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One hundred six women were reported to have died from abortions (55 legal, 10 illegal, and 41 spontaneous) in the United States from 1975 through 1977. In reviewing these deaths, the authors developed a new approach to mortality studies. A catalogue was compiled of behavioral factors (including actions by physicians, patients, communities, and institutions) that in the authors' judgment increased the risk of death from abortion. The proportion of abortion deaths to which each behavioral risk factor contributed was determined. Of the 199 different behavioral factors, 5 contributed to more than 10% of legal abortion deaths, 5 to more than 10% of illegal abortion deaths, and 3 to more than 10% of spontaneous abortion deaths. The most frequent factors involved were delay in obtaining a legal abortion until 13 weeks' gestation or later, incomplete abortion, and inappropriate choice of antibiotics for septic abortion. Assessing the proportion of abortion deaths to which each factor contributed can help identify which factors deserve priority in prevention.

Between August 7 and October 14, 1977, Clostridium perfringens organisms were isolated from endometrial and/or blood specimens from 3 women who had been hospitalized in McAllen, Texas, after having had illegal induced abortions. One of the women died of clostridial septicemia. A single abortionist was suspected in these 3 cases. The authors investigated the illnesses of these 3 women and those of 6 other women who were hospitalized at some time from January through October 1977 after having had illegal abortions but did not identify a common abortionist. The patient who died was a Medicaid-eligible woman who had had an abortion performed by a nonphysician after public funding of abortion was restricted in Texas as of August 5, 1977. The authors examined the medical records of all 230 women hospitalized in McAllen General Hospital with abortion complications from 1977 through January 1978. The local effect of restriction of public funds for abortion was to be studied. The incidence of women admitted to the hospital with febrile abortion complications after August 5, 1977, did not differ from that of women admitted from January 1 through August 4, 1977. However, the incidence of hospitalization of Medicaid-eligible women with abortion-related complications was greater after August 5 than it was in the earlier period.

Published reports disagree on the risks of intraamniotic prostaglandin F2alpha (PGF2alpha) for midtrimester abortion. To evaluate the safety and efficacy of intraamniotic PGF2alpha, we compared 1241 PGF2alpha and 10,013 saline abortions performed during the 13th to the 24th menstrual week. The results were reported in the Joint Program for the Study of Abortion/CDC, a multicenter prospective study. PGF2alpha abortions required less time (P less than .001) but had higher rates of major complications (P less than .01), antibiotic and operative treatment of complications (P less than .001), and readmission to a hospital (P less than .001). These findings challenge the current contention that PGF2alpha is safer than saline as an abortifacient.

The World Health Organization (WHO) Task Force on the Use of Prostaglandins for the Regulation of Fertility has sponsored a series of randomized clinical trials and case-series investigations to assess the effectiveness and safety of prostaglandins as abortifacients. Our reanalysis of the WHO studies found the prostaglandins to be faster and more hazardour than hypertonic saline as intraamniotic abortifacients. Moreover, studies by the Center for Disease Control imply that dilatation and evacuation (D&E) may be more effective, safe, convenient, and inexpensive than prostaglandins for abortions after 12 weeks' gestation, especially in the 13- to 16-week interval. For gestations of greater than or equal to 17 weeks, the occurrence of live births in prostaglandin-induced abortions has produced serious legal and ethical problems in the United States. Until the effectiveness and safety of other prostaglandins regimen approach that of D&E, we feel that D&E should be the index of comparison against which newer methods of inducing abortion are tested.

The rapid emergence of nonhospital abortion facilities as alternatives to traditional hospital-based surgical care has raised important questions concerning their safety. Using 1974--1975 data from the Center for Disease Control's nationwide surveillance of abortion mortality and the Alan Guttmacher Institute's nationwide surveys of abortion providers, we have calculated the risk of death from legally induced abortion in the United States at less than or equal to 12 menstrual weeks' gestation in hospitals and nonhospital facilities (clinics and physicians' ofices). The adjusted death-to-case rate for hospitals was 1.1 deaths/100,000 abortions, compared with a crude rate of 1.0 for nonhospital facilities. The risk of death from legal abortion in nonhospital facilities is apparently similar to the risk in hospitals.