lnt J Gynaecol Obstet 16: 505- 508, 1979
Problems of Implementation and Consequences of the 1975 Provisional Law to Liberalize Abortion in France J. H. 1
2
Soutoul 1 and M.A. Lagroua-Weill-Hall«?
Clinique Gynicologique et Obstitricale, Centre Hospitalier Universitaire, Tours, France Comiti Nationa l Fran~ais pour Ia Regulation des Naissances, Tours, France
ABSTRACT Soutoul J H, Lagroua- Weill-Halle MA (Ciinique Gynecologique et Obstetricale, Centre Hospitalier Universitaire, Tours, France and Comite National Fram;ais pour Ia Regulation des Naissances, Tours, France. Problems of implementation and consequences of the 1975 provisional law to liberalize abortion in France. lnt j Gynaecol Obstet /6: 505- 508, 19 79 The passage of the 1975 law to liberalize abortion in France was inevitable because of the inadequacy of the 1920 law. The new law was passed quickly at the end of 1974 and its rapid implementation onjanuary 17, 1975, caught public health officials by surprise. Two benefits have resulted from the law 's implementation: (a) abortion has become a medical act, reducing the incidence of illegal termination of pregnancy and its complications; and (b) it has limited the need to travel to more liberal countries for an abortion. Chief among the law's disadvantages are the nonapplication of certain of its sections, the absence of means to curb noncomplying physicians and a certain laxity in its application due to inadequate public knowledge of the risks involved in repeated abortions.
INTRODUCTION The 1975 French law liberalizing abortion was inevitable because of the nonenforcement of a 1920 law which was no longer relevant. The 1975 law, in spite of prolonged parliamentary deliberations, was hurriedly voted upon because of its political implications. Its passage revealed the strong antagonism between the supporters of a totally liberalized abortion law and the defenders of a certain medical ethic represented by the National College of Physicians and the Associations for the Defense of Life in all of its forms.
This new law recognizes the woman's right to make an exclusive unilateral decision on abortion, but does not officially recommend any medical control , even in cases where physical or psychological contraindications exist to such a procedure. The law does not foresee true dissuasion, but imposes only a so-called delay which statistics show has had no effect on the eventual decision. The mention of this dissuasion is opposed by the supporters of abortion although information supplied by social workers and marriage counselors is all that would be offered. In addition, the law does not contain any specific penalties in cases where one of its articles is contravened, except for the penalties established by an antiquated law passed in 1920. Three weak deterrents were included with the French law because of pressures from the College of Physicians and from some courageous parliamentarians. First and foremost, a conscience clause is included which protects physicians and paramedical personnel who might refu se to participate in an abortion. This is applicable if those individuals make their position clear at the time of their first contact with a candidate for abortion. The second deterrent sets a time limit for abortion at ten weeks of pregnancy (12 weeks without a menstrual period), except in cases where therapeutic indications are clear. This time limit was set in spite of opposition from representatives of the femini st movement who wanted to base the French legislation on that of Great Britain where the time limit can reach 24 weeks without a menstrual period. The longer time limit can lead to serious surgical complications and often irreversible, sometimes mortal , sequelae. The final deterrent states that abortion procedures may not be reimbursed by health insurance organizations. This clause was imposed by the Ministry of Health, mainly as a preventative measure;
lnt j
Gynaecol Obstet I 6
506
Soutoul and Lagroua- Weill-Halle
contraceptive consultations and materials are reimbursed. The hypocrisy and the ambiguity of this law are illustrated by the passage of an amendment (proposed by Loi S. Veil) which is included in the law as Article 1 on January 17, 1975: The law guarantees the respect of any human being as soon as life begins. This principle should only be contravened in cases of necessity and according to the conditions defin ed by the present law.
The application of the law was more difficult than its passage. Gynecologists and obstetricians had not, for the most part, been consulted because the Ministry of Health had used strong partisans of free abortion as advisors. A ministerial communique dated March 10, 1975 Uournal Officiel Republique Fran~aise) completed the dispositions taken to control the law and stated technical details which are not acceptable to specialists. General anesthesia was mentioned as being sometimes necessary and the use of the aspiration method was listed as possible for up to ten weeks of amenorrhea. This does not correspond, in either case, to the current practice for abortions which are performed under conditions designed to avoid complications and sequelae. The general directors of university hospitals and the directors of some second category hospitals were ordered to provide the facilities, material and personnel necessary for application of the law. As early as August 1, 1975, many temporary facilities were set up, and material and instruments were rapidly acquired. In the recruitment of personnel, however, the administration quickly encountered great difficulties, even among doctors favorable to abortion but not desirous of performing them regularly. It soon became possible to classify the gynecologists responsible for hospital services into three categories. The first included those who systematically refused to apply the law because of the legal conscience clause; the second group were those who agreed to establish an abortion center in an isolated area of their hospitals and authorized some of their staff to perform abortions. The third group consisted of a small number of specialists who actively participated in the application of the law, sometimes pressuring their staff to participate. In many hospitals, the provision of physical facilities and material did not pose many problems. There followed a " call for offers of service," first to all gynecologists of the city and of the region (who unanimously refused), then to all full-time and parttime hospital physicians. Offers of service were re-
lnt j
Gynaecol Obstel 16
ceived from individuals whose medical specialty was far removed from the female genital system: psychiatrists, nephrologists, pediatricians and, most often, biologists, including a number of young general practitioners who were probably seeking entry into the hospital. Gynecologists and obstetricians were incapable of applying a lax law that includes neither medical contraindications to abortion nor the required intervention of a specialist in the decision. They returned to their usual activities (ie, the management of risk pregnancies and the treatment of genital tumors and of sterility which were often the results of complicated or frequent abortions). After 18 months of uncoordinated application of the law, 45 000 to 60 000 abortions were reported in 1975; there were 135 000 in 1976 and approximately 160 000 in 1977. In 1977, it was decided to crystallize the opinion movement which motivated gynecologists and obstetricians as a group to oppose the law. Efforts were made to unite colleagues with diverse backgrounds who were conscious of ethics, but who were also anxious to open the eyes of public officials and of the general population about the consequences of the law. A nonprofit book published in February 1977 was written by technicians and was designed to demonstrate: (a) the deficiencies of the law; (b) its nonapplication; and (c) the laxity of this law and its dangerous consequences for women subject to repeated abortions for unborn children and for the demography of the country (1). Spiritual considerations were ignored; the book emphasized purely medical aspects and stressed the dramatic effect of the law on physicians and specialists who are not prepared to conduct abortions on demand. The effectiveness of this criticism is demonstrated by the violent reactions it caused on both sides of the issue, the interest generated in the mass media and the sympathy and support received from many quarters. The best compliment received was from the well-known European historian and demographer, Pierre Chaunu, who wrote in a letter to J. H. Soutoul, " You have done more in three months than we did in three years!"
THE PRESENT SITUATION IN FRANCE The effects of this law can be summarized objectively. Two advantages in the application of the law are recognized. First, the medicalization of abortion has reduced "homemade abortions" and the resulting infections and renal complications. Second, the
Abortion law in France
decrease in trips to foreign countries (ie, England, Holland and Switzerland) must also be acknowledged. However, these abortion trips continue in cases not covered under the law or for patients who wish to maintain complete anonymity. On the other hand, it must be remembered that the law renders abortion completely uncontrolled and seemingly profitable in two thirds of the cases. The actual number of abortions in France in 1975 and 1976 is estimated to have been between 400 000 and 500 000, based on classical trends at the time of the implementation of the law (ie, 250 000 to 350 000 abortions before 1975, according to reasonable estimates). It is the aut hors' opinion that this law has made criminal and profitable abortion official with the involuntary cooperation of insurance funds and with the support of certain cooperative societies which reimburse members who v.rish to have an abortion performed legally. Underaged girls are aborted even in official abortion centers without the agreement of their parents. The same applies to foreign women who have not been residents for three months as required by the law. In addition, the limits on the number of weeks at which pregnancy may legally be terminated appear not to have been respected. It is impossible to document accurately the number of abortions performed or the financial gains of practitioners who are now " liberated" from any legal constraints. In fact, what magistrates would now dare to penalize a " legal abortionist" in France? Such an action would precipitate a loud protest from feminist movements and the liberal press which, in turn, would affect the thinking of the leaders of political parties. Propositions for changes in the law are scheduled to be presented to the Minister of Health. Some of these originate from the feminist movement which demands the total reimbursement of abortion costs, the extension of the time at which a pregnancy can be interrupted to 22 or 24 weeks and the legal abortion of underaged and foreign women. Surprisingl y, these organizations a lso propose that all French physicians be forced to register each year their willingness or unwillingness to perform abortions. This would prevent the conscience clause from delaying the performance of abortions. Our group, of gynecologists requests the following changes in the law: 1. The strict application of the law, including: (a) the control of official abortion centers; (b) detection of payments by insurance organizations; (c) the interdiction of supplementary insurance payments; (d) the detection of clandestine and lucrative abor-
507
tions through more severe financial controls and through the control of the proportion of abortions compared to the total number of surgical procedures (this kind of control is an unenforced part of the law); and (e) inquest on all abortion complications observed in public hospitals. 2. The adjustment of the law to include the following additional controls and restrictions: (a) respect for medical and psychological contraindications to abort ion; (b) control of the technical formation and the mental and moral stability of physicians who perform abort ions; (c) provision of adequate information to needy women; (d) penalization of physicians and their patients who infringe the law; (e) establishment of responsibility in cases of technical or psychological mistakes in the performance of abortion; and (f) prevention of a second abortion within one year. 3. The continuation of information dissemination to the population on the demogragraphic effects of abortion and of family planning in relation to Article 16 of the law. Information campaigns on the real dangers of abortion through radio and television are a lso recommended. 4. The development of a liberal but positive policy concerning the problems of pregnancy and birth: (a) the true upgrading of the condition of unmarried women; (b) the protection of maternity at all costs through an increase in the length of maternity leave and the number of prenatal physician visits; (c) the complete assumption of treatment in cases of risk pregnancies; (d) the complete assumption of treatment of sterility; and (e) the establishment of a base salary for women having three children. Finally, the prevention of abortion must be based on true sexual information without political, philosophical or ideologic orientation, and on the development of individual responsibilities in young people. It seems urgent that we change the orientation and the teaching in regard to sound family planning provided medical students and practitioners who are continuing their medical education . The main objective of the National Committee for Birth Regulation is to help in the application of Article 3 of the law: "In no circumstances shou ld abortion be considered as a means of birth control." A widespread campaign promoting the use of contraceptive methods adapted to each woman is strongly supported. Such a campaign would reduce the number of abortion and sterilization procedures which these authors believe are unadvisable in France,'1:t country with low population density and a relatively high standard of living.
lnt j Gynaecol Obstet / 6
508
Soutoul and Lagroua- Weill-Halli
CONCLUSION As realistic physicians, we do not believe that the French law can be repealed. But, as it is limited to a period of five years, it can be amended to protect the mental and physical health of French women. The amendments that we propose should protect future children to the maximum by providing a better social and psychological environment for the woman in a "distress pregnancy" situation. We wish to prevent the possibility that simple human contact for the distressed future mother might be replaced with a cheap plastic aspiration device and rapid destruction of a human fetus . Between the two strongly opposed groups arguing this issue, there is, in our opinion, room for the voices of specialists and physicians. Our present concerns agree completely with the opinion of the Minister who prepared, amended and presented to Parliament this historical law: " Nobody has ever contested, least of a ll the Minister of Health, that abortion is a failure, if not a catastrophe. Abortion must, therefore, remain a last resort, an exception for situations without solution" (conclusion of the statements by Madame Veil, Minister of Health, at the time of discussions preceding the vote on the law by the National Assembly in 1974). French parliamentarians, who in January 1980
lnt
J
Gy naecol Obstet 16
will be called upon to vote on a permanent law, deserve to be well informed on certain aspects of the app lication of a temporary law which facilitated " convenience" rather than "last resort" and "exception." In libera li zing the practice of abortion 20 years after the socialist countries, ten years after Great Britain and several years after the USA and Canada, France does not seem to have arrived at a reasonable legislation based on the experience of other countries. If an ideal law exists, one wonders if its application and its effects can be efficiently controlled in democratic states where a very free life style is fundamental.
REFERENCE 1. Soutou l JH : Consequences d'une loi . Avortement An II. La
Table Ronde, Paris, 1977.
Address for reprints:
J. H. Soutoul 2 Boulevard Tonnelle 37.033 Tours, France
Problems of Implementation and Consequences of the 1975 Provisional Law to Liberalize Abortion in France J. H. 1
2
Soutoul 1 and M.A. Lagroua-Weill-Hall«?
Clinique Gynicologique et Obstitricale, Centre Hospitalier Universitaire, Tours, France Comiti Nationa l Fran~ais pour Ia Regulation des Naissances, Tours, France
ABSTRACT Soutoul J H, Lagroua- Weill-Halle MA (Ciinique Gynecologique et Obstetricale, Centre Hospitalier Universitaire, Tours, France and Comite National Fram;ais pour Ia Regulation des Naissances, Tours, France. Problems of implementation and consequences of the 1975 provisional law to liberalize abortion in France. lnt j Gynaecol Obstet /6: 505- 508, 19 79 The passage of the 1975 law to liberalize abortion in France was inevitable because of the inadequacy of the 1920 law. The new law was passed quickly at the end of 1974 and its rapid implementation onjanuary 17, 1975, caught public health officials by surprise. Two benefits have resulted from the law 's implementation: (a) abortion has become a medical act, reducing the incidence of illegal termination of pregnancy and its complications; and (b) it has limited the need to travel to more liberal countries for an abortion. Chief among the law's disadvantages are the nonapplication of certain of its sections, the absence of means to curb noncomplying physicians and a certain laxity in its application due to inadequate public knowledge of the risks involved in repeated abortions.
INTRODUCTION The 1975 French law liberalizing abortion was inevitable because of the nonenforcement of a 1920 law which was no longer relevant. The 1975 law, in spite of prolonged parliamentary deliberations, was hurriedly voted upon because of its political implications. Its passage revealed the strong antagonism between the supporters of a totally liberalized abortion law and the defenders of a certain medical ethic represented by the National College of Physicians and the Associations for the Defense of Life in all of its forms.
This new law recognizes the woman's right to make an exclusive unilateral decision on abortion, but does not officially recommend any medical control , even in cases where physical or psychological contraindications exist to such a procedure. The law does not foresee true dissuasion, but imposes only a so-called delay which statistics show has had no effect on the eventual decision. The mention of this dissuasion is opposed by the supporters of abortion although information supplied by social workers and marriage counselors is all that would be offered. In addition, the law does not contain any specific penalties in cases where one of its articles is contravened, except for the penalties established by an antiquated law passed in 1920. Three weak deterrents were included with the French law because of pressures from the College of Physicians and from some courageous parliamentarians. First and foremost, a conscience clause is included which protects physicians and paramedical personnel who might refu se to participate in an abortion. This is applicable if those individuals make their position clear at the time of their first contact with a candidate for abortion. The second deterrent sets a time limit for abortion at ten weeks of pregnancy (12 weeks without a menstrual period), except in cases where therapeutic indications are clear. This time limit was set in spite of opposition from representatives of the femini st movement who wanted to base the French legislation on that of Great Britain where the time limit can reach 24 weeks without a menstrual period. The longer time limit can lead to serious surgical complications and often irreversible, sometimes mortal , sequelae. The final deterrent states that abortion procedures may not be reimbursed by health insurance organizations. This clause was imposed by the Ministry of Health, mainly as a preventative measure;
lnt j
Gynaecol Obstet I 6
506
Soutoul and Lagroua- Weill-Halle
contraceptive consultations and materials are reimbursed. The hypocrisy and the ambiguity of this law are illustrated by the passage of an amendment (proposed by Loi S. Veil) which is included in the law as Article 1 on January 17, 1975: The law guarantees the respect of any human being as soon as life begins. This principle should only be contravened in cases of necessity and according to the conditions defin ed by the present law.
The application of the law was more difficult than its passage. Gynecologists and obstetricians had not, for the most part, been consulted because the Ministry of Health had used strong partisans of free abortion as advisors. A ministerial communique dated March 10, 1975 Uournal Officiel Republique Fran~aise) completed the dispositions taken to control the law and stated technical details which are not acceptable to specialists. General anesthesia was mentioned as being sometimes necessary and the use of the aspiration method was listed as possible for up to ten weeks of amenorrhea. This does not correspond, in either case, to the current practice for abortions which are performed under conditions designed to avoid complications and sequelae. The general directors of university hospitals and the directors of some second category hospitals were ordered to provide the facilities, material and personnel necessary for application of the law. As early as August 1, 1975, many temporary facilities were set up, and material and instruments were rapidly acquired. In the recruitment of personnel, however, the administration quickly encountered great difficulties, even among doctors favorable to abortion but not desirous of performing them regularly. It soon became possible to classify the gynecologists responsible for hospital services into three categories. The first included those who systematically refused to apply the law because of the legal conscience clause; the second group were those who agreed to establish an abortion center in an isolated area of their hospitals and authorized some of their staff to perform abortions. The third group consisted of a small number of specialists who actively participated in the application of the law, sometimes pressuring their staff to participate. In many hospitals, the provision of physical facilities and material did not pose many problems. There followed a " call for offers of service," first to all gynecologists of the city and of the region (who unanimously refused), then to all full-time and parttime hospital physicians. Offers of service were re-
lnt j
Gynaecol Obstel 16
ceived from individuals whose medical specialty was far removed from the female genital system: psychiatrists, nephrologists, pediatricians and, most often, biologists, including a number of young general practitioners who were probably seeking entry into the hospital. Gynecologists and obstetricians were incapable of applying a lax law that includes neither medical contraindications to abortion nor the required intervention of a specialist in the decision. They returned to their usual activities (ie, the management of risk pregnancies and the treatment of genital tumors and of sterility which were often the results of complicated or frequent abortions). After 18 months of uncoordinated application of the law, 45 000 to 60 000 abortions were reported in 1975; there were 135 000 in 1976 and approximately 160 000 in 1977. In 1977, it was decided to crystallize the opinion movement which motivated gynecologists and obstetricians as a group to oppose the law. Efforts were made to unite colleagues with diverse backgrounds who were conscious of ethics, but who were also anxious to open the eyes of public officials and of the general population about the consequences of the law. A nonprofit book published in February 1977 was written by technicians and was designed to demonstrate: (a) the deficiencies of the law; (b) its nonapplication; and (c) the laxity of this law and its dangerous consequences for women subject to repeated abortions for unborn children and for the demography of the country (1). Spiritual considerations were ignored; the book emphasized purely medical aspects and stressed the dramatic effect of the law on physicians and specialists who are not prepared to conduct abortions on demand. The effectiveness of this criticism is demonstrated by the violent reactions it caused on both sides of the issue, the interest generated in the mass media and the sympathy and support received from many quarters. The best compliment received was from the well-known European historian and demographer, Pierre Chaunu, who wrote in a letter to J. H. Soutoul, " You have done more in three months than we did in three years!"
THE PRESENT SITUATION IN FRANCE The effects of this law can be summarized objectively. Two advantages in the application of the law are recognized. First, the medicalization of abortion has reduced "homemade abortions" and the resulting infections and renal complications. Second, the
Abortion law in France
decrease in trips to foreign countries (ie, England, Holland and Switzerland) must also be acknowledged. However, these abortion trips continue in cases not covered under the law or for patients who wish to maintain complete anonymity. On the other hand, it must be remembered that the law renders abortion completely uncontrolled and seemingly profitable in two thirds of the cases. The actual number of abortions in France in 1975 and 1976 is estimated to have been between 400 000 and 500 000, based on classical trends at the time of the implementation of the law (ie, 250 000 to 350 000 abortions before 1975, according to reasonable estimates). It is the aut hors' opinion that this law has made criminal and profitable abortion official with the involuntary cooperation of insurance funds and with the support of certain cooperative societies which reimburse members who v.rish to have an abortion performed legally. Underaged girls are aborted even in official abortion centers without the agreement of their parents. The same applies to foreign women who have not been residents for three months as required by the law. In addition, the limits on the number of weeks at which pregnancy may legally be terminated appear not to have been respected. It is impossible to document accurately the number of abortions performed or the financial gains of practitioners who are now " liberated" from any legal constraints. In fact, what magistrates would now dare to penalize a " legal abortionist" in France? Such an action would precipitate a loud protest from feminist movements and the liberal press which, in turn, would affect the thinking of the leaders of political parties. Propositions for changes in the law are scheduled to be presented to the Minister of Health. Some of these originate from the feminist movement which demands the total reimbursement of abortion costs, the extension of the time at which a pregnancy can be interrupted to 22 or 24 weeks and the legal abortion of underaged and foreign women. Surprisingl y, these organizations a lso propose that all French physicians be forced to register each year their willingness or unwillingness to perform abortions. This would prevent the conscience clause from delaying the performance of abortions. Our group, of gynecologists requests the following changes in the law: 1. The strict application of the law, including: (a) the control of official abortion centers; (b) detection of payments by insurance organizations; (c) the interdiction of supplementary insurance payments; (d) the detection of clandestine and lucrative abor-
507
tions through more severe financial controls and through the control of the proportion of abortions compared to the total number of surgical procedures (this kind of control is an unenforced part of the law); and (e) inquest on all abortion complications observed in public hospitals. 2. The adjustment of the law to include the following additional controls and restrictions: (a) respect for medical and psychological contraindications to abort ion; (b) control of the technical formation and the mental and moral stability of physicians who perform abort ions; (c) provision of adequate information to needy women; (d) penalization of physicians and their patients who infringe the law; (e) establishment of responsibility in cases of technical or psychological mistakes in the performance of abortion; and (f) prevention of a second abortion within one year. 3. The continuation of information dissemination to the population on the demogragraphic effects of abortion and of family planning in relation to Article 16 of the law. Information campaigns on the real dangers of abortion through radio and television are a lso recommended. 4. The development of a liberal but positive policy concerning the problems of pregnancy and birth: (a) the true upgrading of the condition of unmarried women; (b) the protection of maternity at all costs through an increase in the length of maternity leave and the number of prenatal physician visits; (c) the complete assumption of treatment in cases of risk pregnancies; (d) the complete assumption of treatment of sterility; and (e) the establishment of a base salary for women having three children. Finally, the prevention of abortion must be based on true sexual information without political, philosophical or ideologic orientation, and on the development of individual responsibilities in young people. It seems urgent that we change the orientation and the teaching in regard to sound family planning provided medical students and practitioners who are continuing their medical education . The main objective of the National Committee for Birth Regulation is to help in the application of Article 3 of the law: "In no circumstances shou ld abortion be considered as a means of birth control." A widespread campaign promoting the use of contraceptive methods adapted to each woman is strongly supported. Such a campaign would reduce the number of abortion and sterilization procedures which these authors believe are unadvisable in France,'1:t country with low population density and a relatively high standard of living.
lnt j Gynaecol Obstet / 6
508
Soutoul and Lagroua- Weill-Halli
CONCLUSION As realistic physicians, we do not believe that the French law can be repealed. But, as it is limited to a period of five years, it can be amended to protect the mental and physical health of French women. The amendments that we propose should protect future children to the maximum by providing a better social and psychological environment for the woman in a "distress pregnancy" situation. We wish to prevent the possibility that simple human contact for the distressed future mother might be replaced with a cheap plastic aspiration device and rapid destruction of a human fetus . Between the two strongly opposed groups arguing this issue, there is, in our opinion, room for the voices of specialists and physicians. Our present concerns agree completely with the opinion of the Minister who prepared, amended and presented to Parliament this historical law: " Nobody has ever contested, least of a ll the Minister of Health, that abortion is a failure, if not a catastrophe. Abortion must, therefore, remain a last resort, an exception for situations without solution" (conclusion of the statements by Madame Veil, Minister of Health, at the time of discussions preceding the vote on the law by the National Assembly in 1974). French parliamentarians, who in January 1980
lnt
J
Gy naecol Obstet 16
will be called upon to vote on a permanent law, deserve to be well informed on certain aspects of the app lication of a temporary law which facilitated " convenience" rather than "last resort" and "exception." In libera li zing the practice of abortion 20 years after the socialist countries, ten years after Great Britain and several years after the USA and Canada, France does not seem to have arrived at a reasonable legislation based on the experience of other countries. If an ideal law exists, one wonders if its application and its effects can be efficiently controlled in democratic states where a very free life style is fundamental.
REFERENCE 1. Soutou l JH : Consequences d'une loi . Avortement An II. La
Table Ronde, Paris, 1977.
Address for reprints:
J. H. Soutoul 2 Boulevard Tonnelle 37.033 Tours, France
