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A BASELINE FOR CRIMINAL ABORTIONS?
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normal sea-level values in about 3 months2 and that the increased sensitivity to hypoxia persists for weeks or even months. Would the native in time become imadapted to his original life? If so, he would probably reacclimatise quite quickly.
Annotations A BASELINE FOR CRIMINAL ABORTIONS?
THOSE who support the spirit of the Abortion Act -and even, perhaps, some of those who do notmust hope that it will be seen to bring about a reduction in maternal mortality and illegitimacy and relieve distress not measurable in statistical terms. It is far too early to say whether any of these objectives have been achieved, but in any assessment of the effect on the incidence of self-induced or back-street abortions a reliable baseline would be helpful. Goodhart 12 suggests that previous estimates of the number of illegal abortions done in the U.K. were much too large: more specifically he now claims that the oft-cited figure of around 100,000 illegal abortions a year before the Abortion Act came into operation is about five times too high. Such a claim merits careful evaluation, because if it is correct the interpretation of abortion statistics will be more difficult than it is
Lastly, Goodhart looks to Aberdeen for support. In city there was a sympathetic attitude to abortion long before the 1967 Act, and Baird 14 has suggested that criminal abortion has almost disappeared. Thus, that
many of the 70 or so abortions done in Aberdeen each year might otherwise be done illegally, again producing an abortion-rate on a national scale of far less than 100,000. But Aberdeen is not typical: the city has a better family-planning service that most other
places in Britain, and tubal ligation is offered to and accepted by many women post partum. Goodhart’s paper is useful in eliminating some of the wilder guesses in excess of 100,000, and in stimulating a more critical attitude to these statistics, but his own estimate of 15,000 to 20,000 seems unrealistic. In evaluating the effects of the Abortion Act it seems wiser to accept a higher figure. If we do, and remove from the notifications (45,000 a year) some arbitrary figure for patients coming from overseas and for those who would not have turned elsewhere had a legal termination been refused, we seem to be left with a number of women who continue to have recourse to the illegal operator. As Sir George Godber says on p. 312, " Something is radically wrong if the very women whose safety we hoped to achieve are still seeking illicit and dangerous intervention rather than a service which the N.H.S. could provide."
already. There are three ways of interpreting the statement that 30 maternal deaths in 100,000 abortions seems improbably low. The numerator might be too small (if death certificates understate the true position); the rate could be exactly right, merely unsurprising; or, as Goodhart believes, the denominator could be too large. Most people now agree that the mortality figures for abortions are more or less right, especially since they tally with the data from the confidential inquiries into maternal deaths. In countries such as Japan, Czechoslovakia, and Hungary with longer experience of the workings of a liberal law on abortion, the death-rate for legally terminated pregnancies has been less than 5 per 100,000 operations; in England and Wales there were 3 deaths among at least
25,000 (Diggory’s estimate 13) legal terminations in 1967, and 6 such deaths were notified in 1968 when many more abortions were done. Thus 100,000 a year is compatible with 30 maternal deaths if criminal abortion is taken to be ten times more risky than termination in proper surroundings and by experienced operators. In fact, it may be wrong to concentrate too much on maternal lives saved when justifying the Abortion Act since, of 100,000 pregnant women, about 20 would be expected to die as a result of pregnancy. Hospital inpatient statistics are of little value since no-one knows what proportion of women undergoing illegal intervention will eventually present at hospital with complications. An opinion poll carried out for the Abortion Law Reform Association three years ago had a responserate of only 60%, and so the estimate of 31,000 illegal abortions a year for 1946-65 is not very conclusive.
illegal abortions
12. 13.
Goodhart, C. B. J. biosoc. Sci. 1969, 1, 235. Diggory, P. L. C. Lancet, 1969, i, 873.
SCREENING FOR VITAMIN-B12 DEFICIENCY
VITAMIN-BI2 deficiency may give rise to hamatelogical, neurological, and mental abnormalities either singly or in combination. The commonest cause of vitamin-B12 deficiency in Western countries is pernicious anaemia, and the diagnosis can often be suspected on clinical grounds; but, in the vast majority of cases, whether it is suspected clinically or not, there are associated changes in the peripheral blood, such as anisopoikilocytosis and macrocytosis of the red cells, hypersegmentation of neutrophil nuclei, and megaloblastic changes in the bone-marrow. Less commonly, gastrectomised patients and those with disease involving the terminal ileum may develop vitamin-Bl2 deficiency. Dietary deficiency is a rare cause of vitamin-B12 deficiency and is seen only in strict vegans. Very occasionally the mental abnormalities may dominate the clinical picture in pernicious anaemia and the hasmatological changes may be slight or not apparStrachan and Henderson 15 reported 3 cases of ent. this kind among their psychiatric patients in Aberdeen. The incidence of pernicious anaemia in psychiatric patients is about the same as that in the general population 16 and it accounts for under 1 % of psychiatric illness,17 Nevertheless, because it is a treatable form of mental illness, early diagnosis is important. Henderson et
a1.l7 have put forward the view that occult vitamin-
Bl2 deficiency is a commoner cause of mental illness than is generally believed and they advocate screening all psychiatric patients for pernicious anxmia; for this purpose they propose the immunofluorescence 14. 15. 16. 17.
Baird, D. Eugen. Rev. 1966, 58, 195. Strachan, R. W., Henderson, J. G. Q. Jl Med. 1965, 34, 303. Shulman, R. Br. med. J. 1967, ii, 266. Henderson, J. G., Strachan, R. W., Beck, J. S., Dawson, A. A., Daniel, M. Lancet, 1966, ii, 809.
normal sea-level values in about 3 months2 and that the increased sensitivity to hypoxia persists for weeks or even months. Would the native in time become imadapted to his original life? If so, he would probably reacclimatise quite quickly.
Annotations A BASELINE FOR CRIMINAL ABORTIONS?
THOSE who support the spirit of the Abortion Act -and even, perhaps, some of those who do notmust hope that it will be seen to bring about a reduction in maternal mortality and illegitimacy and relieve distress not measurable in statistical terms. It is far too early to say whether any of these objectives have been achieved, but in any assessment of the effect on the incidence of self-induced or back-street abortions a reliable baseline would be helpful. Goodhart 12 suggests that previous estimates of the number of illegal abortions done in the U.K. were much too large: more specifically he now claims that the oft-cited figure of around 100,000 illegal abortions a year before the Abortion Act came into operation is about five times too high. Such a claim merits careful evaluation, because if it is correct the interpretation of abortion statistics will be more difficult than it is
Lastly, Goodhart looks to Aberdeen for support. In city there was a sympathetic attitude to abortion long before the 1967 Act, and Baird 14 has suggested that criminal abortion has almost disappeared. Thus, that
many of the 70 or so abortions done in Aberdeen each year might otherwise be done illegally, again producing an abortion-rate on a national scale of far less than 100,000. But Aberdeen is not typical: the city has a better family-planning service that most other
places in Britain, and tubal ligation is offered to and accepted by many women post partum. Goodhart’s paper is useful in eliminating some of the wilder guesses in excess of 100,000, and in stimulating a more critical attitude to these statistics, but his own estimate of 15,000 to 20,000 seems unrealistic. In evaluating the effects of the Abortion Act it seems wiser to accept a higher figure. If we do, and remove from the notifications (45,000 a year) some arbitrary figure for patients coming from overseas and for those who would not have turned elsewhere had a legal termination been refused, we seem to be left with a number of women who continue to have recourse to the illegal operator. As Sir George Godber says on p. 312, " Something is radically wrong if the very women whose safety we hoped to achieve are still seeking illicit and dangerous intervention rather than a service which the N.H.S. could provide."
already. There are three ways of interpreting the statement that 30 maternal deaths in 100,000 abortions seems improbably low. The numerator might be too small (if death certificates understate the true position); the rate could be exactly right, merely unsurprising; or, as Goodhart believes, the denominator could be too large. Most people now agree that the mortality figures for abortions are more or less right, especially since they tally with the data from the confidential inquiries into maternal deaths. In countries such as Japan, Czechoslovakia, and Hungary with longer experience of the workings of a liberal law on abortion, the death-rate for legally terminated pregnancies has been less than 5 per 100,000 operations; in England and Wales there were 3 deaths among at least
25,000 (Diggory’s estimate 13) legal terminations in 1967, and 6 such deaths were notified in 1968 when many more abortions were done. Thus 100,000 a year is compatible with 30 maternal deaths if criminal abortion is taken to be ten times more risky than termination in proper surroundings and by experienced operators. In fact, it may be wrong to concentrate too much on maternal lives saved when justifying the Abortion Act since, of 100,000 pregnant women, about 20 would be expected to die as a result of pregnancy. Hospital inpatient statistics are of little value since no-one knows what proportion of women undergoing illegal intervention will eventually present at hospital with complications. An opinion poll carried out for the Abortion Law Reform Association three years ago had a responserate of only 60%, and so the estimate of 31,000 illegal abortions a year for 1946-65 is not very conclusive.
illegal abortions
12. 13.
Goodhart, C. B. J. biosoc. Sci. 1969, 1, 235. Diggory, P. L. C. Lancet, 1969, i, 873.
SCREENING FOR VITAMIN-B12 DEFICIENCY
VITAMIN-BI2 deficiency may give rise to hamatelogical, neurological, and mental abnormalities either singly or in combination. The commonest cause of vitamin-B12 deficiency in Western countries is pernicious anaemia, and the diagnosis can often be suspected on clinical grounds; but, in the vast majority of cases, whether it is suspected clinically or not, there are associated changes in the peripheral blood, such as anisopoikilocytosis and macrocytosis of the red cells, hypersegmentation of neutrophil nuclei, and megaloblastic changes in the bone-marrow. Less commonly, gastrectomised patients and those with disease involving the terminal ileum may develop vitamin-Bl2 deficiency. Dietary deficiency is a rare cause of vitamin-B12 deficiency and is seen only in strict vegans. Very occasionally the mental abnormalities may dominate the clinical picture in pernicious anaemia and the hasmatological changes may be slight or not apparStrachan and Henderson 15 reported 3 cases of ent. this kind among their psychiatric patients in Aberdeen. The incidence of pernicious anaemia in psychiatric patients is about the same as that in the general population 16 and it accounts for under 1 % of psychiatric illness,17 Nevertheless, because it is a treatable form of mental illness, early diagnosis is important. Henderson et
a1.l7 have put forward the view that occult vitamin-
Bl2 deficiency is a commoner cause of mental illness than is generally believed and they advocate screening all psychiatric patients for pernicious anxmia; for this purpose they propose the immunofluorescence 14. 15. 16. 17.
Baird, D. Eugen. Rev. 1966, 58, 195. Strachan, R. W., Henderson, J. G. Q. Jl Med. 1965, 34, 303. Shulman, R. Br. med. J. 1967, ii, 266. Henderson, J. G., Strachan, R. W., Beck, J. S., Dawson, A. A., Daniel, M. Lancet, 1966, ii, 809.