When ‘Abortion’ Wasn’t a Dirty Word

One morning in 2012, eight weeks into her pregnancy, Shannon Withycombe woke up bleeding: She was having a miscarriage. In the emergency room, however, no doctor or nurse uttered that word. Instead, she had to wait to read her discharge papers, which read “incomplete abortion.”

Dr. Withycombe, a medical historian at the University of New Mexico, knew the term from her research on 19th-century medical journals; it was doctorspeak for a miscarriage that had not fully exited the uterus. But it was jarring to see it on her own 21st-century medical notes.

“I’ll admit, I was surprised,” she said. “Like most of us, I had been socialized to think that miscarriage and abortion were very different animals.”

Physiologically, miscarriage and medication abortion are near-identical experiences. Both start with a decrease in the hormones that maintain pregnancy, followed by vaginal bleeding, and then the uterus squeezes like a fist to push out the tissues of pregnancy. Both are managed with the same tools and medications, which is why laws that restrict abortion care also affect women who miscarry.

In the 21st-century United States, of course, the distinction matters. Dr. Withycombe’s odd-sounding diagnosis is a relic of a time when the word “abortion” had none of the legal, moral or political connotations that it does today — a time before doctors had medicalized miscarriage and legislators had moralized abortion.

In medical circles during the 1800s, “abortion” was the preferred term for any form of early pregnancy loss, used interchangeably with the more colloquial “miscarriage.” It was often accompanied by a modifier like “spontaneous” (meaning it happened of its own accord), “missed” (tissues were retained in the uterus) or “habitual” (several miscarriages occurred consecutively).

Women, for their part, often referred to their miscarriages in slang terms, such as “miss,” “mishap” or “slip.” But they occasionally used “abortion” as well, as Dr. Withycombe learned while scouring diaries and letters for her book “Lost: Miscarriage in 19th-Century America.” In 1846, an 18-year-old newlywed who miscarried while on the Santa Fe Trail wrote in her diary that “a mighty Providence” had “by an abortion deprived us of the hope, the fond hope of mortals!”

When it came to intentional pregnancy termination, however, euphemisms and coded language prevailed. Newspaper ads offered herbal mixtures that promised to “remove obstructions,” “bring on the menses” or regulate “female irregularity,” but could also be used to terminate a pregnancy.

Abortion “was not considered a nice thing to do or a particularly honorable thing to do,” said Lara Freidenfelds, a historian of parenting and reproduction. “It was considered necessary.”

While midwives or women might have known the difference between intended and accidental pregnancy loss, doctors rarely drew a distinction. For one, they lacked tools. The reason a woman lost a pregnancy would have remained a mystery, with medical texts suggesting that such misfortune might be brought on by fatigue, dancing, fecal worms or, according to one 1808 textbook, “the pulling of a tooth.”

Moreover, to doctors, the distinction didn’t really matter. Most miscarriages were managed safely at home. Once a doctor or midwife became involved, it meant something had gone wrong. At that point, they didn’t “really care how it started,” Dr. Withycombe said. The sentiment was, “Once we determine that it’s not going to be stopped, we need to get in there and clear the uterus as quickly as possible to save your life,” she added.

By the 1840s, the distinction had grown more salient. An emerging class of gentleman-doctors found itself in competition with midwives, homeopaths and other practitioners. To convince patients to come to them, doctors needed to prove that they had better training and outcomes.

The problem was, they had neither. “Doctors in the 1850s couldn’t do much that the Romans couldn’t do,” said James Mohr, a historian at the University of Oregon and the author of “Abortion in America: Origins and Evolution of National Policy.” “That’s one of the dirty little secrets of the whole thing,” he added.

What they did have was science. As doctors refined their understanding of fetal development, they began devising a more technical vocabulary around pregnancy. By the late 1800s, some medical textbooks defined “abortion” as a miscarriage that occurred in the first three months of pregnancy, and “miscarriage” as one that occurred after the formation of the placenta.

Even still, Dr. Mohr said: “This does not make them better OB-GYNs. They just understand what’s going on.” He added that “by making these distinctions, they are showing that their science matters.”

Some of these doctors saw themselves not just as medical authorities, but as moral ones. One was Dr. Horatio Storer, a young Harvard-trained gynecologist who believed that fetal life began at conception and that women were “destined by nature” to bear children.

In 1857, appalled by what he saw as society’s and women’s lax attitudes toward intentional termination, Dr. Storer began a campaign to make this “evil to society” a crime — unless performed by a doctor. Despite opposition from peers, he eventually succeeded: By 1910, every state had effectively criminalized abortion.

Because “abortion” was still an umbrella term, Dr. Storer used “criminal abortion” in his writings to mean any termination not sanctioned by a doctor; those, he called “therapeutic.”

Soon, the modifier “criminal” was no longer necessary. In the popular imagination, the word “abortion” now implicitly suggested illegality and moral dubiousness.

Doctors were aware of these connotations, even as they continued to employ “abortion” in their own notes and journals. A popular 1940s pregnancy manual, “Expectant Motherhood,” assured women that when their doctors used the term “abortion,” they did not mean to suggest that their miscarriages were intentional. “Be not dismayed or offended,” the author wrote, for “he is simply asking if you have ever had a miscarriage.”

By the 1980s, once abortion had been decriminalized in Britain and the United States, some doctors recognized that patients could be upset by the dissonance. In 1985, three British OB-GYNs pleaded in The Lancet, a medical journal, for doctors to align themselves with the language of their patients, who used “miscarriage” to describe their pregnancy loss and were shocked or offended to hear “abortion.”

“There was this sudden determination on the part of doctors to move these two things away, to separate these two experiences,” said Dr. Andrew Moscrop, a researcher of health inequalities who chronicled the language shift away from “abortion” and toward “miscarriage” in major OB-GYN journals after the Lancet letter was published.

Patients tended to agree with the shift. In 2019, a survey found that a majority of miscarriage patients preferred that their doctors used terms like “miscarriage” or “early pregnancy loss.” By contrast, “spontaneous abortion” was the least recognized and most confusing — “an all-around hated term,” said Dr. Elizabeth Clement, an OB-GYN at Penn Medicine and the lead author of the survey.

This split was well intentioned and meant to avoid encounters like Dr. Withycombe’s, in which a medical term challenges a patient’s lived experience. Yet in some ways, the division of these two experiences has erased the ways in which they can blur and overlap, say doctors who care for pregnant people going through both.

One of the few spaces where abortion and miscarriage still commingle is the Miscarriage and Abortion Hotline. In 1998, Dr. Linda Prine, a co-founder of the hotline, was a family medicine doctor in Lower Manhattan. She provided miscarriage care at her day job at a community health center, and abortions one day a week at a nearby Planned Parenthood clinic.

Although Dr. Prine had the tools and training to provide abortions at the health center, she instead had to direct people who wished to terminate their pregnancies to Planned Parenthood. Along the way, many fell through the cracks. “That really struck me,” she said. “I didn’t feel right having those two practices be divided.”

In 2019, as restrictions on abortion spread and cases of self-managed abortions rose, Dr. Prine had an idea: a hotline that women of all backgrounds could call to access support and guidance when experiencing pregnancy loss. Having researched the confusion and dismissal that miscarrying women faced in the emergency room — as well as having miscarried four times herself — she knew that the hotline should serve women experiencing both miscarriage and abortion.

“We sort  of see it on a continuum,” Dr. Prine said. “It’s all pretty much the same conversation, whether it’s started with a miscarriage or an abortion.”

While it’s unlikely that the word “abortion” will ever again encompass all forms of pregnancy loss, to Dr. Prine, the historical connection is revealing. “The word abortion’ really does apply to both,” she said. “It’s just that we’ve stigmatized the word so badly that we can’t use it accurately. It’s a false division.”