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International Journal of Gynecology & Obstetrics 46 (1994) 173-179


Abortion and women’ reproductive health s
A. Rosenfield
Columbia School of Public Health and Department of Obstetrics and Gynecology, Columbia-Presbyterian 600 West 168th Street, New York, NY 10032, USA Medical Center,

(Received 25 February 1994; revision received 7 April 1994; accepted 7 April 1994


Abortion; Legality; Safety; Women’ health s

Introduction Nothing in the field of health care generates more controversy worldwide than does the issue of abortion. And, unfortunately, there is nothing to suggest that these controversies will decrease in the coming years. For those who believe that life begins at the time of fertilization or at the time of implantation, there is no middle ground: abortion for them equates with murder of the ‘ unborn child’ Similarly for those who believe that women . must have the ultimate right to decide about their bodies, there is no middle ground either: for them women must be able to decide whether or not to carry a pregnancy to term. Thus, there is every indication that the issue of abortion is one that will continue to be unresolvable at any time in the future. Where abortion is legal, there will be continued advocacy and pressure to make it illegal and vice versa. But the question is not really whether or not abortion should be legal or illegal, but whether or not it should be safe or unsafe [l]. In all societies, no matter the legal, moral or cultural status of abortion, there will be some women who desperately seek to terminate an unwanted pregnancy. And in almost all societies, it is the poor and the young who disproportionately suffer the

consequences of illegal abortion. Wealthier and better educated women usually will find the means to terminate a pregnancy more safely than will the poor. Kenneth Ryan, a distinguished Catholic American academician and Professor and Chairman Emeritus of the Department of Obstetrics and Gynecology at Harvard University, recently quoted a statement from a paper he wrote in 1967 [2] as follows:
‘ Even though a pregnancy may not be life threatening, it may be life-devastating enough to force women to desperately seek and obtain an abortion by any means possible, even at considerable risk to their life. Living with children in poverty, sustaining a pattern of futility of life, living with a hopelessly deformed or retarded child or bearing an illegitimate one without paternal support is a life situation many women will not accept. This is a medical and social fact. moral, legal and religious issues not withstanding...the reason the ethical debate about abortion is so intractable is because we lack a compelling analogy with other moral conflicts for which reasonable solutions have been devised. The fetus is in and of the pregnant woman. How can society force her to use her body against her will for purposes of gestation when there is no other, even close example of such a requirement for men or for women in other circumstances even to save a life.

It has been estimated that annually there are approximately 30 million legal abortions performed worldwide, with as many as 20 million more

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In 1973. Wade decision. while recently reaffirming the Roe v. 46 (1994) 173-179 carried out unsafely. Roe v. In contrast to the US. reached a number of decisions in the late 1980s and early 1990s that allowed increasing numbers of restrictions to be made by individual states that resulted in increasing the barriers to abortion services. Further. Interestingly. And yet in the 198Os. made abortion legal in the US in the first two trimesters of pregnancy. Gynecol. had laws making abortion illegal. even more strident and violent protests are likely. physicians led the effort to make abortion illegal. up to the time of viability of the fetus at approximately 24 weeks of gestation. Obstet. including death. the landmark Supreme Court case. in effect. with the fall of communism. along with the resultant democratic changes that occurred. And clearly the policies of the Reagan-Bush administrations were opposed to the legal status of abortion. Abortion in the developed world Perhaps nowhere has the issue been more clearly defined than in the United States (41. abortion is also legal in most of Western Europe. including the targeting of their families for verbal abuse and physical threats. major efforts were undertaken by a variety of advocates to make abortion illegal from the time of conception. all states in the U. Some have suggested that Japanese physicians have opposed the approval of oral contraceptives because of the lucrative nature of the provision of abortion services. who has taken a strong and clear pro-choice stance.abortion was made legal and available throughout the country. are very difficult to make since a majority of illegal abortions are successful and we have no way of accurately documenting the numbers. In Japan. with the result that by the turn of the century. Until the late 18OOs. As a result. usually clandestinely [3]. as well as of clinic staff. no single issue has generated more controversy in the US than abortion. A political party (the Right-to-Life Party) was formed with the sole aim of making abortion illegal and had significant influence during the 1980s in some states. In the last decades of the 19th century.S. With the election of President Clinton. The estimates of numbers of illegal abortions. Physicians have been a particular target for harassment. As a result. many may never be noted in local or national statistics. however. particularly those in large urban centers. a litmus test of suitability for appointment. abortion has been a major method of family planning. By the 1960% there was increasing advocacy to change the legal status of abortion and a few states had made abortion legally available by 1970. along with antiobscenity zealots. there has been increasingly strident harassment of patients attempting to enter clinic facilities. the candidate’ views about s abortion became. And even among those that result in serious complications. who considered abortion an evil crime. These opponents of abortion have become increasingly violent in their protests. illegal abortion complications became a major cause of emergency admission to the gynecology wards of most hospitals. J. Abortion was legalized in most of Eastern Europe and the former Soviet Union after the Second World War. In the 20 years since that decision. along with condom use. particularly since many women with abortion complications never reach any medical institution. In Poland. a liberal abortion policy has become one with many new restrictions.174 A. The case of Italy is interesting because Rome is the seat of the Pope and the administrative center for the Roman Catholic Church. The Supreme Court. Rosenfield/ Int. making access to abortion services much more difficult. abortion fell under British common law in which abortion was legal until the time of quickening (somewhere between the 17th and 20th week of pregnancy). Abortion services were heavily utilized in these countries particularly since contraceptives . however. Wade. The Catholic church was surprisingly quiet on this issue at that time [4]. where oral contraceptives were never approved. particularly for poor women and for adolescents. culminating in 1993 with the murder of a physician who provided abortion services in Florida. as well as in other socialist countries. the Catholic church has become increasingly powerful. Japan is one of the only countries in the world where abortion is so clearly considered a method of family planning for fairly routine use. In their appointment of judges to the federal Supreme Court and the federal appeals courts.

on the other hand. hospital statistics are not representative of the situation in the community or nation. maternal mortality in 1990 was estimated to have dropped to 83 deaths per 100 000 livebirths. the birth rate again began to decline. In a hospital-based study in a series of hospitals in Lagos. s Such occurrences are abhorrent and opposed by all concerned about women’ reproductive rights. by the end of the Ceausescu dictatorship in 1989. legalized abortion many years ago and services are widely available. Similarly. with a ratio estimated at 159 deaths per 100 000 livebirths. treated. the two largest countries in the world [3]. China. In Latin America. Nigeria. particularly in Africa and Latin America. Abortion in the developing world During the past two decades. In the early 197Os. both because contraceptives were obtained through the black market and because of access to illegal abortions. 87% secondary to abortion complications [6]. Fortney reports that septic abortion accounts for a disproportionate share of the . which had been legal and readily available. but also a subsequent increase in abortion-related morbidity and mortality. Kwast and her colleagues found a high maternal mortality rate (566 per 100 000 livebirths) and further noted that 54% of the direct obstetric deaths identified were due to complications of illegal abortion [lo]. The treatment of the complications of incomplete abortion are a heavy burden on the hospital-based health resources. Ethiopia. 46 (1994) 173-179 175 were difficult to obtain. The findings of the small number of community-based studies that have been conducted provide an insight into the problem of abortion-related deaths in a number of societies. for example. There have been unfortunate stories of cases of forced abortion as a component of China’ one child per family population policy. with continued high rates of morbidity and mortality. including China and India. but because of inadequate access to safe abortion services. Romania had the highest maternal mortality ratio in Europe. Complications of poorly performed illegal abortion are estimated to account for approximately 20% of all maternal deaths or a figure probably in excess of 100 000 deaths annually. As a dramatic demonstration of the effect of these changes. but does allow early first trimester ‘ menstrual regulation’ . Gynecol. Rosenfield/lnt. per se. For most of the rest of the developing world. a few developing countries have legalized abortion. the majority of abortions in the country still are carried out unsafely. But as a result of the governmental policies. s Bangladesh is an example of a country which has not formally legalized abortion. J.A. if at all.51% of maternal deaths were abortion related [l 11. between 40% (in many Latin American countries) to more than 80% of women (in sub-Saharan African and Indian sub-continent countries) live in underserved rural areas and many of the abortion complications that occur in these areas are poorly. the Romanian Government ruled that abortion. There are few community-based studies to document the extent of the problem and national data reporting systems are inadequate because vital registration systems are poorly developed and grossly underreport causes of death. The new government removed restrictions that existed up till then on contraception and legalized abortion. as long ago as 1977. In a large community survey in Addis Ababa. Eventually. Romania presents an example of the effect government policy can have on abortion [5]. Depending on the country. India presents an example of a country in which abortion is legal. or the region within a country. the vast majority of them in the developing world [8]. Another hospital-based study in Zimbabwe showed that 15% of all pregnancies known to the institution ended in incomplete or induced abortion [ 121. Obstet. was illegal. up to that time. Even less is known statistically about the resultant morbidity among women who survive an unsafe abortion procedure. which has been made fairly widely available. abortion is illegal and is the cause of significant morbidity and mortality. Maternal mortality is one of the major unresolved problems relating to the health of women in developing countries [7]. Coeytaux reported that abortionrelated deaths are a major cause of mortality in sub-Saharan Africa [9]. There was not only a resultant dramatic increase in the birth rate. The World Health Organization estimates that approximately 500 000 pregnancy-related deaths occur each year.

Gynecol. With abortion. Further a recent analysis of the incidence of induced abortion in Latin America suggests the rate is among the highest in the world. the issue of illegal abortion and its tragic high mortality must be given high profile attention. in the late 197Os. preventable with simple. even second trimester procedures are quite safe if the clinician performing the procedure is well-trained. in both India and South Africa. we have a highly effective treatment for those already pregnant and relatively . but neither the medical profession nor local political leaders seem willing to officially recognize the problem and. such as ACT-UP. with extensive media coverage. We thus have a situation in which there is a relatively simple solution to a major cause of mor- bidity and death of women. as well as total bed nights in the hospital [13]. comparable to rates seen in several East Europe and East Asia countries [14]. Peru and the Dominican Republic). Studies in Brazil suggest that there may be 1. they generally are not ready to implement a program to reduce this cause of mortality.2 per 100 women. there are no services available). and about their health and wellbeing. Rochat and colleagues. Since there is. large sums of funding for research and significant involvement of the medical. to a large extent. J. and found an estimated 207 induced abortions per 1000 livebirths and between 70 000 and 100 000 maternal deaths annually from abortion-related complications in the countries studied [ 181. termination procedures beyond about 10 weeks of gestation have been shown to carry a slightly increased risk of complication for every further week of gestation. year after year. with an abortion rate of between 2. with an untold number of deaths [17]. their demand is primarily for more research and for more effective preventive education and access to treatment services. public health and political leadership of countries and of international organizations. approximately 45% of all deaths caused by abortion were in high parity women (women who have had five or more term pregnancies) [ 15. Somehow. hold protest demonstrations at major medical and political meetings and generally serve as a significant prod to the US consciousness about AIDS. Despite this tragedy of essentially preventable deaths of pregnant women. as yet. Mexico. aged 15-44 [17]. at least it cannot be said that the disease is being ignored. Although. Rosenfield / ht. the topic of abortion is a taboo subject at a majority of local. as with the broader topic of maternal mortality. Thus. The annual international AIDS meeting is attended by thousands of researchers and advocates. national and regional meetings on this disease. there were an estimated 2. reviewed data from some 60 developing countries.3 and 5. Rarely in medical history have we been so willing to simply ignore an important cause of death.8 million unsafe abortions annually in six countries (Brazil. working with survey information. existing technology. Colombia. is among the safest (and probably easiest) of all surgical procedures [19]. And there are many additional local. While much more is needed to fight the most serious epidemic of modem times. the health of women often appears to be ignored when the cause of death is ‘ natural’ (pregnancy-related) or due to some illicit activity (abortion). poorly performed abortions result in the deaths of large numbers of women.176 A. no preventive vaccine and no effective treatment. Few developing countries even discuss the issue at major medical or political meetings. In the late 197Os. Obstet. What about abortion and its high mortality toll? There is little media coverage internationally. Women’ groups need the advocacy stridency s of the American AIDS advocacy groups. Chile.5 million or more illegal abortions performed annually in that country.161. carried out by trained personnel. it is clear that where abortion is illegal (or where even if legal. 46 (1994) 173-179 funds spent on transfusions and operating room costs. In a study of abortion in Latin America. Data from the United States clearly demonstrate that a first trimester abortion. except perhaps to discuss the justification of the continuation of its illegal status (or where abortion is legal to advocate for the return of an illegal status). The tragic AIDS epidemic receives a great deal of media attention. national and international meetings. which interrupt meetings. even if they do. and temporary and permanent morbidity in untold numbers of additional women. particularly one which is. For those concerned about the status of women.

a relatively small number of academic and clinical leaders in some countries have been outspoken about the problem. many women will have abortions no matter the legal or religious status. And certainly the need for termination of pregnancy would be diminished (but not eliminated) with widespread availability of contraceptive services. Thus a combination of readily accessible contraceptive services. Obstet. Gynecol. while only about 200 physicians attended a plenary session on maternal care and maternal mortality [7]. Further. At a FIG0 meeting about ten years ago. Introducing the costly and high technology procedure of in vitro fertilization in settings where basic maternity care is unavailable to the vast majority of the population is a highly inappropriate use of very limited resources. for that matter most physicians in general) have been trained to treat the problems that present in their office or hospital and generally have not been concerned about the antecedents to the problem or the ways to prevent the condition. Since. [7] the reasons are perhaps somewhat dif- ferent. prevention is of high priority. J. This was despite the fact that almost half of the physicians at the meeting were from developing countries where maternal mortality ratios are so high. by and large.I79 177 effective preventive approaches through the widespread use of contraception. and not on maintaining its illegal status. the reality is that the issue will remain probably the most emotionally charged and controversial topic within the field of health. only a very few academic leaders in the . although significant changes in local priorities to develop effective interventions are yet to come. Fortunately. While here too. as stated earlier. When abortion was illegal in this country. The issue of abortion in the US is perhaps instructive as other countries grapple with this most difficult of issues. at least as a tirst step. Rosenfield/ ht. This despite the fact that it has been suggested that the widespread distribution and availability of contraceptive services would do more to improve the health of women and their young children than any other single health intervention [20]. just making contraceptive services available to all women who state that they wish no further pregnancies might reduce pregnancy-related mortality by as much as 50% [21]. recent FIG0 meetings have given high priority to the topic. While it is true that even the basic issue of the extremely high rates of maternal mortality that exist in much of the developing world has also been ignored until recently. 46 (1994) 173. and management of a botched abortion does not require new technological advances. While there has been a significant amount of attention and funding directed towards international family planning programs. it simply requires putting in place an effective maternity care system [7]. the issue of abortion has been largely ignored. The prevention of pregnancies at too young or too old an age or too high a parity would significantly reduce the risk of maternal mortality and increased spacing between births decreases the risk of infant mortality. legalization of abortion and access to abortion services could come close to eradicating the deaths from poorly performed illegal or unsafe abortion procedures. Solving the problems of maternal mortality do not require new technologies or additional basic research. The role of tbe obstetrician The obstetrical community has. Most obstetrician-gynecologists (and. The issue of abortion raises a somewhat different set of issues in terms of its neglect by the medical community in general and by obstetriciangynecologists more specifically. But after ignoring the tragedy of maternal mortality for most of its history. as has been done in the US. At major international meetings of obstetrician-gynecologists.A. the controversial nature of abortion itself adds significantly to the unwillingness of most physicians to become embroiled in the issue. until quite recently. Rather. However. there were several thousand physicians in a packed auditorium to hear a lecture on in vitro fertilization. the issue should be focused on women’ health and the safety of the abortion pros cedure. not been willing to truly come to grips with this issue. in reducing the number of abortions through making contraceptive services widely available and accessible. in the past it has been primarily the result of demographic and environmental-related issues rather than concerns about the health of women. There simply is much greater interest in the technological solutions to problems than in finding ways to prevent them.

46 (1994) 173-l 79 field of Ob/Gyn were willing to take a stand on the issue. midwives and nurse practitioners) can be trained to provide the procedure. twenty years after abortion was legalized in the US. the liberal abortion policies of the past are being reconsidered and overturned in a few countries. s backed by a small number of clinicians. One may not elect to forego training in. and others. other personnel (such as general surgeons. Where abortion is illegal. the majority will not be advocates on the topic and. ‘ i Con\lusion The issue of abortion clearly presents an enormously complex moral and ethical dilemma. And yet. where it is illegal or where services are not readily available and/or personnel are not well trained. for example. moral and political factors. This clearly has had an impact on the Ob/Gyn community. primary care practitioners. abortion is among the safest of all surgical procedures and can save so many lives. one however taken up by very few residents. This is an extraordinary tragedy. women’ groups. were it to be a routine part of training. There is no other issue which so directly effects the health of individuals. where abortion is legal but services are greatly limited). and which is. The situation in the US is somewhat more complex than in other countries in which abortion is legal because of the strength of the opponents of abortion and the level of political activity involved.178 A. J. without much thought at all. abortion carries a high risk of complication and death. Of course. the local Ob/Gyn community has the moral and ethical responsibility to ensure that safe abortion services are readily available and that personnel are trained to provide the services safely and effectively. Where abortion is illegal. there would need to be the option not to receive training if one were strongly opposed to the procedure on religious or moral grounds. Today. Gynecol. complications of a botched abortion are estimated to result in the deaths of more than 100 000 women each year. In countries where abortion is legal. But there are similar problems in many other countries. with increasing support by anti-abortion advocacy groups from the US. The health data are very clear. at the same time. The extremely controversial nature of abortion will not change. so affected by a web of religious. as those physicians who were motivated to provide abortion services because of their exposure to the tragedies seen when abortion was illegal in the US are retiring or dying. In the Eastern European countries. there are increasing pressures being brought to bear to maintain that status. given the strength of feeling among those opposed to abortion and those who support a woman’ right to s terminate an unwanted pregnancy. Only a very small percentage of American Ob/Gyn residency programs include abortion training as a routine component of the residency program [23]. at least for first trimester terminations. Increasingly. and yet training in the technical procedure is optional. Thus abortion is the only common surgical procedure in which obstetrician-gynecologists are the primary provider of care. a majority of obstetricians believe that a woman should have the right to terminate an unwanted pregnancy. Rosenfield / Int. where there is ready access to services and where personnel are well trained in the techniques. but at the same time. The leaders for change in the legal status came primarily from other groups. On the other hand. In these countries also. such as Planned Parenthood. Most make it available as an optional activity. if indeed obstetricians have the health and well-being of women as . their place is not being taken by younger physicians. since these are preventable deaths with existing technologies. it would be unheard of. Where abortion is legal. In those developing countries where abortion is illegal (and in India. training in the techniques of pregnancy termination has been and continues to be essentially neglected. Where there are shortages of obstetriciangynecologists. as Communism was overthrown and the influence of the Catholic Church returned. vaginal hysterectomy. Obstet. although all residents in this field need training in the management of a botched abortion. The issue is an extremely volatile one in Ireland. more importantly most do not wish to perform abortion procedures [22]. these forces will have an impact on obstetrician-gynecologists and their involvement in the provision of abortion services and as advocates in this area for the health of women.

14 Ryan K: Abortion or motherhood. 141 Kunins H. 1993. [31 Henshaw SK: Induced abortion: A world review. Science 215: 1586. 1990. Nairobi. [I81 Rochat RW. . Howell C: Induced abortion and health problems in developing countries. Ethiopia. 1986. References health. Kenya. WI Crowther C. PI Maine D. 1977. Gynecol.A. I51 Wright NH: Restricting legal abortion: Some maternal and child health effects in Romania. Stud Fam Plann 19: 186. Stud Fam Plann 22: 231. 191 Coeytaux F: Induced abortion in sub-Saharan Africa: What we do and do not know. Am J Obstet Gynecol 169: 128. They should join forces with those women’ groups advocating change and assist s them in their mission. Wolf M: Reproductive health in Romania: Reversing the Ceausescu legacy. Cent Afr J Med 31: 67. 1990. Marks F. Obstet. New York. Rosenfield A: Abortion: A legal and public health perspective. Kidane-Mariam W: Maternal s 111Rosenfield A: Women’ reproductive mortality in Addis Ababa. sterilization and abortion. 1989. 181 World Health Organization: Maternal mortality rates: A tabulation of available information. 1161 Lahiri D. 1984 (unpublished). 1985. Rochat RW. 1986. Parker JR: Maternal mortality: A survey of 118 maternal deaths and the avoidable factors involved. suicide and madness. 1231 Westhoff C. Kramer D. Geneva. [131 Fortney JA: The use of hospital resources to treat incomplete abortions: Examples from Latin America. Am J Obstet Gynecol 121: 246. Konar M: Abortion hazards. J Am Med Assoc 262: 376. Nigeria Med J 7: 465. 1990. Rosenfield A: Residency training in contraception. Lw Who will provide abortions: Insuring the availability of qualified practitioners (Recommendations from a national symposium). they have the further responsibility to help educate the public about the serious complications of unsafe abortion procedures and they should work with the political forces of the country to begin the difficult political process of changing the legal status of abortion in their country. Buenos Aires. 1994. Lancet 2: 83. Alan Guttmacher Institute. 1191 Cates W: Legal abortion: The public health record. IlO1 Kwast BE. Background paper for the Conference on Safe Motherhood. 1985. 1990. 1975.3. J Indian Med Assoc 66: 288. New York. 171 Rosenfield A: Maternal mortality in developing countries: An ongoing but neglected “epidemic”. 1980. David HP. Verkuyl D: Characteristics of patients attending Harare Hospital with incomplete abortion. [Ill Akingba JB: Abortion. FHE/86. Lancet 2: 484. Donnay F. Senanayake P. Fam Plann Perspect 22: 76. at a minimum. Atkin LC: The role of induced abortion in the fertility transition of Latin America. 1991. Rosenfield A. Public Health Rep 96: 574. 1977. 161 Hord C. Wallace M: Prevention of maternal deaths in developing countries: How much could family planning help. 1590. then they must ensure.a neglected tragedy. Annu Rev Pub1 Health 12: 361. iI71 Alan Guttmacher Institute Unsafe Abortion or Unwanted Birth: Cruel Choices for the Women of Latin America. 1988. 1992. National Abortion Federation. Am J Obstet Gynecol 166: 1029. Presented at IUSSP/CELADE/CENEP Seminar on the Fertility Transition in Latin America. 1976. 1151 Barford DA. J. Rosenfield/Int. WHO. Stud Fam Plann 17: 288. 46 (1994) 173-179 119 their primary mission. 1991. I141 Frejka T. April 3. 1993. S Afr Med J 51: 501. that readily accessible services are available to treat the complications of a botched abortion in the opinion of the author. Obstet Gynecol 81: 311. PO1 Rosenfield A. maternity and other health problems in Nigeria. 1981. Maine D: Maternity mortality .

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