Abortion

Posted in: 20. Abortion

ABORTION[1]

INTRODUCTION

In Israeli society, saying ”I’m pregnant” immediately evokes a reaction of ‘Mazel Tov!’ [‘congratulations’]. Yet, not every pregnancy is a wanted one, and even a wanted pregnancy does not always end with childbirth. Many women are unsure whether or not to carry a pregnancy to term. Women may face many uncertainties and questions, such as: “Is this pregnancy a choice of mine or was it imposed upon me? Am I mature enough to give birth and raise a child? Do I have a partner for this new road?” On top of all this are questions regarding economic ability and our mental and physical health. The decision to terminate a pregnancy, be the reason for it as it may, is our own. Each woman makes her own decisions about her own body.

In Israel, if you wish to terminate your pregnancy, you will need to undergo a committee. The legislator decided to authorize abortions under the following conditions:

  1. Women under 18, or who are 40 and above
  2. Women who became pregnant through illegal relationships; rape, incest, or outside wedlock
  3. The pregnancy could risk the woman’s health or life
  4. There is a possibility that the foetus might suffer from a physical or mental deficiency

WHAT IS AN ABORTION?

The word abortion may refer to a number of situations:

Natural or spontaneous abortion – An abnormal development of the pregnancy sack or the arrested development of the fetus during the first pregnancy trimester, up to week 13.

(Late) natural abortion – Arrested development of the fetus during the second pregnancy trimester, between weeks 14 and 26.

Induced abortion – The termination of a normal pregnancy for reasons relating to the woman, the fetus, or for other reasons. An induced abortion can be carried out in several ways: oral or intravaginal pills, uterine curettage[2], or birth induction.

Please note that a medication abortion, also called medical abortion or abortion with pills, is different from using emergency contraceptive pills (EC, otherwise known as ‘morning after pills’, Postinor), which can be taken up to three days after unprotected intercourse.

TEN FACTS ABOUT ABORTIONS AROUND THE WORLD [i]

BEFORE AN ABORTION

How to cope with anxiety and stress

Before terminating a pregnancy, we may experience stress and anxiety. These are natural emotions at such a time. Stress can stem from the decision to terminate the pregnancy, from not knowing what to expect, and from worrying about the medical procedure. It is our right to ask the medical staff for more information. In order to ease the stress, it is recommended to have a supportive companion, and to remember to breathe deeply and slowly. We can also consult various organizations which support women in such situations, even before arriving at the hospital.

Frequently asked questions[ii]

I would like to terminate my pregnancy What should I do?

What are my rights?[iii]

Where can I undergo an abortion?[iv]

How much does it cost?[v]

The history of the Israeli Abortion Law[vi]

Medical confidentiality

In hospitals, special efforts are made to maintain the privacy and confidentiality of women or girls who give birth out of wedlock, or who fear they are at risk in their socio-cultural environment. The hospital staff is responsible for the patients’ confidentiality and is not allowed to disclose information to anyone other than the patient herself. In each hospital, the patients’ personal details are kept electronically or manually. Women who are hospitalized for the purpose of undergoing an abortion are registered at a confidential registry and are hospitalized at the Obstetric and Gynecology ward. If anyone asks whether these women are in the hospital they would receive a negative answer.

If you are concerned about the registration, make a special effort to find out how it could be made easier. The HMO staff is extremely sensitive about this issue and makes every effort to prevent exposure. If you are under 19 years of age, you must draw attention to the problem so that the hospital can find a solution for the payment of the excess insurance. Otherwise, the information could be disclosed to your parents when their bank account is debited.

THE ABORTION

Most abortions are carried out under partial or full anesthetic. If you have an abortion using medications, which is not administered under anesthetic, you will be able to take pain killers. Some women find it helpful to drink something warm or to use a hot water bottle to relieve the pain.

No qualms / Dina[vii]

Not very often, in narrow forums of social gatherings, a conversation will begin, usually because someone is not sure what to do, and, suddenly, my opinion is more appreciated because I have been through it. So I tell my story… For the full text (link)

Types of induced abortions

There are several ways of terminating a pregnancy. The doctor will suggest those according to the stage of the pregnancy and the reason for the abortion. If you are interested in having an abortion procedure which has not been offered to you, you have the right to ask the doctor about it.

Three types of abortions are carried out in Israel:

1 – Medicated abortion

In this method, medications are administered which ultimately cause an abortion, the contracting of the uterus and the discharge of the pregnancy contents. The process might be accompanied by stomach aches and a bleeding stronger than menstrual bleeding, just as in a natural abortion. The important advantage of a medicated abortion is that it does not require anesthetic or an operation. However it does require patience, persistence and responsibility. Afterwards, you will have to return to the clinic or the hospital for follow up. Medicated abortions can be carried out during the first weeks of pregnancy, up to week 7, and is suitable for most women. It is unsuitable for women who suffer from certain chronic illnesses.

The medications administered for the induction of an abortion[viii]

Michaela[ix]

When I was 20, as I finished my national service, I went on a three months trip to the USA. There I met family and friends as well as a few charming men. When I returned to Israel, I discovered that my period was late. A small test from the chemist confirmed that I was pregnant. I knew that I was not ready to raise a child on my own at that point in my life.           For the full text (link)

2. Curettage, suction, surgically emptying the uterus

It is possible to use the above-listed methods up to week 24 of the pregnancy; however, the later the stage of pregnancy the greater the risks of using these methods. Most hospitals in Israel use these methods up to weeks 14 to 18 of the pregnancy. During the first weeks of pregnancy the abortion is conducted under local anesthetic, and thereafter under a light full anesthetic. In the early stages of pregnancy it is usually a simple procedure and takes about fifteen minutes.

Curettage, suction, emptying the uterus details of the medical procedure[x]

3 Induced Labor

This method is conducted after weeks 14 to 18, when the pregnancy is at a stage in which curettage is dangerous, and according to the standard practice at the hospital. From week 24 and on the fetus is considered viable, meaning it is able to survive outside the womb and, therefore, it must be put to death before the abortion begins. Unlike laws in other countries around the world, the Israeli law does not qualify abortions from a certain stage of pregnancy, but allows late abortions up to the ninth month.

Nonetheless, approval for a late-term abortion can be issued only by a special committee, called The Committee for Abortion during the Viable Stage. This committee is comprised of more members than the regular abortion committees. The Committee for Abortion during the Viable Stage includes the director of the medical center, the head of the obstetrics and gynecology ward, a senior social worker, the head of the maternity ward, and the director of the genetics institute. At least one of the first three above-listed individuals must be a woman. When appearing before this committee, you will be required to bring a number of documents, such as recent ultrasound images or the results of genetic tests.

Induced labor[xi]

Abortion after week 23[xii]

Hospitals that have abortion committees xiii

After the abortion

Recovery after an abortion

After undergoing a vacuum or surgical abortion, the patient is transferred to  the recovery unit, where every so often the nurses check the patients’ pulse and blood pressure, and follow up for any bleeding. It is natural to have a light to medium flow of blood and even find lumps of tissue in the blood. also It is likely to feel contractions in the lower abdomen which will lessen within the first half hour of recovery. The stay in recovery can last between 20 minutes and an hour or more, depending on the anesthetic you received, the type of abortion you underwent, and how you feel. If the abortion took place under sedation or anesthetic, it is best to have someone who can take you home. You will not be allowed to drive. Before going home, you will receive a prescription for antibiotics in order to prevent infection, as well as medication to minimize the bleeding. You will also receive information about what to expect in the following days and symptoms which may indicate there is a problem. Make sure you know who to contact if there is a problem.

You can resume sexual activities about two weeks to a month after emptying the uterus and after the bleeding from the vagina has stopped. It is possible to become pregnant shortly after an abortion, even before you begin menstruating again, so it is important to use contraceptives if you do not wish to conceive. It is possible to use most contraceptives after an abortion.

Using contraceptives after an abortion xiv

In the follow up meeting, about two weeks after the abortion, the doctor will check your physical and mental recovery. Most women feel well and do not suffer from any special problems after an abortion, but it is normal to be tired, or to feel contractions a few days after the procedure. Some women do not bleed at all after the abortion, while others experience a moderate bleeding which may come and go. Some pregnancy symptoms, such as nausea, may continue for about two days after the abortion. If the abortion took place in a later stage of pregnancy, lactation may also occur. This can be avoided by taking Dopamine agonists, such as Cabergoline, or by wearing a pressure bra. It is possible to place (lukewarm) boiled cabbage leaves inside the bra to help stop the lactation.

Possible complications following an abortion

After the abortion, the medical team of the ward in which you were treated will provide you with information about possible side effects and complications, as well as information about places where you can receive emergency treatment if necessary. These places include the women’s emergency room at the hospital in which you were treated, or in other hospitals. It is also possible to go back to the ward in which you were treated, or to phone the medical staff which took care of you. If you did not receive the above information, you should ask the staff for it.

It is unusual to have complications following an abortion, however if you suffer from one or more of the following complications, contact your doctor immediately.

Heavy bleeding

One out of a hundred women may suffer from heavy bleeding which requires medical attention, and one in a thousand would bleed and need a blood transfusion. The best way to know if you are bleeding excessively after an abortion is to check the number of pads you use, and to look for blood clots. Contact the doctor if the bleeding requires more than two of the largest pads every hour or two, if you find large clots of blood, or if you feel dizzy.

Pain

Uterus contractions are normal after any kind of abortion, but continuous pain in the pelvis may indicate inflammation of the uterus. This is an extremely rare occurrence as no instrument is inserted to the uterus. The frequency of inflammations after a vacuum abortion is less than 2.5 percent and most inflammations are light and can be treated with prescribed antibiotics from your attending physician and without a need for hospitalization. Other causes for pain after an abortion could be fetus or placenta tissue or clots of blood left in the uterus. If the tissues or clots are not discharged without intervention, it is possible that you might need to take medications, or require vacuuming the uterus in order to clean it. If after taking pain killers the pain continues, or if you have a fever, contact your doctor or the ward in which you were treated.

Fever

If your body temperature is more than 37 Degrees Celsius (when tested orally) it is possible that you have an infection. Contact your doctor or the ward in which you were treated.

Continued pregnancy symptoms after an abortion

It is possible that you may continue to experience pregnancy symptoms after the abortion, such as nausea and swollen and sensitive breasts. These symptoms should disappear within a week or two after the abortion. If they persist, it is possible that the abortion was not successful and you are still pregnant. This happens once in a hundred vacuum abortions or medicated abortions. In such cases, consult your gynecologist and do not use a home pregnancy test, as positive results can be obtained up to six weeks after the abortion, even if you are not pregnant.

Genetics and abortions

In Israel it is customary to have many checks during the pregnancy in order to ascertain the fetus’ health. These test lead many a time to the decision of conducting an abortion following a suspicion or a doubt regarding the health of the fetus. Researcher Dr. Hashilony-Dolev links the large number of checks conducted in Israel to a variety of Israeli cultural factors. The main factor is that, according to the perception in Israeli society, human existence can be referred to as ‘living’, only if apart from a physical existence it also has other qualities. Fetuses are not considered to be ‘live creatures’, in particular if there is a doubt as to its physical or mental perfection.

This point of view has a few origins: compared to other religions, Judaism is flexible in defining fetus’ status; it does not glorify suffering, rather wishes to get rid of it; moreover, the Jewish society in Israel tends not to criticize the health system, but attempts to adopt new technologies which it sees as beneficial. Added to this, is the standpoint which views fetuses as part of a future family and not as entities with autonomous rights. Therefore, the future mother or parents have the right to decide to terminate the pregnancy, without considering the fetus’ rights.

Hospital Stay

The duration of the stay in hospital changes according to the type of abortion, and to the standard practice at each hospital. In most cases it involves a short stay, which is defined as day hospitalization. In some hospitals the abortion takes place in a women’s ward, and in others in the day hospitalization ward.

When a medicated abortion is conducted, the patient needs to come to hospital twice, each time for a few hours. In the first stage – you will be required to take Mifegyne tablets, and remain under medical observation for two hours. In the second stage – after 48 hours – you will be required to take Cytotec tablets and remain for six hours under medical observation. If complications develop, you might have to be hospitalized.

In curettage abortions, if the procedure goes as planned, you may be discharged from hospitalization of from day hospitalization a few hours after the procedure, according to the standard practice at the hospital. At some hospitals, curettage is conducted only up to week 12 of the pregnancy, while others may do so up to week 22 (such as Assaf Harofeh). Curettage that is conducted in a later week of pregnancy may result in a longer stay during at the day hospitalization or in longer hospitalization. There are different practices at the different hospitals.

Induced labor is done only in hospitals and not in surgical centers and it involves two or more days of hospitalization, according to treatment progression. Abortion by induced labor is conducted during more advanced stages of pregnancy – one week after the latest week for curettage, according to each hospital standard practice.

Links


[1] Colloquially, termination of pregnancy is defined as an abortion. Despite the negative and judgmental connotations of the term ‘abortion’, we will use it here in its common use.

[2] Uterine curettage – the extraction of the pregnancy sack, the fetus, or the placenta from the uterus, or causing their total or partial discharge, leaving the uterine cavity empty of the pregnancy. The uterine curettage is required only in few of the natural or late abortions and in all cases of induced abortions.


[i] Ten facts about abortions around the world

In most countries, abortions are still illegal and unsafe procedures. The World Health Organization estimates that about 67,000 pregnant women, or post-pregnancy women, die each year as a result of complications following illegal abortions. Even more women suffer throughout their life from medical damage caused during unauthorized abortions.

In order to allow every woman a safe abortion, it is necessary to legalize the medical procedure of abortions and make it safe in every country. Abortion is a safe procedure when it is legal and accessible.

The World Health Organization, the Alan Guttmacher Fund and the Fertility Rights Centre have published the following approximate figures:

1. One in five pregnancies around the world ends in abortion (about 42 million abortions).

2. Almost half of them, approx. 20 million, are unsafe.

3. Most of the abortions in developed countries are safe (92%).

4. More than half of the abortions in third-world countries are unsafe (55%).

5. About 60% of the world’s female citizens have access to legal and safe abortions (in almost all of Europe, Australia, North America, most of Asia, and parts of South America and the FSU republics)

6. 26% of women around the world live in countries in which abortions are illegal (African countries, and some Asian and South American countries)

7. About 13% of death cases of women following medical mal-treatment are of women who have undergone illegal abortions (68,000 women each year).

8. Between 1995 and 2000, many countries changed their laws in order to improve access to safe abortions, including: South Africa, Switzerland and Ethiopia.

9. Some countries have imposed legal limitations that have limited the access to safe abortion (Poland, El Salvador and Nicaragua).

10. Medicated abortion is an accepted procedure in many countries. Currently, at least 39 countries allow the use of Mifepristone.

[ii] Frequently asked questions

Would an abortion affect my ability to have children in the future?

When terminating pregnancy at an early stage, there are almost no complications, and the woman’s future ability to have children is seldom affected. This has been confirmed by many studies. In very rare cases severe pelvic inflammations might cause damage to the uterus. This kind of damage might bring about ectopic pregnancy, or cause fertility problems. The risk can be reduced by taking prescribed antibiotics while having the abortion and by listening to your body. If you identify symptoms of inflammation, you should seek medical treatment.

Does an abortion increase the risk of breast cancer?

No. In February 2003, The National American Institute for Cancer Research gathered more than a hundred worldwide experts in order to survey the research available in this field. The experts concluded that ‘there is no connection between unnatural abortions and the risk factors of breast cancer.’

Do women who have an abortion suffer from post traumatic depression or from abortion syndrome?

No. Many women report that they feel a loss or feel sad after having an abortion, but it has not been proven that abortion has long term or severe psychological implications, such as clinical depression.

Type of anaesthetic Possible side effects
Local anaesthetic: injecting medication into the cervix in order to anesthetize the nerves around the cervix. This reduces the pain caused by enlarging the cervix, but does not alter the contractions. Temporary tinnitus, numbness of the lips, the tongue and the vagina.

Rare side effects: convulsions and allergic reaction.Tranquilizer infusion: injecting medication to prevent pain and anxiety. Does not induce unconsciousness.Nausea, vomiting.

Rare side effects: allergic reaction, respiratory or cardiac problems.General anaesthesia: infusion which induces unconsciousness. This is the most common method in Israel.Nausea and vomiting, nebulisation.

[iii] If I wish to have an abortion, what do I have to do? What are my rights?

If you wish to terminate your pregnancy and you qualify according to the above criteria, you are likely to be approved by the committee. Either way it is important to remember that if you were not approved by the committee to which you have applied, you have the right to apply to another committee in another medical centre. The cost of applying in private medical centres is equal, but the social worker and/or doctors are often more flexible at private centres and could find the right legal section which supports your particular circumstances and application.

Preparing for the committee

If you are married and feel that another pregnancy could be a mental or an emotional burden and you have decided by yourself to terminate it, you can see a psychiatrist and present the committee with his/her professional opinion concerning the mental damage you might suffer. If you wish to terminate the pregnancy following a genetic defect, you need to present the committee with a special approval issued by a genetics specialist.

When you appear before the committee bring your identity card and pregnancy confirmation with you. A pregnancy confirmation is a copy of your ultrasound imaging vaginal check which documents the age of the pregnancy. If you arrive without the confirmation, you will be asked, after filling in your details, to go through this check. Sometimes, women who have the confirmation are also asked to go through the check once more (this usually happens in cases in which the foetus has some deformity; the issue will be discussed separately in the sub-section about abortions during the second and third trimesters).

Remember, you are entitled to choose a committee in any medical centre you wish, even if it is not in your residential area. Check first the office hours of the committee to which you have decided to apply, make sure you do not arrive on a busy day and that you can receive the time and the service you are entitled to.

Medical conditions worth knowing before referring to a committee

  1. What kind of abortions are available to me, considering my medical condition and the stage of my pregnancy?
  2. What choices of anaesthetics do I have?
  3. Is there anything in my current or past medical history that the doctors should know before the abortion?
  4. If I am an HIV carrier, can I have the abortion at the hospital I chose?
  5. If the abortion has side effects, can I receive treatment for them at the department in which I had the abortion?

The committee procedure

The social worker will explain the process of getting the approval to you. If you would like counselling or would like to consider other options (adoption, receiving assistance in raising the child), she will refer you to the relevant bodies. If you are considering adoption, it is worthwhile contacting feminist organizations which have legal and other information to help you decide and realise your rights. Usually this advice is free or subsidized. Hospitals in which an abortion committee exists.

If you decided to terminate your pregnancy, you can use the help of a social worker to fill in the application form for the committee. The form includes your personal details and details about your pregnancy and the reason you wish to terminate it. The form and the accompanying documents are put together in a personal and confidential request application file. The details are used only for statistical purposes. All the information and documents submitted to the committee are private and confidential.

The next stage is appearing before the committee. In some committees, women are required to appear, and, in others, the social worker makes the referral on behalf of the woman. If you do not meet the members of the committee, and receive a negative response, you have the right to discuss this with the doctors in order to find out why your request was not approved.

The committee will advise you which abortion procedure is best for you. The various options would be explained together with the medical pros and cons of each procedure. Finally, you will be asked to sign an informed consent form for the medical procedure you are about to undergo.

The committee’s decision is given immediately, outlining the sections which certify the termination of the pregnancy. The doctors can refer you to any recognized medical institution, but it is your right to decide where you wish to have the abortion.

It is important to note that the man who impregnated you has no legal status vis-à-vis the committee. The decision is entirely yours to make. Even if you are under eighteen, you have the right to have an abortion without informing your parents. It is advisable, however, to arrive with someone to support you.

[iv] Where to have the abortion?

You can terminate your pregnancy in a governmental, private, or HMO hospital. You can choose in which hospital you would like to have the abortion. If you are worried about family, partner or community pressure, you have the right to go to another city and use the hospital services there. Not all hospitals carry out abortions, but in each of the hospitals that do, there is a committee which can approve the procedure. It is advisable to plan this ahead and to speak on the phone with the committee social worker, so as not to arrive on a busy day and have to wait.

[v] How much does it cost?

The fee to the abortion committee is 305 ₪ in most hospitals in Israel. There are a few hospitals in which the fee is slightly lower, about 205₪  (as of April 2009).

Women have the right for a complete or partial reimbursement for the committee fee and for the abortion from their HMO, if the committee approved the abortion for any of the following reasons:

1. Any medical reason – a deformity of the foetus or a risk to the woman’s health (sections 3, 4e, 4f)

2. Any case that involves a girl under 19. Girls under 19 can apply for a commitment form to the committee from the HMO in advance (available in some HMOs)

Most HMOs pay for abortions also in cases of prohibited relationships – i.e. incestuous relationships and rape.

In general hospitals, the abortion rate is fixed and set by the Ministry of Health. The rate varies according to the stage of pregnancy and depending on the manner in which the procedure takes place. For example, in Hadassah hospital, during 2009, abortions conducted during the 12th week are through a one day hospitalization. The cost of these abortions is lower than that of abortions for women in a more advanced stage of pregnancy. The reason for this is that these abortions take place in the Obstetrics and Gynaecology ward where the rate is calculated according to the number of hospitalization days.In other general hospitals, abortions could sometimes be done through a one day hospitalization even after the 12th week of pregnancy, but the cost is higher as the pregnancy advances. In private establishments, such as the various surgical centres (Asuta hospital and Ramat Marpe) the price is higher and can reach thousands of NIS. HMOs pay for abortions only when they take place in a general hospital and not a private centre. All the same, in both Asuta and Ramat Marpe, in the Tel Aviv area, there is the option of a discount of up to 800 ₪ (in April 2009), if a reference is brought from Open Door organization.

[vi] The history of the Israeli abortion law

The way Israel has conducted itself with regards to abortions, always expressed the gap between the various groups in Israeli society. Abortions have always taken place in Israel, but according to the British Mandatory Law, they were illegal. When the State of Israel was established, Israel adopted the existing law on the issue. In 1952, the Haifa District Court authorized abortions based on medical reasons only. From that year on, some hospitals started to organize committees which included gynaecologists, psychiatrists and social workers, to discuss applications submitted by women. These committees tended to authorize the applications.

In 1962, the Israeli government appointed a Committee for Birth Issues. This committee recommended the institutionalisation of abortions, not in order to encourage it, but so it could be controlled. The committee recommended authorising abortions under certain conditions, in licensed hospitals and with a medical committee’s approval. Among other things, the committee recommended that those committees should try to prevent abortions by explaining the risks involved in the medical procedure and by giving material and moral incentives to try and prevent the termination of pregnancy.

In 1978, the Law to Correct the Criminal Law (abortions) 1977 came into effect. The legislator decided to authorise abortions under the following conditions:

  1. Women under 18, or who are 40 and above
  2. Women who became pregnant through illegal relationships; rape, incest, or outside wedlock
  3. The pregnancy could risk the woman’s health or life
  4. There is a possibility that the foetus might suffer from a physical or mental deficiency

In 1980, following a coalition agreement between the political parties Likud and Agudat Israel, the fifth section, named the social section was abolished. This section added another condition: when the continuation of the pregnancy might cause severe damage to the woman or her children as a result of the difficult social and environmental conditions in which the woman lives, including many children. After this section was abolished, there was no substantive change in the number of referrals, but the number of approvals based on the ‘health’ and ‘illegal relationship’ sections increased.

The public debate between those who in favour of a woman’s right to her body and those who oppose abortions (whether total or partial opposition) continued for many years, however the law was not changed since the social section was abolished in 1980. A few bills to change the situation were proposedbut not one passed the first vote in the Knesset.

It is important to point out that according to international rating, Israel is seen as relatively liberal in its approach to abortions, both in the definition of its laws and in the public’s social perception.

About the abortion committees

40 abortion committees operate today in Israel. Every year there are about 20,000 women referring to them from across the country. Each committee consists of two doctors from the hospital in which the committee takes place, and a social worker. The law stipulates that in each committee there must be at least one woman.

The social workers try as best they can to assist the applicants and prevent them from going through unnecessary procedures before referring to the committee. According to official statistics, most of the requests are approved. The main reason for this is that the social worker makes sure, in advance, that the woman meets all the necessary requirements in order to be approved by the committee. The initial questioning helps the applicants and saves time and money. However, it is important to note that many women who are eliminated in advance eventually undergo illegal abortions. To date no estimate has been made of the number of illegal abortions conducted in Israel. According to some estimates, half the abortions each year are illegal and are not carried out under the supervision of the Ministry of Health.

As of 2008, Hadassah hospital (mount Scopus), Soroka, Assaf Harofeh, Bnai Zion and Meir hospitals started a field research, investigating a population of young women under 20 who were referred to the abortion committees. Data was collected over six months in all five hospitals and one of the main findings was that half of the girls age 20 and under, who were referred to the committees were minors.

[vii] No qualms / Dina

I find myself having to defend my lack of interest in prodding unnecessarily into the choice I have made a long time ago. It seems that it is easier to empathize with someone who is suffering. In contrast, if a woman does not bear the scar of an awful trauma in her womb, she is not worthy. She is not believed. People think it is all just a show, it could not be, or accuse her of being insensitive or in denial. Why?

Not very often, in narrow forums of social gatherings, a conversation will begin, usually because someone is not sure what to do, and, suddenly, my opinion is more appreciated because I have been through it. So I tell my story:

I tell them that I woke up one morning and decided that I can’t go on enduring the heart burns I have suffered from over the last few evenings, that I haven’t drunk orange juice for the past two years. So I went to the mirror and looked at myself and thought that something was not right. It’s interesting that I realized that.

Two sets of eyes stare at you, and together they encircle a private ‘creature’ in the room, each on her own piece of furniture, rooted in her own agenda. And I continue to explain how, just to be on the safe side, I already bought a pregnancy test kit.

So that morning I was standing in front of the mirror and thinking why not check? Why not find out? It won’t kill you. I thought to myself that it was not such a big deal to pee on a stick, and then the positive result appeared. What luck, I thought, it’s lucky that this check is not fatal. Lucky, for example, that it’s not Aids. I know that, at the moment, this is an unwanted pregnancy. It is very much wanted in the future, but now is not the time. I felt that the general ethics demanded I have second thoughts. And I felt bad that I found myself in a place where other women might develop a dilemma. Other women would know in advance that they were looking for this pregnancy, or were willing to accept it even if it was unplanned because it suited them. But it did not suit me.

So I rang my mother and told her: ‘mom, I am pregnant. I need to have an abortion.’ It was a short conversation and it did not scare me or stress me. Actually it did not do anything. I just thought that one day it would be so right, but at the moment it simply was not.

I made an appointment with a gynaecologist who asked me questions and told me not to feel guilty. I did not feel guilty. I felt that I was part of the small percentage of women who swallowed a small pill every night before going to bed and, yet, got pregnant.

He explained that there are different procedures, prodded inside my internal parts, sent me with forms and procedures and explained that the night before I would have to come to see him. Mmm… I don’t like very much being touched, but I had no choice and I bit my lips, smiled and accepted my verdict.

I see her fidgeting uncomfortably, and think that it might be the right time to calm her down, but I cannot do it. I decide to go on telling her exactly what happened, without sparing the unpleasant details, so she would know. So she could prepare herself, so as not to lie.

In the evening before that day, I can’t even recall what date it was, I only remember that it was the end of winter and beginning of spring, I arrived at the gynaecologist. I put on a robe and sat on a chair without my underclothes. They put inside me, into the same tunnel from which babies emerge into the world, some kind of a coil and I did not feel a thing. But when I got dressed, the doctor explained that the purpose of the coil is to enlarge the tunnel in order to ease the procedure. Ah! I said to myself, he chose the right word – procedure. I never thought it was killing a baby and certainly not murder. I never thought of a live human being. It was a seed of something which was so far away from a human being that the word procedure was just right. I went home and a few hours later, I almost screamed to high heaven when the coil suddenly sprung loose and did what it was suppose to do.

And that was it.

The next day I found myself between white walls, taking off everything apart from my body and hair, completing a form, answering questions and lying on a bed.

I went into a cool room, where two people wearing masks waited. One asked me to open my hand and said: ‘what does your mother do?’ 20 minutes of my life I cannot remember and another fifteen are very vague. Mainly I remember feeling relief, and that I have gone through this procedure – abortion.

After that I am allowed off the bed. I still haven’t eaten, or urinated. Then I recalled the peeing of that day when I looked at myself in the mirror and thought – well, I assumed it would take such a long time, and here I am already passed it. I am whole. I am here.

From that day on, I do not talk about it, because it is not something you talk about, at least not if the conversation is not specifically about this issue. And in these kinds of conversations, I tell my story.

[viii] The medication prescribed to induce abortion

There are a number of standard medical options to induce abortions using medication:

  1. mifepristone   and – misoprostol oral tablets
  2. mifepristone  and – misoprostol  vaginal tablets
  3. vaginal methrotrexate and -misoprostol
  4. vaginal misoprostol alone

Mifepristone – a medication which blocks the action of the Progesterone hormone, an activity that prevents the thickening of the uterine lining and the continued development of the pregnancy. The medication is administered orally.

Misoprostol [Cytotec®] a medication which causes the uterus to contract and discharge the pregnancy content. The medication is administered orally or vaginally.

Methrotrexate – a medication which targets rapidly dividing cells, amongst them the tropoblast cells, needed in order for the pregnancy to develop.

[ix] Michaela

When I was 20, as I finished my national service, I went on a three months trip to the USA. I met there, family and friends as well as a few charming men. When I returned to Israel, I discovered that my period was late. A small test from the chemist confirmed that I was pregnant. I knew that I was not ready to raise a child on my own at that stage of my life.

The gynaecologist quickly referred me to an ultrasound, and I found out that I was in my sixth week. It was a great relief to learn from the doctor, that I could have an abortion without scraping, with the help of a pill called Misoprostol. The next day, I immediately appeared before the committee for abortions which approved my abortion. The following Sunday I went to the hospital and received the pill to terminate my pregnancy. All the way back to my parents’ home, I felt so grateful and very lucky. Why? Firstly because I lived in a country which allowed me to terminate an unwanted pregnancy without having to resort to an illegal clinic and put my life at risk. And secondly, that I was left with 3,000 NIS which I earned on my trip, and I did not have to ask my parents for the money. I felt that the responsibility for this decision was mine alone, and that I was completely at peace with myself. I did not want to involve my parents. I knew it would sadden them. And maybe the discussion which might have arisen would have made it more difficult for me to have a medicated abortion, which can take place only until the seventh week of pregnancy.

I went back to the hospital two days later, for one day of hospitalization, and was given another pill which caused contractions in the uterus and helped to discharge the foetus. I stayed there half a day with a good friend. I was very happy she came along. We painted together, listened to music on the Discman and she stroked my head whenever I felt painful contractions.

I remember even today how she asked me if I was at peace with the decision to terminate the pregnancy, and I answered I was. I felt clear headed. I knew it was the right thing to do. Even today, six years later, I know it was the right decision for me. Now, I am beginning to plan a future family with my partner, and I thank god that I have the free choice to have children when I feel I’m ready – personally, mentally and financially, and to raise them with a supportive partner.

[x] Curettage, vacuuming and surgical emptying of the uterus the medical procedure

The first stage broadening the cervix. The broadening of the cervix is conducted by inserting metal rods with an increasing diameter. This process takes only a few minutes. The rods absorb the moisture and expand within a few hours, broadening the cervix. You might feel pressure or contractions while the cervix is broadening. Another option for broadening the cervix before the surgical procedure is by using oral or vaginal tablets 3-4 hours before the curettage. This medication (Misoprostol [Cytotec®]) causes the cervix to soften and open. Side effects – such as contractions, nausea, slight diarrhea or a fever – are rare.

At a more advanced stage of pregnancy, it is possible to broaden the cervix using small rods called Laminaria which are produced from sea weeds. The rods are inserted into the cervix a few hours, or a day, before the abortion by a gynaecologist at the clinic. The Laminaria absorbs the liquid in the cervix and expands like a sponge. The slow expansion of the Laminaria enlarges the cervix gradually and without any pain. With this action the broadening of the cervix during the procedure can be avoided. Broadening the cervix during the procedure could be more difficult and, sometimes, could damage the cervix’s ability to carry a pregnancy in the future.

Second stage vacuuming the pregnancy content. Following the broadening of the cervix, a plastic pipe, the diameter of which is decided according to the stage of pregnancy and which has at its end an electric or manual vacuuming instrument, is inserted into the uterus. The pipe is inserted between 5 and 12 millimeters into the uterus and pumps the pregnancy content. The procedure is quite short and its complexity mainly depends on the stage of pregnancy. Sometimes, there is a need to use other devices to extract parts of the pregnancy from the uterus.

Third stage curettage. At the end of the procedure, the clearness of the uterus area is examined and the uterine lining is gently scraped with the help of a scraper – a small metal rod with a round tip. The curettage is usually conducted without imaging, but in advanced pregnancies and in more complicated cases, it is quite common to use an ultrasound.

The whole procedure is conducted under anesthetics and is not painful. At the end, you might experience slight stomach aches similar to those many women have during their period. Usually this may last for two to three days.

Common complications of this procedure are mild and can be cured. Mostly they include uterus infection or the remaining of the pregnancy content in the uterus. Some medical centers prescribe oral or infused antibiotics before or during the procedure in order to prevent infection.

Serious complications include: uterus infection requiring prolonged hospitalization, excessive bleeding, a rupture of the cervix or a puncture of the uterus, and damage to other abdominal organs. These complications sometimes require an additional surgical intervention. The rate of death following surgical vacuuming of the uterus varies according to the stage of pregnancy, and is between 0.1 deaths to 100,000 women in pregnancies of up to week 8, and 7.2 deaths to 100,000 women when the procedure is conducted during week 21 and or later.

Damaging future fertility is extremely rare, and when the vacuuming takes place during the first trimester of pregnancy, it is accepted that the risk of damaging fertility does not increase.

[xi] Inducing early labour

The largest part of late abortions are carried out in Israel because of the foetus’s health. This kind of late abortion is a traumatic experience for the woman. Today, any termination of pregnancy, especially induced labour, is attended by a social worker who meets with the woman at least once before the procedure is conducted. In order to further trauma, women are hospitalised, before and after the procedure, in the gynaecology ward and not in the obstetrics ward. The woman is transferred to the delivery room only when an active birth develops, and is usually put in a sided room. Even after the end of the procedure, the social worker will come and visit to see how you are doing and to help with the required bureaucratic procedures.

Israeli women, who have had late abortions, report feeling complex emotions of loss and guilt. Unfortunately, some women also report a cold and mechanical approach of the medical team, although this has improved over the last few years. More information about dealing with the death of the newborn can be found in the chapter on “Loss of a newborn” (Link to the chapter), there you can also find a list of internet and other support groups.

Only four hospitals in Israel carry out curettage up to week 20. The others carry out induced labours.  After week 24 the emptying of the uterus is conducted in all medical centres by induced labour.

During an induced labour you will experience strong contractions for a few hours or up to a day. It is highly recommended not to have this procedure on your own, but to have a partner or a close person with you, so they can make sure you are treated with the sensitivity required by the team.

This procedure can take a few hours and, sometimes, a few days, and uses medications which causes contractions are, for example:

1. Prostaglandins – sprayed into the uterus through the cervix (inserted through the vagina)

2. Pitocin – given intravenously.

3. Another method is inserting a balloon into the cervix in order to enlarge it.

The uterus contractions cause a gradual opening of the cervix, inducing the birth of the foetus. The medications will bring about stronger and stronger contractions which would become more and more frequent. When the placenta tears, you will feel a warm liquid coming out of the vagina, afterwards you will feel a heavy pressure around the rectum whilst the foetus is being discharged. Usually, after the discharge of the foetus, there is a need to scrape out the placenta or parts of it. Sometimes, the placenta is discharged in full and, after the necessary checks, it can be decided whether curettage is needed.

In order to induce labour you will be hospitalised for two to three days, and when the uterus is being emptied you will be given pain killers, or sometimes a local anaesthetics (Epidural). At the end of the procedure you can decide whether to carry out a pathological test on the foetus and the placenta, or to bring them to burial.

Possible complications of induced labour include a partial abortion and the remaining of placenta particles, bleeding, infection and pulmonary embolism. Failure of the procedure which causes it to be longer than usual which can cause prolonged bleeding and infection.

[xii] Termination of pregnancy after Week 23

Terminating pregnancy after week 23 requires the approval of a special regional high committee. It is possible to refer to regional high committees through the regular committees (the fee would pass from the regular committee to the regional high committee), or through a doctor. It is possible to refer to any regional high committee irrespective of where you live.

There are 6 authorized regional high committees in the following medical centers:

  1. Rambam Medical Centre, Haifa
  2. Belinson Medical Centre, Petah-Tikva
  3. Sheba Medical Centre, Tel-Hashomer
  4. Ichilov Medical Centre, Tel-Aviv
  5. Soroka Medical Centre, Beer-Sheba

xiii Hospitals that have abortion committees

Name and ownership of Institution                   Phone number             Address

Governmental

Sheba Medical Center                            035033030                    Tel Hashomer Ramat Gan 52621

Rambam Medical Center                                    048542389                    POB 9602 Haifa 31096

Assaf Harofeh Medical Center                089648040                    Zrifin Beer Yaakov 70300

Wolfson Medical Center                         035028321                    POB 5 Holon 58100

Rivka Ziv Medical Center                                   046828811                    POB 1008 Safed 13100

Hillel Yaffe Medical Center                     046304304                    POB 169 Hadera 38100

Western Galilee Medical Center Nahariya            049107107                    POB 21 Nahariya 22100

Barzilai Medical Center                           086745600                    2 Histadrut St., Ashkelon 78306

Poriya Medical Center                            046652208                    Lower Galilee R.D. Tiberias 15208

Sourasky Medical Center                                   036974444                    6 Weitzman St., Tel Aviv 64239

Bnai Zion Medical Center                                   048359666                    47 Golomb St., Haifa 31048

Clalit Health Services

Rabin Medical Center – Beilinson Campus          039376014                    Jabotinsky St., Petah-Tikva 49100

Soroka Medical Center                          086403408                    POB 151 Beer Sheva 84101

Sapir Meir Medical Center                      097472568                    POB 88 Kfar Saba 44100

Kaplan Medical Center                           089441520                    POB 4 Rehovot 76100

Emek Mediccal Center                           046494000                    4 Jerusalem St., Afula 18101

Lady Davis Carmel Hospital                   048250301                    7 Michal St., Haifa 34362

Rabin Medical Center – Golda Campus   039372454                    7 Kakal St., Petah-Tikva 49372

Yoseftal Medical Center                         086358015                    POB 600 Eilat 8000

Hadassah

Hadassah Medical Center – Ein Kerem   026777111                    POB 499 Jerusalem 91004

Hadassah Medical Center – Mt. Scopus 025844111                    POB 5032 Jerusalem 91240

Public

Shaare Zedek Hospital                          026555111                    POB 3235 Jerusalem 91031

Bikur Cholim Hospital                            026464111                    5 Strauss St., Jerusalem 91004

Private

Assuta Medical Centers Tel Aviv                        035244344                    62 Jabotinsky St., Tel Aviv 62748

Elisha Hospital                                      048300000                    12 Yair Katz St., Haifa 34636

Herzeliya Medical Center                                    099592555                    7 Ramot Yam St., Herzeliya 46851

Merav Medical Center                            035008800                    POB 3530 Bat Yam 59134

Assuta Medical Centers Petah-Tikva       039053511                    3 Spiegel St., Petah Tikva 49361

Sanitas Hospital                                                035225171                    18 REines St., Tel Aviv 62748

Horev Medical Center                            048305222                    15 Horev St., Haifa 34341

Assuta Medical Centers Beer Sheva       086276640                    POB 5874 Beer Sheva 84151

Assuta Medical Centers Rishon Lezion   039631631                    14 Lazarov St., Rishon Lezion 75654

Assuta Medical Centers Haifa                048810603                    Lev Hamifratz Mall, Haifa

Community Clinics

Assuta Medical Centers Ashkelon                      086738725                    3 Hagvura St., Ashkelon 78306

Medica                                                 088236366                    11 Migdal Hanesiim St., Beer Sheva

Medili                                                   089416023                    36 Yehuda Halevi St., Rehovot 7653

xiv Using contraceptives after an abortion

Contraceptive pills

When to start after a vacuum abortion? On the day of the abortion, or 7 days later

When to start after a medicated abortion? On the day you took Misoprostol, or 5 days later.

Notes: if you intend to start using this contraceptive later, it is recommended to consult the gynaecologist for contraceptives you can use in the meantime.

Vagina coil, sticker?

When to start after a vacuum abortion? On the day of the abortion or 5 days later

When to start after a medicated abortion? On the day you took Misoprostol, or 5 days later.

Notes: if you intend to start using these contraceptives later, it is recommended to consult the gynaecologist for contraceptives you can use in the meantime.

IUD device

When to start after a vacuum abortion? Immediately following the abortion, or at the follow up meeting.

When to start after a medicated abortion? Immediately following foetus discharge

Condoms, diaphragm

When to start after a vacuum abortion? From the first time you have sexual intercourse.

When to start after a medicated abortion? From the first time you have sexual intercourse.

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