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An estimated 12% to 30% of women are assaulted by their male partners at least once during the relationship. Therefore, in their everyday practice, physicians are likely to encounter women who have suffered domestic abuse. The authors define wife abuse, outline epidemiologic aspects and discuss common signs and symptoms. In cases of suspected or confirmed abuse, it is very important for physicians to document the details of the injuries, the patient visit, any treatment and follow-up as well as to screen for associated conditions and ensure that any samples taken are not tampered with. When asked to disclose information by police or courts, physicians need to know when they are obliged to submit copies of their patients' medical records, when patient consent is required, what information should be divulged and how to defend this information in court. The authors present information about the necessary, relevant and appropriate evidence to be collected and documented for both medical and legal purposes. They also discuss the criminal justice system and the role of physicians in legal proceedings concerning wife abuse.

OBJECTIVE: To identify factors associated with increased risk of immediate complications from induced abortion. DESIGN: Retrospective analysis of a provincial database. SETTING: All Ontario general hospitals in which abortions are performed and all free-standing abortion clinics in Ontario. POPULATION: Women in Ontario aged 15 to 44 years who underwent an induced abortion in the province (without concurrent sterilization) between Jan. 1, 1992, and Dec. 31, 1993. OUTCOME MEASURES: Recording of complications at the time of the procedure, gestational age, type of procedure, place of abortion (hospital or clinic), and patient's age, parity and history of previous abortion (spontaneous or induced). RESULTS: During the study period 83 469 abortions were performed that met our inclusion criteria. Immediate complications were reported in 571 cases (0.7%). Multivariate logistic regression analysis revealed that, after other variables were controlled for, the patient's age, parity and history of previous abortions (spontaneous or induced) were not significant risk factors for immediate complications; however, gestational age, method of abortion and place of abortion were significant risk factors (p < 0.001). The odds ratio (OR) for having a complication from abortion was 1.3 (95% confidence interval [CI] 1.02 to 1.63) between 9 and 12 weeks, compared with having one after abortion at 9 weeks or earlier, and increased to 3.3 (95% CI 2.23 to 5.00) after abortion between 17 and 20 weeks. Compared with surgical dilatation and curettage (D&C), instillation of saline and instillation of prostaglandins were more likely to be associated with immediate complications (OR 24.0, 95% CI 13.22 to 43.70, and OR 11.7, 95% CI 6.43 to 21.18, respectively), whereas both suction D&C and insertion of a laminaria tent were less likely to be associated with immediate complications (OR 0.4, 95% CI 0.26 to 0.67, and OR 0.3, 95% CI 0.19 to 0.52, respectively). Compared with women who had an abortion in a free-standing clinic, the risk for immediate complications was greater among those who had an abortion in a hospital, especially a teaching hospital (OR 1.9, 95% CI 1.38 to 2.58), a nonteaching hospital with 200 to 399 acute care beds (OR 3.1, 95% CI 2.27 to 4.21) and a nonteaching hospital with fewer than 200 acute care beds (OR 5.9, 95% CI 4.04 to 8.64). CONCLUSION: The risk of immediate complications from induced abortion is very low. Unlike in previous studies, the woman's age, parity and history of previous spontaneous or induced abortions were not found to be risk factors. However, advancing gestational age and procedures involving instillation of saline or prostaglandins were predictive factors of immediate complications.

Dr. Ellen R. Wiebe's study of the use of methotrexate and misoprostol in combination for early termination of intrauterine pregnancy (see pages 165 to 170 of this issue) is the first Canadian study of the use of this drug combination for medical abortion. The authors compare Wiebe's findings with those of earlier studies on methotrexate and misoprostol, as well as with European findings on the use of mifepristone with prostaglandins. The authors argue that although the methotrexate-misoprostol combination appears to be reasonably safe for the woman, the failure rate and the teratogenicity of methotrexate and misoprosol give cause for concern. The authors conclude that medical abortions ought to be offered only where there is adequate access to laboratory and surgical facilities and where losses to follow-up are systematically minimized to reduce the potential for continued pregnancy resulting in congenital abnormality.

OBJECTIVE: To assess interregional differences in the utilization of abortion services in Ontario from 1985 to 1992. DESIGN: Retrospective analysis of provincial therapeutic abortion database. SETTING: All hospitals conducting abortions between 1985 and 1992 and all free-standing abortion clinics conducting abortions between 1990 and 1992. POPULATION: All women in Ontario aged 15 to 44 years who underwent a therapeutic abortion in Ontario during the study period. OUTCOME MEASURES: Utilization of abortion services by county and age-specific abortion rates by county of residence. RESULTS: From 1985 to 1989, when only hospital data were gathered, the mean therapeutic abortion rate increased by 11.2%. From 1990 to 1992, when data from hospitals and free-standing clinics were collected, the mean rate increased by 26.5%. Logistic regression analysis showed significant variation in the age-standardized abortion rates between counties in each study year (p < 0.0001). The counties with age-standardized rates below the 25th percentile had the highest proportions of women who sought abortion services outside their county of residence; in some of these counties no abortions were performed in local facilities. CONCLUSION: There are interregional variations in the utilization of abortion services in Ontario. These disparities raise questions about the accessibility of abortion services and need to be further investigated.