Pregnancy and Birth Sourcebook Part 4

50.Preventing Unintended Pregnancies Continuous Abstinence This means not having s.e.x (v.a.g.i.n.al, a.n.a.l, or oral) at any time. It is the only sure way to prevent pregnancy and protect against s.e.xually transmitted infections (STIs), including HIV [human immunodeficiency virus].

Natural Family Planning/Rhythm Method This method is when you do not have s.e.x or use a barrier method on the days you are most fertile (most likely to become pregnant).

A woman who has a regular menstrual cycle has about nine or more days each month when she is able to get pregnant. These fertile days are about five days before and three days after ovulation, as well as the day of ovulation.

To have success with this method, you need to learn about your menstrual cycle. Then you can learn to predict which days you are fertile or "unsafe." To learn about your cycle, keep a written record of: * when you get your period; * what it is like (heavy or light blood flow); and * how you feel (sore b.r.e.a.s.t.s, cramps).

This method also involves checking your cervical mucus and recording your body temperature each day. Cervical mucus is the discharge from your v.a.g.i.n.a. You are most fertile when it is clear and slippery like raw egg whites. Use a basal thermometer to take your temperature and record it in a chart. Your temperature will rise 0.4 to 0.8 degrees Fahrenheit on the first day of ovulation. You can talk with your doctor or a natural family planning instructor to learn how to record and understand this information.

Contraceptive Sponge This barrier method is a soft, disk-shaped device with a loop for taking it out. It is made out of polyurethane foam and contains the spermicide nonoxynol-9. Spermicide kills sperm.

Before having s.e.x, you wet the sponge and place it, loop side down, inside your v.a.g.i.n.a to cover the cervix. The sponge is effective for more than one act of intercourse for up to 24 hours. It needs to be left in for at least 6 hours after having s.e.x to prevent pregnancy. It must then be taken out within 30 hours after it is inserted.

51.Pregnancy and Birth Sourcebook, Third Edition Only one kind of contraceptive sponge is sold in the United States.

It is called the Today Sponge. Women who are sensitive to the spermicide nonoxynol-9 should not use the sponge.

Diaphragm, Cervical Cap, and Cervical s.h.i.+eld These barrier methods block the sperm from entering the cervix (the opening to your womb) and reaching the egg.

* The diaphragm is a shallow latex cup.

* The cervical cap is a thimble-shaped latex cup. It often is called by its brand name, FemCap.

* The cervical s.h.i.+eld is a silicone cup that has a one-way valve that creates suction and helps it fit against the cervix. It often is called by its brand name, Lea's s.h.i.+eld.

The diaphragm and cervical cap come in different sizes, and you need a doctor to "fit" you for one. The cervical s.h.i.+eld comes in one size, and you will not need a fitting.

Before having s.e.x, add spermicide (to block or kill sperm) to the devices. Then place them inside your v.a.g.i.n.a to cover your cervix. You can buy spermicide gel or foam at a drug store.

All three of these barrier methods must be left in place for 6 to 8 hours after having s.e.x to prevent pregnancy. The diaphragm should be taken out within 24 hours. The cap and s.h.i.+eld should be taken out within 48 hours.

Female Condom This condom is worn by the woman inside her v.a.g.i.n.a. It keeps sperm from getting into her body. It is made of polyurethane and is packaged with a lubricant. It can be inserted up to 8 hours before having s.e.x. Use a new condom each time you have intercourse. And don't use it and a male condom at the same time.

Male Condom Male condoms are a thin sheath placed over an erect p.e.n.i.s to keep sperm from entering a woman's body. Condoms can be made of latex, polyurethane, or natural/lambskin. The natural kind do not protect against STIs. Condoms work best when used with a v.a.g.i.n.al spermicide, which kills the sperm. And you need to use a new condom with each s.e.x act.

52.Preventing Unintended Pregnancies Condoms are either: * lubricated, which can make s.e.xual intercourse more comfortable; or * non-lubricated, which can also be used for oral s.e.x. It is best to add lubrication to non-lubricated condoms if you use them for v.a.g.i.n.al or a.n.a.l s.e.x. You can use a water-based lubricant, such as K-Y jelly. You can buy them at the drug store. Oil-based lubricants like ma.s.sage oils, baby oil, lotions, or petroleum jelly will weaken the condom, causing it to tear or break.

Keep condoms in a cool, dry place. If you keep them in a hot place (like a wallet or glove compartment), the latex breaks down. Then the condom can tear or break.

Oral Contraceptives-Combined Pill (The Pill) The pill contains the hormones estrogen and progestin. It is taken daily to keep the ovaries from releasing an egg. The pill also causes changes in the lining of the uterus and the cervical mucus to keep the sperm from joining the egg.

Some women prefer the "extended cycle" pills. These have 12 weeks of pills that contain hormones (active) and 1 week of pills that don't contain hormones (inactive). While taking extended cycle pills, women only have their period three to four times a year.

Many types of oral contraceptives are available. Talk with your doctor about which is best for you. Your doctor may advise you not to take the pill if you: * are older than 35 and smoke; * have a history of blood clots; * have a history of breast, liver, or endometrial cancer.

Antibiotics may reduce how well the pill works in some women.

Talk to your doctor about a backup method of birth control if you need to take antibiotics.

Oral Contraceptives-Progestin-Only Pill (Mini-Pill) Unlike "the pill," the mini-pill only has one hormone-progestin.

Taken daily, the mini-pill thickens cervical mucus, which keeps the sperm from joining the egg. Less often, it stops the ovaries from releasing an egg.

53.Pregnancy and Birth Sourcebook, Third Edition Mothers who breastfeed can use the mini-pill. It won't affect their milk supply. The mini-pill is a good option for women who: * can't take estrogen; * are older than 35; * have a risk of blood clots.

The mini-pill must be taken at the same time each day. A backup method of birth control is needed if you take the pill more than 3 hours late. Antibiotics may reduce how well the pill works in some women.

Talk to your doctor about a backup method of birth control if you need to take antibiotics.

The Patch Also called by its brand name, Ortho Evra, this skin patch is worn on the lower abdomen, b.u.t.tocks, outer arm, or upper body.

It releases the hormones progestin and estrogen into the bloodstream to stop the ovaries from releasing eggs in most women. It also thickens the cervical mucus, which keeps the sperm from joining with the egg. You put on a new patch once a week for 3 weeks. You don't use a patch the fourth week in order to have a period.

Shot/Injection The birth control shot often is called by its brand name Depo-Provera. With this method you get injections, or shots, of the hormone progestin in the b.u.t.tocks or arm every 3 months. A new type is injected under the skin. The birth control shot stops the ovaries from releasing an egg in most women. It also causes changes in the cervix that keep the sperm from joining with the egg.

The shot should not be used more than 2 years in a row because it can cause a temporary loss of bone density. The loss increases the longer this method is used. The bone does start to grow after this method is stopped. But it may increase the risk of fracture and osteoporosis if used for a long time.

v.a.g.i.n.al Ring This is a thin, flexible ring that releases the hormones progestin and estrogen. It works by stopping the ovaries from releasing eggs.

It also thickens the cervical mucus, which keeps the sperm from joining the egg.

54.Preventing Unintended Pregnancies It is commonly called NuvaRing, its brand name. You squeeze the ring between your thumb and index finger and insert it into your v.a.g.i.n.a. You wear the ring for 3 weeks, take it out for the week that you have your period, and then put in a new ring.

Implantable Rod This is a matchstick-size, flexible rod that is put under the skin of the upper arm. It is often called by its brand name, Implanon. The rod releases a progestin, which causes changes in the lining of the uterus and the cervical mucus to keep the sperm from joining an egg.

Less often, it stops the ovaries from releasing eggs. It is effective for up to 5 years.

Intrauterine Devices or IUDs An IUD is a small device shaped like a "T" that goes in your uterus.

There are two types: * Copper IUD: Copper IUD: The copper IUD goes by the brand name ParaGard. It releases a small amount of copper into the uterus, which prevents the sperm from reaching and fertilizing the egg. The copper IUD goes by the brand name ParaGard. It releases a small amount of copper into the uterus, which prevents the sperm from reaching and fertilizing the egg.

It fertilization does occur, the IUD keeps the fertilized egg from implanting in the lining of the uterus. A doctor needs to put in your copper IUD. It can stay in your uterus for 5 to 10 years.

* Hormonal IUD: Hormonal IUD: The hormonal IUD goes by the brand name Mirena. It is sometimes called an intrauterine system, or IUS. The hormonal IUD goes by the brand name Mirena. It is sometimes called an intrauterine system, or IUS.

It releases progestin into the uterus, which keeps the ovaries from releasing an egg and causes the cervical mucus to thicken so sperm can't reach the egg. It also affects the ability of a fertilized egg to successfully implant in the uterus. A doctor needs to put in a hormonal IUD. It can stay in your uterus for up to 5 years.

Sterilization Implant (Essure) Essure is the first non-surgical method of sterilizing women. A thin tube is used to thread a tiny spring-like device through the v.a.g.i.n.a and uterus into each fallopian tube. The device works by causing scar tissue to form around the coil. This blocks the fallopian tubes and stops the egg and sperm from joining.

It can take about 3 months for the scar tissue to grow, so it's important to use another form of birth control during this time. Then 55 Pregnancy and Birth Sourcebook, Third Edition you will have to return to your doctor for a test to see if scar tissue has fully blocked your tubes.

Surgical Sterilization For women, surgical sterilization closes the fallopian tubes by being cut, tied, or sealed. This stops the eggs from going down to the uterus where they can be fertilized. The surgery can be done a number of ways. Sometimes, a woman having cesarean birth has the procedure done at the same time, so as to avoid having additional surgery later.

For men, having a vasectomy keeps sperm from going to his p.e.n.i.s, so his e.j.a.c.u.l.a.t.e never has any sperm in it. Sperm stays in the system after surgery for about 3 months. During that time, use a backup form of birth control to prevent pregnancy. A simple test can be done to check if all the sperm is gone; it is called a s.e.m.e.n a.n.a.lysis.

Emergency Contraception (Plan B, Also Called Morning- After Pill) Emergency birth control is used to keep a woman from getting pregnant when she has had unprotected v.a.g.i.n.al intercourse. "Unprotected" can mean that no method of birth control was used. It can also mean that a birth control method was used but did not work-like a condom breaking. Or, a woman may have forgotten to take her birth control pills, or may have been abused or forced to have s.e.x.

Emergency contraception consists of taking two doses of hormonal pills 12 hours apart. They work by stopping the ovaries from releasing an egg or keeping the sperm from joining with the egg. For the best chances for it to work, start the pills as soon as possible after unprotected s.e.x. It should be started within 72 hours after having unprotected s.e.x. Starting emergency contraception within 5 days after having unprotected s.e.x might lower your risk of getting pregnant.

Where Can I Get Birth Control? Do I Need to Visit a Doctor?

Where you get birth control depends on what method you choose.

You can buy these forms over the counter: * male condoms * female condoms 56.Preventing Unintended Pregnancies * sponges * spermicides * emergency contraception pills (girls younger than 17 need a prescription) You need a prescription for these forms: * oral contraceptives, such as the pill and the mini-pill * skin patch * v.a.g.i.n.al ring * diaphragm (your doctor needs to fit one to your shape) * cervical cap * cervical s.h.i.+eld * shot/injection (you get the shot at your doctor's office) * IUD (inserted by a doctor) * implantable rod (inserted by a doctor) You will need surgery or a medical procedure for male and female sterilization.

57.Pregnancy and Birth Sourcebook, Third Edition Section 7.2 Mifepristone (The Morning-After Pill) Excerpted from "Mifeprex (mifepristone)," by the U.S. Food and Drug Administration (FDA, www.fda.gov), August 29, 2007.

Mifeprex is used, together with another medication called misoprostol, to end an early pregnancy (within 49 days of the start of a woman's last menstrual period). Since its approval in September 2000, the Food and Drug Administration has received reports of serious adverse events, including several deaths, in the United States following medical abortion with mifepristone and misoprostol. Each time FDA receives a report of a serious adverse event or death after medical abortion with these drugs, the agency carefully a.n.a.lyzes the available scientific information to determine whether or not the serious adverse event or death is related to the use of the drugs.

As previously reported by the agency, several of the women who died in the United States died from sepsis (severe illness caused by infection of the bloodstream) after medical abortion with mifepristone and misoprostol. Sepsis is a known risk related to any type of abortion. Most of these women were infected with the same type of bacteria, known as Clostridium sordellii Clostridium sordellii. The symptoms in these cases of infection were not the usual symptoms of sepsis. We do not know whether using mifepristone and misoprostol caused these deaths.

Patients should contact a healthcare pract.i.tioner right away if they have taken these medications for medical abortion and develop stomach pain or discomfort, or have weakness, nausea, vomiting or diarrhea with or without fever, more than 24 hours after taking the misoprostol. These symptoms, even without a fever, may indicate sepsis. Patients should make sure their healthcare pract.i.tioner knows they are undergoing a medical abortion.

All providers of medical abortion and emergency room healthcare pract.i.tioners should investigate the possibility of sepsis in women who are undergoing medical abortion and present with nausea, vomiting, or diarrhea and weakness with or without abdominal pain. These symptoms even without a fever may indicate a hidden infection. Strong consideration should be given to obtaining a complete blood count in 58 Preventing Unintended Pregnancies these patients. Significant leukocytosis with a marked left s.h.i.+ft and hemoconcentration may be indicative of sepsis.

FDA recommends that healthcare pract.i.tioners have a high index of suspicion for serious infection and sepsis in patients with this presentation and consider immediately initiating treatment with antibiotics that includes coverage of anaerobic bacteria such as Clostridium Clostridium sordellii sordellii.

FDA does not have sufficient information to recommend the use of prophylactic antibiotics for women having a medical abortion. Reports of fatal sepsis in women undergoing medical abortion are very rare (approximately 1 in 100,000). Prophylactic antibiotic use carries its own risk of serious adverse events such as severe or fatal allergic reactions.

Also, prophylactic use of antibiotics can stimulate the growth of "superbugs," bacteria resistant to everyday antibiotics. Finally, it is not known which antibiotic and regimen (what dose and for how long) will be effective in cases such as the ones that have occurred.

These recommendations are consistent with warnings in the Prescribing Information and information for the patient in the Medication Guide for Mifeprex.

The approved Mifeprex regimen for a medical abortion through 49 day's pregnancy is: * Day One: Mifeprex Administration: 3 tablets of 200 mg of Mifeprex orally at once.

* Day Three: Misoprostol Administration: 2 tablets of 200 mcg of misoprostol orally at once.

* Day 14: Post-Treatment: The patient must return to confirm that a complete termination has occurred. If not, surgical termination is recommended to manage medical abortion treatment failures.

The safety and effectiveness of other Mifeprex dosing regimens, including use of oral misoprostol tablets intrav.a.g.i.n.ally, has not been established by the FDA.

Do not buy Mifeprex over the Internet. You should not buy Mifeprex over the Internet because you will bypa.s.s important safeguards designed to protect your health (and the health of others). Mifeprex has special safety restrictions on how it is distributed to the public. Also, drugs purchased from foreign Internet sources are not the FDA-approved versions of the drugs, and they are not subject to FDA-regulated manufacturing controls or FDA inspection of manufacturing facilities.

59.Pregnancy and Birth Sourcebook, Third Edition Section 7.3 Facts about Abortion in the United States "Abortion in the U.S.: Utilization, Financing and Access," (#3269-02) The Henry J. Kaiser Family Foundation, June 2008. This information was reprinted with permission from the Henry J. Kaiser Family Foundation. The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible information, research and a.n.a.lysis on health issues.

Approximately one-fifth (19%) of the 6.4 million pregnancies occurring annually in the United States end in induced abortion.1 While abortion is one of the most common medical procedures for women,2 access and availability of services has been subject to ethical and political debates. Federal and state policies have a substantial impact on women's access to abortion services. This information provides an overview of the use of abortion services in the United States and reviews state and federal policies that affect women's access.

Incidence and Trends * In 2005, 1.21 million abortions were performed in the United States, down from 1.61 million (the all-time high) in 1990.3 * 49% of pregnancies were unintended in the United States, and of these, 42% resulted in abortions in 2001 (the most recent data available).4 * The abortion rate (the number of abortions per 1,000 women aged 1544) was 19.4 in 2005, a 9% drop since 2000.5 * 89% of abortions were performed in the first 12 weeks of pregnancy in 2004, with about 63% in the first eight weeks and 1% of abortions at 21 weeks or later.6 * About 19% of women having abortions in the United States are teens; 33% are between the ages of 20 and 24; and 48% are ages 60 Preventing Unintended Pregnancies 25 and older.7 Two-thirds (67%) of women have never been married and about 61% of women have given birth before.8 * Abortion rates for black women (49 per 1,000 women), Hispanic women (33 per 1,000) and Asian women (31 per 1,000) are higher than those of white women (13 per 1,000).9 * Abortion rates are higher among low-income women. The abortion rate for poor women has been increasing since 1994, so that the procedure is becoming increasingly concentrated among poor women, including those on Medicaid.10 Methods * Two general types of abortion are available to women in the United States: surgical and medical (non-surgical) abortions.

* Surgical abortions account for the majority (87%) of abortions performed in the United States.11 The most common surgical methods include vacuum aspiration, dilation and curettage (D&C), and dilation and evacuation (D&E). Surgical abortion is generally not performed until the sixth week of gestation.

* In September 2000, the U.S. Food and Drug Administration approved mifepristone (also known as "RU-486"), the first drug specifically designed for use as a method of medical abortion. This drug, in conjunction with misoprostol, is the most commonly used method of medical abortion.12 Methotrexate, usually followed by misoprostol, is also used for medical abortion. Medical abortion can be initiated as soon as a pregnancy is confirmed.

* In 2005, medical abortions accounted for approximately 13% of all abortions (compared to 6% in 2001) and 22% of abortions before nine weeks' gestation.13 * Since the 1990s, 31 states have enacted bans on procedures called "partial-birth" abortions, with 14 state laws (GA, IN, KS, LA, MS, MT, NM, ND, OH, OK, SC, SD, TN, UT) in effect. All include an exception to the ban: four states (GA, KS, NM, OH) include a health exception and the rest of the states include an exception only when a woman's life is in danger.14 * In 2003, the President signed the Partial-Birth Abortion Ban Act of 2003, which banned "partial-birth" abortions with no health exception. This legislation was upheld by the Supreme Court in the April 2007 Gonzales v. Carhart Gonzales v. Carhart decision. The procedure banned 61 decision. The procedure banned 61 Pregnancy and Birth Sourcebook, Third Edition by this Act is sometimes medically defined as intact dilation and extraction.15 Following the high court ruling, state legislatures have been reviving their bans on late-term abortion procedures previously blocked by lower courts.

* Complications from abortions are rare, with less than 0.3% of abortion patients in the United States experiencing a major complication requiring hospitalization.16 The annual risk of death a.s.sociated with abortion has been approximately one death per 100,000 legal abortions.17 * Research has shown that both medical and surgical abortions performed in the first trimester are not significantly a.s.sociated with later infertility, ectopic pregnancy, spontaneous abortion, or preterm or low-birth-weight deliveries18,19,20 and no greater risk of breast cancer.21,22,23 Abortion Financing The cost of an abortion varies depending on factors such as location, facility, timing, and type of procedure. In 2005, a nonhospital abortion at 10 weeks' gestation ranged from $90 to $1,800 (average: $430), whereas an abortion at 20 weeks' gestation ranged from $350 to $4,520 (average: $1,260).24 Costs are higher for a medical abortion than a first-trimester surgical abortion.25 Medicaid * Federal law requires that states cover abortions under Medicaid in the event of rape, incest, and life endangerment, but bans the use of federal Medicaid funds for any other abortions.

* Based on these restrictions, 32 states and DC fund abortions through Medicaid only in the cases of rape, incest, or life endangerment.26 SD covers abortions only in the cases of life endangerment, which does not comply with federal requirements under the Hyde Amendment. IN, UT and WI have expanded coverage to women whose physical health is jeopardized, and IA, MS, UT and VA also include fetal abnormality cases.

* Seventeen states (AK, AZ, CA, CT, HI, IL, MD, MA, MN, MT, NJ, NM, NY, OR, VT, WA, WV) use their own funds to cover all or most "medically necessary" abortions sought by low-income women under Medicaid.27 62.Preventing Unintended Pregnancies Private Insurance * Five states (ID, KY, MO, ND, OK) restrict insurance coverage of abortion services in private plans: OK limits coverage to life endangerment, rape, or incest circ.u.mstances; and the other four states limit coverage to cases of life endangerment.28 * Twelve states (CO, IL, KY, MA, MS, NE, ND, OH, PA, RI, SC, VA) restrict abortion coverage in insurance plans for public employees, with CO and KY restricting insurance coverage of abortion under any circ.u.mstances.29 * U.S. laws also ban federal funding of abortions for Federal employees and their dependents, Native Americans covered by the Indian Health Service, military personnel and their dependents, and women with disabilities covered by Medicare.

Availability of and Access to Abortion Services * 1,787 facilities provided abortions in 2005 in the United States, a 2% decline from the year 2000.30 * 87% of U.S. counties have no abortion provider, and 35% of women of reproductive age (1544) live in these counties.31 Women in the Midwest and South are more likely to live in a county without a provider (50% and 47%, respectively) than women in the North-east and West (17% and 15%, respectively).

* Over half of abortion providers (57%) performed early medical abortions in 2005, up from 33% in 2001.32 More than half of early medical abortions were provided at abortion clinics.

* Most abortion providers performed abortions within the first eight weeks. Forty percent performed early abortion within first four weeks' gestation, whereas 8% of abortion providers performed abortions at 24 weeks.33 * In recent years, 28 states have adopted laws and regulations specific to abortion clinics and providers. These laws involve special requirements for abortion providers to have health facility licenses and ambulatory surgical center licenses, or requirements that abortions after a specified gestation age be performed in a hospital, or that providers have admitting privileges in local hospitals.34 These policies can make it more difficult for providers to offer abortion services to women.

63.Pregnancy and Birth Sourcebook, Third Edition * The Federal Freedom of Access to Clinic Entrances (FACE) Act was pa.s.sed in 1994 to prohibit acts of physical or psychological intimidation to persons seeking or providing reproductive health services. Fifteen states (CA, CO, KS, ME, MD, MA, MI, MN, MT, NV, NY, NC, OR, WA, WI) and DC go beyond the FACE protections and prohibit certain specified actions aimed at abortion providers, such as threatening or intimidating staff, property damage, and telephone hara.s.sment.35 * Twenty-four states have pa.s.sed requirements for women to wait a specified time (usually 24 hours) between receiving counseling and undergoing an abortion.36 As a result, women must make two visits to the clinic, which can be difficult for those who live far from the clinic. Eight percent of women travel more than 100 miles to access abortion services and 19% travel between 50 and 100 miles.37 * Thirty-five states have adopted "parental involvement" laws that require notification and/or consent of one or both parents before a minor has an abortion.38 Most states with these laws apply them to girls under age 18, although several set the level to 16 or 17.

Endnotes Ventura SJ et al. Estimated pregnancy rates by outcome for the United States, 19902004. CDC National Vital Health CDC National Vital Health Statistics, Statistics, 2008. 2008.

Owings MF & Kozak LJ. Ambulatory and inpatient proce- dures in the United States, 1996. CDC National Vital Health CDC National Vital Health Statistics, Statistics, 1998. 1998.

Jones RK et al. Abortion in the United States: Incidence and access to services, 2005. Perspectives on s.e.xual and Reproductive Health, Perspectives on s.e.xual and Reproductive Health, 40(1), 2008. 40(1), 2008.

Finer LB & Henshaw SK. Disparities in rates of unintended pregnancy in the United States, 1994 and 2001. Perspectives Perspectives on s.e.xual and Reproductive Health, on s.e.xual and Reproductive Health, 38(2), 2006. 38(2), 2006.

Jones RK et al. Abortion in the United States: Incidence and access to services, 2005. Perspectives on s.e.xual and Reproductive Health, Perspectives on s.e.xual and Reproductive Health, 40(1), 2008. 40(1), 2008.

Guttmacher Inst.i.tute. Henshaw SK adjustments to Strauss LT et al. Abortion surveillance-United States, 2004. MMWR MMWR, 56(SS-9), 2007.

64.Preventing Unintended Pregnancies Jones RK et al. Patterns in the socioeconomic characteristics of women obtaining abortions in 20002001. Perspectives on Perspectives on s.e.xual and Reproductive Health, s.e.xual and Reproductive Health, 34(5), 2002. 34(5), 2002.

Ibid.

Ibid.

Ibid.

Jones RK et al. Abortion in the United States: Incidence and access to services, 2005. Perspectives on s.e.xual and Reproductive Health, Perspectives on s.e.xual and Reproductive Health, 40(1), 2008. 40(1), 2008.

Virk J, Zhang J et al. Medical abortion and the risk of subsequent adverse pregnancy outcomes. NEJM, NEJM, 357(7), 2007. 357(7), 2007.

Jones RK et al. Abortion in the United States: Incidence and access to services, 2005. Perspectives on s.e.xual and Reproductive Health, Perspectives on s.e.xual and Reproductive Health, 40(1), 2008. 40(1), 2008.

Guttmacher Inst.i.tute. Bans on "partial-birth" abortions. State State Policies in Brief, Policies in Brief, 2008. 2008.

Gostin LO. Abortion politics: Clinical freedom, trust in the Ju-diciary, and the autonomy of women. JAMA, JAMA, 298(13), 2007. 298(13), 2007.

Henshaw SK, Unintended pregnancy and abortion: a public health perspective, in: Paul M et al., eds., A Clinician's Guide A Clinician's Guide to Medical and Surgical Abortion, to Medical and Surgical Abortion, 1999. 1999.

Strauss LT et al. Abortion surveillance-United States, 2004.

MMWR, 56(SS-9), 2007.

Virk J, Zhang J et al. Medical abortion and the risk of subsequent adverse pregnancy outcomes. NEJM, NEJM, 357(7), 2007. 357(7), 2007.

Atrash HK, Strauss LT et al. The relation between induced abortion and ectopic pregnancy. Obstet Gynecol, Obstet Gynecol, 89(4), 1997. 89(4), 1997.