uterine perforation, cervical laceration, uterine bleeding, and post-abortal infection. Rare complications include disseminated intravascular coagulopathy or amniotic fluid embolism. With long-term complications, removal of endometrial decidual layer may result in endometrial adherence, amenorrhea and infertility, cervical damage resulting in cervical incompetence, and increased incidence of placenta previa. The maternal mortality rate increases with the duration of pregnancy, and the incidence of complications such as infections is low when abortion is legally performed. To prevent post-abortion infection after every first- or second-trimester surgical evacuation, prophylactic antibiotics are provided. In case of Rh(−), the woman should receive a Rhogam shot.2 Even if it could be proven that 99% of women who had abortions experienced more benefit than harm, that would still not justify ignoring the 1% who experienced more harm than good.When women have to undergo abortion in situations such as carrying unwanted pregnancies, they may suffer from short and long term mental traumas. It has been proven in many studies that women who abort are at higher risk of many mental health problem.3

Recently, according to the development of the neonatal intensive care unit, the survival rate of premature neonates after 23 weeks is increasing significantly. Depending on the institution's facilities, survival rates of preterm neonates at 23 weeks without specific malformations was 17%, with 24 weeks reporting 39%, 25 weeks 50% and 26 weeks 80%.4 According to the Korean neonatal network from 2013 to 2016, the overall survival rate of all very low birth weight infants and of infants was 86% and rates with gestational age 22–23, 24–25, 26–27, 28–29, 30–32, and > 32 weeks 33%, 65%, 84%, 94%, 97%, and 98%, respectively.5 Active resuscitation and intensive cares are performed for premature babies delivered after 23 weeks. Of course, infants born as prematurely as 21–22 weeks are nearly always born with brain damage and severely disabled. Both mothers and doctors should be aware of the recent advancement of the neonatal care of premature infants.

Discussion of abortion frequently and completely ignores the physicians and focuses on the mother and fetus. The abortions performed by doctors (mostly obstetricians) are different from treating common illness. Health care professionals are individuals, each with a conscience. The mental traumas of doctors who miscarried a viable fetus are probably not measurable, even if the induced abortions are legal. There are few studies on the mental problems of doctors who have aborted pregnancy. Mental health of doctors should be an issue of discussing induced abortion.

Before focusing on induced abortion, we have to discuss prevention of pregnancy. The age at menarche of Korean girls is generally 11 years or the 4th grade in elementary school. They have the potential to become pregnant from then on. Avoiding unwanted pregnancies is called contraception. There are many effective contraceptive methods. We must once again emphasize the importance of contraception for both men and women before cessation of the abortion prohibition law and legal freedom of abortion. Contraception is not a shame. It is our social duty to systematically educate both boys or men and girls or women for right and ethical contraception. Effective contraception is the basic and ideal solution to reduce the enigma of artificial abortion.

Medical concerns on legal artificial abortion are summarized below. 1) Legally induced abortion received by trained doctors is associated with low maternal mortality. Early abortions before 8 weeks are mostly safe and less complicated. 2) To prevent infection after abortion, prophylactic antibiotics are required for all surgical abortions. In case of Rh(−), Rhogam must be injected after the abortion. 3) Doctors must be well trained to improve surgical abortion skills. 4) We have to be reminded that the survival rate of premature neonates born without disease after 23 weeks is increasing. 5) Mental considerations and studies are necessary for doctors who have aborted a viable fetus. 6) Contraception is much safer and more preventive than the abortion. Pre- and post-abortion counselling and contraceptive education of women are required to reduce unwanted pregnancy. 7) There is a need for policies to ensure that adequate sex education and access to contraceptives are compulsory for both men and women from elementary school age to menopause.