From the American Journal of Public Health, October 1992, volume 82, number 10, pages 1328-1331. Reprinted without permission. All typos mine. COMMENTARY: THE PUBLIC HEALTH CONSEQUENCES OF RESTRICTED INDUCED ABORTION - LESSONS FROM ROMANIA Patricia Stephanson, ScD, Marsden Wagner, MD, MSPH, Mihaela Badea, MD, and Florina Serbanescu, MD. INTRODUCTION Abortion policy is being debated in a number of countries in which abortion is currently legal and women have access to safe abortion, performed by qualified practitioners, through the health care system. Some political or religious groups in Hungary, Poland, Germany, Spain, Sweden, and the United States seek to ban abortion or at least to restrict it as much as possible. Both proponents and opponents of legal abortion debate the issue in the abstract terms of women's rights, fetal rights, religious theories, or constitutional principles. However, those who ultimately decide this question will sooner or later have to come to terms with the concrete reality of what can happen to women and children when and if the right to safe abortion is taken away. SAFE ABORTION AND MATERNAL MORTALITY When access to safe abortion has been introduced in a country, maternal mortality has decreased. In the United States during the 1960s, as some states began to change their laws on abortion and hospital abortion policies became less restrictive, gradual decreases in maternal mortality were noted. After the US Supreme Court decision in 1973 guaranteeing women the right to safe abortion, national maternal mortality rates decreased further. In England and Wales there were no deaths due to unsafe abortion in the triennium 1982 to 1984, compared with 75 to 80 such deaths per triennium prior to the Abortion Act of 1967 (which gave free access to safe abortion).[1] Although it is reasonable to conclude that these trends are due to the changes in the abortion laws, one can never completely rule out the possible simultaneous effects of other factors. More instructive is what happens in a country when abortion is made illegal and access to safe abortion is taken away. Before 1966, Romanian women - like their neighbors in other Eastern European countries - had access to safe abortion through the country's health care system. In 1966 Romanian President Nicolae Ceaucescu introduced pronatalist policies, outlawed abortion and contraception, and took measures to enforce the law. Mandatory pelvic examinations at places of employment were imposed on women of reproductive age. Informers for the security police were stationed in maternity hospitals. Doctors could be prosecuted for performing unauthorized abortions, and nurses were to make unannounced supervisory visits to new mothers to determine whether they were taking proper care of their infants. The consequences of this policy and its enforcement are presented in Figures 1 through 3, through data from the Romanian birth and death registration system and the nationwide, ongoing maternal mortality audit system. (World Health Organization site visits from 1991 to 1992 have found that these systems are comparable to those of Western Europe in terms of completeness of reporting and the reliability of data [2]. Romanian vital data systems and maternal mortality reports use ICD-9 CM definitions and diagnostic classifications.) After a brief rise, the crude birth rate fell and continued to fall (Figure 1). Thus the policy intended to increase the birth rate failed. Before the 1966 law went in to effect, the Romanian maternal mortality rate was similar to those of other Eastern European countries. Afterward, abortion-related maternal mortality increased to a level 10 times that of any other European country (Figures 2 and 3). For the decade 1980 to 1989, the average Romanian maternal mortality rate was 150 maternal deaths per 100,000 live births. [6] Many women obtained abortion illegally, and every year approximately 500 otherwise healthy women of childbearing age died from postabortion hemorrhage, sepsis, abdominal trauma, and poisoning. Precise figures on the Romanian prevalence of postabortion morbidity are not available. The country's most common cause of obstetrical death were postpartum hemorrhage and infection, [3] complications that could be associated with unsafe abortion. In Romania, local health professionals report that unsafe abortion - as performed by the woman herself or by untrained persons - may involve very dangerous techniques, such as scraping the uterus with a rubber tube or other instrument, uterine lavage with water or a caustic fluid, introduction of foreign bodies into the uterus, or external trauma. Such methods often result in damage to the uterine cervix, chronic infection, and severe anemia that, in turn, increase the risk of postpartum hemorrhage and infection, infertility, preterm birth, and low birthweight. [7,8] THE SOCIAL IMPACT OF RESTRICTED ABORTION Legions of Romanian children in institutions are another sad legacy of the years of the Ceaucescu pronatalist policy. Some women who did not have illegal abortions bore children after unwanted pregnancies and placed the children in institutions because they and their families simply could not find the means or motivation to care for them. [9] Although the number of children institutionalized before the overthrow of the Ceaucescu government is unknown, shortly after the revolution approximately 150,000 to 200,000 children were in institutional care. [10] Warehousing of children in institutions overwhelmed the health care system and reduced the standard of care. [9] Present programs have returned many institutionalized children to their families or have attempted to place them in adoptive homes. [9] However, several thousand severely retarded and handicapped children are likely to remain in institutions for the rest of their lives. [9] CONCLUSIONS After the December 1989 Romanian revolution, one of the provisional government's first acts abrogated the 1966 law banning abortion and contraception. This was done as an emergency public health measure to try to decrease maternal mortality due to unsafe abortion. Since then, more and more induced abortions have been performed by qualified doctors in hospitals or clinics; the maternal mortality rate fell by 50% in the first year following the change in the law. It continues to fall as more and more women avail themselves of safe abortion. New admissions to children's institutions have decreased in spite of severe economic conditions. [9] The Ro,manian experience demonstrates the futility and folly of attempts to control reproductive behavior through legislation. A law that forbids abortion does not stop women from aborting unwanted pregnancies. In Ireland today, where abortion is illegal, some 4,000 women each year travel to Britain for the procedure. Nor can laws concerning reproductive behavior be effectively enforced. The extreme pronatalist policies in Romania did not succeed in sustaining the desired levels of reproduction and natural increase (Figure 1). To reduce or eliminate abortion, the rational approach is to promote contraception. To paraphrase the position of the 1984 International Conference on Population, the solution to the abortion question is to prevent unwanted pregnancy. [7] The outlawing of abortion and contraception is not pronatalist by antinatalist in that the results are likely to be fewer healthy, fertile women who might have children, reduced fertility from widespread gynecological infection, the birth of more damaged babies, and, in sum, not more but fewer healthy citizens for the future. In the 23 years of its enforcement, the antiabortion law in Romania resulted in over 10,000 deaths of women from unsafe abortion. The pronatalist policy as a whole resulted in the untoward institutionalization of thousands of children and in an elevated rate of infant deaths. In effect, it also turned otherwise law-abiding women and their partners into criminals; women learned to fear the government and its representatives. Doctors and other health care providers were victims as well because they were forced to carry out the policies of the state. Working today to improve and strengthen women's health servicesm Romanian doctors report that many women remain fearful of contact with the health care system. The lessons of the Romanian experience hit home for those of us who remember how it was in our own countries prior to the legalization of abortion. Those who could afford to fly to other places could obtain legal, safe abortion, while those who could not made due with "backstreet" procedures or relinquished their unwanted children to orphanages. Perhaps we have come so far and accomplished so much that we have forgotten the public health consequences of restricting access to safe abortion. In light of those consequences, it does not matter whether, as health professionals, we believe that life begins at conception or whether 8-week-old fetuses should have equal protection under the law. Policy on abortion is being formulated in the rarified atmosphere of legislatures and parliaments, meeting halls and court room. Let us hope that policy makers accept their responsibility for protecting the health and lives of women and children. REFERENCES 1. United Kingdom Department of Health, Report of Confidential Enquiries into Maternal Deaths in England and Wales, 1982-1984. Report on Health and Social Subjects 34. London, England, 1990. 2. World Health Organization, European Regional Office, Maternal and Child Health Unit, Report of an MCH Mission to Romania, january 1991. 3. Birth and Death Register, Bucharest, Romania, 1992. 4. Maternal Mortality Audit System, Bucharest, Romania, 1992. 5. Health for All Database, WHO, Denamrk, 1991 6. Tabulated Birth and Death Statisticsm 1991, Ministry of Health of Romania, 1992. 7. WHO, Maternal and Child Health Unit and Family Planning Division of Family Health, Abortion: A Tabulation of Available Data on the Frequency and Mortality of Unsafe Abortion, WHO, 1990 8. Royston, E, Armstrong,S, Preventing Maternal Deaths, WHO, 1989. 9. The Children's Health Care Collaborative Study Group, The Causes of Institutionalization in Romanian Leagane and Sectii de Distrofici: Report of a Populatio-based Study with Recommendations, Bucharest, 1991. 10. Report of a UNICEF Mission to Develop Emergency Assistance Programme for Institutionalized Children in Romania, New York, United Nations Children's Fund, 1990.