The mortality risk of voluntary surgical contraception.
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Biomedical subjects
Publications and source records attributed to G L Rubin.
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To determine the impact of tubal sterilization on the overall incidence of ectopic pregnancy, the authors compared reported incidence rates of ectopic pregnancy after tubal sterilization with the rates associated with other contraceptive methods or no contraception. For each contraceptive method they then calculated the cumulative lifetime risk of ectopic pregnancy from the age at which a final contraceptive choice was made. Tubal sterilization was found to be associated with a lower cumulative lifetime risk of ectopic pregnancy than no contraception or use of an intrauterine contraceptive device. Tubal sterilization carries a somewhat higher risk of ectopic pregnancy than do barrier methods of contraception. Oral contraceptives are associated with a much lower ectopic pregnancy for most than any other contraceptive method or no contraception. Overall, however, the risk of an ectopic pregnancy for most women undergoing tubal sterilization in the United States is estimated to be lower than if they had not been sterilized and had continued their previous contraceptive practices.
Although complications of anesthesia are now the leading cause of death from abortion at less than or equal to 12 weeks' gestation, the comparative risk of death from abortions performed with local versus general anesthesia is unknown. To estimate this risk for both anesthesia-related and nonanesthesia-related legal abortion deaths at less than or equal to 12 weeks' gestation, we used 1972-1977 data from the Center for Disease Control and the Alan Guttmacher Institute. When adjusted for preexisting disease and concurrent sterilization, the death-to-case rate for abortions at less than or equal to 12 weeks' gestation associated with general anesthesia was 0.37/100,000 abortions, and the rate with local anesthesia was 0.15/100,000. For nonanesthesia-related deaths, the comparable adjusted rates were 0.49 and 0.28, respectively. Use of general anesthesia is associated with a twofold to fourfold increased risk of death from abortion at less than or equal to 12 weeks' gestation.
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Few reliable data exist on the risk of maternal death from cesarean section. To identify more deaths after cesarean section than reported by vital records alone, we linked data from Georgia resident live-birth certificates to those from death certificates of Georgia women aged 10 to 44 years. We found 16 maternal deaths after cesarean section in Georgia during 1975 and 1976, five more (45%) than the 11 reported through vital records alone. We attributed nine of these 16 deaths to the cesarean section per se. We than calculated a total death-to-case rate of 105.3 deaths per 100,000 cesarean sections and a rate attributable to cesarean section of 59.3 deaths per 100,000 procedures. Pulmonary embolism and cardiopulmonary arrest during general anesthesia were the leading causes of death in this series. Preventive measures aimed at reducing these complications may reduce deaths after cesarean section.
From 1973 through 1978, the Center for Disease Control identified ten deaths caused by ruptured ectopic pregnancy after attempted legal abortions for those pregnancies. The women ranged in age from 18 to 31 years, seven were black, three were white, and five were nulliparous. The estimated gestational age was 16 menstrual weeks or earlier. In seven cases tissue obtained at abortion was sent for outside microscopic pathological examination; attempts to contact four of the patients when no products of conception were found were unsuccessful. An important factor in preventing fatal ectopic pregnancy for women who have legal abortions is the identification of products of conception at the time of the abortion procedure while the patient is still available for reexamination and recurretage.
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The Center for Disease Control (CDC), Atlanta, Georgia implemented an eight-month prospective surveillance system in 24 hospitals distributed among states with and without public funding for abortion. Out of 3,157 visits for abortion-related complications, only 10 women gave a history of non-physician or self-induced abortion and none were Medicaid recipients. The small number of hospitals located in non-funded states and the smaller numbers of women served in these hospitals than in the funded states limited the power of out study. Women living along the Texas-Mexico border appeared more likely to have complications after illegal abortions than women from other areas of the country.
During the first five months after the restriction of public funds for abortion, a large percentage of low-income women seeking abortions in a metropolitan area in Texas obtained abortion that were partially subsizied using a combination of reduced clinic fees and public funds for ancillary non-abortion services. Their own personal funds made up the difference between the subsidy and the full cost of the procedure.
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