The Guide On Abortion in Singapore
In Singapore, abortion is legal since 1969, and the MOH accredited clinic that provide abortion service is regulated by the Termination of Pregnancy Act
and Termination of Pregnancy Regulations
, and the MOH Guidelines On TOP
. Deciding to terminate a pregnancy is always a difficult choice, and the reason
to abort is influenced by personal, communal and religious values.
Abortion may be carried out early, by way of medical abortion (<49days) using mifepristone, misoprostol and other new agents, or surgical abortion by vacuum aspiration. The pregnancy may be terminated late but not later than 24 weeks, and it is performed by mid-trimester pregnancy termination. Safe abortion, and not cheap abortion, is the rationale behind legalizing abortion.
Pre-abortion counseling is mandatory, including foreigners who are working or resident in Singapore. In experienced hands, the complication risks of vacuum procedure is less than one percent. Nevertheless, improper assessment of patients, poor selection of procedure type and location may contribute to significant complications. The far-reaching psychological changes a woman may sustain after termination cannot be under-estimated and has to be carefully managed. Post abortion counseling focused on future contraception and moving on in life.
What Is Medical Abortion?
Medical abortion refers to terminating an early pregnancy (of less than 63 days) without surgery, using only abortion pills. Medical abortion began in the 1970s when scientists formulated abortion-inducing medications to act on the uterus. Medical abortion
involves opening the cervix and generating uterine contraction to expel the content of pregnancy. Unlike surgical TOP, which vacuums out the pregnancy over a few minutes, medical abortion typically stretches from several days to weeks. Over the years, various protocols were established using different pharmacological agents, either on its own or in combination. Surveys in the US, UK and Canada have suggested that more than 50% of eligible women may opt for medical abortion.
Advantages of medical abortion
The popularity of medical abortion rests on the avoidance of surgical intervention. The advantages are as below:
No injury to the cervix (neck of the womb).
No injury to the womb and no risk of perforating the uterus.
No need for anaesthesia.
Offers more privacy and control by the woman.
May be use in communities with limited access to a trained doctor who performs surgical abortion.
Medical abortion protocol
During the initial consultation, the diagnosis of an intra-uterine pregnancy will be established after performing the pelvic ultrasound examination. The clinic will arrange for the mandatory pre-TOP counseling
at the appropriate time. The doctor will discuss the feasibility of a medical abortion upon consideration of the gestational age and other patient factors. At least 48 hours after the pre-abortion counseling, one of the common protocols will be implemented. The regimen will last seven days, and will use prostaglandin alone or in combination. The woman will return to the clinic on day three and day seven to inspect on the progress of the medical abortion.
What is a successful medical abortion?
A medical abortion is successful if the pregnancy content is completely expelled. It is deem to have failed when surgical evacuation is necessary to empty the uterus because (1) the pregnancy continues to be viable, (2) the pregnancy is not completely expelled, (3) there is excessive bleeding, or (4) the woman requests to terminate the protocol promptly. The success rate of medical abortion various by the definition of the end point, for example, completely empty by one week, or by the second week will give different figures. Many studies have shown respectable outcomes, mostly above 90%; and those that were performed before 49 days have better success than those carried out before 63 days.
Complications of medical abortion
When the effect of the abortion pills kicks in, the woman will experience a host of complaints, such as – nausea, vomiting, diarrhea, abdominal cramps, headache and fever. The vaginal bleeding and uterine pain will intensify until complete expulsion. The contraction pain may persist for hours or even days in those with tight and stenotic cervix. After removing the bulk of the pregnancy, the pain and bleeding subside. It will not cease bleeding if substantial pregnancy products remain un-discharged.
In clinical practice, about 10-25% of woman who embarked on medical abortion require a suction curettage to expedite the abortion process.
Cost of medical abortion
Medical abortion costs $1000+GST for an intra-uterine pregnancy of less than 49 days, and $1200+GST for pregnancy of less than 63 days. The protocol includes the medications and ultrasound examinations during the three office-hours clinic consultations. There will be separate and additional costs for after-office consultation (within the protocol period), subsequent visits (beyond the protocol period) and any surgical procedures.
What Is Surgical Abortion?
refers to terminating an unplanned pregnancy using surgical methods. Only a trained and MOH accredited gynecologist can carry it out, and he will use medications in the preparatory and pre-operative stages. He will propose the surgical method to use and where it ought to be done, according to the gestation age, history of prior delivery, the mode of past deliveries, and the woman’s health status.
First trimester and early second trimester surgical abortion
Most abortion, estimated 90%, are conducted before the 12th week of pregnancy. A pre-determined level of anesthesia will be administer before the procedure. The first stage is to open up the cervix by gradually stretching it with dilatators (which are steel rods of increasing diameter). A sterile plastic cannula is then introduce into the womb cavity. The content of the pregnancy is vacuum out by negative pressure. Ultrasound imaging can check for completeness of the evacuation.
Priming of cervix
Preparing the cervix medically allows the vacuum procedure to be less painful and less risky. Many studies have attested to the effectiveness of prostaglandins in ripening the cervix to reduce complications (Ngai SW 1995, de Jonge 2009). The tightness of the cervix occasionally lead to complete failure when the cannula is unable to pass into the womb. Several prostaglandin regimens can be use, and the gynecologist will choose the most appropriate for the subject.
Pain relief (Anesthesia)
Pain during surgical abortion is one, if not the most important concern for many. One of several types of anesthesia will be administer. Local cervical anesthesia (lidocaine 10-20ml), intravenous sedation and deep sedation are integral to a successful procedure. The doctor may use a dose of pain tablet and calming tablet before the surgery. Immediately after the abortion, there will be “menstrual-like” cramp, which can be intense, and strong intra-muscular injections will be needed to control.
Use of antibiotics
Amongst women seeking abortion, studies estimated the incidence of chlamydia infection at 7 to 20 (Ross S 2005, Renton A 2006). The use of peri-operative antibiotics was shown to reduce the risk of post-abortal infection. It is important to complete the standard course of antibiotic prescribed before going home.
What Is The Cost Of Abortion?
The total cost of the abortion include the first consultation to confirm and date the pregnancy using ultrasound scan, preparing the womb before the surgery, the procedure itself and the post-operative medication and care. This initial consultation costs about S$250.The abortion procedure is charged base on the weeks of gestation at the performance of the procedure. It is more difficult to abort a more advance pregnancy and it is charged higher. An early stage abortion procedure costs S$900-1300 (procedure only), and the fees go up after 8 weeks of pregnancy. An additional charge will be levied when an anaesthetist is called in when the women has pre-existing medical illness. We will not compromise on your safety. It is best to discuss your needs and constraints with us and we will advise you accordingly.
Schedule of fees (a guide)
The above estimates do not include GST.
|Initial Consultation and Ultrasound for pregnancy dating:
|Early Trimester Medical Abortion (from 7 weeks to 8 wks gestation, dated from the last menstrual period):
|Early Trimester Surgical Abortion (from 7 weeks to 8 wks gestation, dated from the last menstrual period, NOT INCLUDING anaesthetist fees):
|First Trimester Surgical Abortion (from 9 weeks to less than 12 weeks of gestation, NOT INCLUDING anaesthetist fees):
|First Trimester Abortion (from 12 weeks to <24 weeks of gestation):
Can medisave be used to pay for the abortion?
The clinic is registered with CPF Board to make claims on your behalf. So if you wish to use your Medisave to pay for part of or full amount of the procedure cost, you will need to indicate during your initial consultation. Please check that your Medisave account has adequate funds. You will need to provide a recent print out of the CPF account statement. We may be able to confirm your account status through the CPF Board website if you have a SingPass for access. An administrative charge ill be levied if you wish to tap into your Medisave account (the clinic staff will advise you on the prevailing charge).
Can I pay by instalments?
It is not our normal practice to have payment by instalments. We advised that you secure adequate funds before attending for the procedure. If necessary, taking a loan from your friend or friends, or visiting a pawn-facility, may be a better option than to delay the procedure.
Are there any subsidy?
The clinic is not in a position to grant you any subsidy. We advised that you secure adequate funds before attending for the procedure.
Complications Of Surgical Abortion
As in any surgical procedure, surgical abortion has potential complications. Legalizing abortion is to help prevent serious complications that accompany back-street abortions. Gynecologists receive extensive surgical training, and are best suited to reduce these risks substantially. Majority of women will experience no complication after surgical abortion
. In general, the procedure is safer when it is conducted in the first trimester (less than twelve weeks). The rate of major complications is now at about 1 in 1000 procedures.
Injury to womb
During abortion, the neck of the womb is progressively dilated to allow the smallest vacurette to enter. While dilating the cervix, it may be damaged (less than 1 in 100 procedures). If the neck is inadequately dilated, inserting subsequent instruments will be difficult, putting the womb at higher risk of being perforated. Piercing the uterus (about 0.8-1.4 in 1000 procedures) does not permanently damage the uterus. However additional procedures may have to be performed to diagnose if other abdominal organs are injured. On the other hand, excessive dilating the womb opening may lead to repeated miscarriages.
Incomplete removal of pregnancy
Abortion is normally a “blind procedure” where the products of conception is removed by feel (and not by sight). The complete removal of all products is not guaranteed. Incomplete evacuation, when some of the products or membrane is left in the womb, is likely when the pregnancy is implanted in a peripheral position in the womb, or if the womb is abnormally shaped.It happens in lss than 1% of procedures. In abortion, it is a balance between excessive effort and damage to the womb; and possibly leaving some products in the womb. Most of these products will be expelled with the bleeding in the following days. In those cases where it remained stuck to the womb, a repeat procedure is necessary. Using ultrasound scan to guide the procedure improves the safety.
Excessive bleeding may follow a successfuly abortion, occuring in 0.5-2.0 per 1000 procedures. It may be up to 5 per 1000 procedures when the pregnancy is 20 weeks or more. In uncomplicated cases, we expect the vaginal bleeding to be mild and last for about a week or two, and it should be bleeding less each day. If you find that your bleeding becomes more and does not appear to be stopping, you need to return to the clinic. Besides incomplete evacuation, you may be developing a womb infection as well.
Unpleasant vaginal discharge, running a temperature and having lower abdominal pain are features of an ongoing infection. Inflammation sets in when your womb is trying to respond to residual pregnancy products that are degenerating, or when bacteria find their way into the womb. Infection occurs up to 1 in 100 procedures, which is not common, but it is significant because it contributes to 30% of the death cases due to surgical abortion. Therefore, any suspected infection has to be aggressively treated with appropriate antibiotics and possibly a repeat evacuation. Until we have eradicated the infection, we advise that you avoid soaking yourself in baths, swimming and sexual intercourse.
Can your abortion lead to infertility?
Each surgical abortion will impart a small degree of physical trauma to the womb. The injury is minimal in most instances, and the women recover well and go on to have normal pregnancies. Abortion is not a contraceptive method and should not become a habit. Theoretically, repeated abortions damage to the wall of the womb cavity, enough for it to stick together patchy area, preventing a pregnancy to take root. This complication is also seen in Chlamydia infection of the womb and tubes, which occurs more in women with repeated abortions as well. It is good practice to check for Chlamydia infection and have it fixed. At the same time, repeating surgical abortions many times may injure the cervix enough to cause miscarriage in future pregnancies. However, this perception has not been proven in good clinical research yet.
Some women have a Rhesus-NEGATIVE blood group, and they are at risk of iso-immunisation when they undergo induced abortion. This phenomenon affects future pregnancies and anti-D serum is necessary to prevent it.
The risk of dying from a surgical abortion is very rare, estimated to be 3 in 100,000 procedures in the early second trimester (13-15 weeks), and 12 in 100,000 procedures in the late second trimester (after 20 weeks).
Every woman will experience one or more feelings, including sadness, disappointment, anxiety, grief, guilt, regret or relief. This normal response will soon settles in a few weeks and majority will find their way to cope with the loss. Serious emotional problems, though uncommon, can occur and the affected distressed person will need professional support.
(2) The abortion procedure explained