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Abortion and Subsequent Pre-term Birth: Update 2012

Abortion and Subsequent Pre-term Birth: Update 2012. Byron C. Calhoun, MD, FACOG, FACS, MBA Professor and Vice Chair, Obstetrics and Gynecology West Virginia University-Charleston Charleston, WV, USA February, 2012. Disclosure.

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Abortion and Subsequent Pre-term Birth: Update 2012

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  1. Abortion and Subsequent Pre-term Birth: Update 2012 Byron C. Calhoun, MD, FACOG, FACS, MBA Professor and Vice Chair, Obstetrics and Gynecology West Virginia University-Charleston Charleston, WV, USA February, 2012

  2. Disclosure There are no commercial products mentioned in this lecture nor is support being supplied by any vendor, agency, or governmental grant/agent.

  3. Outline • I Introduction/Objectives • II. Frequency of PTB • III. Morbidity of PTB • IV. Review important recent studies • V. Latest Studies 2008-2011 • VI. US Societal costs of abortion • VII. Future issues in abortion and PTB

  4. I. Frequency & Costs • Incidence of preterm delivery is 6% year in US • Births average 3-4 million/year in U.S. • Therefore, 180-240,000 births/year in US • The very preterm births (<28 weeks) include approximately 1% births or 30,000-40,000 births annually • Induced abortion is associated with >$1.2 billion (US) to health costs annually1 1Calhoun BC, Shadigian E, Rooney B. Induced abortion: cost consequences of an attributable risk for preterm birth and its impact on informed consent and medical malpractice. J Repro Med 2007;52 (10):929-937.

  5. II. Morbidity of Preterm Birth • Very low-birth (VLBW) weight costs 28 times (RR) term • ($280,146 versus $9,803)2,3,4 • Low-birth weight costs 4 times (RR) term • ($38,367 versus $9,393)2,3,4 • Cerebral palsy increases by 147 times in VLBW compared to term (> 37 weeks)5 2Petrou S, Mehta Z, Hockley C, Cook-Mozaffari P, Henderson J, Goldacre M. Pediatrics 2003;112(6):1290-1297 3Luke B, Bigger H, Leurgas S, Siesma D. The cost of prematurity: a case-control study of twins vs. singeltons. AM J Publ Health. 1996;86(6):809-814. 4Infant Health in America:Everybody’s Business. Hartford, CT:CIGNA Corp 2000 5Himpens E, Master PT, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type, distribution of cerebral palsy in relation to gestational age: a meta-analysis review. Develop Med & Child Neuro 2008;50:334-340.

  6. Previous Studies Continued • Swingle HM, Colaizy TT, Zimmerman MB, Morriss FH. Abortion and the risk of subsequent preterm birth: A systematic review with meta-analyses. J Rrepro Med 2009;54:95-108.6 • Shah PS, Zao J. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analysis. BJOG 2009;116:1425-1442.7

  7. Meta-analysis by Swingle, et al 2009.6 • Meta-analyses of literature 1995-2007 • Pro-abortion & pro-life authors • 7,891 titles, 349 abstracts, 130 papers • 30 abortion & 26 SAB papers included • Analyzed data from 12 induced and 9 SAB papers • Demonstrated 64% increased risk with single abortion for very preterm birth < 32 weeks

  8. Meta-analysis by Swingle, et al 2009.8 • 12 studies used to calculate common OR’s for induced abortion • 1 induced abortion 1.25 OR [1.03-1.48] increased risk preterm birth < 37 weeks • > 1 induced abortion 1.51 OR [1.21-1.75] increased risk preterm birth < 37 weeks

  9. Meta-analysis by Swingle, et al 2009.6 • 4 studies available for common OR’s for induced abortion < 32 weeks • Common OR 1.64 [1.38-1.91] • Increased very preterm delivery rate of 64% • Similar to other literature’s findings

  10. Meta-analysis by Swingle, et al 2009.6 • 7/12 studies available for common OR with SAB’s for preterm delivery < 37 weeks • 1 SAB 1.43 OR [1.05-1.66] • > 1 SAB 2.27 OR [1.98-2.81]

  11. Meta-analysis by Shah, et al 20097 • Screened 834 papers • Excluded 765 for lack data/objective • 69 citations retrieved • 32 excluded

  12. Meta-analysis by Shah, et al 20097:32 excluded studies • Exclusions • 7 studies no neonatal outcomes • 7 reported combined SAB/abortions • 5 no comparison group • 4 reports reviews • 3 reported VLBW and LBW only • 2 studies specific population only • 2 studies previously published data • 1 duplication publication • 1data not available

  13. Meta-analysis by Shah, et al 20097:37 included studies • 18 studies with Low Birth Weight (LBW) • 22 studies for preterm birth (PTB) • 3 studies for small for gestationaal age (SGA

  14. No abortion vs 1 TAB 18 studies 280,529 patients OR 1.35 [1.20-1.52] No abortions vs > 1 5 studies of 18 49,347 patients 1.72 [1.45-2.04] Meta-analysis by Shah, et al 20097:18 LBW Studies

  15. No abortion vs 1 TAB 22 studies 268,379 patients OR 1.36 [1.24-1.50] No abortions vs > 1 7 studies of 22 158,421 patients 1.93 [1.38-2.71] Meta-analysis by Shah, et al 20097:22 PTB Studies

  16. No abortion vs 1 TAB 3 studies 38,835 patients OR 0.87 [0.69-1.09] No abortions vs > 1 2 studies of 3 35,422 patients 1.06 [0.84-1.33] Meta-analysis by Shah, et al 20097:3 SGA Studies

  17. 2011: another busy year for preterm birth and abortion studies (now 127 studies) • 3 new interesting studies on preterm birth and abortion8-10 • 1 data based linked8 • 2 cohort studies9-10

  18. Di Renzo, et al8 • Multicenter, observational, retrospective and cross-sectional study in 9 centers in Italy • Records linked to outcomes • Power analysis done prior found needed 6,000 women to determine a difference in preterm birth (baseline PTB rate 5%) • Sample included 7,634 women (September-December 2008)

  19. Di Renzo, et al8 • 15 variables evaluated as co-factors • Included BMI, age, medical comorbidities, tobacco abuse, previous cesarean section, and abortion • Did not separate out when abortions occurred or numbers of abortions • Multivariate analysis

  20. Di Renzo, et al8 • OR increased risk preterm birth 1.954 (1.162-3.285) with previous abortion • Also found in the study increased risk with: • BMI >25 OR 1.662 (1.033-2.676) • Previous cesarean OR 2.904 (1.66-7.910)

  21. Di Renzo, et al8 • Conclusions: • Positives • Large, linked data base with power/multivariate analysis • Found increased PTB risk in ALL patients with previous abortions as separate factor • Negatives • Did not separate out abortion timing • Did not do analysis for multiple abortions

  22. Liao, et al9 • Cohort study • 4 years from January 2006-December 2009 • Interview based with delivery outcomes • 18,323 women (19,527 interviewed) (93.8%)

  23. Liao, et al9 • Divided into 3 comparison groups: • Nulliparous women with 1 or more first trimester medical abortions (mefepristone) • Nulliparous with surgical abortions (elective) • Nulliparous with no previous abortions

  24. Liao, et al9 • 7,478 with complete follow up in abortion group out of original 7,558 (98.9%) • 10,546 with complete follow up in no abortion group out of original 10,681 (98.9%)

  25. Liao, et al9 • In no abortion group there were 332 spontaneous abortions 332/10,546 or 3.15% • In the abortion group there were: • 1,769 one medical abortion 1,769/7,468(24%) • 2,900 one surgical abortion 2,900/7,468(38%) • 553 >1 medical abortion 553/7,468(7.4%) • 1,088 >1 surgical abortion 1,088/7,468(15%) • 1,168 with medical/surgical 1,168/7,468 (16%)

  26. Liao, et al9 • OR 1.4 (1.1-1.8) preterm birth with 1 surgical abortion • OR 1.62 (1.27-3.42) preterm birth > 3 surgical abortions (dose effect) • OR 2.18 (1.51-4.42) preterm birth with medical & surgical abortions

  27. Liao, et al9 • OR 1.03 (0.53-1.63) no increase risk of preterm birth with medical abortions compared to no abortions • However, buried in article found 20.3% of patients needed a post-abortion suction curettage • OR 1.69 (1.02-3.16) preterm birth risk in women with medical abortion < 7 weeks with curettage! • AND risk for < 32 week delivery OR was 3.61 (1.43-4.93) with < 7 week medical abortion with curettage (20% of patients!) • Did not report either of these findings in abstract

  28. Liao, et al9 • Conclusions: • Positives • Large group of patients (18,323) • Large number of abortions in several categories • Found increased risk of PTB with surgical abortions and combined surgical/medical abortions

  29. Liao, et al9 • Negatives • Did not share most startling findings regarding abortion in this paper • OR 1.4 (1.1-1.8) preterm birth with 1 surgical abortion • OR 1.62 (1.27-3.42) preterm birth > 3 surgical abortions (dose effect) • OR 2.18 (1.51-4.42) preterm birth with medical & surgical abortions

  30. Liao, et al9 • Negatives continued • need for curettage in 20% medical abortions • OR 1.69 (1.02-3.16) preterm birth risk in women with medical abortion < 7 weeks with curettage! • AND risk for < 32 week delivery OR was 3.61 (1.43-4.93) with < 7 week medical abortion with curettage (20% of patients!) • Interview study and not really data linked

  31. Almedia et al10 • Abstract only in English (Portuguese from Brazil) • Interview and hospital records • 213 live borns < 1500 gms in 2000-2001 • Abortion prior to index delivery related to increased risk for neonatal demise from preterm birth.

  32. V. Societal Costs of Abortion11 • Child born=$1.4 million (US) benefit to society • Child aborted-$200,000 (US) cost to society • Child born=$200,000 (US) input into treasury • Child aborted=$32,000 (US) cost to treasury 11Finger R, Harden H. Societal costs of abortion. Focus on Family, Focus on Social Issues, Worldview and Culture, September 22, 2005. http://family.org/cforum/fosi/worldview/essays/a0038002.cfm

  33. VI. Future Issues: Liability and Informed Consent • Malpractice costs continue to sky-rocket • Median damage award for childbirth: • >$2 million (US) between 1994-200012 • Malpractice premiums ratchet up 30%-50%/year in US • Latest Washington Supreme Court (12/2009) struck down malpractice caps-opens whole tort problem up again 12Zimmerman R, Oster C. Assigning liability: insurers’ missteps helped provoke malpractice “crisis”. Wall St J 2002; June 24:A1.

  34. Questions regarding Abortion and Public Health • Has patient had an abortion prior to incident pregnancy? • How many abortions did patient have? • Dose response • Was patient informed of increased PTB risk with previous abortion? Particularly ethnic risks. • Was patient informed of PTB risk abortion with cerebral palsy risk?

  35. Abortion and PTB • Increase awareness of science, risk, costs • Publish papers documenting known risks • Emphasize risk been known for many years • Encourage policy makers to address • Develop strategies to decrease abortions

  36. Conclusions • Induced abortion increases PTB rates substantially in latest large studies/meta analyses • Ethnic influence compounds the damage in Blacks • Now 127 studies now with statistical significance (February, 2012) • No studies show decreased risk PTB • PTB increases risk for CP by 147 times • Health/care-neonatal costs increased by over $1.2 Billion (US) • Child aborted-$200,000 (US) cost to society/child aborted-$32,000 (US) cost to treasury • Health care organizations/government need to know costs • Patients ought to be informed of long term health/reproductive risks of abortion • Abortion counseling ought to include the preterm birth risk particularly in Blacks and Native Americans.

  37. Questions • Voice Mail: 304-388-1599 • Fax: 304-388-2915 • Email: byron.calhoun@camc.org

  38. References 1Calhoun BC, Shadigian E, Rooney B. Induced abortion: cost consequences of an attributable risk for preterm birth and its impact on informed consent and medical malpractice. J Repro Med 2007;52 (10):929-937. 2Petrou S, Mehta Z, Hockley C, Cook-Mozaffari P, Henderson J, Goldacre M. Pediatrics 2003;112(6):1290-1297 3Luke B, Bigger H, Leurgas S, Siesma D. The cost of prematurity: a case-control study of twins vs. singeltons. AM J Publ Health. 1996;86(6):809-814. 4Infant Health in America:Everybody’s Business. Hartford, CT:CIGNA Corp 2000 5Himpens E, Master PT, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type, distribution of cerebral palsy in relation to gestational age: a meta-analysis review. Develop Med & Child Neuro 2008;50:334-340.

  39. References 6Swingle HM, Colaizy TT, Zimmerman MB, Morriss FH. Abortion and the risk of subsequent preterm birth: A systematic review with meta-analyses. J Rrepro Med 2009;54:95-108. 7Shah PS, Zao J. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analysis. BJOG 2009;116:1425-1442.

  40. References 8Di Renzo GC, Giardia I, Rosati A, Clerici G, Torricelli M, Petraglia F. Matnernal risk factors for preterm birth: a country-based population analysis. Eur J OB/GYN Repro Bio 2011;159:342-346 9Liao H, Weu Q, Duan L, Ge J, Zhou Y, Zeng W. Repeated medical abortions and the risk of preterm birth in the subsequent pregnancy. Arch GynecolObstet 2011;284:579-586.

  41. References 10Almeda MF, et al. Survival and risk factors for neonatal mortality in a cohort of very low birth weight infants in the southern region of Sao Paulo city, Brazil Cad SaudePublica 2011:;27 (6):1088-1098. (English abstract only/paper-Portuguese) 11Finger R, Harden H. Societal costs of abortion. Focus on Family, Focus on Social Issues, Worldview and Culture, September 22, 2005. http://family.org/cforum/fosi/worldview/essays/a0038002.cfm 12Zimmerman R, Oster C. Assigning liability: insurers’ missteps helped provoke malpractice “crisis”. Wall St J 2002; June 24:A1.

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