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Abortion Reproductive Health Women's Issues

Revisit Menstrual Extraction

Image courtesy of IPAS

            Before Roe v. Wade, and before pregnancy tests were easily available, there were ways a woman could get her period started if it was late. This is called “Menstrual Extraction” (ME) or “menstrual regulation”. Without knowledge if she were pregnant or her period was just late, ME was not considered an abortion.

            ME can be done with herbs, medicines or instruments. In Indonesia a doctor told me about “EM Kapsuls”, which are advertised on TV. Kapsuls are used to ease menstrual cramps, plus they are advertised to start a late period.

  “Emmenagog” is the word for herbs or medicines that are used to start a woman’s period. Herbal emmenagogs are used in many cultures and have a long history. One of the most used emmenagogic plants, pennyroyal, is mentioned in Aristophanes’ play, Peace, written in 421 BCE! Although pennyroyal is apparently effective both in starting menses or causing an abortion, it is also toxic; it can cause severe liver damage and death. Tansy and rue are two other plants with similar effects—and toxicity.

            Dr. Karmen, a psychologist, developed a MR technique using instruments: a flexible cannula and a syringe for suction. It is fast, simple and safe in the hands of an experienced person. That technology is still used for early abortions and incomplete miscarriages. I used Karmen cannulas until the office nurse pointed out that patients seemed to have more problems with that type of cannula than with the conventional, rigid cannula.

            In general, Islam is against abortion—although there are exceptions. For instance, abortion is illegal in Bangladesh, a Muslim country, but ME is acceptable. It was introduced to decrease maternal mortality associated with unsafe abortion. A doctor can legally perform MR up to 12 weeks from the onset of a woman’s last menstrual period. 

In addition to using herbs or suction to remove the tissue in the uterus, ME can be done with the same tablets, mifepristone and/or misoprostol, that a woman can take for a medication abortion. These medicines are even available in some countries without a prescription. They are also available in some states of the USA for ME through the Period Pills Project.

What are the dangers of ME? There is a risk that pregnancy, if indeed the woman is pregnant, may continue. Rarely the pregnancy isn’t in the uterus, but in a tube. A tubal pregnancy may have the same symptoms as a normal pregnancy, but it can tear the tube as it grows and cause internal hemorrhaging.

Performing an ultrasound before an abortion is wise for 2 reasons—to determine the pregnancy’s location and its gestational age. However, MR may skip the ultrasound if it’s done outside of the medical system. This means an ectopic pregnancy could escape detection, or that a pregnancy might be too far advanced for safe MR. Fortunately, the possibility of a continuing pregnancy can be excluded if the woman has a negative pregnancy test a week or two after she has had the ME.

Is MR going to make a comeback in US states where abortion is severely limited or entirely illegal? That is difficult to predict. However, there are studies suggest that women are interested in the idea. 

An old video, No Going Back, shows how ME is done with the Karmen cannula. Unfortuately, it neglects to mention sterile technique and other precautions, so I don’t recommend it. Nevertheless, do-it-yourself ME might be safer than a back-alley abortion.

I searched and could only find information about the efficiency of ME using a combination of mifepristone and misoprostol, which are very effective. There doesn’t seem to be any study of the success rate of either a single medication or of herbal products. A study is being done in California to test misoprostol; it will be interesting to find its results.

            The recent Dobbs decision by the Supreme Court has limited access to safe abortion care. However, ingenious women can find ways to get around the law. I just hope they can do so without compromising their safety.

© Richard Grossman MD, 2022

Categories
Abortion Reproductive Health

Grasp the Consequences of Making Abortion Illegal

The media have done a good job of describing the implications of the Supreme Court’s abolishment of Roe to individuals. However, I have read little about the effects this regrettable decision will have on society.

First of all, it means that as many as 140,000 people will not have desired abortions. This estimate was published by the Guttmacher Institute and is hopefully too high. People all over the country are working to help refer women to abortion services in states that still allow this important healthcare procedure. However, there are many who cannot afford the time away from home or money to travel that a referral would entail.

Let’s estimate what this might mean to our population growth. Currently there are about 4 million births in the USA. Let’s say that 40,000 women are able to travel to receive abortion services or otherwise end up not giving birth. This would mean that the number of births is increased by 100,000 or almost 3 percent. We need to decrease the number of unintended births, not increase them!

Other than increasing the growth rate of the USA, will these added births have any effect on society? This is difficult to know, but there is reason to believe that many of these new people will not turn out to be the best citizens.

Dr. Henry David studied unintended pregnancies in Czechoslovakia during the 1960s, with the help of Czech researchers. Those researchers did all the detective work to find the mothers, gain their permission to test their children, and continue to follow them for all those 30 years.

Abortion was legal but needed approval by a state agency. A woman could appeal if her request for an abortion was denied —however, some women were denied twice. David’ group looked at these unwilling mothers, their children and controls (mothers with wanted pregnancies), following them for over 30 years. The results are available in “Born Unwanted”, and are summarized: “The overall findings suggest that, in the aggregate, denial of abortion for unwanted pregnancy entails an increased risk for negative psychosocial development and mental well-being in adulthood.” The children of unwanted pregnancies had more brushes with the law, were less satisfied with their lives, had less education and more mental health problems.

Another project, the Turnaway Study, focused on women who wished to abort a pregnancy. These women were refused abortion care because their pregnancies were too far advanced for the clinic they attended. The Study looked at families after the birth of a denied abortion and found that they didn’t thrive well after the unwelcome addition. There was poor maternal bonding, and the mothers’ other children’s development suffered. Furthermore, these families were more likely to live below the federal poverty level than the mothers who received abortion care. I’ll write more about this revealing study in the future.

A possible cause of the decline in crime in the 1990s was popularized by freakonomics.com. Males from age 18 to 24 are most likely to commit crimes, and the theory is that the decrease in crime 18 years after Roe v. Wade in 1972 was due to increased access to abortion. The decrease in the births of unintended children may have resulted in better citizens and less criminal behavior as kids reached adolescence and adulthood.

As a young doctor, I took care of a toddler who had been scalded. I remember his young mother saying “I didn’t want him.” She told me that he was fussy and she thought a bath would help quiet him, but instead he became fussier. Out of desperation she turned up the hot water to punish her son. She deeply resented the baby who prevented her from doing normal teen things. 

The Freakonomics hypothesis is controversial. One analysis of the data suggests that the benefits to society were confined to the decline in teenage mothers. Certainly, my teen patient’s son had suffered from being unwanted. I have no follow up information on how he turned out, however.

Decreased access to safe abortion services will be a tragedy for some people and our society may suffer.

©Richard Grossman MD, 2022