Which is safer?

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Registered: 03-26-2003
Which is safer?
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Fri, 07-06-2007 - 2:19pm
Ok...assuming all variables are equal.....which would be safer wrt
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Registered: 06-03-2007
Fri, 07-06-2007 - 4:10pm

Yowch that's a tough one.
Hydro - this may not be answerable. There are too many variables.

The safety of a surgical abortion is directly related to the stage of gestation, I'm currently searching for the citation that quantified the increase in risk per week, it was something like 80% increase in risk of complication (that's bleeding, scarring, infection, etc.) once we get into curettage (not aspiration) abortions. It also depends on the reason for the abortion - if the fetus has been dead in utero for some time, or if there has been ongoing bleeding that makes it more dangerous, or there are certain kinds of physiological fetal abnormalities that can complicate the procedure.

The same is true for cesarean section. There are fewer complications with a planned cesarean, because the patient isn't already in distress and the OR staff aren't rushing. I believe that bleeding after cesarean depends on what drugs are already circulating in the woman, the placement of the placenta, and many many other factors which are tough to control for. Except that planned cesareans often happen for women that are sick, so we'd have to find a study that excludes preeclampsia, gestational diabetes, or other conditions that make them seem sicker than non-sick women having D&E.

Perhaps we could compare morbidity (that's medicalese for "sickness due to") of abortion of a certain gestation stage with morbidity of planned cesarean? Or fertility after? I'm poking around but I haven't seen it.

I really wish I had an answer. But this may be like trying to recommend one perfect diet for all lifestyles - people are just too variable.

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Registered: 03-26-2003
Fri, 07-06-2007 - 5:51pm

I agree...it may depend on each woman's situation....

I've had two c-sections, but one was an emergency and one was planned...so both were very different.

Sue

Avatar for hydromommy
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Fri, 07-06-2007 - 9:02pm
Ok
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Sat, 07-07-2007 - 9:25am

I think that'd be even harder to answer. Abortion that late is so rare that we it becomes difficult to make meaningful statistics.

This is gonna be rambly as I follow the data. Apologies.

cdc mmwr 2003 states that 1.4% of legal induced abortions occurred at >21 weeks. They don't break it down into smaller groups because it's such a small fraction.
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5511a1.htm (table 6 at the bottom)

And here's the method they used - looks like over 21 weeks is primarily lumped together as curettage, which would include D&E.
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5511a1.htm (table 18 at the bottom)

They don't report complications other than death in that report, so we move on to other data sources. As I start this search, I am lead over and over again to pay-for journal content that I can only access from on-campus (where I am not), and I am loathe to use it here anyway because y'all can't see my sources.

On the general-access web, I did find this bit that was submitted to the courts as part of the Hyde Act, it's a protocol for D&E written in 1998 by a late-term abortion provider describing his technique, and clearly states that for anyone over 32 weeks he refers them for induction abortion.
Here's the link - it's very straightforward so don't read it if it will upset you.
http://eileen.250x.com/Main/7_R_Eile/Haskell_Desc.html
Interestingly, if inductions are about 2% of the 2% of abortions occurring after 21 weeks, and abortions after 32 weeks are recommended to use induction abortion, does this imply that 0.04% of abortions occur after 32 weeks?

So potentially we could compare a 22-to-32 week D&E with a planned cesarean. The easiest way to examine planned cesarean in healthy women is to look at planned cesarean for breech presentation, as it doesn't imply sickness of either woman or fetus.

From a huge huge Canadian study:
"The planned cesarean group comprised 46 766 women v. 2 292 420 in the planned vaginal delivery group; overall rates of severe morbidity for the entire 14-year period were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest ... wound hematoma ... hysterectomy ... major puerperal infection ... anesthetic complications ... venous thromboembolism ... and hemorrhage requiring hysterectomy ... and stayed in hospital longer ...than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion..."
(I took out the numbers for easier reading - here's the source)
http://www.cmaj.ca/cgi/content/full/176/4/455

But going back to the abortion side, I cannot find available morbidity numbers. So we drop back to mortality. I found this stating that risk of death after 21 weeks is 1/11,000.
http://www.greenjournal.org/cgi/content/full/103/4/729
The pregnancy-related mortality rate was higher among women delivered by cesarean (10.3/100,000). That's after they removed the women who died at that time of non-pregnancy causes such as cardiac, renal, mental health, or severe preeclampsia complications. http://www.greenjournal.org/cgi/content/full/97/2/169

If we work the math, the absolute death risk is the same for 21-32 week D&E for all patients, any reason, even in sick women, and planned healthy cesarean. If we were to compare only the healthy with the healthy, I don't know what we would find.

I know that's not what you asked... but it's what I could find.




Edited 7/7/2007 9:26 am ET by wobitnobby
Avatar for hydromommy
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Sat, 07-07-2007 - 10:26am
Thanks for trying, I know it's a hard question. What I'm basically gathering from all that is * in general* abortions. even late term are still safer then c-sections.
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Sat, 07-07-2007 - 11:53am

It may be true that c-sections are riskier...c-sections are major abdominal surgery...no question about that...c-sections are designed to save lives...sometimes abortions are also...sometimes they aren't. But in every abortion someone dies...even though I understand "why" a woman would choose abortion, this is the truth that I struggle with.

Sue

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Registered: 06-03-2007
Sat, 07-07-2007 - 12:19pm

I think that nearly everything becomes pretty risky when a woman is more than 35 weeks pregnant. C-section is more risky than vaginal delivery (except for moderate levels of hemorrhage, and risk of urinary incontinence later in life). It seems like vaginal delivery is probably similarly risky to abortion when it's that late along, because as far as I can tell it seems like abortion that late along is typically performed by induction so it's very much the same.

I suppose another way to look at it logically would be to consider why abortion via hysterotomy is so rare - hysterotomy literally means "cut a hole in the uterus" and includes cesarean section, and is a potential method for late abortion that is rarely chosen, it was grouped in with the small "miscellaneous other" group in the cdc data. It's just not the safest way to get anything that's inside out.

Sue- I was trying to come at this 100% from the perspective of procedure safety for the woman, not weighing what is still a huge consideration - the moral weight of why one does what one does. Sometimes it is easier to break a complex issue down into small pieces and sort them separately, then allow each person to weigh each fragment as they see fit.

The most important message I get from researching this is that we American medical people do a piss-poor job creating an environment in which women can safely and comfortably have full-term vaginal delivery as opposed to cesarean sections for term deliveries. The World Health Organization states that there's no reason that more than ~10% of women should require cesarean delivery, and that the rest of our ~30% cesarean section rate deliveries should be prevented through different labor management or proper full informed consent.

Once again, I do feel that the principle of individual choice applies - if a woman prefers to take that additional risk upon herself I think she should be allowed to pay the additional cost when it's not medically necessary (surgical delivery is more expensive than natural delivery). But there's a huge proportion of those births that follow from labor management practices which do not enable vaginal delivery as successfully as European nations. And that's a failure of our medical system.

I know that's way off topic and belongs on another board and I do post there about this, I just wanted to share that this is where this whole thread sends my mind.

Avatar for hydromommy
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Sat, 07-07-2007 - 5:06pm
I wonder what the loss of fertility is comparing late term abortion to
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Avatar for myshkamouse
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Sat, 07-07-2007 - 7:08pm
No idea. But I'd think a D&E/X is safer in general (less invasive, not major surgery) than a c section! I've had a c section (emergency) with my twins. I can't imagine that's the best way if we are talking about a later stage abortion or misscarriage. Ugh, btw. Awful scenario.
Avatar for hydromommy
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Sat, 07-07-2007 - 7:29pm

Yeah, but I know that one of the risks of D&E/X is that having to continually go into the uterus to remove the fetus & tissue, thus creating more scar tissue ,making it harder for an egg to attach. The (elective)

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