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â] -5~_ INSTITUTE OF MEDICINE LEGALIZED ABORTION AND THE PUBLIC HEALTH Report of a study by a committee of the Institute of Medicine May 1975 NAS-NAE MAY 2 71975 i National Academy of Sciences LIBRARY Washington, D.C.
NOTICE This is the report of a project undertaken with the approval of the Council of the Institute of Medicine, National Academy of Sciences. Such approval manifests the judgment that the project is of national importance and appropriate both to the purposes and professional resources of the Institute of Medicine. The members of the committee appointed to conduct the project and prepare the report were selected for recognized competence and with due consideration for the balance of disciplines appropriate to the project. Responsibility for the substantive aspects of the report rests with that committee. Each report issuing from a study committee of the Institute of Medicine is reviewed by an independent group of qualified individuals according to procedures established and monitored by the National Academy of Sciences. Only upon satisfactory completion of the review process is distribution of a report approved. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of medical and other professions for the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 Congressional charter responsibility to be an advisor to the Federal Government, and its own initiative in identifying issues of medical care, research, and education. 2101 Constitution Avenue, N.W., Washington, D.C. 20418 Area 202-389-6891 IOM Publication 75-02
INSTITUTE OF MEDICINE Study on Legalized Abortion and the Public Health STEERING COMMITTEE Chairwoman Mildred Mitchell BATEMAN, M.D., Director, West Virginia Department of Mental Health Members Helen BARNES, M.D., Associate Professor, Department of Obstetrics and Gynecology, University of Mississippi Elise BOULDING, Ph.D., Professor of Sociology, Institute of Behavioral Science, University of Colorado Robert E. COOKE, M.D., Vice Chancellor for Health Sciences, University of Wisconsin Henry W. FOSTER, M.D., Professor and Chairman, Department of Obstetrics and Gynecology, Meharry Medical College Ruth Watson LUBIC, M.A., C.N.M., General Director, Maternity Center Association Brian MACMAHON, M.D., Ph.D., D.P.H., Professor and Head, Department of Epidemiology, Harvard University School of Public Health Frederick C. ROBBINS, M.D., Dean, School of Medicine, Case Western Reserve University Lisbeth Bamberger SCHORR, B.A., Children's Defense Fund Eleanor Bernert SHELDON, Ph.D., President, Social Science Research Council Christopher TIETZE, M.D., Senior Consultant, The Population Council
STUDY STAFF Martha 0. Blaxal1, Ph.D., Director Judith A. Folkenberg, Research Associate Sarah Spaght Brown, M.P.H., Professional Associate Karen L. Grimm, Professional Associate Lewis Okun, Research Assistant Henry P. David, Ph.D., Consultant ACKNOWLEDGEMENTS The many persons who assisted the committee and staff in preparing this report and providing valuable comments on its earlier drafts are too numerous for individual acknowledgment. The study group is grateful for their contributions. Particular mention is due the Center for Disease Control of the Department of Health, Education, and Welfare, and to Wlllard Gates, Jr., M.D., for providing unpublished data and assuring their appropriate use in the report. Welcome assistance in locating materials was also provided by Jean van der Tak, and J. Joseph Speidel, M.D. Finally, we would like to thank Bernard Greenberg, Ph.D., chairman of the Institute of Medicine report review committee for this study, for his help in integrating reviewer comments and in enlisting additional re- viewers from the University of North Carolina at Chapel Hill. The Institute of Medicine receives its principal financial support from five philanthropic foundations (The Robert Wood Johnson Foundation, The W. K. Kellogg Foundation, The Andrew W. Mellon Foundation, The Common- wealth Fund and the Richard King Mellon Foundation) and The National Academy of Sciences. This public policy study of legalized abortion was supported by grants from a consortium of private organizations, including The Population Counci1, The Grant Foundation, The Maurice Falk Medical Fund, and the Sunnen Foundation. Their grants do not constitute endorse- ment of any statement or conclusion in the report. ii
CONTENTS Summary and Conclusions 1 1. Introduction 9 2. The Medical and Demographic Aspects of Legal Abortion in the United States 19 3. Abortion and the Risk of Medical Complications 47 4. Abortion and the Risk of Death 72 5. The Psychological Effects of Abortion 88 6. Birth Defects and Selective Abortion 103 7. Contraception and Abortion 115 Appendix A: Summary of the Supreme Court 128 Decisions on Abortion, Roe v. Wade and Doe v. Bolton, January 22, 1973 Appendix B: Glossary 132 Bibliography 145 iii
FIGURES AND TABLES FIGURES 1 Methods of Induced Abortion by Weeks of Pregnancy 20 2 Number of Reported or Estimated Legal Abortions and Abortion Ratios, United States, 1970-1973 25 3 Percent Distribution of Reported Legal Abortions by Place of Occurrence, 1972 and 1973 27 4 Number of Abortions Obtained in Upstate New York by Georgia Residents, by Quarter, 1972-1973 30 5 Percent Distribution of New York City Abortions by Type of Provider and Residency Status, July 1, 1970-June 30, 1972 32 6 Percent Distribution of Reported Legal Abortions by Age, Selected States, 1973 33 7 Number of Hospital Admissions for Complications due to Illegal Abortions, Grady Hospita1, Atlanta, 1969-1973 66 8 Abortion Mortality Ratios by Weeks of Gestation, United States, Combined 1972-1973 Data 75 9 Abortion Deaths by Type of Abortion, 1958-1973 82 Iv
TABLES 1 A Classification of Abortion Legislation 11 2 Chronological Record of the Number of States Reporting to the Center for Disease Contro1, 1969-1973 23 3 Number of Reported Legal Abortions in 1972 and 1973, by State, and Legal Status of Abortion in 1972 28 4 Reported Legal Abortions and Abortion Rates for Non-White Women, Selected States, 1972 and 1973 35 5 Number of Legal Abortions and Abortion Rates, by Race, for Residents of New York City, California, and Maryland 37 6 Estimated Out-of-Wedlock Birthrates for Women Aged 15 to 44 in States by Type of Abortion Legislation, United States, 1965-1973 40 7 Infant Mortality Rates for United States and Selected States, 1968-1972 41 8 Total and Major Post-abortal Complications per 100 Women Obtaining Abortions by Gestation, Procedure, Pre-existing Complications, and Concurrent Sterilization, Total Patients and Local Patients with Follow-up, JPSA, July 1, 1970 - June 30, 1971 50 9 Number and Complication Rates of Local Patients with Follow-up Who were Aborted by Suction, by Type of Facility 52 10 Complications of First Trimester Abortion, Ljubljana, 1971-72 53 11 Admissions to Municipal Hospitals in New York City for Incomplete Abortions, 1969-1973 65 12 Reported Deaths Associated with Legal Abortions in the United States, by Weeks of Gestation and Method of Abortion, 1972 and 1973 74 13 Historical Trends on the Number of Legal Abortions, Number of Deaths, and Mortality per 100,000 Abortions, Selected Areas and Periods 78 14 Mortality Ratios of Selected Surgical Procedures, United States 1969 80
Tables - continued 15 Abortion - Related Deaths in New York City, Resident Women, ⢠July 1966-June 1974 83 16 Deaths Attributed to Illegal Abortion in Romania, 1965-1971 84 17 Abortion Mortality Rates Associated with Other-than-Legal Abortions, by Race, United States, 1968-1973 84 18 Milunsky Survey of North American Experience with Amnio- centesis for Prenatal Genetic Studies 106 19 Estimated Annual Number of Pregnancies and Pregnancy- Related Deaths per 100,000 Women for Selected Combinations of Abortion And Contraception. 117 vi
