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In the United States of America, abortion was first legalized nationwide in 1975 after the renowned Roe v. Wade case. Over the decades to follow, there has been gathered enough evidence to make significant advancements in terms of abortion availability and technique refinement. In 2016, the National Academies of Sciences, Engineering, and Medicine were asked to conduct an extensive study on the current state of science, thus, systematizing existing data and putting together a clear picture of abortion care. In preparation for the study, the authors outlined several research questions:
- What kinds of abortion services are available in the US?
- What is the association between the appropriateness of specific abortion services and various clinical circumstances?
- What are the physical and mental health effects of abortion?
- How safe are abortion services?
- What are the minimum standards a medical facility needs to meet to provide abortion services?
- What are the professional requirements that health practitioners need to meet to conduct abortion and abortion-related procedures?
- What safeguards are necessary to handle clinical emergencies?
- How safe is the pain management provision?
- Are there any knowledge gaps associated with pre-and post-abortion care (National Academies of Sciences, Engineering, and Medicine, 2018)?
The experts at the National Academies of Sciences, Engineering, and Medicine adopted two primary approaches towards forming a comprehensive report on abortion care. The first approach is Donabedian’s structure-process-outcome framework used by assessing the quality of healthcare. Within the said approach, the structure is interpreted as a sum of contributing organizational factors be it established guidelines at a given medical facility or trained staff and the level of its competencies. According to Donabedian (1980), the process refers to what happens to a patient in a clinical setting. Ideally, all the methods and procedures chosen should be based on robust evidence. Lastly, the outcome is the result of the conducted procedure which should match the initial objective and not have any potential short- or long-term risks.
At the time the report was in the making, the US healthcare quality assessment operated upon six dimensions developed by the Institute of Medicine in its 2001 report “Crossing the Quality Chasm: A New Health System for the 21st Century.” The said six dimensions include:
- Safety: avoiding injuries and complications.
- Effectiveness: evidence-based services provision.
- Patient-centeredness: consideration of personal needs and preferences.
- Timeliness: reduction of unnecessary waits and delays.
- Efficiency: material and intellectual waste reduction.
- Equity: non-discrimination based on age, gender, race, and other factors (Institute of Medicine, 2001).
As for the data collection, several workgroups conducted extensive literature research concerning different aspects of the subject matter. The chosen research method was in-depth reviews of available data in the form of studies and reports regarding the epidemiology of abortions, complication and mortality rates, and the safety and effectiveness of different abortion types. The experts also examined the effects of abortion on patients’ mental and physical health. Lastly, relevant standards and regulations on local, state, and national levels were analyzed to check the current state of the science for compliance and the legislation itself for adequacy.
The authors were able to answer each of the research questions outlined in the introduction. A summary of key findings regarding each research question is presented below:
- The committee identified four common types of abortion: medication, aspiration, D&E (dilation and evacuation), and induction. Health practitioners choose between the options based on the length of gestation. Medication and aspiration are recommended up until the tenth week whereas aspiration is possible up to 14 or 16 weeks. Past 14-16 weeks, only D&E and induction are deemed feasible options.
- The authors did not find an association between abortion and infertility, abnormal placentation, and breast cancer. Moreover, having an abortion does not increase the likelihood of developing a mental disorder.
- The evidence showed that abortion in the US is both safe and effective.
- Most abortions are conducted in office-based or clinical settings. The facilities need to be equipped for resuscitation with emergency transfer available in case sedation is performed.
- Both trained physicians and physician assistants have the right to perform an abortion. They need to be competent in patient preparation, pain management, side effects management, and counseling.
- The key safeguards are competent personnel, necessary equipment, and an emergency transfer plan.
- Safe pain management includes non-steroidal anti-inflammatory drugs provision.
- The authors did not detect any critical knowledge gaps regarding abortion.
Discussion and Future Implications
In each section dedicated to a specific question, the authors outlined literature research limitations. For instance, although overall, the golden standard for study selection is a randomized control trial, in some situations, it is not the case. While studying the long-term mental and physical health effects of abortion, the experts discovered that a study design with control and intervention groups was not possible. The chosen observational study design, however, had its downsides: selection and selection recall bias as women who had an abortion tended to underreport facts and experiences.
All in all, the committee positively assessed the quality and safety of abortion care in the United States of America. However, it identified shortcomings in some areas: for instance, in some states, there were issues with gaining explicit and informed consent due to health providers’ inability to convey information properly. Further, it is recommended to address the issue of abortion availability and the needs of women who have low income. The authors conclude that there is a need for further continuous assessment of abortion services and patient outcomes.
Donabedian, A. (1980). The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press.
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.
National Academies of Sciences, Engineering, and Medicine. (2018). The safety and quality of abortion care in the United States. Washington, DC: National Academies Press.