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Increasing governmental regulation such as called for in PSRO and health planning legislation, pressures to contain rising costs, physician strikes, and other manifestations of change suggest that traditional hospital organization and management patterns ought to be re-examined. Moreover, as the United States moves toward a governmentally financed and regulated system, experiences in Great Britain and other nationalized systems become more pertinent to us. The 1974 major reorganization of the British National Health Service provides for considerable physician participation in management. A similar participative approach to the management of the hospitals in the United States is worthy of consideration as a way to meet increasing challenges of a governmentally financed and controlled health care system.

Critics have challenged previous comparisons of mortality from legal abortion and childbirth for containing biases in the crude data that spuriously favor the safety of abortion. To evaluate this concern, we reviewed the sources of mortality data on which these comparisons are based and examined the completeness of abortion mortality statistics, the completeness of childbirth mortality statistics, and the accuracy of the denominators for both these events. We found the evidence to be consistent in two directions: (1) abortion deaths appear to be more completely ascertained than childbirth deaths; (2) use of different denominator estimates has relatively little impact on the comparison. From this evidence, we conclude that the crude data are biased in a direction that overestimates the abortion risks for the woman relative to the risks of childbearing. ( JAMA 1982;248:192-196)

Since January 1, 1972, five women in the United States are reported to have died from paracervical anesthesia used for first-trimester abortions. This report describes the three most recent deaths. Toxic doses of lidocaine, substantiated by post-mortem blood levels of 5 and 9 μg per milliliter, probably led to two deaths; an intolerance to or inadvertent intravenous administration of mepivacaine probably caused the third. Administration of an appropriate dose of local anesthetic appears to be the single most important factor in preventing catastrophic reactions. (N Engl J Med 295:1397–1399, 1976)

Little is known about maternal deaths after spontaneous abortion. We studied 122 such deaths reported to the Centers for Disease Control from 1972 through 1980; 21 were intrauterine (contraceptive) device related. The number of non-IUD-related deaths decreased from 15 in 1972 to six in 1980; the mortality ratio (deaths per million live births) decreased from 4.6 in 1972 to 1.7 in 1980. Non-IUD-related deaths were results of infection (48%), hemorrhage (21%), embolism (11%), and other causes (20%). Risk factors for these deaths were age over 29 years, being of minority race, and unmarried status. Most deaths (58%) occurred between 12 and 19 weeks' gestation. The risk of death was much higher for abortion in the second trimester than in the first. Deaths following spontaneous abortion, although rare, do occur; older, black, and unmarried women are at higher risk. (JAMA1985;253:3119-3123)

In Reply.— Dr Iffy's continued concerns about the effects of induced abortion, particularly DE he also selectively references those American studies that he believes support his contentions. In the interest of space, we refer the reader to a recent review article 4 that synthesized all the available data on the effects of induced abortion on reproductive function. It comes to a conclusion different from Dr Iffy's. His assessment of the influence of follow-up information on the rate of abortion complications is erroneous. Women who suffer complications after legally induced abortion are more (not less) likely than women without any complications to notify the facility performing

EACH DAY, tens of millions of Americans swallow a pill, slide in a diaphragm, or slip on a condom to prevent unwanted pregnancies. These strategies are working, although not as well as they could. While rates of unwanted pregnancies have declined dramatically in recent years,1nonuse or inconsistent use of contraception, especially among sexually active teenagers,2persists. In general, fear of complications, not the complications themselves, is the most powerful deterrent to contraception.3Much of this fear is unwarranted, fueled in part by inaccurate or incomplete media coverage.4Although no new contraceptive chemical has been introduced in the United States since 1968,5the safety and acceptability of existing contraceptive methods have improved greatly. In this review, I will provide a brief clinical update on reversible contraception, including current use of contraception, the efficacy of various methods, the safety of these methods, and a brief overview

play a critical role in caring for newborns, they need to be aware of the controversy regarding circumcision in order to counsel families more effectively about potential benefits and risks of this operation. gressively occurs, so that by age 16 to 17, phimosis occurs in only one percent of uncircumcised males(4). Selection of candidates for surgery is based primarily on the mother's wishes. Fathers generally take little interest in the circumcision decision(1,5). The reasons mothers give for deciding to have their sons circumcised suggest that the decision is often irrational. In

Reproductive mortality has three principal components: deaths related to pregnancy, contraception, and sexually transmitted diseases (STDs). The last component is usually overlooked. In 1955, deaths due to STDs constituted a minimum of 32% of all reproductive mortality in the United States; in 1965 and 1975, the percentages were 32% and 20%, respectively. Pelvic inflammatory disease and syphilis account for most deaths due to STDs. In 1979, the mortality rate due to pelvic inflammatory disease was 0.29 deaths per 100,000 women aged 15 to 44 years; the corresponding figure for syphilis was 0.17. If cervical cancer is viewed as an STD, then deaths due to this cause alone (approximately 6,800 per year) would far outnumber deaths due to all other reproductive causes combined. Surveillance of reproductive mortality in the United States should be expanded to encompass deaths due to STDs. ( JAMA 1986;255:1727-1729)

The growing number of couples seeking to adopt may have outstripped the number of babies in the United States available for adoption. Although increased availability and use of abortion have resulted in fewer single women continuing their pregnancies, the increased tendency of unmarried mothers to raise rather than relinquish their children has, in particular, limited the number of babies available for adoption. Despite the unpopularity of adoption among women with unintended pregnancies, addressing this option remains an important part of pregnancy counseling. Appropriate obstetric care of women placing their babies for adoption includes acknowledgment of the loss these women experience. Knowledge of adoption resources and willingness to discuss adoption can help physicians provide better care of unintentionally pregnant as well as infertile patients. ( JAMA 1987;258:3537-3541)

In Reply.— We appreciate the opportunity to respond the questions posed in Dr Myers' letter. Mention of "postcoital disinfection" among males was intentionally omitted from our review of local measures because we could find no controlled studies of efficacy. Supervised application of local germicides for personal use were widespread during wartime. The efficacy of these measures was inferred from subsequent dramatic declines in rates of sexually transmitted diseases. 1 However, the mandatory punishment for acquisition of these diseases (court martial) probably resulted in dramatic declines in reporting. In the early 1900s, any "enthusiastic endorsement" by the medical profession for local preventive methods probably resulted from the alarming lack of antibiotic cures for gonorrhea and syphilis rather than from the inherent efficacy of the methods. Although in vitro germicidal qualities of spermicides were described decades ago, in vivo efficacy has been studied only recently. The first report of clinical efficacy was

Unplanned pregnancies constitute an epidemic in the United States. Over 3 million unplanned pregnancies occur, and over 1.5 million induced abortions are performed each year. Women of minority races and those with less than 12 years of education are at high risk of having unwanted children. Fear of complications (not the complications themselves) is the most powerful deterrent to women's use of contraception. Much of this fear is due to bad press. Recent good news about contraception, such as protection against ovarian and endometrial cancer, protection against ectopic pregnancy, and absence of teratogenic effects, has not received appropriate media coverage. For healthy women younger than 35 years, failure to use fertility control is more dangerous than use of any method.

The relative safety of suction curettage abortions performed with either local or general anesthesia has not been clearly established. To compare the safety of these two anesthetic techniques, we studied 36,430 women who received local anesthetics and 17,725 who received general anesthetics for this operation in the United States from 1971 through 1975. The aggregated major complication rates for the two groups were similar, but there were significant differences between local and general anesthesia for specific complications and treatments. Local anesthesia was associated with higher rates of febrile and convulsive morbidity; however, general anesthesia was associated with higher rates of hemorrhage, cervical injury, and uterine perforation. Both anesthetic techniques appear to be safe, with similar degrees of overall safety, although each is associated with a different spectrum of complications.

Late abortion remains a complex and difficult issue in the United States, where about 10 percent of all abortions are performed at 13 or more weeks' gestation. The reasons why women delay having abortions appear to be largely personal, and most are not amenable to public health intervention. Dilatation and evacuation (DE for later abortions, D&E and instillation abortion have similar risks of complications and death. The rare instances in which an abortion procedure ends in a live birth represent the most controversial aspect of second-trimester abortion. However, trends toward abortions at earlier gestational ages, use of D&E and increased reliance on ultrasonography to confirm gestational age should reduce the frequency with which such events occur. Research in the area of midtrimester abortion should seek ways to reduce the need for such procedures, to improve their safety and to minimize the trauma of the experience for women.

To the Editor.— Pronouncements of the Centers for Disease Control (CDC) concerning prevention of the acquired immunodeficiency syndrome (AIDS) carry great weight, yet the CDC's selective silence on this issue may be even more noteworthy. Since the beginning of the AIDS epidemic, the CDC has been silent about induced abortion as an option for women infected with the human immunodeficiency virus (HIV). The CDC acknowledges that perinatal transmission is one of only three known modes of transmission and it advises that HIV-infected women not conceive. 1 But what of the growing numbers 1,2 who do become pregnant? The CDC's avoidance of this issue has been persistent. The 1985 CDC committee assembled to develop guidelines to prevent perinatal transmission of AIDS concurred that the option of abortion should be discussed with HIV-infected pregnant women. This language was deleted from the final institutional report. 2 More recent reports on prevention of AIDS

In Reply.— The Lanskas and Dr Rimm suggest that because cesarean delivery is more hazardous for women than vaginal delivery, 1 "maternal mortality caused by abortion should be compared with both vaginal delivery and cesarean delivery separately." Precise national data required to calculate these rates are unavailable; nevertheless, existing data 2 do not support the hypothesis that 90% of all maternal deaths are related to cesarean delivery. Moreover, the suggested comparison would not be clinically useful. Approximately 16% 3 of women in the United States who give birth do so by cesarean delivery; a pregnant woman choosing between abortion and childbirth usually cannot predict which type of delivery she will have. A woman who chooses to carry her pregnancy to delivery is subject to the risks inherent in the process, regardless of their source. Hence, the appropriate comparison is between the mortality rate associated with all methods of abortion and

In Reply.— Dr Dolan's letter questions our conclusions regarding the relative safety of legal abortion in the United States by citing references from England and Eastern Europe that describe high rates of early and late complications. Extrapolating rates from foreign studies to this country can be misleading. The majority of published reports from the United States on the early medical complications from legal abortion 1-4 have described much lower rates of total and major complications than have the reports of Dr Stallworthy and his associates in England. 5 Moreover, the issue of late sequelae after legally induced abortion is unresolved. To date, no studies on long-term complications have been reported from the United States. However, in contrast to those studies cited by Dr Dolan, other well-controlled studies in the Far East and Eastern Europe have found no adverse effects on reproductive function for women who had previous induced abortions. 6-8

In Reply. —Dr Gunn's Letter diverts attention from the CDC's suppression of abortion information by raising two specious issues. First, he argues that no "committee" was assembled in 1985 to develop guidelines. While he is correct that the group of consultants assembled in Atlanta in October 1985 did not constitute a "committee" (a semantic nuance that is lost on those who are unfamiliar with the bureaucracy), a CDC committee was already at work by the time Dr Gunn became involved (memorandum, Richard M. Selick, MD, to James A. Curran, MD, Oct 3, 1985). Then a commissioned officer at the CDC, I was involved with both the committee and the consultants. Second, Dr Gunn alleges that there was vigorous objection to the mention of elective abortion. Louise B. Tyrer, MD, a representative from the Planned Parenthood Federation of America, recommended that HIV-infected pregnant women be counseled about the option of abortion.

In 1980, approximately 100,000 women underwent abortion by dilatation and evacuation between 13 and 24 weeks' gestation; an estimated 500 women experienced serious complications. The comparative safety of local versus general anesthesia for second-trimester dilatation and evacuation is unknown. To compare the serious complications (hemorrhage requiring transfusion, unintended major surgery, and a temperature of greater than or equal to 38 C for greater than three days), 4147 women who received general anesthesia and 5389 women who received local anesthesia at 13 centers in the United States from 1975 to 1978 were studied. Women who had a dilatation and evacuation abortion under general anesthesia had a relative risk of serious complications of 2.6 (95% confidence interval 1.4 to 4.9) compared with women who underwent dilatation and evacuation abortion under local anesthesia. Local anesthesia for second-trimester dilatation and evacuation appears to be both safer and less expensive than general anesthesia.

The gestational age threshold of 12 weeks for induced abortion by curettage procedures has been challenged in the United States1 and in developed countries abroad.2 In developing countries, however, dilatation and evacuation (D&E) procedures at 13 weeks' gestation or later are still felt by many to be less safe and practical than other alternatives for terminating pregnancies at these later gestational ages.3 In this article, we describe the D&E procedure as it is currently being performed, present the reported advantages and disadvantages of D&E in developed countries, discuss potential problems with the D&E method in developing countries, and finally describe the reasons for pilot testing D&E procedures in the developing world.

Although uterine perforation is a potentially life-threatening complication of curettage abortion, little is known about the risk factors associated with uterine perforation or how to prevent it. Using linear logistic regression, we analyzed 67,175 curettage abortions performed at 13 institutions in the United States from 1975 through 1978. The overall incidence of confirmed perforation was 0.9 per 1,000 abortions. Performance of the abortion by a resident rather than by an attending physician was a powerful risk factor for perforation (relative risk, 5.5; 95% confidence interval, 3.3 to 9.2). Use of Laminaria for dilation had a protective effect, although this effect was not statistically significant (relative risk, 0.17; 95% confidence interval, 0.02 to 1.2). Among factors beyond the control of the physician, advancement of gestational age and previous delivery were significant risk factors. Use of Laminaria and performance of the abortion by an attending physician considerably lowered the risk of uterine perforation.

Two recent reports have suggested that wormlike structures characteristic of helminths are associated with preeclampsia. We identified these vermiform structures in toluidine blue O-stained venous blood smears from four women with preeclampsia, cord blood taken at delivery of three of their neonates, and venous blood from five control subjects without preeclampsia and from five healthy beagle dogs. The structures, which had diameters between 30 and 670 μm, could not be concentrated by passing the blood through a 12-μm filter, yet they could be demonstrated in stained smears prepared from blood that had been filtered. We conclude that these structures are not helminths; they are most likely artifacts of staining. (JAMA1983;250:2970-2972)

Some clinicians have hesitated to perform dilatation and evacuation (D & E) procedures at 13 weeks' gestation or later because D & Es are more difficult to perform safely than suction-curettage procedures. Moreover, many clinicians still believe all second-trimester abortion procedures should be performed in a hospital. To evaluate these concerns, we analyzed 24,664 abortion performed between 1973 and 1978 by four physicians associated with a large outpatient abortion facility; 3,711 (15%) of the abortions were second-trimester procedures. Dilatation and evacuation was associated with a lower rate of serious complications per 100 procedures (0.23) than instillation of either dinoprost (prostaglandin F2 alpha) (1.28) or hypertonic saline (2.26). In addition, D & E had lower rates for most other specific complications. We conclude that D & E, while requiring more operator skill than earlier suction-curettage procedures, can be learned by gynecologists familiar with suction-curettage, can be performed more safely than the alternative instillation procedures, and can be safely practiced in selected ambulatory settings.

Critics have challenged previous comparisons of mortality from legal abortion and childbirth for contrasting population groups with different clinical characteristics. They allege that most women dying from abortion were young, white, and healthy, while those dying from childbirth had serious underlying conditions. To address this question, we calculated standardized abortion and childbirth mortality rates between 1972 and 1978. We also adjusted independently for preexisting medical conditions. These adjustments for demographic and health differences between the two populations actually widened the difference in the mortality risk between abortion and childbirth. Thus, between 1972 and 1978, women were about seven times more likely to die from childbirth than from legal abortion, with the gap increasing in the more recent years. (JAMA1982;248:188-191)

In Reply. —"A Physician's Guide to Adoption" was not intended to be exhaustive. As indicated by the article's introduction, we focused on those components of adoption that are most relevant to physicians who care for women with unintended pregnancies and for infertile couples. References cited in our article, particularly the Adoption Fact-book , 1 cover many facets of adoption that we did not address. If our article stimulates others to expand the medical literature on adoption, we would be delighted.

Since January 1, 1972, five women in the United States are reported to have died from paracervical anesthesia used for first-trimester abortions. This report describes the three most recent deaths. Toxic doses of lidocaine, substantiated by post-mortem blood levels of 5 and 9 μg per milliliter, probably led to two deaths; an intolerance to or inadvertent intravenous administration of mepivacaine probably caused the third. Administration of an appropriate dose of local anesthetic appears to be the single most important factor in preventing catastrophic reactions. (N Engl J Med 295:1397–1399, 1976)

Among 2475 maternal deaths that occurred in the United States from 1974 to 1978, 408 were related to pregnancies with abortive outcomes, and 2067 were related to other causes. Ectopic pregnancy was the most frequent cause of death in the former group. Embolism, hypertensive disease of pregnancy, obstetric hemorrhage, and obstetric infection were the most common causes of death in the latter group. Women who were 30 years of age or older or of minority race were at increased risk of death. Nationwide surveillance of maternal mortality is feasible and should help to increase the safety of childbearing.

To assess the use of Rh immunoglobulin (RhlG) after ectopic pregnancy, we reviewed the charts of 305 patients treated from 1975 through 1978 at a large metropolitan hospital. We compared these patients with 389 who had had spontaneous abortions and been treated at the same hospital in 1975. The rate of ascertainment of Rh type was significantly higher for the group with ectopic pregnancy than for the group with spontaneous abortion (98.4% versus 95.1%; p not to receive RhlG than candidates after spontaneous abortion (64.3% versus 19.4%; p