Dr. TIETZE. It is a 2-year experience. I do not think I could have made the estimate if we had not had the very unique situation in New York that in the first year of the liberalized abortion law, 197071, the number of legal abortions was much greater than the corresponding decline in the number of births, but in the next year, the decline in the number of births was 2.5 times the increment of abortions. The remarkable thing in New York is that the number of legal abortions on resident women increased by about 65,000 during the first year of the new law, but in the next year the incrementation was only 7,700 and by the third year it had dropped to less than 4,000. In other words, the number of legal abortion is leveling out while the number of births has continued to decline. Senator BAYH. And how does one relate the decline of birth rate to other figures like the use of contraception, changes in economic factors, or other issues affecting prospective parents that have caused the general decline in the birth rate throughout the country? How do you nail that down? Dr. TIETZE. Well, it is very difficult to nail it down because of the basic fact that, by the nature of the thing, we do not have statistics on the number of illegal abortions, either before or after the change in the law. Theoretically, legal abortions can do three things: They can replace illegal abortions, they can replace live births, and they can terminate pregnancies which occur because a more relaxed legal posture induces people to be less careful with their contraception. My argument was the following: We know the decline in live births corresponding to the first year of the new law, and I could estimate how many abortions are needed to replace such live births, thus I could estimate the numbers of legal abortions that did and did not replace live births. The latter would either have replaced illegal abortions or any extra pregnancies resulting from the hypothetical deterioration of contraception practice. However, in the next year the decline in births was much greater than the increment in the numer of abortions; it was therefore clear that the number of conceptions had declined for other reasons than the increment in the number of abortions. Ordinarily, such changes in reproductive behavior does not happen very suddenly; hence I estimated that the same forces were already operating in the first year of the new abortion law, on the order of about 10,000 fewer conceptions. These considerations were the basis on which I came to the estimate of 50,000 legal abortions replacing illegal abortions. I cannot specify what are the factors other than abortion which produced a decline in the number of births, but we can speculate on them, and you have mentioned some of them. One explanation would be a decline in the number of marriages. There was such a decline from 1970 to 1971 but it was rather insignificant. Another reasonI think that is one you alluded to, sir-was probably a more widespread use of contraception by more couples, also a more skillful use, and the use of more effective methods. During the period under consideration surgical sterilization, especially of men, became quite popular. There are no figures available for New York City, but a total of some 700,000 vasectomies was mentioned on a nationwide basis. The period was also one of economic difficulties, so it is very understandable that people decided to postpone children which they might otherwise wanted to have in 1971 or 1972. Senator BAYH. Thank you. One of the problems the Committee is confronting is the conflicting figures from those who oppose the Court decision and those who support it, relative to the whole abortion area. That is why I wanted to zero in on that particular question, as well as some others, if I might, because I do not believe any of the reputable people that we have had expressing themselves would intentionally distort figures. They might rely on different sources. I wonder if we might have your opinion, Doctor, inasmuch as you have probably had as good a chance as anybody in the world to examine the way other countries handle this problem, and the way they report it. Could you give us the benefit of your thoughts, sir, as to the accuracy of the reporting procedures that we are now relying on for data on the impact of abortions. For instance, how accurate are doctors filing abortion death certificates; who reviews and examines these records on a local, state, or national basis; how accurate is the review-you mentioned in your testimony that you were going to give us information relative to other countries, and compare the health, sanitation, and other features that might be relevant in comparing foreign data with U.S. data. How do we really get to the nitty-gritty of the truth as it is, rather than as it may be misreported inadvertently? Dr. TIETZE. I should like to do that, and I shall concentrate on the comparison of U.S. with foreign data, because Dr. Tyler, who is with the U.S. Public Health Service is far better qualified to discuss the internal U.S. situation. Senator BAYH. Excuse me for interrupting, It has been suggested to the committee by one of our witnesses that where abortion is legal, the number of illegal abortions, is still alarmingly high. Is that true or false? Can one compare illegal abortions in Japan with illegal abortions in the United States? In addresing yourself to the comparison of other data, I wish you would touch on that one factor, please. Dr. TIETZE. You are correct. Abortion in Japan is legal. While the relevant paragraph of the law requires that the mother's health be endangered either by medical or economic grounds, this has been interpreted as permitting abortion on request and it is so handled. Hence, all abortions in Japan are legal, but not all of them are reported. The number of reported abortions under the eugenic protection law, which is the title of their law, increased to about 14 million in the midle fifties and has since declined to somewhere in the vicinity of 740,000. However Japanese scholars have pointed out. among other things, that the differences in the reported incidence of abortion in the different prefectures are far greater than one could expect on the basis of economic and social differences between the prefectures. A very reputable Japanese scholar, Minoru Muramatsu has tried in various ways to make estimates of the true figure in excess of 3 million, which is four times the reported number of legal abortions. Senator BAYH. I am sorry, Doctor. You said four times the number of legal abortions? Dr. TIETZE. I said the number of legal abortions reported. Dr. TIETZE. The reported number is now about 740,000 and the total number estimated by Muramatsu is in the vicinity of 3 million. Senator BAYH. You say that these are legal abortions under the normal sterile conditions but not reported? What we are concerned about is how many of the kitchen table butchers are there in Japan right now? Dr. TIETZE. These are abortions done by physicians licensed to perform abortions, i.e., trained gynecologists. It is said, but of course it cannot be proven, that the Japanese equivalent of the Internal Revenue Service is checking the numbers of abortions reported by doctors versus the income that they admit to and if the discrepancy is too great the doctors may be in trouble. Now, as for deaths, the Japanese cause-of-death statistics have been very good for a long time, and can be related to the number of abortions. I have shown such figures in the abortion factbook. Because there is agreement among the Japanese public health people that the reporting of death is more complete than the reporting of abortions, the Japanese abortion mortality rate which has been less than five per 100,000 since 1960, is actually even lower. Because of the doubt that surrounds the Japanese abortion statistics, I have not included them in this selection of data which I have put together here I believe you have a copy of them. Senator BAYH. Yes; I want to be sure we put that in the record. [The material referred to follows:] Studies in Volume 3, Number 6 Joint Program for the Study of Abortion (JPSA): by CHRISTOPHER TIETZE, M.D., and SARAH LEWIT A PUBLICATION OF THE POPULATION June 1972 Christopher Tietze is associate director of the Population Council's Biomedical Division, and Sarah Lewit is research associate in the division. The authors wish to express their gratitude to the staff members of the Biomedical Division whose conscientious application and efficiency contributed to the completeness and accuracy of the data in this report. Those who were directly concerned with the Joint Program for the Study of Abortion were: Edward L. Hedgepeth, Deborah A. Dawson, Gloria D. Robinson, Elizabeth A. Engelhard, Joanne White, William Collins, Dorothy B. Marino, and Catherine Chan. Thanks are also due to Philip Chen, who was responsible for the design and implementation of the computer program, and to the investigators, whose cooperation made this study possible. The participating institutions and principal investigators are listed in Appendix A. This work was supported in part by grant #1 PO1 HD05671-01, from the National Institute of Child Health and Human Development, Bethesda, Maryland, and by funds provided by the Agency for International Development. FOREWORD In the United States, as in many other countries, the appropriate public policy to be taken with regard to induced abortion has become a matter of growing concern in recent years. The philosophical and ethical issues have been analyzed and re-analyzed, argued and re-argued, but no resolution is in hand or in prospect. Perhaps for this reason more attention has recently been given to the social, demographic, and medical aspects of the matter. This publication is a pioneering study to that end It is a study of who secured legal abortions in the United States, under what institutional conditions, when in the course of the pregnancy, by what medical means, and with what medical complications if any. It is, to our knowledge, the largest such study ever undertaken on the subject. Certainly it is the most comprehensive evaluation of the early medical complications of legal abortion. The study is a model of how systematic collaboration can be carried out by a large number of investigators in a complex research effort. It is also a model of how a body of valid information can be expeditiously gathered, analyzed, and presented as a guide to the formulation of medical and public policy. As part of its effort to provide sound information on population-related problems and as its first major research project in the abortion field, the Population Council is proud to present this report. We are indebted to the participating investigators and the authors for this contribution to knowledge. Bernard Berelson The Population Council Summary and Conclusions A total of 72,988 abortions, performed. from 1 July 1970 to 30 June 1971, about one-seventh of all legal abortions in the United States during that period, was reported by 66 institutions participating in the Joint Program for the Study of Abortion (JPSA), sponsored by the Population Council. The major findings and conclusions are: 1. Although the type of patient most frequently seen in JPSA institutions was a young, single, white woman, pregnant for the first time and aborted as a private patient, the proportions of married, black, parous, and nonprivate patients increased significantly in the course of one year, with little change in the age distribution of the women (Tables 1, 32). 2. About three out of four abortions were performed in the first trimester (12 weeks) of pregnancy; the proportion of early abortions increased substantially over the year (Tables 5, 32). 3. Late abortions were most frequent among women under 18 years of age, nonprivate patients, black women, and mothers who had had six or more children (Table 6). 4. Most abortions in the first trimester were performed by suction (vacuum aspiration) and most abortions at 17 weeks or later, by saline. Classical dilatation and curettage (D & C) accounted for 4.5 percent of all abortions and hysterotomy and hysterectomy together, for 2.4 percent. Over the year, the share of the last three procedures was almost halved (Tables 7, 32). 5. The incidence of early medical complications, including minor complaints, during the first trimester of pregnancy was on the order of one in 20 abortions; the incidence of major complications, as defined in this report, was one in 200 abortions (Tables 15, 34). 6. The risk to health associated with abortions was three to four times as high in the second trimester of pregnancy as in the first trimester (Tables 15, 34). 7. Complication rates were higher for abortions performed at six weeks' gestation or less, than at seven to ten weeks' gestation, especially for major complications. However, the complication rates were far lower for the earliest abortions than for abortions in the second trimester (Tables 15, 34). 8. As might be expected, the risk of postabortal complications, and particularly major complications, was higher for women with known preexisting complica tions than for apparently healthy women (Table 16). 9. Nonprivate patients had significantly higher complication rates than private patients, especially for abortions in the second trimester (Tables 17, 35). 10. Complication rates were lowest for abortions by suction, followed in ascending order by classical D & C, saline, hysterotomy, and hysterectomy (Tables 18, 19). 11. Complication rates in the second trimester increased markedly with age of woman and parity; for the first trimester, there was no association with parity and a slight downward trend with age of woman (Tables 20, 21). 12. The incidence of complications increased markedly when abortion by suction or D & C was combined with tubal sterilization, except for sterilization by laparoscopy (Table 22 and p. 112). 13. Complication rates for abortions by suction were lowest at seven to eight weeks' gestation, from which point they increased steadily to 15 weeks or more; this trend was repeated with minor irregularities for specific types of complications (Tables 24, 25). 14. Complication rates for abortions by suction, excluding women with preexisting complications, or sterilizing operations, or both, were lower for clinics than for hospitals and lower for hospital outpatients than for hospital inpatients. These differentials were due in part to variations in periods of gestation and in type of service (private versus nonprivate). Other factors that probably contributed to the differentials were: (a) more rigorous selection of patients, (b) greater experience of physicians, and (c) less complete recording of complications. (Tables 27, 28.) 15. Local anesthesia was associated both with a higher incidence of complications than general anesthesia at each period of gestation among patients aborted by suction, and with a notably higher rate of repeat curettage (Table 31). 16. Complication rates for abortions by suction declined approximately 50 percent from the third quarter of 1970 to the second quarter of 1971 (Table 33). Participating Institutions Of the 66 JPSA institutions, 60 were teaching hospitals and six were facilities not located in hospitals, designated as clinics throughout this report. Almost one-half (29) of the hospitals and five of the clinics were in New York State. Of the About 80 percent of the 72,988 abortions were performed in the 60 JPSA hospitals, and 20 percent in the 6 clinics, with one clinic accounting for about one-half of all abortions performed in clinics. Sixty-one percent of the abortions were performed in institutions in New York State, an additional 12 percent in California, and the remaining 27 percent elsewhere. Although hospitals participated in JPSA for varying periods of time during the 12-month period from mid-1970 to mid-1971, data on such parameters as age, prior pregnancies, marital status, period of gestation, and primary procedure were quite similar for hospitals reporting during the full year and those reporting for shorter periods. It can be assumed, therefore, that the combined data for all hospitals are representative of all abortions performed during 1970-1971 in all JPSA hospitals. Participants in JPSA included strongly research oriented institutions connected with medical schools, municipal and county hospitals providing service to large numbers of indigent patients, and hospitals operating under private group health insurance plans. One important type of hospital not represented in JPSA was the proprietary hospital specializing in abortion services. Although distributions of the JPSA women by most demographic characteristics were quite similar in the participating hospitals, the distributions differed on such variables as type of service (the range was from no private patients in some hospitals to all private patients in others) and ethnic group (black women constituted less than 1 percent of the patients in some hospitals and 95 percent in other hos |