Clinical Updates in Reproductive Health

Adolescents: Safety and effectiveness

Last reviewed: September 19, 2023

Recommendation:

  • Vacuum aspiration and medical abortion are safe and effective for adolescents and should be offered as methods of induced abortion.
  • Cervical preparation before vacuum aspiration should be considered for adolescents.
  • Adolescents should be able to access safe abortion services without delay.

Strength of recommendation: Strong

Quality of evidence: Moderate

Adolescents and abortion

The World Health Organization (WHO) defines adolescents as individuals 10-19 years of age, and young people as 20-24 years of age. Adolescents face barriers to accessing safe abortion care and present for abortions at later gestational ages than adults (Jatlaoui et al., 2017; Sowmini, 2013). Adolescents are at increased risk of complications of unsafe abortion due to delays in seeking and receiving care, seeking care from unskilled providers and not accessing services when complications arise (Espinoza, Samandari, & Andersen, 2020; Fatusi et al., 2021; Keogh et al., 2021; Olukoya et al., 2001). The Guttmacher Institute estimates that in 2019, 5.7 million adolescents aged 15-19 living in low- and middle-income countries experienced pregnancies that ended in abortion, the majority of which were unsafe (Sully et al., 2020).  Decreasing barriers to abortion services may particularly benefit adolescents and young people.

When adolescents receive safe abortion services, they experience fewer complications than do older people. In a large United States-based retrospective cohort study which captured all complications within six weeks of 54,911 surgical and medical abortions, adolescents experienced the lowest rate of abortion-related complications—1.5%—of any age group (Upadhyay et al., 2015). Results were not stratified by method of uterine evacuation, trimester or type of complication. 

Vacuum aspiration

Effectiveness

Success rates for vacuum aspiration have not been disaggregated by age. In studies reporting data for adolescent and older women together, rates of incomplete and failed abortion were less than 1% (Upadhyay et al., 2015; Warriner et al., 2006; Weitz et al., 2013). A 2014 systematic review, which included 25 randomized and observational trials documenting abortion care for adolescent and young people concluded that abortion, including vacuum aspiration, is safe and effective although specific effectiveness rates were not reported (Renner, de Guzman, & Brahmi, 2014). 

Safety

A large, prospective, United States multi-center cohort study of 164,000 women undergoing legal abortion, 50,000 of whom were adolescents, found that mortality and major morbidity were lower in adolescents compared to older women (Cates Jr., Schulz, & Grimes, 1983). The mortality rate was 1.3 per 100,000 in women under 20 years old compared to 2.2 per 100,000 in women age 20 and older. Serious adverse events including major surgery, hemorrhage requiring transfusion, and uterine perforation were less common in those under age 20. However, age of 17 years or younger was associated with higher rates of cervical injury, even after controlling for nulliparity (5.5 per 1000 compared to 1.7 per 1000 in women aged 30 years and older, relative risk 1.9, 95% CI 1.2, 2.9) (Cates et al., 1983; Renner et al., 2014; Schulz, Grimes, & Cates, 1983). To reduce this risk, cervical preparation before vacuum aspiration should be considered for adolescents (Allen & Goldberg, 2016; WHO, 2022).

Acceptability

Age-stratified data on acceptability of vacuum aspiration among adolescents are lacking (Renner et al., 2014). 

Medical abortion

Effectiveness

Clinical trials and cohort studies have shown that young women have similar (Haimov-Kochman et al., 2007; Heikinheimo, Leminen, & Suhonen, 2007) or increased (Niinimäki et al., 2011; Shannon et al., 2006) success rates when using mifepristone and misoprostol for medical abortion compared to older women. A large Finnish population-based retrospective cohort study that compared 3,024 adolescents to 24,006 adult women up to 20 weeks gestational age found the risk of surgical evacuation following medical abortion was significantly lower in adolescents (Niinimäki et al., 2011).

In a prospective cohort that included young women, the success rate of misoprostol-only medical abortion was the same for young and older women (Bugalho et al., 1996). Two prospective cohort studies of misoprostol-only abortion have enrolled only adolescents; efficacy in both studies was equivalent to that reported in trials of adult women (Carbonell et al., 2001; Velazco et al., 2000).

Safety

The Finnish population-based retrospective cohort study referenced above found that complication rates after medical abortion among adolescents were similar to or lower than those of older women, even when controlling for nulliparity. In this study, adolescents had a significantly lower incidence of hemorrhage, incomplete abortion, and need for surgical evacuation. Postabortion infection occurred at similar rates among adolescents and older women, despite adolescents’ higher rates of chlamydia infection in the population (Niinimäki, et al., 2011). In studies of misoprostol-only medical abortion that include adolescents, adolescents do not experience higher rates of adverse outcomes than adult women (Carbonell et al., 2001; Velazco et al., 2000).

Acceptability

A Finnish study compared the pain experience of 56 adolescents undergoing medical abortion to that of 76 adult women, finding that the pain experienced in both groups was similar, and that more than half of all participants experienced severe pain (Kemppainen et al., 2020). Despite this, satisfaction with care was high in both the adolescent and adult groups, with 90% of participants stating they would choose medical abortion again. In one small, non-comparative study of 28 adolescents aged 14-17 using mifepristone and misoprostol medical abortion, 96% found medical abortion acceptable and 79% reported satisfaction with the procedure by four weeks of follow-up (Phelps, Schaff, & Fielding, 2001).

Subsequent perinatal outcomes

Three studies have examined perinatal outcomes in pregnancies in adolescent and young women who have had a previous abortion—a United States-based retrospective cohort study comparing 654 nulliparous adolescent deliveries to 102 adolescent deliveries with a prior abortion (van Veen, Haeri, & Baker, 2015), a German retrospective cohort including 7,845 nulliparous adolescent deliveries and 211 adolescent deliveries with one prior induced abortion (Reime, Schucking, & Wenzlaff, 2008) and a Hong Kong case-control study comparing 118 adolescent deliveries with one or more prior abortions to 118 age- and parity-matched controls (Lao & Ho, 1998). The American and Hong Kong studies found no difference in adverse perinatal outcomes between study groups. After adjusting for confounding factors, the German study found an increased risk of very low birthweight infants among adolescents who had a previous abortion. Method of abortion and whether preoperative cervical preparation was undertaken was not specified in any of these studies.

References

Allen, R., & Goldberg, A. (2016). Society of Family Planning Clinical Guideline 20071: Cervical dilation before first trimester surgical abortion (< 14 weeks gestation). Contraception, 93(4), 277-291.

Bugalho, A., Faundes, A., Jamisse, L., Usfa, M., Maria, E., & Bique, C. (1996). Evaluation of the effectiveness of vaginal misoprostol to induce first trimester abortion. Contraception, 53(4), 243-246.

Cates Jr, W., Schulz, K. F., & Grimes, D. A. (1983). The risks associated with teenage abortion. New England Journal of Medicine, 309(11), 621-624.

Carbonell, J. L., Velazco, A., Varela, L., Tanda, R., Sanchez, C., Barambio, S., & Mari, J. (2001). Misoprostol for abortion at 9-12 weeks’ gestation in adolescents. The European Journal of Contraception and Reproductive Health Care, 6(1), 39-45.

Espinoza, C., Samandari, G., & Andersen, K. (2020). Abortion knowledge, attitudes and experiences among adolescent girls: A review of the literature. Sexual and Reproductive Health Matters, 28(1), 175-195.

Fatusi, A., Riley, T., Kayembe, P.K., & Mabika, C. (2021). Unintended pregnancy, induced abortion and abortion care-seeking experiences among adolescents in Kinshasa, Democratic Republic of Congo: A cross-sectional review. BMJ Open, 11(9), e044682.

Haimov-Kochman, R., Arbel, R., Sciaky-Tamir, Y., Brzezinski, A., Laufer, N., & Yagel, S. (2007). Risk factors for unsuccessful medical abortion with mifepristone and misoprostol. Acta Obstetricia et Gynecologica Scandinavica, 86(4), 462-466.

Heikinheimo, O., Leminen, R., & Suhonen, S. (2007). Termination of early pregnancy using flexible, low-dose mifepristone–misoprostol regimens. Contraception, 76(6), 456-460.

Kemppainen, V., Mentula, M., Palkama, V., & Heikinheimo, O. (2020). Pain during medical abortion in early pregnancy in teenage and adult women. Acta Obstetricia et Gyncologica Scandinavica, 99(12), 1603-1610.

Keogh, S.C., Otupiri, E., Castillo, P.W., Li, N.W., Apenkwa, J., & Polis, C.B. (2021). Contraceptive and abortion practices of young Ghanian women aged 15-24: Evidence from a nationally representative sample. Reproductive Health, 18(1), 150.

Lao, T. T., & Ho, L. F. (1998). Induced abortion is not a cause of subsequent preterm delivery in teenage pregnancies. Human Reproduction, 13(3), 758-761.

Niinimäki, M., Suhonen, S., Mentula, M., Hemminki, E., Heikinheimo, O., & Gissler, M. (2011). Comparison of rates of adverse events in adolescent and adult women undergoing medical abortion: A population register based study. BMJ: British Medical Journal, 342, d2111.

Olukoya, A., Kaya, A., Ferguson, B., & AbouZahr, C. (2001). Unsafe abortion in adolescents. International Journal of Gynecology & Obstetrics, 75(2), 137-147.

Phelps, R. H., Schaff, E. A., & Fielding, S. L. (2001). Mifepristone abortion in minors. Contraception, 64(6), 339-343.

Reime, B., Schucking, B. A., & Wenzlaff, P. (2008). Reproductive outcomes in adolescents who had a previous birth or an induced abortion compared to adolescents’ first pregnancies. BioMed Central Pregnancy and Childbirth, 8(4).

Renner, R. M., de Guzman, A., & Brahmi, D. (2014). Abortion care for adolescent and young women. International Journal of Gynecology & Obstetrics, 126, 1-7.

Schulz, K., Grimes, D., & Cates, W. (1983). Measures to prevent cervical injury during suction curettage abortion. The Lancet, 321(8335), 1182-1185.

Shannon, C., Wiebe, E., Jacot, F., Guilbert, E., Dunn, S., Sheldon, W., & Winikoff, B. (2006). Regimens of misoprostol with mifepristone for early medical abortion: A andomized trial. BJOG: An International Journal of Obstetrics & Gynaecology, 113(6), 621-628.

Sowmini, S.V. (2013). Delay in termination of pregnancy among unmarried adolescents and young women attending a tertiary hospital abortion clinic in Trivandrum, Kerala, India. Reproductive Health Matters, 21(41), 243-250.

Sully, E.A., Biddlecom, A., Darroch, J.E., Riley, T., Ashford, L.S., Lince-Deroche, N., Firestein, L., & Murro, R. (2020). Adding it up: Investing in Sexual and Reproductive Health 2019. New York: Guttmacher Institute.

Upadhyay, U. D., Desai, S., Zlidar, V., Weitz, T. A., Grossman, D., Anderson, P., & Taylor, D. (2015). Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology, 125(1), 175-83.

Van Veen, T. R., Haeri, S., & Baker, A. M. (2015). Teen pregnancy: Are pregnancies following an elective termination associated with increased risk for adverse perinatal outcomes? Journal of Pediatric and Adolescent Gynecology, 28, 530-532.

Velazco, A., Varela, L., Tanda, R., Sanchez, C., Barambio, S., Chami, S., … Carbonell, J. L. L. (2000). Misoprostol for abortion up to 9 weeks’ gestation in adolescents. The European Journal of Contraception and Reproductive Health Care, 5, 227-233.

Warriner, I. K., Meirik, O., Hoffman, M., Morroni, C., Harries, J., My Huong, N., & Seuc, A. H. (2006). Rates of complication in first-trimester manual vacuum aspiration abortion done by doctors and midlevel providers in South Africa and Vietnam: A andomized controlled equivalence trial. The Lancet, 368(9551), 1965-1972.

Weitz, T. A., Taylor, D., Desai, S., Upadhyay, U. D., Waldman, J., Battistelli, M. F., & Drey, E. A. (2013). Safety of aspiration abortion performed by nurse practitioners, certified nurse midwives, and physician assistants under a California legal waiver. American Journal of Public Health, 103(3), 454-461.

World Health Organization. (2022). Abortion care guideline. Geneva: World Health Organization.

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