ABORTION PROBLEM

Evening Star, Issue 22619, 10 April 1937, Page 15

ABORTION PROBLEM

13% INCIDENCE IN DOMINION 4,01)0 CRIMINAL EVASIONS ANNUALLY < INQUIRY COMMITTEE'S FINDING . The Minister of Health, the Hon. P, Fraser, has released the report of the committee set up in August to inquire into the incidence of septic abortion in New Zealand. Some of the statistics elicited are alarminjj, as, f° r example, that while in the year ended ' March, 1936, there were 24,395 live births, there were probably 6,066 abortions, of which 4,000 • were criminally induced, EXCEEDINGLY FREQUENT. 1 Under the heading of “ incidence,” the committee states: — All the evidence brought before the committee indicates that abortion is exceedingly frequent in New Zealand. It is quite impossible to assess the incidence with complete accuracy, tor the reason that a very considerable number of; these cases do not come ufader medical or hospital observation, but some definite indication _ of the frequency is given by the statistics obtained from various hospitals and practices. . In one urban district, for instance, in which the total lirs births for a two-year period were 4,000, tbe number of cases of abortion treated in the public hospital alone was 400. ■ When to this number were added tbo • cases treated in the various private ‘ hospitals, those attended by doctors in the patients’ homes, and those not medically attended at all, it was computed that a total of 1,000 abortions was a conservative figure. _ In other words, roughly . 20 pregnancies in every "!() terminated in abortion. Looked at from a somewhat different angle, figures were presented from one hospital showing that in a group. of 568 uhseleoted women of child-bearing age, there were 549 abortions in 2,801 pregnancies, or 23 per hundred. It must be explained that a certain number of cases of abortion occur perfectly innocently as the result of some condition of ill-health, or, occasion- ' ally, as the result of accident. These “ spontaneous ’’ cases constitute an entirely medical problem. All other cases are artificially produced or “ induced. A very small number of these are bonqurably performed .by medical practitioners when the mother’s life is seriously endangered. This procedure is termed “ therapeutic induction of abortion.” The remainder of the induced cases are unlawfully produced by ' the, person herself or by some other person—criminal abortion. The committee received much evidence regarding the methods used m the attempt to procure abortion. In the first instance it was shown that the use of so-called abortifacient drugs was extensively practised and was usually a first resort. Little need be said about the matter at this stage except to state that the New Zealand evidence entirely supports the opinions expressed elsewhere that drug-taking is rarely effective: Those tempted to use- «these drugs- should realise the n futility, of the practice for the purpose intended and the frequency with which disturbances of health are caused Ijy taking them. Their only value is as a lucrative' source of gam to those people who, knowing their inefficacy, .-. . .yet exploit ' the' distress of certain women by selling them. It is perfectly . ’ dear that the real .menace-is the in.strumentally produced abortion, either ' :: self-induced by the person herself or ‘ the result of an illegal operation performed by some outside person. These abortionists include a few unprincipled doctors and chemists, a tew women with-varying degrees of nursing . training, and a number of unskuTed. people. , . It was a matter of considerable importance for the' Committee to attempt to determine first the extent to which spontaneous abortions contribute to the total figures; the prevalence of unlawful abortion could then be better realised. t i Here again it was found exceedingly difficult to obtain exact figures, but the evidence, suggests that probably less than seven pregnancies in every 100 terminate in spontaneous abortion. • Taking the records of one group of 1,Q95 women where the incentives _ to interference, were prabably at a mini- • mum, it- was found that out of a total .of 2,189. pregnancies, only 152, or 6.97. per cent., terminated in abortion,_ while in a series of 5,337 pregnancies in patients (taken from the records of St. Helens Hospitals, 6 per cent, terminated in abortion. Even assuming that all these were spontaneous (which was probably not ' 'the case), the incidence is approximately 6 per cent, to 7 per cent. If, then, the total abortion rate is . 20 per 100,. it is clear that the incidence of . criminal abortion is at least 13 ; in . every • 100 pregnancies. The committee believes that'this fig- .'. tire can be accepted as a conservative . estimate of the prevalence of unlawful .abortion in New Zealand. Some of the figures presented suggested a still higher incidence. Applying’ the figures given to the whole of New Zealand it means that while in the year ending March, 1936, there' were 42,395 live births, there were probably 6.066 abortions, of which nearly two-thirds (4,000 were criminally induced. ' The. impression of the committee, is that this is an underestimate. Serious as this is on general grounds, ' the matter is of particular importance iri regard to the special problem which ’ Ted to the setting-up of this committee of inquiry—the incidence of septic abortion. Septic infection, or blood poisoning, is the most serious complication which may follow abortion. Grave concern has been occasioned by > a realisation of the frequency of septic abortion, the most significant indication of which is the number of women who lose their lives as the result of this complication. During the five-year period 1931-35, 176 women died from sepsis following abortion. In the same period there were only 70 deaths from sepsis following full-time child-birth. Some of the distressing repercussions from these tragedies have been revealed in the annual report of the Director-General of Health, 1936. which shows that in , that period 338 children were left motherless by the death of 109 married women. Another serious fact is that, while, owing to the strenuous efforts of those engaged in. the direction and practice of midwifery, there has been a most gratifying fall in deaths from post-con-finement sepsis from 2.02 per 1.000 live births in 1927 to 0.4 per 1,000 in 1935, deaths from post-abortion sepsis in the same period rose from 0.50 per 1,000

live births in 1927 to 1.73 per 1,000 in 1934, with a fall to 1 per 1,000 in 1935. One of the unfortunate features of this matter from the public health point of view is the extent to which this increase in deaths from abortion sepsis is counterbalancing and masking the very real improvement which has been achieved by the obstetrical services in the work for wliich they may justly be held responsible. According to the international system of recording, these cases are included in the total maternal mortality.

Actually in New Zealand in the five-year period mentioned, abortion sepsis was responsible for onequarter of the total maternal deaths. In the larger urban areas the position is even more unfortunate. In the case of the four urban areas deaths from septic abortion account for approximately twofifths of the total maternal mortality. With these cases excluded, the maternal mortality associated with child-birth proper was 3.20 per 1,000 live births. Clearly, any comparison between ' different maternity services should be made on the basis, of these latter figures alone. PRACTICE HAS INCREASED. In so far as the deaths from septic abortion can be taken as a comparative indication of the occurrence of abortion generally—and the committee believes this is a fair index—there seems little doubt that there has been a marked increase. There is reason to hope that the fall in 1935 means an improvement in the general situation. Professor Dawson, giving evidence regarding admissions to the -Dunedin Hospital, showed that in iJie - five-year period 1931-35 there was an increase of 23.7 per cent, in the cases of abortion as compared with the previous five-year period. The evidence of other medical witnesses was practically unanimous on this point. According to the report of the British Medical Association Committee on the medical aspects of abortion (1936), the position in Great Britain would appear to be very similar to that existing in New Zealand. In that report it is stated that the incidence of abortion is generally reckoned at from 16 per cent; to 20' per cent, of all pregnancies. The spontaneous-abortion rate is suggested as probably about 5 per cent, of all pregnancies. The evidence set before that committee suggested that there has been an increase in criminal abortion in the last decade. In England and Wales 13.4 per cent, of the total maternal deaths were due to abortion. That committee concludes that “ illegal instrumentation contributes to an overwhelming degree to the mortality from abortion.” POSSIBLE REMEDIAL MEASURES. Having reviewed the position as it .exists in New Zealand, and having set out what appear to be the main causes, the committee considers possible preventive. measures:— In so far as hardships resulting from economic difficulties are, genuine, the committee believes that there is a real call for and that there are definite possibilities of relief by the State. Two classes in particular call for most sympathetic consideration: —(1) The wives of the unemployed, or of those precariously employed. (2) The wives of those engaged in small farming, especially in the dairy farming districts ,of the North:lsland. For isiidh women we consider that- much- could’, be done by way ox financial, domestic, and obstetrical help. In .general terms alkefforts at social betterment—the reduction of unemployment, the improvement of wages and relief, the reduction of taxation, direct and indirect, and the provision of better housing conditions—should undoubtedly help to ; make conditions more secure and more satisfactory for the rearing of larger families. But further than this, we believe that really adequate financial assistance directly related to the encouragement of the family is urgently called for. It is perfectly clear that general financial improvement does not, itself, necessarily bring about larger families; limitation of the family is probably more prevalent amongst those more fortunately placed. What form this financial aid to the family should take requires much consideration. The assistance is required not merely at the time of confinement, but also during the much longer period' of the rearing and the education of the family. A general extension of the maternity allowance under any national health scheme would afford some ; immediate financial assistance.

~ Income tax exemption for children, however generous the scale, would not benefit these badly circumstanced cases, for already they are below the income tax limit.

. It would appear that further financial provision would have to take the form of a direct children’s allowance.

It is suggested that this might be put into effect by amending the present Family Allowances Act to provide that—

(1) The amount be increased; (2) The permissible income level be increased; . (3) That, where given, the allowance be in respect of all the children in the family: and (4) That the age limit of the children he increased to 16. Equally important is the provision of domestic assistance, and here we are faced with a problem of the greatest difficulty—a national problem whicli is affecting women in all walks of life and of which this is but one aspect. In many farming districts it is clear that lack of domestic help is a greater burden to the harassed mother than even financial stringency. Many admirable efforts are being made to give assistance in this direction—in the country by the housekeeper plans of the Women’s Division of the Farmers’ Union and other organisations, in the city by the Mothers’ Help Society and similar agencies. Extension of such system is highly desirable, and the possibility of their organisation on a much larger scale with Government subsidy well deserves consideration. In many cases these efforts are limited as much by lack of personnel as by lack of funds.

Alternatively, we suggest—(l) That the Government should inaugurate and recruit a National Domestic Service Corps of young women agreeable to enter the domestic service profession : (2) That the recruits lie guaranteed continuity of employment and remuneration as long as their service was satisfactory ; (3) That they undergo whatever training is considered desirable at technical school or otherwise; _ (4) That they agree to perform service whenever required by the Domestic Service Department, which department shall ensure that the living and working conditions are up to standard ; (5) That tho service be made available to all women, and that first consideration be given to expectant mothers, mothers convalescent after

childbirth, and mothers who _ have young families, and that the service be either free or charged for according to the circumstances of each case.

Again, realising the fact that many of the considerations involved in this question of domestic help are beyond the scope of this committee, we recommend that a full investigation should be made of the whole matter. OBSTETRICAL AID. As for obstetrical help, we believe that the position is in the main adequate and good. As far as the larger centres are concerned, no woman, however poor her circumstances, need lack complete ante-natal supervision, for which no charge is made, and proper confinement care, at most moderate cost, in the St. Helens Hospitals or the various maternity annexes of the public hospitals; where the mother is actually indigent, free provision is available through the hospital boards or St. Helens Hospitals. The country mother in certain dis-tri-ts is, however, much less well placed, although the Health Department, through its district nurses, maternity annexes, and subsidiser] small country hospitals is trying to moflt the need. Wo realise, however, that genuine economic hardship is not confined to the unemployed, the wives of strugling farmers, and those on the lowest wage levels; relative to their own circumstances and responsibilities, the difficulties of many women whose hus,bauds are in the lower-salaried groups, or in small businesses, for instance, are just as anxious. For these we should also advocate the extension of the maternity allowanc6 and such further direct financial encouragement of the family as can be devised. _ Here, too, is the definite need for domestic help—possibly on a subsidised plan. . Many of these women prefer to make their own private arrangements for their confinements, and to enable them to do.so we suggest that further assistance might be given by the provision of more maternity hospitals of the intermediate type, in wliich these mothers may have all adequate facilities with the right of attendance by their own doctors. Here, too, we believe that proper knowledge of child spacing is most desirable,. though wo consider that this is a matter for private arrangement. SUMMARY AND CONCLUSIONS After detailing its findings as the result of taking extensive evidence under the various other headings, the committee sets out its summary and conclusions as follows:—■ The committee is convinced that the induction of abortion is exceedingly common in New Zealand, and that it has definitely increased in recent years. It has been estimated that at least one pregnancy in every five ends in abortion; in other words, that some 6,000 abortions occur in New Zealand every year. Of these, it is believed that 4,000, at a conservative estimate, arc criminally induced, through the agency of criminal abortionists _or hy self-induction, either of which is equally dangerous. It is clear that death _from i septic abortion occurs almost entirely in such cases. Such deaths have greatly increased in recent years, and now constitute one-quarter of the total maternal mortality; in some urban districts it amounts to nearly half of the total maternal mortality. -New Zealand has. according to comparative international statistics, ofie of the highest death rates from abortion in the world. ■ The committee, after taking evidence from witnesses representing"a 11 sections of-the community, has formed the conclusion that the main causes for this resort to abortion are: (1) Economic and domestic hardship: (2) changes in social and moral outlook; (3) pregnancy amongst the unmarried; and /4) in a. small proportion of cases, fears of childbirth- . Consideration has been given to the nossible remedying of these, causes. In so far as economic hardship is the primary factor, certain fecommendatipns have been made regarding financial, domestic, and obstretrical help by - the State. To lessen any fear of childbirth where this exists, it has been recommended that the public should be informed that New Zealand now has a very low death rate in actual childbirth and that relief of pain in labour is largely used. At the, same time the committee has advocated tliat_ further efforts in the direction of pain relief should be explored.

For dealing with the problem of the unmarried mother, the committee considers that the attack must be along the lines of more careful education of the young in matters of sex, prohibition of the advertisement and sale of contraceptives to. the young, and a more tolerant attitude on the part of society towards these girls and their children.

The committee believes, however, that the most important cause of all is a change in the outlook of women which expresses itself in a demand of the right to limit —or avoid—the family,, coupled with a widespread half-knowledge and use of birth-control methods —often ineffective. These failing, the temptation to abortion follows, POSSIBLE CONTROL. The committee can see only two directions ,i n which abortion resulting from these tendencies can bo controlled : 1. By the direction of birth-control knowledge through more responsible channels, where, while the methods would bo more reliable, the responsibilities and privileges of motherhood, the advisability of self-discipline in certain directions, and other aspects of the matter would be discussed. The committee believes that it is through the agency of well-informed doctors, and. to a certain extent, through clinics associated with our hospitals, that this advice should bo given. It is not, however, considered that this is a matter for the State except to a limited degree. 2. To appeal to the womanhood of New Zealand, in so far as selfish and unworthy motives have entered into onr family life, to consider the grave physical and moral dangers, not to speak of the dangers of race suicide which are involved. This, it is considered, is a matter for "till women’s social organisations to take up seriously. Certain further measures of a more general nature came under the examination of the committee. The prohibition of the promiscuous advertisement of contraceptives, and of their sale to the young; the licensing of the importation of certain types of contraceptives ; the restriction of the sale or distribution of contraceptives to practising chemists, doctors, hospitals, and clinics; the prohibition of the advertisement, or of the sale, except on medical prescription, of certain ' drugs and appliances which might be' used for abortion pnrnoses; these measures are recommended. MEDICO-LEGAL ASPECT. The specific legislation of therapeutic abortion (by doctors for health reasons) as a safeguard to doctors was fully examined, but is not recommended. The committee is satisfied that the pre-

sent interpretation of the law is such that, where the reasons for the operation are valid, the doctor runs no risk of prosecution. The risks of an alteration in the law are great. . Legalisation of abortion for social and economic reasons was also put forward. The committee has discussed the matter, and strongly condemns any countenancing of this measure. Though it may be conceded that legalised performance of the operation by doctors in hospitls might reduce the incidence of surreptitious abortion and deaths from septic abortion, we do not accept this as any justification of a procedure which is associated with grave moral and physical dangers. With regard to sterilisation, the committee adopts the same view as towards the specific legalisation of therapeutic abortion. It is believed that, where the reasons for the operation are in accord with generally-accepted medical opinion, there is no bar to its performance. We see, however, tendencies in the direction of extending this operation far beyond the_ bounds of this accepted medical opinion. For this reason we do not recommend any alteration in the present position. The failure to obtain the conviction of the criminal abortionist, even in cases where the guilt seems beyond all doubt, has been discussed ns a matter of serious concern, and the committee can only bring before the public its responsibility as represented by members of juries, for the virtual encouragement of this evil practice. Finally, the committee, while fully conscious of its inability to suggest a complete and certain solution of this grave problem, or one which will satisfy all shades of opinion, believes that a definite service will have been done through this investigation if full publicity is given to the facts of the situation as here revealed, and if the public conscience is awakened to the fact that, although the State aid and legal prohibitions may do something to remove causes and to deter crime, the ultimate issue rests with the attitude and action of the people themselves. The committee, which comprised Dr D. G. M'Millan, M.P. (chairman), Mrs Janet Fraser, Dr Sylvia G. Chapman, Dr T. F. Corkill, and Dr T. L. Paget, was asked to examine (a) the incidence of septic abortion among married and single women; (b) whether the rate of incidence has increased during recent years; (c) how New Zealand compares with other countries in this respect. It was also asked to inquire into and report upon the underlying causes for the occurrence of septic abortion in New Zealand, including medical, economic, social, and any other factors; to advise as to the best means of combating and preventing the occurrence of septic abortion in New Zealand; and generally to make any other observations or recommendations that appeared appropriate to the committee on the subject.