珍屯医学

标题: 流产 [打印本页]

作者: 大江 时间: 2018-12-21 00:00
标题: 流产
堕胎是怀孕的结束，因为胚胎或胎儿在子宫外能够存活之前将其移除。[注1]自发发生的堕胎也称为流产。当采取刻意的措施来结束怀孕时，它被称为人工流产，或者更少的是“诱导流产”。堕胎一词通常用于表示只有人工流产。[1]胎儿可能在子宫外存活后的类似程序被称为“晚期终止妊娠”或不太准确的“晚期流产”。[2]

在法律允许的情况下，发达国家的堕胎是最安全的医学程序之一。[3] [4]现代方法使用药物或手术进行堕胎。[5]药物米非司酮联合前列腺素似乎与妊娠中期和孕中期的手术一样安全有效[5] [6]。最常见的手术技术包括扩张子宫颈和使用抽吸装置。[7]避孕药可以在堕胎后立即使用，例如避孕药或宫内避孕器。[6]如果合法安全地进行，人工流产不会增加长期精神或身体问题的风险。[8]相比之下，不安全的堕胎（由非熟练人员，危险设备或不卫生设施进行的堕胎）导致每年47,000人死亡和500万人入院。[8] [9]世界卫生组织建议所有妇女都能获得安全合法的堕胎。[10]

世界上每年约有5600万例堕胎，[11]其中约45％的堕胎不安全。[12] 2003年至2008年期间堕胎率几乎没有变化，[13]之前，随着计划生育和计划生育的增加，堕胎率下降了至少20年。[14]截至2008年，世界上40％的妇女可以在没有理由限制的情况下获得合法堕胎。[15]允许堕胎的国家对允许堕胎的晚期有不同的限制。[15]

从历史上看，已经尝试使用草药，尖锐工具，强力按摩或其他传统方法进行堕胎。[16]堕胎法和堕胎的文化或宗教观点在世界各地都不同。在某些地区，堕胎只在特定情况下是合法的，例如强奸，胎儿问题，贫困，妇女健康风险或乱伦。[17]在许多地方，关于堕胎的道德，伦理和法律问题存在很多争论。[18] [19]那些反对堕胎的人经常认为胚胎或胎儿是一个有生命权的人，所以他们可以比较堕胎和谋杀。[20] [21]那些赞成堕胎合法性的人常常认为女性有权决定自己的身体。[22]其他人则赞成将合法和无障碍堕胎作为一项公共卫生措施。[23]

目录
1 类型
1.1 诱导
1.2 自发性
2 方法
2.1 医疗
2.2 手术
2.3 人工流产
2.4 其他方法
3 安全
3.1 心理健康
3.2 不安全流产
3.3 活产
4 发病率
4.1 孕龄和方法
5 动机
5.1 个人
5.2 社会性
5.3 孕产妇和胎儿的健康
6 历史和宗教
7 社会与文化
7.1 堕胎辩论
7.2 现代堕胎法
7.3 性别选择性流产
7.4 反堕胎暴力
8 其他动物
9 参考

类型
诱发
人工流产可分为治疗性（根据妇女或胎儿的健康状况进行）或选择性（由于其他原因选择）。[24]

全世界每年大约有2.05亿人怀孕。超过三分之一是无意识的，大约五分之一是人工流产。[13] [25]大多数堕胎都是由于意外怀孕造成的。[26] [27]在英国，1％至2％的堕胎是由于胎儿的遗传问题而完成的。[8]怀孕可以通过多种方式故意中止。选择的方式通常取决于胚胎或胎儿的胎龄，随着妊娠的进展，胎龄会增加。[28] [29]由于合法性，地区可用性以及医生或女性的个人偏好，也可以选择特定程序。

获得人工流产的原因通常表征为治疗性或选择性。堕胎在医学上被称为治疗性堕胎，用于挽救孕妇的生命;防止伤害妇女的身心健康;终止妊娠，表明儿童的死亡或发病几率会大大增加;或选择性地减少胎儿数量，以减轻多胎妊娠相关的健康风险。[30] [31]堕胎在妇女非医疗原因的要求下进行时被称为选择性或自愿性堕胎。[31]由于“选择性手术”通常是指所有预定的手术，无论是否在医学上是必要的，因此有时会出现“选择性”一词的混淆。[32]

自发
主要文章：流产
自然流产，也称为流产，是在妊娠第24周之前无意中驱逐胚胎或胎儿。[33]妊娠37周结束导致活产婴儿的妊娠被称为“早产”。[34]当胎儿在生存后或分娩过程中在子宫内死亡时，通常称为“死产”。[35]早产和死产通常不被认为是流产，尽管这些术语的使用有时可能会重叠。[36]

只有30％到50％的概念在第一个三个月过去了。[37]绝大多数没有进步的人在女性意识到受孕之前就已经失去了[31]，许多怀孕在医生检测到胚胎之前就已经失去了。[38]根据孕妇的年龄和健康状况，已知怀孕的15％至30％在临床明显流产期结束。[39]这些自然流产中有80％发生在孕早期。[40]

妊娠早期自然流产的最常见原因是胚胎或胎儿的染色体异常，[31] [41]占早期妊娠丢失量的至少50％。[42]其他原因包括血管疾病（如狼疮），糖尿病，其他激素问题，感染和子宫异常。[41]提高产妇年龄和女性先前自然流产的历史是导致自然流产风险增加的两个主要因素。[42]意外创伤也可引起自然流产;故意创伤或压力导致流产被认为是人工流产或堕胎。[43]

方法

[attach]6088[/attach]
孕龄可以决定实施哪种堕胎方法。

药物
主要文章：药物流产
医疗堕胎是由堕胎药物诱发的堕胎。药物流产成为另一种流产方法，在20世纪70年代有前列腺素类似物和20世纪80年代抗孕激素米非司酮（也称为RU-486）。[5] [6] [44] [45] [46]

最常见的早期妊娠早期药物流产方案使用米非司酮联合前列腺素类似物（米索前列醇或前列素）至胎龄9周，甲氨蝶呤联合前列腺素类似物至多7周妊娠，或单独使用前列腺素类似物[ 44]米非司酮 - 米索前列醇联合用药比甲氨蝶呤 - 米索前列醇联合用药更快，在妊娠晚期更有效，联合用药比单用米索前列醇更有效。[45]该制度在妊娠中期有效。[47]在怀孕63天之前，在24至48小时之后，涉及米非司酮和米非司酮的药物流产团在面颊中有效。[48]

在早期流产，妊娠7周，使用米非司酮 - 米索前列醇联合方案的药物流产被认为比手术流产（真空吸引术）更有效，特别是当临床实践不包括对吸入组织的详细检查时。[49]使用米非司酮的早期药物流产方案，随后24-48小时后口服或阴道米索前列醇，在胎龄9周时有效率为98％。[50]如果药物流产失败，必须使用手术流产来完成手术。[51]

早期的医疗堕胎占英国孕前9周的大部分堕胎，[52] [53]法国，[54]瑞士，[55]和北欧国家。[56]在美国，截至2014年，早期医疗堕胎的比例约为30％。[57]

使用米非司酮联合前列腺素类似物的药物流产方案是加拿大，大多数欧洲，中国和印度使用的最常见的中期妊娠方法，[46]与美国相比，其中96％的孕中期流产率通过扩张和疏散手术进行。[58]

外科

[attach]6084[/attach]
在孕周8周（受精后6周）进行真空吸引流产。
1：羊膜囊
2：胚胎
3：子宫内膜
4：窥器
5：Vacurette
6：安装在抽吸泵上
妊娠长达15周，吸痰或真空吸引是最常见的人工流产手术方法。[59]手动真空吸引术（MVA）包括使用手动注射器通过抽吸移除胎儿或胚胎，胎盘和膜，而电动真空抽吸（EVA）使用电动泵。这些技术的不同之处在于用于施加抽吸的机制，在怀孕早期如何使用，以及是否需要宫颈扩张。

MVA，也称为“微吸”和“月经提取”，可以在很早的怀孕期间使用，并且不需要宫颈扩张。扩张和刮宫术（D＆C）是第二种最常见的手术流产方法，是一种标准的妇科手术，由于各种原因而进行，包括检查子宫内膜是否存在可能的恶性肿瘤，调查异常出血和流产。刮宫是指用刮匙清洁子宫壁。只有当MVA不可用时，世界卫生组织才推荐这种程序，也称为急性刮宫术。[60]

从妊娠第15周到大约26日，必须使用其他技术。扩张和撤离（D＆E）包括打开子宫颈并使用手术器械和抽吸清空子宫颈。在妊娠第16周后，也可以通过完整的扩张和提取（IDX）（也称为宫内颅减压）诱导堕胎，这需要在撤离前对胎儿的头部进行手术减压。 IDX有时被称为“部分分娩流产”，在美国被联邦政府禁止。

在怀孕的第三个三个月，人工流产可以通过完整的扩张和拔除或通过子宫切开术手术进行。子宫切开术流产是一种类似于剖腹产的手术，在全身麻醉下进行。它需要比剖腹产更小的切口，并在怀孕的后期使用。[61]

妊娠早期手术通常可以使用局部麻醉进行，而孕中期方法可能需要深度镇静或全身麻醉。[62]

人工流产
在缺乏扩张和拔除所需的医疗技能的地方，或者从业者更喜欢的地方，可以通过先引诱分娩然后在必要时诱导胎儿死亡来诱导堕胎。[63]这有时被称为“诱导流产”。该过程可以从妊娠13周到妊娠晚期进行。虽然在美国非常罕见，但在整个孕中期超过80％的人工流产是瑞典和其他附近国家的人工流产。[64]

只有有限的数据可用于比较这种方法与扩张和提取。[64]与D＆E不同，18周后的劳动力流产可能因胎儿短暂存活而复杂化，这可能在法律上被定性为活产。因此，在美国，劳动人工流产具有法律风险[64] [65]。

其他方法
历史上，许多据称具有堕胎特性的草药已被用于民间医学。其中包括：艾菊，薄荷属植物，黑升麻和现已灭绝的罗盘草。[66]：44-47,62-63,154-155,230-231

1978年，科罗拉多州的一名妇女在尝试通过服用薄荷油进行堕胎时死亡，另一名妇女严重受伤。[67]因为不加区分地使用草药作为堕胎药会导致严重甚至致命的副作用，例如多器官衰竭[68]，医生不建议这样使用。

有时会通过对腹部造成创伤来尝试堕胎。如果严重的话，力度会导致严重的内伤，而不一定会成功引发流产。[69]在东南亚，有一种古老的传统，即通过强力腹部按摩来进行堕胎。[70]装饰柬埔寨吴哥窟的浮雕之一描绘了一名恶魔对一名被送往黑社会的妇女进行堕胎。[70]

报告的不安全自行流产方法包括误用米索前列醇，以及将非手术器具如针织衣架和衣架插入子宫内。这些和其他终止妊娠的方法可称为“诱导流产”。这些方法很少用于手术流产合法且可获得的国家。[71]

安全

[attach]6085[/attach]
南非的堕胎传单
堕胎的健康风险主要取决于该程序是安全还是不安全地进行。世界卫生组织将不安全堕胎定义为由非熟练人员，危险设备或不卫生设施进行的堕胎。[72]在发达国家进行的合法堕胎是最安全的医疗程序之一。[3] [73]在美国，堕胎造成的孕产妇死亡风险为每10万次手术造成的死亡风险为0.7，[4]堕胎妇女比分娩安全约13倍（每10万活产婴儿死亡人数为8.8）。[74] [75]在美国，从2000年到2009年，堕胎的死亡率低于整形手术。[76]与堕胎有关的死亡风险随着孕龄而增加，但至少在妊娠21周时仍然低于分娩的风险。[77] [78] [79]从妊娠64到70天，门诊流产安全有效，从57天到63天不等。[80]药物流产对于早于妊娠6周的妊娠是安全有效的。[81]

妊娠早期的真空吸引术是最安全的手术流产方法，可以在初级保健办公室，堕胎诊所或医院进行。罕见的并发症可能包括子宫穿孔，盆腔感染和需要第二次手术撤离的保留受孕产品。[82]感染占美国堕胎相关死亡人数的三分之一。[83]无论手术是在医院，手术中心还是办公室进行，妊娠早期真空吸引流产的并发症发生率相似。[84]预防性抗生素（如多西环素或甲硝唑）通常在选择性流产前给予，[85]因为它们被认为可以大大降低术后子宫感染的风险。[62] [86]根据堕胎是由医生还是中级医生执行，失败程序的比率似乎没有显着差异。[87]妊娠中期流产后的并发症与妊娠早期流产后的并发症相似，并且在某种程度上取决于所选择的方法。孕中期堕胎通常耐受良好。[88]

使用米非司酮联合米索前列醇和手术流产（真空抽吸）联合治疗妊娠早期妊娠9周的药物流产的安全性和有效性差异不大[49]。单独使用前列腺素类似物米索前列醇的药物流产比使用米非司酮和米索前列醇或手术流产的联合方案的药物流产效果更差且更痛苦。[89] [90]

一些据称堕胎的风险主要是由反堕胎组织推动的，[91] [92]但缺乏科学支持。[91]例如，已经广泛研究了人工流产与乳腺癌之间的联系问题。主要的医学和科学机构（包括世界卫生组织，国家癌症研究所，美国癌症协会，皇家OBGYN学院和美国国会OBGYN）得出的结论是，堕胎不会导致乳腺癌。[93]

在过去，甚至非法也不会自动意味着堕胎是不安全的。在谈到美国时，历史学家琳达戈登说：“事实上，这个国家的非法堕胎有着令人印象深刻的安全记录。”[94]：25根据Rickie Solinger的说法，

一个由广泛关注堕胎和公共政策的人发布的相关神话是，在合法化之前，堕胎者是肮脏而危险的后巷屠夫...... [9]他的历史证据并不支持这种说法。[95] ：4

作者Jerome Bates和Edward Zawadzki描述了20世纪初美国东部非法堕胎者的案例，他为成功完成13,844次堕胎而感到自豪。[96]：59 1970年代纽约市着名的堕胎者/助产士Restell夫人（Anna Trow Lohman）似乎在超过100,000名患者中失去了极少数女性[97] - 死亡率低于当时的分娩死亡率。 1936年，着名的妇产科教授Frederick J. Taussig写道，在美国非法入狱期间，死亡率上升的原因是

随着过去五十年的每十年，这次事故[子宫穿孔]的实际和比例频率增加，首先是由于仪器诱导堕胎数量的增加;第二，医生处理的堕胎比例增加，而助产士处理的堕胎比例增加;第三，流行倾向于使用器械而不是手指来清空子宫。 [98]：223

精神健康
主要文章：堕胎和心理健康
目前的证据发现大多数人工流产与心理健康问题之间没有关系[8] [99]，而不是任何意外怀孕的预期。[100]美国心理学会的一份报告得出的结论是，女性的第一次堕胎在头三个月进行时不会对精神健康构成威胁，这些女性不会比那些怀有意外怀孕的女性更容易出现心理健康问题。女性第二次或更大次堕胎的心理健康结果不太确定。[100] [101]一些较早的评论得出的结论是，堕胎与心理问题的风险增加有关; [102]但是，他们没有使用适当的对照组。[99]

虽然一些研究表明，由于胎儿异常，在孕早期选择堕胎的妇女的心理健康结果为负，[103]需要进行更严格的研究才能最终证明这一点。[104]一些被提议的堕胎的负面心理影响被反堕胎倡导者称为一种称为“堕胎后综合症”的单独病症，但美国的医学或心理专业人员并未认识到这一点。[105]

不安全的堕胎
主要文章：不安全堕胎

[attach]6091[/attach]
大约1925年的苏联海报，警告反对助产士进行堕胎。标题翻译：“由受过训练或自学成才的助产士进行的堕胎不仅会伤害女性，还会导致死亡。”
寻求终止妊娠的妇女有时采用不安全的方法，特别是在限制合法堕胎的情况下。他们可能会试图自我堕胎或依赖其他没有经过适当医疗培训或获得适当设施的人。这有导致严重并发症的趋势，例如不完全流产，败血症，出血和内脏损伤。[106]

不安全堕胎是全世界妇女受伤和死亡的主要原因。虽然数据不准确，但估计每年约有2000万次不安全堕胎，其中97％发生在发展中国家。[3]据信不安全堕胎会导致数百万人受伤。[3] [107]死亡人数估计数根据方法而有所不同，在过去十年中有37,000至70,000人不等; [3] [9] [108]不安全堕胎造成的死亡约占所有孕产妇死亡人数的13％。[109]世界卫生组织认为，自1990年代以来死亡率已下降。[110]为减少不安全堕胎的数量，公共卫生组织一般主张强调堕胎合法化，培训医务人员以及确保获得生殖健康服务。[111]作为回应，反对堕胎的人指出，堕胎禁令绝不会影响选择将胎儿带到足月的妇女的产前护理。 2012年签署的“关于孕产妇健康的都柏林宣言”指出，“禁止堕胎不会以任何方式影响孕妇获得最佳护理。”[112]

是否安全地进行堕胎的一个主要因素是堕胎的法律地位。与堕胎合法且可获得的堕胎相比，具有限制性堕胎法的国家的不安全堕胎率和类似的总体堕胎率相似。[9] [13] [111] [113] [114] [115] [116]例如，1996年南非堕胎合法化对堕胎相关并发症的频率产生了直接的积极影响，[117]与堕胎有关的死亡率下降了90％以上。[118]在其他国家放宽了堕胎法之后，例如罗马尼亚和尼泊尔，也观察到产妇死亡率的类似下降。[119] 2011年的一项研究得出结论，在美国，一些州级反堕胎法与该州较低的堕胎率相关。[120]然而，该分析没有考虑到没有这些堕胎法律的其他国家的旅行。[121]此外，缺乏有效避孕措施导致不安全堕胎。据估计，如果现代计划生育和产妇保健服务在全球范围内可以获得，不安全堕胎的发生率可降低多达75％（每年从2000万减少到500万）。[122]这种堕胎的比率可能难以衡量，因为它们可以被不同地报告为流产，“诱导流产”，“月经调节”，“小堕胎”和“延迟/暂停月经的调节”。[123] [124] ]

世界上40％的女性能够在妊娠期内接受治疗性和选择性堕胎[15]，而另外35％的女性在符合某些身体，心理或社会经济标准的情况下可以进行合法堕胎。[17]虽然产妇死亡率很少是安全堕胎造成的，但不安全堕胎每年导致70,000人死亡和500万残疾。[9]不安全堕胎的并发症占全世界大约八分之一的孕产妇死亡，[125]尽管这种情况因地区而异。[126]不安全堕胎引起的继发性不孕影响了大约2400万妇女。[114] 1995年至2008年，不安全堕胎率从44％增加到49％。[13]为解决这一现象，已提出健康教育，获得计划生育以及改善堕胎期间和之后的医疗保健。[127]

活产
虽然这种情况非常罕见，但在妊娠18周后接受手术流产的妇女有时会生出可能短暂存活的胎儿。[128] [129] [130] 22周后可以长期存活。[131]

如果医务人员观察到生命迹象，他们可能需要提供护理：如果孩子有很好的生存机会，则需要紧急医疗护理;如果没有，则需要姑息治疗。[132] [133] [134]为避免这种情况，建议在妊娠20-21周后终止妊娠前诱导胎儿死亡。[135] [136] [137] [138] [139]

堕胎引起的活产死亡给出了ICD-10基本原因描述代码P96.4;数据被识别为胎儿或新生儿。在1999年至2013年期间，美国疾病预防控制中心记录了新生儿死亡人数531例，[140]每10万例堕胎中约有4例死亡。[141]

发生率
有两种常用的测量流产发生率的方法：

堕胎率 - 每1000名15至44岁妇女的堕胎数量
堕胎百分比 - 100例已知怀孕中的堕胎数量（怀孕包括活产，堕胎和流产）
在许多地方，堕胎是非法的或带有沉重的社会耻辱感，堕胎的医疗报告并不可靠。[113]因此，必须在不确定与标准误差相关的确定性的情况下估算堕胎的发生率。[13]

近年来，全世界的堕胎数量似乎保持稳定，2003年有4160万人，2008年有4380万人。[13]全世界的堕胎率为每千名妇女28人，但发达国家为每千名妇女24人，发展中国家为每1000名妇女29人。[13]同一项2012年的研究表明，2008年，全世界已知怀孕的估计堕胎率为21％，发达国家为26％，发展中国家为20％。[13]

平均而言，堕胎的发生率在具有限制性堕胎法的国家和更容易获得堕胎的国家中是相似的。但是，限制性堕胎法与不安全堕胎百分比的增加有关。[15] [142] [143]发展中国家不安全的堕胎率部分归因于无法获得现代避孕药具;据古特马赫研究所称，提供避孕药具将使全世界每年不安全堕胎减少约1450万人，减少38,000人死于不安全堕胎。[144]

法律，人工流产率在世界范围内差异很大。根据Guttmacher研究所员工的报告，2008年在统计数据完全统计的国家中，每1000名妇女（德国和瑞士）为7名，每1000名妇女（爱沙尼亚）为30名。人工流产结束的怀孕比例约为10 ％（以色列，荷兰和瑞士）占同一组别的30％（爱沙尼亚），但在匈牙利和罗马尼亚可能高达36％，其统计数据被认为是不完整的。[145] [146]

堕胎率也可以表示为妇女在生育年龄期间的平均堕胎数量;这被称为总堕胎率（TAR）。

孕龄和方法

[attach]6089[/attach]
2004年英格兰和威尔士孕龄堕胎直方图。（左）

[attach]6092[/attach]
2004年孕龄在美国的堕胎。（右）
堕胎率也取决于怀孕阶段和实践方法。 2003年，美国疾病控制和预防中心（CDC）报告称，据报道，美国报告的合法人工流产率为26％，孕期不到6周，7周时为18％，8岁时为15％。周，9至10周时为18％，11至12周时为9.7％，13至15周时为6.2％，16至20周时为4.1％，超过21周时为1.4％。其中90.9％被分类为“刮宫术”（吸痰，扩张和刮宫，扩张和撤离），7.7％用“医疗”方式（米非司酮），0.4％用“宫内滴注”（盐水或前列腺素））和“其他”（包括子宫切开术和子宫切除术）的1.0％。[147]根据疾病预防控制中心的说法，由于数据收集困难，数据必须被视为暂定的，如果通过与人工流产相同的程序完成死胎的移除，则报告超过20周的一些胎儿死亡可能是自然死亡被错误地归类为堕胎。[148]

Guttmacher研究所估计，2000年美国有2,200个完整的扩张和提取程序;这占当年堕胎总数的0.17％。[149]同样，在2006年的英格兰和威尔士，89％的终止发生在12周或12周以下，9％发生在13周和19周之间，1.5％发生在20周或20周以上。报告的64％是真空抽吸，6％是D＆E，30％是医疗。[150]中国，印度和越南等发展中国家的孕中期堕胎数量超过发达国家。[151]

动机
个人
妇女堕胎的原因多种多样，而且在世界各地都有所不同。[148] [152]

[attach]6083[/attach]
一张条形图，描绘了一份1998年AGI元研究中的选定数据，该研究报告了妇女堕胎的原因。
一些最常见的原因是将生育推迟到更合适的时间或将精力和资源集中在现有儿童身上。其他包括无论是抚养孩子的直接成本还是在照顾孩子时失去收入，父亲缺乏支持，无力支付额外的孩子，为现有儿童提供教育的愿望，都无法负担孩子的费用。，破坏自己的教育，与伴侣的关系问题，过于年幼，不能生孩子，失业，以及不愿意抚养因强奸或乱伦等原因而被抚养的孩子。[152] [ 153]

社会
由于社会压力，一些堕胎经历了。这些可能包括偏爱特定性别或种族的儿童，[154]不赞成单身或早期母亲，对残疾人的侮辱，对家庭的经济支持不足，无法获得或拒绝避孕方法，或对人口的努力控制（如中国的独生子女政策）。这些因素有时会导致强制堕胎或性别选择性堕胎。[155] [未引用]

2002年的一项美国研究得出结论，大约一半的堕胎妇女在怀孕时使用了一种避孕方法。一半使用安全套的人和使用避孕药的人中有四分之一报告使用不一致;使用安全套的人中有42％报告因滑倒或破损而失败。[156]古特马赫研究所估计，“美国大多数堕胎都是少数民族妇女”，因为少数民族妇女“意外怀孕率高得多”。[157]

孕产妇和胎儿的健康
另一个因素是孕产妇或胎儿健康的风险，这被认为是一些国家超过三分之一的堕胎的主要原因，并且是其他国家仅有一位数百分比的堕胎的重要因素。[148] [152]

在美国，最高法院在Roe v.Wade和Doe诉Bolton案中的判决：“裁定国家对胎儿生命的兴趣仅在生存能力方面变得引人注目，定义为胎儿可以存活的点独立于母亲。即使在生存能力之后，国家也不能支持胎儿的生命对孕妇的生命或健康的影响。在隐私权下，医生必须自由地使用他们的“医学判断来保护母亲的生命或健康状况。“在法院判决Roe的同一天，它还决定了Doe诉Bolton，其中法院对健康的定义非常广泛：”医疗判决可以根据所有因素行使 - 身体，情感，心理，家庭和女性的年龄 - 与患者的福祉相关。所有这些因素都可能与健康有关。这使得主治医生能够做出最佳医学判断所需的空间。“[158]：1200-1201

在电视名人Sherri Finkbine在怀孕第五个月发现她接触过沙利度胺之后，公众舆论在美国转移。由于无法在美国获得合法堕胎，她前往瑞典。从1962年到1965年，德国麻疹爆发导致15,000名婴儿出现严重的先天缺陷。 1967年，美国医学会公开支持堕胎法的自由化。 1965年的一项全国舆论研究中心民意调查显示，当母亲的生命处于危险之中时，73％支持堕胎，出生缺陷时为57％，强奸或乱伦导致妊娠占59％。[159]

癌症
怀孕期间的癌症发病率为0.02-1％，并且在许多情况下，母亲的癌症导致考虑流产以保护母亲的生命，或者响应于治疗期间胎儿可能发生的潜在损害。对于宫颈癌尤其如此，其中最常见的类型发生在每2,000-13,000例妊娠中的1例中，其中治疗的开始“不能与保持胎儿生命共存（除非选择新辅助化疗）”。非常早期的宫颈癌（I和IIa）可以通过根治性子宫切除术和盆腔淋巴结清扫术，放射疗法或两者来治疗，而后期阶段通过放射治疗来治疗。化疗可以同时使用。怀孕期间治疗乳腺癌也涉及胎儿因素，因为不鼓励乳房肿瘤切除术有利于改良根治性乳房切除术，除非晚期妊娠允许在分娩后进行随访放射治疗。[160]

接触单一化疗药物估计会对胎儿造成7.5-17％的致畸作用风险，多种药物治疗的风险更高。超过40 Gy的辐射治疗通常会导致自然流产。在妊娠早期，特别是8至15周的发育期间接触低得多的剂量可导致智力残疾或小头畸形，并且在此阶段或后续阶段的暴露可导致胎儿宫内发育和出生体重减少。暴露于0.005-0.025 Gy之间会导致智商的剂量依赖性降低[160]。根据被照射的区域离胎儿的距离，可以大大减少腹部屏蔽对辐射的影响。[161] [162]

出生过程本身也可能使母亲处于危险之中。 “阴道分娩可能导致肿瘤细胞扩散到淋巴血管通道，出血，宫颈裂伤和外阴切开术部位的恶性细胞植入，而腹部分娩可能会延迟非手术治疗的开始。”[163]

历史和宗教
主要文章：堕胎史

[attach]6086[/attach]
在柬埔寨吴哥窟的浅浮雕，c. 1150年，描绘了一个通过用杵敲打孕妇腹部诱导堕胎的恶魔。[70] [164]

[attach]6087[/attach]
“法国期刊丸”。 1845年1月出版的“波士顿每日时报”刊登的秘密广告的一个例子。
自古以来，人们就已经使用草药，尖锐的工具，用武力或通过其他传统方法进行堕胎。[16]人工流产历史悠久，可以追溯到神农（公元前2700年左右），古埃及及其埃伯斯纸莎草（公元前1550年），以及青年时期罗马帝国（c）的文明。 .200 CE）。[16]有证据表明怀孕是通过多种方法终止的，包括堕胎药物的使用，尖锐器具的使用，腹压的应用以及其他技术。最早已知的堕胎艺术表现形式之一是吴哥窟的浅浮雕（约1150年）。在印度教和佛教文化中代表死后判断的一系列饰带中，它描绘了腹部流产的技术。[70]

一些医学学者和堕胎反对者认为希波克拉底誓言禁止古希腊医生进行堕胎; [16]其他学者不同意这种解释，[16]并指出希波克拉底语语料库的医学文本包含对堕胎技术的描述。宣誓。[165]医生Scribonius Largus在公元43年写道，希波克拉底誓言禁止堕胎，Soranus也是如此，尽管当时并非所有医生都严格遵守堕胎。根据Soranus的第一或第二世纪CE工作妇科学，一个医疗从业者党按照希波克拉底誓言的要求消灭了所有堕胎;另一方 - 他所属的 - 愿意开堕胎，但只是为了母亲的健康。[166] [167]

亚里士多德在他关于政治政治的论文（公元前350年）中，谴责杀婴是一种人口控制手段。在这种情况下，他更倾向于堕胎，并且限制[168]“必须在它产生感觉和生命之前对其实施;因为合法和非法堕胎之间的界限将以感觉和存在的事实为标志。活着。” [169]在基督教中，教皇西斯图斯五世（1585-90）是1869年之前唯一一位宣布堕胎是凶杀的教皇，无论怀孕阶段如何; [170]他的继承人在三年后宣布他的1588年宣告被撤销。在其历史的大部分时间里，天主教会对是否认为堕胎是谋杀是否存在分歧，并且直到19世纪才开始大力反对堕胎。[16]事实上，一些历史学家写过[171] [172] [173]，在19世纪之前，大多数天主教作者并未将“加速”或“堕胎”作为堕胎之前终止妊娠。

1995年的一项调查报告说，天主教女性与一般人群一样可以终止妊娠，新教徒不太可能这样做，而福音派基督徒最不可能这样做。[148] [152]传统上，伊斯兰传统允许堕胎，直到穆斯林相信灵魂进入胎儿的时间点，[16]各种神学家认为受孕，受孕后40天，受孕后120天或加速。[174]但是，在伊斯兰教信仰高的地区，如中东和北非，堕胎受到严重限制或禁止。[175]

在欧洲和北美，堕胎技术从17世纪开始发展。然而，大多数医生对性问题的保守性阻碍了安全堕胎技术的广泛扩展。[16]除了一些医生之外，其他医生也在宣传他们的服务，直到19世纪才开始对他们进行广泛监管，当时美国和英国都禁止这种做法（有时称为restellism）[176]。[16]教会团体和医生在反堕胎运动中具有很大的影响力。[16]在美国，根据一些消息来源，堕胎比分娩更危险，直到大约1930年，堕胎手术相对于分娩的逐步改善使堕胎更安全。[注2]然而，其他消息来源认为，在19世纪卫生的早期堕胎助产士通常工作的条件相对安全。[177] [178] [179]此外，一些评论员写道，尽管医疗程序有所改善，但从20世纪30年代到合法化期间，反堕胎法律的执行也更加热烈，同时有组织犯罪对堕胎服务提供者的控制也越来越多。[180] [181] [182] [183] [184]

苏联俄罗斯（1919年），冰岛（1935年）和瑞典（1938年）是最早将某些或所有形式的堕胎合法化的国家之一。[185] 1935年，纳粹德国通过了一项法律，允许对那些被视为“遗传性疾病”的人进行堕胎，而被认为是德国种群的妇女则被明确禁止堕胎。[186]从二十世纪下半叶开始，堕胎在更多的国家合法化。[16]

社会与文化
堕胎辩论
主要文章：堕胎辩论
人工流产一直是引起大量争论的根源。围绕堕胎的道德，道德，哲学，生物，宗教和法律问题与价值体系有关。关于堕胎的意见可能涉及胎儿权利，政府权威和妇女权利。

在公开辩论和私人辩论中，赞成或反对堕胎获取的论点集中于人工流产的道德允许性，或者允许或限制堕胎的法律的理由。[187]世界医学会关于治疗性堕胎的宣言指出，“使母亲的利益与其未出生的孩子的利益发生冲突的情况造成了两难，并提出了是否应故意终止怀孕的问题。”[188]堕胎辩论，特别是与堕胎法有关的堕胎辩论，往往由倡导这两个职位之一的团体牵头。支持对堕胎采取更多法律限制的反堕胎团体，包括完全禁止，往往称自己为“依赖生命”，而反对这种法律限制的堕胎权利团体则称自己为“支持选择”。[189]一般来说，前者的立场认为，人类胎儿是一个有生命权的人，使堕胎在道德上与谋杀一样。后一种观点认为，妇女具有一定的生殖权利，特别是决定是否怀孕的权利。

现代流产法
主要文章：堕胎法
另见：堕胎法辩论的历史
[attach]6090[/attach]
堕胎法的国际地位

联合国2013年关于堕胎法的报告。[190]

  法律要求
  对产妇生命，健康，心理健康，强奸和/或胎儿缺陷以及社会经济因素的法律保护
  对于孕产妇，健康，精神健康和/或强奸以及胎儿缺陷都是非法的
  对于孕产妇，健康和/或心理健康以及强奸都是非法的
  非生育，健康和/或心理健康的例外情况
  非产妇生活例外
  非法，没有例外
  没有资料[191]
目前有关堕胎的法律是多种多样的。宗教，道德和文化因素继续影响着全世界的堕胎法。生命权，自由权，人身安全权和生殖健康权是人权的主要问题，有时构成堕胎法存在或不存在的基础。

在堕胎合法的司法管辖区，在妇女获得安全合法堕胎之前必须经常满足某些要求（未经妇女同意而进行的堕胎被视为堕胎）。这些要求通常取决于胎儿的年龄，通常使用基于三个月的系统来调节合法性的窗口，或者像美国一样，根据医生对胎儿活力的评估。有些司法管辖区要求在程序前等待一段时间，规定有关胎儿发育的资料分布，或要求在未成年女儿要求堕胎时与父母联络。[192]其他司法管辖区可能要求妇女在中止胎儿之前获得胎儿父亲的同意，堕胎提供者告知妇女该程序的健康风险 - 有时包括医学文献不支持的“风险” - 并且多个医疗机构认证堕胎在医学上或社会上是必要的。在紧急情况下可以免除许多限制。中国已经结束了[193]独生子女政策，现在有了两个孩子的政策，[194] [195]有时将强制堕胎作为其人口控制战略的一部分。[196]

其他司法管辖区几乎完全禁止堕胎。许多（但不是全部）允许在各种情况下进行合法堕胎。这些情况因管辖权而异，但可能包括怀孕是由于强奸还是乱伦，胎儿的发育受损，妇女的身心健康受到威胁，还是社会经济因素导致分娩困难。[17]在完全禁止堕胎的国家，如尼加拉瓜，医疗当局因怀孕而直接和间接地导致孕产妇死亡率上升，以及由于医生担心如果他们治疗其他妇科紧急情况而可能会因死亡而死亡。[197] [198]一些国家，如孟加拉国，名义上禁止堕胎，也可能支持以月经卫生为幌子进行堕胎的诊所。[199]这也是传统医学的术语。[200]在堕胎非法或带有严重社会耻辱感的地方，孕妇可以从事医疗旅游并前往可以终止妊娠的国家。[201]没有旅行手段的妇女可以诉诸非法堕胎提供者或试图自行堕胎。[202]

自1999年以来，女性波浪组织一直在提供有关医疗堕胎的教育。该非政府组织在一个集装箱内创建了一个移动医疗诊所，然后在租用的船上前往具有限制性堕胎法的国家。由于船舶在荷兰注册，因此当船舶在国际水域时，荷兰法律占主导地位。在港口，该组织提供免费的讲习班和教育;在国际水域，医务人员在法律上能够开出药物流产药物和咨询。[203] [204] [205]

性别选择性流产
主要文章：性别选择性流产
超声和羊膜穿刺术允许父母在分娩前确定性别。这项技术的发展导致性别选择性堕胎，或基于性别终止胎儿。选择性终止女性胎儿是最常见的。

性别选择性堕胎是造成一些国家男女儿童出生率明显不同的部分原因。据报道，亚洲许多地区都存在对男孩的偏好，台湾，韩国，印度和中国报告了用于限制女性出生的堕胎。[206]尽管有关国家可能已正式禁止性别选择性堕胎甚至性别筛查，但这种情况与男性和女性的标准出生率有所偏差。[207] [208] [209] [210]在中国，1979年颁布的独生子女政策加剧了对男童的历史偏好。[211]

许多国家已采取立法措施，以减少性别选择性堕胎的发生率。在1994年国际人口与发展会议上，180多个国家同意消除“对女童的一切形式歧视和儿子偏好的根本原因”，[212]条件也在2011年的PACE决议中受到谴责。[213]世界卫生组织和联合国儿童基金会以及联合国其他机构发现，减少性堕胎的措施在减少性别选择性堕胎方面的效果远远低于减少性别不平等的措施。[212]

反堕胎暴力
主要文章：反堕胎暴力
在许多情况下，堕胎提供者和这些设施遭受各种形式的暴力，包括谋杀，谋杀未遂，绑架，跟踪，殴打，纵火和爆炸。政府和学术界将反堕胎暴力列为恐怖主义。[214] [215]只有一小部分反对堕胎的人实施暴力。

在美国，四名进行堕胎的医生被谋杀：David Gunn（1993），John Britton（1994），Barnett Slepian（1998）和George Tiller（2009）。在美国和澳大利亚，还有其他人员在堕胎诊所就诊，其中包括接待员和保安人员，如詹姆斯巴雷特，香农洛尼，李安尼科尔斯和罗伯特桑德森。伤口（例如，Garson Romalis）和谋杀未遂也发生在美国和加拿大。发生了数百次爆炸，纵火，酸性袭击，入侵以及对堕胎提供者的破坏事件。[216] [217]着名的反堕胎暴力犯罪者包括Eric Robert Rudolph，Scott Roeder，Shelley Shannon和Paul Jennings Hill，他们是第一个因谋杀堕胎提供者而在美国被处决的人。[218]

在堕胎合法的一些国家，已经对堕胎获得法律保护。这些法律通常旨在保护堕胎诊所免受阻挠，故意破坏，纠察和其他行为的侵害，或保护这些设施的妇女和雇员免受威胁和骚扰。

比身体暴力更常见的是心理压力。 2003年，克里斯丹泽在德克萨斯州组织了支持生命的组织，以防止在奥斯汀建立计划生育设施。这些组织在网上发布了个人信息，涉及建设者，每天最多发送1200个电话并联系他们的教堂。[219]一些抗议者记录妇女在相机上进入诊所。[219]

其他动物
更多信息：流产
各种动物都会发生自然流产。例如，在绵羊中，它可能是由压力或体力消耗引起的，例如通过门挤或被狗追逐。[220]在奶牛中，流产可能是由传染性疾病引起的，例如布鲁氏菌病或弯曲杆菌，但通常可以通过接种疫苗来控制。[221]吃松针还可以诱导奶牛堕胎。[222] [223]已知有几种植物，包括苦菜，臭鼬卷心菜，毒铁杉和树烟，会导致牛的胎儿畸形和流产[224]：45-46以及绵羊和山羊。[224]：77-80在马，a如果胎儿有致命的白色综合征（先天性肠神经节病），胎儿可能会被流产或再吸收。对于显性白色基因（WW）纯合的驹胚胎理论上也在出生前被中止或再吸收。[225]在许多种类的鲨鱼和rays鱼中，在捕获时经常发生应激性流产。[226]

病毒感染可导致狗流产。[227]由于多种原因，猫可能会经历自然流产，包括荷尔蒙不平衡。对怀孕的猫进行联合堕胎和喷洒，特别是在Trap-Neuter-Return计划中，以防止不想要的小猫出生。[228] [229] [230]当雌性啮齿动物暴露于不负责怀孕的男性的气味时，可以终止怀孕，称为布鲁斯效应。[231]

在畜牧业的背景下，也可以在动物中诱导流产。例如，堕胎可能是在母马中引起的，这些母马交配不当，或者是那些没有意识到母马怀孕或怀有双胞胎马驹的主人购买的。[232]由于男性对母马的骚扰或强迫交配，马匹和斑马可能会发生杀戮，[233] [234] [235]尽管野外频率受到质疑。[236]雄性灰叶猴可能会在男性接管后攻击雌性，导致流产。[237]

说明：
Definitions of abortion, as with many words, vary from source to source. Language used to define abortion often reflects societal and political opinions (not only scientific knowledge). For a list of definitions as stated by obstetrics and gynecology (OB/GYN) textbooks, dictionaries, and other sources, please see Definitions of abortion.
By 1930, medical procedures in the US had improved for both childbirth and abortion but not equally, and induced abortion in the first trimester had become safer than childbirth. In 1973, Roe v. Wade acknowledged that abortion in the first trimester was safer than childbirth:
"The 1970s". Time communication 1940–1989: retrospective. Time Inc. 1989. Blackmun was also swayed by the fact that most abortion prohibitions were enacted in the 19th century when the procedure was more dangerous than now.
Will, George (1990). Suddenly: the American idea abroad and at home, 1986–1990. Free Press. p. 312. ISBN 0-02-934435-2.
Lewis, J.; Shimabukuro, Jon O. (28 January 2001). "Abortion Law Development: A Brief Overview". Congressional Research Service. Archived from the original on 14 May 2011. Retrieved 1 May 2011.
*Schultz, David Andrew (2002). Encyclopedia of American law. Infobase Publishing. p. 1. ISBN 0-8160-4329-9. Archived from the original on 9 December 2015.
Lahey, Joanna N. (24 September 2009). "Birthing a Nation: Fertility Control Access and the 19th Century Demographic Transition" (PDF; preliminary version). Colloquium. Pomona College. Archived (PDF) from the original on 7 January 2012.

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96% of all abortions performed in nonhospital facilities × 31% early medical abortions of all nonhospital abortions = 30% early medical abortions of all abortions; 97% of nonhospital medical abortions used mifepristone and misoprostol—3% used methotrexate and misoprostol, or misoprostol alone—in the United States in 2014.
Hammond C, Chasen ST (2009). "Dilation and evacuation". In Paul M, Lichtenberg ES, Borgatta L, Grimes DA, Stubblefield PG, Creinin MD. Management of unintended and abnormal pregnancy: comprehensive abortion care. Oxford: Wiley-Blackwell. pp. 178–192. ISBN 1-4051-7696-2.
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Society of Family Planning (February 2011). "Clinical Guidelines, Labor induction abortion in the second trimester". Contraception. 84 (1): 4–18. doi:10.1016/j.contraception.2011.02.005. Retrieved 25 September 2015. 10. What is the effect of feticide on labor induction abortion outcome? Deliberately causing demise of the fetus before labor induction abortion is performed primarily to avoid transient fetal survival after expulsion; this approach may be for the comfort of both the woman and the staff, to avoid futile resuscitation efforts. Some providers allege that feticide also facilitates delivery, although little data support this claim. Transient fetal survival is very unlikely after intraamniotic installation of saline or urea, which are directly feticidal. Transient survival with misoprostol for labor induction abortion at greater than 18 weeks ranges from 0% to 50% and has been observed in up to 13% of abortions performed with high-dose oxytocin. Factors associated with a higher likelihood of transient fetal survival with labor induction abortion include increasing gestational age, decreasing abortion interval and the use of nonfeticidal inductive agents such as the PGE1 analogues.
"2015 Clinical Policy Guidelines" (PDF). National Abortion Federation. 2015. Archived (PDF) from the original on 12 August 2015. Retrieved 30 October 2015. Policy Statement: Medical induction abortion is a safe and effective method for termination of pregnancies beyond the first trimester when performed by trained clinicians in medical offices, freestanding clinics, ambulatory surgery centers, and hospitals. Feticidal agents may be particularly important when issues of viability arise.
Riddle, John M. (1997). Eve's herbs: a history of contraception and abortion in the West. Cambridge, Massachusetts: Harvard University Press. ISBN 978-0-674-27024-4. OCLC 36126503.
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Grimes DA (January 2006). "Estimation of pregnancy-related mortality risk by pregnancy outcome, United States, 1991 to 1999". American Journal of Obstetrics & Gynecology. 194 (1): 92–4. doi:10.1016/j.ajog.2005.06.070. PMID 16389015.
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Schneider, A. Patrick II; Zainer, Christine; et al. (August 2014). "The breast cancer epidemic: 10 facts". The Linacre Quarterly. Catholic Medical Association. 81 (3): 244–277. doi:10.1179/2050854914Y.0000000027. PMC 4135458. Retrieved 11 November 2015. an association between [induced abortion] and breast cancer has been found by numerous Western and non-Western researchers from around the world. This is especially true in more recent reports that allow for a sufficient breast cancer latency period since an adoption of a Western life style in sexual and reproductive behavior.
Position statements of major medical bodies on abortion and breast cancer include:
World Health Organization: "Induced abortion does not increase breast cancer risk (Fact sheet N°240)". World Health Organization. Archived from the original on 13 February 2011. Retrieved 6 January 2011.
National Cancer Institute: "Abortion, Miscarriage, and Breast Cancer Risk". National Cancer Institute. Archived from the original on 21 December 2010. Retrieved 11 January 2011.
American Cancer Society: "Is Abortion Linked to Breast Cancer?". American Cancer Society. 23 September 2010. Archived from the original on 5 June 2011. Retrieved 20 June 2011. At this time, the scientific evidence does not support the notion that abortion of any kind raises the risk of breast cancer.
Royal College of Obstetricians and Gynaecologists: "The Care of Women Requesting Induced Abortion" (PDF). Royal College of Obstetricians and Gynaecologists. p. 9. Archived from the original (PDF) on 27 July 2013. Retrieved 29 June 2008. Induced abortion is not associated with an increase in breast cancer risk.
American Congress of Obstetricians and Gynecologists: "ACOG Finds No Link Between Abortion and Breast Cancer Risk". American Congress of Obstetricians and Gynecologists. 31 July 2003. Archived from the original on 2 January 2011. Retrieved 11 January 2011.
Gordon, Linda (2002). The Moral Property of Women. University of Illinois Press. ISBN 0252027647.
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Society of Family Planning (February 2011). "Clinical Guidelines, Labor induction abortion in the second trimester". Contraception. 84 (1): 4–18. doi:10.1016/j.contraception.2011.02.005. Transient survival with misoprostol for labor induction abortion at greater than 18 weeks ranges from 0% to 50% and has been observed in up to 13% of abortions performed with high-dose oxytocin.
Fletcher; Isada; Johnson; Evans (August 1992). "Fetal intracardiac potassium chloride injection to avoid the hopeless resuscitation of an abnormal abortus: II. Ethical issues". Obstetrics and Gynecology. 80 (2): 310–313. PMID 1635751. following later abortions at greater than 20 weeks, the rare but catastrophic occurrence of live births can lead to fractious controversy over neonatal management.
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Gerri R. Baer; Robert M. Nelson (2007). "Preterm Birth: Causes, Consequences, and Prevention. C: A Review of Ethical Issues Involved in Premature Birth". Institute of Medicine (US) Committee on Understanding Premature Birth and Assuring Healthy Outcomes;. Archived from the original on 31 December 2015. In 2002, the 107th U.S. Congress passed the Born-Alive Infants Protection Act of 2001. This law established personhood for all infants who are born "at any stage of development" who breathe, have a heartbeat, or "definite movement of voluntary muscles", regardless of whether the birth was due to labor or induced abortion.
Chabot, Steve (5 August 2002). "H.R. 2175 (107th): Born-Alive Infants Protection Act of 2002". govtrack.us. Archived from the original on 14 November 2015. Retrieved 30 October 2015. The term "born alive" is defined as the complete expulsion or extraction from its mother of that member, at any stage of development, who after such expulsion or extraction breathes or has a beating heart, pulsation of the umbilical cord, or definite movement of the voluntary muscles, regardless of whether the umbilical cord has been cut, and regardless of whether the expulsion or extraction occurs as a result of natural or induced labor, cesarean section, or induced abortion.
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Committee on Health Care for Underserved Women (November 2014). "Committee Opinion 613: Increasing Access to Abortion". Obstetrics & Gynecology. 124: 1060–1065. doi:10.1097/01.aog.0000456326.88857.31. Archived from the original on 28 October 2015. Retrieved 28 October 2015. "Partial-birth" abortion bans—The federal Partial-Birth Abortion Ban Act of 2003 (upheld by the Supreme Court in 2007) makes it a federal crime to perform procedures that fall within the definition of so-called "partial-birth abortion" contained in the statute, with no exception for procedures necessary to preserve the health of the woman...physicians and lawyers have interpreted the banned procedures as including intact dilation and evacuation unless fetal demise occurs before surgery.
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Milliez Jacques (2008). "FIGO (International Federation of Gynecology and Obstetrics) Committee Report: Ethical aspects concerning termination of pregnancy following prenatal diagnosis". International Journal of Gynecology and Obstetrics. 102 (1): 97–98. doi:10.1016/j.ijgo.2008.03.002. PMID 18423641. Termination of pregnancy following prenatal diagnosis after 22 weeks must be preceded by a feticide
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