Ciba Foundation Symposium 115 - Abortion: Medical Progress and Social Implications

291 Pages·1985·19.78 MB·English

Abortion: medical progress and social implications
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Abortion:
medical progress and
social implications
Ciba Foundation Symposium 115
1985
Pitman
London
0C iba Foundation 1985
ISBN 0 272 79815 0
Published in July 1985 by Pitman Publishing Ltd, 128 Long Acre,
London WC2E 9AN, UK
Distributed in North America by Ciba Pharmaceutical Company (Medical Education Division).
P.O. Box 18060, Newark, NJ 07101. USA
Suggested series entry for library catalogues:
Ciba Foundation symposia
Ciba Foundation symposium 115
+
viii 284 pages, 15 figures, 52 tables
Abortion: medical progress and social implications.
-(Ciba Foundation Symposium; 115)
1. Abortion
I. Series
363.4’6 RG734
Printed in Great Britain at The Bath Press, Avon
Con tents
Symposiumo n Abortion: medical progress and social implications, held at the
Ciba Foundation, London, 27-29 November 1984
The original suggestion for this symposium came from Dr Malcorn Potts
Editors: Ruth Porter (Organizer) and Maeve O’Connor
D. T. Baird Introduction I
D. B. Paintin Legal abortion in England and Wales 4
Discussion 12
L. AndolSek Abortion services in Slovenia 21
D. A. Grimes Provision of abortion services in the United States 26
General discussion 1 Abortion law and abortion services in Japan and other
countries 32
S. Wanjala, N. M. Murugu and J. G. K. Mati Mortality due to abortion
at Kenyatta National Hospital, 1974-1983 41
Discussion 48
T. N. Singnomklao Abortion in Thailand and Sweden: health services and
short-term consequences 54
Discussion 63
P. Frank Sequelae of induced abortion 67
Discussion 79
D. A. Grimes and K. F. Schulz The comparative safety of second-trimester
abortion methods 83
Discussion 96
S. L. Barron Some aspects of late abortion for congenital abnormality 102
Discussion 11 1
General discussion 2 Ethical aspects of abortion 115
V
vi CONTENTS
W. H. Kitchen, A. L. Rickards, G. W. Ford, M. M. Ryan and J. V. Lissenden
Live-born infants of 24 to 28 weeks’ gestation: survival and sequelae at
two years of age 122
Discussion 132
Z. MatgjSjfek, Z. Dytrych and V. Schuller Follow-up study of children born
to women denied abortion 136
Discussion 147
H. P. David Post-abortion and post-partum psychiatric hospitalization 150
Discussion 161
J. Mattinson The effects of abortion on a marriage 165
Discussion 173
D. T. Baird and Iain T. Cameron Menstrual induction: surgery versus pro-
staglandins 178
Discussion 187
E. E. Baulieu Contragestion by antiprogestin: a new approach to human
fertility control 192
Discussion 207
R. J. Cook Legal abortion: limits and contributions to human life 211
Discussion 2 18
A. V. Campbell Viability and the moral status of the fetus 228
Discussion 235
J. I. Rosoff Politics and abortion 244
Discussion 253
Final general discussion Providing effective abortion services 256
Effects on society of changes in abortion laws 257
Contragestion 261
M. Potts Medical progress and the social implications of abortion: summing-
up 263
Biographies of contributors 269
Index of contributors 275
Subject index 277
Participants
A. K. Agarwal (Ciba Foundation Bursar) Division of Endocrinology,
Central Drug Research Institute, Chattar Manzil, Post Box No. 173,
Lucknow 226001, India
L. AndolSek Tozd Univerzitetna Ginekoloika Klinika, Slajmerjeva 3,
61000 Ljubljana, Yugoslavia [contributor unable to attend the symposium]
D. T. Baird (Chairman) Department of Obstetrics and Gynaecology,
Centre for Reproductive Biology, University of Edinburgh, 37 Chalmers
Street, Edinburgh EH3 9EW, UK
S. L. Barron Department of Obstetrics and Gynaecology, The Princess
Mary Maternity Hospital, Great North Road, Newcastle upon Tyne
NE2 3BD, UK
E. E. Baulieu Inserm U33, Facult6 de Medecine de BicCtre, Universite de
Paris Sud, 78 Avenue du General Leclerc, 94270 BicCtre, France
I. T. Cameron Department of Obstetrics and Gynaecology, Centre for
Reproductive Biology, University of Edinburgh, 37 Chalmers Street,
Edinburgh EH3 9EW, UK
A. V. Campbell Department of Christian Ethics and Practical Theology,
University of Edinburgh, New College, The Mound, Edinburgh EH12LX,
UK
F. Cockburn Department of Child Health, University of Glasgow, Royal
Hospital for Sick Children, Yorkhill, Glasgow G3, UK
R. J. Cook School of Public Health, Columbia University, 60 Haven Avenue
B-3, New York, NY 10032, USA
H. P. David Transnational Family Research Institute, 8307 Whitman Drive,
Bethesda, Maryland 20817, USA
P. L. C. Diggory 10 Campden Hill Square, London W8 7LB, UK
vii
viii PARTICIPANTS
G. Dunstan Department of Theology, Queen’s Building, The University,
R.
Exeter EX4 4QH, UK
G. Dworkin Faculty of Law, The University, Southampton SO9 5NH, UK
P. I. Frank The Royal College of General Practitioners, Manchester
Research Unit, Attitudes to Pregnancy Study, 8 Barlow Moor Road,
Manchester M20 OTR, UK
D. A. Grimes Centers for Disease Control, Atlanta, Georgia 30033, USA
J. P. Hearn Institute of Zoology, Zoological Society of London, Regent’s
Park, London NW1 4RY, UK
W. H. Kitchen Department of Obstetrics and Gynaecology, University of
Melbourne, Parkville, Victoria 3052, Australia
A. McLaren MRC Mammalian Development Unit, University College
London, Wolfson House, 4 Stephenson Way, London NW1 2HE, UK
Z. MatGjtek Postgraduate Medical Institute, Thomayer Hospital, Prague
KRC. Czechoslovakia
J. Mattinson Institute of Marital Studies, The Tavistock Centre, 120 Belsize
Lane, London NW3 5BA, UK
M. Muramatsu Dept of Public Health Demography, Institute of Public
Health, 4-61 Shirokanedai, Minato-ku, Tokyo, Japan
D. Paintin Department of Obstetrics and Gynaecology, St Mary’s Hospital,
London W2 lPG, UK
M. Potts Family Health International, Research Triangle Park, North
Carolina 27709, USA
J. I. Rosoff The Alan Guttmacher Institute, 2010 Massachusetts Avenue
N.W., Washington, DC 20036, USA
T. N. Singnomklao Faringeplan 42-11, 16-361 Spanga, Sweden
S. Wanjala Department of Obstetrics and Gynaecology, University of
Nairobi, Kenyatta National Hospital, P.O. Box 30588, Nairobi, Kenya
Abortion: medical progress and social implications
0C iba Foundation 1985
Introduction
DAVID BAIRD
Department of Obstetrics and Gynaecology, Centre for Reproductive Biology, University of Edin-
burgh, UK
I985 Aborrion: medical progre.s.sa rid sociul implicutions. Piiniun. London (Cibu Foundation Sym-
posium 115)p 1-3
What is the purpose of holding a meeting on ‘Abortion: medical progress and
social implications’? The need to check the unlimited growth of the world’s
population has been accepted by most responsible authorities for about 20
years. In a world with limited resources there will inevitably come a time when
the population outstrips the capacity of the world to provide food and other
needs. In some parts of the world at the moment we are already seeing what
happens when food runs out as a resource. This increasing awareness of the
populatiori explosion has led to attempts to disseminate knowledge and exper-
tise on various methods of birth control at an unprecedented rate.
The successful application of birth control has however been limited, first by
the relative ineffectiveness of present methods of family planning but perhaps
more importantly by social, religious and political barriers to their widespread
use. These limitations in the methods of birth control or family planning dictate
that, at least in the foreseeable future, there will probably be a demand for
therapeutic abortion. In those countries where contraception is discouraged or
is only available on a limited scale, this demand will be reflected in a high
incidence of illegal abortion. Even in countries like the United Kingdom,
where free family planning services are available within the National Health
Service, the number of therapeutic abortions done each year has levelled off at
about 175 000 (including non-residents) but shows no sign of dropping. The
present methods of contraception are not 100% effective; even if they were, in
a highly motivated society mistakes will happen and hence there will be a
demand for therapeutic abortion.
The introduction of legalized abortion in most countries has almost always
been in response to the demand for the individual couple to have control over
their own reproductive functions, the so-called ‘fifth freedom’. There are few
exceptions to this. In Japan 40 or 50 years ago there was a pressing need to limit
population growth and this was achieved by making abortion more easily
1
2 BAIRD
available. Most societies make a very clear distinction between abortion-the
destruction of a pre-viable fetus-and infanticide, but with advances in neonat-
al care the dividing line has become blurred, and it requires constant redraw-
ing. I hope that we shall hear more about the ethical implications of this moving
target.
One reason why most societies and cultures tolerate abortion is that the rate
of abortion which occurs naturally in our species is very high: only about one
fertilized egg in four results in a viable offspring. The reason for this very high
embryonic loss is unknown, although most losses occur very early in pregnan-
cy, many before the woman realizes she is pregnant at all. Before the eighth
week of pregnancy, that is at up to eight weeks of amenorrhoea or six weeks
after conception, over 60% of spontaneous clinical abortions are associated
with a very obvious chromosome abnormality in the embryos. Recent studies
of very early human embryos fertilized in vitro show that these too have a
similarly high percentage of abnormal karyotypes (Angel1 et a1 1983). So it is
likely that a significant number of embryos fail to implant in the uterus and
hence are lost before the next menstrual period. This high natural wastage
should be borne in mind during discussions of the newer methods of contracep-
tion involving induction of abortion in early pregnancy. As the gestation period
increases, the rate of spontaneous abortion decreases, as does the incidence of
abnormal fetuses. Most people are increasingly reluctant to terminate a preg-
nancy as it advances, except for very obvious suspected fetal abnormalities.
Yet many women who ask for termination of pregnancy in the second trimester
do so because their social circumstances are less than optimum and they find
it difficult to avail themselves of the medical services. These are the people
who on social grounds have the most pressing personal need to limit their
further reproduction. For all these reasons it seems likely that even in the
best-organized society there will be a continuing demand for abortion.
Fortunately, in the last 20 years the methods for inducing therapeutic abor-
tion have become simpler and more effective. The most promising develop-
ment in recent years has been the possibility of inducing early abortion-
so-called menstrual induction-by simple medical means, without resort to
surgery. If methods of menstrual induction prove effective they could have
wide social and legal implications, because they would not require the interven-
tion of skilled medical personnel. But it is unlikely that these methods will ever
replace the necessity to perform abortions later in pregnancy, although they
should increase the availability of abortion to individual women.
It is therefore relevant that at this time we should review what methods of
abortion are available, how abortion services are provided in different
societies, and what the legal and ethical implications are of the provision of
these methods of abortion throughout the world.