Published online August 1, 2006
PEDIATRICS
Vol. 118
No. 2
August 2006, pp.
795-796
(doi:10.1542/peds.2006-0603)
Is the High Rate of Preterm Birth in the United States Linked to Previous Induced Abortions?
Emile Papiernik, MD
Emeritus Professor, Department of Obstetrics and Gynecology, University Réné Descartes, Maternité de Port-Royal, Paris, France
Abbreviations: OR, odds ratio • CI, confidence interval
There is empirical evidence to support the claim that repeated induced abortions are a risk factor for premature delivery in subsequent pregnancies, as demonstrated by a case-control study aimed at describing the risk factors for premature births undertaken in 16 European countries.1In this study, which included 2938 women who delivered before 37 weeks' gestation and 4781 who delivered at term, there was no increased risk associated with 1 previous induced abortion (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 0.99–1.33 [in all countries]; and OR: 1.08; 95% CI: 0.86–1.36 [in Western European countries]), but the risk increased significantly when women had 
2 previous abortions (OR: 1.63; 95% CI: 1.3–2.0 [for all countries]; and OR: 1.80; 95% CI: 1.2–2.7 [for Western European countries]).
There is empirical evidence to support the claim that repeated induced abortions are a risk factor for premature delivery in subsequent pregnancies, as demonstrated by the EUROPOP study, a case-control study aimed at describing the risk factors for premature births undertaken in 16 European countries. Reducing repeated induced abortions by improving access to contraception could be a strategy for decreasing the preterm birth rate in countries in which abortion is used more commonly to control fertility, as in Eastern Europe. In the EUROPOP study, 16% of controls in Romania and 20% of controls in Russia had 2 previous abortions. In other Western European countries, however, only 2% of the controls had 2 previous abortions. It would be interesting to compare the rates of repeated abortions in the United States with those observed in Europe to assess to what extent this factor could be implicated in US/European differences in preterm birth rates.
It is my opinion, however, that other factors, and in particular legislation governing work leave during pregnancy, are responsible for the higher preterm birth rates in the United States. The same European case-control study addressed the question of risk related to work during pregnancy.2To work during pregnancy is not a risk factor, and working women had lower rates of premature births than unemployed women. However, an increased risk of preterm births was observed for manual workers, a category that includes industrial, agricultural, and unskilled workers. These women had an excess of preterm births compared with professionals and associates. Women working long hours (>42 hours, compared with 30–39 hours), those working in a standing position for >6 hours a day, and those reporting dissatisfaction with their job also had a significantly higher risk.
Furthermore, the risk associated with working during pregnancy depended on the social and legislative context related to work leave. The magnitude of the effect of working conditions was greatest in the countries of Eastern Europe, in which long prenatal leave was less frequent. The effects were also stronger in the group of Western European countries in which long work leave was less common compared with other countries in which work leave is granted frequently. One hypothesis to explain this result is that implementing policies to limit work-related health risks attenuates the impact of these risks. This interpretation has been put forth to explain the absence of an effect of working conditions on pregnancy outcomes in Sweden3and France.4
There are obvious differences between the United States and all European countries with respect to paid work leave, which is not established as a policy in the United States as it is in most European countries. The social support factor is more likely to explain the higher rates of premature births in the United States.
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FOOTNOTES
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Accepted Mar 2, 2006.
Address correspondence to Emile Papiernik, MD, Emeritus Professor, Obstetrics and Gynecology, University Réné Descartes, Maternité de Port-Royal, 123 Boulevard Port-Royal, 75014 Paris, France. E-mail: emile.papiernik{at}wanadoo.fr
The author has indicated he has no financial relationships relevant to this article to disclose.
Opinions expressed in this commentary are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
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