6-Y &

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

lc8

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

Keywords:

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

0020-729Y94/$07.00 0 1994 International Federation of Gynecology and Obstetrics SSDI 0020-7292(94)02114-E

174

A. Rosenfield/

Int. J. Gynecol. Obstet. 46 (1994) 173-179

carried out unsafely, usually clandestinely [3]. The estimates of numbers of illegal abortions, however, are very difficult to make since a majority of illegal abortions are successful and we have no way of accurately documenting the numbers. And even among those that result in serious complications, including death, many may never be noted in local or national statistics, particularly since many women with abortion complications never reach any medical institution. Abortion in the developed world Perhaps nowhere has the issue been more clearly defined than in the United States (41. Until the late 18OOs, 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). In the last decades of the 19th century, however, major efforts were undertaken by a variety of advocates to make abortion illegal from the time of conception, with the result that by the turn of the century, all states in the U.S. had laws making abortion illegal. Interestingly, physicians led the effort to make abortion illegal, along with antiobscenity zealots, who considered abortion an evil crime. The Catholic church was surprisingly quiet on this issue at that time [4]. As a result, illegal abortion complications became a major cause of emergency admission to the gynecology wards of most hospitals, particularly those in large urban centers. 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. In 1973, the landmark Supreme Court case, Roe v. Wade, made abortion legal in the US in the first two trimesters of pregnancy, up to the time of viability of the fetus at approximately 24 weeks of gestation. In the 20 years since that decision, 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. And clearly the policies of the Reagan-Bush administrations were opposed to the legal status of abortion. In their appointment of judges to the federal Supreme Court and the federal appeals courts, the candidate views about s

abortion became, in effect, a litmus test of suitability for appointment. The Supreme Court, while recently reaffirming the Roe v. Wade decision, 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, particularly for poor women and for adolescents. Further, there has been increasingly strident harassment of patients attempting to enter clinic facilities, as well as of clinic staff. Physicians have been a particular target for harassment, including the targeting of their families for verbal abuse and physical threats. These opponents of abortion have become increasingly violent in their protests, culminating in 1993 with the murder of a physician who provided abortion services in Florida. With the election of President Clinton, who has taken a strong and clear pro-choice stance, even more strident and violent protests are likely. In contrast to the US, abortion is also legal in most of Western Europe. The case of Italy is interesting because Rome is the seat of the Pope and the administrative center for the Roman Catholic Church. And yet in the 198Os,abortion was made legal and available throughout the country. In Poland, with the fall of communism, along with the resultant democratic changes that occurred, the Catholic church has become increasingly powerful. As a result, a liberal abortion policy has become one with many new restrictions, making access to abortion services much more difficult. In Japan, where oral contraceptives were never approved, abortion has been a major method of family planning, along with condom use. 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. Some have suggested that Japanese physicians have opposed the approval of oral contraceptives because of the lucrative nature of the provision of abortion services. Abortion was legalized in most of Eastern Europe and the former Soviet Union after the Second World War, as well as in other socialist countries. Abortion services were heavily utilized in these countries particularly since contraceptives

A. Rosenfield/lnt.

J. Gynecol. Obstet. 46 (1994) 173-179

175

were difficult to obtain. Romania presents an example of the effect government policy can have on abortion [5]. In the early 197Os, the Romanian Government ruled that abortion, which had been legal and readily available, up to that time, was illegal. There was not only a resultant dramatic increase in the birth rate, but also a subsequent increase in abortion-related morbidity and mortality. Eventually, the birth rate again began to decline, both because contraceptives were obtained through the black market and because of access to illegal abortions. But as a result of the governmental policies, by the end of the Ceausescu dictatorship in 1989, Romania had the highest maternal mortality ratio in Europe, with a ratio estimated at 159 deaths per 100 000 livebirths, 87% secondary to abortion complications [6]. The new government removed restrictions that existed up till then on contraception and legalized abortion. As a dramatic demonstration of the effect of these changes, maternal mortality in 1990 was estimated to have dropped to 83 deaths per 100 000 livebirths.
Abortion in the developing world

During the past two decades, a few developing countries have legalized abortion, including China and India, the two largest countries in the world [3]. India presents an example of a country in which abortion is legal, but because of inadequate access to safe abortion services, the majority of abortions in the country still are carried out unsafely, with continued high rates of morbidity and mortality. China, on the other hand, legalized abortion many years ago and services are widely available. There have been unfortunate stories of cases of forced abortion as a component of China one child per family population policy. s Such occurrences are abhorrent and opposed by all concerned about women reproductive rights. s Bangladesh is an example of a country which has not formally legalized abortion, per se, but does allow early first trimester menstrual regulation . which has been made fairly widely available. For most of the rest of the developing world, particularly in Africa and Latin America, 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]. The World Health Organization estimates that approximately 500 000 pregnancy-related deaths occur each year, the vast majority of them in the developing world [8]. 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. Depending on the country, or the region within a country, 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, if at all, treated. Coeytaux reported that abortionrelated deaths are a major cause of mortality in sub-Saharan Africa [9]. The treatment of the complications of incomplete abortion are a heavy burden on the hospital-based health resources. 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. Even less is known statistically about the resultant morbidity among women who survive an unsafe abortion procedure. Similarly, hospital statistics are not representative of the situation in the community or nation. 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. In a large community survey in Addis Ababa, Ethiopia, for example, 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]. In a hospital-based study in a series of hospitals in Lagos, Nigeria, as long ago as 1977,51% of maternal deaths were abortion related [l 11. Another hospital-based study in Zimbabwe showed that 15% of all pregnancies known to the institution ended in incomplete or induced abortion [ 121. In Latin America, Fortney reports that septic abortion accounts for a disproportionate share of the

176

A. Rosenfield / ht. J. Gynecol. Obstet. 46 (1994) 173-179

funds spent on transfusions and operating room costs, as well as total bed nights in the hospital [13]. Further a recent analysis of the incidence of induced abortion in Latin America suggests the rate is among the highest in the world, comparable to rates seen in several East Europe and East Asia countries [14]. In the late 197Os, in both India and South Africa, approximately 45% of all deaths caused by abortion were in high parity women (women who have had five or more term pregnancies) [ 15,161. Studies in Brazil suggest that there may be 1.5 million or more illegal abortions performed annually in that country, with an untold number of deaths [17]. Rochat and colleagues, in the late 197Os, reviewed data from some 60 developing countries, working with survey information, 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. In a study of abortion in Latin America, there were an estimated 2.8 million unsafe abortions annually in six countries (Brazil, Colombia, Chile, Mexico, Peru and the Dominican Republic), with an abortion rate of between 2.3 and 5.2 per 100 women, aged 15-44 [17]. Thus, it is clear that where abortion is illegal (or where even if legal, there are no services available), poorly performed abortions result in the deaths of large numbers of women, and temporary and permanent morbidity in untold numbers of additional women. Despite this tragedy of essentially preventable deaths of pregnant women, year after year, the topic of abortion is a taboo subject at a majority of local, national and international meetings. Data from the United States clearly demonstrate that a first trimester abortion, carried out by trained personnel, is among the safest (and probably easiest) of all surgical procedures [19]. Although, 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, even second trimester procedures are quite safe if the clinician performing the procedure is well-trained. We thus have a situation in which there is a relatively simple solution to a major cause of mor-

bidity and death of women, but neither the medical profession nor local political leaders seem willing to officially recognize the problem and, even if they do, they generally are not ready to implement a program to reduce this cause of mortality. Rarely in medical history have we been so willing to simply ignore an important cause of death, particularly one which is, to a large extent, preventable with simple, existing technology. The tragic AIDS epidemic receives a great deal of media attention, large sums of funding for research and significant involvement of the medical, public health and political leadership of countries and of international organizations. While much more is needed to fight the most serious epidemic of modem times, at least it cannot be said that the disease is being ignored. The annual international AIDS meeting is attended by thousands of researchers and advocates, with extensive media coverage. And there are many additional local, national and regional meetings on this disease. What about abortion and its high mortality toll? There is little media coverage internationally. Few developing countries even discuss the issue at major medical or political meetings, 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). Somehow, as with the broader topic of maternal mortality, 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). For those concerned about the status of women, and about their health and wellbeing, the issue of illegal abortion and its tragic high mortality must be given high profile attention. Women groups need the advocacy stridency s of the American AIDS advocacy groups, such as ACT-UP, which interrupt meetings, hold protest demonstrations at major medical and political meetings and generally serve as a significant prod to the US consciousness about AIDS. Since there is, as yet, no preventive vaccine and no effective treatment, their demand is primarily for more research and for more effective preventive education and access to treatment services. With abortion, we have a highly effective treatment for those already pregnant and relatively

A. Rosenfield/ ht. J. Gynecol. Obstet. 46 (1994) 173- I79

177

effective preventive approaches through the widespread use of contraception. While there has been a significant amount of attention and funding directed towards international family planning programs, in the past it has been primarily the result of demographic and environmental-related issues rather than concerns about the health of women. 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]. 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. Further, 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]. 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, legalization of abortion and access to abortion services could come close to eradicating the deaths from poorly performed illegal or unsafe abortion procedures, as has been done in the US. Since, as stated earlier, many women will have abortions no matter the legal or religious status, the issue should be focused on women health and the safety of the abortion pros cedure, and not on maintaining its illegal status. However, the reality is that the issue will remain probably the most emotionally charged and controversial topic within the field of health. The role of tbe obstetrician The obstetrical community has, by and large, not been willing to truly come to grips with this issue. At major international meetings of obstetrician-gynecologists, until quite recently, the issue of abortion has been largely ignored. 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, [7] the reasons are perhaps somewhat dif-

ferent. Most obstetrician-gynecologists (and, 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. There simply is much greater interest in the technological solutions to problems than in finding ways to prevent them. At a FIG0 meeting about ten years ago, there were several thousand physicians in a packed auditorium to hear a lecture on in vitro fertilization, while only about 200 physicians attended a plenary session on maternal care and maternal mortality [7]. 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. 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. But after ignoring the tragedy of maternal mortality for most of its history, recent FIG0 meetings have given high priority to the topic, although significant changes in local priorities to develop effective interventions are yet to come. Solving the problems of maternal mortality do not require new technologies or additional basic research. Rather, at least as a tirst step, it simply requires putting in place an effective maternity care system [7]. 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. While here too, prevention is of high priority, in reducing the number of abortions through making contraceptive services widely available and accessible, and management of a botched abortion does not require new technological advances, the controversial nature of abortion itself adds significantly to the unwillingness of most physicians to become embroiled in the issue. Fortunately, a relatively small number of academic and clinical leaders in some countries have been outspoken about the problem. The issue of abortion in the US is perhaps instructive as other countries grapple with this most difficult of issues. When abortion was illegal in this country, only a very few academic leaders in the

178

A. Rosenfield / Int. J. Gynecol. Obstet. 46 (1994) 173-l 79

field of Ob/Gyn were willing to take a stand on the issue. The leaders for change in the legal status came primarily from other groups, such as Planned Parenthood, women groups, and others, s backed by a small number of clinicians. Today, twenty years after abortion was legalized in the US, a majority of obstetricians believe that a woman should have the right to terminate an unwanted pregnancy, but at the same time, the majority will not be advocates on the topic and, more importantly most do not wish to perform abortion procedures [22]. Increasingly, 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, their place is not being taken by younger physicians. Only a very small percentage of American Ob/Gyn residency programs include abortion training as a routine component of the residency program [23]. Most make it available as an optional activity, one however taken up by very few residents. Thus abortion is the only common surgical procedure in which obstetrician-gynecologists are the primary provider of care, and yet training in the technical procedure is optional. One may not elect to forego training in, for example, vaginal hysterectomy; it would be unheard of. And yet, without much thought at all, training in the techniques of pregnancy termination has been and continues to be essentially neglected. Of course, were it to be a routine part of training, there would need to be the option not to receive training if one were strongly opposed to the procedure on religious or moral grounds, although all residents in this field need training in the management of a botched abortion. 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. This clearly has had an impact on the Ob/Gyn community. But there are similar problems in many other countries. In the Eastern European countries, as Communism was overthrown and the influence of the Catholic Church returned, the liberal abortion policies of the past are being reconsidered and overturned in a few countries. The issue is an extremely volatile one in Ireland.

Where abortion is illegal, there are increasing pressures being brought to bear to maintain that status, with increasing support by anti-abortion advocacy groups from the US. In these countries also, 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.
i

Con\lusion

The issue of abortion clearly presents an enormously complex moral and ethical dilemma. There is no other issue which so directly effects the health of individuals, and which is, at the same time, so affected by a web of religious, moral and political factors. The health data are very clear. Where abortion is legal, where there is ready access to services and where personnel are well trained in the techniques, abortion is among the safest of all surgical procedures and can save so many lives. On the other hand, where it is illegal or where services are not readily available and/or personnel are not well trained, abortion carries a high risk of complication and death. The extremely controversial nature of abortion will not change, given the strength of feeling among those opposed to abortion and those who support a woman right to s terminate an unwanted pregnancy. In those developing countries where abortion is illegal (and in India, where abortion is legal but services are greatly limited), complications of a botched abortion are estimated to result in the deaths of more than 100 000 women each year. This is an extraordinary tragedy, since these are preventable deaths with existing technologies. In countries where abortion is legal, 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 there are shortages of obstetriciangynecologists, other personnel (such as general surgeons, primary care practitioners, midwives and nurse practitioners) can be trained to provide the procedure, at least for first trimester terminations. Where abortion is illegal, if indeed obstetricians have the health and well-being of women as

A. Rosenfield/Int. J. Gynecol. Obstet. 46 (1994) 173-179

119

their primary mission, then they must ensure, at a minimum, that readily accessible services are available to treat the complications of a botched abortion in the opinion of the author, 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. They should join forces with those women groups advocating change and assist s them in their mission. References
health. Am J Obstet Gynecol 169: 128, 1993. 14 Ryan K: Abortion or motherhood, suicide and madness. Am J Obstet Gynecol 166: 1029, 1992. [31 Henshaw SK: Induced abortion: A world review, 1990. Fam Plann Perspect 22: 76, 1990. 141 Kunins H, Rosenfield A: Abortion: A legal and public health perspective. Annu Rev Pub1 Health 12: 361, 1991. I51 Wright NH: Restricting legal abortion: Some maternal and child health effects in Romania. Am J Obstet Gynecol 121: 246, 1975. 161 Hord C, David HP, Donnay F, Wolf M: Reproductive health in Romania: Reversing the Ceausescu legacy. Stud Fam Plann 22: 231, 1991. 171 Rosenfield A: Maternal mortality in developing countries: An ongoing but neglected epidemic. J Am Med Assoc 262: 376, 1989. 181 World Health Organization: Maternal mortality rates: A tabulation of available information. FHE/86.3, 1986, WHO, Geneva. 191 Coeytaux F: Induced abortion in sub-Saharan Africa: What we do and do not know. Stud Fam Plann 19: 186, 1988. IlO1 Kwast BE, Rochat RW, Kidane-Mariam W: Maternal s 111Rosenfield A: Women reproductive

mortality in Addis Ababa, Ethiopia. Stud Fam Plann 17: 288, 1986. [Ill Akingba JB: Abortion, maternity and other health problems in Nigeria. Nigeria Med J 7: 465, 1977. WI Crowther C, Verkuyl D: Characteristics of patients attending Harare Hospital with incomplete abortion. Cent Afr J Med 31: 67, 1985. [131 Fortney JA: The use of hospital resources to treat incomplete abortions: Examples from Latin America. Public Health Rep 96: 574, 1981. I141 Frejka T, Atkin LC: The role of induced abortion in the fertility transition of Latin America. Presented at IUSSP/CELADE/CENEP Seminar on the Fertility Transition in Latin America, Buenos Aires, April 3, 1990. 1151 Barford DA, Parker JR: Maternal mortality: A survey of 118 maternal deaths and the avoidable factors involved. S Afr Med J 51: 501, 1977. 1161 Lahiri D, Konar M: Abortion hazards. J Indian Med Assoc 66: 288, 1976. iI71 Alan Guttmacher Institute Unsafe Abortion or Unwanted Birth: Cruel Choices for the Women of Latin America, 1994, Alan Guttmacher Institute, New York. [I81 Rochat RW, Kramer D, Senanayake P, Howell C: Induced abortion and health problems in developing countries. Lancet 2: 484, 1980. 1191 Cates W: Legal abortion: The public health record. Science 215: 1586, 1590. PO1 Rosenfield A, Maine D: Maternity mortality - a neglected tragedy. Lancet 2: 83, 1985. PI Maine D, Rosenfield A, Wallace M: Prevention of maternal deaths in developing countries: How much could family planning help. Background paper for the Conference on Safe Motherhood, Nairobi, Kenya, 1984 (unpublished). Lw Who will provide abortions: Insuring the availability of qualified practitioners (Recommendations from a national symposium), National Abortion Federation, New York, 1990. 1231 Westhoff C, Marks F, Rosenfield A: Residency training in contraception, sterilization and abortion. Obstet Gynecol 81: 311, 1993.