The Institute of Medicine reports on legalized abortion and the public health. (Comment and Controversy).

Two major conclusions emerge from the year-long study by the National Academy of Sciences' Institute of Medicine about how legalized abortion affects the public health:

* "Fewer deaths and a lower rate of medical complications" may be expected when abortion legalization permits women to obtain abortions in "proper medical surroundings" than when restrictive laws and practices prevail. This is because "many women will seek to terminate an unwanted pregnancy by abortion whether it is legal or not . . . [and] the mortality and morbidity associated with illegal abortion . . . are clearly greater than the risks associated with legal abortion." The institute's report notes that 70 percent of legal abortions in the United States replace abortions that were previously obtained illegally.

* "Laws, medical practices, and educational programs should enable and encourage women who have chosen abortion to obtain it in the first three months of pregnancy," since the risks of death and illness are much greater for second-trimester than first-trimester abortions. (The report points out, however, that abortions cannot usually be performed before the second trimester when the purpose is to avert genetic abnormalities, since procedures for diagnosis of fetal defects can rarely be performed until the fifteenth week of pregnancy. The investigators emphasize the importance of research to find safer methods of inducing abortion in the second trimester.)

The report also places "highest priority" on continued investigation of long-term medical complications of induced abortion; "the effects of abortion and denied abortion on the mental health and social welfare of individuals and families"; and "factors of motivation, behavior, and access associated with contraceptive use and the choice of abortion." High priority is accorded to research on whether induced abortion "aggravates" the high risk of medical complications teenagers face from any pregnancy.

The group of scholars, researchers, health practitioners and concerned lay persons that conducted the study (*) was called together by the institute in 1974 "to review the existing evidence on the relationship between legalized abortion and the health of the public, . . . to examine the medical risks to women who obtained legal abortions," and to document changes in the risks as "the status of abortion shifts from essentially illegal to legal." (About 745,000 legal abortions were reported in the United States in 1973, and an estimated 800,000 in 1974, compared to fewer than 23,000 legal abortions in 1969, the year before passage of nonrestrictive abortion laws by four states.) The study group also closely examined the relative risks of early as compared to later abortion.

Complications from Abortion

The investigators found that the risk of early medical complications from legal abortion increases with the length of gestation. While this is true even within the first trimester, the differences are most marked between first- and second-trimester abortions; the total and major complication rate (*) is more than three times higher for abortions performed following the twelfth week, than for those performed earlier. Most of the report's conclusions on complications were drawn from the Joint Program for the Study of Abortion (JPSA) study made in the United States in 1970/1971 of 73,000 legal abortions (see Table 1).

Not unexpectedly, women with preexisting complications and women who underwent concurrent sterilization had substantially higher complication rates than healthy women who underwent abortion alone. The report points out that the high complication rate reported in the JPSA survey for women undergoing concurrent sterilization probably no longer obtains, since more sterilizations are now being performed by laparoscopy (which does not require extensive abdominal surgery) than was the case in 1970-1971. The authors point to a recent study which found that. 9.2 percent of abortion patients undergoing suction abortion and concurrent laparoscopic sterilization suffered complications, compared to 7.2 percent of those undergoing abortion alone. The report notes that this is "a significantly smaller differential than in the JPSA study and much lower rates than the rates reported with other sterilization techniques."

Nearly three-quarters of abortions are performed by the suction method in the United States. Complication rates are somewhat lower for this method than for the second most frequently used method during the first trimester, dilatation and sharp curettage (D & C). Complication rates associated with the suction method, the report states, "are substantially lower for [freestanding] clinic patients than for either outpatients or inpatients in hospitals." The authors attribute this to the fact that clinic physicians, "who usually perform a higher number of abortions [than hospital doctors], may be more experienced than other physicians in performing abortions; and there may be less complete reporting of delayed complications for clinic patients than for those treated in hospitals."

The report notes that while many of the complications associated with saline abortion (the most commonly employed method during the second trimester) are beyond the physician's control, one very common problem-hemorrhaging--can be markedly reduced if the placenta is removed within one hour after the fetus is delivered. After careful examination of all the available evidence, the study group concludes that "no definitive conclusions can be drawn . . . about the long-term complications of legal abortion in the United States." Cervical incompetence, scar tissue from infection, or other trauma to the reproductive organs after abortion have been suggested as long-term complications that might lead to subsequent spontaneous abortion or prematurity, subsequent ectopic pregnancy, or infertility. The report finds the evidence contradictory and the methodology seriously flawed in published studies. What is more, all of the studies made thus far were made outside the United States, so that their "direct applicability t o the United States is not known at this time."

The report points out that a World Health Organization task force has initiated controlled prospective studies in European countries on the effects of induced abortion on subsequent pregnancies, but that the results of these studies will not be available until 1977.

With regard to long-term complications among adolescent women who have abortions, the report concludes: "Teenage women constitute a special case, in that any pregnancy, be it terminated by abortion or by a full-term birth, seems to increase the risk of prematurity in subsequent pregnancies." As an example, the report cites a study of school-age pregnant women made during 1967-1969: Twelve percent of first pregnancies ended in premature births, but 27 percent of subsequent pregnancies resulted in premature births. Although available evidence does not indicate that the increased risk of prematurity Laced by teenagers with increased pregnancy order is aggravated by induced abortion, the study group states that Thigh priority" should be given to research in this area, since nearly one-third of legal abortions in the United States are obtained by teenagers.

Medical complications associated with illegal (nonmedical or self-induced) abortion appear to have declined markedly since abortion legalization, based on hospital records of admissions due to septic and- incomplete abortion--two adverse consequences of the illegal procedure. While increased use of effective contraception may have contributed to this decline (resulting in fewer unwanted pregnancies), the study group concludes that "the introduction of less restrictive abortion legislation was a major factor."

Abortion and the Risk of Death

Fewer than two women in 100,000 are likely to die from causes associated with legal induced abortion performed during the first trimester, the study group found, "less than the risks associated with illegal abortion, full-term pregnancy, and most surgical procedures." (See Figure 1.)

The report notes, however, that the mortality risk associated with legal abortion "increases dramatically with the duration of pregnancy," rising from 0.5 deaths per 100,000 procedures performed between nine and 10 weeks to 16 deaths per 100,000 at 16 weeks or later. Mortality was lowest for abortions performed by suction (1.6 per 100,000 procedures), and highest for those performed by hysterotomy and hysterectomy (61.3). Deaths associated with saline abortions were 15.4 per 100,000 procedures.

Overall, there were 22 deaths reported in the United States in 1973 associated with legal abortion, or 3.6 deaths per 100,000 procedures. This is lower than the rates reported from England, Denmark and Sweden, but higher than those reported from Czechoslovakia and Hungary. The difference is attributed largely to the fact that there were a larger proportion of late procedures in the former three countries, and a much smaller proportion of late procedures in the latter two, than in the United States.

Deaths from illegal abortions have declined sharply since legal abortions became more available beginning in 1967 (from an average of 218 deaths per year in 1963-1967 to 27 deaths in 1973). Abortion mortality rates have declined from 0.30 per 100,000 women aged 15-44 in 1968 to 0.06 in 1973. The absolute decline has been much greater for nonwhite women (from 1.29 to 0.29) than for white women (0.16 to 0.03), but nonwhites still face nearly 10 times the risk of death from illegal abortion as whites.

The report also points to data from Romania, which show that "when nonrestrictive abortion laws are tightened, deaths associated with illegal abortion increase." (Restrictions were introduced in 1966. Illegal abortion deaths rose from 64 in 1965 to 364 in 1971.)

Psychological Effects

The study group concludes that although "abortion may elicit feelings of guilt, regret or loss in some women, these reactions tend to be temporary and appear to be outweighed by positive life changes and feelings of relief. Moreover, ... although abortion may indeed be followed by some minor negative feelings, major psychiatric trauma is essentially nonexistent." The report cites the JPSA findings that postabortion psychosis ranged from 0.2 to 0.4 episodes per 1,000 legal abortions, lower than the U.S. postpartum psychosis rate of one to two per 1,000 deliveries, suggesting, at the very least, that abortion is not "significantly more hazardous psychologically than is term delivery."

The report cautions, however, that abortion "cannot be viewed as a solution for psychiatric disturbance, and may perhaps exacerbate the condition [of women who are psychotic]."

The study group describes two studies, one in Sweden and the other in Czechoslovakia, which suggest that children born to women who were denied abortion exhibit more social and psychological problems than children born to women who chose to carry their pregnancies to term.

Women who delay abortion until late in the pregnancy "may have more feelings of ambivalence, denial of the pregnancy, or objection on religious grounds, than those obtaining abortions in the first trimester," the study group concludes. However, it adds, "some second-trimester abortions result from procedural delays, difficulties in obtaining a pregnancy test, locating appropriate counseling, or arranging and financing the procedure." The investigators suggest that research to define the psychological differences between women seeking early and late abortion, "coupled with research on the social and economic barriers to earlier abortions, may suggest ways to encourage women seeking abortion to do so in the first trimester," when the procedure is most safe. Greater availability of early abortion and better education about the greater safety of first-trimester procedures may reduce the proportion of women seeking second-trimester abortions.

However, such late abortions will continue to be necessary "to prevent the birth of children with severe genetic disorders and to help ensure the birth of unaffected children," the report states. It points out that in North America,

amniocentesis was performed in more than 6,000 second-trimester pregnancies between 1967 and 1974. The diagnostic accuracy was close to 100 percent and complication rates were about two percent. Less than 10 percent of the diagnoses disclosed an affected fetus, meaning that the great majority of parents at risk averted an unnecessary abortion and were able to carry an unaffected child to term.

The authors conclude: "Pending the availability of techniques for earlier detection of a fetus with severe genetic disorders, prevention of the birth of children with these disorders will remain an important reason for second-trimester abortions."

The study group could find no evidence to support the allegation that legalization of abortion leads to a relaxation of contraceptive diligence. On the contrary, it found that contraceptive counseling at the time of abortion may have resulted in the initiation of contraceptive use among women who had previously not used contraception or had used it poorly."

Although there has been some increase in the cumulative number of repeat abortions being reported, this is entirely consistent, the report states, with the expected increase, given the fact that no method of contraception is 100 percent effective, nor is any contraceptive likely to be used with maximum care on all occasions. The data show, according to the study group, "the importance of abortion facilities paying greater attention to the future contraceptive needs of their patients. The timing of such postabortion contraceptive services is particularly significant, since some data suggest that ovulation ... may occur as early as 10 days [after the abortion]."

Richard Lincoln is editor of Family Planning Perspectives.

(*.) The committee is chaired by Mildred Mitchell Bateman, Director, West Virginia Department of Mental Health. Members include: Helen Barnes, Associate Professor, Department of Obstetrics and Gynecology, University of Mississippi; Elise Boulding, Professor of Sociology, Institute of Behavioral Science, University of Colorado; Robert E. Cooke, Vice Chancellor for Health Sciences, University of Wisconsin; Henry W. Foster, Professor and Chairman, Department of Obstetrics and Gynecology, Meharry Medical College; Ruth Watson Lubic, General Director, Maternity Center Association; Brian MacMahon, Professor and Head, Department of Epidemiology, Harvard University School of Public Health; Frederick C. Robbins, Dean, School of Medicine, Case Western University; Lisbeth Bamberger Schorr, Children's Defense Fund; Eleanor Bernert Sheldon, President, Social Science Research Council; and Christopher Tietze, Senior Consultant, The Population Council.

(*.)"Total" complications include all complaints registered by the patient, as well as diagnoses made by the physician. Minor problems, such as a single day of fever or vomiting, would be included In total complications, while the need for major surgery, one or more blood transfusions, prolonged illness and sustained fever would be classified as "major" complications.

Table 1

Total and major postabortal complications per 100 local patients with
follow-up, by gestation, procedure, preexisting complications, and
concurrent sterilization, JPSA, July 1, 1970-June 30, 1971

Type of                                Complication rates
 abortion                       Total                 Major

All patients
  12 weeks or less               7.8                    1.1
  13 weeks or more              26.1                    3.0

Patients without preexisting
 complications, by procedure
 complication, by procedure
  Suction (*)                    6.1                    0.6
  D & C (*)                      8.2                    0.8
  Saline (*)                    27.2                    2.4
  Hysterotomy (+)               32.9                    6.9
  Hysterectomy                  50.9                   15.6

Patients without complications
 or sterilization
  12 weeks or less               6.2                    0.6
  13 weeks or more              26.0                    2.1

Patients without preexisting
 complications, with
 sterilization
  12 weeks or less              28.0                    7.2
  13 weeks or more              35.4                    8.0
Patients with preexisting
 complications, without
 sterilization
  12 weeks or less              17.1                    2.0
  13 weeks or more              35.1                    6.7

Patients with preexisting
 complications and
 sterilization
  12 weeks or less              46.2                   17.1
  13 weeks or more              60.4                   17.4

(*)Without tubal sterilization.

(+)With tubal sterilization.

Source: C. Tietze and D. A. Dawson, "Induced Abortion: A Factbook,"
Reports on Population/Family Planning, No. 14, Dec. 1973.
Figure 1

Death rate per 100,000 selected procedures, United States

                       Death rate

Legal abortion,
 first trimester (*)          1.7
Legal abortion,
 second trimester (*)        12.2
Tonsillectomy and
 adenoldectomy (+)            5.0
Tubal litigation (+)          5.0
Childbirth (++)              14.1
Cesarean Section (+)        111.0
Hysterectomy (+)            204.0
Appendectomy (+)            352.0


(*)Based on 1972-1973 data from the Center for Disease Control.

(+)1969 data from C.G. Child III, "Surgical Intervention," In Life and
Death and Medicine, W. H. Freeman, San Francisco, 1973, p. 65. This book
originally appeared as the Sept. 1973 edition of Scientific American.

(++)National Center for Health Statistics, DHEW, "Summary Report: Final
Mortality Statistics, 1973," Monthly Vital Statistics Report, Vol. 23,
No. 11, Supplement (2), 1975.