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Dr. TIETZE. I have limited myself to European and North American areas. As you can see the number of abortions involved in these statistics are very large and the number of deaths are small, you will have to look primarily at the pattern of rates as a whole. Individual death rates based on half a dozen deaths are, of course, subject to random variation.

Now I would like to stress that in all of these countries, except the United States, there exists a special system of reporting legal abortions which also includes the associated deaths; hence it is possible to relate numbers of deaths from abortion to the characteristics of the women, including the duration of the pregnancy and the surgical procedures.

I would say that all of the countries included here have statistical systems in which I would have considerable confidence. You can see, for instance, in Table 3, how the mortality has declined in Sweden since the 1940's and in Denmark, Hungary, and Czechoslovakia since the 1950's. The important thing to consider here, is the fact that the practices of abortion, as regulated by law and by medical custom, from country to country. For instance, in Sweden in past years, most abortions were done quite late in pregnancy but there has been a dramatic shift in the last 5 years from later to earlier abortions. A similar shift has taken place, less dramatically, in England and also in the United States, whereas in Czechoslovakia and in Hungary abortion has always been limited to the first 12 weeks of pregnancy, with the exception of rare medical cases.

If you look at the statistics for England and Wales and for the United States, as shown in table 3, you will see that the mortality rates are substantially higher in England than in the United States; the reason for this lies in a combination of several factors.

First, the medical authorization required by the British Abortion Act results in a larger proportion of legal abortion in the second trimester. Second, in the United Kingdom, abortion is far more often combined with sterilizing operations which increases the risk to the woman because she is really subject to two procedures, and third, our British colleagues still use procedures in the second trimester which are not considered suitable for the second trimester by American gynecologists.

In table 4 I have made an attempt to compare some data from England and Wales and from New York State. While the overall mortality rates in table 3 may be quite different, when you come down to abortions without sterilization in the first trimester, at 12 weeks of gestation or less, the mortality rates in England is 3.8 and in New York it is 2.9 per 100,000 legal abortions. Given the small numbers of deaths on which these rates are based, they are certainly not significantly different, nor are they different in the second trimester, at 13 weeks of gestation or more.

I would like to mention specially that the deaths shown here from New York State include the deaths of several women who obtained abortions in New York, because of its liberal abortion law, then went home, developed complications, and died in their home States. The population council, together with the New York City Health Department and with the Center for Disease Control, sponsored a survey of all gynecologists in the United States to locate these additional deaths.

Senator Bayh. I hate to keep coming back to the Japanese situation, but I want to make absolutely certain that I heard and understood what you said.

You said that there were a number of legally performed abortions by doctors in the sterile atmosphere of an operating room that were unreported. Did I also understand you to say that there were still illegal abortions of significant proportions going on in Japan or have those been terminated ?

Dr. TIETZE. I did not say that there were illegal abortions done in large numbers in Japan. I have not come across any such statement in the literature. However, I have said that illegal abortion has not completely disappeared in certain other countries, even after several years of legalization. The main reason for that appears to be that in these countries the necessary procedure for obtaining a legal abortion involves a lower level of privacy than women are willing to accept.

For instance, we know that some women die from illegal abortion in Hungary, and it is estimated that a few thousand illegal abortions are still being done each year. Apparently, these cases involve mostly women in two sets of circumstances. Some of them may have missed the 12-week limit, so they cannot be legally aborted and, therefore, they may go to a wise woman in the town or else they may be women who are known in the hospital, have friends there, who want to cover up not the abortion, but the pregnancy, because their husbands might have been away working elsewhere, or whatever, and because of their concern for privacy they do not seek to obtain abortion through official channels.

In Japan this would not be an important factor, because most Japanese abortions are done by physicians in their own offices, many of which have a few beds attached which is an established form of medical practice in Japan, rather than in public hospitals as would be the case in Hungary. Illegal abortions are not a major problem in Japan unless you define failure to report as constituting illegality.

Senator Bayh. In looking at the world picture, inasmuch as you suggested that Dr. Tyler might be the best to ask questions relevant to the picture in the United States, have you been able to arrive at some conclusion relative to the degree to which legal abortions decrease the use of other means to prevent pregnancy.

Is there any correlation there?

Dr. TIETZE. Your question is difficult to answer and the answer is probably most closely related to the stage of development both of contraceptive knowledge and practice and to the availability of contraceptive services.

Legal abortion was introduced in Japan in 1948 and reintroduced in the Soviet Union and introduced in other countries of Eastern Europe in the 1950's. At that time, what we call “modern contraceptives such as the pill, also the modern intrauterine devices, did not exist, nor was voluntary sterilization being used to any extent, particularly not in Eastern Europe where it has become associated in the public mind with the use of involuntary sterilization during the Nazi period.

In these countries with relatively primitive contraception, legal abortion was introduced. It may very well be that the adoption of modern contraceptives has been slower Japan and Eastern Europe than it might have been without the liberalization of abortion laws.

Senator Bays. I understand what you said is relevant. Familiarity with contraceptive devices and the historical background in the country all relate to the use of contraceptives. But in a country where abortions are made legal or laws are changed which might make them more readily available, have you had a decline in the same country in the use of contraceptives?

Dr. TIETZE. In Japan, where abortion was legalized in 1948, the proportion of married couples practicing contraception increased from 21 percent in 1950 to 59 percent in 1971, according to a series of nationwide surveys conducted by the Population Problems Research Council of the Mainchi newspapers. In terms of "ever-users,” that is including couples who had not used it at the time of the survey, the corresponding figures were 31 percent and 81 percent respectively. Hence there has been a substantial increase in the reported practice of contraception in Japan during the years of legalized abortion. As I'v said earlier, there has also been a decline in the reported number of abortions and these two observations taken together suggest that while the level of legal abortions in Japan may be grossly understated, the decline was a real one.

In Hungary the number of legal abortions has declined more than 13 percent since 1969, without any change in law, but combined with increasing distribution to turn to contraception and away from abortion.

From England we have reports that the medical profession has become far more willing to give contraceptive advice after the Abortion Act of 1967 came into force. Presumably there is now more contraception in most segments of the British population, rather than less.

In New York, as I have already said, I cannot see any evidence of a deterioration of contraceptive practice.

Senator Bayh. Thank you very much, Doctor, you have been very kind.

Dr. TIETZE. Thank you, sir.

Senator Bayn. Our next witness is Dr. Andre E. Hellegers, professor of obstetrics and gynecology at Georgetown University Hospital, director of The Joseph and Rose Kennedy Institute for the study of human reproduction and bioethics in Washington.

Dr. Hellegers, we appreciate your coming here this morning.

Dr. HELLEGERS. Senator, I want to make it clear that I am testifying on behalf of myself and not of any organization that I am affiliated with.

STATEMENT OF DR. ANDRE HELLEGERS, PROFESSOR OF OBSTET

RICS AND GYNECOLOGY AT GEORGETOWN UNIVERSITY HOSPITAL; AND DIRECTOR, THE JOSEPH AND ROSE KENNEDY INSTITUTE FOR THE STUDY OF HUMAN REPRODUCTION AND BIOETHICS, WASHINGTON, D.C.

Dr. HELLEGERS. It seems to me that the subject of abortion has been discussed in many ways, but factually, there would not be very much discussion of abortion if it were not for the fact of whether what was involved was killing a human life or not. That is still the fundamental problem.

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