Abortion and women’s reproductive health

8/6/2019 Abortion and womens reproductive health

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6 - Y& lc8International Journal of Gynecology & Obstetrics 46 (1994 ) 173-1 79

Abortion and wom ens reproductive healthA. Rosenfield

Columbia School of Public Health and Department of Obstetrics and Gynecology, Columbia-Presbyterian Medical Center,600 West 168th Street, New York, NY 10032, USA

(Received 2 5 February 1994 ; revision received 7 April 1994 ; accepted 7 April 199 4

Keywords: Abortion; Legality; Safety; Womens health

IntroductionNoth ing in the field of health care generates

more controversy worldwide than does the issue ofabortion. An d, unfortunately, there is nothing tosugge st that these controversies will decrease in thecoming years. For those who believe that lifebegins at the time of fertilization or at the time ofimplantation, there is no middle ground: abortionfor them equates with murder of the unbornchild. Similarly for those who believe that womenmust have the ultimate right to decide about theirbodies, there is no midd le groun d either: for themwomen must be able to decide whether or not tocarry a pregnancy to term. T hus, there is every in-dication that the issue of abortion is one that willcontinue to be unresolvable at any time in the fu-ture. Where abortion is legal, there will be con-tinued advocacy and pressure to make it illegaland vice versa.But the question is not really whethe r or notabortion should be legal or illegal, but whether ornot it should be safe or unsafe [l]. In all societies,no matter the legal, moral or cultural status ofabortion, there will be some women w hodesperately seek to terminate an unwanted preg-nancy. And in almost all societies, it is the poorand the young who disproportionately suffer the

consequences of illegal abortion. Wealthier andbetter educated women usually will find the meansto terminate a pregnancy more safely than w ill thepoor.

Kenneth Ryan, a distinguished Catholic Am eri-can academician and Professor and ChairmanEmeritus of the Department of Obstetrics andGynecology at Harva rd Unive rsity, recentlyquoted a statement from a paper he wrote in 1967[2] as follows:

Even though a pregnancy m ay not be life threatening, itmay be life-devastating enough to force women todesperately seek and obtain an abortion by any means pos-sible, even at considerable risk to their life. Living withchildren in poverty, sustaining a pattern of futility of life,living with a hopelessly deformed or retarded child or bear-ing an illegitimate one w ithout paternal support is a life sit-uation many women will not accept. This is a medical andsocial fact. moral, legal and religious issues not withstand-ing...the reason the ethical debate ab out abortion is so in-tractable is because we lack a compelling analogy with othermoral conflicts for which reasonable solutions have beendevised. The fetus is in and of the pregnant woman. Howcan society force her to use her body against her will forpurposes of gestation when there is no other, even close ex-ample of such a requirement for men or for women in othercircumstances even to save a life.

It has been estimated that annually there areapproximately 30 million legal abortions perform-ed worldwide, with a s many as 20 million m ore0020 -729Y 94/$0 7.00 0 199 4 International Federation of Gynecology and ObstetricsSSDI 0020-7292(94)02114-E


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carried ou t unsafely, usua lly clandestinely [3]. Theestimates of numbers of illegal abortions, however,are very difficult to make since a majority of illegalabortions are successful and w e have no way of ac-curately docum enting the numbers. And evenamong those that result in serious complications,including death, many may never be noted in localor nationa l statistics , particularly since manywomen with abortion complications never reachany medical institution.Abortion in the developed world

Perhaps nowhere has the issue been more clearlydefined than in the United States (41. Until the late18OO s, bortion fell under British common law inwhich abortion was legal until the time of quicken-ing (somewhere between the 17th and 20th week ofpregnancy ). In the last decade s of the 19th century,howev er, major efforts were undertak en by a vari-ety of advocate s to ma ke abortion illegal from thetime of conception, with the result that by the turnof the century, all states in the U.S. had laws mak-ing abortion illegal. Interestingly, physician s ledthe effort to mak e abortion illegal, along with anti-obscenity zealots, who considered abortion an evilcrime. The Catholic church w as surprisingly quieton this issue at that time [4].As a result, illegal abortion complicationsbecame a major cause of emergency admission tothe gynecology wards of most hospitals, par-ticularly those in large urban centers. By the 1960%there was increasing advocacy to change the legalstatus of abortion and a few states had m ade abor-tion legally available by 1970. In 1973, the land-mark Suprem e Court case, Roe v. Wade, m adeabortion legal in the U S in the first two trimestersof pregnancy , up to the time of viability of thefetus at approximately 24 weeks of gestation. Inthe 20 years since that decision, no single issue hasgenerated m ore controversy in the US than abor-tion. A political party (the Right-to-Life Party)was formed with the sole aim of making abortionillegal and had significant influence during the1980 s in some state s. A nd clearly the policies of theReagan-Bush administrations were opposed to thelegal status of abortion. In their appointment ofjudges to the federal Supreme Court and thefederal appeals courts, the candidates views about

abortion becam e, in effect, a litmu s test ofsuitability for appointment.The Suprem e Court, while recently reaffirmingthe Roe v. Wad e decision, reached a number ofdecisions in the late 1980s and early 1990s thatallowe d increasing num bers of restrictions to bemade by individual states that resulted in increas-ing the barriers to abortion services, particularlyfor poor wom en and for adolescents. Further,there has been increasingly strident harassment ofpatients attem pting to enter clinic facilities, as wellas of clinic staff. Physicians have been a particulartarget for harassment, including the targeting oftheir families for verbal abuse and physical threats.These opponents of abortion have become increas-ingly violent in their protests, culminating in 1993with the murder of a physician who provided abor-tion services in Florida. W ith the election of Presi-dent Clinton, who has taken a strong and clearpro-choice stance, even more strident and violentprotests are likely.In contrast to the US, abortion is also legal inmo st of W estern Europe. The case of Italy is in-teresting because Rome is the seat of the Pope andthe administrative center for the Rom an CatholicChurch. And yet in the 19 8Os, abortion was madelegal and available throughout the country. InPoland, with the fall of comm unism, along withthe resultant dem ocratic changes that occurred,the Catholic church has become increasinglypowe rful. A s a result, a liberal abortion policy hasbecome one with many new restrictions, makingaccess to abortion services muc h more difficult. InJapan, w here oral contraceptives were never ap-proved, abortion has been a major m ethod offamily planning, along with condom use. Japan isone of the only countries in the world w here abor-tion is so clearly considered a metho d of familyplanning for fairly routine use. Some have sug-gested that Japanese physicians have opposed theapprova l of oral contraceptives because of thelucrative nature of the provision of abortionservices.Abortion was legalized in most of EasternEurope and the former Soviet Union after theSecond World War, as well as in other socialistcountries. Abo rtion services were heavily utilizedin these countries particularly since contraceptives


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were difficult to obtain. Roma nia presents an ex-am ple of the effect government policy can have onabortion [5]. In the early 197Os, the Rom anianGovernment ruled that abortion, which had beenlegal and readily available, up to that time, was il-legal. There w as not only a resultant dramaticincrease in the birth rate, but also a subsequentincrease in abortion-related morbidity and mortal-ity. Eventually, the birth rate again beg an todecline, both because contraceptives were obtain-ed through the black market and because of accessto illegal abortions. But as a result of the govern-mental policies, by the end of the Ceausescu dic-tatorship in 1989, Rom ania had the highestmaternal mortality ratio in Europe, with a ratioestimated at 159 deaths per 100 000 livebirths, 87%secondary to abortion complications [6]. The newgovernment removed restrictions that existed uptill then on contraception and legalized abortion.As a dram atic dem onstration of the effect of thesechanges, maternal mortality in 1990 was estimatedto have dropped to 83 deaths per 100 000livebirths.Abortion in the developing world

During the past two decades, a few developingcountries have legalized abortion, including Chinaand India, the two largest countries in the world[3]. India presents an example of a country inwhich abortion is legal, but because of inadequateaccess to safe abortion services, the majority ofabortions in the country still are carried out un-safely, with continued high rates of morbidity andmortality. China, on the other hand, legalizedabortion many years ago and services are widelyavailable . There have been unfortunate stories ofcases of forced abo rtion as a comp onent ofChin as one child per family population policy.Such occurrences are abhorrent and opposed byall concerned about wom ens reproductive rights.Bangladesh is an example of a country which hasnot formally legalized abortion, per se, but doesallow early first trimester menstrual regulation.which has been made fairly widely available. Formost of the rest of the developing world , pa r-ticularly in Africa and Latin A merica, abortion isillegal and is the cause of significant morbidity andmortality.

Maternal mortality is one of the major unresolv-ed problems relating to the health of women indeveloping countries [7]. The World H ealth O rga-nization estimates that approximately 500 000pregnancy -related death s occur each year, the vastmajority of them in the developing world [8].Com plications of poorly performed illegal abor-tion are estimated to account for approximately20% of all mate rnal deaths or a figure probably inexcess of 100 000 deaths annually. Depending onthe country, or the region within a country, be-tween 40% (in many Latin Am erican countries) tomore than 80% of women (in sub-Saharan Africanand Indian sub-continent countries) live inunderserved rural areas and many of the abortioncomp lications that occur in these areas are poorly,if at all, treated. Coeytaux reported that abortion-related d eaths are a majo r cause of mortality insub-Saharan Africa [9]. The treatment of the com-plications of incomp lete abortion are a heavyburden on the hospital-based health resources.

There are few comm unity-based studies to docu-ment the extent of the problem and national datareporting systems are inadequate because vitalregistration systems are poorly developed andgrossly underreport cause s of death. Even less isknown statistically about the resultant morbidityamong women who survive an unsafe abortionprocedure. Similarly, hospital statistic s are notrepresentative of the situation in the comm unity ornation. The findings of the small number ofcommunity-based studies that have been con-ducted provide an insight into the problem ofabortion-related deaths in a num ber of societies.In a large community survey in Addis Abab a,Ethiopia, for example, Kwast and her colleaguesfound a high maternal mortality rate (566 per100 000 livebirths) and further noted that 54% ofthe direct obstetric deaths identified were due tocom plications of illegal abortion [lo]. In ahospital-based study in a series of hospitals inLagos, Nigeria, as long ago as 1977,51% of mater-nal deaths were abortion related [l 11 . Anotherhospital-based study in Zimbabw e showed that15% of all pregnancies known to the institutionended in incomplete or induced abortion [121. InLatin America, Fortney reports that septic abor-tion accoun ts for a disproportiona te share of the


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funds spent on transfusions and operating roomcosts, as well as total bed nights in the hospital[13]. Further a recent a nalysis of the incidence ofinduced abortion in Latin America suggests therate is among the highest in the world, comparableto rates seen in several East Europe and East Asiacountries [14].In the late 197O s, in both India and SouthAfrica, approximately 45% of all deaths caused byabortion were in high parity women (women w hohave had five or more term pregnancies) [15,161.Studies in Brazil suggest that there may be 1.5million or more illegal abortions performed an-nually in that country, with an untold number ofdeaths [17]. Rochat and colleagues, in the late197Os, reviewed data from some 60 developingcountries, working with survey information, andfound an estimated 2 07 induced abortions per1000 livebirths and between 70 000 and 100 000maternal deaths annually from abortion-relatedcomplications in the countries studied [ 181. In astudy of abortion in Latin A merica, there were anestimated 2.8 million unsafe abortions annually insix countries (Brazil, Colombia, Chile, Mexico,Peru and the Dom inican Republic), with an abor-tion rate of between 2.3 and 5 .2 per 100 women,aged 15-44 [17].

bidity and death of women, but neither the medi-cal profession nor local political leaders seemwilling to officially recognize the problem and,even if they do, they generally are not ready toimplement a program to reduce this cause of mor-tality. Rarely in med ical history have we been sowilling to simply ignore a n important cause ofdeath, particularly one which is, to a large extent,preventable with simple, existing technology.The tragic AIDS epidemic receives a great dealof med ia attention, large sums of funding for re-search and significant involvement of the medical,public health and political leadership of countriesand of international organizations. While muchmore is needed to fight the most serious epidemicof modem times, at least it cannot be said that thedisease is being ignored. The annu al internationalAIDS meeting is attended by thousands of resear-chers and advocates, with extensive mediacoverage. And there are many additional local, na-tional and regional meetings on this disease.

Thus, it is clear that where abortion is illegal (orwhere even if legal, there are no services available),poorly performed abortions result in the death s oflarge numbers of women, and temporary and per-manent morbidity in untold numbers of additionalwomen. Despite this tragedy of essentially preven-table deaths of pregnant wom en, year after year,the topic of abortion is a taboo subject a t a majori-ty of local, nationa l a nd international mee tings.Data from the United States clearly demonstratethat a first trimester abortion, carried out bytrained personnel, is among the safest (and prob-ably easiest) of all surgical procedures [19].Although, termination procedures beyond about10 weeks of gestation have been show n to carry aslightly increased risk of comp lication for everyfurther week of gestation, even second trimesterprocedures are quite safe if the clinician perform-ing the procedure is well-trained.

Wh at about abortion and its high mortality toll?There is little med ia coverage in ternationally. Fewdeveloping countries even discuss the issue atmajor medical or political meetings, exceptperhap s to discuss the justification of the con-tinuation of its illegal status (or where abortion islegal to advocate for the return of an illegalstatus). Somehow , as with the broader topic of ma-ternal mortality, the health of wom en often ap-pears to be ignored when the cause of death isnatural (pregnancy-related ) or due to some illicitactivity (abortion). For those concerned about thestatus of women, and about their health and well-being, the issue of illegal abortion and its tragichigh mortality must be given high profile atten-tion. Womens groups need the advocacy stridencyof the American AIDS advocacy groups, such asACT-UP, which interrupt meetings, hold protestdemonstrations at major medical and politicalmeetings and generally serve as a significant prodto the US consciousness about AIDS . Since thereis, as yet, no preventive vaccine and n o effectivetreatment, their demand is primarily for moreresearch and for more effective preventive educa-tion and access to treatment services.We thus have a situation in which there is a With abortion, we have a highly effective treat-

relatively simple solution to a major cause of mor- ment for those already pregnant and relatively


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effective preventive approa ches through thewidespread use of contraception. While there hasbeen a significant am ount of attention and fundingdirected towards international family planningprograms, in the past it has been primarily theresult of demographic and environmental-relatedissues rather than concerns about the health ofwomen. This despite the fact that it has been sug-gested that the widespread distribution andavailability of contraceptive services wou ld domore to improve the health of women and theiryoung children than any other single health inter-vention [20]. The prevention of pregnan cies at tooyoung or too old an age or too high a parity wouldsignificantly reduce the risk of mate rnal mortalityand increased spacing between births decreases therisk of infant mortality. Further, just making con-traceptive services available to all women whostate that they wish no further pregnancies mightreduce pregnancy-related mortality by as much as50% [21]. And certainly the need for terminationof pregnancy would be diminished (but noteliminated) w ith widespread availability of con-traceptive services.

Thus a comb ination of readily accessib le con-traceptive se rvices, legalization of abortion andaccess to abortion services could come close toeradicating the deaths from poorly performed il-legal or unsafe abortion procedures, as has beendone in the US. Since, as stated earlier, manywom en will have abortions no matter the legal orreligious status, the issue should be focused onwom ens health and the safety of the abortion pro-cedure, and not on maintaining its illegal status.However, the reality is that the issue will remainprobably the most emotionally charged an d con-troversial 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 thisissue. At major international meetings of obste-trician-gyneco logists, until quite recently, the issueof abortion has been largely ignored. W hile it istrue that even the basic issue of the extremely highrates of maternal mortality that exist in much ofthe developing world has also been ignored untilrecently, [7] the reasons are perhaps somewh at dif-

ferent. M ost obstetrician-gynec ologists (and, forthat matter most physicians in general) have beentrained to treat the problems that present in theiroffice or hospital and generally have not been con-cerned about the antecedents to the problem or theway s to prevent th e condition. There sim ply ismuc h greater interest in the technological solu-tions to problems than in finding ways to preventthem. At a FIG0 meeting about ten years ago,there were several thousand physicians in a packedauditorium to hear a lecture on in vitro fertiliza-tion, while only about 200 physicians attended aplenary session on maternal care and maternalmortality [7]. This was despite the fact that almosthalf of the physicians at the meeting were fromdeveloping countries where maternal mortality ra-tios are so high. Introducing the costly and hightechnology procedure of in vitro fertilization insettings where basic maternity care is unavailableto the vast majority of the population is a highlyinapprop riate use of very limited resource s.But after ignoring the tragedy of mate rnal mor-tality for most of its history, recent FIG 0 mee tingshave given high priority to the topic, a lthough sig-nificant ch anges in local priorities to develop effec-tive interventions are yet to come. Solving theproblems of maternal mortality do not require newtechnologies or additional basic research. R ather,at least as a tirst step, it simply req uires putting inplace an effective maternity care system [7].

The issue of abortion raises a somewh at dif-ferent set of issues in terms of its neglect by themedical community in general an d by obstetrician-gynecologists more specifically. While here too,prevention is of high priority, in reducing the num -ber of abortions through mak ing contraceptiveservices widely available and accessible, and man-agem ent of a botched abortion does not requirenew technological advances, the controversialnature of abortion itself adds significantly to theunwillingness of most physicians to become em-broiled in the issue. Fortunately, a relatively sm allnumber of academic and clinical leaders in somecountries have been outspoken about the problem.The issue of abortion in the US is perhaps in-structive as other countries grapple w ith this mostdifficult of issues. When abortion was illegal in thiscountry, only a very few academ ic leaders in the


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field of Ob/Gyn were willing to take a stand on theissue. The leaders for change in the legal statuscame primarily from other groups, such asPlanned Parenthood, womens groups, and others,backed by a small number of clinicians. Today,twenty years after abortion wa s legalized in theUS , a majority of obstetricians believe that awom an should have the right to terminate an un-wanted pregnancy, but at the same time, the ma-jority w ill not be advoca tes on the topic and, m oreimportantly most do not wish to perform abortionprocedures [22].

Where abortion is illegal, there are increasingpressures being brought to bear to maintain thatstatus, with increasing support by anti-abortionadvocacy groups from the US. In these countriesalso, these forces will have an impact onobstetrician-gynec ologists and their involvemen tin the provision of abortion services and as ad-vocates in this area for the health of women.

iCon\lusion

Increasingly, as those physicians who were moti-vated to provide abortion services because of theirexposure to the tragedies seen when abortion wasillegal in the US are retiring or dying, their placeis not being taken by younger physicians. Only avery small percentage of American Ob/Gynresidency programs include abortion training as aroutine compone nt of the residency program [23].Most m ake it available as an optional activity, onehowever taken up by very few residents. Thusabortion is the only common surgical procedure inwhic h obstetrician-gyneco logists are the primaryprovider of care, an d yet training in the technicalprocedure is optional. One may not elect to foregotraining in, for exam ple, vaginal hysterectomy; itwould be unheard of. And yet, without muchthough t at all, training in the techniqu es of preg-nancy termination has been and continues to beessentially neglected. Of course, were it to be aroutine part of training, there would need to be theoption not to receive training if one were stronglyopposed to the procedure on religious or mora lgrounds, although all residents in this field needtraining in the managem ent of a botched abortion.

The issue of abortion clearly presents an enor-mously complex moral and ethical dilemma. Thereis no other issue which so directly effects the healthof individuals, and w hich is, at the same time, soaffected by a web of religious, mora l a nd politicalfactors. The health data are very clear. Whereabortion is legal, where there is ready ac cess toservices and where personnel are well trained inthe techniqu es, abortion is amo ng the safest of allsurgical procedures and can save so many lives. Onthe other hand , w here it is illegal or where servicesare not readily available and/or personnel are notwell trained, abortion carries a high risk of com-plication and death. The extremely controversialnature of abortion will not change, given thestrength of feeling among those opposed to abor-tion and those who support a wom ans right toterminate an unwanted pregnancy. In thosedeveloping c ountries where abortion is illegal (andin India, w here abortion is legal but services aregreatly limited ), com plications of a botched abor-tion are estimated to result in the deaths of morethan 100 000 women each year. This is an extra-ordinary tragedy, since these are preventabledeaths with existing technologies.The situation in the US is somew hat more com- In countries whe re abortion is legal, the localplex than in other countries in which abortion is Ob/Gyn community has the moral and ethicallegal because of the strength of the opponents of responsibility to ensure that safe abortion servicesabortion and the level of political activity involv- are readily available and that personnel are traineded. This clearly has had an impact on the Ob/Gyn to provide the services safely and effectively,community. But there are similar problems in Where there are shortages of obstetrician-

many other countries. In the Eastern European gynecolog ists, other person nel (such as generalcountries, as Comm unism was overthrown and the surgeons, primary care practitioners, midwivesinfluence of the Catho lic Ch urch returned, the and nurse practitioners) can be trained to provideliberal abortion policies of the past are being the procedure, at least for first trimester termina -reconsidered and overturned in a few countries. tions. W here abortion is illegal, if indeed obstetri-The issue is an extremely volatile one in Ireland. cians have the health and well-being of women as


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their primary mission, then they must ensure, at aminimum, that readily accessible services are avail-able to treat the complications of a botched abor-tion in the opinion of the author, they have thefurther re sponsibility to help educate the publicabout the serious complications of unsafe abortionprocedures and they should w ork with the politicalforces of the country to begin the difficult politicalprocess of chang ing the legal status of abortion intheir country. They shou ld join forces with thosewom ens groups advocating change and assistthem in their mission.References11114[3 114 1I5 1

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Rosenfield A: Womens reproductive health. Am JObstet Gynecol 169: 128, 1993.Ryan K: Abortion or motherhood, suicide and madness.Am J Obstet Gynecol 166: 1029, 1992.Henshaw SK : Induced abortion: A world review, 1990.Fam Plann Perspect 22 : 76, 1990.Kunins H , Rosenfield A: Abortion: A legal and publichealth perspective. Annu Rev Pub1 Health 12: 361, 1991.Wright NH: Restricting legal abortion: Some maternaland child health effects in Romania. Am J ObstetGynecol 1 21: 246, 1975.Hord C, David HP, Donnay F, Wolf M: Reproductivehealth in Romania: Reversing the Ceausescu legacy. StudFam Plann 22: 231, 1991.Rosenfield A: Maternal m ortality in developing coun-tries: An ongoing but neglected epidemic. J Am MedAssoc 262: 376, 1989.World Health Organization: Maternal m ortality rates: Atabulation of available information. FHE /86.3, 198 6,WHO, Geneva.Coeytaux F: Induced abortion in sub-Saharan Africa:What we do and do not know. Stud Fam Plann 19: 186,1988.Kwast BE, Rochat R W, Kidane-Mariam W: Maternal

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mortality in Addis Ababa, Ethiopia. Stud Fam Plann 17:288, 1986.Akingba JB: Abortion, maternity and other health pro-blems in Nigeria. Nige ria M ed J 7: 465, 1977 .Crowther C, Verkuyl D: Characteristics of patients atten-ding Harare H ospital with incomplete abortion. Cent AfrJ Med 31: 67, 1985.Fortney JA: The use of hospital resources to treat incom-plete abortions: Examples from Latin America. PublicHealth Rep 96: 574, 1981.Frejka T, Atkin LC: The role of induced abortion in thefertility transition of Latin America. Presented atIUSSP/C ELAD E/CEN EP Seminar on the Fertility Tran-sition in Latin America, Buenos Aires, April 3, 1990.Barford DA, Parker JR: Maternal mortality: A survey of118 maternal deaths and the avoidable factors involved.S Afr Med J 51: 501, 1977.Lahiri D, Konar M: Abortion hazards. J Indian MedAssoc 66: 288, 1976.Alan Guttmacher Institute Unsafe Abortion or Un-wanted Birth: Cruel Choices for the Women of LatinAmerica, 19 94, Alan Guttmacher Institute, New York.Rochat RW, Kramer D, Senanayake P, Howell C:Induced abortion and health problems in developingcountries. Lancet 2: 484, 1980.Cates W: Legal abortion: The public health record. Sci-ence 215: 1586, 1590.Rosenfield A, Maine D: Maternity m ortality - aneglected tragedy. Lancet 2: 83, 1985.Maine D, Rosenfield A, Wallace M: Prevention of mater-nal deaths in developing countries: How much couldfamily planning help. Background paper for the Con-ference on Safe Motherhood, Nairobi, Kenya, 19 84(unpublished).Who will provide abortions: Insuring the availability ofqualified practitioners (Recommendations from a na-tional symposium), National Abortion Federation, N ewYork, 1990.Westhoff C, Marks F, Rosenfield A: Residency trainingin contraception, sterilization and abortion. ObstetGynecol 81: 311, 1993.

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Abortion and women’s reproductive health