prals and women in other ethnic groups ranged from a fraction of 1 percent to 5 percent).

JPSA data on clinics cannot be considered as representative of all clinic experence for the following reasons:

• The participating clinics were those wling to cooperate and capable of seting up and maintaining adequate recordKeep ng systems.

• More than one-half of the abortions were performed in one clinic with an outnding reputation for quality care.

Several of the chnics entered the progam during the last few months of its operation (One clinic reported 1,649 paerts treated by its staff in a hospital with which the clinic was affiliated. These patients were included with other hospital private patients but the affiliated hospital was not counted as one of the 60 JPSA hospitals.) Data on abortions performed in physicians' offices were not collected by JPSA.

To initiate the program, the Population Council sent letters setting forth the need or information on early morbidity assocated with abortions performed under medical auspices to the chiefs of the Departments of Obstetrics and Gynecology Ob Gyn) of some 300 teaching hospitals throughout the United States and inviting their participation in a cooperative study. The hospitals participating in JPSA undertook to complete and forward to the Council, on a form designed and provided for that purpose, a brief abstract of the medical chart of each patient who was aborted, to maintain adequate recordkeeping systems, and to set up suitable follow-up procedures. Most of the hos pitais expected to perform at least 500 abortions during the course of one year. As a rule, hospitals that expected to perform less than 500 abortions per year were excluded from the survey because of the high cost per case; a few such hos

pitals were included to improve JPSA's geographic coverage.

Meetings of investigators were held in the late summer and early fall of 1970, in New York City for those located in the eastern states, and in San Francisco for those west of the Mississippi. The hospitals were represented by a principal investigator, usually the Ob/Gyn chief, who was to have the overall responsibility for JPSA in his hospital, and a program director, appointed by the principal investigator, who had the responsibility for completing the records, maintaining filing systems, and instituting follow-up procedures. The final form of the JPSA record, recommended record-keeping procedures, instructions for filling out JPSA records, and financial arrangements for payment were discussed at these meetings.

To allow time for information on the

postabortal course of the patient to be entered on the JPSA record, investigators were asked to retain records for four to six weeks after the procedure before mailing them to the Council. A separate form was also provided for additional information obtained by the hospital after the JPSA record had been mailed.

Since the printed JPSA forms were not available until October, it was agreed that some hospitals with good medical records would fill out JPSA forms retroactively starting with 1 July 1970.

The JPSA record was printed on three sides on heavy paper, folded to an 8.5 by 14 inch size, with a detachable 3 inch stub at the top. The stub, which contained the identifying information on the patient, was retained at the hospital, and the record itself was mailed to the Council. The record and the stub were linked through a common preprinted number, thus assuring the patient's anonymity. The JPSA record contained information on such demographic characteristics as the patient's age and prior pregnancies, on preexisting complications, on the abortion procedure and such associated factors as use of anesthesia and sterilization, on postabortal complications and their treatment, and on follow-up, including readmission to the hospital.

Since hospital charts from which much of the information for the JPSA record was obtained do not ordinarily contain data on such socioeconomic variables as occupation and education, type of service was used as the principal indicator of socioeconomic status within the JPSA population. Patients in the private category were: (1) all hospital patients who

paid for their own care or who were insured with private carriers and (2) all clinic patients, although a small number of the latter group may have been served without charge. All of the patients in the nonprivate category were hospital patients, including all staff and service patients, as well as all women on Medicaid and Medi-Cal. (It was felt that the latter groups, both in their social background and in the care they received at the hospital, were closer to "ward patients" in the traditional sense than they were to private patients.) On the other hand, some women who would have been eligible for nonprivate service in their home states had to pay for private service for an abortion outside their area of residence and were, therefore, classified as private patients. For these reasons, the differences in complication rates between private and nonprivate patients were probably smaller than comparable differences between middle-class and medically indigent women in the general population. JPSA records were edited and coded at the Council, and queried by sending to the investigators photocopies of pages on which missing or inconsistent items were marked.

An information retrieval system was designed to support the JPSA survey analysis. It was implemented on the IBM/360 computer operating in OS/MVT environment at the Columbia University Computer Center. The system was written in both COBOL and FORTRAN languages so that changes and implementations could be performed easily and in minimal time. The CROSSTAB II, a report generation system, was used to generate the reports.

The system basically comprised four major tasks as follows:

Task 1: Validation of survey data: all input data were validated for coding errors and for internal consistency.

Task 2: Creation and periodic update of the data base.

Task 3: Generation of quality control reports.

Task 4: Generation of survey reports using the CROSSTAB II tabulation sys

tem.

Two preliminary reports were published in July and October 1971 (1, 2). Future JPSA reports will deal with specific aspects of abortion, such as experience with intra-amniotic instillation of hypertonic saline solution.

at the time of the abortion, 10 percent were under 18 years, 24 percent were less than 20 years of age, and more than onehalf were in their twenties, Forty-seven percent of the women were pregnant for the first time; slightly less than 4 percent had been pregnant before but had terminated all prior pregnancies by abortion. About 10 percent had had at least four prior births and somewhat more than 2 percent had given birth to six or more children.

Single women represented 56 percent of the total; currently married women, 30 percent; and previously married women, 14 percent. Sixty-nine percent were white, 26 percent were black, and 5 percent belonged to other ethnic groups-mainly Puerto Rican and Oriental.

The expected correlations among such demographic variables as age, prior pregnancies, and marital status were found among the JPSA patients. Young women under 25 years of age tended to be single and pregnant for the first time; older women were more likely to have given birth and to be, or to have been, married. Nine out of ten primigravidae (women pregnant for the first time) were single and three out of four single women had experienced no previous pregnancies. The proportions less than 18 years old, parous, and widowed, divorced, or separated were higher for black women than for other JPSA patients.

Private patients, including all clinic patients, represented about three-fifths of the total JPSA population. Comparing private and nonprivate patients, the women in the nonprivate group were considerably

more often black, from disrupted mat riages, and parous (Table 2). Private pa tients were three times as likely to be from out-of-area as were nonprivate patients The age patterns for the two groups and the proportions of single and currently married women were similar.

Local patients also made up abou three-fifths of the total population; tw out of five lived out-of-area, as defined by each institution in terms of its customary area of service, which may or may not b determined by city, county, or stat boundaries. Compared with out-of-are women, local residents were older an more frequently parous, currently previously married, nonwhite, and ot nonprivate service (Table 3). The fac that 88 percent of the clinic patients wen nonresidents and that clinic patient tended to be young, single, white, preg nant for the first time, and that all wen private patients by definition, contribute to the differences between the two resi dence groups. These differences were par ticularly marked by ethnic group and type of service, where the proportions of black and of nonprivate patients were abou

Figure 1. Percent Distribution of Pa

Age (years)

tients with Induced Abortions, by Age, Prior Pregnancies, Marital Status, Ethnic Group, Type of Service, and Residence

14 15-17

18-19

20-24

25.29

30 34

35. 39 240

Prior pregnancies

None

1 Abortion only 2+ Abortions only

1 Birth

2 Births

3 Births

4.5 Births

6+ Births

Marital status

Single Married

Widowed/divorced/

separated

56.3

34.0

Ethnic group

the uterus. Seventeen ectopic pregnancies were reported. Of these, three underwent salpingectomy immediately and four, later, including one woman who apparently had a tubal abortion prior to the attempted evacuation of the uterus. Nine of the women experienced rupture of their ectopic pregnancies within three weeks of the primary procedure. The outcome was not reported for one case. Hydatidiform moles were diagnosed in 12 cases. Total abdominal hysterectomy was reported in two of these cases; the other ten women were still under observation when the hospital submitted the history. Uterine anomalies were reported in 44 cases, usually diagnosed as bicornuate, septate, or "double" uterus, of which 38 were associated with suction or D & C.

One additional category with a preexisting condition, not classified as a complication, was the group of 164 women, who underwent an abortion procedure because they were misdiagnosed as pregnant. Because an abortion procedure was performed and because these women were subject to substantially the same risks as pregnant women undergoing abortion, they were included in the total number of aborted women and any complications they experienced were included with postabortal complications. All of the women in the nonpregnant category were diagnosed as in the first trimester of preg nancy, representing 0.3 percent of the women in that gestational group.

The proportions of women with preexisting complications increased sharply with age and with parity, rising from less than one woman in 30 among the young

est women and those with no previous pregnancies, to about one in ten among women in the oldest age and highest parity groups (Table 4). Among women with previous histories of two or more abortions only (with no births) the proportion with preexisting complications was also high (9.1 percent); one-third of these women apparently had their previous pregnancies terminated because of severe and permanent physical or mental impairments. Fewer single women had preexisting complications than married or previously married women because single women were more often young and pregnant for the first time. White women and those on private service were apparently healthier than black women and those on nonprivate service. The higher proportion of women with preexisting complications for those in the second trimester of gestation may reflect, in part, a more cautious attitude among physicians toward women in a more advanced stage of pregnancy. Period of Gestation

Period of gestation in this report is always stated in completed weeks, count

ing the first day of LMP, as reported, from
the date of the abortion (for the saline
method, the date of instillation). In 8.4
percent of all cases, the physician's esti-
mate, based on a pelvic examination, was
substituted because the date of the LMP
was not reported or was obviously errone-
ous. Eighty-seven cases (0.1 percent) were
distributed at random because both the
date of LMP and the physician's estimate
were either not reported or clearly in-
compatible with the abortion procedure.

Approximately 74 percent of the abor-
tions were performed in the first trimester
of pregnancy, and the remaining 26 per-
cent at 13 weeks or later, including 2.3
percent at 21 weeks or later (Table 5 and
Figure 2). Almost one-fourth of all abor-
tions were performed at eight weeks' ges-
tation or earlier and one-half at 9-12
weeks. The number of abortions in the
next four-week period, 13-16 weeks, was
smaller than in the following period, 17-20
weeks, reflecting the opinion widely held
among clinicians that the fourth lunar
month of pregnancy is too late for suction
and too early for saline.

Period of gestation, in general, was in-
versely associated with the woman's age
at the time of abortion; that is, the
younger the woman the more advanced
her pregnancy; the older the woman, the
earlier she had the abortion (Table 6 and
Figure 3). The proportion of second tri-
mester abortions was highest by far for the
youngest women (49 percent) and lowest
for women in their early thirties (20 per-
cent), followed by a slight increase during
the later years of the reproductive period.
The frequency of late abortions among the
young probably reflects their inexperience
in recognizing the symptoms of preg-
nancy, their unwillingness to accept the
reality of their situation, their hesitation
to confide in their parents, and their
ignorance about where to seek advice and
help. Lack of money and, in some hos-
pitals, regulations prohibiting surgery on
minors without parental consent may
have also caused delays.

In terms of prior pregnancies, the pro-
portion of second trimester abortions was
highest among the comparatively few
women with six or more births (34 per-
cent). The next highest percentage of late
abortions was found in the large group of
women with no previous pregnancies be-
cause this group included many women
under 18 years of age. The proportion of
second trimester abortions was smallest
among women who had aborted all previ-
ous pregnancies. The association of
period of gestation with age and with
prior pregnancies observed for the total

Sogle women and those who were widosed, divorced, or separated tended to be oned later in pregnancy than currently married women, and black women were aborted later than either white women or women in other ethnic groups. Nonpri

e patients had abortions substantially later in pregnancy than private patients, with 36.5 percent and 18.9 percent, respectively, having second trimester aborbons. To what extent this was due to bureaucratic delays to which nonprivate pena may have been subjected or to ter requests for abortion by private patients requires further study. Local tes dents, also, tended to have their aborBers somewhat later in pregnancy than but-of-area women. Excluding clinic patemade little difference in the distribution by period of gestation among local pems, but increased to 39 the percentage of second trimester abortions aning out-of-area patients.

Primary Procedures

Virtually all the abortions performed in the PSA institutions were initiated by five major procedures: suction (vacuum peration), usually followed by explorahoe of the uterine cavity with a sharp curate (72.6 percent); classical dilatation and curettage (D & C) (4.5 percent); transabdominal intra-amniotic instillation of hipertonic saline solution (20.1 perbent; abdominal hysterotomy (1.3 percent) and hysterectomy (1.1 percent), Riso in most cases by the abdominal route (Table 7). Included with the hyster

of

mes was a small number of cases in which another procedure was used to Evacuate the uterus prior to the surgery. Other procedures (0.4 percent) included a few cases of intra- and extra-amniotic station of saline by the vaginal route, stilation of 50 percent glucose, about 100 cases of Rivanol instilled through the vx, intravenous administration prostaglandin, and a variety of other proures. The entire group was too small and heterogeneous to warrant analysis. Most abortions by suction and D & C about 95 percent-were performed during the first trimester of pregnancy. The medan gestational periods were 10.0 weeks for suction and 9.6 weeks for D&C. Conversely, most abortions by the (92.5 percent) were performed at 13 weeks or later, with a median of 18.5 weeks Abortions by hysterotomy and

erectomy were scattered over the enrange of gestation, with a median of 155 weeks for the former and 13.1 weeks for the latter.

Total

Although the first suction apparatus was introduced into the United States as recently as 1966, this procedure accounted for 93 percent of all abortions in the first trimester in the institutions participating in JPSA (Table 7). The other relatively new procedure, instillation of saline, was used in almost 95 percent of all terminations at 17 weeks or later. During the

100.0 100.0 100.0 100.0

intervening period, 13-16 weeks, 38 percent of the pregnancies were terminated by suction and 51 percent by saline.

Women aborted by suction, D & C, and saline were more likely to be younger than 25 years of age, nulliparous, and healthy than women aborted by hysterotomy or hysterectomy (Table 8). Women aborted by major surgical procedures