The effect of legalized abortion on morbidity resulting from criminal abortion RONALD
S.
LAWRENCE
D.
MALCOLM Atlanta,
KAHAN, G.
BAKER,
M.D. M.D.
FREEMAN,
M.D.,
F.A.C.0.G
Georgia
In order to examine the efect of legalized abortion on the complications a surveillance system was established at a large urban hospital in Atlanta, 1969 and early 1973, legally induced abortions at this hospital increased
of criminal
Georgia. logarithmically
abortion,
Between
from 8 to 498 per quarter year. The number of women admitting to attempts at illegal abortion decreased significantly, but the decline began only after three years of increasing numbers of legal abortions. A slight decrease in the number of septic “spontaneous” abortions also occurred. Making legal abortion services available can result in a decrease in morbidity associated with broad to obviate
illegal abortion, but the availability having to resort to criminal means.
of
legal abortion
A D E c R E A s E in the morbidity and deaths resulting from criminal abortion is one anticipated consequence of the establishment of legal abortion services. If legal abortion services are made freely available one would assume that most women will choose legal over illegal means. As a result, fewer women will seek medical care for complications caused by criminal abortion. The present study was designed to examine this relationship in a place where abortion has been legal for over four years. While earlier studieslt 2 demonstrated decreases in the numbers of septic abortions, with increased legal abortions, we have, by restricting analysis to women who have admitted to attempts at illegal abortion, made it unnecessary to rely on septic abortion as an indicator of illegal abortion activity. From
the Family
ENvaluation Division, Center for Disease Control, United States Public Health Service, Department of Health, Education, and Welfare, and the Division of Perinatal Pathology, Department of Gynecology-Obstetrics, Emory University School of Medicine.
Revised Accepted Reprint Planning Control,
for May
Planning
May
publication
February
be suficiently
The investigation was carried out at Grady Memorial Hospital, a 1,100 bed facility serving the medically indigent of two Georgia counties, Fulton and DeKalb, which include the city of Atlanta. Until very recently, Grady Hospital was the only source of legal abortion services for low-income women in the Atlanta area. Moreover, the citizens of this area rely heavily on this hospital for emergency medical treatment and for treatment of women with obstetric complications. Ready availability of legal abortion is likely to show most effect on illegal-abortion morbidity in a population such as that served by Grady Hospital. A law patterned after the American Law Institute’s Model Penal Code has permitted abortions in Georgia since 1968,” though the procedural requirements became somewhat less cumbersome in 1970’ and even less so in 1973.5
Bureau of Epidemiology,
Received
must
Methods
The Abortion Surveillance Project at Grady Hospital was established in 1969 to keep detailed records of all abortion patients. Trained personnel collected data on women undergoing legal pregnancy terminations, women admitted to the hospital because of incomplete spontaneous abortions, and women seeking care for complications resulting from illegal abortions. Information came from emergency
5, 1974.
22, 1974. 24, 1974.
requests: Dr. Ronald S. Kahan, Family Evaluation Division, Center for Disease Atlanta, Georgia 30333.
114
Volume Number
121 1
room records, in-hospital clinical charts, pathology reports, and patient interviews. Only women who actually admitted to criminal abortion attempts were considered illegal abortion patients in this study. Results
Table I shows numbers of legally induced abortions and illegal-abortion complications recorded at Grady Hospital by quarter year for the period from January 1969 to March 1973. During this period, the number of pregnancies terminated legally at Grady Hospital increased steadily-from about 8 per quarter during 1969 to 498 in the first quarter of 1973. However, from 1969 to early 1972, the average number of women with complications of admitted illegal abortions remained relatively constant, averaging 21.5 per quarter. Only beginning with the second quarter of 1972 did the number of such patients begin to decline sharply, reaching a level of 5 for the first quarter of 1973. Fig. 1 is a graph showing these values on a semilogarithmic scale, with a moving average technique used for smoothness. Comment
One argument in favor of legalizing abortion is the salutary effect it should have on the incidence of complications attributable to criminal abortion. Though intuitively acceptable to many people, such an assertion requires empirical verification. Huldt” was unable to show such an association in Stockholm. On the other hand, Stewart and Goldstein’ found that the number of admissions to San Francisco General Hospital for septic abortion declined with the increasing availability of legal abortion services. Seward, Ballard, and Ulene2 reported similar findings at Los Angeles County Hospital. Septic abortions, however, can only be presumed to be illegally induced. Our data deal directly with women who admit to criminal intervention. No assumptions about septic abortions are needed. It is interesting to note, however, that, as the number of criminal abortions declined in our study, the number of women with septic “spontaneous” abortion requiring treatment at Grady Hospital declined as well. This suggests that the decrease in the number of women with illegal-abortion complications is not an artifact caused by unwillingness to admit to intervention. Only after three years of increasing numbers of legal abortions, when the abortion:live birth ratio
Legalized
abortion
on
morbidity
from
criminal
abortion
115
Table I. Patients having legal abortions and patients treated for complications of illegal abortions, Grady Memorial Hospital, 1969 to first quarter of 1973 Illegal
Legal Yea7
I
Ouarter
I
No.
1 AB:LB*
No.
1 AB:LB*
4.9 6.5 5.6 3.8 13.4 16.2 20.6 34.6
16 14 20 16 28 33 25 11
11.3 11.4 12.5 10.3
13.2 19.2 15.1 15.5
3.6
1969
1 2 3 4
1970
1 2 3 4
1971
1 2 3 4 1 2 3 4
74 87 157 175
46.7 66.8 103.0 117.9
258 299 371 296
182.6 227.4 245.7 211.8
21 25 23 23 24 9 9 6
1
498
356.2
5
1972
1973 *Abortions
7 8 9 6 19 23 35 56
1
per
1,000
live
19.7 24.2 14.7 6.8
17.0 6.8 6.0 4.3
births.
at Grady Hospital reached 227 abortions per 1,000 live births, did the decline in illegal-abortion complications begin. Clearly, the availability of abortion services must be sufficiently broad to obivate having to resort to criminal means. Though it is likely that many women who would undergo legal abortions would not resort to criminal methods, each legal abortion does not necessarily eliminate one illegal abortion. Moreover, since every criminal abortion does not result in a woman seeking hospital care, one would predict that a large number of legal abortions must be performed before an effect on illegal-abortion morbidity is observed. The number of criminal abortions that must be eliminated before illegal-abortion morbidity decreases will depend on many factors, including the skill of the illegal abortionists in the community and the number of women with complications admitted to the study hospital. We cannot be certain that the number of illegalabortion complications has decreased because of availability of abortion services at Grady Hospital. It might be that women who previously underwent criminal abortions now journey to New York or Washington, D. C., where there were also great increases in the numbers of legal abortions performed on Georgia residents during this period.7 Yet it matters little whether Grady Hospital, out-of-state facilities, or a combination of the two is responsible for the decline. The availability of legal abortion services seems to have reduced the use of illegal
116
Kohan,
Baker, and Freeman
IO00 8OC
-
LEGAL
600
-----
ILLEGAL
ABORTIONS AEORTIONS
200
100 80 60
7 I
2
3
411
,969
2
3
411
2
1970
3
411
2
,971
3
411
1972
1973
OVARTER
Fig. 1. Numbers of Georgia, 1969 to first
abortions quarter
recorded of 1973.
(by
abortion among the women who look to Grady Hospita1 as their source of emergency medical care. Improved contraceptive usage is an alternative explanation for the decrease in illegal abortion activities. Fewer unwanted pregnancies could lead to a decreased demand for illegal abortion. Better con-
quarter)
at
Grady
Memorial
Hospital,
Atlanta,
traception may well have played a part in producing these observations, though, if it were the sole factor, one would be hard pressed to explain why the demand for legal abortions has increased so dramatically.
REFERENCES
1. 2. 3. 4.
Stewart, G. K., and Goldstein, P. J.: Obstet. Gynecol. 37: 510, 1971. Seward, P. N., Ballard, C. A., and Ulene, A. L.: AM. J. OBSTET. GYNECOL. 115: 335, 1973. Georgia Code, Sections 26-1201 and 26-1202. Doe vs. Bolton, Civil Action No. 13676 in the United
5. 6. 7.
States District Court for the Northern District Georgia, Atlanta Division, August 24, 1970. Doe vs. Bolton (41 U.S.L.W. 4233). Huldt, L.: Lancet 1: 467, 1968. Center for Disease Control: Abortion Surveillance 1970, 1971, and 1972.
of
S.
LAWRENCE
D.
MALCOLM Atlanta,
KAHAN, G.
BAKER,
M.D. M.D.
FREEMAN,
M.D.,
F.A.C.0.G
Georgia
In order to examine the efect of legalized abortion on the complications a surveillance system was established at a large urban hospital in Atlanta, 1969 and early 1973, legally induced abortions at this hospital increased
of criminal
Georgia. logarithmically
abortion,
Between
from 8 to 498 per quarter year. The number of women admitting to attempts at illegal abortion decreased significantly, but the decline began only after three years of increasing numbers of legal abortions. A slight decrease in the number of septic “spontaneous” abortions also occurred. Making legal abortion services available can result in a decrease in morbidity associated with broad to obviate
illegal abortion, but the availability having to resort to criminal means.
of
legal abortion
A D E c R E A s E in the morbidity and deaths resulting from criminal abortion is one anticipated consequence of the establishment of legal abortion services. If legal abortion services are made freely available one would assume that most women will choose legal over illegal means. As a result, fewer women will seek medical care for complications caused by criminal abortion. The present study was designed to examine this relationship in a place where abortion has been legal for over four years. While earlier studieslt 2 demonstrated decreases in the numbers of septic abortions, with increased legal abortions, we have, by restricting analysis to women who have admitted to attempts at illegal abortion, made it unnecessary to rely on septic abortion as an indicator of illegal abortion activity. From
the Family
ENvaluation Division, Center for Disease Control, United States Public Health Service, Department of Health, Education, and Welfare, and the Division of Perinatal Pathology, Department of Gynecology-Obstetrics, Emory University School of Medicine.
Revised Accepted Reprint Planning Control,
for May
Planning
May
publication
February
be suficiently
The investigation was carried out at Grady Memorial Hospital, a 1,100 bed facility serving the medically indigent of two Georgia counties, Fulton and DeKalb, which include the city of Atlanta. Until very recently, Grady Hospital was the only source of legal abortion services for low-income women in the Atlanta area. Moreover, the citizens of this area rely heavily on this hospital for emergency medical treatment and for treatment of women with obstetric complications. Ready availability of legal abortion is likely to show most effect on illegal-abortion morbidity in a population such as that served by Grady Hospital. A law patterned after the American Law Institute’s Model Penal Code has permitted abortions in Georgia since 1968,” though the procedural requirements became somewhat less cumbersome in 1970’ and even less so in 1973.5
Bureau of Epidemiology,
Received
must
Methods
The Abortion Surveillance Project at Grady Hospital was established in 1969 to keep detailed records of all abortion patients. Trained personnel collected data on women undergoing legal pregnancy terminations, women admitted to the hospital because of incomplete spontaneous abortions, and women seeking care for complications resulting from illegal abortions. Information came from emergency
5, 1974.
22, 1974. 24, 1974.
requests: Dr. Ronald S. Kahan, Family Evaluation Division, Center for Disease Atlanta, Georgia 30333.
114
Volume Number
121 1
room records, in-hospital clinical charts, pathology reports, and patient interviews. Only women who actually admitted to criminal abortion attempts were considered illegal abortion patients in this study. Results
Table I shows numbers of legally induced abortions and illegal-abortion complications recorded at Grady Hospital by quarter year for the period from January 1969 to March 1973. During this period, the number of pregnancies terminated legally at Grady Hospital increased steadily-from about 8 per quarter during 1969 to 498 in the first quarter of 1973. However, from 1969 to early 1972, the average number of women with complications of admitted illegal abortions remained relatively constant, averaging 21.5 per quarter. Only beginning with the second quarter of 1972 did the number of such patients begin to decline sharply, reaching a level of 5 for the first quarter of 1973. Fig. 1 is a graph showing these values on a semilogarithmic scale, with a moving average technique used for smoothness. Comment
One argument in favor of legalizing abortion is the salutary effect it should have on the incidence of complications attributable to criminal abortion. Though intuitively acceptable to many people, such an assertion requires empirical verification. Huldt” was unable to show such an association in Stockholm. On the other hand, Stewart and Goldstein’ found that the number of admissions to San Francisco General Hospital for septic abortion declined with the increasing availability of legal abortion services. Seward, Ballard, and Ulene2 reported similar findings at Los Angeles County Hospital. Septic abortions, however, can only be presumed to be illegally induced. Our data deal directly with women who admit to criminal intervention. No assumptions about septic abortions are needed. It is interesting to note, however, that, as the number of criminal abortions declined in our study, the number of women with septic “spontaneous” abortion requiring treatment at Grady Hospital declined as well. This suggests that the decrease in the number of women with illegal-abortion complications is not an artifact caused by unwillingness to admit to intervention. Only after three years of increasing numbers of legal abortions, when the abortion:live birth ratio
Legalized
abortion
on
morbidity
from
criminal
abortion
115
Table I. Patients having legal abortions and patients treated for complications of illegal abortions, Grady Memorial Hospital, 1969 to first quarter of 1973 Illegal
Legal Yea7
I
Ouarter
I
No.
1 AB:LB*
No.
1 AB:LB*
4.9 6.5 5.6 3.8 13.4 16.2 20.6 34.6
16 14 20 16 28 33 25 11
11.3 11.4 12.5 10.3
13.2 19.2 15.1 15.5
3.6
1969
1 2 3 4
1970
1 2 3 4
1971
1 2 3 4 1 2 3 4
74 87 157 175
46.7 66.8 103.0 117.9
258 299 371 296
182.6 227.4 245.7 211.8
21 25 23 23 24 9 9 6
1
498
356.2
5
1972
1973 *Abortions
7 8 9 6 19 23 35 56
1
per
1,000
live
19.7 24.2 14.7 6.8
17.0 6.8 6.0 4.3
births.
at Grady Hospital reached 227 abortions per 1,000 live births, did the decline in illegal-abortion complications begin. Clearly, the availability of abortion services must be sufficiently broad to obivate having to resort to criminal means. Though it is likely that many women who would undergo legal abortions would not resort to criminal methods, each legal abortion does not necessarily eliminate one illegal abortion. Moreover, since every criminal abortion does not result in a woman seeking hospital care, one would predict that a large number of legal abortions must be performed before an effect on illegal-abortion morbidity is observed. The number of criminal abortions that must be eliminated before illegal-abortion morbidity decreases will depend on many factors, including the skill of the illegal abortionists in the community and the number of women with complications admitted to the study hospital. We cannot be certain that the number of illegalabortion complications has decreased because of availability of abortion services at Grady Hospital. It might be that women who previously underwent criminal abortions now journey to New York or Washington, D. C., where there were also great increases in the numbers of legal abortions performed on Georgia residents during this period.7 Yet it matters little whether Grady Hospital, out-of-state facilities, or a combination of the two is responsible for the decline. The availability of legal abortion services seems to have reduced the use of illegal
116
Kohan,
Baker, and Freeman
IO00 8OC
-
LEGAL
600
-----
ILLEGAL
ABORTIONS AEORTIONS
200
100 80 60
7 I
2
3
411
,969
2
3
411
2
1970
3
411
2
,971
3
411
1972
1973
OVARTER
Fig. 1. Numbers of Georgia, 1969 to first
abortions quarter
recorded of 1973.
(by
abortion among the women who look to Grady Hospita1 as their source of emergency medical care. Improved contraceptive usage is an alternative explanation for the decrease in illegal abortion activities. Fewer unwanted pregnancies could lead to a decreased demand for illegal abortion. Better con-
quarter)
at
Grady
Memorial
Hospital,
Atlanta,
traception may well have played a part in producing these observations, though, if it were the sole factor, one would be hard pressed to explain why the demand for legal abortions has increased so dramatically.
REFERENCES
1. 2. 3. 4.
Stewart, G. K., and Goldstein, P. J.: Obstet. Gynecol. 37: 510, 1971. Seward, P. N., Ballard, C. A., and Ulene, A. L.: AM. J. OBSTET. GYNECOL. 115: 335, 1973. Georgia Code, Sections 26-1201 and 26-1202. Doe vs. Bolton, Civil Action No. 13676 in the United
5. 6. 7.
States District Court for the Northern District Georgia, Atlanta Division, August 24, 1970. Doe vs. Bolton (41 U.S.L.W. 4233). Huldt, L.: Lancet 1: 467, 1968. Center for Disease Control: Abortion Surveillance 1970, 1971, and 1972.
of
