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Chapter 2 THE MEDICAL AND DEMOGRAPHIC ASPECTS OF LEGAL ABORTION IN THE UNITED STATES The history of abortion as an illegal activity in the United States has resulted in a widespread lack of knowledge about the medical procedures used and the characteristics of women who obtain abortions. This chapter describes common methods of abortion, provides some medical definitions, and outlines the basic demographic features of women in the U.S. who undergo legal abortion. It concludes with a discussion of the trend in illegal abortions in recent years, the extent to which legal abortions have replaced illegal abortions, and a short summary of the demographic effects of the legalization of abortion in the United States. Medical Definition and Methods of Abortion As generally defined in medical textbooks, abortion is the termination of a pregnancy before the fetus is viable, that is, before it is indepen- dently capable of sustaining life outside the uterus. In a number of textbooks, a non-viable fetus is defined as one weighing less than 500 grams, or just over one pound. Immature birth, not abortion, is generally used to describe the expulsion of a fetus weighing 500 to 999 grams (approximately 17 ounces to 2.2 pounds), whether it is born alive or dead.* *A fetus of 500 to 999 grams usually does not survive, even with extraordinary life support measures. For an infant who does survive, however, improved medical technology offers a reasonable chance for maturation and normal life. For statistical purposes and international uniformity, the definition of a premature infant has been based on a weight of 1,000 to 2,499 grams (2.2 to 5.5 Ibs). A more accurate measurement would take into account both birth weight and gestational age; there are medically important differences between infants of similar weight but different gestational ages. 17 The low birth weight of prematurity is a leading cause of infant mortality. 19
20 Abortion may occur spontaneously, in which case it is commonly referred to as a miscarriage, or it may be deliberately induced. Figure 1 summarizes the methods used to induce abortions at different stages of pregnancy. The three most frequently used methods in the United States are suction (vacuum aspiration) and dilatation and sharp curettage (D&C) for pregnancies in the first three months, and replace- ment of amniotic fluid with a concentrated salt solution (saline abortion) for second trimester pregnancies. In late 1973, the Food and Drug Admini- stration approved the limited use (only in hospitals) of prostaglandins, as an alternative to a saline solution for second-trimester abortions. Hysterotomy, and hysterectomy with abortion, both of which involve major surgery, are not frequent methods of abortion in this country. FIGURE 1 Methods of Induced Abortion By Weeks of Pregnancy First day of the Last Menstrual Period (LMP) Fertilization F rst Missed Period Pregnancy Tests Are Not Reliable Prior to 6th Week LMP i: i | I Men* 1 Suction No trual | Dilation & Standard Prostaglandin Saline Hysterotomy8 Hysterectomy3 i | laTon | Curetta9e I Method III 1 1 1 1 12 /\ 14 16 20 26 FIRST TRIMESTER SECOND TRIMESTER TIME IN WEEKS FROM LAST PERIOD a/ These two methods can also be used in the first trimester. Source: Adapted from Theresa van der Vlugt, and P. T. Piotrow. "Uterine Aspiration Techniques," Population Report, Series F, No. 3, Washington, D.C.: The George Washington University Medical Center, Population Information Programs, June 1973.
21 For a suction abortion, or vacuum aspiration, the cervical canal* is gradually forced open by the insertion of surgical instruments (dilators) until the opening is large enough for passage of a tube (cannula) into the uterine cavity. The fetus and placental tissue are then suctioned out by means of a vacuum pump connected to the cannula.** In dilatation and sharp curettage, or D&C, the cervix is dilated to a greater extent and the fetal and placental tissue are scraped out of the uterus with a curette, which resembles a small spoon. Suction or D&C are performed almost exclusively in the first trimester, under either local or general anesthesia. At the end of the first trimester, approximately 13 weeks, the fetus is still very small, weighing approximately one-half ounce. Intrauterine instillation of a saline solution, or saline abortion, is the most commonly used method in the second trimester, and is usually per- formed at or after sixteen weeks of pregnancy.*** A portion of the amniotic fluid that surrounds the fetus is withdrawn by means of a hollow needle inserted through the womarf s abdominal wall into the uterine cavity. *See the diagram of the reproductive organs under Ectopic Pregnancy in the Glossary. **A procedure that may become of more importance in the U.S. is menstrual regulation. Menstrual regulation (also known as menstrual induction, menstrual extraction, and endometrial aspiration) is a suction procedure performed five to six weeks after the first day of the last menstrual period (i.e., during the two-week interval following the expected onset of a missed menstrual period). The procedure usually does not require anesthesia or dilatation of the cervix. A plastic cannula is inserted into the uterus and the contents of the uterus are pumped out. Menstrual regula- tion is performed before the time that pregnancy tests are reasonably reliable, which is six weeks after the beginning of the last menstrual period. Some physicians believe that menstrual regulation poses a small medical risk, which is unwarranted if the woman is not pregnant. (Dr. Elton Kesse1, director of the International Fertility Research Program at the University of North Carolina, found no pregnancy in two-thirds of women whose menstrual periods were five days late, nor in one-third who were two weeks late.2/ If a woman is pregnant and menstrual regulation does not completely empty the uterus, there is a risk of continuing pregnancy or prolonged bleeding.3/ ***There is some medical disagreement about the best method of abortion for the gestational period between 12 and 15 weeks. Some physicians believe that no method of abortion is medically desirable during this time period and would wait to perform a saline abortion after 15 weeks gestation. Other physicians use a combination of vacuum aspiration and some mechanical manipulation involving the scraping of the uterus since the fetus is too large to be solely suctioned out.
22 This fluid is replaced with a concentrated salt solution, which induces labor and results in the expulsion of the fetus and placenta approximately 24 to 48 hours later. The fetus usually does not survive the procedure. A prostaglandin abortion is similar in procedure to a saline abortion and also is performed in the second trimester. One type of prostaglandin, which causes strong muscular contractions, is injected in milligram doses into the uterine cavity without withdrawing any amniotic fluid. The interval between injection and expulsion of the fetus is generally of a shorter duration than with a saline solution.4_/ Hysterotomy, or surgical entry into the uterus, is performed in either the first or second trimester, but more usually in the second. In effect, it is a cesarean section that removes a fetus too small to survive.* Many physicians believe that any subsequent pregnancies will require cesarean section delivery. If no further pregnancies are desired, a hysterotomy abortion is often combined with tubal sterilization. Hysterectomy for pregnancy termination consists of the removal of the uterus, with or without the fetus inside, and is usually performed when a pathological condition of the uterus, such as fibroid tumors, warrants its remova1, or when the woman desires sterilization. Since hysterotomy and hysterectomy are major surgical procedures, they represent more of a risk to the woman than the other abortion methods and are not often used in the United States. (See Chapter 4 for further discussion.) In both 1972 and 1973 about 83 percent of the abortions in the United States were performed in the first trimester,x most commonly by means of suction or D&C. During 1972, 65 percent of the abortions were performed by suction, 23 percent by D&C, and 10 percent by the saline method.6/ During 1973, the percentage of abortions performed by suction increased to 74 percent while those performed by D&C declined to 13 percent; the percentage of abortions performed by saline remained at 10 percent.?/ Characteristics of Abortion in the United States Most of the national data on legal abortion in this report were obtained from Abortion Surveillance Reports, published by the Center for Disease Control (CDC). CDC began collecting abortion statistics from 10 state public health departments beginning with 1969 data. By 1972, 19 states and the District of Columbia provided statewide data on the number of abortions performed in their jurisdictions, and eight other states provided partial data. *There are a few known cases in which a physician has miscalculated the duration of the woman's pregnancy; viable fetuses have been removed and have survived.
23 Twenty-five states and the District of Columbia reported statewide abortion statistics for 1973 with partial reporting provided by hospitals in additional states. Table 2 summarizes the status of national abortion reporting as of April 1975.8/ TABLE 2 Chronological Record of the Number of States Reporting to the Center for Disease Contro1, 1969-1973. 1969 Number of states 8 from which statewide abortion data were reported a/ Additional states 2 7 7 8 26 from which abortion data are reported from individual hospitals or facilities Total Number of 10 24 25 28 51 states from which partial or complete abortion data are reported a/ Total Number of 22,670 193,491 485,816 586,760 615,831 abortions reported to CDC a/ Including the District of Columbia, beginning in 1970. Source: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control. Abortion Surveillance: 1973, issued May 1975.
24 There is no uniform national reporting system; states have established their own systems, or do not require reports of abortion. The number of legal abortions reported to CDC is less than the actual number performed nationwide, though it is probable that in 1972 the majority of legal abortions obtained in the United States were performed in the reporting states. The basis for this judgment is that 16 of 17 states with non- or moderately restrictive legislation in 1972 reported statewide data, and the other, New Mexico, reported partial data. Data were also reported from the District of Columbia, where a large number of abortions were performed in 1972. Although the Supreme Court decisions that legalized abortion in all 50 states were handed down in January, 1973, many states have not yet developed adequate reporting systems for channeling abortion data to their public health departments, which in turn report to CDC. Therefore, the number of abortions reported to CDC for 1973 (25 states reported statewide data) continued to be lower than the actual number performed. The Alan Guttmacher Institute, the research and development division of Planned Parenthood-World Population, conducted a nationwide survey of 1,642 providers (hospitals, clinics, and private physicians) that enables a more complete estimate of the number of legal abortions obtained in the U.S. during 1973.£/ Unlike CDC, which depends upon reports from the public health departments, this survey obtained its information directly from the providers of abortion services in all 50 states and the District of Columbia, and is therefore more comprehensive than the CDC reports. The survey also estimated the number of abortions that would occur in 1974 based on a straight-line projection of the last three quarters of 1973 and first quarter of 1974. No national abortion data for 1974 were available from CDC by May 1975. Figure 2 shows the rise in the number of reported legal abortions since 1970 and the increase in the national abortion ratio since that year.* The increases in the number of reported abortions reflect two factors: (1) an increase in the number of states providing information to CDC; and (2) an increase in the frequency of legal abortions within the United States, The specific effect of each of these factors has not been identified in Figure 2, although the number of states that reported data in each of those years has been indicated. *Two termsâabortion ratio and abortion rateâare used to measure the relative frequency of abortions. Abortion ratio generally refers to the number of abortions per 1,000 live births in the same year; abortion rate refers to the number of abortions per 1,000 women 15-44 years of age.
25 FIGURE 2 Number of Reported or Estimated Legal Abortions and Abortion Ratios United States, 1970-1973 £/ AGI Survey CDC OC m UJ .. 55 c Ir 100 =. * a 50 - a/ The number of states reporting statewide or partial data to CDC in these years is given below. For those states reporting only partial data to CDC, there are no estimates of how many abortions were performed but were not reported. 1970 - 24 states 1972 - 28 states 1971 - 25 states 1973 - 51 states Source: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control. Abortion Surveillance: 1972, issued April 1974; Abortion Surveillance: 1973, issued May 1975; and 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 7: 25 January/February 1975.
26 From 1971 to 1972, the number of abortions reported to CDC increased 21 percent, but from 1972 to 1973, the increase in reported abortions was only five percent, even though the number of reporting states nearly doubled. If the more complete survey data compiled by The Alan Guttmacher Institute are used, a 27 percent increase occurred in the number of abortions obtained in 1973 compared with the 1972 CDC data. A direct causal relationship cannot be inferred between the increasing legalization of abortion (culminating with the Supreme Court decisions) and the increasing number of abortions shown by Figure 2. The Supreme Court decisions did not necessarily increase the number of abortions; many of those obtained under non-restrictive abortion practices would earlier have been obtained illegally. Legalization of abortion and the establishment of reporting systems has caused them to become visible. As the substitution effect diminishes over time the rate of increase in the number of reported abortions is likely to decline.* The abortion ratio per 1,000 births has continued to rise, not only because of the increase in the number of abortions, but also because of the decrease in the total number of births during this period. Geographic Location and Residency Status During 1972, according to data reported to CDC from 28 states, the majority of legal abortions were performed in the non-restrictive jurisdictions of the District of Columbia, New York, Washington, Alaska, and Hawaii, and in some moderately restrictive states, such as California and Kansas, where abortions were obtained without great difficulty (Table 3). Seventy-five percent of the total abortions were performed in New York and California, and an additional 12 percent were obtained in the District of Columbia, Washington, and Kansas (see Figure 3). During that year, 44 percent of the abortions were obtained by out-of-state residents who traveled to states with non-restrictive practices to obtain their abort ions ,â¢10_/ Because of this migration, the abortion rates (numbers of total abortions per 1,000 resident women age 15-44) in states with non-restrictive practices were disproportionately high. For example, the District of Columbia had an abortion rate of 214 because women from Maryland, Virginia, and elsewhere in the South (where moderate or restrictive abortion legislation was in force) traveled to the District for their abortions. *The substitution of legal for previously illegal abortions is discussed on p. 38.
27 FIGURE 3 Percent Distribution of Reported Legal Abortions by Place of Occurrence, 1972 and 1973 Total: 586,800 Total: 745,400 All Other States 13% District of Columbia 7% California 24% New York 51% â¢Kansas 2% â¢Washington 3% Kansas 2% - Washington 2% ⢠All Other States 42% District of Columbia 6% California 19% New York 29% 1972 1973 Source: Table 3. After the Supreme Court decisions on abortion in January 1973, the geographic distribution of legal abortions changed to reflect the growing number of abortions performed in states that had previously had restrictive abortion practices (Table 3 and Figure 3). According to The Alan Gutt- macher Institute survey, the number of abortions in New York during 1973 was 216,000, a decline of 83,000 from the 1972 figure of 299,900 reported by CDC. A total of 86,900 abortions were obtained in Illinois, Michigan, and Ohio during 1973; none of these states reported any abortions to CDC in 1972, (all of these were states with restrictive policies in 1972). It is likely that part of the New York decline during 1973 can be attributed to the initiation of abortion services in these three mid- western states during that year.
28 TABLE 3 Number of Reported Legal Abortions in 1972 and 1973, By State, and Legal Status of Abortion in 1972 1972 a/b/ 1972 c/ 1973 d/ 1973 e_/ Non-restrictive States Abortions Rates Abortions Rates Alaska 1,172 12.0 1,200 16.5 Hawaii 4,546 25.7 4,600 26.1 New York f/ 299,891 75.9 216,000 53.7 Washington 17,767 23.8 17,200 22.5 District of Columbia i/%J 38,868 207.9 44,500 233.4 Moderately Restrictive States Arkansas 793 2.0 1,100 2.8 California 138,584 30.6 143,400 30.7 Colorado 5,260 10.3 7,600 14.3 Delaware 1,342 10.8 2,000 15.6 Florida 3,378 i/ 2.4 23,600 16.4 Georgia 2,509 ~~ 2.4 11,000 10.3 Kansas t] 12,248 26.6 12,600 27.0 Maryland 9,093 10.1 11,100 11.8 New Mexico £/ 5,989 h/ 26.7 4,600 20.3 North Carolina 8,365 7.4 12,100 10.7 Oregon 7,143 15.7 8,000 17.4 South Carolina 854 1.5 2,200 3.6 Virginia 4,496 4.3 9,000 8.5 Restrictive States Alabama Arizona Connecticut Idaho Illinois Indiana Iowa Kentucky Louisiana Maine Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada 1,156 h/ 1.5 4,500 6.1 275 h/ .7 2,900 7.2 2,579 h/ 3.9 6,800 10.1 y 300 2.0 n/ 32,500 13.4 k/ 1,800 1.6 I/ 3,400 5.9 1 2,600 3.8 m/ m/ 600 3.5 3,394 J/ 2.8 14,100 11.5 k/ 37,200 18.6 k/ 7,600 9.2 61 .1 100 0.2 k/ 3,200 3.4 k/ 400 2.8 789 h/ 2.6 2,100 7.1 k/ 1,200 9.9
29 Restrictive States (con't) New Hampshire \sj 700 3.7 New Jersey k/ 10,000 6.4 North Dakota k_/ m/ m/ Oklahoma k/ 700 1.1 Ohio k/ 17,200 7.2 Pennsylvania 8,540h/ 3.5 29,800 12.1 Rhode Island k/ 1,100 5.6 South Dakota k/_ 1,700 12.2 Tennessee h/m/ 3,700 4.2 Texas k/ 17,600 7.1 Utah k/ 100 0.4 Vermont 231 2.4 1,200 15.8 West Virginia Vj m/ m/ Wisconsin 7,427h/ 8.3 8,200 8.6 Wyoming k/ 300 4.3 U.S. Total 586,800 745,400 16.5 a/ Includes all states that reported information to CDC. Other states may have performed abortions but did not report them to CDC. b_/ Data from state health departments unless otherwise noted. cj Data to calculate abortion rates on women aged 15-44 were obtained from U.S. Census Bureau population projections for 1972. d_/ Based on The Alan Guttmacher Institute survey. e/ Abortion rates were calculated using the number of abortions by state of occurrence as the numerator, and the number of women aged 15-44 as of July 1, 1973, by state of residence (based on U.S. Census Bureau projec- tions) as the denominator. The quotient is multiplied by 1,000 to obtain the abortion rate per 1,000 women aged 15-44. i/ These states performed at least one-half of their abortions on out-of- state residents in 1972. g/ Technically, non-restrictive legislation was not in force in the District of Columbia, but a series of court decisions had voided the previous restrictive legislation and de facto non-restrictive practices were in force. h/ Reported from one or more hospitals in the state. i^/ April-December 1972. j_/ October 1971-September 1972. k/ States that did not report abortions to CDC or did not perform abortions during 1972. m/ States performing less than 50 abortions. Note: 1973 abortion numbers are rounded to nearest hundred. Source: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control. Abortion Surveillance: 1972 issued April 1974; Abortion Surveillance: 1973, issued May 1975; 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 7:25 January/February 1975.
30 The change in geographic distribution of abortions following the Supreme Court decisions also can be illustrated by examining the abortion statistics for upstate New York and Georgia itemized by state of residence. In 1972, upstate New York reported an average of 19,000 abortions per quarter, with 60 percent obtained by out-of-state residents. Georgia residents obtained an average of 400 abortions per quarter in upstate New York. After January 1973, however, access to abortion improved in Georgia and the number of abortions obtained in upstate New York by Georgia women declined from 248 in the first quarter of 1973 to only one in the fourth quarter of that year. Figure 4 illustrates this trend.ll/ FIGURE 4 Number of Abortions Obtained in Upstate New York by Georgia Residents by Quarter, 1972 - 1973 IV QUARTER 1972 1973 Source: Jack C. Smith, Ronald S. Kahan, and Winthrop A. Burr. "Abortions in the United States: Before and After the Supreme Court Decision,' paper presented at Twelfth Annual Meeting, Association of Planned Parenthood Physicians, Memphis, Tennessee, April 1974, pp. 9-10.
31 One effect of the Supreme Court decisions was the more equal distribution of abortion accessibility and, at least for some women, the increased opportunity to obtain abortions closer to home. There are positive health benefits in obtaining abortions nearer a woman's home: If a complication should arise, she has access to the same facility that performed the abortion, where her medical history is available to facilitate care. Type of Health Care Facility Information on the type of health care facility where abortions are performed is available for New York City during a two-year period from July 1, 1970 through June 30, 1972. Some nationwide data are available from the survey conducted by The Alan Guttmacher Institute. From 1970-1971 to 1971-1972, non-hospital clinics performed 39 percent of the abortions in New York City, with the remainder distributed among various types of hospital facilities (Figure 5). When examined by place of residence, 51 percent of non-residents (112,070 women) obtained their abortions in non-hospital clinics while only 16 percent of New York resi- dents (18,100 women) obtained their abortions in those clinics.12/ Possible reasons for this difference are that the resident woman either has her own doctor, who will recommend her to an affiliated hospita1, or she seeks her medical care at a municipal hospital. The largest number of abortions obtained by New York City residents, by facility, was the 40,246 abortions performed in the municipal hospitals. According to The Guttmacher Institute survey of clinics, hospitals, and private physicians, the public hospitals have been the slowest to respond to the mandate implied in the Supreme Court's decision. Of 2,144 public hospitals identified by the American Hospital Association in 1972, only 17 percent (362 hospitals) provided abortions during 1973 and the first quarter of 1974.* This may have restricted the availability of abortions to low-income women who are more likely to obtain their medical services in these facilities than middle or upper class women. The number of abortions performed in all hospital settings declined throughout 1973 from 102,600 in the first quarter to 92,000 in the fourth quarter, while the abortions performed in non-hospital-based clinics increased steadily during this period.L3_/ By the first quarter of 1974 the number of abortions performed in free-standing clinics was greater than those performed in hospitals. *The relative paucity of abortion services in public hospitals may reflect not only their reluctance to respond to the Supreme Court decisions, but also a lack of funds to provide the necessary facilities and personnel.
32 FIGURE 5 Percent Distribution of New York City Abortions by Type of Provider and Residency Status, July 1, 1970 - June 30, 1972 ALL WOMEN 35% 8% 39%.-. 1% 1% RESIDENTS NON-RESIDENTS Voluntary hospitals, non-private patients | | Municipal hospitals ^i^-O-l Voluntary hospitals, private patients \ Vr.''.r-.\ Proprietary hospitals Y///A Non-hospital clinic Source: Jean Pakter, Donna 0'Hare, Frieda Nelson and Martin Svigir. "Two Years Experience in New York City with the Liberalized Abortion Law - Progress and Problems," American Journal of Public Health 63: 526, June 1973.
33 Characteristics of Women Obtaining Abortion in the United States Age Of abortions for which the age of the patient was known, approxi- mately one-third of the women obtaining abortions in the United States in 1972 were less than 20 years old, another third were between 20 and 25 years of age, and the rest were 25 or older. Data for 1973 (Figure 6) show that the age distribution for women obtaining abortions almost exactly parallels the distribution by age during 1972. FIGURE 6 Percent Distribution of Reported Legal Abortions by Age, Selected States, 1973^/ Less than 15 years 1.5% a/ There were 489,735 abortions, out of a total of 615,831, for which age was reported. The percentages do not equal 100 because 3.5 percent of the ages were unknown. Source: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control. Abortion Surveillance: 1973, issued May 1975.
34 Race Race was specified for 489,446 women obtaining abortions in 1972, of which 76 percent (370,644) were white and 24 percent were black or other non-white. Slightly fewer abortions were identified by race in the CDC reports for 1973; of these 27 percent were obtained by black and other non-white women.14/* A comparison of the number of abortions and abortion rates for non- white women (residents and non-residents) in certain states during 1972 and 1973 suggests that these rates tend to be higher when non-restrictive abor- tion practices are in effect (Table 4). During 1972, for example, California and Kansas experienced higher non-white abortion rates than Georgia and North Carolina. New York state had the highest rate, probably reflecting both the ease with which resident women could obtain abortions in New York, and the influx of non-white women from out of state. From July 1, 1971 to June 30, 1972, about 18,000 abortions were provided to this latter group of women in New York City.JJ)/ During 1973, however, both the number and the rate of abortions obtained by non-white women declined in New York state, part of which can undoubtedly be explained by the reduction in abortions obtained by out-of-state residents in that year. The higher rates observed in Georgia, North Carolina, Virginia, and South Carolina during 1973 must reflect improved access to legal abortions for non-white women in these states, some of which may have been obtained in New York in previous years. In most states, an examination of the incidence of abortion between white and non-white women during 1972 (and to a lesser extent, during 1973) requires a comparison of abortion rates for resident women only. In states with moderate or restrictive legislation prior to the Supreme Court decisions (Georgia, Maryland, North and South Carolina and Virginia), many more white women tend to leave their state for an abortion than non-white women, thereby artifically lowering the abortion rates for white women. In non-restrictive states, there was no distortion in the rates for residents, but the inclusion of non-residents in the total rates tended to cause an upward distortion for white women.** *CDC does not provide data on race at a more disaggregated level. The category, "black and other," contains Negro, American Indian, Chinese, Japanese, Hawaiian, part Hawaiian, and other. **In their article on illegitimacy rates in Science, Sklar and Berkov point to the greater use of out-of-state abortion by white women in non-abortion states as one factor purporting to explain their declining illegitimate birth rates.16/
35 TABLE 4 Reported Legal Abortions a/ and Abortion Rates for Non-White Women, Selected States, 1972 and 1973 State 1972 1973 Reported Abortions Rates c_/ Reported Abortions Rates c/ Alaska b/ 271 21.0 287 22.2 California 26,913 52.2 23,078 44.8 Colorado 501 22.8 584 26.5 Georgia 1,263 4.9 4,084 15.9 Hawaii b_/ 2,743 26.4 2,936 28.2 Kansas b_/ 1,432 55.3 1,819 70.3 Maryland 4,419 26.6 4,680 28.1 New York State b/ 67,310 112.4 60,090 100.3 North Carolina " 2,729 10.8 4,233 16.8 South Carolina 297 1.8 611 4.0 Virginia 2,181 11.6 3,108 16.6 a/ Includes abortions obtained by both resident and non-resident women. b_/ State with non-restrictive legislation in 1972. c/ The number of women aged 15 to 44 is from 1970 Census data. Source: U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control. Abortion Surveillance: 1972. issued April 1974; ASR, 1973, issued May 1975; and U.S. Department of Commerce, Social and Economics Statistics Administration, Bureau of the Census, Age and Race of the Population of the United States, by States, 1970. An illustration of non-residents distorting the distribution is provided by New York, where 61 percent of all abortions in 1972 were obtained by non-residents. Most of those were obtained in New York City. Of the 132,040 abortions provided to non-residents of New York City during the period July 1, 1971 to June 30, 1972, about 114,000 (86 percent) were obtained by white and Puerto Rican women, and only 14 percent by non-white women. But among residents, about 51,500 abortions (55 percent of the total) were obtained by whites.17/
36 Table 5 provides data on the number of induced abortions and rates, by race, during 1972 for residents of three localities. In all three places, the rates for blacks and other non-whites were approximately twice as high as for whites. To some extent this may reflect an under- reporting of white abortions because private practitioners, to whom whites would go more frequently than would non-whites, probably report less completely than do public facilities. Although there are few scientific studies available to explain this differentia1, it is possible that poverty, cultural attitudes, and ignorance about reproduction may have limited the access by non-white women to family planning methods, particularly before Federal funds became available in the early 1970"s. This may have led historically to a greater reliance on illegal abortion as a method of birth contro1, which has continued to be reflected in the reported data on legal abort ion .JjJ/ A 1968 survey in North Carolina estimated that one conception in seven among white women resulted in an illegal abortion, compared with one out of three among black women.19/* If non-white women are more likely to resort to abortion but are less likely to take advantage of out-of-state abortion opportunities, it would appear that non-white women have easier access to legal abortion only when all legal obstacles to abortion are reduced in their home states. Marital Status and Number of Living Children Approximately 28 percent of the women whose abortions were reported to CDC in 1973 were married at the time of the procedure, and the remaining 72 percent were single, sepa- rated, divorced or widowed.21/** Data for 1972 from CDC parallel the 1973 proportions. These statistics indicate the woman's marital status at the time of abortion, which does not necessarily reflect her marital status at conception. A sizeable number of women who conceive out of wedlock married their partners and did not obtain abortions. Acording to Sklar and Berkov, the legalization of abortions not only helps to prevent out-of-wedlock births, but also helps reduce the incidence of pregnancy- related marriages.^2_/ Fifty percent of the women obtaining abortions in 1973 had one or more children at the time of the abortion.23/ *A study done by Bauman and Udry in the early 1970's found a higher percen- tage of unwanted pregnancies and births among blacks than among whites. This statistic was associated with blacks" lesser use of non-physician- administered contraceptive methods, greater non-use of contraception, higher failure rates with pills or IUD's and lower family size desired. The study was based on a 1969-1970 survey of low income, married or formerly married women in seventeen U.S. cities and comparable data from the 1965 and 1970 National Fertility Studies.20/ **Approximately seven percent of the abortions were reported with marital status unknown, and were distributed proportionately.
37 TABLE 5 Number of Legal Abortions and Abortion Rates by Race for Residents of New York City, California, and Maryland Locality Number of Abortions Abortion Rates White Non-White White Non-White New York City 39,700 35,400 31.7 71.8 (1971/72) California 85,780 17,356 21.9 51.2 (1971/72) Maryland 7,711 3,545 10.9 19.9 (1971) Sources: New York City - Christopher Tietze and Deborah Dawson. "Induced Abortion: A Factbook," Reports on Population/Family Planning, New York: The Population Counci1, December 1973, p. 11. California - June Sklar and Beth Berkov. "The Effects of Legal Abortion on Legitimate and Illegitimate Birth Rates: The California Experience," Studies in Family Planning, New York: The Population Counci1, 1973, p. 290. Maryland - Ira Rosenwaike and Robert J. Melton. "Legal Abortion and Fertility in Maryland, 1960-1971," Demography 11: 388-389, August 1974.
38 Legalization of Abortion and the Trend in Illegal Abortions Even though abortions were illegal in a majority of states before the Supreme Court decisions in January 1973, many women were able to obtain them. But illegal abortions are not reported to public health authorities and almost never to the police. Estimates of their numbers have to be based on occasional surveys and extrapolations from hospital admission and discharge data, which makes impossible a calculation of illegal abortion ratios or rates, or the development of trend data on the incidence. The most widely quoted figure on the number of illegal abortions comes from a committee established after a 1955 Arden House conference on abortion, sponsored by Planned Parenthood. The committee concluded that "a plausible estimate of the frequency of induced abortion in the United States could be as low as 200,000 and as high as 1,200,000 per year... [with] no objective basis for the selection of a particular figure between the two estimates as an approximation of the actual frequency. "2â¢4/ Another estimate by two authors was that in 1955 there were probably 699,000 illegally induced abortions and in 1967, 829,000 illegally induced abortions. These figures were based on randomized response estimates of induced abortion in women aged 15-44 in North Carolina, and then applied to the United States as a whole. The estimates are in the mid-range of the Arden House estimate cited above.25J Evidence provided in Chapters 3 and 4 show that the medical indicators of the frequency of illegal abortions, i.e. hospital admissions for incomplete or septic abortions and deaths from other-than-legal abortions, have declined significantly in locations with non-restrictive abortion practices. These data suggest that the number of illegal abortions has declined in recent years and that most women will choose a legal abortion over an illegal abortion when that choice is available. Tietze has calculated that 70 percent of the legal abortions obtained in New York City from July 1, 1970 to June 30, 1972 by resident women replaced illegal abortions which had previously taken place, and that the remainder was responsible for about one-half of the decline in live births that occurred between 1970 and 1972.26/ Other Demographic Effects of the Legalization of Abortion Although Tietze has argued that the predominant effect of the legaliza- tion of abortion has been a substitution of legal abortions for what other- wise would have been illegal abortions, he and other authors agree that there has been a demographic effect as wel1, namely that there has been a more rapid decline in the birth rate in states with non-restrictive abortion practices than in other states, and particularly in the rates of out-of- wedlock births.27/
39 Pakter and Nelson have shown that the continued rise in the number of out-of-wedlock births in New York City during the 196(Ts (from 16,412 in 1962 to 31,903 in 1970) was not reversed until 1971, the first full year of New York's non-restrictive abortion law. In that year, out-of-wedlock births declined by 12 percent to 28,099^28/ the first decrease since illegitimate births began to be recorded in 1954.J29_/ The authors conclude that "it was only after abortions became available that the number of out-of-wedlock births began to diminish. Two-thirds of the terminations of pregnancy for New York City residents were among the unmarried, and 90 percent of the teenagers undergoing abortions were unmarried."30/ Similar data have been reported from California, where the out-of- wedlock fertility rate fell 16 percent, from 27 to 22.6 per 1,000 unmarried women between 1970 and 1971, the first year that non-restrictive abortion practices were widely adopted. Again, this was the first decline since 1966 when records on legitimacy status began to be kept. Concomitant with this decline was an increase in the teenage abortion rate from 30.8 per 1,000 women aged 15-19 during July 1970-June 1971, to 41.2 per 1,000 in 1971-1972, an increase of 22.8 percent.3JV From a detailed analysis of the relation- ship between legal abortion and out-of-wedlock births in California since 1970, Sklar and Berkov have concluded that the availability of legal abortion was a significant factor in the decline in illegitimacy for California between 1970 and 1972.â¢32_/ A comparison of out-of-wedlock birthrates from 1965 to 1971 for the United States as a whole and for those states that had introduced less restrictive abortion legislation suggests that abortion may have had an immediate downward push on illegitimacy (Table 6). From 1965 to 1970, out-of-wedlock birthrates in all states had an annual average increase of approximately three percent. After 1970, however, when a dozen states had adopted moderately restrictive or non-restrictive legislation, out-of-wedlock birthrates declined 12 percent in states with liberalized abortion laws and only two percent in states with restrictive laws.33/ Although these data can be interpreted as showing some relationship between the legalization of abortion and a decline in out-of-wedlock births in the subsequent year, no conclusions can be drawn with respect to the long-term trend in out-of-wedlock births in an area with non-restrictive abortion legislation. In New York, the number of out-of-wedlock births reversed its two-year decline and increased in 1973 from 27,619 to 28,292.â¢34/ For the U.S. as a whole, the illegitimate birthrate increased in 1972 and then dropped slightly in 1973, but not to the low level achieved in 1971. Too many other factors affect the decision to bear a child, and particularly an out-of-wedlock child, to allow conclusions about the demographic effects of legal abortion.
40 TABLE 6 Estimated Out-of-Wedlock Birthrates for Women Aged 15 to 44 in States by Type of Abortion Legislation, United States, 1965-1973 Qut-of-Wedlock Births per 1.000 Unmarried Women Aged 15-44 Year 1965 1966 1967 1968 1969 1970 1971 1972 1973 All States 22, 22 22, 23.2 24. 25. 24. 24.9 24.5 ,1 ,7 ,2 States with Moderate and Non-restrictive Legislation a/ 23. 23. 24.4 25.0 25.9 27, 23. NA NA ,5 .7 .1 .7 States with Restrictive Legislation 21.5 21.4 21. 22. 23, 24.9 24.5 NA NA 1965-1970 +3.0 1970-1971 -5.8 1971-1972 -1-2.9 1972-1973 -1.7 Average Annual Percent Change +2.9 -12.4 +3.0 -1.9 a/ Includes the following states: Alaska, Arkansas, California, Colorado, Delaware, Hawaii, Kansas, Maryland, New Mexico, New York, North Carolina, Oregon, South Carolina, Virginia, and Washington. Source: June Sklar and Beth Berkov. "Teenage Family Formation in Postwar America," Family Planning Perspectives 6: 86, Spring 1974; and U.S. Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics. Monthly Vital Statistics Report, Summary Report, Final Natality Statistics, 1973, Vol. 23, No. 11, Supplement, January 30, 1975.
41 Another public health issue related to the legalization of abortion are the effects, if any, on the birthrates of women (e.g., teenagers) at high risk of bearing a child that is premature and of low birth weight. Infants with these characteristics have a greater risk of mortality than normal birth weight children.â¢35_/ Although it should be possible to prove an effect of increased frequency of teenage abortions on the total proportion of newborns weighing less than 2,500 grams, the data to analyze this issue are not now available to the study group. However, there are data on overall infant mortality rates for the United States and selected states with non-restrictive abortion practices during part of that period. If women at high risk of having a premature birth are obtaining abortions disproportionate to their representation in the population of women having children, there should be a greater decline in infant mortality rates in states with non-restrictive practices than for the remainder of the U.S. The data presented in Table 7 show that this difference is demonstrable. TABLE 7 Infant Mortality Rates for United States and Selected States: 1968-1972 (Deaths per 1,000 Live Births) Percent Decline 1970-1972 Area 1968 1969 1970 1971 1972 United States a/ 22.3 21.2 20.4 19.5 19.0 -6.9 California 19.0 18.3 17.2 16.4 15.6 -9.3 New York 0.9 21.2 19.4 18.3 17.6 -9.3 Washington 19.7 18.9 18.7 18.3 17.1 -8.6 a/ Excludes California, Kansas, New York, and Washington Source: U.S. Department of Health, Education, and Welfare, Public Health Service, National Center for Health Statistics. U.S. Vital Statistics. Vol. 1, Natality. 1968, 1969. Individual state statistics for 1970-1973 are unpublished.
42 Summary During 1972 and 1973 more than 1.2 million legal abortions obtained in the United States were reported to the Center for Disease Control. The three major methods of abortion used were suction, D&C and saline. About 83 percent of the abortions were performed in the first trimester with suction as the predominant method of termination. The majority of abortions during 1972 were obtained in New York, California, and the District of Columbia all of which had non-restrictive abortion practices which attracted a large number of out-of-state residents. Forty-four percent of the abortions obtained in 1972 were obtained outside of the home state of the patient. After the Supreme Court decisions on abortion in January 1973, legal abortions began to be distributed more evenly throughout the students. During 1973, one-third of the women obtaining abortions were less than 20 years of age, another third were between 20 and 25 years of age and the remaining third were over 25. Nearly 30 percent of the women were married; the rest were single, divorced, separated, or widowed. An examination by race shows that 73 percent of the women obtaining abortions were white and 27 percent were black or of other non- white origins, although in 1972 non-white women had legal abortion rates more than twice as great as those of white women. A national survey of abortion providers conducted by The Alan Guttmacher Institute in 1974 provides comprehensive data on the number of abortions performed in the U.S. during 1973 by State and type of provider. A total of 745,400 abortions were reported in the survey, 53 percent of those in physicians' offices. Many public hospitals did not provide any abortion services even though many low-income women rely on these instructions for most of their health care needs. A comparison of the 1972 and 1973 data on abortion supports the conclusion that nonrestrictive abortion practices lead to: 1) an increase in the number of reported legal abortions; 2) a decline in the number of women traveling outside their home state to obtain an abortion; and 3) a significantly greater use oflegal abortion by non-white women within their state of residence as compared to white women. Although there are no data on the trend in the number of illegal abortions, one study has shown that 70 percent of the abortions in New York City during 1970-1971 and 1971-1972~the first two years of New York's non-restrictive legislationâreplaced illegal abortions which would have been performed illegally, and that the remaining 30 percent accounted for
43 about one-half of the decline in births that occurred from 1970 to 1972, One aspect of birthrate trends is the number of out-of-wedlock births. In New York City and California legalization of abortion has been followed the next year by a decline in the number of these births, representing a reversal of previous upward trends in the number of children born out-of-wedlock in these areas. Similarly, legalization of abortion has not been shown to result in a dramatic reduction in infant mortality. However, no final conclusions on the causal relation- ship between non-restrictive abortion legislation and the trend in out-of-wedlock births or infant mortality rates can be drawn at this time.
44 REFERENCES 1. Committee on Fetus and Newborn, 1969-1971. Hospital Care of Newborn Infants, Evanston, Illinois: American Academy of Pediatrics, 1967, p. 19. 2. Family Planning Digest, 3, September, 1974. 3. "Menstrual Regulation - what is it?" Population Report, Series F., No. 2, Washington, D.C.: The George Washington University Medical Center, April 1973. 4. "Symposium: A Report on Prostaglandins for Abortion", Contemporary OB/GYNt 2, ; Lonnie S. Burnett, Anne Colston Wentz, and Theodore M. King. "Techniques of Pregnancy Termination," Part II, Obstetri- cal and Gynecological Survey, 29: 32, Janaury, 1974; and American College of Obstetrics & Gynecology, "Induction of Mid-Trimester Abortion with Prostaglandin F2," Technical Bulletin, 1974. 5. U.S. Department of Health, Education and Welfare, Public Health Service, Center for Disease Control, Abortion Surveillance: 1972, issued April 1974, Table 18; and Abortion Surveillance: 1973 (forthcoming). Abortions for which there were no data available on trimester or method of termination have been excluded from the percent distribution discussed in the text. 6. ASR, 1972, Table 15. 7. ASR, 1973, Table 15. 8. ASR, 1972, Table 15. 9. Edward Weinstock, Christopher Tietze, Frederick S. Jaffe, and Joy G. Dryfoos. "Legal Abortions in the United States Since the 1973 Supreme Court Decision," Family Planning Perspectives,7: 3, January/February, 1975. 10. ASR, 1972, Table 4. 11. Jack C. Smith, Ronald S. Kalian, and Winthrop A. Burr. "Abortions in the United States: Before and After the Supreme Court Decision," paper presented at Twelfth Annual Meeting, Association of Planned Parenthood Physicians, Memphis, Tennessee, April 1974. 12. Jean Pakter, Donna O'Hare, Frieda Nelson and Martin Svigir, "Two Years Experience in New York City with the Liberalized Abortion Law - Progress and Problems," American Journal of Public Health, Vol. 63, (June 1973), p. 526.
45 13. Weinstock, Tietze, Jaffe, and Dryfoos. pp. 29-31. 14. ASR, 1972, Table 2 and 1973, Table 2. 15. Pakter et^ al_., p. 529. 16. June Sklar and Beth Berkov. "Abortion, Illegitimacy, and the American Birth Rate," Science 185: 911, September 13, 1974. 17. Pakter et^ a^., p. 529. 18. Karl E. Bauman and J. Richard Udry. "The Difference in Unwaned Briths between Blacks and Whites," Demography, 10: 315-328, August 1973. 19. Ira Rosenwaike and Robert J. Melton. "Legal Abortion and Fertility in Maryland, 1960-1971," Demography 11: , August 1974. 20. James R. Abernathy, Bernard G. Greenberg and Daniel F. Horvitz. "Estimates of Induced Abortion in Urban North Carolina," Demography 7: 27, February 1970. 21. ASR, 1972, Table 10. 22. Sklar and Berkov, Science p. 914. 23. ASR, 1972, Table 13. 24. Mary Calderone, ed. Abortion in the United States New York: Hoeber- Harper Books, 1958, p. 180. 26. Christopher Tietze. "Two Years' Experience with a Liberal Abortion Law: Its Impact on Fertility Trends in New York City," Family Planning Perspectives 5: 39-41, Winter 1973. 27. Ibid., p. 39. 28. June Sklar and Beth Berkov. "Teenage Family Formation in Postwar America," Family Planning Perspectives 6: , Spring 1974; Sklar and Berkov, Science: 909-915; and Jean Pakter and Frieda Nelson. "Factors in the Unprecedented Decline in Infant Mortality in New York City," Bulletin of the New York Academy of Medicine 2nd series, July-August 1974. 29. Pakter and Nelson (1974), pp. 851-852, and Jean Pakter, Donna O'Hare, and Frieda Nelson. "Teen-age Pregnancies in New York City: Impact of Legalized Abortion," presented at the 102nd meeting of the American Public Health Association, New Orleans, October 23, 1974. Table 3.
46 30. Jean Pakter, Donna O'Hare, Frieda Nelson, and Martin Svigir. "A Review of Two Years' Experience in New York City with the Liberalized Abortion Law," The Abortion Experience: Psychological and Medical Impact, Howard Osofsky and Joy Osofsky, eds., Hagerstown, Md.: Harper and Row, 1974, pp. 65-66. 31. Pakter and Nelson, p. 852. 32. June Sklar and Beth Berkov. "The Effects of Legal Abortion on Legitimate and Illegitimate Birth Rates: The California Experience," Studies in Family Planning New York: The Population Counci1, 1973, pp. 284-285. 33. Sklar and Berkov. "Teen-age Family Formation". 34. Sklar and Berkov. "Teenage Family Formation," p. 86. 35. Pakter, CTHare and Nelson, "Teen-age Pregnancies," Table 3. 36. See Jean Pakter and Frieda Nelson, pp. 859-863, Infant Death: An Analysis by Maternal Risk and Health Care, Contrasts in Health Status 1: 72+81, Washington, D.C.: Institute of Medicine, 1973, pp. 72 & 81; and Helen C. Chase, ed. "A Study of Risks, Medical Care, and Infant Mortality," American Journal of Public Health 63: 35, Supplement, September 1973.
