/. biosoc. Sci. (1976) 8, 229-251
SOME COMMENTS ON THE DEMOGRAPHIC AND SOCIAL EFFECTS OF THE 1967 ABORTION ACT RICHARD LEETE Office of Population Censuses and Surveys, London {Received 29th September 1975) Summary. Estimates of the incidence of illegally induced abortions are critically reviewed and on the basis of a revised estimate it is tentatively suggested that there were 50,000 (legal plus illegal) abortions induced annually between 1964 and 1966. A substantial reduction in the extent of illegal abortions is an important consequence of the 1967 Abortion Act. But induced abortion is seen as a contributory factor only in the decline of legitimate fertility which has been greater at all ages and all parities than the increment of abortions to married women. A particularly marked reduction in legitimate births occurred between 1972 and 1975 whereas the number of induced abortions performed on married women declined slightly. However, the reversal of the secular trend of increasing illegitimacy is evidence of the demographic impact of the Act. Regional rates of abortion are found to be unassociated with the decline in high parity births but negatively associated with illegitimacy ratios. At the regional level differences in the proportion of abortions performed under the NHS remain. At the national level a lower proportion of early terminations occur in the public sector than in the private sector, and women in the least skilled occupational groups have their abortions latest.
Introduction
With the liberalization of abortion, through the 1967 Abortion Act, Britain has moved from a situation in which abortion as an acceptable medical procedure was covert and suppressed to one in which a woman could obtain termination on grounds that went beyond the strictly medical. However, the Act was not effected as an implement of family planning and population control and no provisions were made for abortion on demand. This paper attempts to put into perspective some of its initial demographic and social effects, analysing published (Registrar General, 1969-73) and hitherto unpublished abortion and fertility registration data, at the national and regional levels. 229
230
Richard Leete Incidence of abortion before the 1967 Act
Both as a background and as a yardstick for measuring the demographic impact of the Act, an assessment of the incidence of induced abortion before 1967 is necessary. Unfortunately, before 1967 there was no statutory requirement to notify therapeutic abortions to the Chief Medical Officer. The only official source of information was the Hospital In-Patient Enquiry (HIPE) which took an annual 10% sample of discharges and deaths from NHS hospital records. However, the data obtained from NHS records must be considered an absolute minimum because, as Diggory (1969) has noted 'Many gynaecologists used to record such procedures under the euphemistic title "dilatation and curettage"'. Table 1 shows that the Table 1. Estimates of the incidence of induced abortion before 1967, England and Wales No. of therapeutic abortions Year
NHS*
Privatef
Total
1963 1964 1965 1966 1967
2300 3000 4000 5700 8600
14,000 15,000 15,000 15,000 17,500
16,300 18,000 19,000 20,700 26,100
No. of illegal abortions^
Total no. of abortions
30,000 30,000 30,000
48,000 49,000 50,700
Source: * Chief Medical Officer, 1973 t Diggory et al., 1970 % This paper's estimate.
number of recorded therapeutic abortions estimated to have occurred in NHS hospitals increased from 2300 to 8600 in the 5 years preceding the Act, an increase of 274%. This probably reflects an increasing willingness on the part of gynaecologists to perform more abortions under the NHS or to record as abortions those being carried out under the NHS in the years immediately preceding the Act. In addition to the number of therapeutic abortions carried out in NHS hospitals there was a large but unrecorded number performed in private clinics. Diggory, Peel & Potts (1970) have attempted to quantify the amount on the basis of a personal enquiry among a sample of practising gynaecologists. Table 1 shows that the incidence of reported private abortions increased from 14,000 in 1963 to 17,500 in 1967, an increase of 25% in the five years preceding the Act. The rate of increase in the private sector was not as great as that in the public sector but, of the estimated 26,100 legal abortions carried out in 1967, twice as many were performed in private institutions as in NHS hospitals (Table 1). Estimates of the number of abortions procured illegally before the Act have generally been either speculative or impaired by vested interests. The figure of 100,000 is frequently adduced but evidence to substantiate this number is difficult
Effects of the 1967 Abortion Act
231
to find (e.g. Rhodes, 1966). Despite the difficulties involved it is of fundamental importance to have an estimate, or a range of estimates, in order to arrive at the total number of induced abortions procured annually before 1967. The Lane Committee (1974) agreed and added that 'A low estimate of pre-1967 illegal abortions implies that the Act has created a large demand for abortion whilst a high estimate implies that abortions have merely transferred from the illegal to legal sector'. However, this over-simplification misses the important point that there may have been a large unmet demand before the Act. Indeed the further back in time one goes the greater the probable demand for abortion, given today's wider availability of more effective contraception and its greater use-effectiveness. Before attempting to estimate the incidence of illegal abortions before 1967, this paper briefly examines the arguments of Goodhart (1964, 1969, 1973) and of James' (1971) adaption of Goodhart's premises. In 1966 the NOP conducted a postal survey which, among other things, attempted to estimate the 'incidence' of abortion between 1946 and 1965. Out of a sample of 3500 women, 2132 replied of whom 4 % admitted having undergone an illegal abortion. Assuming the response was representative of the entire sample and by extrapolating this ratio to all women in the fertile age group it was estimated that there was an annual average of 31,000 illegal abortions. Commenting on this estimate Goodhart (1973) argued that, because of the small number of positive replies involved, misunderstood or deliberately false answers could have introduced a serious bias when extrapolated to the total population. Given the social climate at the time of the survey, and because the questions asked aroused strong personal emotions, Goodhart concluded that it was highly likely that systematic false positive answers inflated the estimate. James (1971), however, felt that women would be most unlikely to report criminal acts in a postal questionnaire and suggested that 31,000 was 'almost certainly a gross under-estimate'. For several reasons it is unrealistic to infer anything from the results of the NOP survey. Apart from the problems of sampling error, not knowing whether the respondents to the survey were representative of the sample, and the nature and direction of any possible bias which could have operated in either direction, there is the additional problem (which apparently both Goodhart and James overlooked) that the survey only elicited prevalence information from which one cannot derive an incidence rate. The NOP survey represents the only direct attempt at estimating the extent of illegal abortion before 1967 but there have been several indirect approaches. One of these, pioneered by Goodhart, attempted to utilize data on induced abortions from the Royal Infirmary in Aberdeen. It was suggested that Scotland in general, and Aberdeen in particular, had as liberal an abortion policy in the pre-1967 era as that prevailing in England and Wales after 1967. On the assumptions that there were very few or no criminal abortions in Aberdeen, that all abortions on women of Aberdeen were done within the City, that the total demand was fully met, and that this demand was representative of the entire population of England and Wales, Goodhart concluded that illegal abortions could not have exceeded 20,000 annually.
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James (1971) rejects the first three of these assumptions and, working with a revised hypothesis, builds his own argument on an adaptation of the fourth. Pointing out that septic abortions were not as rare in Aberdeen as Goodhart had believed, and assuming that about 20-25 % of all criminal abortions later require hospital admission, and further, that most septic abortions are caused by illegal abortions, James asserts that there certainly were more than a few criminal terminations. Next he notes that married abortion patients in Aberdeen outnumbered the unmarried by a ratio of 8 to 1 and that this is contrary to post-1967 experience. Consequently he hypothesizes that 'Many incipient demands for abortion from unmarried lower class girls were stifled by the GP without the patient seeing the obstetrician'. Not only does James feel that the demand for abortions was unmet but that the demand was atypical of the rest of the country, since the 'effective family planning services' resulted in a 'diminution of unwanted pregnancies'. In particular, because the rate of sterilization was higher in Aberdeen than elsewhere the demand for abortion was correspondingly lower. After taking the above factors into account James concludes that the legal rates under-estimated the number of abortions by a factor of 4J and, multiplying Goodhart's estimate by this amount and subtracting legal terminations, estimates that there were 60,000 illegal abortions annually. The assumptions of James' argument are untenable. In particular, it is extremely doubtful whether one can extrapolate the demand for abortions from either Goodhart's original rate for Aberdeen or from James' revised rate. First, was the demand for abortions in Aberdeen from women of Aberdeen ? How many married women temporarily obtained Aberdeen addresses and doctors simply to secure an abortion there ? Second, a positive abortion policy of a particular kind may generate a greater demand from a given sub-group than would be associated with that group if a negative policy prevailed. The demand for abortions in Aberdeen may have been met but that does not mean the demand would not have been more or less if other systemic changes had been made. Third, James assumes that single women who he alleges were unable to obtain an abortion in Aberdeen would have wanted to, and been able to, in other parts of the country. But if these women were from the lower social classes, as James suggests, they might have had quite strong feelings against termination, since they might have had different social norms and values regarding illegitimacy and abortion from those of middle-class women. Of course, norms and values can and do change over time. Finally, the assumption that a high sterilization rate is associated with a low abortion rate, although plausible, is an as yet unanswered empirical question. In attempting to estimate the number of unlawful abortions procured before 1967 there is another possible approach. If one knows the number who die from illegal abortions in a given year and the mortality rates associated with illegal abortions then one can readily calculate such an estimate. However, there are difficulties, although not insuperable ones, in fulfilling either of these conditions. In England and Wales there are strictly defined regulations surrounding death certification. A doctor must know the cause of death and be sure that it is natural before he can sign the death certificate; if he is in any reasonable doubt about meeting the legal criteria he must refer the case to a coroner. The coroner should
Effects of the 1967 Abortion Act
233
then order an autopsy to establish the true cause of death. In practice there are doubts concerning the accuracy of death certification, especially in relation to illegal abortion. Diggory (1969) has stated that there are pressures on a doctor to 'repress his suspicions when he feels that a woman has died after a criminal abortion, and only deaths in cases of proven criminal abortion are recorded as such by the Registrar General'. Johnson (1969) has shown that even in those cases referred to a coroner a small number of abortion deaths are certified as natural when in fact the cause is unnatural. Thus it seems that there are strong grounds for rejecting the accuracy of pre-1967 death registration. After balancing the factors alluded to above, James (1971) suggested, somewhat arbitrarily, that death registration of illegally induced abortion is underestimated by a factor of two. Mortality rates associated with criminal abortion are obviously a function of a combination of factors, including the circumstances in which the abortions are performed, length of gestation, skill of the person performing, and the availability and utilization of medical and hospital facilities in emergencies. Given the knowledge of antisepsis and the availability of antibiotics in the 1960s, it seems unreasonable to assume that on average ('average' since it balances the combination of factors mentioned above) illegally induced abortion was much more than ten times more fatal than abortion procured legally in the first few years after 1967. An illegal abortionist probably would not have wanted to continue his practice if he had been responsible for, and had a reputation for, causing more than one death. Assuming that official data on illegally induced abortion deaths just before the Abortion Act represents an underestimation by a factor of two, and that illegally induced abortion was ten times more dangerous than legally procured abortion, a revised annual estimate of the incidence of criminal abortion for the period 1964-66 is set out below. (a) The legally induced abortion death rate is taken as the average of the rates for the years 1969 and 1970, 31-0 and 16-2 per 100,000 abortions respectively, namely 23-6. (Some of these deaths were not necessarily attributed to the abortion operation but to some other 'underlying cause'. However, it is likely that some abortion deaths were not recorded by the notifying doctor since death may occur after the patient has been discharged from the place of operation. It is assumed that the two cancel out.) (b) The annual average number of illegally induced abortion deaths for 196466 was 33. Therefore the estimated annual number of criminal abortions for 1964-66 was:
_
= 16
estimated illegal abortion deaths estimated illegal abortion death rate reported illegal abortion deaths x estimated under-reporting factor A ^ * illegal abortion death rate . ,, 1 u _ x f—-———-: ———— estimated legal abortion death rate x —-,— estimated legal abortion death rate 33 x 2 TyT-? = approximately 30,000 xl
To^ °
234
Richard Leete
Although the assumptions on which this estimate is based are not strong they are no weaker than those on which previous estimates have been based. But in a field where accurate measurement is impossible the estimated figure of 30,000 annual illegal abortions must be regarded as tentative and merely indicative, and should be used with caution. Furthermore, it cannot serve as a basis for estimating the demand for abortions before 1967. There is, for instance, no way of estimating how many women unsuccessfully attempted to self-induce an abortion before 1967, or how many women would have had an abortion had adequate facilities been available. Illegal abortion since 1968 It was estimated in Table 1 that there was an annual average of about 50,000 induced abortions, including 30,000 performed illegally between 1964 and 1966. A likely result of the increased availability of legal abortion is a decrease in the utilization of illegal abortion services. The trend in the number of hospital discharges after septic abortion has been downward since 1968 (Chief Medical Officer, 1973). In the period 1968-72 they fell from 2600 to 1000, a reduction of 62 %. (Sepsis is a common concomitant of illegal abortion, although not all septic abortions are illegal; some are the result of spontaneous abortions.) Since the number of septic discharges resulting from spontaneous abortion is not likely to have varied by much during this period, and, assuming that the hospital admission rate for septic illegal abortions has remained constant, it can be estimated that the incidence of illegal abortions has declined by at least 62 %, and probably by much more, since 1968. Thus a further tentative hypothesis of this paper is that by 1972 there were no more than 10,000 illegal abortions and probably considerably fewer. ' "•
Abortion and its relationship to subsequent fertility
The relationship between abortion and subsequent fertility is complicated by the intervening variable of contraception. Following conception a woman goes through three periods of different risks of subsequent conception. First, there is an absolute refractory period, for during pregnancy, it is impossible to become pregnant again; second, there is a relative refractory period, for following delivery there is a marked reduction in fecundity that is enhanced by breast feeding and may include anovulatory cycles; third, there is an extended period of normal risk of pregnancy with exposure. This third period can be connected to one of absolute refractoriness with effective contraception or relative refractoriness with inefficient contraception. Abortion will affect subsequent fertility by (a) reducing the absolute refractory period from 9 to 3 months on the average, and (b) eliminating the relative refractory period by, among other effects, removing the possibility of breast feeding. Evidence that properly performed abortions have deleterious effects and among other things cause subsequent sterility is dubious (Daling & Emanuel, 1975). Potter (1972; see also Tietze & Bongaarts, 1975) has calculated that births averted per abortion depend primarily on the efficiency of accompanying contraception, and, to a much lesser degree, on the duration of gestation and the age of
Effects of the 1967 Abortion Act
235
the woman. Depending on assumptions about these three variables the figure for net births averted per abortion varies from 0-45 where contraception is not being employed, to 0-90 where 97 % effective contraception is practised. In England and Wales a study carried out by Bone (1973) has confirmed the findings of the 1967 Population Investigation Committee Survey (Glass, 1970) that birth control has permeated society, at least among married women. However, the methods used are (a) not necessarily the most reliable ones and (b) are not used with equal effectiveness by all sections of the community. As Glass (1970) points out, 'The prevalence of birth control as practised so far does not in itself guarantee that all births are planned' and he adduces evidence which suggests that within marriage there are a large number of 'accidental' and unwanted pregnancies, the rate increasing with parity. To the extent that abortion supplements conventional methods of birth control, particularly as a back up method to contraceptive failure, and thus prevents a birth that is not wanted now or later, it makes a positive contribution to a decline in the birth rate. If, however, abortion is merely used to prevent a child that is not wanted at the time, but wanted later, its demographic significance is merely theoretical, unless a significant number of abortions occur in which case the rate of natural increase will be reduced and the mean length of a generation extended. The number of unwanted pregnancies among unmarried women is high. This is not to say that all illegitimate conceptions are unwanted; such an assertion lacks sociological realism. The number of births averted when unmarried women have abortions is difficult to estimate. Of the single women aged 16-36 in Bone's sample only 24% had ever used some method of birth control but as not all unmarried women have intercourse before marriage this figure may not be very useful. One needs to know whether unmarried women not using birth control before abortion do so after the event, and with what degree of efficiency. Potter's figure of 0-45 births averted per abortion assumes that contraception is not, and will not be, used. However, one cannot assume that, in England and Wales, unmarried women who obtain an abortion remain a non-contracepting population. Computing the number of births averted per abortion in England and Wales for either married or unmarried women is extremely hazardous and the ultimate demographic significance of births averted is impossible to quantify in any meaningful way. It is wrong to assume that all women who experience an unwanted pregnancy will have, or want to have, an abortion. Bone (1973) found that 40% of single women and 30 % of married women said they would not have an abortion under any circumstances. Among the positive replies a large number said they would do so only for medical reasons. But there is no way of assessing the strength, or lack of strength, of convictions measured by attitudinal studies. And, of course, attitudes towards abortion do change over time as has been shown by Westoff & Jones (1972) in America. It would be dangerous to extrapolate attitudes or intentions into predictions about future behaviour, especially since the circumstances surrounding an actual decision on whether or not to seek an abortion are quite different to those prevailing at the time of an interview. Nevertheless some women will prefer to continue with an unwanted pregnancy rather than procure an abortion.
236
Richard Leete Abortion and the decline in fertility
Clearly the relationship between abortion, contraception and fertility is complex. Abortion and contraception, however, are merely means of fertility control; they do not cause a decline in fertility, they are merely associated with such a decline. In order to elucidate cause one needs to move to a different level of social reality. Indeed, historically, fertility has declined without the use of mechanical appliance methods of contraception and the question of whether high rates of abortion were associated with the decline remains unanswered. The Abortion Act took effect when period fertility rates had already begun to decline and cohort rates were apparently declining. In order to explain this decline one would need to look at individuals, singly and in groups, at the motives and meanings of their actions and the changing social and economic context which helped to shape their actions. The concern here, however, is only to explain if and how abortion was associated with the decline. Text-fig. 1 shows that the number of induced abortions climbed from 55,000 in 1969 to a peak of 167,000 in 1973. In 1974 there was a slight down-turn in the trend and with the liberalization of abortion laws in other Western countries there was a more substantial reduction in 1975 when there were 140,000 abortions. This trend in total abortions masks an interesting pattern in the level of abortions performed on residents of England and Wales (all subsequent tables and citations will refer only to residents). The number of abortions performed on residents rose in successive years reaching 111 ,000 in 1973; subsequently, in 1974 and 1975, there were major fluctuations around this number with a suggestion of a slight downward turn to the trend. With wider availability of contraception coupled with greater use-effectiveness some decline in induced abortion might have been expected over the last 2 years. That there has been no significant decline may be indicative of an increasing desire among women to limit their child-bearing. Thus, there has been an annual net increase of around 60,000 abortions since the passing of the Act. It is unrealistic to assert that legal abortions have merely replaced former illegal ones; the demand for abortion is not completely unrelated to the type of abortion services available. Measures of the incidence of abortion in a community are generally computed in an analogous manner to fertility rates. For instance, the general abortion rate, which is the number of abortions to women in the reproductive age group divided by the female population in the same age group, is analogous to the general fertility rate. The frequency of abortion can be measured in relation to births and is conventionally expressed as a ratio. Since for these data only maternal age at the time of termination of pregnancy—whether by abortion or delivery—is available, the age-specific abortion ratios computed below will have a small bias which may be particularly pronounced in the youngest age group. This is because women who conceive between the ages of 19 j and 19J will appear in the under-20 age group if they have an abortion while those who give birth will appear in the 20-24 age group. This difficulty can be overcome by 'de-aging' (Tietze & Murstein, 1975), not undertaken here. Table 2, which depicts abortion ratios and rates for all women in the fertile
Effects of the 1967 Abortion Act
237
175,000 —
150,000-
125,000-
o
100,000 —
I o
75,000-
50,000-
25,000—
0—I
1968
1969
1970
1971 Year
1972
1973
1974
Text-fig. 1. Distribution of reported induced abortions, England and Wales, 1968-74: abortions in NHS hospitals on residents, is; non-NHS abortions on residents, si; abortions on non-residents, D. Source: Registrar General's Supplements on Abortion (196873) and OPCS Monitor Reference AB75/1. Data for 1974 relate to notifications.
age-group, reflects the s,teep rise in abortions between 1969 and 1973. The abortion ratios exhibit a U-shaped distribution with the highest ratios in the youngest and oldest age groups, where the absolute number of births is lowest. By contrast, the abortion rates exhibit an inverted J-shaped distribution, with the intensity of abortions greatest in the age group 20-24 where generally the highest number of conceptions occur. In a time of declining fertility, when there is a tendency to postpone births at the younger ages and complete childbearing earlier, abortion ratios can increase sharply even when the number of abortions remains constant and to some extent the numerator varies inversely with the denominator which
238
Richard Leete
Table 2. Abortion ratios and rates for all women, 1969 and 1973, England and Wales 'Abortion ratios/1000 total tjirthst Age group All ages
SOME COMMENTS ON THE DEMOGRAPHIC AND SOCIAL EFFECTS OF THE 1967 ABORTION ACT RICHARD LEETE Office of Population Censuses and Surveys, London {Received 29th September 1975) Summary. Estimates of the incidence of illegally induced abortions are critically reviewed and on the basis of a revised estimate it is tentatively suggested that there were 50,000 (legal plus illegal) abortions induced annually between 1964 and 1966. A substantial reduction in the extent of illegal abortions is an important consequence of the 1967 Abortion Act. But induced abortion is seen as a contributory factor only in the decline of legitimate fertility which has been greater at all ages and all parities than the increment of abortions to married women. A particularly marked reduction in legitimate births occurred between 1972 and 1975 whereas the number of induced abortions performed on married women declined slightly. However, the reversal of the secular trend of increasing illegitimacy is evidence of the demographic impact of the Act. Regional rates of abortion are found to be unassociated with the decline in high parity births but negatively associated with illegitimacy ratios. At the regional level differences in the proportion of abortions performed under the NHS remain. At the national level a lower proportion of early terminations occur in the public sector than in the private sector, and women in the least skilled occupational groups have their abortions latest.
Introduction
With the liberalization of abortion, through the 1967 Abortion Act, Britain has moved from a situation in which abortion as an acceptable medical procedure was covert and suppressed to one in which a woman could obtain termination on grounds that went beyond the strictly medical. However, the Act was not effected as an implement of family planning and population control and no provisions were made for abortion on demand. This paper attempts to put into perspective some of its initial demographic and social effects, analysing published (Registrar General, 1969-73) and hitherto unpublished abortion and fertility registration data, at the national and regional levels. 229
230
Richard Leete Incidence of abortion before the 1967 Act
Both as a background and as a yardstick for measuring the demographic impact of the Act, an assessment of the incidence of induced abortion before 1967 is necessary. Unfortunately, before 1967 there was no statutory requirement to notify therapeutic abortions to the Chief Medical Officer. The only official source of information was the Hospital In-Patient Enquiry (HIPE) which took an annual 10% sample of discharges and deaths from NHS hospital records. However, the data obtained from NHS records must be considered an absolute minimum because, as Diggory (1969) has noted 'Many gynaecologists used to record such procedures under the euphemistic title "dilatation and curettage"'. Table 1 shows that the Table 1. Estimates of the incidence of induced abortion before 1967, England and Wales No. of therapeutic abortions Year
NHS*
Privatef
Total
1963 1964 1965 1966 1967
2300 3000 4000 5700 8600
14,000 15,000 15,000 15,000 17,500
16,300 18,000 19,000 20,700 26,100
No. of illegal abortions^
Total no. of abortions
30,000 30,000 30,000
48,000 49,000 50,700
Source: * Chief Medical Officer, 1973 t Diggory et al., 1970 % This paper's estimate.
number of recorded therapeutic abortions estimated to have occurred in NHS hospitals increased from 2300 to 8600 in the 5 years preceding the Act, an increase of 274%. This probably reflects an increasing willingness on the part of gynaecologists to perform more abortions under the NHS or to record as abortions those being carried out under the NHS in the years immediately preceding the Act. In addition to the number of therapeutic abortions carried out in NHS hospitals there was a large but unrecorded number performed in private clinics. Diggory, Peel & Potts (1970) have attempted to quantify the amount on the basis of a personal enquiry among a sample of practising gynaecologists. Table 1 shows that the incidence of reported private abortions increased from 14,000 in 1963 to 17,500 in 1967, an increase of 25% in the five years preceding the Act. The rate of increase in the private sector was not as great as that in the public sector but, of the estimated 26,100 legal abortions carried out in 1967, twice as many were performed in private institutions as in NHS hospitals (Table 1). Estimates of the number of abortions procured illegally before the Act have generally been either speculative or impaired by vested interests. The figure of 100,000 is frequently adduced but evidence to substantiate this number is difficult
Effects of the 1967 Abortion Act
231
to find (e.g. Rhodes, 1966). Despite the difficulties involved it is of fundamental importance to have an estimate, or a range of estimates, in order to arrive at the total number of induced abortions procured annually before 1967. The Lane Committee (1974) agreed and added that 'A low estimate of pre-1967 illegal abortions implies that the Act has created a large demand for abortion whilst a high estimate implies that abortions have merely transferred from the illegal to legal sector'. However, this over-simplification misses the important point that there may have been a large unmet demand before the Act. Indeed the further back in time one goes the greater the probable demand for abortion, given today's wider availability of more effective contraception and its greater use-effectiveness. Before attempting to estimate the incidence of illegal abortions before 1967, this paper briefly examines the arguments of Goodhart (1964, 1969, 1973) and of James' (1971) adaption of Goodhart's premises. In 1966 the NOP conducted a postal survey which, among other things, attempted to estimate the 'incidence' of abortion between 1946 and 1965. Out of a sample of 3500 women, 2132 replied of whom 4 % admitted having undergone an illegal abortion. Assuming the response was representative of the entire sample and by extrapolating this ratio to all women in the fertile age group it was estimated that there was an annual average of 31,000 illegal abortions. Commenting on this estimate Goodhart (1973) argued that, because of the small number of positive replies involved, misunderstood or deliberately false answers could have introduced a serious bias when extrapolated to the total population. Given the social climate at the time of the survey, and because the questions asked aroused strong personal emotions, Goodhart concluded that it was highly likely that systematic false positive answers inflated the estimate. James (1971), however, felt that women would be most unlikely to report criminal acts in a postal questionnaire and suggested that 31,000 was 'almost certainly a gross under-estimate'. For several reasons it is unrealistic to infer anything from the results of the NOP survey. Apart from the problems of sampling error, not knowing whether the respondents to the survey were representative of the sample, and the nature and direction of any possible bias which could have operated in either direction, there is the additional problem (which apparently both Goodhart and James overlooked) that the survey only elicited prevalence information from which one cannot derive an incidence rate. The NOP survey represents the only direct attempt at estimating the extent of illegal abortion before 1967 but there have been several indirect approaches. One of these, pioneered by Goodhart, attempted to utilize data on induced abortions from the Royal Infirmary in Aberdeen. It was suggested that Scotland in general, and Aberdeen in particular, had as liberal an abortion policy in the pre-1967 era as that prevailing in England and Wales after 1967. On the assumptions that there were very few or no criminal abortions in Aberdeen, that all abortions on women of Aberdeen were done within the City, that the total demand was fully met, and that this demand was representative of the entire population of England and Wales, Goodhart concluded that illegal abortions could not have exceeded 20,000 annually.
232
Richard Leete
James (1971) rejects the first three of these assumptions and, working with a revised hypothesis, builds his own argument on an adaptation of the fourth. Pointing out that septic abortions were not as rare in Aberdeen as Goodhart had believed, and assuming that about 20-25 % of all criminal abortions later require hospital admission, and further, that most septic abortions are caused by illegal abortions, James asserts that there certainly were more than a few criminal terminations. Next he notes that married abortion patients in Aberdeen outnumbered the unmarried by a ratio of 8 to 1 and that this is contrary to post-1967 experience. Consequently he hypothesizes that 'Many incipient demands for abortion from unmarried lower class girls were stifled by the GP without the patient seeing the obstetrician'. Not only does James feel that the demand for abortions was unmet but that the demand was atypical of the rest of the country, since the 'effective family planning services' resulted in a 'diminution of unwanted pregnancies'. In particular, because the rate of sterilization was higher in Aberdeen than elsewhere the demand for abortion was correspondingly lower. After taking the above factors into account James concludes that the legal rates under-estimated the number of abortions by a factor of 4J and, multiplying Goodhart's estimate by this amount and subtracting legal terminations, estimates that there were 60,000 illegal abortions annually. The assumptions of James' argument are untenable. In particular, it is extremely doubtful whether one can extrapolate the demand for abortions from either Goodhart's original rate for Aberdeen or from James' revised rate. First, was the demand for abortions in Aberdeen from women of Aberdeen ? How many married women temporarily obtained Aberdeen addresses and doctors simply to secure an abortion there ? Second, a positive abortion policy of a particular kind may generate a greater demand from a given sub-group than would be associated with that group if a negative policy prevailed. The demand for abortions in Aberdeen may have been met but that does not mean the demand would not have been more or less if other systemic changes had been made. Third, James assumes that single women who he alleges were unable to obtain an abortion in Aberdeen would have wanted to, and been able to, in other parts of the country. But if these women were from the lower social classes, as James suggests, they might have had quite strong feelings against termination, since they might have had different social norms and values regarding illegitimacy and abortion from those of middle-class women. Of course, norms and values can and do change over time. Finally, the assumption that a high sterilization rate is associated with a low abortion rate, although plausible, is an as yet unanswered empirical question. In attempting to estimate the number of unlawful abortions procured before 1967 there is another possible approach. If one knows the number who die from illegal abortions in a given year and the mortality rates associated with illegal abortions then one can readily calculate such an estimate. However, there are difficulties, although not insuperable ones, in fulfilling either of these conditions. In England and Wales there are strictly defined regulations surrounding death certification. A doctor must know the cause of death and be sure that it is natural before he can sign the death certificate; if he is in any reasonable doubt about meeting the legal criteria he must refer the case to a coroner. The coroner should
Effects of the 1967 Abortion Act
233
then order an autopsy to establish the true cause of death. In practice there are doubts concerning the accuracy of death certification, especially in relation to illegal abortion. Diggory (1969) has stated that there are pressures on a doctor to 'repress his suspicions when he feels that a woman has died after a criminal abortion, and only deaths in cases of proven criminal abortion are recorded as such by the Registrar General'. Johnson (1969) has shown that even in those cases referred to a coroner a small number of abortion deaths are certified as natural when in fact the cause is unnatural. Thus it seems that there are strong grounds for rejecting the accuracy of pre-1967 death registration. After balancing the factors alluded to above, James (1971) suggested, somewhat arbitrarily, that death registration of illegally induced abortion is underestimated by a factor of two. Mortality rates associated with criminal abortion are obviously a function of a combination of factors, including the circumstances in which the abortions are performed, length of gestation, skill of the person performing, and the availability and utilization of medical and hospital facilities in emergencies. Given the knowledge of antisepsis and the availability of antibiotics in the 1960s, it seems unreasonable to assume that on average ('average' since it balances the combination of factors mentioned above) illegally induced abortion was much more than ten times more fatal than abortion procured legally in the first few years after 1967. An illegal abortionist probably would not have wanted to continue his practice if he had been responsible for, and had a reputation for, causing more than one death. Assuming that official data on illegally induced abortion deaths just before the Abortion Act represents an underestimation by a factor of two, and that illegally induced abortion was ten times more dangerous than legally procured abortion, a revised annual estimate of the incidence of criminal abortion for the period 1964-66 is set out below. (a) The legally induced abortion death rate is taken as the average of the rates for the years 1969 and 1970, 31-0 and 16-2 per 100,000 abortions respectively, namely 23-6. (Some of these deaths were not necessarily attributed to the abortion operation but to some other 'underlying cause'. However, it is likely that some abortion deaths were not recorded by the notifying doctor since death may occur after the patient has been discharged from the place of operation. It is assumed that the two cancel out.) (b) The annual average number of illegally induced abortion deaths for 196466 was 33. Therefore the estimated annual number of criminal abortions for 1964-66 was:
_
= 16
estimated illegal abortion deaths estimated illegal abortion death rate reported illegal abortion deaths x estimated under-reporting factor A ^ * illegal abortion death rate . ,, 1 u _ x f—-———-: ———— estimated legal abortion death rate x —-,— estimated legal abortion death rate 33 x 2 TyT-? = approximately 30,000 xl
To^ °
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Richard Leete
Although the assumptions on which this estimate is based are not strong they are no weaker than those on which previous estimates have been based. But in a field where accurate measurement is impossible the estimated figure of 30,000 annual illegal abortions must be regarded as tentative and merely indicative, and should be used with caution. Furthermore, it cannot serve as a basis for estimating the demand for abortions before 1967. There is, for instance, no way of estimating how many women unsuccessfully attempted to self-induce an abortion before 1967, or how many women would have had an abortion had adequate facilities been available. Illegal abortion since 1968 It was estimated in Table 1 that there was an annual average of about 50,000 induced abortions, including 30,000 performed illegally between 1964 and 1966. A likely result of the increased availability of legal abortion is a decrease in the utilization of illegal abortion services. The trend in the number of hospital discharges after septic abortion has been downward since 1968 (Chief Medical Officer, 1973). In the period 1968-72 they fell from 2600 to 1000, a reduction of 62 %. (Sepsis is a common concomitant of illegal abortion, although not all septic abortions are illegal; some are the result of spontaneous abortions.) Since the number of septic discharges resulting from spontaneous abortion is not likely to have varied by much during this period, and, assuming that the hospital admission rate for septic illegal abortions has remained constant, it can be estimated that the incidence of illegal abortions has declined by at least 62 %, and probably by much more, since 1968. Thus a further tentative hypothesis of this paper is that by 1972 there were no more than 10,000 illegal abortions and probably considerably fewer. ' "•
Abortion and its relationship to subsequent fertility
The relationship between abortion and subsequent fertility is complicated by the intervening variable of contraception. Following conception a woman goes through three periods of different risks of subsequent conception. First, there is an absolute refractory period, for during pregnancy, it is impossible to become pregnant again; second, there is a relative refractory period, for following delivery there is a marked reduction in fecundity that is enhanced by breast feeding and may include anovulatory cycles; third, there is an extended period of normal risk of pregnancy with exposure. This third period can be connected to one of absolute refractoriness with effective contraception or relative refractoriness with inefficient contraception. Abortion will affect subsequent fertility by (a) reducing the absolute refractory period from 9 to 3 months on the average, and (b) eliminating the relative refractory period by, among other effects, removing the possibility of breast feeding. Evidence that properly performed abortions have deleterious effects and among other things cause subsequent sterility is dubious (Daling & Emanuel, 1975). Potter (1972; see also Tietze & Bongaarts, 1975) has calculated that births averted per abortion depend primarily on the efficiency of accompanying contraception, and, to a much lesser degree, on the duration of gestation and the age of
Effects of the 1967 Abortion Act
235
the woman. Depending on assumptions about these three variables the figure for net births averted per abortion varies from 0-45 where contraception is not being employed, to 0-90 where 97 % effective contraception is practised. In England and Wales a study carried out by Bone (1973) has confirmed the findings of the 1967 Population Investigation Committee Survey (Glass, 1970) that birth control has permeated society, at least among married women. However, the methods used are (a) not necessarily the most reliable ones and (b) are not used with equal effectiveness by all sections of the community. As Glass (1970) points out, 'The prevalence of birth control as practised so far does not in itself guarantee that all births are planned' and he adduces evidence which suggests that within marriage there are a large number of 'accidental' and unwanted pregnancies, the rate increasing with parity. To the extent that abortion supplements conventional methods of birth control, particularly as a back up method to contraceptive failure, and thus prevents a birth that is not wanted now or later, it makes a positive contribution to a decline in the birth rate. If, however, abortion is merely used to prevent a child that is not wanted at the time, but wanted later, its demographic significance is merely theoretical, unless a significant number of abortions occur in which case the rate of natural increase will be reduced and the mean length of a generation extended. The number of unwanted pregnancies among unmarried women is high. This is not to say that all illegitimate conceptions are unwanted; such an assertion lacks sociological realism. The number of births averted when unmarried women have abortions is difficult to estimate. Of the single women aged 16-36 in Bone's sample only 24% had ever used some method of birth control but as not all unmarried women have intercourse before marriage this figure may not be very useful. One needs to know whether unmarried women not using birth control before abortion do so after the event, and with what degree of efficiency. Potter's figure of 0-45 births averted per abortion assumes that contraception is not, and will not be, used. However, one cannot assume that, in England and Wales, unmarried women who obtain an abortion remain a non-contracepting population. Computing the number of births averted per abortion in England and Wales for either married or unmarried women is extremely hazardous and the ultimate demographic significance of births averted is impossible to quantify in any meaningful way. It is wrong to assume that all women who experience an unwanted pregnancy will have, or want to have, an abortion. Bone (1973) found that 40% of single women and 30 % of married women said they would not have an abortion under any circumstances. Among the positive replies a large number said they would do so only for medical reasons. But there is no way of assessing the strength, or lack of strength, of convictions measured by attitudinal studies. And, of course, attitudes towards abortion do change over time as has been shown by Westoff & Jones (1972) in America. It would be dangerous to extrapolate attitudes or intentions into predictions about future behaviour, especially since the circumstances surrounding an actual decision on whether or not to seek an abortion are quite different to those prevailing at the time of an interview. Nevertheless some women will prefer to continue with an unwanted pregnancy rather than procure an abortion.
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Richard Leete Abortion and the decline in fertility
Clearly the relationship between abortion, contraception and fertility is complex. Abortion and contraception, however, are merely means of fertility control; they do not cause a decline in fertility, they are merely associated with such a decline. In order to elucidate cause one needs to move to a different level of social reality. Indeed, historically, fertility has declined without the use of mechanical appliance methods of contraception and the question of whether high rates of abortion were associated with the decline remains unanswered. The Abortion Act took effect when period fertility rates had already begun to decline and cohort rates were apparently declining. In order to explain this decline one would need to look at individuals, singly and in groups, at the motives and meanings of their actions and the changing social and economic context which helped to shape their actions. The concern here, however, is only to explain if and how abortion was associated with the decline. Text-fig. 1 shows that the number of induced abortions climbed from 55,000 in 1969 to a peak of 167,000 in 1973. In 1974 there was a slight down-turn in the trend and with the liberalization of abortion laws in other Western countries there was a more substantial reduction in 1975 when there were 140,000 abortions. This trend in total abortions masks an interesting pattern in the level of abortions performed on residents of England and Wales (all subsequent tables and citations will refer only to residents). The number of abortions performed on residents rose in successive years reaching 111 ,000 in 1973; subsequently, in 1974 and 1975, there were major fluctuations around this number with a suggestion of a slight downward turn to the trend. With wider availability of contraception coupled with greater use-effectiveness some decline in induced abortion might have been expected over the last 2 years. That there has been no significant decline may be indicative of an increasing desire among women to limit their child-bearing. Thus, there has been an annual net increase of around 60,000 abortions since the passing of the Act. It is unrealistic to assert that legal abortions have merely replaced former illegal ones; the demand for abortion is not completely unrelated to the type of abortion services available. Measures of the incidence of abortion in a community are generally computed in an analogous manner to fertility rates. For instance, the general abortion rate, which is the number of abortions to women in the reproductive age group divided by the female population in the same age group, is analogous to the general fertility rate. The frequency of abortion can be measured in relation to births and is conventionally expressed as a ratio. Since for these data only maternal age at the time of termination of pregnancy—whether by abortion or delivery—is available, the age-specific abortion ratios computed below will have a small bias which may be particularly pronounced in the youngest age group. This is because women who conceive between the ages of 19 j and 19J will appear in the under-20 age group if they have an abortion while those who give birth will appear in the 20-24 age group. This difficulty can be overcome by 'de-aging' (Tietze & Murstein, 1975), not undertaken here. Table 2, which depicts abortion ratios and rates for all women in the fertile
Effects of the 1967 Abortion Act
237
175,000 —
150,000-
125,000-
o
100,000 —
I o
75,000-
50,000-
25,000—
0—I
1968
1969
1970
1971 Year
1972
1973
1974
Text-fig. 1. Distribution of reported induced abortions, England and Wales, 1968-74: abortions in NHS hospitals on residents, is; non-NHS abortions on residents, si; abortions on non-residents, D. Source: Registrar General's Supplements on Abortion (196873) and OPCS Monitor Reference AB75/1. Data for 1974 relate to notifications.
age-group, reflects the s,teep rise in abortions between 1969 and 1973. The abortion ratios exhibit a U-shaped distribution with the highest ratios in the youngest and oldest age groups, where the absolute number of births is lowest. By contrast, the abortion rates exhibit an inverted J-shaped distribution, with the intensity of abortions greatest in the age group 20-24 where generally the highest number of conceptions occur. In a time of declining fertility, when there is a tendency to postpone births at the younger ages and complete childbearing earlier, abortion ratios can increase sharply even when the number of abortions remains constant and to some extent the numerator varies inversely with the denominator which
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Richard Leete
Table 2. Abortion ratios and rates for all women, 1969 and 1973, England and Wales 'Abortion ratios/1000 total tjirthst Age group All ages
