Urogynaecology & Pelvic Reconstructive Surgery,
Minimally Invasive & Robotic Laparoscopic Gynae Surgery

+65-62585530
jameslee.gyne@gmail.com

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 (less than 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.

Abortion Mitigates Educational Under-achievements
(in young women with unplanned pregnancy)

No one age group precludes unwanted pregnancy. For women below 21 years and have mis-timed pregnancies, many would opt to terminate them. The usual reasons are: disruption in their education (Torres & Forrest 1988), effect on career, inadequate finances and unstable relationships (Broen 2005).

In this millennium, young women are not prepared for motherhood. Finer found that this unpreparedness arises mainly from the interference to educational opportunities. The commercial value of education in each society differs according to the culture and economic development. In some communities, especially in East Asia, scholastic accomplishment makes or breaks a youngster’s career and future.

Earlier surveys in the late 1990s and early 2000s found indirect evidence of teenage abortion possibly benefiting subsequent life course outcomes. The common thread of teenage parenthood leading to educational under-achievement, poverty, welfare dependence, domestic violence and impaired relationships was repeatedly shown. Hofferth in 2001 reported teenage mothers completed two fewer years of schooling then mothers who first give birth after age thirty. Moore in 1993 wrote that lower ages at first birth were strongly associated with increasing risks of poverty for women at age twenty-seven. Adolescent mothers were more likely to become welfare dependent (Grindstaff 1988) and at increased risk for partner violence and relationship problems (Wiemann).

Does Abortion of Unwanted Teenage Pregnancies Reduce Adverse Life Course Outcomes?

In young women who had mis-timed pregnancies, those who seek abortion showed advantaged outcomes when compared with those who continued with the pregnancies. Zabin in 1989 found them more likely to complete high school and secured employment two years after.

The major reasons to abort unplanned pregnancies are to reduce the perceived adverse life course outcomes. In 2007, Fergusson studied abortion pattern among young women in Christchurch (New Zealand). He reported that those who seek abortion had relatively advantaged outcomes on educational achievement, income, avoidance of welfare dependence and partnership relationships. After analyzing the confounding factors, these differences were attributed to the advantaged social and educational standing of those who terminated the pregnancies. When due allowance was made for pre-pregnancy factors, only educational difference remained statistically significant.

Bailey in 2001 also highlighted that abortion may protect the educational opportunities in young women. Terminating the unplanned pregnancy mitigated the educational disadvantage associated with early pregnancy in adolescents. The statistics may illuminate certain benefits, but the abortion debate will rage on, dominated by the pro-life and pro-choice ideologies. Each camp stands on extreme views, neither willing to see or accept the counter argument.

What Is Surgical Abortion?

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)

Initial Consultation and Ultrasound for pregnancy dating:	$260
Early Trimester Medical Abortion (from 7 weeks to 8 wks gestation, dated from the last menstrual period):	$1000-1200
Early Trimester Surgical Abortion (from 7 weeks to 8 wks gestation, dated from the last menstrual period, NOT INCLUDING anaesthetist fees):	$900-1300
First Trimester Surgical Abortion (from 9 weeks to less than 12 weeks of gestation, NOT INCLUDING anaesthetist fees):	$1400-1600
First Trimester Abortion (from 12 weeks to <24 weeks of gestation):	To consult

The above estimates do not include GST.

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.

Bleeding

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.

Infection

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.

Infertility

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.

Rhesus isoimmunisation

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.

Death

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).

Psychological impact

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.