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Inherent in this question, are the uncomfortable, emotional feelings shared by all of us in regards to abortion and more particularly mid-trimester terminations. The occurrence of fetal demise in utero eliminates the dilemma posed by a live born fetus. However, the explicit purpose of abortion is the termination of that pregnancy. It is our responsibility as medical personnel to offer a patient the safest and most effective form of treatment.
Prostaglandins have been demonstrated to eliminate a number of serious complications associated with hypertonic saline, thereby reducing the hazards associated with mid-trimester abortions. Currently only intra-amniotic Prostaglandins (PG) Fz is available which necessitates delaying termination until at least sixteen weeks gestation. In the near future, PGE, vaginal suppositories will be made available offering the possibility of earlier termination and a reduction in the incidence of a live born fetus. Question from: Richard B. Nicholls, M.D., Norfolk, Virginia
Do you believe that carefully administered estrogen tends to raise the blood pressure in postmenopausal women?
I believe all women who can take estrogen should take it under supervision indefinitely to maintain normal health as aging occurs. Do you think I am wrong?
Why do many physicians other than obstetricians and gynecologists shy away from estrogen and frequently condemn its use?
A patient currently under my care, age 50, has just been advised by an internist to stop estrogen for a three month trial period to see “if the estrogen is the prime cause of her hypertension.” She had a hysterectomy and bilateral salpingo-oophorectomy in 1972 for abnormal uterine bleeding due to adenomyosis. Her blood pressure was 114/76 and she was placed on conjugated estrogen, 1.25 mg., for 25 days of each month. One year later her blood pressure was 152/92. Now her blood pressure is 170/110. The patient is quite uncomfortable with hot flushes and other menopausal symptoms.
How do you manage this type patient?
ADDENDUM TO STATEMENT OF JEANNE HEAD, R.N.
Mr. Chairman, Honorable members of the Subcommittee: I respectfully submit the following in addition to my testimony of March 26, 1976. We would like to correct a widespread impression which surfaced recently as testimony during the Subcommittee Hearings. The testimony was given March 26, 1976 by Dr. Elizabeth B. Connell, Associate Director for Health Services at The Rockefeller Foundation.
On page 5 of her testimony, Dr. Connell asserts, “Another predictable change we are now seeing is a decrease in the number and rate of out-of-wedlock births." Perhaps Dr. Connell has not consulted the appropriate statistics. According to the Monthly Vital Statistics Report from the National Center for Health Statistics, Vol. 24, No. 11, supplement 2, dated February 13, 1976, on page 2:
National estimates of the number of illegitimate births are based on information reported on the birth certificates of 38 States and the District of Columbia.
There were an estimated 418,100 illegitimate births in 1974, an increase of less than 3 percent over 1973. White illegitimate births increased 3 percent over the previous year, to 168,500. This was the second year in which an increase occurred, following a decrease for 2 consecutive years. Negro illegitimate births increased over this time period with a nearly 2 percent increase to 238.000 during 1974."
In other words, illegitimate births decreased from 1970 to 1971. There was a further decrease from 1971 to 1972. However, in 1973 there was an increase in out-of-wedlock births. Again in 1974 there was an increase. Let's be more specific; until the Supreme Court decision of Roe v. Wade in 1973, there had been a two-year reduction in out-of-wedlock births. With the advent of Roe, we have experienced a continued increase in illegitimate births. These statistical facts directly contradict Dr. Connell's testimony. It would seem that the abortion decision in Roe v. Wade may have helped to increase the problem of illegitimacy.
I respectfully request that this addendum be included with the permanent records of the Subcommittee Hearings, as well as the enclosed reprint from Medical World News, October, 1973_"Czechs tighten reins on abortion”. Thank you.
[From Medical World News, October 1973)
ECONOMICS AND RISING RATE OF PREMATURE BIRTHS CITED AS CHIEF REASONS
While abortion on demand is a growing trend in the U.S., another nation with a long history of free abortion—Czechoslovakia-has recently begun to tighten its liberal policy.
One reason: a rising incidence in premature births due to cervical scarring, which is the legacy of repeated abortion. Until recently, 6% of premature deliv. eries were the result of cervical incompetence; that figure has risen to 9% and continues to mount, according to a Czech official. To a large extent, the situation can be explained by the fact that only one Czech woman in ten uses any kind of contraceptive measure; most count on their gynecologist to do the job. Contraceptives are considered unesthetic
Another reason for the reversal in government policy is economic. Abortion has been virtually free in Czechoslovakia since 1957, and in the years immediately thereafter, nobody foresaw any great problems, notes Dr. Jan Zidovsky, director of the Institute for the Care of Mother and Child in Prague. "However, now we are at the point where there are 200,000 live deliveries annually in the country and 110,000 abortions."
Recently, the government has begun to apply pressure to control the number of abortions, concerned by the fact that the Czech population has remained stable at about 14 million for the past decade. They are discovering that there simply aren't enough people around to satisfy the requirement of their commercial and industrial projects.
Medical indications for abortion are decided strictly by a woman's physician and differ little from what is accepted in this country. An abortion for nonmedical reasons can be obtained only through the 12th week of pregnancy under the following circumstances: the woman is over age 40, she already has three living children, she has been raped, the family cannot afford another child, her husband has died, there is no room for a newcomer in the apartment.
"In other words, if she can show that having another child will lower the standard of living of the entire family, she is fairly sure of getting an abortion," notes Dr. Bohumir Vedra, an obstetrician at the institute. Also, if her pregnancy is engendering a divorce situation, her prospects for receiving permission are good.
The woman seeking an abortion for nonmedical reasons must present her case to a district committee, consisting of one gynecologist, one director of health services for the area in which she lives, and one member of the local town council. The latter usually has considerable sway over the housing situation. He or she may be able to dangle the prospect of a larger apartment before the pregnant applicant, and thus remove the reason of tight living space from her argument for abortion.
Under a new policy issued in July of this year, the committee members are instructed to grant abortions only in cases of what they consider true necessity. Up until now, many women have sought an abortion because they were more interested in having a new car or a place in the country than a new baby, according to Dr. Vedra.
"Often it is a young woman who has managed to get pregnant but doesn't want to get married. ... Other times the woman will claim the child's father is not her husband. In any case, it is often impossible to verify these explanations."
Drs. Vedra and Zidovsky are doubly concerned about the upswing in premature deliveries because their institution is known for high-quality obstetric care. The perinatal morality rate stands at only 18 per 1,000, one of the lowest in the world. And 70% of perinatal mortality can be attributed to prematurity, they stress.
Repeated abortion can have two effects: The cervix can become damaged and weakened, leading to spontaneous abortion or premature delivery; or the cavity of the endometrium can become damaged, leading to the formation of scar tissue and to spontaneous abortion.
The situation in Prague would be even more severe except for the fact that the Institute for the Care of Mother and Child makes special preparations for a woman who has previously undergone an abortion and is trying to get pregnant.
If she has had three or more abortions, either spontaneous or induced, she is asked to come to the hospital before conceiving and undergo histologic examination and X-ray.
If the physicians can visualize scar tissue, they will suture her cervix in the 12th or 13th week of pregnancy. The patient stays in the hospital as long as nec essary, which in some cases means the entire nine months.
The liberal Czech abortion law was instituted 15 years ago essentially to stem the flood of demands for criminal abortions that followed World War II, Dr. Zidovsky recalls. “After the war there were no new flats going up ... often a wife would live with her parents, a husband with his ... and if they had children, the situation was even more serious.”
Thus legalized abortion rose on the ashes of economic need. Women who could not win committee approval for an abortion usually went out and found somebody else to do the job. Knowing this was the case, the committee seldom turned down a request.
Drs. Vedra and Zidovsky hope that the new government policy will not result in a resurrection of the abortion black market. Currently women are being subjected to an intensive advertising campaign, urging them to adopt less dangerous forms of birth control, or, if they are pregnant, to consider having the child.
"Coital interruption is still standard for many couples ... in fact I know many female doctors who simply refuse to take the pill, use a diaphragm, wear an IUD, or anything else," Dr. Vedra reports. “That's why the situation has come to the point where a gynecologist will do from 20 to 40 abortions per week, one after another like an assembly line. It is appalling."
While saline injection is a widely used abortion technique in the U.S. after the 12th week of pregnancy, Czech physicians use only surgical evacuation, regard. less of the length of pregnancy.
The ignorance of physicians as to the dangers of abortion has not improved the situation, Dr. Vedra adds. Many have been assuring their patients for years that abortion is completely harmless procedure, unaware of the consequences that are evident only when a woman decides she wants to have a baby.
“Not that we like doing it, but there is no choice-we know the woman will go elsewhere,” the physicians point out. “However, particularly in the eastern part of the country-in Moravia, where there are many Catholics-physicians themselves are beginning to become increasingly alarmed."
Postgraduate training is compulsory in Czechoslovakia thus all physicians are exposed to conferences, seminars, and classes, in addition to journal articles. Abortion complications are being stressed in these seminars.
Czech families are urged to have at least two children and three if possible in order to get the population on the rise, explains Dr. Vedra, who has three himself. Various material advantages are dangled before the eyes of prospective parents. For example, with the birth of a second child, the family receives a flat payment of about $250, and for the next two years, a monthly sum of about $60.
The mother continues to draw her full salary for the first five months after her child is born, although she is not going to work. After two years she will return to the job, which has been held for her.
If the couple has more than two children, they are granted various tax de creases and extra allowances. With four children, the rent is cut in half automatically. The advantages do not increase beyond four children.
Another consequence of the abortion situation which Drs. Vedra and Zidovsky have noticed : a growing number of children born prematurely who must attend special schools because they are not as intelligent as their full-term peers. "What we face is not just a health problem, but a moral, philosophical, and practical one for the state as a whole."
STATEMENT ON BEHALF OF THE AMERICAN JEWISH CONGRESS
I. THE AMERICAN JEWISH CONGRESS POSITION
The American Jewish Congress welcomes the opportunity to submit this state ment on the subject of proposed amendments to the United States Constitution dealing with abortion.
The American Jewish Congress is a membership organization which includes in its program defense of the constitutional rights of all American citizens. One of the resolutions of its 1972 National Biennial Convention dealt with the subject of abortion. It reads as follows:
"American Jewish Congress affirms its position that all laws prohibiting or restricting abortion be repealed. Restrictive or prohibitive abortion laws violate the right of a woman to choose whether to bear a child, her right of privacy and her liberty in matters pertaining to marriage, family and sex.
"Abortions are performed; that fact cannot be denied. Meanwhile, prohibitive and restrictive abortion laws have perpetuated inequality between those who can afford an abortion and those who cannot, leading to grave risks to the emotional and physical health of the woman, her family and the community and aggravating already grave social problems.
"Those who find abortion unacceptable as a matter of religious conviction or conscience are free to hold and live by their beliefs, but should not seek to impose such beliefs, by government action, on others.
"It is, therefore, the position of American Jewish Congress that all laws prohibiting or restricting abortion be repealed and that the matter be left to the woman concerned.”
A resolution adopted at the most recent Biennial Convention, in 1976, reads in part.
"The American Jewish Congress expresses its total support for the decisions of the United States Supreme Court of January 1973 interpreting the Bill of Rights as restricting legislation limiting the right of a woman to choose whether to bear a child. We oppose efforts to nullify those decisions, through the adoption of constitutional amendments or through the enactment of legislative rider's barring the use of government funds for the performance of abortions which a woman and her doctor believe should be performed.
"We respect the religious and conscientious scruples of those who reject the practice of abortion. However, to the extent that they would embody those scruples in law binding on all, we oppose them."
II. THE SUPREME COURT DECISIONS
The current effort to amend the Constitution so as to bar abortions is generally regarded as having been prompted by the decisions of the United States Supreme Court in Roe v. Wade, 410.U.S. 113 (1973), and Doe v. Bolton, 410 U.S. 179 (1973), in which the Supreme Court set forth constitutional rights and restraints regarding abortion. The Court balanced three fundamental interests which it had identified—the constitutionally protected right to privacy, the state's interest in protecting maternal health, and the state's interest in preserving potential human life. The Supreme Court held that the constitutionally mandated balance required giving special importance to each interest at a particular time in the pregnancy.
During the first trimester of pregnancy, the Court held, the state's interests are minimal, and it cannot intervene in the decision about terminating pregnancy. This decision is one to be made by the woman and her doctor. During the second trimester of pregnancy, the state, in promoting its interest in the health of the mother, may if it chooses regulate the abortion procedure in ways reasonably related to protecting maternal health, so that safety standards may be prescribed on abortions limited to licensed facilities. After viability of the fetus, in the third trimester, the state, in promoting its interest in protecting the potentiality of human life, may if it chooses regulate or proscribe abortion except when it is necessary to preserve the life or health of the mother. Roe v. Wade, supra, 410 U.S. at 163–4.
In reaching its decisions, the Supreme Court carefully analyzed historical material, current laws, and medical and legal opinions. Since it predicated its rulings on the Constitution, the only direct method of undoing their effect is through constitutional amendment."
III. THE PROPOSED AMENDMENTS There are over 60 constitutional amendments pending before this subcommittee. They fall into three general categories.
1. “Right to Life" From Moment of Conception; exemplified by: H.J. Res. 99, introduced by John L. Erlenborn; H.J. Res. 41, introduced by James J. Delaney; and H.J. Res. 147, introduced by Joshua Eilberg.
1 Since the Supreme Court decisions, indirect effort to restrict their effect have been made in the U.S. Congress by offering amendments to appropriation bills to bar the use of the appropriated moneys for the performance of abortions. The effect of such amendments is to preclude abortions for the poor, who are generally participants in federally. funded health programs, but not for those who can seek abortions with their own money. This class of constitutional amendment would guarantee the fetus the right to life from the moment of fertilization. Its effect would be to ban not only abortion but also the sale of certain birth control devices designed to prevent pregnancy by preventing implantation of the fertilized ovum. It would also vitiate the effect of such decisions of the Supreme Court as Eisenstadt v. Baird, 405 U.S. 438 (1972) and Griswold v. Connecticut, 381 U.S. 479 (1965), which recognized the constitutionally protected zone of privacy in the contraception area.
2. “Every Stage of Biological Development" Except to Save the Women's Life; exemplified by: H.J. Res. 132, introduced by James L. Oberstar; and H.J. Res. 221, introduced by Albert H. Quie.
This type of constitutional amendment would ban all abortions except in those cases where the life of the pregnant woman was at stake,
3. "States Rights”; exemplified by: H.J. Res. 96, introduced by G. William Whiteburst; H.J. Res. 61, introduced by Richard Ichord; and H.J. Res. 97, introduced by John D. Dingell.
A constitutional amendment in this class would allow states once again to enact legislation either prohibiting or restricting abortion.
IV. THE PROPOSED AMENDMENTS WOULD MATERIALLI REDUCE FREEDOM OF RELIGION
AND WOULD IMPAIR SEPARATION OF CHURCH AND STATE AS GUARANTEED BY THE FIRST AMENDMENT
This Committee invited Dr. Leo Pfeffer to testify on the pending amendments, recognizing his expertise as a constitutional lawyer on the subjects of religious freedom and separation of church and state. Dr. Pfeffer submitted his testimony on March 24. Since the views expressed by Dr. Pfeffer in his testimony coincide with the policies of the American Jewish Congress, which he serves as Special Counsel, we refrain from again detailing the reasons why we believe that the proposed amendments would constitute a substantial restriction on religious freedom and would weaken separation of church and state.
V. THE PROPOSED AMENDMENTS WOULD HAVE SERIOUS ADVERSE IMPACT ON THE HEALTH
OF WOMEN AND CHILDREN
The proposed amendments would have substantial adverse consequences for the health and safety of women and children. A. Health and Safety of Women
Prior to the Supreme Court's decision, it was estimated that from one to 142 million abortions were performed each year in the United States outside of hospitals or other proper medical settings and that 5,000 to 10,000 deaths resulted from these procedures. Backstreet abortions accounted for one-fifth of all maternal deaths in the United States and the number was increasing. Kummer and Leavey, Journal of American Medical Association, January 1966. Kummer, Jesse & Spence, Abortion, the Hidden Epidemic, 95 Virginia Medical Monthly, 447 (1968). Further, a recent study conducted by the Institute of Medicine of the National Academy of Sciences concluded that many women will seek to terminate an unwanted pregnancy by abortion whether legal or not. It found further that evidence suggests that laws permitting women to obtain abortions in proper medical surroundings lead to fewer deaths and a lower rate of medical complications. Report of a Study; Legalized Abortions and the Public Health, Summary and Conclusions (May, 1975) at p. 5.
Enactment of these amendments would, therefore, increase morbidity and mortality among women. In addition, contraceptive devices, used wisely by women, would be illegal under some of the amendments proposed.
Finally, the proposed amendments would require that women who became pregnant by rape would be forced to bear the child of the assailant, a harsh and inhumane result of the crime. B. Health of Infants and Children
The proposed amendments would nullify the effect of recent advances made in the areas of fetal research and the development of methods whereby women need no longer bear genetically diseased babies. Fetal research is essential to improve the health of all persons as well as the fetuses which are to be born.
Great advances have recently been made in diagnosis of genetic diseases of the fetus in utero through the use of amniocentesis. As a result, parents and