I came across a NYT article that stated how having multiple (12) abortions affected a woman's ability to carry a pregnancy later in life.
This was in reference to Marilyn Monroe, so these alleged abortions would have taken place in the midcentury. Presumably, they would have been illegal, but relatively safe considering her means, resources, and connections at the time. Since Marilyn was never seen visibly pregnant, we can assume these all also took place early in the pregnancy.
I want to state, for the record, I have no idea where this number comes from. Most other sources say there is no evidence she had an abortion at all, let alone twelve. However, she was known to have miscarried several times.
Regardless, I would like to verify how true the rest of the statement is. Could having multiple abortions in that time period cause someone to struggle to conceive or miscarry later in life?
Biologist here!
The effect of a 1950s abortion on future fertility depends, firstly, on the method of abortion used. A 1981 survey gives us a peak into the techniques used in 20th century Australia.^1 The study states, for example, that drugs for inducing abortion were "easily available by the 1890s" and included "purgatives, such as oil of savin, croton oil, aloe, or they caused contractions of the blood vessels or of the uterus, as did ergot of rye." Other techniques involved physical violence, such as extremely hot baths, jumping off tables, or falling down stairs. Finally, abortions may be induced via mechanical or surgical means. Given the risks of poisoning or injuring oneself through a DIY abortion, the option with the lowest morbidity and mortality rates would have been the Dilation and Curettage, a surgical method still in use today. The technique involves dilating the cervix and scraping out uterine tissue.^2
We don't know for sure what method an individual in Marilyn Monroe's position would have used. There is some evidence, however, that access to a physician who would conduct a dilation and curettage was readily available to those who looked for it and, importantly, to those who paid for it. In a 1966 article published by the Washington Post, Dr. John Skilling asserted that a woman in Washington - where abortion was illegal with few exceptions - "with $600 [$4,700 in 2019] can often get a safe, competently performed abortion in a local hospital."^3 The article goes on to describe how women in need of an abortion would seek out psychiatrists who would diagnose the patient with suicidal tendencies, on account of the pregnancy, and a gynecologist would conduct the abortion. Or, a sympathetic physician may take blood from the woman's arm and squirt it into her vagina, simulating the appearance of a miscarriage that needs dilation and curettage to clear dead tissue. As such, it seems reasonable that an individual of means would have access to a medical professional willing to conduct a surgical abortion.
The question, then, is whether or not surgical abortion via dilation and curettage has any effect on a woman's ability to carry a pregnancy later in life. The answer to that is, generally speaking, no. The scientific consensus largely holds that both drug-induced and surgical abortions have little effect on the patient's future fertility, barring any complications that may arise. Specifically, we can look at Frank et al. who found in 1993 that in both prospective and retrospective study, "induced abortion does not appear to have an important effect on future fertility."^4 Specific to surgical abortion, Lohmann-Bigelow et al. concluded that dilation and curettage may predispose patients to postpartum hemorrhage after giving birth, but not to preterm delivery or miscarriage.^5 And Lemmers et al. finds no evidence of changes in future fertility between women who underwent a natural miscarriage versus women whose miscarriages were treated with dilation and curettage.^6
There are, as with any surgical intervention, possible complications with dilation and curettage. Asherman syndrome, where scar tissue forms inside the uterus, is a potential complication associated with dilation and curettage and, in some circumstances, may increase the patient's risk of miscarriage.^7 Importantly, Asherman Syndrome is more common when the surgery has been repeated.
Taken together, the scientific and historical evidence suggests that it is possible for a woman of means in the 1950s to experience miscarriage after previously undergoing multiple abortions. That said, there is certainly no guarantee of reduced fertility after abortion, and given the seeming lack of evidence in the case of Marilyn Monroe, other theories as to the cause of her miscarriages should be considered first.
Bird J. Abortion techniques in Australia: a history. Fam Plann Inf Serv. 1981 Apr;1(6):9-15. PMID: 12263459.
Hammond, Ian. (2011). Atlas of Pelvic Anatomy and Gynecologic Surgery, 3rd Edition. ANZ Journal of Surgery. 81. 10.1111/j.1445-2197.2011.05924.x.
Stevens, 2019. "When abortion was illegal: A 1966 Post series revealed how women got them anyway" https://www.washingtonpost.com/history/2019/06/09/when-abortion-was-illegal-post-series-revealed-how-women-got-them-anyway/
Frank, P., Mcnamee, R., Hannaford, P. C., Kay, C. R., & Hirsch, S. (1993). The effect of induced abortion on subsequent fertility. BJOG: An International Journal of Obstetrics and Gynaecology, 100(6), 575–580. doi:10.1111/j.1471-0528.1993.tb15313.x
Lohmann-Bigelow J, Longo SA, Jiang X, Robichaux AG 3rd. Does dilation and curettage affect future pregnancy outcomes? Ochsner J. 2007 Winter;7(4):173-6. PMID: 21603540; PMCID: PMC3096409.
Lemmers M, Verschoor MAC, Overwater K, Bossuyt PM, Hendriks D, Hemelaar M, Schutte JM, Adriaanse AH, Ankum WM, Huirne JAF, Mol BWJ. Fertility and obstetric outcomes after curettage versus expectant management in randomised and non-randomised women with an incomplete evacuation of the uterus after misoprostol treatment for miscarriage. Eur J Obstet Gynecol Reprod Biol. 2017 Apr;211:78-82. doi: 10.1016/j.ejogrb.2017.01.055. Epub 2017 Jan 30. PMID: 28199872.
Smikle C, Yarrarapu SNS, Khetarpal S. Asherman Syndrome. [Updated 2022 Jun 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448088/
I'd be interested in seeing the article, if you've got a link, so I can share with some colleagues who will join me in hating on it.
The short answer is: there is zero clinical evidence of that any number of elective terminations will have any adverse impact on future pregnancy. There is an overwhelming amount of data showing that abortion is safe. There is data showing that pregnancy after abortion is essentially the same as any other pregnancy. There is, admittedly, limited data on pregnancy after multiple abortions, however, the data we do have suggests that pregnancy after multiple abortions is essentially the same as any other pregnancy. This is is assuming that the any unwanted pregnancy was terminated in a safe and clinically competent manner. Modern "surgical" abortion (i.e. dilation and curettage) is extremely safe and has been for decades. Since the wide availability of antibiotics it is in fact one of the safest invasive procedures that can be done, and in the hands of a competent physician there is no reason why one or a dozen abortions would cause any complications.
The earliest written reference I know to elective abortion is in The Code of the Assura, which dates back to Assyria in 1075 BCE, and which spells out punishments for various offenses women and men can commit. One of them, punishable by death, is if a woman intentionally "drop[s] that which is within her": that is, terminates a pregnancy. This is probably not before surgical abortion was attempted - I can't say when that may have been first tried - but it is certainly long before surgical abortion was attempted with any regularity, to say nothing of safety and efficacy. This is not to say that other methods were safe or effective: they generally were not. Throughout history there have been a vast range of methods suggested to end a pregnancy. Often in historic documents these are referred to euphemistically. One might, for example, tell their husband that a lady doctor recommended a friend to "open her womb". If you browse 19th century archives of newspapers, they're full of ads from doctors (who may or may not have been doctors) selling medicines and treatments for "the disease unique to females" or offering to relieve "suppression of their natural illness". Women knew what this meant, and additionally, folk remedies were and still are passed down generation to generation orally.
Jumping forward a couple thousand years or so, there was no legal way for Monroe to get an abortion in the US within her lifetime: by 1910 elective abortion was banned in every state, with a very few number of exceptions for the life of the woman, and state laws wouldn't begin to change until 1969. I have no idea when or how Monroe obtained the care she received, but I can guess at two scenarios:
Scenario 1a, which I imagine was most likely: Buying them. There have always been doctors who would perform abortions. When they were illegal, this required having the right connection to find such a doctor, as for much of the 20th century even seeking an abortion was a crime in some states, including California. This was done almost exclusively by word-of-mouth: one would talk with her female friends, and someone would say that they heard Doctor So-and-So on Main Street had helped their sister out, and off you'd go to Dr So-and-So. If you had the cash, he would perform an abortion. This would have been a "surgical abortion" and for the patient who could pay well, it could be performed by a trained doctor, using sterile instruments in a clean medical office, and include drugs for sedation and pain relief. This obviously would need to be paid for in cash, and never spoken of. It also left you wholly dependent on the goodwill of the doctor: they certainly could turn on you and report you to the police. However, from a clinical standpoint, assuming the doctor is ethical, there is no reason why doing this 12 times would result in any complications for future pregnancy.
Scenario 1b: someone who did not have money would likely have been able, again by asking around, to find a doctor who would perform an elective termination. It's impossible to generalize here, as there absolutely were kind, sympathetic, and ethical doctors who believed that a woman should have the right to end a pregnancy, particularly if it was severely effecting them physically and/or emotionally. It is possible that someone without financial means would have been able to obtain a safe abortion. However, there was also a thriving black market of sorts where, essentially, you got what you paid for. There may have been no sedation, no pain management, and little to no consideration for basic hygiene, to say nothing of sterility. Given Monroe's privilege, I find it unlikely that she would have dealt with the stereotypical "back alley" abortion.
Scenario 2: Try to induce a miscarriage on your own. The clinical term for a miscarriage is spontaneous abortion, and again, there's dozens of things that can potentially induce one. I will not discuss any of them in any detail here, because many of them do pose a significant risk. The primary risks are 1) it won't work at all, 2) a woman may in fact poison herself, which may or may not cause a miscarriage but also may or may not cause her death in the immediate, short, or long term, and 3) it will partially work. Some herbs and modern medicines which could be used for this could cause organ damage. Some could cause uterine bleeding and contraction, but not enough to expel the uterine contents, which puts the patient at tremendous risk of uncontrolled bleeding and/or infection. Those complications could potentially cause difficulty with further pregnancy: in extreme cases a hysterectomy may be necessary, particularly before modern antibiotics were commonly available. While it's not unheard of for someone to attempt to terminate a pregnancy on their own multiple times, it strikes me as extremely unlikely that someone would attempt it 12 times, to say nothing of being able to successfully do so as many times.
Essentially, those would have been Monroe's options for an unwanted pregnancy during her lifetime. While there are potential complications in any of them, particularly the last two, that has no relationship to how many procedures she may have had before. The risk of complications has everything to do with what is done and how, and her social and financial privilege likely would have allowed her to seek safer procedures with trained providers.
Some sources: Lopes A, King PA, Duthie SJ, To WK, Ma HK. The impact of multiple induced abortions on the outcome of subsequent pregnancy. Aust N Z J Obstet Gynaecol. 1991 Feb;31(1):41-3. doi: 10.1111/j.1479-828x.1991.tb02762.x. PMID: 1872772.
Hogue CJ, Cates W Jr, Tietze C. The effects of induced abortion on subsequent reproduction. Epidemiol Rev. 1982;4:66-94. doi: 10.1093/oxfordjournals.epirev.a036252. PMID: 6754410.
Atrash HK, Hogue CJ. The effect of pregnancy termination on future reproduction. Baillieres Clin Obstet Gynaecol. 1990 Jun;4(2):391-405. doi: 10.1016/s0950-3552(05)80234-2. PMID: 2225607.
Aviva Romm, CHAPTER 11 - Pregnancy and Botanical Medicine Use and Safety, Editor(s): Aviva Romm, Mary L. Hardy, Simon Mills, Botanical Medicine for Women's Health, Churchill Livingstone, 2010, Pages 321-333, ISBN 9780443072772, https://doi.org/10.1016/B978-0-443-07277-2.00013-1. (https://www.sciencedirect.com/science/article/pii/B9780443072772000131)
Reagan, Leslie J. When Abortion Was a Crime: Women, Medicine, and Law in the United States, 1867-1973. Berkeley: University of California Press, c1997 1997. http://ark.cdlib.org/ark:/13030/ft967nb5z5/
Gold RB, Guttmacher Institute. Lessons from before Roe: Will Past Be Prologue? Guttmacher Institute. https://www.guttmacher.org/gpr/2003/03/lessons-roe-will-past-be-prologue. Published August 30, 2022. Accessed October 25, 2022.
Ginsburg FD. Contested Lives: The Abortion Debate in an American Community. Updated Edition. University of California Press; 1998.
Johanna Schoen. Choice & Coercion: Birth Control, Sterilization, and Abortion in Public Health and Welfare. The University of North Carolina Press; 2005.