Manuscript A Second Opinion from 2500 Practitioners: Response to 100 Professors" Word Count 3026

We've read with interest, and concern, the recent Clinical Opinion "statement on abortion by 100 professors of obstetrics 40 years later." We acknowledge the achievements of these distinguished professors, and are grateful for the information that they taught us over the years. However, we would like to present an alternative statement from another group of obstetricians, who stand in opposition to abortion-on-demand. We'd also like to propose some possible and positive solutions, which hopefully we can all agree on, for helping both mother and child in a problem pregnancy.

To begin on the positive side, here are some suggestions......

1.) If a woman is troubled because she cannot afford obstetric care, you can offer to provide her care without charge. Many of us have done this, and its not a great burden.

2. If a woman is in an abusive relationship and has no safe place to stay, you can offer her a place in your home throughout the pregnancy and until she feels able to move out on her own. Some of us have done this, and can tell you that your home will be edified by good people, who may stay in touch for years, and are grateful for your help in giving life to their child.

3. If a woman is worried that she won't be able to financially care for her child, you can put her in touch with one of the many pregnancy aid centers which can provide clothing, food, diapers, and a crib, and then you can support these centers financially. Many of us have done this - it helps.

4. If a woman feels that the pregnancy and caring for the child will crush her dreams of an education, you can encourage her that it doesn't need to, and in fact, the need to care for a child can be a strong motivation for doing well in school. Many of us have done this, and it has helped women who need encouragement to care for their child.

5. If a woman feels she can't raise a child with disabilities, you can put her in touch with one of the agencies (eg. Bethany Christian Services, Michigan Adoption Resource Exchange, and others) which have waiting lists of families willing to provide love and comfort for children with disabilities, even the most severe and lethal problems, such as anencephaly or Trisomy 18, for as long as the child lives. Many of us have done this, and it helps both the mom of the disabled child, and the families who welcome that child into their lives.

6. You can also help families in temporarily stressful situations by opening your home to foster children. You'll provide a safe and loving environment for the child while the parents work out their problems. When the child eventually goes home, you can start a 529 educational fund for the child. Some of us have done this many times, and it's encouraging to the parents that someone believes enough in them and their child to think a higher education is possible. It

makes them see their child differently. It gives the parents more hope for this child and perhaps for their other children, present and future.

Now for the areas in which we disagree with these 100 professors; we write not in any great hope of changing their minds and hearts. We realize that once physicians have advocated for or performed elective abortions, it is very difficult to change their positions, but many of us have done just that. Many of us have performed abortions and realized over time that the procedure was destroying both of our patients. However, it is rare for a physician who has come to understand the humanity of both of our fetal and maternal patients to ever reverse their stand against abortion as the solution to a problem pregnancy. We write in the hope that other obstetricians, as well as residents and medical students who are not yet committed to either position will realize that "100 professors" does not in any way mean 100% of professors, and that there are more positive solutions to a problem pregnancy than ending the life of the unborn child. Here are the main areas of disagreement which we have with the 100 professors statement:

1. We believe they are forgetting someone. In their whole statement there's no mention of the 50 million lives which have been lost due to abortion. They have forgotten the following statement in the 1971 edition of Williams Obstetrics 1:

"Since World War II, and especially in the last decade, knowledge of the fetus and his environment has increased remarkably. As an important consequence the fetus has

acquired status as a patient to be cared for by the physician as he long has been accustomed to caring for the mother."

Even after the tragic decision to legalize abortion on demand, the 18 th edition of Williams Obstetrics (1989, dedicated to Dr. Jack Pritchard and edited by Dr.s Cunningham, MacDonald and Gant) clearly states: Obstetrics is an unusual specialty of medicine. Practitioners of this art and science must be concerned simultaneously with the lives and well-being of two persons; indeed the lives of the two who are interwoven. Obstetricians above all other specialties are keenly aware of the interwoven nature of these two persons, and the unique responsibility that Hippocratic Medicine calls for in caring for both patients. It is sad to see 100 current distinguished professors of Obstetrics and Gynecology having forgotten that history. How and where did things change so that we are now expected to end the life of one of our patients at the request of the other? Have we abandoned the Hippocratic admonishment to First do no harm? None of us will hesitate to end a pregnancy if the mother's life is truly at risk, but even the most ardent advocates of liberalized abortion must admit that the great majority of pregnancies don't truly threaten the mother's life.

It must cause great internal conflict for an obstetrician to tell one mother at nineteen weeks gestation with a dilated cervix due to cervical insufficiency that "We can try to save your baby

with an emergency cerclage," but the same day tell another patient with an uncomplicated but unwanted pregnancy at 19 weeks that "We can remove the products of conception," or "We can empty the uterus," or "We can do an abortion." If we speak of saving the baby with the cerclage, the honest way to state the alternative is "We'll kill the baby by an abortion if it's what you desire." Euphemisms such as removing the products of conception, terminating the pregnancy, etc., dont change the fact that the unborn childs life is ended. These euphemisms deny the mother important factual information that she needs to understand the choice of abortion. No matter how safely an abortion can be done for the mother, even if the risk could someday be reduced to zero, it's never safe for the fetus, who is always killed. What happened to being "concerned simultaneously with the lives and well-being of two persons," as noted in Williams? 2. We dont believe the 100 professors are truly being pro-choice. Glossing over the evidence-based risks and negative effects of pregnancy termination on women, and denying the scientific humanity and biological reality of the unborn child denies women a truly informed choice. And in an age of "choice", hospitals, nurses, and physicians should also have a choice not to participate, in any way, in an act which to them is simply and clearly the destruction of an innocent life - the killing of an unborn child who has never done anyone any harm? Medical practitioners shouldnt be forced to participate in, refer for, or pay for someones elective abortion, an act which clearly violates the Hippocratic oath we took as physicians. The 100 Professors claim that hospitals are disregarding their responsibility by not perfo rming more abortions, leaving 90% to be done away from the hospitals. But those professors ignore

the fact that the reason most abortions are done outside of a hospital is by the choice of the abortionist. Abortions performed in a physicians office often have few safety requirements and minimal accountability, as evidenced by the recent tragic deaths in the office of Dr. Gosnell. By performing abortions in the office, the abortionist can circumvent restrictions which are routine in surgi-centers and in hospitals performing similar levels of outpatient surgery. The 100 Professors claim that fetal and maternal health restrictions are "contrived", by some sort of "ethics committees." Yet it is certainly the role of an ethics committee to comment on when the taking of a human life is permissible; especially in a hospital administered by a religious organization. The 100 Professors also fault conscience clause legislation which does not require referral to an abortionist by an obstetrician who chooses not to do elective abortions. But these professors would allow for physicians not to refer for other elective procedures such as female genital mutilation, on the basis that such surgery destroys rather than enhances life. Surely since a human life is destroyed in abortion, then it is reasonable for a physician to refuse to cooperate in destroying the life of one of her or his patients. The 100 Professors fault political regression which has put some restrictions on liberal abortion policies. They fault the Hyde Amendment for not funding abortions with tax dollars. But these accusations are political, not medical arguments. 3. In regard to the safety of abortion, these "100 professors" state that abortion is safe. We disagree and can provide pages of peer-reviewed published references to the contrary.

From a medical stand-point, all abortions, even those done under ideal medical conditions, have immediate risks, as evidenced by excellent studies using the nationalized healthcare database in Finland which included over 42000 women2. These immediate risks of medical and surgical abortion in the first trimester include:

1) hemorrhage (15.6% of women undergoing medical abortion vs 2.1% of surgical abortion p<0.001), 2) incomplete abortion ( medical 6.7% vs surgical 1.6% p<0.001) 3) need for surgical re-evacuation ( medical 5.95 vs surgical 1.8% p<0.001)

These complications increase dramatically as gestational age increases, as evidenced by CDC data as well as other studies3 4 . In fact, according to CDC data, the legal induced abortion mortality rate for abortions performed after 22 weeks exceeds the estimated risk of death from live birth.5 6

It is surprisingly disingenuous for the "100 professors" to cite NARAL, and to cite the Guttmacher institute five times, given the Guttmacher's past relationship to Planned Parenthood, the nations largest abortion provider, and neglect the entire body of medical literature performed by researchers not financially profiting from elective abortion.

But, even more concerning than the immediate risks are the long term complications of elective abortion which have been documented in hundreds of studies for decades.

The medical literature clearly demonstrates that women who have elective abortions are at increased risk for preterm birth in subsequent pregnancies. There are over 4 decades of studies in the medical literature confirming these findings, including recent large studies such as:

Shaw (2009 BJOG) reviewed 37 studies and found an odd ratio (OR) of 1.3 after one induced abortion, OR of 1.9 after more than one induced abortion.7

A French study by Henriet (BJOG, 2001) also suggested "a history of induced abortions increases the risk of preterm delivery, particularly for women who have had repeated abortions", with the same odds ratios as noted by Shaw (1.3 after one abortion, 1.9 after two or more).8

The Epipage study, by Moreau er al., (BJOG, 2004) found that "Women with a history of induced abortion were at higher risk of very preterm delivery than those with no such history (OR 1.5); the risk was even higher for extremely preterm deliveries (<28 weeks).9 A study by Ancel (European Society of Human Reproduction and Embryology, 2004) on the risk factors for preterm births in 17 European countries, reported that "Previous Induced abortions were significantly associated with preterm delivery and the risk of preterm birth increased with the number of abortions." 10 170+ studies11 over the last four decades confirm this association,

including a study published in AJOG in 2010 12. And the more abortions a woman has, the higher her risk of preterm birth in subsequent pregnancies. Different studies have reported a

RR of 1.3 after one abortion, and nearly a doubling of the risk (RR = 1.9) after more than one abortion. Since preterm birth is the leading cause of mortality and morbidity in non-anomalous newborns, it would seem that abortion not only destroys the life of the current child in the womb, but has risks for the mother and for future children as well.

The medical literature also clearly demonstrates an association between elective abortions and an increased risk of adverse mental health outcomes such as major depression, suicide and substance abuse. While the professors can cite articles reporting no increased maternal risks, we can cite over 90 articles13 over the past three decades, which provide evidence to the contrary; one of which is a 2011 quantitative comprehensive meta-analysis14 which reports as much as an 81% overall increased risk for mental health problems, including depression, anxiety, alcohol abuse, and suicide behaviors in women who abort vs women with live birth. And two large registry based studies demonstrate a three to six fold increased risk of suicide in women who abort vs women who give birth 15 16

Also, in the subset of women who electively terminate their first pregnancy prior to 32 weeks gestation, and delay subsequent term pregnancy, there is some evidence for an increased risk of breast cancer, as evidenced by multiple studies in the medical literature over the past 5 decades17, including recent studies from the past two years,18 19 one in the French BRCA cohort.
20

In fact, overall all cause mortality is higher in women who abort vs women who give birth. The recent contention that abortion is 14 times safer than childbirth had been well countered by two recent articles21 22.

In conclusion, while we respect the knowledge and dedication of the 100 professors, and are thankful for their contributions to the field of obstetrics, we think they are mistaken on this issue, and so we have tried to put forth an alternative approach to a woman with a problem pregnancy. We believe we can, and should, love both mother and child.

1 2

Hellman LM, Pritchard JA. Williams Obstetrics, 14th Ed. New York,,Appletone-Century-Crofts, 1971, p. 199. Maarit Niinimki, MD, Anneli Pouta, MD, PhD, Aini Bloigu, Mika Gissler, BSc, PhD, Elina Hemminki, MD, PhD, Satu Suhonen, MD, PhD, and Oskari Heikinheimo, MD, PhD, Immediate Complications After Medical Compared With Surgical Termination of Pregnancy. (Obstet Gynecol 2009;114:795 804 3 Bartlett L, Berg C, Shulman H, Zane S, Green C, Whitehead S, Atrash H. Risk Factors for Legal Induced Abortion Related Mortality in the United States, ) Obstet Gynecol 2004; 103:729 37. 4 Mentula, Maarit, Niinimaki M, Suhonen S. Hemminki E, Gissler M and Heinkinheimo O. "Immmediate adverse events after second trimester medical termination of pregnancy: results of a nationwide registry study". Human Reproduction (0)(0) p 1-6 2011 5 Bartlett L, Berg C, Shulman H, Zane S, Green C, Whitehead S, Atrash H. Risk Factors for Legal Induced Abortion Related Mortality in the United States, ) Obstet Gynecol 2004; 103:729 37. 6 Chang J, Elam-Evans L, Berg C, Herndon J, Flowers L, Seed K, Syverson C, Pregnancy-Related Mortality Surveillance-United States-1991-1999. 52(SS02); 1-8 Division of Reproductive Health, Center for Disease Control, Atlanta Georgia Feb 21, 2003. 7 Shah PS, Zao J. Knowledge Synthesis Group of Determinants of Preterm/LBW Births. Induced termination of pregnancy and low birth weight and preterm birth: a systematic review and metaanalysis. BJOG. 2009; 116:1425 1442. [PubMed: 19769749]
8

Henriet L, Kaminski M. Impact of induced abortions on subsequent pregnancy outcome: the 1995 French national perinatal survey. BJOG. 2001; 108:10361042. [PubMed: 11702834]
9

Moreau C, Kaminski M, Ancel PY, et al. for the EPIPAGE Group. Previous induced abortions and the risk of very preterm delivery: results of the EPIPAGE study. BJOG. 2005; 112:430437. [PubMed: 15777440]
10

Ancel PY, Lelong N, Papiernik E, et al. for EUROPOP. History of induced abortion as a risk factor

for PTB in European countries: results of the EUROPOP survey. Hum Reprod. 2004; 19:734740. [PubMed: 14998979] 11 Complete list of 170+studies available at http://www.aaplog.org/complications-of-induced-abortion/inducedabortion-and-pre-term-birth/bibliography/ last visited Jan 6 2014 12 Iams JD, Berghella V. Care for women with prior preterm birth Am J Obstet Gynecol. 2010 August ; 203(2): 89 100. doi:10.1016/j.ajog.2010.02.004. 13 available at http://www.aaplog.org/complications-of-induced-abortion/induced-abortion-and-mentalhealth/complete-bibliography-on-abortion-and-mental-health/ (last visited Jan 6, 2014) 14 Coleman, P.K. Abortion and mental health: quantitative synthesis and analysis of research published 1995 2009 The British Journal of Psychiatry (2011) 199, 180186. doi: 10.1192/bjp.bp.110.077230 15 Gissler M, Hemminki E, Lonnqvist J. Suicides after pregnancy in Finland, 1987-94: Register linkage study. Br Med J 1996; 313: 1431-4. 16 Reardon DC, Cougle J, Ney PG, Scheuren F, Coleman PK, Strahan TW. Deaths associated with delivery and abortion among California Medicaid patients: A record linkage study. South Med J 2002; 95: 834-841 17 Available at http://www.bcpinstitute.org/epidemiology_studies_bcpi.htm (last visited Jan 6, 2014) 18 Huang Y, Zhang X, Li W, Song F, Dai H, Wang J, Gao Y, Liu X, Chen C, Yan Y, Wang Y Chen K, A meta -analysis of the association between induced abortion and breast cancer risk among Chinese females Cancer Causes Control DOI 10.1007/s10552-013-0325-7
19

Bhadoria AS, Kapil U, Sareen N, Singh P Reproductive factors and breast cancer: A casecontrol study in tertiary care hospital of North IndiaIndian Journal of Cancer | OctoberDecember 2013 | Volume 50 | Issue 4 316-321,,
20

LeCarpentier J, Nogues C, Mouret-Fourme E, Gauthier-Villars M, Lasset C, Fricker J, Caron O, Stoppa-Lyonnet D, Berthet P, et. Al. Variation in breast cancer risk associated with factors related to pregnancies according to truncating mutation location, in the French national BrCA carrier cohort (GENEPSO) Breast Cancer Research 2012, 14:R99 doi:10.1186/bcr3218 21 Coleman P, Reardon D, Calhoun B. Reproductive history patterns and long term mortality rates: a Danish, population-based record linkage study. European J of Public Health Sept 5 2012 p 1-6. 22 Calhoun B. The maternal mortality myth in the context of legalized abortion. The Linacre Quarterly 0 (0) 2013, 113