A 26-Year-Old Woman Seeking an Abortion

DR Daley: Ms B is a 26-year-old student and part-time worker seeking to terminate a pregnancy. She lives near Boston with her parents. Her health insurance is through public assistance in Massachusetts. She receives her primary care from Dr K, a house officer at Beth Israel Deaconess Medical Center.

The patient is a primigravida who has been sexually active in a monogamous relationship for the past 6 years. After she and her partner received counseling about the use and efficacy of various forms of contraception, they chose to use the rhythm method. Her last menstrual period was March 24, 1999. On May 6, she sought medical attention after her period was late and a home pregnancy test result was positive. She noted breast tenderness and generalized fatigue.

Citing cultural and family prohibitions to having a child while unmarried, she asked for counseling and a referral for an abortion. She also noted that she is currently attending college part-time and working part-time and is concerned about her financial and emotional capacity to care for an infant in the way she envisages the future. She notes that she has discussed this at some length with her partner, who is in full agreement.

Medical history reveals gastric bypass surgery for morbid obesity, allergy-induced asthma, and trauma after a motor vehicle injury. Current medications include nonsteroidal anti-inflammatory agents for dysmenorrhea and "herbs" for weight loss. She does not smoke, drink alcohol, or use illicit drugs.

Physical examination reveals a moderately obese woman in no acute distress. Vital signs were normal and general physical examination findings were unremarkable. Pelvic examination was also normal. Pregnancy test result was positive.

I've been sexually active for 6 years but this was my first pregnancy. I've only had 1 partner for the whole 6 years. I never have used any birth control. I've never used any condoms. I know for a fact that I'm the only one and he's the only one. So we cannot catch any diseases or anything like that. But we always were watching the calendar not to get pregnant. But this time—I guess I don't know—it just happens.

My only option was to have an abortion. I really cannot have a baby, for so many reasons. First, financial reasons. Second, cultural reasons. Third—this is not an important issue in this country to be married or to have a husband—but in my culture you have to be married and have a husband and a family, to be able to have a baby.

My boyfriend has been very supportive, because both of us know that we cannot afford a baby right now. We have too many plans to handle a baby now. We can't. It's not just because of one thing, it's everything. Emotionally we have no time for each other. I don't think we would have time for a baby. And to have a baby is not an easy step. It's a major thing. I understand that it's better to have an abortion than to have a baby—bring life to this earth that you cannot handle. You cannot buy him food, or you cannot buy him anything he wants. But just to bring another life to struggle with you when you are already struggling yourself.

Doctors shouldn't say it is easy for people to have an abortion. Because it's not an easy thing. People like my friends get pregnant, get an abortion, get pregnant, get an abortion, get pregnant, get an abortion. You know what I mean? All my friends that I've called say, "Oh, it's a piece of cake." For me, it wasn't a piece of cake. From now on, I'm telling everyone to use condoms and birth control, and that's it. I'm going to use birth control pills starting from this Sunday, and I'm just going to protect myself more.

DR K: Ms B came into the office very distraught because she had missed her period. She was 7 days late. She had taken a home pregnancy test that morning, and it was positive. So she came in not knowing what to do next, but with the idea or intention of wanting an abortion. This situation was new for me, having just recently become a resident. I had never actually had a patient come into my office saying flat out, "I want to have this pregnancy terminated." So it kind of took me by surprise. It's always awkward when somebody walks into your office who is the same age as you, or a similar age to you. Because it makes you realize that you may have friends out there who are going through this. Because I saw her and saw the level of distress that she had—just looking at her face you could see how distressed she was—it made me feel very sad. Because some people have to go through this alone. That's why I tried so hard to make sure that she got the proper information and was connected appropriately to the services that she needed so she could get all her questions answered. I tried to alleviate her fears and her distress as much as possible without judging her.

Ms B was referred to a local family planning clinic. After extensive counseling, Ms B decided to proceed with an abortion 1 week later. When interviewed 1 day after the abortion, Ms B reported feeling relieved.

What is the prevalence of abortion in the United States and in other countries? What are the barriers to getting an abortion? Who gets abortions? What are the medical risks, benefits, and epidemiology of medical abortions, other types of abortions, and illegal abortions? What are the psychosocial and mental health consequences associated with abortion? What is considered "good" counseling before and after an abortion? What are the roles of the primary care physician and the gynecologist? What, if anything, is on the horizon in this area? What do you recommend for Ms B?

Dr Grimes: Abortion remains one of the most common operations performed on adults in the United States. In 1996, the most recent year for which preliminary data are available, more than 1.2 million US women had induced abortions.¹ A survey of all known abortion providers in the United States² revealed a total of 1,366,000 abortions in 1996. The latter figure is probably more complete than the Centers for Disease Control and Prevention total¹ because of underreporting to state health departments.

Two measures reveal how common the abortion experience is for US women like Ms B. The abortion rate is the number of induced abortions per 1000 women aged 15 through 44 years. For 1996, the rate was 20.¹ Put differently, 2% of all women of reproductive age in the United States had an induced abortion in 1996. The second measure is the abortion ratio: the number of induced abortions per 1000 live births. The 1996 abortion ratio was 314.¹ In other words, nearly 1 in 4 recognized pregnancies ended in induced abortion. More than 30 million US women have had induced abortions since nationwide legalization of abortion in 1973. Thus, like Dr K, clinicians who care for women will regularly encounter patients who have had or who will have an abortion.³

Abortion is a common experience for women throughout the world. The World Health Organization (WHO) estimates that each day between 100,000 and 150,000 induced abortions occur, or about 36 to 53 million worldwide each year. Approximately one third of these occur under adverse medical, social, or legal circumstances. These unsafe abortions kill about 70,000 women annually and account for about 13% of all maternal deaths.⁴ Each hour, 8 women die from unsafe abortions. Most of these preventable deaths occur in developing countries. However, these deaths from unsafe abortion are just 1 facet of this neglected global tragedy: for every woman who dies, many more suffer serious injuries and permanent disabilities.

Rates of induced abortion vary widely around the world. Among countries thought to have complete statistics, abortion rates (per 1000 women aged 15-44 years) in 1996 ranged from 6.5 in the Netherlands to 77.7 in Cuba.⁵ The US rate for that year (20.0¹ to 22.9⁵ ) was intermediate but higher than that of most industrialized nations. In other countries with incomplete or questionable statistics, rates ranged from 2.7 in India to 83.3 in Vietnam.⁵

Although abortion has been legal nationwide for more than a quarter century, access remains difficult for many women. Since abortion services in the United States are concentrated in metropolitan centers, women who live in rural areas often must travel long distances to obtain care. In 1996, 86% of US counties had no known abortion provider; 32% of US women live in these counties.² Moreover, of the 320 metropolitan areas in the United States, 89 (28%) had no provider. In 1993, about 24% of women had to travel at least 50 miles one-way to reach a nonhospital provider.⁶

Other barriers to abortions include cost, gestational age limits, and harassment. The average cost in 1993 for a first-trimester abortion under local anesthesia was $341, and the median charge was $298.⁶ Most women pay for their abortions out-of-pocket.⁶ About a third of women have no health insurance. Among those who have health insurance, about one third have plans with limited or no coverage of abortion services. In addition, women with insurance may not have met their deductible or may be concerned about confidentiality should the benefits statement be sent to their homes. In 1977, the Hyde Amendment cut off federal Medicaid coverage for nearly all abortions. Today, only a minority of states pay for abortions for medical reasons. Ms B is fortunate that Massachusetts is one of these, and her abortion was covered by state Medicaid.

Abortion providers may have both upper and lower gestational age limits. While the upper range usually receives more attention, the lower was relevant to Ms B. In large cohort studies in the 1970s, suction curettage abortions done at 6 menstrual weeks or earlier had higher rates of complications, including failed attempted abortion, than did procedures done later.⁷ As a result, about 43% of nonhospital providers require that a woman be at least 6 weeks from her last menses before an abortion.⁶ In 1992, 19% of clinics set the limit at 5 weeks and only 7% at 4 weeks. Since Ms B was only "a week late" for her menses, I infer that she was about 5 to 6 weeks pregnant. Again, she was fortunate to find a local provider willing to perform her abortion without delay.⁸

Harassment is a daily event for many large abortion providers. Indeed, most nonhospital providers (55%) experienced 1 or more forms of harassment in 1992.⁶ The likelihood of harassment increased with the size of the facility: 86% of providers doing more than 400 abortions annually were the victims of harassment in 1992.⁶ In her videotape interview, Ms B commented on the "awesome" security measures at the Boston clinic from which she received care. Sadly, these security measures are necessary to ensure the safety of patients and staff. On December 30, 1994, John Salvi killed 2 receptionists and wounded 5 others at 2 Brookline, Mass, clinics that provided abortions.⁹ Ms B received care from 1 of these clinics.

Legislative barriers continue to grow. The epidemic of antiabortion legislation includes bans of specific abortion methods, mandated waiting periods, spousal or parental notification, regulation of abortion facilities, and zoning ordinances.

Like Ms B, women who have induced abortions in the United States tend to be young and unmarried.¹ In 1996, 20% were younger than age 20 years, and 32% were age 20 through 24 years old (Table 1). Most were unmarried (80%) and white (59%). About 56% had given birth before. Curettage procedures (including vacuum aspiration, sharp curettage, and dilation and evacuation) accounted for nearly all (99%) abortions. Women obtained abortions early in pregnancy: in 1996, 55% had their procedures within 8 weeks from their last menstrual period, and 88% had abortions within 12 weeks.¹

Based on national data, women can expect to have 1.4 unintended pregnancies by the time they reach age 45 years, and 43% will have had an induced abortion.³ Like Ms B, many of these women get pregnant despite using contraception. Indeed, 58% of women who had an abortion in 1994 reported using contraception in the month in which they conceived. Ms B and her partner had successfully used periodic abstinence for 6 years, but contraceptive methods and their use are fallible. The 1995 National Survey of Family Growth revealed that within 6 months of beginning to use periodic abstinence 14.5% (95% confidence interval [CI], 9.8%-21.1%) of women will have a contraceptive failure.¹⁰ By 24 months, this figure rises to 34.0% (95% CI, 21.7%-48.9%). An analysis of the National Survey of Family Growth, which corrected for underreporting of induced abortion, suggested a first-year failure rate with periodic abstinence of 21%.¹¹ While hormonal and barrier methods are associated with a lower failure rate, failures still occur.

Interest in early medical abortion is growing internationally. The antiprogestin mifepristone (RU 486) has been licensed for use in early medical abortions in 4 countries: France, Sweden, the United Kingdom, and China. Recently, other European Union countries have approved its use as well.¹² In France, 49 days from last menses is the upper gestational age limit, while in the United Kingdom it is 63 days. When followed by administration of a prostaglandin (a uterotonic agent) such as misoprostol, mifepristone can achieve high abortion rates in early pregnancy (around 95%).¹³ With the US Preventive Services Task Force rating system,¹⁴ class I evidence supports a class A recommendation that single mifepristone doses of 600 mg and 200 mg have similar efficacy. In addition, vaginal misoprostol at a dose of 800 µg appears significantly more effective and better tolerated than the same dose given orally.¹³

The principal risk of medical abortion is bleeding, which occasionally can be heavy, but which rarely requires transfusion. The risk of infection or other serious complications is very low. Benefits of medical abortion include the potential for very early abortion, avoidance of surgical intervention and its risks, a greater sense of control for women, and the potential for greater privacy.¹⁵

Frustrated by the slow progress in introducing mifepristone into the United States, investigators began in 1993 to offer methotrexate as an alternative. The intramuscular methotrexate dose chosen was that used to treat ectopic pregnancy: 50 mg/m². When followed by 800 µg of misoprostol vaginally 7 days later, abortions will occur in around 90% of women when followed up for 45 days. Although regimens and definitions have not been uniform, reports have described success rates as high as 92%¹⁶ to 96%.¹⁷ Level I evidence supports a class A recommendation that 800 µg of misoprostol given vaginally 7 days after methotrexate is superior to the same dose given 3 days after methotrexate.¹³ Recent developments in methotrexate-misoprostol abortions include the use of oral instead of parenteral methotrexate¹⁸ and the option of having women administer the vaginal misoprostol themselves at home (unlike the clinic administration required in France).¹⁹

The methotrexate-misoprostol regimen has both advantages and disadvantages when compared with the mifepristone-misoprostol regimen. Methotrexate is widely available and inexpensive. Toxicity from single-dose treatment with methotrexate for ectopic pregnancy has been rare. On the other hand, the methotrexate-misoprostol regimen is both slower and less effective than the mifepristone-misoprostol regimen. In general, the earlier the pregnancy, the better the efficacy, especially with methotrexate-misoprostol; 49 days from last menses is a reasonable upper limit.²⁰

Abortion resolves an agonizing crisis for many women. Ms B's pregnancy threatened her financially, personally, and culturally. She and her partner lack the money to rear a child. They have little time at present to devote to each other, and she felt that they would not have the time to commit to a child. Her family and culture would not accept a pregnancy outside of marriage so keeping the pregnancy secret was essential. In addition, she was so sick with the symptoms of early pregnancy that she missed a week of work while awaiting her abortion. After the abortion, Ms B reported that she felt relief . . . "like being a prisoner and now out."

Overall, studies have shown that the psychological sequelae of abortion are minimal for most women. A review²¹ of the methodologically sound studies of the emotional sequelae of abortion revealed that most women express relief after abortion. Feelings of loss and guilt may occur, but they are normal and self-limiting.²² As former Surgeon General C. Everett Koop testified before Congress, the issue of psychological problems related to abortion is "minuscule from a public health perspective." Moreover, the neologism "abortion trauma syndrome" alleged by some abortion opponents is a medical nonentity,²³ like "partial-birth abortion."²⁴

Abortion should not be viewed in a psychological vacuum. Clinicians and patients need to understand the context in which a pregnancy has occurred and then consider the options for the woman. Unless a pregnancy is lost through spontaneous abortion, the only alternative to induced abortion is to continue the pregnancy until birth. The psychological toll of childbearing is far heavier: in 1 population-based study, the incidence of psychosis was 6 times higher after delivery than after induced abortion.²⁵ Other studies using psychiatric hospitalization as a marker for serious morbidity have confirmed more than a 10-fold difference in rates after childbirth vs after induced abortion.²² Refusing women abortions carries its own risks. Women denied an abortion feel resentment for years, and their children have a range of social and occupational deficiencies that persist at least into early adulthood.²⁶ For a woman who wishes to have an abortion, the default option of childbirth is far more dangerous psychologically²² and medically²⁷ than is abortion.

What constitutes "good" counseling before and after an abortion is unclear. Women vary greatly in their need to talk. Although counseling by a person other than the operating physician is commonly part of abortion services, the need for a separate counselor has not been established. For example, "There is no evidence that antecedent therapeutic counseling is more requisite for the woman considering abortion than for the women deciding to have a baby or a surgical procedure."²² I am unaware of any randomized trials that have evaluated women's emotional responses to abortion counseling by a trained counselor compared with that by a physician.

Counseling commonly includes the usual elements of informed consent, a discussion of plans for contraception after the abortion, and an attempt to identify those at increased risk of psychological problems during or after the abortion. Like Ms B, most women reach an abortion provider resolute in their decisions.²⁸ Lengthy exploration of the patient's motivation and options is generally unnecessary and often unwanted. However, should the woman seem ambivalent or coerced, further discussion is useful.

The informed consent includes a discussion of the planned procedure, its risks, benefits, and likelihood of success, as well as the alternatives to the proposed procedure and their risks, benefits, and likelihood of success. The alternatives include giving birth and keeping the child or giving it up for adoption. Although adoption is routinely discussed, few women find it acceptable.²⁹ Some women harbor unrealistic fears about the risk of dying from the operation or from anesthesia, and simple explanations can relieve their concerns.

Several features signal women who may have emotional problems during and after an abortion.²² Women living in chaotic (eg, alcohol or drug dependence) or abusive situations have unique reproductive problems. For them, ongoing contraception may pose a real challenge, and coercive or dangerous sexual activity is common. Women who are victims of rape or incest and those who have abortions because of fetal abnormalities bring additional emotional turmoil—and often ambivalence—to the abortion process. An unintended pregnancy can precipitate abandonment (or its threat) by the male partner, making women especially vulnerable. Even exposure to antiabortion protests may heighten anxiety for patients who must run a gauntlet to see a physician.²² Other risk factors include preexisting psychiatric illness, lack of social supports, paralyzing ambivalence, and advanced gestational age.²⁸ These women may need extra attention before, during, and after an abortion.

The roles of the primary care physician and the gynecologist are largely determined by the former: the primary care physician can either perform the abortion or refer the patient for care. I do not know what type of residency Dr K is pursuing. If she is in family medicine, then I believe that performing Ms B's abortion herself, with appropriate supervision, would have been desirable.^{30 - 31}

Few family physicians have learned how to perform abortions or are providing abortions for their patients.^{32 - 33} Only 12% of programs nationwide offered abortion training as of 1993-1994.³⁴ A 1995 nationwide survey³⁵ showed that only 15% of chief residents had experience with suction curettage abortion. The recommended core educational guidelines for all family practice residents include endometrial biopsy and dilation and curettage for incomplete abortion. Elective abortion up to 10 weeks' gestation is deemed an optional "advanced skill."³⁶ However, performing a very early abortion, such as the 5- or 6-week gestation of Ms B, is analogous to doing an office endometrial biopsy with a Karman cannula and hand-held syringe.³⁷

Having family physicians provide early abortions for their patients would both improve continuity of care and help to alleviate the growing shortage of providers.³⁸ For example, in Massachusetts, the number of providers fell by 20% between 1992 and 1996.³⁹ Based on Ms B's reaction to the security measures at the clinic, I suspect she would have felt more comfortable with a physician she trusted and surroundings she knew.

Several new developments in early abortion are on the horizon. After years of wrangling, mifepristone appears to be inching closer to approval and marketing in the United States. In July 1996, the US Food and Drug Administration (FDA) Reproductive Health Drugs Advisory Committee recommended final approval of mifepristone pending final information on manufacturing, labeling, and distribution. An "approvable" letter from the FDA followed, noting that the drug was safe and effective, but that supplemental information was needed. The Danco Group, based in New York City, has been licensed by the Population Council to make and distribute mifepristone in the United States.⁴⁰

Other experimental approaches involve misoprostol alone or in combination with tamoxifen. An early trial⁴¹ showed that misoprostol alone was not as effective as was methotrexate followed by misoprostol. However, other investigators have used repetitive doses of vaginal misoprostol alone^{16 ,42 - 43} to achieve success rates similar to that with methotrexate plus misoprostol. However, nausea, vomiting, and diarrhea are much more frequent with repeat doses of misoprostol. Another approach has been to use vaginal misoprostol after oral administration of tamoxifen.⁴⁴ At present, the evidence consists of only case-series reports (level III evidence) supporting a class C recommendation for all of these.

A recent surgical innovation has been very early suction curettage (less than 6 menstrual weeks' gestation). Pioneered by Edwards and Carson,⁴⁵ the method uses a rigid 7-mm diameter plastic cannula and a hand-held syringe as a suction source. The technique requires highly sensitive pregnancy tests, high-resolution preoperative and postoperative ultrasound (while the patient is still on the table), and careful inspection of the aspirate to identify the pregnancy. Again, only level III evidence exists to support a class C recommendation; additional experience is needed to establish the safety and efficacy of very early vacuum aspiration.

Another innovation has been the use of misoprostol for cervical dilation before suction curettage abortion. Level I evidence supports a class A recommendation that vaginal misoprostol is superior to oral misoprostol for cervical dilation and is an acceptable alternative to the use of laminaria.⁴⁶ The optimal dose appears to be 400 µg given vaginally a few hours before the abortion.⁴⁷

What would I recommend for Ms B? She opted for a very early suction curettage.⁸ Since little is known about the likelihood of a continuing pregnancy⁷ with this new approach, I would encourage follow-up with either Dr K or the clinic. An insensitive urine pregnancy test can then confirm that the pregnancy has ended. Of note, the clinic where Ms B received care also offers the methotrexate-misoprostol regimen, and the gestational age of Ms B's pregnancy would have made her eligible.

In her videotaped interview, Ms B reported that "everything was great all the way" at the clinic, and the staff treated her "like my own family." She considered her abortion care superior to that experienced during her gastric bypass operation. Her favorable assessment is consistent with a recent nationwide survey of abortion patients conducted by Boston's Picker Institute⁴⁸ : 60% of women judged their overall care as excellent, 26% as very good, and 12% as good. We have known for decades that abortion in the United States is safe⁴⁹ ; we now have evidence that patients give high marks to their care as well.

A PHYSICIAN: What proportion of residency programs train residents how to perform abortions?

DR GRIMES: The training is widely available; the question is whether it's optional or a routine rotation. A 1991-1992 survey showed that 70% of residency programs in obstetrics and gynecology offered training in first-trimester abortion. However, since 1985, the proportion providing routine training had declined from 23% to 12%.⁵⁰ Some residents opt out for reasons of conscience, while others decline participation because, without alternative duties, it may lighten their workload.

A PHYSICIAN: How do you help a woman decide between medical and surgical approaches?

DR GRIMES: Many women come with a firm decision already in mind. We offer medical abortions for early pregnancies, specifically less than 49 days. One randomized controlled trial done in Scotland⁵¹ offered interesting insight on acceptability. Women coming to the clinic who wanted medical abortions got them with mifepristone and gemeprost vaginal suppositories. Those who wanted surgical abortions got vacuum aspiration. A group of women in the middle didn't have a strong preference and were willing to be randomly allocated to abortion method. Those randomized to medical abortion were much less happy than those allocated to surgery. In contrast, those who wanted a medical abortion were very satisfied with their care.

A PHYSICIAN: Are there any data on the impact of abortion on fertility?

DR GRIMES: This has been studied intensively around the world.^{22 ,52 - 53} We can say with assurance that having 1 suction curettage abortion has no adverse effect. The only exception I know of may be sharp curettage under general anesthesia in Eastern Europe, which may damage the endometrium.⁵²

A PHYSICIAN: Massachusetts is having a debate about "partial-birth" abortion. Could you comment on this?

DR GRIMES: "Partial-birth abortion" is a not a medical term.^{24 ,54} As noted by Annas,⁵⁵ "what makes the term ‘partial-birth abortion' politically powerful is its inaccurate conflation of 2 polar-opposite results of pregnancy, birth, and abortion." One barrier to care I did not discuss today because of time limitations is legislative harassment. This is ongoing nationwide. We have an epidemic of antiabortion bills, ranging from zoning ordinances to gestational age limits. One of the most common has been this "partial-birth abortion" ban. It's bad medicine and bad law. These laws have been overturned or enjoined in many states, most recently Iowa.⁵⁶ We need to oppose this legislation. As noted by the American College of Obstetricians and Gynecologists,⁵⁴ this is an inappropriate intrusion of legislators into the practice of medicine.

A PHYSICIAN: Is there any way we can get this whole process out of the legislative arena?

DR GRIMES: I see no hope in the near future, and I think we're going to have more of the same. Opponents of abortion plan to continue to nibble away at the periphery of Roe v Wade and try to legislate safe abortion out of existence.

A PHYSICIAN: The best way to prevent this tragedy from happening is good contraception. I don't know whether this patient's period is regular enough to use periodic abstinence, whether the patient knows how to use this method properly, or whether the patient realizes that the failure rate is so high. Now she will choose another method instead of rhythm. If she chose a better method in the first place, maybe this whole thing could have been avoided.

DR GRIMES: I don't know what Ms B knew about the efficacy of periodic abstinence. It clearly served her well, however, for a period of 6 years. All contraceptives are fallible. In the National Survey of Family Growth for 1995, the first-year failure rate for oral contraceptives was 7%.¹⁰

A PHYSICIAN: Could you speak about emergency contraception and how little we physicians know about it or use it?

DR GRIMES: The medical profession has not been proactive enough concerning emergency contraception. We need to let our patients know about it and give them prescriptions for it in advance. As Glasier and Baird⁵⁷ demonstrated last year, giving women emergency contraception in advance of need does not undermine contraception. I'm a big fan of primary prevention of unintended births. This encompasses traditional contraception and emergency contraception. Abortion—what we've discussed today—is secondary prevention of unintended births.

I believe the next wave with emergency contraception will be use of levonorgestrel alone. Last year, a randomized controlled trial by the World Health Organization⁵⁸ and published in The Lancet showed that levonorgestrel alone, 0.75 mg, repeated in 12 hours, was both more effective and better tolerated than was the Yuzpe regimen we now have in the United States. The FDA recently approved this levonorgestrel regimen for use as emergency contraception.⁵⁹

A PHYSICIAN: Any thoughts on how to improve the safety of abortion providers?

DR GRIMES: The underlying problem is violence in America. Whether one is a high school student or an abortion provider, we're all in some peril. An interesting article in JAMA revealed how common violence is against healthcare providers.⁶⁰ Abortion providers have not been the only murder victims. From 1980 to 1990, more than 100 healthcare workers were killed on the job, and most of these murders involved firearms. This is an ongoing problem in our violent society.