Legalized Abortion and the Public Health: Report of a Study (1975)

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Chapter 1 INTRODUCTION This is the report of a committee appointed by the Institute of Medicine to examine the effects of abortion on the health of the public. A major emphasis is on the risks of death and medical complications to women obtaining abortions, and the documentable changes in these risks when the status of abortion shifts from essentially illegal to legal. The report also emphasizes the relative risks of early abortion—before 12 weeks gestation—and later abortion—usually in the second trimester of pregnancy. Both comparisons—legal as against illegal abortion, and first- as against second-trimester abortion—are highly significant to considerations of the consequences of abortion for public health. Defining the Health Effects of Abortion "Health effects" is a broad concept that could include almost all aspects of personal and social well being if health is defined as more than "merely the absence of disease or infirmity. "l/_ The health effects of abortion include physica1, menta1, emotiona1, and social outcomes of the procedure. The health of an individual woman obtaining an abortion is affected, but in a larger sense so also is the health of the family and of society. Further, the increased availability of abortion has led to alterations in the medical care system, in the roles of health professionals, and in certain demographic measures—each change affecting the public health to some degree. A truly comprehensive analysis of the abortion-health relationship should deal thoroughly with all of these topics. However, the lack of data on many of these subjects precludes much detailed discussion. For example, information on the effects of abortion—obtained and denied—on family health and cohesiveness is only speculative, as is information on the impact of abortion on marital relationships. There are almost no data on the health outcomes resulting from innovation in women's health services, such as the creation of independent abortion and gynecology clinics. Similarly, it is difficult to assess the health impact of the research stimulated

10 by non-restrictive abortion legislation. Research on reproductive physiology, contraceptive methods, and the behavioral aspects of human sexuality has a clear relationship to health, but its relation- ship to abortion is not known. The scope of this report, therefore, has been defined to a great extent by the availability of data. The study group decided that the potentially great number of topics in a consideration of the health effects of abortion should be limited as much as possible to those for which useful data are available. Further notes on specific data con- siderations appear at the end of this chapter. Law and the Health Effects of Abortion A common theme throughout this report is that the health effects of abortion are related to the legality of the procedure. However, there is no legal mode1, applicable to all Jurisdictions, which can be used to evaluate the relationship between abortion laws and health. In some countries, for example, induced abortion is prohibited completely, despite considerable evidence that abortions will continue to be sought and obtained regardless of the risk or illegality. In some other countries abortions are illegal but can be easily obtained safely in licensed medical facilities staffed by qualified medical personnel. And in still other jurisdictions, abortions can be obtained legally, but only after the pregnant woman has satisfied medical and procedural requirements specified by legislation. In an effort to bring these divergent models together, writers in the field often use the notion of a legal and procedural continuum. At one end, the law states that abortion may be easily obtained at the initiative of the woman; in the middle, legal abortion is available only under specified medical or socio-economic conditions and procedural requirements; and at the other end, the law prohibits abortion completely, with occasional exceptions if the life or health of the pregnant woman is seriously endangered.2/ The study group found this legal classification spectrum useful and therefore adopted a set of terms and definitions, used with con- sistent meaning throughout this report, to reflect the continuum: non-restrictive legislation, moderately restrictive legislation, and restrictive legislation. These definitions can be applied with minimum difficulty to the more detailed discussions on health begin- ning in Chapter 2. Table 1 summarizes the definitions of each of these terms, and the various conditions and procedural requirements applying to each category. It also gives examples of countries where a particular type of legislation is currently in force.

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12 De Jure and De Facto Legal Status Abortion statutes often do not present an accurate picture of actual practices. In fact, the day to day implementation of the legislation may be quite different from the apparent intent of the law. Although legislation may be restrictive, abortion may be freely practiced by the medical profession in open disregard of the law and generally accessible to the majority of women. For example: . In the Netherlands, both the patient and the physician can legally be prosecuted for abortion, but the law is not enforced and eleven abortion clinics are currently in operation.^/ . Abortion was technically illegal in Korea before January 1973, but it was generally available to all women. In a 1971 survey of Korean women who had obtained abortions, one-third thought that abor- tions were legal and one-third were unaware of its actual legal status.4/ . In Greece, although induced abortion is illega1, it is still freely practiced "under the cover of false medical terminology such as... menstrual disorder."5/ Even when laws restricting induced abortion are generally observed by physicians, women with adequate financial resources are often able to obtain "illegal" but safe abortions, performed in the physician's private office. Women without such resources may obtain illegal abortions from non-medical practitioners, or attempt self-abortion. Examples of these conditions: . In Colombia, the Dominican Republic, and elsewhere in Latin America, illegal abortions are known to be widespread. 6^/ In El Salvador, one out of every five admissions to the San Salvador maternity hospital in 1965 was for complications from illegally-induced abortion.^/ . In the Middle East and North Africa (with the exception of Tunisia) illegal but medically safe abortions are generally available to upper and middle class women from practicing physicians, although the vast majority of women who obtain abortions are presumed to obtain them illegally in unsanitary environments. A 1971 conference of the International Planned Parenthood Federation on induced abortion concluded that illega1, criminally induced abortion was widespread in the Middle East and North Africa and that legal restrictions were not effective in containing the demand for abortions.8/ Another variation of the difference between abortion legislation and practices is seen in jurisdictions with moderately restrictive abortion laws that are interpreted in a restrictive fashion. For example, although Romania's abortion legislation is only moderately restrictive, it is interpreted very narrowly and women find it difficult to obtain an abortion.9_/ The state of Georgia adopted moderately restrictive laws in 1968 but actual practices

13 were relatively restrictive until 1972. There is evidence that many women did not shift from illegal to legal abortions until the second quarter of 1972, as indicated by a delayed decline in hospital admissions for medical complications of illegal abortions in Grady Hospita1, Atlanta.JU)/ The situation is reversed in some countries with moderately restrictive abortion legislation but non-restrictive practices. For example, in Japan and Poland, abortion laws are moderately restrictive but abortion practices are virtually non-restrictive. Some Swedish women used to travel to Poland for abortions to avoid the delays caused by the procedural requirements of Sweden's moderately restrictive legis- lation, ll/ And in some countries, non-restrictive laws coincide with non- restrictive practices, to make abortion widely available to most women. Women of lower socio-economic status, however, still may not be able to secure abortions in medical settings because fear or unfamiliarity about the abortion clinics limit their access, or because health facilities they rely on may be slow to provide abortion services. In the United States, there were considerable delays by the public hospitals, which traditionally serve low-income citizens, in responding to the 1973 Supreme Court decision. Only 17 percent of these facilities were providing abortion services in the first quarter of 1974.12/ In short, even where abortion legislation is restrictive, some women may be able to obtain them from licensed physicians in proper medical surroundings with risks similar to an abortion obtained through legal channels. On the other hand, even with moderately restrictive legislation (and to a lesser extent non-restrictive legislation) some women will still be unable to obtain abortions in a medical setting and will resort to self abortion or an illegal abortion from untrained individuals in an unsanitary environment. It can be assumed, but not proved, that most of the deaths and medical complications from illegal abortion cited in Chapters 3 and 4 derive from such abortions. In this report, reference to "health effects of illegal abortion" will imply this latter model of illegal abortion and not the technically illegal abortions provided by a medically trained person in a comparatively safe environment. The Legal Status of Abortion in the United States Before 1967, induced abortion was permitted in 42 states only if two or more physicians agreed that the abortion was necessary to preserve the life of the pregnant woman. Five states—Alabama, Oregon, Colorado, New Mexico and Maryland—and the District of Columbia permitted abortions under slightly broader rules concerning preservation of the woman's health. Three states—Massachusetts, New Jersey, and Pennsylvania—prohibited unlawful or unjustifiable abortion without specifically defining what was meant by those terms.13/

14 In 1957, the American Law Institute proposed an abortion statute as part of its Model Penal Code which expanded the conditions under which therapeutic abortions could be obtained. This code stated that A licensed physician is justified in terminating a pregnancy if he believes there is substantial risk that continuance of the pregnancy would gravely impair the physical or mental health of the mother, or that the child would be born with grave physical or mental defect, or that the pregnancy resulted from rape, incest or other felonious intercourse. All illicit intercourse with a girl below the age of 16 shall be deemed felonious for purposes of this subsection. Justifiable abortions shall be performed only in a licensed hospital except in case of emergency when hospital facilities are unavailable.14/ Beginning with Colorado in 1967, thirteen states* adopted moderately restrictive abortion legislation that incorporated most of the conditions included in the American Law Institute's Model Penal Code. And, in 1970, four more states—Alaska, Hawaii, New York, and Washington—adopted non-restrictive legislation that removed nearly all restrictions on the conditions under which legal abortions could be obtained. The legal status of abortion became an issue of heightened political controversy throughout the United States after a ruling by the Supreme Court on January 22, 1973 that greatly limited the extent to which the states could regulate abortion. In Roe v. Wade and Doe v. Bolton, the Court held abortion principally to be a matter of medical judgment for the pregnant woman and her attending physician during the first trimester of pregnancy. State intervention was permitted during the second trimester only to ensure that an abortion conform to safe medical practices. Subsequent to that time, the state could forbid abortion except in those cases where medical judgment deemed it necessary "for the preservation of the life or health of the mother." **15/ Following the Supreme Court decision, legal abortions theoretically became available to all pregnant women in the United States. In some states, however, the procedural requirements of hospitals and other related factors continue to limit the actual number of abortions performed, especially for the poor, even though many of these barriers are contrary to the intent of the Court's ruling. In terms of the classification system *Arkansas, California, Colorado, Delaware, Florida, Georgia, Kansas, Maryland, New Mexico, North Carolina, Oregon, South Carolina, and Virginia. **A more complete discussion of the Supreme Court's ruling is contained in Appendix A.

15 presented earlier, current U.S. abortion practices are classified as non-restrictive, although in some states and for selected sub- populations, implementation is moderately restrictive. Data Limitations Most of the medical literature on abortion relates to techniques of abortion or provides data on deaths, medical complications, and the mental health effects of the procedure. Data on subjects less directly connected with the abortion procedure itself are sparse or non-existent. For example, the study group would have wished to evaluate the impact of legalizing abor- tion on infant mortality rates, teenage marriage trends, and out-of-wedlock births. However, discussion of these and similar topics is constrained in three ways. First, non-restrictive abortion laws have been in effect for so short a time that it is difficult to establish valid trend data; second, differentiating the health and demographic effects of abortion from many other variables is difficult both theoretically and practically; and third, it is difficult to demonstrate the connections between demo- graphic trends and health status. Inadequate data also preclude a discussion of the more general health effects of denying abortion to women including the social and psychological risks of carrying an unwanted pregnancy to term. Another problem arises in determining when it is appropriate to apply foreign data to U.S. circumstances. In genera1, information from abroad has been used in this report only when the study group believed that the data could be compared transnationally, regardless of cultural factors or differences in medical procedures. European and Japanese abortion mortality data and figures on selected medical complications are used in the first several chapters of the report. But foreign data on such issues as post- abortion contraceptive use or the emotional impact of abortion are not presented because cultural factors unrelated to the quality of the research effort or the data collected may substantially limit their relevance. One exception is a reference to two foreign studies of children born to mothers denied abortion; no U.S. studies on this topic could be found. The possible long-term medical complications of abortion provide another example of the problem with foreign data. Most studies con- ducted abroad on this subject have weaknesses in research design that limit the validity of the conclusions even for the country of origin. Transnational comparisons are hampered by different methods of pregnancy termination, varying systems for the delivery of medical care, and general cultural differences. However, because the U.S. has not yet collected adequate data on long-term complications, some foreign data are used in this report—with the shortcomings clearly identified.

16 Summary The relationship between health and abortion has two main themes in this report. One is the health consequences of legal as against illegal abortions. The other is the difference in risks between first- and second- trimester terminations. Although the "health effects" of abortion can in- clude a wide range of subjects, data constraints have limited the report's analysis to those topics on which there is useful information. Foreign data are presented and carefully qualified, only if there are no comparable U.S. data on a particular subject or if transnational com- parisons seem valid. To bring some order to the wide variety of abortion laws and procedures, the study group has adopted a classification scheme of "restrictive, moderately restrictive, and non-restrictive" circumstances, taking into account the occasionally wide differences between the letter of the law and actual practice.

17 REFERENCES 1. World Health Organization. Basic Documents, 25 ed., 1975, p. 1. 2. Jean van der Tak. Abortion. Fertility, and Changing Legislation: An International Review, Lexington: D.C. Heath, 1974, pp. 8 & 10. 3. Abortion Research Notes, Vol. 3, No. 2, International Reference Center for Abortion Research, May, 1974. 4. Sun-bong Hong. "Induced Abortion in Korea," in Henry P. David, ed. Abortion Research: International Experience, Lexington: D.C. Heath, 1974, pp. 155-159. 5. Emily Moore-Cavar. International Inventory of Information on Induced Abortion, New York: International Institute for the Study of Human Reproduction, Columbia University, 1974, p. 93. 6. Jean van der Tak. "Abortion in Selected Capitals of Latin America," in Abortion Research: International Experience, pp. 145-152. 7. Stephen Isaacs and H. L. Sanhueza. "Abortion in Latin America - A Legal Perspective." Unpublished manuscript, 1973. 8. Isam R. Nazer. "The Middle East and North Africa," in Abortion Research: International Experience, p. 239. 9. Mary G. Kalis and Henry P. David. "Abortion Legislation: A Summary International Classification," in Abortion Research: International Experience, p. 22. 10. Ronald S. Kahan, Lawrence D. Baker and Malcolm G. Greeman. "The Effects of Legalized Abortion on Morbidity resulting from Criminal Abortion," American Journal of Obstetrics and Gynecology 121: 115, January 1, 1975. 11. Kalis and David, pp. 16-25. 12. Edward Weinstock, Christopher Tietze, Frederick S. Jaffe and Joy G. Dryfoos. "Legal Abortions in the United States Since the 1973 Supreme Court Decisions," Family Planning Perspectives 1:23-31, January- February 1975.

18 13. Betty Sarvis and flyman Rodman. The Abortion Controversy, 2nd ed., New York: Columbia University Press, 1974, pp. 29-33. 14. American Law Institute, Model Penal Code, sec. 207.11 (Proposed Official Draft, 1957) 15. 410 U.S. 113, 93 S. Ct. 705 (1973) and 410 U.S. 179, 93 S. Ct. 739 (1973).