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Family Planning Perspectives
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The Effect of Legalization of Abortion on
Population Growth and Public Health
By Christopher Tietze
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The Effect of Abortion Legalization
from FY 1970 (the 12-month period end- abortions from 1969 to 1973. If 70 percent 100,000 live births was reported for
ing June 30) to FY 1972, allowing for a of the new legal abortions replaced about 1973.3 According to data collected by the
small number of legal abortions in the 500,000 illegal abortions, the remaining Center for Disease Control (CDC) for
earlier year, and a small residual of illegal 30 percent, or 250,000, could have re- 1973, there were 45 deaths associated
abortions in the later year. placed about 200,000 live births. The last with legal abortions during the two-year
The number of live births in New York figure is one-fifth of the imputed decline period 1972-1973.4 If we use as a denomi-
City declined by 25 percent from 1970 to of about one million births, from the 4.1 nator the 586,800 legal abortions reported
1972, taking into account changes in the million expected in FY 1974 on the basis by the CDC for 1972 plus the 745,400
age distribution of the female population. of the age-specific fertility rates in FY identified in the AGI survey for 1973,5 for
According to this estimate, the increased 1970, to the reported total of about 3.1 a total of 1,332,200, the death-to-case
number of legal abortions was responsible million births. The smaller contribution ratio was 3.4 per 100,000 legal abortions.
for about one-half of this decline in births;of legal abortion to the national decline in In the remainder of this article we will
other changes in reproductive behavior the number of births, compared with its employ a conservative (higher) estimate of
accounted for the remainder. There can contribution (50 percent) to the decline in five deaths per 100,000 legal abortions.
be little doubt that the most important ofNew York City over two years, reflects the Figures on mortality associated with il-
these changes was more general and/or lower abortion rates and ratios that pre- legal abortion are the least reliable ele-
more effective practice of fertility regula-vail in the rest of the nation, where many ment of the available information on
tion, which may reflect changing prefer- states continue in 1975 to enforce restric- deaths from abortion. It is generally rec-
ences regarding family size and birth tive abortion laws, two years after the ognized that mortality is much higher fol-
spacing or the greater availability of Supreme Court abortion decisions. lowing abortions that are self-induced, or
highly effective contraceptive methods, induced by other untrained persons, than
including a growing acceptance of surgi- following those performed in hospitals
Public Health Effects
cal sterilization. and clinics. However, as in all medical
Because about 45 percent of all legal Whereas the demographic impact of the procedures, mortality associated with il-
abortions of city residents during the two-legalization of abortion reflects primarily legal abortion reflects not only the skill of
year period 1970-1972 were obtained by the replacement of unwanted births by the person performing or initiating the
women who had never given birth, and induced abortions, the public health ef- abortion, but also the availability and uti-
almost 20 percent by women with only lization of medical and hospital services,
fect relates primarily to the substitution of
one prior birth, it can be assumed that legal abortions for illegal abortions. and the quality of care available when
about one-half of the aborted pregnancies Although abortion and its complica- complications occur. For developed coun-
would be made up at some future time. tions no longer constitute a major cause tries,
of where the majority of illegal abor-
Hence, the long-term effect of legalizationdeath in the United States and other de- tions are performed by medical practi-
would be reflected by about one-fourth ofveloped countries, the impact of legaliza- tioners and adequate facilities are avail-
the decline in the number of births from tion can be assessed most conveniently in able for the treatment of complications, a
FY 1971 to FY 1972, or in terms of total terms of mortality. The fact of death, at very low estimate of mortality associated
fertility rates by about 0.15 births in a de-least, is unequivocal, although its associa- with these procedures might be 40 per
cline from 2.4 births per woman in 1970 tion with abortion, legal or illegal, and its 100,000, roughly corresponding to mater-
to 1.8 two years later. appropriate documentation may be sub- nal mortality, excluding abortion-related
The experience for New York City can ject to interpretation. Definitions of mor- deaths, in the United States 20 years ago.
be extrapolated to the United States. bidity, including nonfatal complications, Since the risk to life associated with
While the number of legal abortions in are always to some degree arbitrary; they pregnancy and childbirth (14 per 100,000
the United States in 1969 is not known, reflect what is expected in the 'normal live births) is about three times higher
50,000 would seem to be a reasonable course of events'. For example, a blood than that assumed to be associated with
estimate, * and a high level of precision isloss of 300 or even 500 ml is frequently legal abortion (five per 100,000 abor-
not required for the argument. In 1973, seen during and after an uncomplicated tions), and the assumed risk with illegal
about 745,400 legal abortions were per- full-term delivery. The same amount of abortion (40 per 100,000) is eight times
formed, according to a nationwide survey bleeding occurs infrequently with an as- higher than that associated with legal
of hospitals, clinics and physicians spon- piration procedure at eight or 10 weeks' abortions, it follows that:
sored by The Alan Guttmacher Institute gestation, and is generally considered a * the substitution of legal abortions for
(AGI).2 Allowing for an undercount of 'major' hemorrhage by physicians. either live births or illegal abortions
five to 10 percent, a total of 800,000 is Three parameters of mortality must be would tend to reduce the total number of
probably a reasonable estimate, corre- considered in connection with the legal- deaths, and
sponding to an increment of 750,000 legal ization of abortion: maternal mortality, * a very large increment in the total
excluding deaths from abortion; mortalitynumber of abortions would be required to
* Only 22,670 abortions are recorded for that year
associated with legal abortion; and mor- offset this effect.
in the abortion surveillance summary published
by DHEW's Center for Disease Control (CDC). tality associated with illegal abortion. Table 1 presents a hypothetical model
However, only eight of the nine states that had In developed societies, levels of mater- of the reproductive intentions and behav-
abortion reform laws, and none of the states withnal mortality from complications of, or ior of a population of 24 million women
more restrictive laws, reported abortion data to associated with, pregnancy and child- 15-44 years of age (a total chosen to avoid
the CDC for that year; so an adjustment must be
birth, excluding induced abortion, have fractional numbers of deaths), living in a
made in these figures to account for the therapeu-
dropped sharply in recent decades. In the
tic abortions performed in the other 42 states and
developed country where a restrictive
the District of Columbia (see reference 4). United States, a rate of 14 deaths per abortion law is not vigorously enforced,
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City in FY 1973. Deaths associated with
Table 1. Model of reproductive intention and behavior: restrictive abortion law
abortion and childbirth have declined by
Reproductive intention Women Total Live Illegal
one-half from 540 to 264.
and behavior aged preg- births abortions
15-44 nancies*
In Table 3 (p. 126) it is assumed that
Total (OOOs) 24,000 2,520 1,800 720 one-sixth of all contraceptors (3.6 million
among 21.6 million, col. 1) have aban-
I. Pregnancies intended-
doned contraception in favor of legal
contraception not used (OOs) 2,400 1,200 1,200 na
abortion. In the absence of contraception
II. (Pregnancies not intended- (and assuming a moderate amount of
contraception used-000s)t (21,600)t (1,320)t (600)t (720)t
breast feeding), 2.5 abortions are required
1. Pregnancies carried to term (OOs) 10,800 600 600 na
to replace one live birth;7 hence 4.5
2. Pregnancies term. by abortion (OOs) 10,800 720 na 720
million legal abortions are added for a
Rate per 1,000 women aged 15-44 na 105 75 30 total of 5.4 million (col. 4). All other vari-
Ratio per 1,000 live births na na na 400 ables remain unchanged, including con-
Death per 100,000 pregnancies na na 14 40 traceptive effectiveness among the 18 mil-
Number of deaths (units) na 540 252 288 lion women continuing to use contracep-
* Excluding those ending in spontaneous fetal deaths. tion. Compared with Table 1, total preg-
t Subtotals in parentheses not included in totals. nancies (col. 2) have almost tripled and
Note: na = not applicable. abortions (col. 4) have increased 7.5
times, but the estimated number of deaths
thus making illegal abortion available would have brought their unintended from abortion and childbirth is still lower:
under relatively favorable conditions. The 473
pregnancies to term rather than risk il-compared with 540 (although the
small family pattern is well established legal abortions obtain legal terminations. number of deaths is substantially higher
and, at any given time, only 10 percent Compared with the data in Table 1, total than in the model that hypothesizes a con-
(2.4 million) of the women are noncon- pregnancies (col. 2) have marginally in- tinued high level of contraceptive use).
traceptors (col. 1), producing 1.2 million creased, live births are reduced by one-
intended live births per year (col. 2). The sixth (from 1.8 million to 1.5 million, col. Decline Not Hypothetical
remaining 21.6 million women use con- 3), and abortions have increased by one-
traception at a level of effectiveness of ap- half (from 720,000 illegal to 1.08 million A decline in the number of deaths due to
proximately 95 percent. One-half of the legal procedures, col. 4). Two-thirds of complications of abortion following legal-
contraceptors carry their unintended the legal abortions (720,000) replace an ization not only is a hypothetical con-
pregnancies to term; the other half termi- equal number of illegal abortions; one- struct but also has occurred in the real
nate them by illegal abortions. The num- third (360,000) replace a somewhat world. Table 4 (p. 127) summarizes the
ber of abortions (720,000, col. 4) required smaller number of live births (300,000) at relevant statistics for the United States
by the latter group exceeds by one-fifth a ratio of 1.2 abortions per live birth. The during the period 1958-1973. The top
the number of live births (600,000, col. 3) abortion ratio (bottom panel, col. 4) has panel shows the numbers of deaths attrib-
to the women who bring their unintended risen to 720 per 1,000 live births, about uted to the several categories of abortion,
pregnancies to term (1.2 abortions replac- the same ratio as obtained in New York as published by the National Center for
ing one live birth6). The general fertility
rate is 75 live births per 1,000 women
Table 2. Model of reproductive intention and behavior: abortion legalized, contraception
aged 15-44; the abortion ratio is 400 abor-
unchanged
tions per 1,000 live births (bottom panel,
cols. 3 and 4). This rate and ratio com- Reproductive intention Women Total Live Legal
and behavior aged preg- births abortions
pare with a general fertility rate of 86 and
15-44 nancies*
an estimated (illegal) abortion ratio of 340
Total (000s) 24,000 2,580 1,500 1,080
in New York City in 1969. Application of
a mortality rate of 14 per 100,000 (col. 3) I. Pregnancies intended-
contraception not used (OOs) 2,400 1,200 1,200 na
to the 1.8 million live births, and of 40 per
100,000 (col. 4) to the 720,000 illegal II. (Pregnancies not intended-
abortions of the model population gener- contraception used-000s)t (21,600)t (1,380)t (300)t (1,080)t
ates a total of 540 deaths (col. 2) associ- 1. Pregnancies carried to term (0OOs) 5,400 300 300 na
ated with pregnancy and childbirth, 252 2. (Pregnancies term. by abortion-O??s)t (16,200)t (1,080)t na (1,080)t
of which are associated with delivery and a) Replacing illegal abortions (0OOs) 10,800 720 na 720
288 with illegal abortion. b) Replacing live births (OOs) 5,400 360 na 360
Table 2 presents the same population
Rate per 1,000 women aged 15-44 na 107.5 62.5 45.0
except that abortion has been legalized
Ratio per 1,000 live births na na na 720
and made readily available to all women
Deaths per 100,000 pregnancies na na 14 5
who want to avail themselves of this ser-
Number of deaths (units) na 264 210 54
vice. Reproductive intentions, number of
* Excluding those ending in spontaneous fetal death.
wanted pregnancies and contraceptive
t Subtotals in parentheses not included in totals.
practice remain unchanged. However, in
Note: na = not applicable.
this model, one-half of the women who
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The Effect of Abortion Legalization
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than the proportional decline in the num-
Table 4. Deaths attributed to and associated with abortion, by type of abortion: United
ber of illegal abortions. The absolute
States, 1958-1973
numbers of illegal abortions at the begin-
Year or Deaths, by type of abortion
period Total Legal Other than legal
ning and end of the period under consid-
average Total Illegal Sponta- Undeter- eration remain unknown.
neous mined
Although more general and more effec-
Deaths attributed to abortion (NCHS)
tive use of contraceptives, notably the pill
1958-1962 292 5 287 112 175 and the IUD, and increasing acceptance
1963-1967 222 4 218 91 127 of surgical sterilization certainly con-
1968 133 2 131 55 22 54 tributed to the decline in illegal abortions,
1969 132 1 131 59 16 56 it is difficult not to link the acceleration of
1970 128 10 118 58 9 51 the downward trend to the legalization of
1971 99 15 84 32 9 43
abortion.
1972 70 10 60 26 12 22
References
1973 36 8 28 11 3 14
"Undetermined" distributed pro rata 1. C. Tietze, "Two Years' Experience with a lib-
1968 133 3 130 93 37 na eral Abortion Law: Its Impact on Fertility Trends
in New York City," Family Planning Perspectives,
1969 132 2 130 102 28 na
5:36, 1973.
1970 128 17 111 96 15 na
2. E. Weinstock, C. Tietze, F. S. Jaffe and J. G.
1971 99 26 73 57 16 na
Dryfoos, "Legal Abortions in the United States
1972 70 15 55 38 17 na Since the 1973 Supreme Court Decisions," Family
1973 36 13 23 18 5 na Planning Perspectives, 7:23, 1975.
Deaths associated with abortion (CDC) 3. National Center for Health Statistics, DHEW
1972 83 21 62 38 22 2 (NCHS), "Summary Report: Final Mortality Sta-
1973 51 24 27 17 8 2 tistics, 1973," Monthly Vital Statistics Report,
Vol. 23, No. 11, Supplement (2), 1975, Table 11.
Attributed deaths after legal abortion
adjusted to associated deaths 4. Center for Disease Control, DHEW (CDC),
1968 150 5 145 95 50 na Abortion Surveillance, Annual Summary, 1973,
Atlanta, 1975, Table 1 (in press).
1969 145 3 142 104 38 na
1970 145 27 118 98 20 na 5. E. Weinstock et al., 1975, op. cit.
could reflect improved treatment facilities entirely possible that the death-to-case 7. Ibid.
and practices. Two of the major fatal ratio following illegal abortion is now 8. For 1958-1969: NCHS, Vital Statistics of the
complications of induced abortion are in- higher, not lower, than it was 10 or 15 United States, Vol. II, Mortality, U.S. Govern-
fection and hemorrhage, which are also years ago. ment Printing Office, Washington, D.C., various
years; for 1970-1973: NCHS, "Summary Report:
important causes of maternal mortality * Some of the deaths attributed to other-
Final Mortality Statistics," Vol. 22, No. 11, Sup-
that is not abortion-related.'2 Deaths at- than-legal abortions (although not neces- plement, 1974, Table 7; Vol. 23, No. 3, Supple-
tributed to puerperal sepsis and hemor- sarily the numbers shown in Table 4) ment, 1974, Table 7; Vol. 23, No. 8, Supplement
rhage totaled 433 in 1960, corresponding probably resulted from complications of 2, 1974, Table 7; and Vol. 23, No. 11, Supple-
ment (2), 1975, Table 11.
to a rate of 10.2 per 100,000 live births. genuinely spontaneous abortions. The
By 1973, the number of deaths from these ratio of spontaneous abortions to births is 9. CDC, 1975, op. cit.
two causes had dropped to 158, and the not likely to have changed substantially 10. World Health Organization, International
rate had declined to 5.0 per 100,000 live from 1960 to 1973, and the number of Classification of Diseases, 1965 Revision, Geneva,
1967, Vol. 1, p. 431.
births. Adjustment for changes in the age- births was only one-fourth smaller in the
distribution of births raises the 1973 rate later than in the earlier year. Hence, the 11. CDC, 1975, op. cit.
to 6.2 per 100,000. decline in the number of deaths from il- 12. G. S. Berger, C. Tietze, J. Pakter and S. H.
It would be inappropriate, however, to legal abortions must have been greater Katz, "Maternal Mortality Associated with Legal
extrapolate to abortion-related mortality than the decline shown for all other-than- Abortion in New York State: July 1, 1970-June 30,
1972," Obstetrics and Gynecology, 43:315, 1974.
this 40 percent reduction in mortality legal abortions.
from infection and hemorrhage that is not In view of these considerations, we con-
abortion-related. In the 1960s, a substan- clude that the number of illegal abortions
tial proportion of illegal abortions in the in the United States has declined from the
United States were performed by physi- early 1960s to 1973 at least as rapidly as,
cians, including some highly experienced and probably more rapidly than, the re-
practitioners. This is no longer true. ported number of deaths attributed to
Credits
Women who had recourse to illegal abor- other-than-legal abortions. Since the
tions in 1973 were probably the poorest number of women of childbearing age has Cover design, charts (pp. 99-102, 113, 126) and
illustrations (pp. 104, 105, 109) by Rudolph de
and least educated, and were most likely increased 25 percent over the same
Harak; p. 112: B. P. Wolff, Photo Researchers; p.
to obtain the services of unqualified prac- period, the decline in the illegal abortion 114: K. Heyman; p. 117: R. Burri, Magnum; p.
titioners or to attempt self-abortion. It is rate must have been substantially greater 133: L. Freed, Magnum.
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