Induced Abortion and Subsequent Preterm Birth:

Evidence of Risk Association

Byron C. Calhoun, M.D., FACOG, FACS, MBA

Professor & Vice-Chair, Department of Obstetrics & Gynecology
West Virginia University-Charleston

U.S. Surgeon General’s Conference on the Prevention of

Preterm Birth
June 16 & 17, 2008
The abstracts, referenced studies, and two papers contained in this document provide
evidence of a causal link between surgical induced abortion (IA) and subsequent preterm
birth. One of the two papers at the conclusion of the document gives further consideration
to this causal link with respect to both cost consequences and impact on informed
consent.

ABSTRACTS
The following abstracts represent six studies which demonstrate the strongest and most
significant risk association between IA and later preterm birth.

(1.) Lumley J. The epidemiology of preterm birth. Bailliere's Clin Obstet Gynecology.
1993;7(3):477-498
ABSTRACT
Secular trends in the prevalence of preterm birth and international comparisons of the rates of
preterm birth are difficult to interpret because of differences, both formal and informal, in the
registration of extremely preterm births. Accurate estimation of gestational age is another
problem in the measurement of preterm birth. Preterm birth is heterogeneous in several ways. It is
heterogeneous in terms of the extent to which the birth is preterm (20-27 weeks, 28-31 weeks or
32-36 weeks of gestation); in whether the birth was elective or spontaneous; and among
spontaneous idiopathic preterm births, in whether there was preterm labour or premature rupture
of the membranes. Case-control study designs taking account of these subgroups have been a
recent feature of epidemiologic approaches. The classic social associations of preterm birth--low
socioeconomic status, extremes of maternal age, primiparity, being unmarried--apply to
extremely preterm and moderately preterm births as well as to the mildly preterm group. The
strength of these associations is small compared with factors in the prior reproductive history and
with medical and obstetric complications of the current pregnancy. Recent epidemiological
research activities have focused on the ways in which risk factors such as physical workload,
drugs and alcohol, lack of social support and infection might be mediating factors between
sociodemographic status and preterm birth. As Eastman (1947) pointed out almost 50 years ago,
'only when the factors causing prematurity are clearly understood can any intelligent attempt at
prevention be made'. [References: 74]

(2.) Lumley J. The association between prior spontaneous abortion, prior induced
abortion and preterm birth in first singleton births. Prenat Neonat Med 1998;3:21-24.
DISCUSSION (in lieu of Abstract)
The evidence for and against a causal relationship between prior shortened pregnancies
and preterm birth is as follows. Selection bias into the study can be excluded since the data are
population-based with 99.6% of births captured in the data system. Measurement error of the
exposures cannot be totally excluded. Though the data have been validated against hospital
records there is likely to be incomplete reporting of prior induced abortions in hospital records.
Non-differential under-reporting would result in the relative risk being too low. Differential
under-reporting is which prior abortions were more completely ascertained when there was a
preterm birth could have occurred but the timing of data collection on prior pregnancies is at the
first antenatal visit, before the outcome is known. Chance (random error) is unlikely since the
95% confidence intervals for the association with prior abortions do not include 1.00 .
Confounding is likely. Maternal age, marital status and the presence of a birth defect in
the index birth can be excluded since the associations in Figures 1 to 3 are still present at a similar
level in a restricted data stratum of married women, age 20-34 years, with no birth defect in the
index birth (unpublished data). Data on socioeconomic status, occupation, smoking, alcohol
consumption and other substance use are not collected routinely. The strength of association of
these factors with preterm birth, however, is much smaller than the associations in Figures 1 to 3.
The association of abortions with preterm birth cannot be explained by gravidity because the
relative risks for prior births are different from prior pregnancies. Data on the gestation of the
prior abortions, indications, complications, and inter-pregnancy intervals are not available in the
routine perinatal data.
Termination of pregnancy has been legal under case interpretation of legislation since
1969 and the procedure is covered by the federal government universal health insurance system
[4].
The data meet four of the criteria for causality. The temporal sequence is clear: the
abortions preceded the preterm birth. The association is a strong one. There is a dose-response
relationship: the greater the number of prior pregnancies the higher the relative risk. The
association is plausible: possible mechanisms exist which are outlined below. The other criteria
cannot be fully met a present: the study design (a retrospective cohort) is rated as moderate.
Reversibility of the exposure is not applicable to these exposures. No other papers have reported
an analysis stratified by gestation and by number of prior pregnancies so that the consistency of
the findings cannot be assessed.
One possible mechanism is that cervical instrumentation can facilitate the passage of
organisms into the upper part of the uterus, increasing the probability of inapparent infection and
subsequent preterm birth [5]. Another is the removal of the endometrium carries a small risk of
damaging the decidual stroma in such a way as to impair trophoblast invasion, migration and the
full transformation of the maternal spiral arteries [6].

(3.) Moreau C, Kaminski M, Ancel PY, Bouyer J, Escande B, et al. Previous induced
abortions and the risk of very preterm delivery: results of the EPIPAGE study.
British J Obstetrics Gynaecology 2005;112(4):430-437.
ABSTRACT
Objectives: To evaluate the risk of very preterm birth (22-32 weeks of gestation) associated with
previous induced abortion according to the complications leading to very preterm delivery in
singletons. Design: Multicentre, case-control study (the French EPIPAGE study). Setting:
Regionally defined population of births in France. Sample: The sample consisted of 1943 very
preterm live-born singletons (< 33 weeks of gestation), 276 moderate preterm live-born
singletons (33-34 weeks) and 618 unmatched full-term controls (39-40 weeks). Methods: Data
from the EPIPAGE study were analysed using polytomous logistic regression models to control
for social and demographic characteristics, lifestyle habits during pregnancy and obstetric history.
The main mechanisms of preterm delivery were classified as gestational hypertension, antepartum
haemorrhage, fetal growth restriction, premature rupture of membranes, idiopathic preterm labor
and other causes. Main Outcome Measures: Odds ratios for very preterm birth by gestational
age and by pregnancy complications leading to preterm delivery associated with a history of
induced abortion. Results: Women with a history of induced abortion were at higher risk of very
preterm delivery than those with no such history (OR + 1.5, 95% CI 1.1-2.0); the risk was even
higher for extremely preterm deliveries (< 28 weeks). The association between previous induced
abortion and very preterm delivery varied according to the main complications leading to very
preterm delivery. A history of induced abortion was associated with an increased risk of
premature rupture of the membranes, antepartum haemorrhage (not in association with
hypertension) and idiopathic spontaneous preterm labour that occur at very small gestational ages
(< 28 weeks). Conversely, no association was found between induced abortion and very preterm
delivery due to hypertension. Conclusion: Previous induced abortion was associated with an
increased risk of very preterm delivery. The strength of the association increased with decreasing
gestational age.
(4.) Stang P, Hammond AO, Bauman P. Induced Abortion Increases the Risk of Very
Preterm Delivery; Results from a Large Perinatal Database. Fertility Sterility Sept
2005;S159
ABSTRACT
Objective: 49% of pregnancies among American women are unintended; 1/2 of these are
terminated by abortion. In 2000, 1.31 million abortions took place in the USA. There has been
debate over the impact of induced abortions (VTP) on future pregnancy outcome, particularly the
risk of very preterm birth (<28 weeks). Sequelae of very preterm delivery remain a major public
health burden. The objective of our study was to evaluate the association between prior induced
abortions and birth before 28 weeks gestation. Design: Retrospective analysis of a perinatal data
base. Materials and methods: Setting: 29 delivery units in the State of Schleswig-Holstein,
Germany, between 1991 and 1997. Patients: 170,254 women with singleton pregnancies.
Intervention: Univariate cross table analysis and logistic regression were conducted to determine
the association between previous induced first trimester abortions and delivery before 28 weeks
gestation. Main outcome measures: Maternal age, smoking, cervical incompetence, preterm
premature rupture of membranes (PPROM), history of uterine hemorrhage before 28 weeks,
maternal hypertension, delivery before 28 weeks. Results: 64586 nulliparous women were
included, 4572 (7.1 %) of whom had up to 9 VTPs . Maternal age was 27.4 ± 4.7 years in controls
and 29.1 ± 5.2 in the subjects. There was no difference in gestational age[(25.9 ± 1.9 weeks
(controls), 25.4 ± 2.1 (subjects)]. Univariate relations between VTP and risk factors for preterm
delivery are shown in table 1. Logistic regression demonstrated the following associations with
delivery before 28 weeks: Cervical incompetence OR 4.46, CI 3.18-6.27; hemorrhage < 28 wks,
OR 3.33, CI 2.37 - 2.69; hypertension, OR 3.18, CI 2.17-4.67; PPROM, OR 4.67, CI 3.45-6.33,
first trimester miscarriage, OR 1.67, CI 1.25-2.21, and VTP, OR 1.55, CI 1.07-2.34. There was no
association between smoking or AMA and very preterm delivery.

(5.) Smith GCS, Shah I, White IR, Pell JP, Crossley JA, Dobbie R. Maternal and
biochemical predictors of spontaneous preterm birth among nulliparous women: a
systematic analysis in relation to degree of prematurity. Intl J Epidem
2006;35(5):1169-1177.
ABSTRACT
Background: Nulliparous women are at increased risk of spontaneous preterm birth. Other
maternal and biochemical risk factors have also been described. However, it is unclear whether
these associations are strong enough to offer clinically useful prediction. It is also unclear whether
the predictive power of these factors varies in relation to the degree of prematurity. Methods: The
risk of spontaneous preterm birth associated with maternal characteristics and second trimester
serum screening data was analysed in a dataset of 84 391 first births in Scotland between 1992
and 2001 using Cox and logistic regression. Variation in the relative risk of preterm birth over the
period 24–36 weeks was assessed using a test of the proportional hazards assumption. Results:
The risk of spontaneous preterm birth was positively associated with maternal serum levels of
alpha-fetoprotein, socioeconomic deprivation, number of previous therapeutic abortions, smoking,
and being unmarried and was negatively associated with height and body mass index. The risk of
preterm birth at 24–28 weeks, but not later gestations, was increased in association with maternal
levels of human chorionic gonadotrophin >95th percentile, maternal age <20, and two or more
previous miscarriages. The area under the receiver operating characterise curve (95% CI) for
models based on these factors was 0.67 (0.63–0.71) for 24–28 weeks, 0.65 (0.62–0.68) for 29–32
weeks, and 0.62 (0.61–0.63) for 33–36 weeks. Conclusions: Time to event analytic methods can
identify factors that are differentially associated with spontaneous preterm birth according to the
degree of prematurity. However, models based on maternal and biochemical data perform poorly
as a screening test for any degree of spontaneous preterm birth.

(6.) Levin AA, Schoenbaum SC, Monson RR, Stubblefield PG, Ryan JA. Association of
Induced Abortion with Subsequent Pregnancy Loss. JAMA 1980;243(24):2495-2499
ABSTRACT
We compared prior pregnancy histories of two groups of multigravidas--240 women having a
pregnancy loss up to 28 weeks' gestation and 1,072 women having a term delivery. Women who
had had two or more prior induced abortions had a twofold to threefold increase in risk of first-
trimester spontaneous abortion, loss between 14 to 19 and 20 to 27 weeks. The increased risk was
present for women who had legal induced abortions since 1973. It was not explained by smoking
status, history of prior spontaneous loss, prior abortion method, or degree of cervical dilatation.
No increase in risk of pregnancy loss was detected among women with a single prior induced
abortion. We conclude that multiple induced abortions do increase the risk of subsequent
pregnancy losses up to 28 weeks' gestation.

BIBLIOGRAPHY
The following list provides 51 peer-reviewed studies demonstrating a significant risk
between IA and subsequent preterm birth since 1989. This list is not exhaustive.

* studies that included spontaneous and induced abortions but did not report preterm birth and
low birth weight (LBW) risk separately for each.

+ studies that found a dose response effect (signifying an increased risk of preterm birth
following increased number of induced abortions.)

1990s

+A01 Vasso L-K, Chryssa T-B, Golding J. Previous obstetric history and subsequent
preterm delivery in Greece. European J Obstetrics & Gynecology Reproductive
Biology 1990;37:99-109.

A02 Li YJ, Zhou YS. Study of factors associated with preterm delivery. Zhongjua Liu
Xing Bing Xue Za Chi. Aug 1990;11(4):229-234.

A03 Harger JH, Hsing AW, Tuomala RE, Gibbs RS, Mead PG et al. Risk factors for
preterm premature rupture of fetal membranes: A multicenter case-control study.
Am J Obstet Gynec 1990;163:130-137.

A04 McGregor JA, French J, Richter R. Antenatal microbiologic and maternal risk
factors associated with prematurity. Amer J Obstet Gynecol 1990;163:1465-1473

A05 Pickering RM, Deeks JJ. Risks of Delivery during 20th to the 36th Week of
Gestation. Intl. J Epidemiology 1991;20:456-466.

*+A06 Zhang J, Savitz DA. Preterm Birth Subtypes among Blacks and Whites.
Epidemiology 1992;3:428-433.
*A07 Michielutte R, Ernest JM, Moore ML, Meis PJ, Sharp PC, Wells HB, Buescher
PA. A Comparison of Risk Assessment Models for Term and Preterm Low
Birthweight. Preventive Medicine 1992;21:98-109.

A08 Gong JH. Preterm delivery and its risk factors. Zhounghua Fu Chan
Ke Za Chi Jan. 1992;27(1):22-24

A09 Mandelson MT, Maden CP, Daling JR. Low Birth Weight in Relation Multiple
Induced Abortions. Am J Public Health 1992;82;391-394

+A10 Lumley J. The epidemiology of preterm birth. Bailliere's Clin Obstet Gynecology.
1993;7(3):477-498

A11 Algert C, Roberts C, Adelson P, Frammer M. Low birth weight in New South
Wales, 1987: a Population-Based Study. Aust New Zealand J Obstet Gynaecol
1993;33:243-248.

A12 Ekwo EE, Grusslink CA, Moawad A. Previous pregnancy outcomes and
subsequent risk of premature rupture of amniotic sac membranes. Brit J Obstet
Gynecol 1993;100(6):536-541.

A13 Lekea-Karanika V, Tzoumaka-Bangoula C. Past obstetric history of the mother

and its association with low birth weight of a subseaquent child: a population-
based study. Paediatric Perinat Epidemiol 1994;8:173-187

A14 Guinn D, Goldenberg RL, Hauth JC, Andrews WA, Thom E, Romero R. Risk
factors for the development of preterm premature rupture of membranes after
arrest of preterm labor. AJOG 1995;173(4):1310-1315.

*A15 Hillier SL, Nugent RP, Eschenbach DA, Krohn MA,et al. Association Between
Bacterial Vaginosis And Preterm Delivery Of A Low-Birth-Weight Infant. NEJM
1995;333:1737-1742.

A16 Khalil AK, El-Amrawy SM, Ibrahim AG, et al. Pattern of growth and
development of premature children at the age of two and three years in
Alexandria, Egypt. Eastern Mediterranean Health Journal 1995;1(2):186-193.

A17 Meis PJ, Michielutte R, Peters TJ, Wells HB. Factors associated with preterm
birth in Cardiff, Wales. Amer J Obstet Gynecol 1995;173:590-596.

+A18 Lang JM, Lieberman E, Cohen A. A Comparison of Risk Factors for Preterm
Labor and Term Small-for-Gestational-Age Birth. Epidemiology 1996;7:369-376.

*A19 Hagan R, Benninger H, Chiffings D. Evans S, French H. Very preterm birth - a

regional study. Part 1: Maternal and obstetric factors. BJOG 1996;103:230-238.
A20 Chie-Pein Chen, Kuo-Gon Wang, Yuh-Cheng Yang, Lai-Chu See. Risk factors
for preterm birth in an upper middle class Chinese population. Eur J Obstet
Gynecol Reprod Bio 1996;70(1):53-59.

A21 Jacobsen G, Schei B, Bakketeig LS. Prepregnant reproductive risk and subsequent
birth outcome among Scandinavian parous women. Norsk Epidemiol
1997;7(1):33-39.

+A22 Lumley J. The association between prior spontaneous abortion, prior induced
abortion and preterm birth in first singleton births. Prenat Neonat Med 1998;3:21-
24.

+A23 Martius JA, Steck T, Oehler MK, Wulf K-H. Risk factors associated with preterm
(<37+0 weeks) and early preterm (<32+0 weeks): univariate and multi-variate
analysis of 106 345 singleton births from 1994 statewide perinatal survey of
Bavaria. European J Obstetrics & Gynecology Reproductive Biology 1998;80:
183-189.

A24 Small Babies in Scotland A Ten Year Overview 1987-1996. Information and
Statistics Division. The National Health Service in Scotland. Scottish Program
for Clinical Effectiveness. Edinburgh 1998 ISBN 1-902076-07-9.

A25 Lee KS, Lee WC, Meng KH, Lee Ch, Kim SP. Maternal Factors Associated with
the Premature Rupture of Membrane in the Low Birth Weight Infant Deliveries.
Korean J Prev Med 1998;21(2):207-216.

+A26 Ancel PY, Saurel-Cubizolles M-J, Renzo GCD, Papiernik E, Breart G. Very and
moderate preterm births: are the risk factors different? British J Obstetrics and
Gynaecology 1999;106:1162-1170.

+A27 Zhou W, Sorenson HT, Olsen J. Induced Abortion and Subsequent Pregnancy
Duration. Obstetrics & Gynecology 1999;94:948-953.

A28 Ancel PY, Saurel-Cubizolles, Di Renzo GC, Papiernik E, Breart G Social

Differences of very preterm birth in Europe: interaction with obstetric history.
American J Epi 1999;149(10):908-915.

2000-2007

A29 Foix-L'Helias L, Ancel PY, Blondel B. Changes in risk factors of preterm

delivery in France between 1981 and 1995. Paediatric and Perinatal
Epidemiology. Oct 2000;14(4):314-323.

A30 Foix-L'Helias L, Ancel, Blondel B. Risk factors for prematurity in France and
 comparisons betweeen spontaneous prematurity and induced labor; results from
the National Perinatal Survey 1995. J Gynecol Obstet Bio Reprod (Paris) Feb
2000;29(1);55-65.

*A31 Gardosi J, Francis A. Early Pregnancy predictors of preterm birth: the role
of a prolonged menstruation-conception interval. BJOG 2000;107(2):228-237.

A32 Bettiol H, Rona RJ, Chin S, Goldani M, Barberi M. Risk Factors Associated
with preterm births in Southeast Brazil: a comparison of two birth cohorts
born 15 years apart. Paediatric Perinatal Epidemiol 2000;14(1):30-38.

+A33 Henriet L, Kaminski M. Impact of induced abortions on subsequent pregnancy

outcome: the 1995 French national perinatal survey. British J Obstetrics
Gynaecology 2001;108:1036-1042.

A34 Letamo G, Majelantle RG. Factors Influencing Low Birth Weight and Prematurity
in Botswana. J Biosoc Sci 2001;33(3):391-403.

A35 Grimmer I, Buhrer C, Dudenhausen JW. Preconceptional factors associated with

very low birth weight delivery: a case-control study. BMC Public Health 2002;
2:10 [Germany].

A36 Balaka B, Boeta S, Aghere AD, Boko K, Kessie K, Assimadi K. Risk factors
associated with prematurity at the University of Lme, Togo. Bull Soc Pathol Exot
Nov 2002;95(4):280-283.

A37 Han WH, Chen LM, Li CY. Incidences of and Predictors for Preterm Births and
Low Birth Weight Infants in Taiwan. Chinese Electronic Periodical Services
2003:131-141.

A38 Reime B, Schuecking BA, Wenzlaff P. Perinatal outcomes of teenage

pregnancies according to gravidity and obstetric history. Annals of Epidemiology
2004;14(8):619-619 [German subjects].

+A39 Ancel PY, Lelong N, Papiernik E, Saurel-Cubizolles MJ, Kaminski M. History

of induced abortion as a risk factor for preterm birth in European countries:
results of EUROPOP survey. Human Repro 2004; 19(3): 734-740.

A40 Umeora OUJ, Ande ABA, Onuh SO, Okubor PO et al. Incidence and risk factors
for preterm delivery in a tertiary health institution in Nigeria. J Obstet Gynaecol
2004;24(8):895-896.

+A41 Moreau C, Kaminski M, Ancel PY, Bouyer J, Escande B, et al. Previous induced
abortions and the risk of very preterm delivery: results of the EPIPAGE study.
British J Obstetrics Gynaecology 2005;112(4):430-437.

A42 Conde-Agudelo A, Belizan JM, Breman R, Brockman SC, Rosas-Bermudez.

 Effect of the interpregnancy interval after an abortion on maternal and perinatal
health in Latin America. Int J Gynaecol & Obstet 2005;89 (Supp. 1):S34-S40.

A43 Stang P, Hammond AO, Bauman P. Induced Abortion Increases the Risk of
Very Preterm Delivery; Results from a Large Perinatal Database. Fertility
Sterility Sept 2005;S159.

A44 Etuk SJ, Etuk IS, Oyo-Ita AE. Factors Influencing the Incidence of Pre-term
Birth in Calabar, Nigeria. Nigerian J Physiological Sciences 2005;20(1-2):63-68.

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Characteristics and treatment modalities on singleton pregnancies after assisted
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2006;6:13.

A47 Smith GCS, Shah I, White IR, Pell JP, Crossley JA, Dobbie R. Maternal and
biochemical predictors of spontaneous preterm birth among nulliparous women: a
systematic analysis in relation to degree of prematurity. Intl J Epidem
2006;35(5):1169-1177.

A48 Briunsma F, Lemley J, Tan J, Quinn M. Precancerious changes in the cervix and
risk of subsequent preterm birth. BJOG Jan. 2007;114(1):70-80

A49 Jackson JE, Grobman WA, Haney E, Casele H. Mid-trimester dilation and
evacuation with laminaria does not increase the risk for severe subsequent
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*+A50 Brown TS, Adera T, Masho SW. Previous abortion and the risk of low birth
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A51 Reime B, Schuecking BA, Wenzlaff P. Reproductive Outcomes in Adolescents

Who Had a Previous Birth or an Induced Abortion Compared to Adolescents'
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Induced Abortion and
Risk of Later Premature Births
Brent Rooney
Byron C. Calhoun, M.D.
ABSTRACT
At least 49 studies have demonstrated a statistically significant
increase in premature births (PB) or low birth weight (LBW) risk in
women with prior induced abortions (IAs). This paper will focus on
the risk of early premature births (EPBs) (< 32 weeks gestation)
and extremely early premature births (XPBs) (< 28 weeks gesta-
tion). Large studies have reported a doubling of EPB risk from two
prior IAs. Women who had four or more IAs experienced, on aver-
age, nine times the risk of XPB, an increase of 800 percent.
These results suggest that women contemplating IA should be
informed of this potential risk to subsequent pregnancies, and that
physicians should be aware of the potential liability and possible
need for intensified prenatal care.
Informed consent for an elective surgical procedure must gen-
erally cover long-term consequences and not just immediate risk. A
woman considering an induced abortion (IA) should thus expect to
be informed of potential effects on her fertility and the health of fu-
ture infants, as well as her own future health. An elevated risk of
bearing a child afflicted with a serious disability such as cerebral
palsy might influence her decision, as well as future liability deter-
minations by courts.
Low birth weight (LBW) and premature birth (PB) are the most
important risk factors for infant mortality or later disabilities1 as
well as for lower cognitive abilities and greater behavioral
problems2 and thus contribute importantly to the liability exposure
of obstetricians.
A literature review retrieved 49 studies that demonstrated at
least 95 percent confidence in an increased risk of preterm birth
(PB), or surrogates such as low birth weight or second-trimester
spontaneous abortion, in association with previous induced abor-
tions. A list of these studies, which probably does not comprise all
such studies, is appended to this article. If these 49 statistically sig-
nificant associations were the result of chance alone, as may happen
in 5 of 100 tests, IA should be associated with a reduction in PBs,
with P<.05, in an equivalent number of tests. Not one such instance
has been found in the literature.
A MedLine search from 1966 to March, 2003, retrieved 8 stud-
ies that purportedly failed to show a significant increase in prema-
ture births after IA.3-10 Most showed an increase that did not reach
statistical significance because of the small sample size: fewer than
1,000 pregnancies following an IA. In one, an increased risk of PB
in women who had had an IA was nonsignificant when controlled
for parity.3 These studies did not consider separately the risk of
EPBs or XPBs, or the effect of multiple IAs, except one that showed
a statistically significant increase of EPB, despite the statement in
the abstract that “in the Netherlands there are no significant indica-
tions that spontaneous midtrimester abortions or premature deliver-
ies are caused by a previous induced abortion.”6
46 Journal of American Physicians and Surgeons Volume 8
A 1986 review concluded that “more research is needed before
it is clear whether multiple induced abortions carry an increased
11
risk of adverse pregnancy outcomes.” The more recent, large stud-
ies discussed here help supply this lack.
Australian Study
12
A 1993 study in Victoria, Australia, involved 121,305 total
births and compared the risk of PB and XPB in women with various
numbers of IAs, compared with a control group of women who had
no prior pregnancies (see Table 1, derived from data in this report).
Table 1: Premature birth risk by number of prior induced abortions (IAs)
12
compared with outcome of first pregnancies, Victoria, 1986-1990
As Lumley explains:
The associations are different in the three gestation catego-
ries (20-27, 28-31, and 32-36 weeks), being particularly
striking for births before 28 weeks. In this category, there is
also evidence for a dose-response relationship between num-
ber of prior lost pregnancies and the prevalence of preterm
birth: relative risks of 1.66 and 1.55 for one spontaneous or
induced abortion, of 2.94 and 2.46 for two, and of 5.89 and
5.58 for three or more. These last four relative risks are sub-
stantially greater than any of those associated with maternal
age, marital status, parity or socioeconomic status: that is,
the association is most unlikely to be explained by con-
12
founding factors of a sociodemographic kind.
Lumley's argument that “small single possible confounders can-
not explain big risk factors such as 2.46 and 5.58” would also apply
to any attempt to pose smoking or drug abuse as an explanation for
the entire abortion-premature birth association.
The great majority of theAustralian IAs were via vacuum aspi-
ration; thus the PB risk cannot be attributed to dilation & curet-
tage IAs.
The author noted that cross-sectional studies show that the rel-
ative risk of preterm delivery increases with the number of the pre-
vious preterm births, but that the risk of subsequent preterm
12
births diminishes with each full-term delivery. Thus, IA re-
moves the protective potential of a full-term delivery, as others
13
have also observed.
Number 2 Summer 2003
 In 1998, with twice the number of births (243,679) to analyze as
14
in 1993, Lumley validated her 1993 results and additionally
showed that women with four or more prior IAs had an XPB risk
nine times that of primigravidas.
German Study
Another large study of 106,345 births in Bavaria,15 including 85
percent of births in the state and 1,146 EPBs, showed a comparable
dose-response curve (see Table 2, extracted from Table 2 in the
Bavarian study), confirming the Australian finding of the greatest
increased risk for the earliest premature infants.
In a multivariate analysis that included many of the possible con-
founding variables, including previous stillborns, infertility treat-
ment, age under 18 or over 35 years, malpresentation, premature
rupture of membranes, and preeclampsia, the effect of even a single
IAremained significant.
Table 2: Odds ratio (OR) for premature births by number
of prior induced abortions (IAs)
15
Danish Study
A 1999 study of Danish women16 is especially important be-
cause it used an IA registry, thus eliminating recall bias, the hypoth-
esis that women with prior IAs who deliver prematurely are more ac-
curate in reporting reproductive history than women who deliver at
full term, as a possible explanation for the results.
This study of 61,753 women found an odds ratio for preterm
birth at <34 weeks gestation of 1.99 (95% CI 1.64-2.43) for one
prior IA and 2.03 (95% CI 1.36-3.04) for two or more prior IAs.
Vacuum aspiration (VA) was the method used in 92.3 percent of all
abortions. For VA, PB (gestation <37 weeks) odds ratios for 1, 2, 3
or more IAs were: 1.82, 2.45, and 2.00, respectively.
Dilation and evacuation increased the risk substantially. One
evacuation was associated with a PB odds ratio of 2.27 whereas two
prior evacuations had a very large odds ratio of 12.55.
Mechanisms forAbortions Causing a Premature Birth Risk
An accepted risk of surgical IA is incompetent cervix, which is
a PB risk factor.17 Nulliparous women who have multiple IAs boost
their odds of being over age 35 at their first term delivery, a risk fac-
tor for PB.14,15 Additional risk factors for PB that may be increased
by abortion include uterine adhesions,14,23 infection,17-19 and mental
distress.17
The evidence meets four of the criteria for determining
causality:14 (1) the abortions preceded the premature births; (2) the
association is strong; (3) there is a dose-response relationship; and
(4) the association is plausible. A criterion for causality that could
not be met in 1998 was confirmation by a prospective study.
However, the Danish study identified all subsequent pregnancies
until 1994 of the women under study, whose first pregnancies oc-
Journal of American Physicians and Surgeons Volume 8 Number 2 Summer 2003
curred in 1980, 1981, and 1982.16 Reversibility of the exposure is
not applicable to this circumstance. Consistency of findings with
earlier studies cannot be assessed because these were not stratified
by length of gestation, number of prior pregnancies, and number of
IAs.14 However, the large studies in Germany, Denmark, and
Australia consistently support multiple prior IAs as boosting EPB
risk.14-16 Only theAustralian studies included an XPB category.12,14
Liability and Informed Consent
Recent litigation by women who claim that they were not fully
informed about all the risks of an elective abortion, especially a pos-
sible increased lifetime risk of breast cancer, has drawn attention to
the process of obtaining informed consent for this procedure.
Moreover, even a signed consent form does not suffice to relieve a
physician in the U.S. or Canada of the responsibility to withhold a
treatment that he knows, or ought to know, is medically contraindi-
cated.20 What level of risk will courts determine to constitute a medi-
cal contraindication?
Liability costs are especially high in cases involving damaged
babies. The median damage award in cases of medical negligence
in attending at childbirth was $2,050,000 between 1994 and 2000.21
Women are warned in a classic book covering 50 risk factors for
PB that “if you have had one or more induced abortions, your risk of
prematurity with this pregnancy increases by about 30 percent.”22
As shown here, the risk could be substantially higher than that, de-
pending on the number of abortions and the method used.
It has been claimed that “induced abortion...is directly responsi-
ble for many thousands of cases of cerebral palsy–in North America
alone–that otherwise would not have occurred.”23 Supporting this
assertion is the fact that the cerebral palsy risk in XPB is about 38
times higher than in the overall population of newborns,1 in which
the risk of cerebral palsy is approximately 2-3 per 1,000 births.24 As
the liability costs for cerebral palsy are exceptionally high, induced
abortion, particularly without very detailed informed consent, may
carry an unsupportable legal liability. Courts may not require defin-
itive proof of causation; the existence of a number of positive stud-
ies, in the absence of definitive refutation, may be sufficient reason
to include discussion of a potential serious adverse effect in obtain-
ing informed consent.
A consent form that simply lists such items as “incompetent cer-
vix” or “infection” as potential complications, but does not inform
women of the elevated future risk of a preterm delivery, and that the
latter constitutes a risk factor for devastating complications such as
cerebral palsy, may not satisfy courts.
The authors of a recent CME review survey article, which eval-
uated 24 studies of abortion and PB, strongly affirmed the need for
informed consent. They stated that prior IAs boost the risk of PB
and that 7 of 12 significant studies that they reviewed identified a
dose-response effect, with risks increasing with the number of IAs.25
Brent Rooney is a medical researcher. He may be contacted at the Reduce
Preterm Risk Coalition, 3456 Dunbar St. (146), Vancouver, Canada V6S
2C2. E-mail address: stopcancer@yahoo.com or whatsup@vcn.bc.ca.
Byron C. Calhoun, M.D., F.A.C.O.G., F.A.C.S., is Director, Perinatal
Assessment Unit, Rockford Memorial Medical Center in Rockford, IL;
Visiting Clinical Professor in Obstetrics and Gynecology, University of
Illinois at Chicago; and Adjunct Professor of Obstetrics and Gynecology,
Midwestern University, Chicago College of Osteopathic Medicine.
Editorial assistance by Jane M. Orient, M.D., is gratefully acknowledged.
47

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Meirik O, Bergstrom R. Outcome of delivery subsequent to vacuum-
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Van der Slikke JW, Treffers PE. Influence of induced abortion on gesta-
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Schott G, Ehrig E, Wulff V. Prospective studies into pregnancies of
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Kalish RB, Chasen ST, Rosenzweig LB, Rashbaum WK, Chervenak FA.
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Lao TT, Ho LF. Induced abortion is not a cause of subsequent preterm de-
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Hogue CJ. Impact of abortion on subsequent fecundity. Clin Obstet
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Lumley J. The epidemiology of preterm birth. Bailliere's Clin Obstet
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Hogue CJ, Cates W Jr., Tietze C. Impact of vacuum aspiration on future
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Lumley J. The association between prior spontaneous abortion, prior in-
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Martius JA, Steck T, Oehler MK, Wulf K-H. Risk factors associated with
preterm (<37+0 weeks) and early preterm (<32+0 weeks): univariate
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perinatal survey of Bavaria. Eur J Obstet Gynecol Reprod Biol
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Zhou W, Sorenson HT, Olsen J. Induced Abortion and subsequent preg-
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Berkowitz GS, Papiernik E. Epidemiology of preterm birth. Epidemiol Rev
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Muhlemann K, Germain M, Krohn M. Does an abortion increase the risk of
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Daling JR, Krohn MA, Miscarriage or termination in the immediately pre-
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Picard E, Robertson G. Legal Liabilities of Doctors and Hospitals in
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APPENDIX: Studies that showed a statistically
significant increase in preterm birth after induced
abortion
*Ancel P-V, Saurel-Cubizolles M-J, Renzo GCD,
Papiernik E, Breart G. Very and moderate
preterm births: are the risk factors different? Br
J Obstet Gynaecol 1999;106:1162-1170.
Barsy G, Sarkany J. Impact of induced abortion
on the birth rate and infant mortality.
Demografia 1963;6:427-467.
Berkowitz GS. An epidemiologic study of
pr e t erm d elivery. A m J Ep id e miol
1981;113:81-92.
Bognar Z, Czeizel A. Mortality and morbidity asso-
ciated with legal abortions in Hungary, 1960-
1973. Am J Public Health 1976;66:568-575.
Czeizel A, Bognar Z, Tusnady G, et al. Changes in
mean birth weight and proportion of low-
weight births in Hungary. Br J Prev Soc Med
1970;24:146-153.
Drac P, Nekvasilova Z. Premature termination of
pregnancy after previous interruption of preg-
nancy. Cesk Gynekol 1970;35:332-333.
Furusawa Y, Koya Y. The influence of artificial
abortion on delivery. In: Koya Y, ed. Harmful
Effects of Induced Abortion. Tokyo: Family
Planning Federation of Japan; 1966:74-83.
Grindel B, Lubinski H, Voigt M. Induced abortion
in primigravidae and subsequent pregnancy,
with particular attention of underweight.
Zentralbl Gynaekol 1979;101:1009-1114.
Harlap S, Davies AM. Late sequelae of induced
abortion: complications and outcome of preg-
n a n c y a n d l a b o r. A m J E p i d e m i o l
1975;102:219-224.
Henriet L, Kaminski M. Impact of induced abor-
tions on subsequent pregnancy outcome: the
1995 French national perinatal survey. Br J
Obstet Gynaecol 2001;108:1036-1042.
*Hillier SL, Nugent RP, Eschenbach DA, Krohn
MA, et al. Association between bacterial
vaginosis and preterm delivery of a low-
birth-weight infant. N Engl J Med 1995;333:
1737-1742.
Hungarian Central Statistical Office.
Perinatalishalazons. Budapest: Hungarian
Central Statistical Office; 1972.
Koller O, Eikhom SN. Late sequelae of induced
abortion in primigravidae. Acta Obstet Gynecol
Scand 1977;56:311-317.
Kreibich H, Ludwig A. Early and late complica-
tions of abortion in juvenile primigravidae (in-
cluding recommended measures). Z Aerztl
Fortbild (Jena) 1980;74:311-316.
Lang JM, Lieberman E, Cohen A. A Comparison
of Risk Factors for Preterm Labor and Term
Small-for-Gestational-Age Birth. Epidemiology
1996;7:369-376.
Lean TH, Hogue CJR, Wood J. Low birth weight
after induced abortion in Singapore. Presented
at the 105th Annual Meeting of the American
Public Health Association, Washington D.C.,
Oct. 31, 1977.
Legrillo V. Quickenton P, Therriault GD, et al.
Effect of induced abortion on subsequent re-
productive function. Final report to NICHD.
Albany, N.Y.: New York State Health
Department; 1980.
Lerner RC, Varma AO. Prospective study of the
outcome of pregnancy subsequent to previous
induced abortion. Final report, Contract no.
(N01-HD-62803). New York: Downstate
Medical Center, SUNY, January 1981.
Levin A, Schoenbaum S, Monson R, Stubblefield
P, Ryan K. Association of abortion with subse-
quent pregnancy loss. JAMA 1980;243(24):
2495-2499.
L i e b e r m a n E , R y a n K J, M ons on RR,
Schoenbaum SC. Risk factors accounting for
racial differences in the rate of premature birth.
N Engl J Med 1987;317: 743-748.

48 Journal of American Physicians and Surgeons Volume 8 Number 2 Summer 2003

Lumley J. Very low birth-weight (less than 1500g)
and previous induced abortion: Victoria 1982-
1983. Aust NZ J Obstet Gynecol 1986;26:268-272.
Lumley J. The epidemiology of preterm birth.
Bailliere's Clin Obstet Gynecol 1993;7(3): 477-498.
Lumley J. The association between prior sponta-
neous abortion, prior induced abortion and
preterm birth in first singleton births. Prenat
Neonat Med 1998;3:21-24.
Martius JA, Steck T, Oehler MK, Wulf K-H. Risk fac-
tors associated with preterm (<37+0 weeks)
and early preterm (<32+0 weeks): univariate
and multivariate analysis of 106 345 singleton
births from 1994 statewide perinatal survey of
Bavaria. Eur J Obstet Gynecol Reprod Biol
1998;80:183-189.
Meirik O, Bergstrom R. Outcome of delivery sub-
sequent to vacuum aspiration abortion in
nulliparous women. Acta Obstet Gynecol
Scand 1982;61:415-429.
*Michielutte R, Ernest JM, Moore ML, Meis PJ,
Sharp PC, Wells HB, Buescher PA. A
Comparison of Risk Assessment Models for
Term and Preterm Low Birthweight. Prev Med
1992;21:98-109.
Miltenyi K. On the effects of induced abortion.
Demografia 1964;7:73-87.
Mocsary P, Csapo AI. Effect of menstrual induc-
tion on prematurity rate. Lancet 1978;1:1159-
1160.
Mueller-Heubach E, Guzick DS. Evaluation of
risk scoring in a preterm birth prevention study
of indigent patients. Am J Obstet Gynecol
1989;160:829-837.
Obel E, et al. Pregnancy complications following
legally induced abortion with special reference
to abortion technique. Acta Obstet Gynecol
Scand 1979;58:147-152.
Pantelakis SN, Papadimitriou GC, Doxiadis SA.
Influence of induced and spontaneous abor-
tions on the outcome of subsequent pregnan-
cies. Am J Obstet Gynecol 1973;116:799-805.
“Since among practitioners there will prove to be so much difference of opinion about acute diseases that
the remedies which one physician gives in the belief that they are the best are considered by a second to be
bad, laymen are likely to object to such that their art resembles divination; for diviners too think that the
same bird, which they hold to be a happy omen on the left, is an unlucky one when on the right, while other
diviners maintain the opposite.”
[Fortunately AAPS can discern right from left, and open debate is welcome.]
Journal of American Physicians and Surgeons Volume 8
Papaevangelou G, Vrettos AS, Papadatos D,
Alexiou C. The effect of spontaneous and in-
duced abortion on prematurity and
birthweight. J Obstet Gynaecol Br
Commonwealth. 1973;80(May):418-422.
Pickering RM, Forbes J. Risk of preterm delivery
and small-for-gestational age infants following
abortion: a population study. Br J Obstet
Gynecol 1985;92:1106-1112.
Pickering RM, Deeks JJ. Risks of Delivery during
20th to the 36th Week of Gestation. Int J
Epidemiol 1991;20:456-466.
Puyenbroek J, Stolte L. The relationship between
spontaneous and induced abortions and the
occurrence of second-trimester abortion in sub-
sequent pregnancies. Eur J Obstet Gynecol
Reprod Biol 1983;14:299-309.[This is the only
study in this complete list that uses second-
trimester abortion as a surrogate for PTB.]
Ratten G et al. Effect of abortion on maturity of
subsequent pregnancy. Med J Aust
1979(June):479-480.
Richardson JA, Dixon G. Effect of legal termina-
tion on subsequent pregnancy. BMJ
1976;1:1303-1304.
Roht LH, Aoyama H, Leinen GE, et al. The associ-
ation of multiple induced abortions with subse-
quent prematurity and spontaneous abortion.
Acta Obstet Gynaecol Jpn 1976;23:140-145
Schoenbaum LS, Monson RR. No association be-
tween coffee consumption and adverse out-
comes of pregnancy. N Engl J Med
1982;306:141-145.
Seidman DS, Ever-Hadani P, Slater PE, Harlap S,
et al. Child-bearing after induced abortion: reas-
sessment of risk. J Epidemiology Community
Health 1988;42:294-298.
Shiono PH, Lebanoff MA. Ethnic differences and
very preterm delivery. Am J Public Health
1986;76:1317-1321.
Medical Controversy
Hippocrates Regimen in Acute Diseases
Number 2 Summer 2003
Slater PE, Davies AM, Harlap S. The effect of abor-
tion method on the outcome of subsequent
pregnancy. J Reprod Med 1981;28:123-128.
Van der Slikke JW, Treffers PE. Influence of in-
duced abortion on gestational duration in sub-
sequent pregnancies. BMJ 1978;1:270-272.
Vasso L-K, Chryssa T-B, Golding J. Previous ob-
stetric history and subsequent preterm deliv-
ery in Greece. Eur J Obstet Gynecol Reprod
Biol 1990;37:99-109.
World Health Organization. Special Programme
of Research, Development and Research
Training in Human Reproduction: Seventh
Annual Report, Geneva, Nov. 1978.
World Health Organization Task Force on the
Sequelae of Abortion. Gestation, birthweight
and spontaneous abortion. Lancet
1979;1:142-145.
*Zhang J, Savitz DA. Preterm birth subtypes
among blacks and whites. Epidemiology
1992;3:428-433.
Zwahr C, Voigt M, Kunz L, et al. Relationships be-
tween interruption abortion, and premature
birth and low birth weight. Zentralbl Gynaekol
1980;102: 738-747.
Zhou W, Sorenson HT, Olsen J. Induced abortion
and subsequent pregnancy duration. Obstet
Gynecol 1999;94:948-953.
*Studies that included spontaneous and in-
duced abortions but did not report PTB/LBW
risk separately for each
– Lawrence R. Huntoon, M.D., Ph.D.
49