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ABORTION: PART II
THURSDAY, APRIL 25, 1974
Washington, D.C. The subcommittee met, pursuant to recess, at 10:15 a.m., in Room 2221, Dirksen Senate Office Building, Senator Birch Bayh (chairman of the subcommittee) presiding.
Present: Senator Bayh (presiding).
Also present: J. William Heckman, Jr., chief counsel; and Abby Brezina, chief clerk.
Senator Bayh. We will reconvene our hearings, this morning.
Our first witness is Dr. Christopher Tietze, senior consultant for the Population Council, New York City.
Dr. Tietze, we appreciate your being with us this morning. STATEMENT OF DR. CHRISTOPHER TIETZE, SENIOR CONSULTANT,
THE POPULATION COUNCIL, NEW YORK, N.Y. Dr. TIETZE. My name is Christopher Tietze, I am a resident of the State and city of New York, a physician and demographer by profession, and currently employed by the Population Council as a senior consultant.
Over the past 35 years, I have been the author or coauthor of about 185 articles published in medical and scientific journals, concerned for the most part with human reproduction and its regulation, including 45 papers on abortion. Recently, I was personally responsible for the most comprehensive evaluation of early medical complications of legal abortion ever attempted in this country. The joint program for the study of abortion, JPSA, involved the voluntary cooperation of the obstetrical/gynecological departments of 60 teaching hospitals and six free-standing clinics in 17 states and the District of Columbia. Individual medical records were collected for 73,000 abortions performed during a 1 year period from mid-1970 to mid-1971, about one-seventh of the total number of legal abortions in the United States. These data were analyzed in terms of age of woman, prior pregnancies, marital status, ethnic group, type of service, preexisting complications, period of gestation, primary procedures, sterilizing operations, total and major complications, and a number of other variables. Copies of the definitive report of JPSA and of a more recent publication, entitled “Induced Abortion: A Factbook” have been submitted to the subcommittee; others can be made available on request.
I have been invited to testify here today as an expert medical witness. I am honored by this invitation and shall make every effort to answer all questions to the best of my ability. If I don't know the answer I shall not hesitate to say so. However, expert witnesses cannot be expected to be political eunuchs. Most of them hold personal opinions about the subject under consideration and I believe that you are entitled to know my personal views in order to assess any possible bias in my testimony. I fully support the decision by the Supreme Court of the United States in the matter of abortion of January 22, 1973, and I am strongly opposed to any legislation designed to reverse this decision or to provent its full implementation.
Before placing myself at your disposal for questioning, I should like to touch upon a few of the points the subcommittee may wish to consider. One obvious concern is the incidence of early medical complications of legal termination of pregnancy and of deaths resulting from these procedures. Many erroneous and misleading statements have been made in public in regard to these matters. It has been alleged, among other things, that
the low rates of complications and of mortality, associated with legal abortion in the United States, lack credibility because some comparable rates from other countries have been substantially higher. I call these statements misleading because they fail to take into consideration such factors as the duration of pregnancy at which the abortions were performed, the state of health of the women, the simultaneuos performance of sterilizing operations, and the surgical procedures employed. I hope to presen evidence from several countries which will show that legal abortion during the first 12 weeks of pregnancy, in healthy women and without concurrent sterilization, is associated with mortality rates between 1 and 4 deaths per 100,000 abortions, compared with a rate of maternal mortality from complications of pregnancy and childbirth, excluding abortion, of 18 deaths per 100,000 live births in the United States in 1970, the last year for which these statistics are available.
Complication rates and mortality rates following abortion in the second trimester of pregnancy are, of course, higher than in the first trimester. I hope you will give me an opportunity to discuss in some detail the statistics contained in the materials submitted to you.
Reliable information on late complications or sequelae of legal abortion is quite limited and most of the statements in the literature are based on observations of individual cases or small groups of cases. frequently of a highly selected character, on inference from time series or geographic patterns, or on other methodologically inadequate approaches. It may please the subcommittee to learn that the World Health Organization has a task force, of which I am the chairman, developing research in this area. Meanwhile, I shall try to furnish whatever information is now available.
Another matter to which I would like to address myself is the frequency of illegal abortion. For obvious reasons, this is an area in which reliable statistics are not available and in which some extraordinary estimates have been made. In general, proponents of free choice in matters of abortion have tended to make high estimates while persons opposed to abortion have tended to make low estimates. It is possible, however, to obtain some idea as to the probable number of illegal abortions, at least for certain places.
One of these places is New York City where large numbers of legal abortions have been performed since July 1, 1970, and where reasonably complete statistics have been collected. During the first year of the liberalized abortion law, the increase in the number of legal abortions of resident women was far greater than the corresponding decline in the number of births, but in the second year the increment in the number of abortions was much less than the decline in the number of births. On the basis of these statistics, I have made the estimate that about 70 percent of the legal abortions during the first 2 years of the liberalized law replaced illegal abortions, while 30 percent of the legal abortions were responsbile for about one-half of the decline in the number of births from 1970 to 1972. The other half of the decline in the number of births resulted from other factors, including more widespread and more effective use of contraception. There is no evidence that the practice of contraception in New York City has deteriorated since the passage and implementation of the liberalized abortion law.
Senator BAYH. Excuse me, Dr. Tietze, I do not want to interrupt your train of thought, but I only interject the question, because now might be the best time. I would like to have the basis by which you arrived at the estimate of the 70 percent/30 percent figure. It does not have to be now. But I would like to have that information.
Dr. TIETZE. Yes, Senator. This estimate is contained in one of the articles. I have a copy with me, and I'will, in response to your question try to explain it, and if you prefer, I will leave the document
Senator Bayi. Perhaps we might try both. Thank you.
Senator Bayh. Yes, I just want to make sure we return to that point.
Dr. TIETZE. Surely.
If my estimate is correct, about 50,000 illegal abortions per year were obtained by residents of New York City prior to 1970. The illegal abortion ratio in the late 1960's appears to have been on the order of 330 per 1,000 live births, not much less than the legal abortion ratio in Czechoslovakia at the present time.
Abortion is an inefficient method of fertility regulation. To achieve a low birth rate, corresponding to two or three children per couple, by abortion alone would require a very large number of abortions, at least 10 per woman during her lifetime. This is due to the fact that in the absence of contraception, at least two abortions are needed to replace one live birth. A pregnancy ending in abortion is on the average 6 months shorter than a pregnancy ending in a live birth and the period of infertility following the pregnancy is also shorter by several months. Hence the average interval between conception is considerably reduced. If contraception is used with even moderate effectiveness only slightly more than one abortion is required to replace one birth and relatively few abortions are needed to limit the number of children to whatever level is wanted by the parents.
This observation is important from the point of view of the relative risks to life and health associated with the use of contraception and abortion as methods of fertility control. A few years ago, I wrote a paper in which I could show that the risk to life experienced by a group of women using no contraception and terminating all pregnancies by early abortion was approximately equal to the risk of dying from pulmonary embolism experienced by a group of women using the oral contraceptives then available. However, if the women had used a moderately effctive method of contraception. without fatal side effects but with early abortion as a backstop, the risk to life would have been reduced by somewhere between fourfifths and nine-tenths. On the basis of this stud yl concluded that, in turns of a risk to the woman's life, the most rational procedure for regulating fertility is the use of a perfectly safe, although not 100 percent effective, method of contraception backed up by the early termination of unwanted pregnancies. In the course of the 4 years since this study was published, levels of mortality associated with legal abortion and with oral contraception have bee nreduced, but the basic argument remains uneffected.
At this point, I should like to summarize my overall evaluation of legal abortion from the medical and public health point of view. In my opinion, legal abortion is a necessary component of a complete system of voluntary fertility control. Other components, such as sex education and contraceptive services, are equally necessary but legalization of abortion is the only way to replace dangerous discriminatory, undignified, and costly illegal abortions by legal abortions, performed under medical auspices, with minimum risks to life and health and accessible to pregnant women in all economic and social groups throughout the Nation.
I am now ready to answer any questions you may wish to put to me.
Senator Bayh. Doctor, would you go back to the original question I asked you about your testimony, about how you arrived at the 70 percent figure of illegal abortions.
Dr. TIETZE. I shall be happy to do so and if I may I would like to read from my article in the Winter 1973 issue of Family Planning Perspectives, condensing the material as I go along. During the first year of the new abortion law, that is from July 1, 1970 through June 30, 1971, about 67,400 resident women obtained legal abortions in New York City which represents an increment of about 65,000 over those performed during the preceding 12 months. Most pregnancies terminated during the 12 months ending June 30, 1971, would have produced full-term infants during 1971. The number of live births registered in New York City during that year was about 131,900. Application of the age-specific fertility rates of 1970 to the age distribution of women in 1971 generates an expected total of 150,700 births, thus creating an imputed decline of 18,800 births or 12.6 percent.
Accepting the imputed decline of 18,800 in New York City from 1970 to 1971 as a first approximation of the number of births prevented or postponed by legal abortion, the next step is to estimate the number of abortions required to achieve this decline. Available information on the practice of contraception among the population of New York City suggests that a ratio of 1.2 abortions replacing one live birth is probably an appropriate estimate. Hence, 22,600 legal abortions or 35 percent of the increment of 65,000 legal abortions from 1969–1970 to 1970–1971, may have been required to prevent 18,800 births 6 months later. This estimate suggests further that, during the first year under the new law about 44,200 of the legal abortions of New York City residents involved pregnancies which, without legalization, would have been terminated by illegal abortion, or, possibly included some pregnancies resulting from a deterioration of contraceptive practice.
During the second year under the liberalized abortion law, the estimated number of abortions of New York City residents was 75,100 representing an increase of only 7,700 over the corresponding total for the preceding 12 months. Live births during 1972 numbered 115,500. Application of the agespecific fertility rates of 1971 to the projected age distribution of women in 1972 generates a total of 134,500 expected births, 19,000 more than the number registered in 1972. Hence, the decline in the number of births from 1971 to 1972 was about 2.5 times the estimated increment in the number of legal abortions among local residents 6 months earlier.
There is no evidence that the number of pregnancies increased during the second year of the liberalized abortion law, which makes it highly unlikely that a significant number of pregnancies resulting from a deterioration of contraceptive practice occurred even during the first year. Hence, virtually all of the increment in legal abortions in 1970–1971 which did not replace unwanted or mistimed (mostly out-of-wedlock) births terminated pregnancies which would otherwise have been terminated by illegal abortions.
It is unlikely that the sharp decline in illegal abortion from 1969— 1970 to 1970-1971 continued in the next 12 months, partly because illegal abortions had already reached a low level.
Changes in reproductive behavior other than more frequent legal abortions contributed significantly to the decline in the number of births in New York City from 1971 to 1972. If the proposition is accepted that 1.2 abortions were required to replace one birth, about 6,400 births were prevented by the increment of 7,700 legal abortions from 1970–71 to 1971–72, or fewer if illegal abortions continued even a modest decline. This leaves a residual of perhaps as many as 12,600 births prevented or postponed by other changes in reproductive behavior. These factors must have been operative on a major scale in 1971–72 and probably also in 1970–71. Hence, our original estimate of 18,800 unwanted births prevented or postponed by legal abortions during the first year of the liberal abortion law is probably too high, and the corresponding estimate of 44,200 illegal abortions replaced by legal abortions, too low. We may assume, arbitrarily and solely for purposes of illustration, that the impact in 1971 of changes in reproductive behavior other than increased utilization of legal abortion was one-half of what it appears to have been in 1972, or the equivalent of 6,300 fewer births. Under this assumption, the unexplained decline in the number of births from 1970 to 1971 would be on the order of 12,500; the number of legal abortions required to achieve this decline would be about 15,000 or 23 percent