METHODS 3a This paper is based on data from a pilot study using a self-administered questionnaire given to patients at two large medical facilities in Honolulu during the period from June 1 ti July 15, 1970. The questionnaire was given to all abortion patients at hospital admission, and was filled out by the patient prior to the abortion. The same questionnaire was filled out by maternity patients on the first or second post-partum day. Participation by all patients was voluntary. Although the questionnaire was designed to reach every woman admitted to the two participating hospitals for either an abortion or a delivery during the data collection period, there were two groups for whom questionnaire data are not available: those who refused the questionnaire, and those who were inadvertantly missed. Usable questionnaires were received from 400 maternity patients and 272 abortion patients. There were 56 refusals, of which 25% (14) were maternity patients and 75% (42) were abortion patients. This represents a 97% return rate for the maternity sample, and an 87% return rate for the abortion sample. Tabulation of the demographic data from hospital charts for those who refused the questionnaire reveals no major differences between respondents and nonrespondents in either the maternity or the abortion population. Those who were inadvertantly missed in the questionnaire administration likewise appear to be a random selection. RESULTS & DISCUSSION The reasons most often cited by abortion patients as the major cause of terminating their pregnancies were (1) "I am not married," (2) "I cannot afford a child at this time," (3) "A child would interfere with my education," (4) "A child would interfere with my job or other activity," and (5) “I think I am too young to have a child." (See Table I) These reasons suggest that abortion-seekers do not want to carry their pregnancies to term because they do not meet certain standards of marital status, income, occupation, or age. A comparison of maternity and abortion patients reveals that abortion patients actually do meet these demographic and social standards to a considerably lesser degree than maternity patients." The mean age of the abortion population is 22.5 years, as compared with 24 years for the maternity population. However, 55% of the abortions were first pregnancies, as compared with 38.7% of the maternities. Taking only the first pregnancies among the two populations, the abortion group is still consistently younger. Among 155 first pregnancies in the abortion population, the mean age was 20, while for 150 first pregnancies in the maternity population, the mean was 22 years. The age distribution of the abortion population shows an extremely high mode at age 20. While this might be actual, it does appear to reflect the legal requirement of parental consent for surgical procedures performed on minors The data presented below were collected as part of a wide-ranging study of pregnancy, birth control and abortion, which is being conducted through the auspices of the University of Hawaii College of Health Sciences and Social Welfare. An allocation from the Hawaii State Legislature to the University of Hawaii School of Public Health facilitated initiation of the study, and a supplemental grant from the Population Council supported data collection during the first year. The study is designed to permit systematic comparisons among various groups in the pregnant population: women who attempted to prevent pregnancy; women who did not attempt to prevent pregnancy; women carrying pregnancy to term; and women terminating pregnancy by abortion. Data are being collected throughout the State of Hawaii on abortion patients and a control sample of maternity patients, from hospital charts, self-administered questionnaires, and in-depth interviews. These three instruments provide extensive information on the medical, demographic, psycho-social and attitudinal aspects of legal abortion, within the broader context of alternative outcomes of pregnancy. 3 These two hospitals represent 74.5% of the abortions reported in the state. The maternity data are from patients in the hospital for delivery during June-July 1970, who became pregnant too soon to have been eligible for legal abortions in Hawaii The comparison is thus between those who obtained abortions when they were legally available locally to most pregnant women, and those who did not obtain abortions when they were available (1) illegally locally, (2) legally under rare circumstances locally, and (3) legally at considerable expense outside the state or the country. This comparison will provide the base-line data for a future report on whether legalizing abortion actually makes the service available to a larger population of abortion-seekers. (the age of majority in Hawaii is 20). Thus, the two-year age difference in the mean age of first pregnancy maternity and abortion patients represents the minimum age gap between the two. Depending on the size of the group whose actual age is lower than that reported, the abortion population may be even younger in relation to maternities. In either case, it is clear that those women who abort their first pregnancy tend to become pregnant at an earlier age than those who carry their first pregnancy to term. The largest single occupational category reported by abortion patients was "student." This corroborates the finding that interference with education was the third most commonly reported reason for having an abortion. Of the abortion patients, 41.5% reported current employment. If those students who did not report current employment were added, probably well over half of the abortion patients were engaged in non-domestic activities. By contrast, only 19% of the maternity patients were employed. Nearly half of the maternity population reported their usual occupation as housewife, while only 16.2% of the abortion patients reported that they were housewives. Thus, it is clear that a much higher proportion of maternity patients are already in the occupational position most easily adapted to childbirth and infant care, while a high proportion of abortion patients are committed to activities outside the home which would be interrupted or curtailed by childbirth. Financial reasons for abortion are substantiated by the income distribution comparisons, which show a higher proportion of abortion patients than maternity patients in the lower income brackets. Moreover, the proportion of abortion patients in lower income brackets is more than that of the state income distribution; thus, abortion patients are not only less affluent than maternity patients, but also when measured against the state as a whole (See Table II.) The great majority of the women under 21 in both the maternity (63%) and abortion (86%) populations were unmarried at the time of conception. For the young woman in this position, there are three possible alternatives: marriage, to legitimize the birth of the child; bearing the child out-of-wedlock; or abortion. Within the maternity population, half chose the first alternative, and married before the child was born, while the other half remained unmarried when the child was born. The higher proportion of abortion patients giving the reason "I am not married" for having an abortion indicates that these women either were unable to marry, or refused to allow pregnancy to become the reason for marriage. At the same time, they also rejected the alternative of bearing a child while unmarried. The percentage of single (never-married) women drops rapidly with age in both populations, but more rapidly among maternities. After the age of 25, the difference in the percentage of married women between the two populations is largely accounted for by a much higher proportion of separated, divorced and widowed women in the abortion group. (See Table III.) Overall, 87.2% of the maternity patients were married at the time of delivery. Thus, the women who carry their pregnancies to term seem to have relatively stable family situations into which to bring children, while abortion tends to be chosen by women who do not have those family conditions. CONCLUSIONS Demographic and social characteristics of abortion patients have been compared with those of a control group of maternity patietns, to determine whether the reasons for abortion reflected the abortion-seekers' actual social condition. The reasons given by abortion patients pointed to factors of age, occupation, marital status, and income, all of which relate to the capacity to provide a satisfactory environment in which to raise a child. The maternity and abortion samples reveal clear differences on these criteria. Overall, the women carrying their pregnancies to term are in a better position to provide a stable home for a child than are the abortion patients. It appears that abortion patients are objectively evaluating their own capacity to provide for a child, and are making a decision that is not only in their own interest, but also in the best interest of the potential child. TABLE 1. REASONS MOST FREQUENTLY CITED BY ABORTION PATIENTS 1 Other possible choices were "I want more time between children;,, "a child would interfere with the father's education;" "I already have enough children;" "a child would interfere with the father's job or other activity;" "I was raped; "the father is a blood relative;" "my husband is not the father;"' "'I am concerned about over-population;" "my husband is not the father;" "I am concerned about over-population;' "my marriage is too shaky;" "I do not want to have any children at all;" "my parents do not want me to have the child;""I feel that I am not physically strong enough to have the child;""medical (please give reason)" and "other (please give reason)." TABLE II.-FAMILY INCOME OF MATERNITY AND ABORTION PATIENTS, COMPARED WITH STATE INCOME DIS 1 Data on State income distribution calculated from table 47, U.S. Department of Commerce, "General Social & Economic Characteristics," 1970, PC (1)–C13, Hawaii. TABLE III.-MATERNITY AND ABORTION PATIENTS' AGE AND MARITAL STATUS AT CONCEPTION (By Patricia G. Steinhoff*, Associate Professor of Sociology and Roy G. Smith*, Professor of Maternal and Child Health, University of Hawaii, Honolulu, Hawaii) There are presently three types of abortion laws in the United States: those which prohibit abortion except to preserve the life of the mother; those which specify reasons for which abortions may be performed; and those which do not limit the reasons for which abortions may be performed. The traditional prohibitive type of abortion law, permitting abortion only to save the life of the mother, prevailed until the mid-1960's. Abortion laws in several states have been reformed to permit abortion for limited reasons, although they still hold abortion in general to be criminal. Hawaii, New York, Alaska, and Washington have passed abortion laws which do not limit the reasons for which abortions may • We are grateful to our colleagues. James A. Palmore, Jr., and Milton Diamond, for their helpful suggestions on an earlier version of this paper. be performed. These laws essentially remove abortion from the realm of criminal behavior and make it a medical service available to women upon request. Court actions nullifying prohibitive abortion laws have produced the same effect in some other areas. Regardless of which law prevails, obtaining a legal abortion in the United States involves at least three parties: the State, the woman; and the physician. The law specifies under which conditions and for what reasons abortions may be performed. Independently of this, women determine for their own reasons whether they want to terminate a pregnancy. However, physicians and in some cases hospitals or certifying boards decide which abortions will be performed. Their practices may be more stringent or more liberal than the intent of the law. Under both prohibitive and limited abortion laws, the physician is in the key position of mediating between the needs of his patients and the requirements of the law. We would therefore expect that the physician who is philosophically in agreement with women who want to terminate unwanted pregnancies will be influenced by the prevailing attitudes. When he feels that he is under more surveillance by the law, he will permit fewer abortions; and when he feels that he has strong public support, he will permit more abortions, even though the written law remains constant. Where abortion has been legalized and decriminalized, it is possible to examine women's motives for terminating a pregnancy, as well as the actual medical need for abortion. Thehe can then be compared with the formal criteria in prohibitive and limited abortion laws, and with the actual diagnostic classification used as justification by the physician under those conditions. Such a study requires complete data on all legal abortions within a known population base, over a period of years which encompasses a change from a restrictive abortion law to full legalization of abortion. It must also be possible to correlate historical data relevant to changes in the abortion law and in the climate of opinion regarding abortion. Sufficient data are available for the state of Hawaii. The state's small size and geographic isolation facilitate efficient data collection on a statewide basis. When Hawaii became the first state to fully legalize abortion in 1970, there already existed a sound data base on the subject, which was soon supplemented by a statewide study of abortion patients. METHODS The paper is based on data from several sources. Data on women's reasons for abortion after the legalization were obtained from questionnaires distributed throughout the state by the Hawaii Pregnancy, Birth Control and Abortion Study (1). Questi annaire respondents were asked to check their most important reasons for having the abortion. A list of twenty-one possible reasons was offered, with a space for writing in additional reasons. Up to five reasons were coded for each respondent. Hawaii State Department of Health Statistics on therapeutic abortions were obtained for the period 1961-1970 (2). These records were extracted from fetal death certificates, which are required following the death of any fetus from any cause, regardless of length of gestation. The certificates record the causes of fetal death and in cases of induced abortion the medical reason, diagnosis or justification, as stated by the physician. For the years 1967-1970, data on therapeutic abortions were also collected from hospital charts as part of the Hawaii Pregnancy, Birth Control and Abortion Study. This source produced a considerably higher number of cases than was reported to the Health Department. Historical data were collected as part of a study of how the 1970 Hawaii abortion law was passed (3). Sources include legislative records, newspaper reports, and interviews with persons involved in the passage of the law. FINDINGS AND DISCUSSION From 1870 to 1970, Hawaii law permitted abortion only to save the life of the mother. In March, 1970, a new law went into effect which permits abortions to be performed by licensed physicians in accredited hospitals prior to the viability of the fetus outside the uterus and when the woman has been a resident of the state for 90 days or more immediately prior to the abortion. The law requires no justification for the abortion. The Demand for Abortion During the first year of the new law, 3,643 induced abortions were performed in Hawaii. Although this number may seem small, in a state with a population of 769,913 and a crude birth rate of 22.9 in 1970, it represents a ratio of one abortion to every 4.5 live births. There is considerable evidence that the present demand was not the product of the legalization, but had existed for some time prior to it. A 1969 study of Hawaii physicians' attitudes toward the legalization of abortion revealed that even before the law was changed, physicians were receiving a considerable volume of requests for abortion from their patients (4). For the state as a whole, this demand was estimated at about 3,000 cases per pear, which is close to the actual number after the law was passed. Respondents in the Hawaii Pregnancy, Birth Control and Abortion Study were also asked what they thought they would have done if abortion had been illegal: 32.1% of the abortion patients said they would have attempted to obtain an abortion, legally or illegally; another 30% said they would have tried to get an abortion, but if they could not, they would have had the baby. Thus an estimated 2,200 persons would have sought, if not obtained, abortions even if the law had not been changed. Among women who obtained abortion after passage of the new law, the most common reason for abortion was "I am not married," which was given by 36.2%. The second most common reason was "I cannot afford a child at this time," (32.4%). The reasons "A child would interfere with my education" and "I feel that I am not able to cope with a child at this time" were each given by 22.8% of the women. The reasons "I already have enough children" and "I think I am too young to have a child" were each given by 14.7% of the women. Overpopulation concern was a factor for 9.5% of them, and only 2% said they did not want to have any children at all. Since up to five reasons were coded per respondent, these percentages total more than 100 (5). The reasons bear little relation to medical conditions. Rather, they reflect the woman's attempt to cope with her immediate personal situation. Comparison with the Limited Alternative At the time Hawaii's new law was being debated in the State Legislature, an alternative under consideration was the American Law Institute's (ALI) model abortion law. That law would have limited abortion to instances where: there is substantial risk that continuance of the pregnancy (1) would gravely impair the physical or mental health of the mother, or (2) that the child would be born with grave physical or mental defect, or (3) that the pregnancy resulted from rape, incest or other felonious intercourse. All illicit intercourse with a girl below the age of sixteen shall be deemed felonious*** (6). Data from the first year after legalization of abortion reveal that only a small percent of abortions performed would have been legal under this alternative. Less than 1% of the abortions performed in the first year of legalization involved rape or incest. Another 2.5% were performed on women under the age of sixteen, and thus would have been classified as felonious intercourse or statutory rape. Even after legalization, if there was a medical reason for abortion, it was recorded on the hospital chart by the physician. Medical reasons reported included risks for the mother as well as potential damage to the child. This is used to estimate the incidence of medical indications for abortion under the American Law Institute definition. During the first year of the new law, 61 abortions were performed for medical reasons and nineteen for psychiatric reasons. Nearly one-fourth (19) of these eighty cases were performed to prevent the birth of a damaged child. This represents 31% of those performed for medical reasons. Among the remaining 61 cases, many of the reasons would have been classified unacceptable or questionable grounds for therapeutic abortion if strict medical or psychiatric criteria were required. In five cases the medical reason was not even specified. Of the forty-two abortions performed for medical reasons related to the mother's health or life, 54.8% (23 cases) were for reasons which would not be acceptable under the ALI definition. These included such conditions as arthritis, diabetes, back injury, biopsy of the right breast, cancer of the colon, liposarcoma of the right thigh, chronic cervicitis, Parkinson's disease, and IUD in the wall of the uterus. Another two (4.8%) were questionable (hemolytic anemia and one heart disease case). Among the 19 abortions performed for |