Abortion and Subsequent Pre-term Birth: Update 2012

Abortion and Subsequent Pre-term Birth: Update 2012Abortion and Subsequent Pre-term Birth: Update 2012

Byron C. Calhoun, MD, FACOG, FACS, MBAByron C. Calhoun, MD, FACOG, FACS, MBAProfessor and Vice Chair, Obstetrics and GynecologyProfessor and Vice Chair, Obstetrics and Gynecology

West Virginia University-CharlestonWest Virginia University-CharlestonCharleston, WV, USA Charleston, WV, USA

February, 2012February, 2012

DisclosureDisclosure

There are no commercial products There are no commercial products mentioned in this lecture nor is support mentioned in this lecture nor is support being supplied by any vendor, agency, or being supplied by any vendor, agency, or governmental grant/agent.governmental grant/agent.

OutlineOutline

• I Introduction/ObjectivesI Introduction/Objectives• II. Frequency of PTBII. Frequency of PTB• III. Morbidity of PTBIII. Morbidity of PTB• IV. Review important recent studiesIV. Review important recent studies• V. Latest Studies 2008-2011V. Latest Studies 2008-2011• VI. US Societal costs of abortionVI. US Societal costs of abortion• VII. Future issues in abortion and PTBVII. Future issues in abortion and PTB

I. Frequency & CostsI. Frequency & Costs

• Incidence of preterm delivery is 6% year in USIncidence of preterm delivery is 6% year in US• Births average 3-4 million/year in U.S.Births average 3-4 million/year in U.S.• Therefore, 180-240,000 births/year in USTherefore, 180-240,000 births/year in US• The very preterm births (<28 weeks) include The very preterm births (<28 weeks) include

approximately 1% births or 30,000-40,000 births annuallyapproximately 1% births or 30,000-40,000 births annually• Induced abortion is associated with >$1.2 Induced abortion is associated with >$1.2 billion (US) billion (US) to to

health costs annuallyhealth costs annually11

11Calhoun BC, Shadigian E, Rooney B. Induced abortion: cost consequences Calhoun BC, Shadigian E, Rooney B. Induced abortion: cost consequences of of an attributable risk for preterm birth and its impact on informed consent and an attributable risk for preterm birth and its impact on informed consent and

medical malpractice. J Repro Med 2007;52 (10):929-937. medical malpractice. J Repro Med 2007;52 (10):929-937.

II. Morbidity of Preterm BirthII. Morbidity of Preterm Birth

• Very low-birth (VLBW) weight costs 28 times (RR) termVery low-birth (VLBW) weight costs 28 times (RR) term• ($280,146 versus $9,803)($280,146 versus $9,803)2,3,42,3,4

• Low-birth weight costs 4 times (RR) termLow-birth weight costs 4 times (RR) term• ($38,367 versus $9,393)($38,367 versus $9,393)2,3,42,3,4

• Cerebral palsy increases by 147 times in VLBW compared Cerebral palsy increases by 147 times in VLBW compared to term (> 37 weeks)to term (> 37 weeks)55

22Petrou S, Mehta Z, Hockley C, Cook-Mozaffari P, Henderson J, Goldacre M. Pediatrics Petrou S, Mehta Z, Hockley C, Cook-Mozaffari P, Henderson J, Goldacre M. Pediatrics 2003;112(6):1290-12972003;112(6):1290-1297

33Luke B, Bigger H, Leurgas S, Siesma D. The cost of prematurity: a case-control study of twins vs. Luke B, Bigger H, Leurgas S, Siesma D. The cost of prematurity: a case-control study of twins vs. singeltons. AM J Publ Health. 1996;86(6):809-814.singeltons. AM J Publ Health. 1996;86(6):809-814.

44Infant Health in America:Everybody’s Business. Hartford, CT:CIGNA Corp 2000Infant Health in America:Everybody’s Business. Hartford, CT:CIGNA Corp 200055Himpens E, Master PT, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type, Himpens E, Master PT, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type,

distribution of cerebral palsy in relation to gestational age: a meta-analysis review. Develop Med & distribution of cerebral palsy in relation to gestational age: a meta-analysis review. Develop Med & Child Neuro 2008;50:334-340.Child Neuro 2008;50:334-340.

Previous Studies ContinuedPrevious Studies Continued

• Swingle HM, Colaizy TT, Zimmerman MB, Swingle HM, Colaizy TT, Zimmerman MB, Morriss FH. Abortion and the risk of subsequent Morriss FH. Abortion and the risk of subsequent preterm birth: A systematic review with meta-preterm birth: A systematic review with meta-analyses. J Rrepro Med 2009;54:95-108.analyses. J Rrepro Med 2009;54:95-108.66

• Shah PS, Zao J. Induced termination of Shah PS, Zao J. Induced termination of pregnancy and low birthweight and preterm birth: pregnancy and low birthweight and preterm birth: a systematic review and meta-analysis. BJOG a systematic review and meta-analysis. BJOG 2009;116:1425-1442.2009;116:1425-1442.77

Meta-analysis by Swingle, et al 2009.6


• Meta-analyses of literature 1995-2007Meta-analyses of literature 1995-2007• Pro-abortion & pro-life authorsPro-abortion & pro-life authors• 7,891 titles, 349 abstracts, 130 papers7,891 titles, 349 abstracts, 130 papers• 30 abortion & 26 SAB papers included30 abortion & 26 SAB papers included• Analyzed data from 12 induced and 9 SAB papersAnalyzed data from 12 induced and 9 SAB papers• Demonstrated 64% increased risk with single Demonstrated 64% increased risk with single

abortion for very preterm birth < 32 weeksabortion for very preterm birth < 32 weeks



• 12 studies used to calculate common OR’s 12 studies used to calculate common OR’s for induced abortionfor induced abortion

• 1 induced abortion 1.25 OR [1.03-1.48] 1 induced abortion 1.25 OR [1.03-1.48] increased risk preterm birth < 37 weeksincreased risk preterm birth < 37 weeks

• > 1 induced abortion 1.51 OR [1.21-1.75] > 1 induced abortion 1.51 OR [1.21-1.75] increased risk preterm birth < 37 weeksincreased risk preterm birth < 37 weeks



• 4 studies available for common OR’s for 4 studies available for common OR’s for induced abortion < 32 weeksinduced abortion < 32 weeks

• Common OR 1.64 [1.38-1.91]Common OR 1.64 [1.38-1.91]• Increased very preterm delivery rate of 64%Increased very preterm delivery rate of 64%• Similar to other literature’s findingsSimilar to other literature’s findings



• 7/12 studies available for common OR with 7/12 studies available for common OR with SAB’s for preterm delivery < 37 weeksSAB’s for preterm delivery < 37 weeks

• 1 SAB 1.43 OR [1.05-1.66]1 SAB 1.43 OR [1.05-1.66]• > 1 SAB 2.27 OR [1.98-2.81]> 1 SAB 2.27 OR [1.98-2.81]

Meta-analysis by Shah, et al 20097Meta-analysis by Shah, et al 20097

• Screened 834 papersScreened 834 papers• Excluded 765 for lack data/objectiveExcluded 765 for lack data/objective• 69 citations retrieved69 citations retrieved• 32 excluded32 excluded

Meta-analysis by Shah, et al 20097: 32 excluded studiesMeta-analysis by Shah, et al 20097: 32 excluded studies

• ExclusionsExclusions• 7 studies no neonatal outcomes7 studies no neonatal outcomes• 7 reported combined SAB/abortions7 reported combined SAB/abortions• 5 no comparison group5 no comparison group• 4 reports reviews4 reports reviews• 3 reported VLBW and LBW only3 reported VLBW and LBW only• 2 studies specific population only2 studies specific population only• 2 studies previously published data2 studies previously published data• 1 duplication publication1 duplication publication• 1data not available1data not available

Meta-analysis by Shah, et al 20097: 37 included studiesMeta-analysis by Shah, et al 20097: 37 included studies

• 18 studies with Low Birth Weight (LBW)18 studies with Low Birth Weight (LBW)• 22 studies for preterm birth (PTB)22 studies for preterm birth (PTB)• 3 studies for small for gestationaal age 3 studies for small for gestationaal age

(SGA(SGA

Meta-analysis by Shah, et al 20097: 18 LBW StudiesMeta-analysis by Shah, et al 20097: 18 LBW Studies

• No abortion vs 1 TABNo abortion vs 1 TAB• 18 studies18 studies• 280,529 patients280,529 patients• OR 1.35 [1.20-1.52]OR 1.35 [1.20-1.52]

• No abortions vs > 1No abortions vs > 1• 5 studies of 185 studies of 18• 49,347 patients49,347 patients• 1.72 [1.45-2.04]1.72 [1.45-2.04]

Meta-analysis by Shah, et al 20097: 22 PTB StudiesMeta-analysis by Shah, et al 20097: 22 PTB Studies



Meta-analysis by Shah, et al 20097: 3 SGA StudiesMeta-analysis by Shah, et al 20097: 3 SGA Studies



2011: another busy year for preterm birth and abortion studies (now 127 studies)2011: another busy year for preterm birth and abortion studies (now 127 studies)

• 3 new interesting studies on preterm birth 3 new interesting studies on preterm birth and abortionand abortion8-108-10

• 1 data based linked1 data based linked88

• 2 cohort studies2 cohort studies9-109-10

Di Renzo, et al8Di Renzo, et al8

• Multicenter, observational, retrospective and Multicenter, observational, retrospective and cross-sectional study in 9 centers in Italycross-sectional study in 9 centers in Italy

• Records linked to outcomesRecords linked to outcomes• Power analysis done prior found needed 6,000 Power analysis done prior found needed 6,000

women to determine a difference in preterm birth women to determine a difference in preterm birth (baseline PTB rate 5%)(baseline PTB rate 5%)

• Sample included 7,634 women (September-Sample included 7,634 women (September-December 2008)December 2008)


• 15 variables evaluated as co-factors15 variables evaluated as co-factors• Included BMI, age, medical comorbidities, Included BMI, age, medical comorbidities,

tobacco abuse, previous cesarean section, tobacco abuse, previous cesarean section, and abortionand abortion

• Did not separate out when abortions Did not separate out when abortions occurred or numbers of abortionsoccurred or numbers of abortions

• Multivariate analysisMultivariate analysis


• OR increased risk preterm birth 1.954 OR increased risk preterm birth 1.954 (1.162-3.285) with previous abortion(1.162-3.285) with previous abortion

• Also found in the study increased risk with:Also found in the study increased risk with:• BMI >25 OR 1.662 (1.033-2.676)BMI >25 OR 1.662 (1.033-2.676)• Previous cesarean OR 2.904 (1.66-7.910) Previous cesarean OR 2.904 (1.66-7.910)


• Conclusions:Conclusions:• PositivesPositives

• Large, linked data base with power/multivariate Large, linked data base with power/multivariate analysisanalysis

• Found increased PTB risk in Found increased PTB risk in ALLALL patients with patients with previous abortions as separate factorprevious abortions as separate factor

• NegativesNegatives• Did not separate out abortion timingDid not separate out abortion timing• Did not do analysis for multiple abortionsDid not do analysis for multiple abortions

Liao, et al9Liao, et al9

• Cohort studyCohort study• 4 years from January 2006-December 20094 years from January 2006-December 2009• Interview based with delivery outcomesInterview based with delivery outcomes• 18,323 women (19,527 interviewed) 18,323 women (19,527 interviewed)

(93.8%)(93.8%)


• Divided into 3 comparison groups:Divided into 3 comparison groups:• Nulliparous women with 1 or more first Nulliparous women with 1 or more first

trimester medical abortions (mefepristone)trimester medical abortions (mefepristone)• Nulliparous with surgical abortions (elective)Nulliparous with surgical abortions (elective)• Nulliparous with no previous abortionsNulliparous with no previous abortions


• 7,478 with complete follow up in abortion 7,478 with complete follow up in abortion group out of original 7,558 (98.9%)group out of original 7,558 (98.9%)

• 10,546 with complete follow up in no 10,546 with complete follow up in no abortion group out of original 10,681 abortion group out of original 10,681 (98.9%)(98.9%)


• In no abortion group there were 332 In no abortion group there were 332 spontaneous abortions 332/10,546 or 3.15%spontaneous abortions 332/10,546 or 3.15%

• In the abortion group there were:In the abortion group there were:• 1,769 one medical abortion 1,769/7,468(24%)1,769 one medical abortion 1,769/7,468(24%)• 2,900 one surgical abortion 2,900/7,468(38%)2,900 one surgical abortion 2,900/7,468(38%)• 553 >1 medical abortion 553/7,468(7.4%)553 >1 medical abortion 553/7,468(7.4%)• 1,088 >1 surgical abortion 1,088/7,468(15%)1,088 >1 surgical abortion 1,088/7,468(15%)• 1,168 with medical/surgical 1,168/7,468 (16%)1,168 with medical/surgical 1,168/7,468 (16%)


• OR 1.4 (1.1-1.8) preterm birth with 1 OR 1.4 (1.1-1.8) preterm birth with 1 surgical abortionsurgical abortion

• OR 1.62 (1.27-3.42) preterm birth OR 1.62 (1.27-3.42) preterm birth > > 3 3 surgical abortions (dose effect)surgical abortions (dose effect)

• OR 2.18 (1.51-4.42) preterm birth with OR 2.18 (1.51-4.42) preterm birth with medical & surgical abortionsmedical & surgical abortions


• OR 1.03 (0.53-1.63) no increase risk of preterm birth with OR 1.03 (0.53-1.63) no increase risk of preterm birth with medical abortions compared to no abortionsmedical abortions compared to no abortions

• However, buried in article found 20.3% of patients needed However, buried in article found 20.3% of patients needed a post-abortion suction curettagea post-abortion suction curettage

• OR 1.69 (1.02-3.16) preterm birth risk in women with OR 1.69 (1.02-3.16) preterm birth risk in women with medical abortion < 7 weeks medical abortion < 7 weeks with curettage!with curettage!

• AND AND risk for < 32 week delivery OR was 3.61 (1.43-4.93) risk for < 32 week delivery OR was 3.61 (1.43-4.93)

with with < 7 week medical abortion with< 7 week medical abortion with curettage (20% of curettage (20% of patients!)patients!)

• Did not report either of these findings in abstractDid not report either of these findings in abstract


• Conclusions:Conclusions:• PositivesPositives

• Large group of patients (18,323)Large group of patients (18,323)• Large number of abortions in several categoriesLarge number of abortions in several categories• Found increased risk of PTB with surgical abortions Found increased risk of PTB with surgical abortions

and combined surgical/medical abortionsand combined surgical/medical abortions


• NegativesNegatives• Did not share most startling findings regarding Did not share most startling findings regarding

abortion in this paperabortion in this paper• OR 1.4 (1.1-1.8) preterm birth with 1 surgical OR 1.4 (1.1-1.8) preterm birth with 1 surgical

abortionabortion• OR 1.62 (1.27-3.42) preterm birth OR 1.62 (1.27-3.42) preterm birth > > 3 surgical 3 surgical

abortions (dose effect)abortions (dose effect)• OR 2.18 (1.51-4.42) preterm birth with medical & OR 2.18 (1.51-4.42) preterm birth with medical &

surgical abortionssurgical abortions


• Negatives continuedNegatives continued• need for curettage in 20% medical abortionsneed for curettage in 20% medical abortions

• OR 1.69 (1.02-3.16) preterm birth risk in women with medical OR 1.69 (1.02-3.16) preterm birth risk in women with medical abortion < 7 weeks abortion < 7 weeks with curettage!with curettage!

• AND AND risk for < 32 week delivery OR was 3.61 (1.43-4.93) risk for < 32 week delivery OR was 3.61 (1.43-4.93) with with < 7 week medical abortion with curettage (20% of < 7 week medical abortion with curettage (20% of patients!)patients!)

• Interview study and not really data linkedInterview study and not really data linked

Almedia et al10Almedia et al10

• Abstract only in English (Portuguese from Abstract only in English (Portuguese from Brazil)Brazil)

• Interview and hospital recordsInterview and hospital records• 213 live borns < 1500 gms in 2000-2001213 live borns < 1500 gms in 2000-2001• Abortion prior to index delivery related to Abortion prior to index delivery related to

increased risk for neonatal demise from increased risk for neonatal demise from preterm birth.preterm birth.

V. Societal Costs of Abortion11V. Societal Costs of Abortion11

• Child born=$1.4 million (US) benefit to society Child born=$1.4 million (US) benefit to society • Child aborted-$200,000 (US) cost to society Child aborted-$200,000 (US) cost to society

• Child born=$200,000 (US) input into treasuryChild born=$200,000 (US) input into treasury• Child aborted=$32,000 (US) cost to treasuryChild aborted=$32,000 (US) cost to treasury

1111Finger R, Harden H. Societal costs of abortion. Focus on Family, Focus on Social Issues, Finger R, Harden H. Societal costs of abortion. Focus on Family, Focus on Social Issues, Worldview and Culture, September 22, 2005.Worldview and Culture, September 22, 2005.http://family.org/cforum/fosi/worldview/essays/a0038002.cfmhttp://family.org/cforum/fosi/worldview/essays/a0038002.cfm

VI. Future Issues: Liability and Informed ConsentVI. Future Issues: Liability and Informed Consent

• Malpractice costs continue to sky-rocketMalpractice costs continue to sky-rocket• Median damage award for childbirth:Median damage award for childbirth:

• >$2 million (US) between 1994-2000>$2 million (US) between 1994-20001212

• Malpractice premiums ratchet up 30%-50%/year in USMalpractice premiums ratchet up 30%-50%/year in US• Latest Washington Supreme Court (12/2009) struck Latest Washington Supreme Court (12/2009) struck

down malpractice caps-opens whole tort problem up down malpractice caps-opens whole tort problem up againagain

1212Zimmerman R, Oster C. Assigning liability: insurers’ missteps helped Zimmerman R, Oster C. Assigning liability: insurers’ missteps helped provoke malpractice “crisis”. Wall St J 2002; June 24:A1.provoke malpractice “crisis”. Wall St J 2002; June 24:A1.

Questions regarding Abortion and Public HealthQuestions regarding Abortion and Public Health

• Has patient had an abortion prior to incident Has patient had an abortion prior to incident pregnancy?pregnancy?

• How many abortions did patient have?How many abortions did patient have?• Dose responseDose response

• Was patient informed of increased PTB risk with Was patient informed of increased PTB risk with previous abortion? Particularly ethnic risks.previous abortion? Particularly ethnic risks.

• Was patient informed of PTB risk abortion with Was patient informed of PTB risk abortion with cerebral palsy risk?cerebral palsy risk?

Abortion and PTBAbortion and PTB

• Increase awareness of science, risk, costsIncrease awareness of science, risk, costs• Publish papers documenting known risksPublish papers documenting known risks• Emphasize risk been known for many yearsEmphasize risk been known for many years• Encourage policy makers to addressEncourage policy makers to address• Develop strategies to decrease abortionsDevelop strategies to decrease abortions

ConclusionsConclusions

• Induced abortion increases PTB rates substantially in latest large Induced abortion increases PTB rates substantially in latest large studies/meta analysesstudies/meta analyses

• Ethnic influence compounds the damage in BlacksEthnic influence compounds the damage in Blacks• Now 127 studies now with statistical significance (February, 2012)Now 127 studies now with statistical significance (February, 2012)• No studies show decreased risk PTBNo studies show decreased risk PTB• PTB increases risk for CP by 147 timesPTB increases risk for CP by 147 times• Health/care-neonatal costs increased by over Health/care-neonatal costs increased by over $1.2 Billion (US)$1.2 Billion (US)• Child aborted-$200,000 (US) cost to society/child aborted-$32,000 Child aborted-$200,000 (US) cost to society/child aborted-$32,000

(US) cost to treasury(US) cost to treasury• Health care organizations/government need to know costsHealth care organizations/government need to know costs• Patients ought to be informed of long term health/reproductive risks of Patients ought to be informed of long term health/reproductive risks of

abortion abortion • Abortion counseling ought to include the preterm birth risk Abortion counseling ought to include the preterm birth risk

particularly in Blacks and Native Americans.particularly in Blacks and Native Americans.

QuestionsQuestions

• Voice Mail: 304-388-1599Voice Mail: 304-388-1599• Fax: 304-388-2915Fax: 304-388-2915• Email: [email protected]: [email protected]

ReferencesReferences

11Calhoun BCCalhoun BC,, Shadigian E, Rooney B. Induced abortion: cost consequences of an Shadigian E, Rooney B. Induced abortion: cost consequences of an attributable risk for preterm birth and its impact on informed consent and attributable risk for preterm birth and its impact on informed consent and medical malpractice. J Repro Med 2007;52 (10):929-937.medical malpractice. J Repro Med 2007;52 (10):929-937.

22Petrou S, Mehta Z, Hockley C, Cook-Mozaffari P, Henderson J, Goldacre M. Petrou S, Mehta Z, Hockley C, Cook-Mozaffari P, Henderson J, Goldacre M. Pediatrics 2003;112(6):1290-1297Pediatrics 2003;112(6):1290-1297

33Luke B, Bigger H, Leurgas S, Siesma D. The cost of prematurity: a case-control Luke B, Bigger H, Leurgas S, Siesma D. The cost of prematurity: a case-control study of twins vs. singeltons. AM J Publ Health. 1996;86(6):809-814.study of twins vs. singeltons. AM J Publ Health. 1996;86(6):809-814.

44Infant Health in America:Everybody’s Business. Hartford, CT:CIGNA Corp Infant Health in America:Everybody’s Business. Hartford, CT:CIGNA Corp 20002000

55Himpens E, Master PT, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck Himpens E, Master PT, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P. Prevalence, type, distribution of cerebral palsy in relation to gestational age: P. Prevalence, type, distribution of cerebral palsy in relation to gestational age: a meta-analysis review. Develop Med & Child Neuro 2008;50:334-340.a meta-analysis review. Develop Med & Child Neuro 2008;50:334-340.


66Swingle HM, Colaizy TT, Zimmerman MB, Morriss FH. Abortion and Swingle HM, Colaizy TT, Zimmerman MB, Morriss FH. Abortion and the risk of subsequent preterm birth: A systematic review with meta-the risk of subsequent preterm birth: A systematic review with meta-analyses. J Rrepro Med 2009;54:95-108.analyses. J Rrepro Med 2009;54:95-108.

77Shah PS, Zao J. Induced termination of pregnancy and low birthweight Shah PS, Zao J. Induced termination of pregnancy and low birthweight and preterm birth: a systematic review and meta-analysis. BJOG and preterm birth: a systematic review and meta-analysis. BJOG 2009;116:1425-1442.2009;116:1425-1442.


88Di Renzo GC, Giardia I, Rosati A, Clerici G, Torricelli M, Petraglia F. Di Renzo GC, Giardia I, Rosati A, Clerici G, Torricelli M, Petraglia F. Matnernal risk factors for preterm birth: a country-based population Matnernal risk factors for preterm birth: a country-based population analysis. Eur J OB/GYN Repro Bio 2011;159:342-346analysis. Eur J OB/GYN Repro Bio 2011;159:342-346

99Liao H, Weu Q, Duan L, Ge J, Zhou Y, Zeng W. Repeated medical Liao H, Weu Q, Duan L, Ge J, Zhou Y, Zeng W. Repeated medical abortions and the risk of preterm birth in the subsequent pregnancy. abortions and the risk of preterm birth in the subsequent pregnancy. Arch Gynecol Obstet 2011;284:579-586.Arch Gynecol Obstet 2011;284:579-586.


1010Almeda MF, et al. Survival and risk factors for neonatal mortality in a Almeda MF, et al. Survival and risk factors for neonatal mortality in a cohort of very low birth weight infants in the southern region of Sao cohort of very low birth weight infants in the southern region of Sao Paulo city, Brazil Cad Saude Publica 2011:;27 (6):1088-1098. Paulo city, Brazil Cad Saude Publica 2011:;27 (6):1088-1098. (English abstract only/paper-Portuguese) (English abstract only/paper-Portuguese)

1111Finger R, Harden H. Societal costs of abortion. Focus on Family, Focus Finger R, Harden H. Societal costs of abortion. Focus on Family, Focus on Social Issues, Worldview and Culture, September 22, 2005.on Social Issues, Worldview and Culture, September 22, 2005.http://family.org/cforum/fosi/worldview/essays/a0038002.cfmhttp://family.org/cforum/fosi/worldview/essays/a0038002.cfm

1212Zimmerman R, Oster C. Assigning liability: insurers’ missteps helped Zimmerman R, Oster C. Assigning liability: insurers’ missteps helped provoke malpractice “crisis”. Wall St J 2002; June 24:A1.provoke malpractice “crisis”. Wall St J 2002; June 24:A1.

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Abortion and Subsequent Pre-term Birth: Update 2012