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Achieving public health objectives through family planning services
Reproductive Health Matters, No 2, November 1993
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throughFami%PlnningServices Rachael N Pine
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N formulating laws and policies related to reproductive health, r e s e a r c h examining the public health c o n s e q u e n c e s of different approaches is of p a r a m o u n t importance. Policy decisions in this field are often fraught with c ont r o v ers y and meaningful public debate can be absent or polarised. In this context, reliance on public health data helps to ensure a balance between the public health concerns of governments and the rights and health needs of women. This p a p e r reviews evidence f r o m the United States and E u r o p e d e m o n s t r a t i n g that desired public health objectives can best be achieved th r ough c o m p r e h e n s i v e family planning prog r a m m e s that include safe, legal abortion.
PUBLIC HEALTH BENEFITS OF FAMILY PLANNING PROGRAMMES The literature is replete with evidence substantiating the w i s d o m of laws and policies supporting b r o a d - b a s e d access to family planning services. I Use of contraception enables couples and individuals to d e t e r m i n e the n u m b e r and spacing of their children. W i d e r birth spacing has a positive impact on w o m e n ' s health, infant mortality rates and perinatal health. 1-3 Family planning p r o g r a m m e s can p r o m o t e maternal and infant health by d r a w i n g w o m e n into the health care system and providing them with access to medical information and counselling which, in turn, fosters i n f o r m e d and responsible procreative decisions. 1,4,5 Evidence from a US study further suggests that family planning services may increase w o m e n ' s use of antenatal care. 5 Similarly, w o m e n w h o m i g h t not have access to o t h er formal health services can obtain t re at m en t for conditions that might otherwise have been ignored. 6 Comparative data also reveal that the frequency of abortion is d e t e r m i n e d above all by the
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quality of use of contraceptive methods. Family planning initiatives result in increased contraceptive use which, in turn, reduces the incidence of u n w a n t e d p r e g n a n c y - and thus abortion. W h e t h e r this result is v i e w e d as a public health benefit or a c o n s e q u e n c e of g r eat er reproductive choice, r e d u c i n g reliance on abortion is an oftenstated objective of policymakers. The link b e t w e e n use of effective contraceptives and the abortion rate is largely a matter of c o m m o n sense: "If the use o f contraceptive methods improves... both the n u m b e r o f births and the n u m b e r of abortions decrease. If the quality of use decreases, then the n u m b e r o f pregnancies rises - above all probably the n u m b e r o f unwanted pregnancies." 7 This was illustrated in a short-term w ay during the so-called 'pill-scare.' Although safety concerns about the birth control pill .have long since been laid to rest 8, in r e s p o n s e to a w a v e of negative information about adverse health risks of high-dose pills in the 1970s, many w o m e n switched to less effective contraceptive methods. In the United States, d e c r e a s e d use of the pill and the IUD 9 was associated with an increased abortion rate b e t w e e n 1975 and 1980. l° Likewise, in the Netherlands, the abortion rate j u m p e d by 14 p e r cent from 1979 to 1980, after reports of pillrelated deaths w e r e televised in the autumn of 1979.7,11 Over the l o n g e r term, the connection b et w een contraceptive k n o w l e d g e and use and abortion rates is also apparent. A 1992 international comparison r e a c h e d this conclusion: "lA]bortion rates have declined m o s t rapidly in those European countries where legal abortion is part o f a comprehensive family planning programme, where a full range o f contraceptive I
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m e t h o d s is available free o f c h a r g e o r at l o w cost, a n d w h e r e s e r v i c e s are r e s p o n s i v e to client n e e d s w i t h i n a sociocultural c o n t e x t f o s t e r i n g res p o n s i b l e social b e h a v i o u r . " 12
A comparative analysis of the public health c o n s e q u e n c e s of family planning policies in the Netherlands, United States and f o r m e r Soviet Union is illustrative. The history of the Netherlands' extensive family planning p r o g r a m m e traces back to the mid-1960s, w h e n oral contraceptives w e r e first m a d e available from family physicians. 11 In 1971, oral contraceptives w e r e c o v e r e d by public medical insurance. By 1974, m o r e than half of currently m a r r i e d w o m e n of reproductive age w e r e using the pill. 11 A recent study found 56 p er cent of Dutch w o m e n protected by sterilisation, the pill or the IUD. 13 As a result of this successful introduction of contraceptives, the Netherlands has h a d one of the lowest abortion rates in W e s t e r n Europe. 4,11-14 The success of the Netherlands" well studied family planning p r o g r a m m e seems to result f r o m tw o crucial factors. First, contraceptive services are widely available from both individuals' chosen general practitioners and clinics. Services and prescription contraceptives are free of c h a r g e to most citizens as part of a g o v e r n m e n t s p o n s o r e d health care system. Second, r e s p o n sible discussion has b e e n e n c o u r a g e d and information about sexuality and family planning have b e e n t h o r o u g h l y disseminated t h r o u g h health education courses in schools, candid presentations in the media, and a network of counselling centres t h r o u g h o u t the country. These counselling centres provide both inperson and telephonic guidance and referrals to anyone in need of assistance with birth control. 11A3,15-17 The combination of accessible birth control and w i d e s p r e a d family planning information has reinforced social attitudes about the i m p o r t a n c e of p r e v e n t i n g u n w a n t e d p r e g n a n c y t h r o u g h responsible use of contraceptives. 1%16 Due to these efforts, the Netherlands has app r o a c h e d the theoretical model of the 'perfect contraceptive population'.18 The United States has a less c o m p r e h e n s i v e family p r o g r a m m e and consequently, a higher abortion rate. Unlike m o s t o t h e r W e s t e r n countries, the United States has neither national health insurance n o r a national health care system providing family planning free of c h a r g e
to all w o m e n . Instead, most w o m e n pay for both a consultation/medical examination and for the m e t h o d itself. 4,19 In addition, there is a lack of readily available contraceptive information and services, and f ew public health m e s s a g e s in the mass media e n c o u r a g i n g contraceptive use. 4 This is due in p a r t to the high level o f religious and political rhetoric p r o m o t i n g abstinence, cond e m n i n g sex, and creating adverse political consequences for those even willin 9 to discuss or address the p r o b l e m of u n w a n t e d pregnancy. 2° A 1988 study related to family planning during the 1982-1986 p e r i o d found that 46 p e r cent of all w o m e n o f childbearing age in the US w e r e not using any m e t h o d of birth control. 4 In 1988, one in ten w o m e n a g e d 15-44 at risk o f u n w a n t e d p r e g n a n c y w e r e not using any contraceptive method. Almost twice the p e r c e n t a g e of p o o r w o m e n , as c o m p a r e d to w o m e n above the poverty line, r e p o r t e d no contraceptive use. 21 Mo r eo v er , use of the m o r e effective forms of birth control (the pill, IUD, and sterilisation) has b e e n appreciably l o w er a m o n g US w o m e n than a m o n g m a n y of their E u r o p e a n counterparts. 4,7 Thus, the 1988 abortion rate for the US was 27 p er 1,000 w o m e n o f reproductive age, m o r e than five times the Netherlands rate of 5 p er 1,000.12 In Russia - which did not officially adopt a family planning policy until 1991 - wide availability of legal abortion coupled with low availability of reliable contraceptive methods and inadequate family planning services have resulted in even higher abortion rates, which are t h o u g h t to be a m o n g the highest in the world. 22,23 • In Russia knowledge of family planning and contraception is scant; m o d e r n reliable methods of contraception are generally unavailable; and supplies of m o d e r n methods are irregular. '22 As a result, a 1990 survey revealed that only 22 per cent of all Russian w o m e n of reproductive age used contraceptives regularly. 23,24 This situation has been attributed largely to a 20-year 'antipill' campaign, w h i ch has led w o m e n to perceive oral contraceptives to be ' d a n g e r o u s to their health' and a m o n g the least effective methods, along with spermicides and the diaphragm. E v e n in 1990, Russian w o m e n believed c o n d o m s and withdrawal to be the m o s t effective methods, yet the quality and availability of S o v i et - p r o d u ced co n d o m s left m u c h to be desired. 23,24 Moreover, most abortion providers 'offer little contraceptive counselling, are often
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unaware of technical advances published in other languages, and are seldom motivated to change their practices. '12 Although it has begun to change, birth control in Russia, as in the other republics of the former Soviet Union, has thus been based primarily on abortion. W o m e n h a v e a v e r a g e d six or m o r e abortions during their reproductive years, 12 and some are r e p o r t e d to have h a d as many as 25 abortions. 25 The legal abortion rate for the 1980s, reported in 1987, was at least 112 abortions p er 1,000 w o m e n of reproductive age, which is considerably h i g h e r than the rate for the US and the Netherlands. 12,22 Eastern European countries likewise reflect the access to and use of contraceptives. 12A4,26,27
PUBLIC HEALTH BENEFITS OF SAFE, LEGAL A B O R T I O N Although a comprehensive family planning prog r a m m e and increased contraceptive use will reduce abortion rates, contraceptives cannot and do not eliminate the need for abortion. 12,28 F o r the vast majority of women, abortion is a necessary back-up method for use w h e n contraception fails, is not available or has not been used, and in cases of rape and incest w h e r e w o m e n have no opportunity to p r o t e c t them~ selves f r o m u n w a n t e d pregnancy. F o r some, abortion m ay be a p r ef e r r e d m e t h o d of birth control due to particular social or personal situ~ ations, or inadequacies in contraceptive m e t h o d s or health care delivery systems. 32 Liberalisation of abortion laws has been shown to be a significant factor in decreasing mortality rates f r o m unsafe abortion. W h e n abortion services are normalised as a standard c o m p o n e n t of w o m e n ' s health care, the quality of service tends to increase, and associated medical risks are minimised. 3° Early abortion by v a c u u m aspiration is one of the safest of all surgical procedures. Up to the 16th week of pregnancy, abortion is ten times safer than childbearing, and the risk of death from abortion r em ai n s l o w e r than the risk of death from childbirth t h r o u g h o u t most of the second trimester. 31,32 The risk of an abortionrelated death in W e s t e r n E u r o p e is generally less than 1 per 100,000 abortions, c o m p a r e d with about 5-7 m a t e r n a l deaths p e r 100,000 live births. 14
In the United States, abortion b e c a m e legal in all states following a S u p r e m e Court ruling in 1973. 33 In the years b e f o r e the Court's decision, illegal abortion acco u n t ed for approximately 17 p e r cent of all deaths attributable to p r e g n a n c y and childbirth. 34 By 1985, mortality from legal abortions d ecr eased m o r e than flvefold to 0.4 deaths p er 100,000 procedures. I m p r o v e d training and physician skills, safer methods, and earlier termination of p r e g n a n c y due to imp r o v e d access to safe services contributed to this dramatic reduction. 35 M a n y other countries, such as Hungary, Ro m an i a and the f o r m e r Czechoslovakia, ex p er i en ced similar declines in their abortion-related mortality rates following legalisation of abortion. 12,14,26,27 Liberalisation of abortion laws alone, however, does not g u a r a n t e e the availability of safe abortion services. In the United States, federal health care r e i m b u r s e m e n t p r o g r a m m e s do not c o v er abortion unless the w o m a n ' s life is in danger, or in the event of rape or incest. Independent state funding for abortion, absent a threat to a w o m a n ' s life, is available in only a fraction of the states. 14,36 A b o u t half the w o m e n having abortions after 15 weeks of p r e g n a n c y have been delayed by the n e e d to make financial arrangements to pay for the procedure. 35 Inadequate information leads m a n y w o m e n to poorly trained, low quality providers, often at inflated cost. a7 In addition, 83 p er cent of all counties in the US have no abortion provider, forcing many w o m e n to travel long distances at significant expense to obtain an abortion. 35,36 Moreover, there is a g r o w i n g s h o r t a g e of physicians and hospitals w i r i n g to p r o v i d e abortion services. 38 Such circumstances lead to delayed abortions, thus exposing w o m e n to i n cr eased health risks associated with later procedures. Generally, maternal morbidity and mortality from abortion increases with 9estational age. 14 Moreover, w o m e n w h o face such obstacles have an even m o r e difficult time finding a provider; only 25 per cent of US providers will p e r f o r m an abortion b e y o n d the 16th week of pregnancy. 35 In the f o r m e r Soviet Union, legal abortion also has not resulted in optimal quality abortion services for w o m e n . In state abortion clinics, w o m e n describe 'assembly-line' abortions, p e r f o r m e d without anaesthesia, with up to eight w o m e n having p r o c e d u r e s in the same r o o m at the same time. 24,25 Figures for 1988 reveal 3.4
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deaths p er 100,000 legal abortions in state hospitals in the Soviet Union, and the situation is even w o r s e outside the state health sector. 24 The c u m b e r s o m e administrative p r o c e d u r e s and low quality of care in hospitals and clinics lead m a n y Russian w o m e n to seek illegal abortions. 12 In 1989, one-fifth of all abortions in w o m e n without children w e r e illegally performed. 23] "Illegal p r o c e d u r e s are responsible for 68 p er cent of all deaths due to abortion; and 31 p er cent of all maternal deaths in 1989 resulted from complications of criminal abortions. '23 Illegal procedures, typically p e r f o r m e d by physicians after regular hours, cost b e t w e e n one-fourth to one-half of w o m e n ' s a v e r a g e monthly income. 12 These "handsome fees" for unauthorized abortion p r o c e d u r e s have b e e n cited as a powerful but hidden motivation for biases against and lack of availability o f contraceptives. 39 The available evidence demonstrates that public health objectives are seriously undermi ne d unless abortion services are available a m o n g the panoply of r e p r o d u c t i v e health services offered to women. In fact, countries that have legalised the p r o c e d u r e , and taken other steps to make abortion services m o r e accessible, have wi t n es s ed a dramatic i m p r o v e m e n t in w o m e n ' s health. 14 It should be n o t e d that, in the p r e s e n c e of strong family planning initiatives, liberalisation of abortion laws has not increased the overall rate of abortion in the long term. 7,~2,4° For example, the Netherlands, a country with one of the most liberal abortion laws, also has one of the lowest abortion rates in Europe.
SPECIAL NEEDS OF ADOLESCENTS G o v e r n m e n t - f u n d e d contraceptive information and supplies are especially i m p o r t a n t for teenagers, the population often at highest risk for u n w a n t e d pregnancy. 41,42 Indeed, a 1990 international study concluded that '[i]n Scandinavia and Engiish-speaking countries, especially the United States, the m o s t im p o r t a n t prerequisite for r e d u c i n g unintended p r e g n a n c y and abortion is an i m p r o v e m e n t in contraceptive use a m o n g young, u n m a r r i e d w o m e n . '14 In line with this observation, a 1988 study found t e e n a g e abortion rates to be lowest in countries w h e r e contraceptive services w e r e widely available to teenagers, confidential, free
or very inexpensive, and w h e r e timely information about sexuality and contraception was p r o v i d e d t h r o u g h the schools or media. 4 The Netherlands's low t een ag e birth and abortion rates can be in part attributed to its o p e n p r e s e n t a t i o n and discussion o f matters relating to sexuality and birth control. 13,2° '[S]ex education begins in early school years and is considered a lifelong effort, p r o m o t e d at all levels of society, including health professionals and the media. '12 In addition, t e e n a g e r s w h o prefer anonymity may visit family planning clinics, m a n y of w h i c h are open evenings and weekends. In fact, delivery of contraceptive services to teenagers - a g r o u p singled out by the g o v e r n m e n t as n e e d i n g special attention - is a p r i m a r y focus of the largest n e t w o r k of clinics. Visits by adolescents are government-subsidised. Additionally, a n e t w o r k o f counselling centres are available to pr o v i d e guidance, information and referrals related to sexuality and birth control. 13 In contrast, w h e r e t e e n a g e r s face obstacles in obtaining contraceptive information and services, adolescent fertility and abortion rates are higher. The comparatively high t een ag e birth and abortion rates in the United States have been attributed to a lack of openness about sexual matters. US t e e n a g e r s often lack access to contraceptive and abortion information and free or low-cost contraceptives, a° The decision w h e t h e r and h o w to teach about contraceptive met h o d s is left up to individual schools or local authorities. 4,2° There are no national guidelines on the content or quality of sex education programmes, and state and local guidelines have been described as 'purposely v ag u e to assure m a x i m u m c o m m u n i t y flexibility."41 In addition, family planning clinics are not tailored to the special needs of teenagers. Some teens avoid clinics, v i ew i n g t h e m as places "where only welfare clients 9o." 20,43 Consequently, in the US, one in five t e e n a g e r s exposed to the risk of p r e g n a n c y in 1988 w e r e not using any form of birth control. 21 W o m e n below the age of 25 account for 61 p e r cent of total abortions, as c o m p a r e d with 40 p e r cent in the Netherlands. 4 Studies have pointed to a n u m b e r of approaches that m i g h t help reduce t een ag e p r e g n a n c y rates. These include u p g r a d i n g family planning clinics to provide free or low-cost contraceptive services to teenagers; establishing special clinics for adolescents, p er h ap s as-
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sociated with schools, to provide confidential c o n t r a c e p t i v e s e r v i c e s as p a r t o f g e n e r a l h e a l t h care; e n c o u r a g i n g local s c h o o l d i s t r i c t s t o p r o vide s e x e d u c a t i o n p r o g r a m m e s ; a n d r e l a x i n g restrictions on advertising of non-prescription c o n t r a c e p t i v e s s u c h as c o n d o m s a n d s p e r m i cides. 2° Recent efforts to improve contraceptive use a m o n g t e e n a g e r s in t h e U S h a v e h a d s o m e success. B e t w e e n 1982 a n d 1988, t h e p r o p o r t i o n of a d o l e s c e n t s a g e d 15-19 w h o h a d e v e r h a d s e x u a l i n t e r c o u r s e , i n c r e a s e d f r o m 47 p e r c e n t to 53 p e r cent. Yet t h e p r e g n a n c y r a t e o f w o m e n o f t h e s a m e a g e g r o u p r e m a i n e d c o n s t a n t . 21 T h e r e a s o n w a s u n d o u b t e d l y a n i n c r e a s e in c o n t r a c e p t i v e use. F o r e x a m p l e , t h e p r o p o r t i o n o f w o m e n a g e d 15-19 w h o u s e d a m e t h o d t h e first t i m e t h e y h a d i n t e r c o u r s e i n c r e a s e d f r o m 48 p e r c e n t t o 65 p e r cent. 21 N e v e r t h e l e s s , c o n t r a c e p t i v e n o n u s e a n d failure rates remain somewhat higher among teen ~ a g e r s . 43-45 I n a r e c e n t s t u d y b a s e d o n 1988 d a t a , t h e failure r a t e f o r all c o n t r a c e p t i v e m e t h o d s f o r w o m e n u n d e r 20 w a s 26 p e r c e n t , in c o n t r a s t to 14 p e r c e n t f o r all w o m e n . 45 T h u s , i n t e g r a t i o n o f free o r l o w - c o s t safe, l e g a l a b o r t i o n s e r v i c e s i n t o family p l a n n i n g p r o g r a m m e s is p a r t i c u l a r l y critical f o r a d o l e s c e n t s . O f p a r t i c u l a r i m p o r t a n c e to p o l i c y m a k e r s a r e t h e life c o n s e q u e n c e s o f u n w a n t e d t e e n p a r e n t h o o d . T h e h e a l t h , e c o n o m i c , a n d social c o s t s of a d o l e s c e n t p r e g n a n c y a n d c h i l d b e a r i n g h a v e b e e n well d o c u m e n t e d . 46,47 P r e g n a n t t e e n a g e r s h a v e h i g h e r r a t e s of c o m p l i c a t i o n s , m a t e r n a l morbidity and mortality, and more premature and/or low birthweight babies. Early childbear-
References
i n g also h a s a d e t r i m e n t a l i m p a c t o n e d u c a t i o n a l a t t a i n m e n t w h i c h , i n p a r t , c o n t r i b u t e s to l o w e r work status and income. Thus, 'women who e n t e r p a r e n t h o o d as t e e n a g e r s a r e a t g r e a t e r risk o f l i v i n g in p o v e r t y , b o t h in t h e s h o r t a n d l o n g term." In a d d i t i o n , c h i l d r e n o f t e e n a g e m o t h e r s h a v e b e e n s h o w n t o face i n c r e a s e d h e a l t h risks, c o g n i t i v e deficits a n d s o c i o - e m o t i o n a l p r o b l e m s . 46 A c c e s s t o a b o r t i o n is e s s e n t i a l to e n a b l e t e e n a g e r s w h o so c h o o s e to a v o i d unwanted parenthood.
CONCLUSIONS T h e c o n c l u s i o n s a r e clear. T h e p o o r e r t h e q u a l i t y o f c o n t r a c e p t i v e p r o v i s i o n a n d use, t h e h i g h e r t h e levels o f u n w a n t e d p r e g n a n c y a n d a b o r t i o n . Illegal a n d u n s a f e a b o r t i o n l e a d s to a h i g h r a t e o f m a t e r n a l m o r t a l i t y . I n b o t h cases, t h e h e a l t h o f w o m e n suffers. T h u s , g o v e r n m e n t p o l i c i e s p r o m o t i n g b r o a d a c c e s s to q u a l i t y f a m i l y p l a n n i n g s e r v i c e s - i n c l u d i n g safe, l e g a l a b o r t i o n - a r e t h e b e s t m e a n s o f e n s u r i n g g o v e r n m e n t o b j e c t i v e s as well as t h e h e a l t h a n d r i g h t s o f w o m e n .
Note The author would like to thank Lori F Fischler for her assistance in preparing this paper. This paper is adapted from a Brief Amici Curiae, filed in the German Constitutional Court in 1992 in support of the compromise German abortion legislation, on behalf of a number o f organisations. The brief, co-authored with Julie A Mertus, was written in close consultation with Stanley K Henshaw of the Alan Guttmacher Institute.
and Notes
1. Rinehart, W et al, 1984. Healthier mothers and children through family planning, Population Reports. Series J, 27:657-96. 2. Rosenfield, A, 1986. Birthspacing and health: an overview. International Family Planning Perspectives. 12(3):69-70.
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4.
Jones, E F et al, 1988. Unintended pregnancy, contraceptive practice and family planning services in developed countries. Family Planning Perspectives. 20(2):5367. The countries surveyed included Australia, Austria, Belgium, Canada, Denmark, Finland, France, West Germany, Greece, Ireland, Italy, the Netherlands, New Zealand, Norway, Portugal, Spain,
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Sweden, Switzerland, the United Kingdom, and the United States. 5. Jamieson, D J and Buescher, P A, 1992. The effect of family planning participation on prenatal care use and low birth weight. Family Planning Perspectives. 24(5):214-18. 6. ArM, S O et al, 1986. Screening for sexually transmitted diseases by family planning providers: is it adequate and
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appropriate? Family Planning Perspectives. 18(6):255-58. 7. Ketting, E and van Praag, P, 1985. Schwangerschafts-
abbruch, gesetz und praxis im internationalen vergleich. DGVT-Verlag, Tubingen. 8. See for example: Harlap, S e t al, 1991. Preventingpregnancy,
protecting health: a n e w look at birth control choices in the United States. Alan Guttmacher Institute, New York. 9. The IUD likewise received significant adverse public attention. Forrest, J D, 1986. The end of IUD marketing in the United States: what does it m e a n for American w o m e n ?
Family Planning Perspectives. 18(2):52-57. 10. Henshaw, S K et al, 1984. Abortion services in the United States, 1981 and 1982. Family Planning Perspectives. 16(3): 11927. 11. Ketting, E, 1982. Contraception and fertility in the Netherlands.
International Family Planning Perspectives. 8(4):141-47. 12. David, H P, 1992. Abortion in Europe, 1920--1991: A public health perspective. Studies in Family Planning. 23(1):1-22. 13. Torres, A and Jones, E F, 1988. The delivery of family planning services in the Netherlands.
Family Planning Perspectives. 20(2):75-79. 14. Henshaw, S K, 1990. Induced abortion: a world review 1990.
Family Planning Perspectives. 22(2):76-89. While Czechoslovakia, Hungary, a n d the GDR kept fairly accurate abortion statistics during this time, Romania and the Soviet Union did not. The actual abortion rates in these latter countries are likely to be m u c h higher. 15. Dutch g o v e r n m e n t aid to family planning reduces abortion use.
International Family Planning Perspectives. 7:117. 16. Ketting, E and Schnabel, P, 1980. Induced abortion in the
Netherlands: a decade of experience 1970-80. Studies in Family Planning. 11(12):385-394. 17. Rademakers, J, 1990. Abortus in Nederland. Stimezo, Utrecht. 18. Bumpass, L A and Westoff, C F, 1970. The 'perfect contraceptive' population. Science. 169:1177. 19. Apparently, in W e s t Germany, the national health care p r o g r a m m e pays for the doctor's visit but not the pills themselves. See Jones, E F et al, 1989. Pregnancy, contraception,
and family planning in industrialized countries. Yale University Press, New Haven. 20. Jones, E F et al, 1985. Teenage p r e g n a n c y in developed countries: determinants and policy implications. Family Planning Perspectives. 17(2):5363 21. Forrest, J D and Singh, S, 1990. The sexual and reproductive behavior of American w o m e n 1982-1988. Family Planning Perspectives. 22(5):206-14. 22. Popov, A A, 1993. Contraceptive knowledge, attitudes, and practice in Russia during the 1980s. Studies in Family Planning. 24(4):227-35. 23. Popov, A A, 1993. A short history of abortion and population policy in Russia.
Planned Parenthood in Europe. 22(2):23-25 24. Benkelman, S, 1993. Russia's culture of abortion/sex in Russia: 'whatever happens, happens.' Long Island Newsday. A u g u s t 31. 25. Gray, F du Plessix, 1989. Soviet
Women: Walking the Tight Rope. A n c h o r Books, Doubleday, New York. 26. Frejka, T, 1983. Induced abortion and fertility: a quarter century of experience in Eastern Europe. Population and Development Review. 9:494. 27. Hord, C et al, 1991. Reproductive health in Romania: reversing the Ceausescu legacy. Studies in Family Planning. 22(4):231-40.
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28. Frejka, T, 1985. Induced abortion and fertility.
International Family Planning Perspectives. 11(4):125-29. 29. Dixon-Mueller, R, 1993. Abortion is a m e t h o d of family planning. Four Essays on Birth
Control Needs and Risks. International W o m e n ' s Health Coalition, New York. 30. Blinkin, A J, 1986. Trends in induced legal abortion morbidity and mortality. Clinical
Obstetrics and Gynecology. 13:83/90. And: Grimes, D A and Schulz, K F, 1985. Morbidity and mortality from second trimester abortions. Journal o f Reproductive Medicine. 30: 505-14. 31. Tietze, C and Henshaw, S K, 1986. Induced abortion: a world review 1986. Alan Guttmacher Institute, New York. 32. Cares Jr, W e t al, 1982. Mortality from abortion and childbirth: are the statistics biased? Journal
of American Medical Association. 248:192/196. 33. Roe v. Wade, 410 U.S. 113 (1973) 34. Mortality, Vital Statistics o f the United States, 1965. II(A). US National Center for Health Statistics, 1967. 35. Council on Scientific Affairs, American Medical Association, 1992. Induced termination of p r e g n a n c y before and after Roe v Wade: trends in the mortality and morbidity of women.
Journal of American Medical Association. 268(22):3231-39. 36. Henshaw, S K, 1991. The accessibility of abortion services in the United States. Family Planning Perspectives. 23(6):24652/263. 37. Bernstein, E M, 1993. A lesson in one w o m a n ' s decision: knowledge is key in choosing clinics for abortions. N e w York Times. July 19, B1/B4. 38. Who will provide abortions?
Ensuring the availability o f qualified practitioners. Recommendations from a NAF/ACOG National
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Symposium, October 25-26, 1990. National Abortion Federation, 1991. 39. Russia's women face a new reign of fear. The Financial Times. August 21722, 1993, II:I/XVIII. 40. Simons, M, 1989. Abortion fight has new front in Western Europe. N e w York Times. June 28, A1. 41. David, H P e t al, 1990. United States and Denmark: different approaches to health care and family planning. Studies in Family Planning. 21(1):1719. 42. Rademakers, J, 1991. Study of teenagers gives pointers for better sex education. Entre Nous. 17:6. 43. Winter, L and Breckenmaker, L C, 1991. Tailoring family planning services to the special needs of adolescents. Family Planning Perspectives. 23(1): 24-30. 44. Henshaw, S K et al, 1991. Characteristics of US women having abortions 1987. Family Planning Perspectives. 23(2): 75-81. 45. Jones, E F and Forrest, J D, 1992. Contraceptive failure rates based on 1988 NSFG. Family Planning Perspectives 24(1): 12-19. 46. Risking the future: adolescent sexuality, pregnancy, and childbearing. National Research Council. National Academy Press, Washington DC, 1987. 47. Furstenberg Jr, F F et al, 1990. The children of teenage mothers: patterns of early childbearing in two generations. Family Planning Perspectives. 22(2):54~61.
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N formulating laws and policies related to reproductive health, r e s e a r c h examining the public health c o n s e q u e n c e s of different approaches is of p a r a m o u n t importance. Policy decisions in this field are often fraught with c ont r o v ers y and meaningful public debate can be absent or polarised. In this context, reliance on public health data helps to ensure a balance between the public health concerns of governments and the rights and health needs of women. This p a p e r reviews evidence f r o m the United States and E u r o p e d e m o n s t r a t i n g that desired public health objectives can best be achieved th r ough c o m p r e h e n s i v e family planning prog r a m m e s that include safe, legal abortion.
PUBLIC HEALTH BENEFITS OF FAMILY PLANNING PROGRAMMES The literature is replete with evidence substantiating the w i s d o m of laws and policies supporting b r o a d - b a s e d access to family planning services. I Use of contraception enables couples and individuals to d e t e r m i n e the n u m b e r and spacing of their children. W i d e r birth spacing has a positive impact on w o m e n ' s health, infant mortality rates and perinatal health. 1-3 Family planning p r o g r a m m e s can p r o m o t e maternal and infant health by d r a w i n g w o m e n into the health care system and providing them with access to medical information and counselling which, in turn, fosters i n f o r m e d and responsible procreative decisions. 1,4,5 Evidence from a US study further suggests that family planning services may increase w o m e n ' s use of antenatal care. 5 Similarly, w o m e n w h o m i g h t not have access to o t h er formal health services can obtain t re at m en t for conditions that might otherwise have been ignored. 6 Comparative data also reveal that the frequency of abortion is d e t e r m i n e d above all by the
I 77
quality of use of contraceptive methods. Family planning initiatives result in increased contraceptive use which, in turn, reduces the incidence of u n w a n t e d p r e g n a n c y - and thus abortion. W h e t h e r this result is v i e w e d as a public health benefit or a c o n s e q u e n c e of g r eat er reproductive choice, r e d u c i n g reliance on abortion is an oftenstated objective of policymakers. The link b e t w e e n use of effective contraceptives and the abortion rate is largely a matter of c o m m o n sense: "If the use o f contraceptive methods improves... both the n u m b e r o f births and the n u m b e r of abortions decrease. If the quality of use decreases, then the n u m b e r o f pregnancies rises - above all probably the n u m b e r o f unwanted pregnancies." 7 This was illustrated in a short-term w ay during the so-called 'pill-scare.' Although safety concerns about the birth control pill .have long since been laid to rest 8, in r e s p o n s e to a w a v e of negative information about adverse health risks of high-dose pills in the 1970s, many w o m e n switched to less effective contraceptive methods. In the United States, d e c r e a s e d use of the pill and the IUD 9 was associated with an increased abortion rate b e t w e e n 1975 and 1980. l° Likewise, in the Netherlands, the abortion rate j u m p e d by 14 p e r cent from 1979 to 1980, after reports of pillrelated deaths w e r e televised in the autumn of 1979.7,11 Over the l o n g e r term, the connection b et w een contraceptive k n o w l e d g e and use and abortion rates is also apparent. A 1992 international comparison r e a c h e d this conclusion: "lA]bortion rates have declined m o s t rapidly in those European countries where legal abortion is part o f a comprehensive family planning programme, where a full range o f contraceptive I
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m e t h o d s is available free o f c h a r g e o r at l o w cost, a n d w h e r e s e r v i c e s are r e s p o n s i v e to client n e e d s w i t h i n a sociocultural c o n t e x t f o s t e r i n g res p o n s i b l e social b e h a v i o u r . " 12
A comparative analysis of the public health c o n s e q u e n c e s of family planning policies in the Netherlands, United States and f o r m e r Soviet Union is illustrative. The history of the Netherlands' extensive family planning p r o g r a m m e traces back to the mid-1960s, w h e n oral contraceptives w e r e first m a d e available from family physicians. 11 In 1971, oral contraceptives w e r e c o v e r e d by public medical insurance. By 1974, m o r e than half of currently m a r r i e d w o m e n of reproductive age w e r e using the pill. 11 A recent study found 56 p er cent of Dutch w o m e n protected by sterilisation, the pill or the IUD. 13 As a result of this successful introduction of contraceptives, the Netherlands has h a d one of the lowest abortion rates in W e s t e r n Europe. 4,11-14 The success of the Netherlands" well studied family planning p r o g r a m m e seems to result f r o m tw o crucial factors. First, contraceptive services are widely available from both individuals' chosen general practitioners and clinics. Services and prescription contraceptives are free of c h a r g e to most citizens as part of a g o v e r n m e n t s p o n s o r e d health care system. Second, r e s p o n sible discussion has b e e n e n c o u r a g e d and information about sexuality and family planning have b e e n t h o r o u g h l y disseminated t h r o u g h health education courses in schools, candid presentations in the media, and a network of counselling centres t h r o u g h o u t the country. These counselling centres provide both inperson and telephonic guidance and referrals to anyone in need of assistance with birth control. 11A3,15-17 The combination of accessible birth control and w i d e s p r e a d family planning information has reinforced social attitudes about the i m p o r t a n c e of p r e v e n t i n g u n w a n t e d p r e g n a n c y t h r o u g h responsible use of contraceptives. 1%16 Due to these efforts, the Netherlands has app r o a c h e d the theoretical model of the 'perfect contraceptive population'.18 The United States has a less c o m p r e h e n s i v e family p r o g r a m m e and consequently, a higher abortion rate. Unlike m o s t o t h e r W e s t e r n countries, the United States has neither national health insurance n o r a national health care system providing family planning free of c h a r g e
to all w o m e n . Instead, most w o m e n pay for both a consultation/medical examination and for the m e t h o d itself. 4,19 In addition, there is a lack of readily available contraceptive information and services, and f ew public health m e s s a g e s in the mass media e n c o u r a g i n g contraceptive use. 4 This is due in p a r t to the high level o f religious and political rhetoric p r o m o t i n g abstinence, cond e m n i n g sex, and creating adverse political consequences for those even willin 9 to discuss or address the p r o b l e m of u n w a n t e d pregnancy. 2° A 1988 study related to family planning during the 1982-1986 p e r i o d found that 46 p e r cent of all w o m e n o f childbearing age in the US w e r e not using any m e t h o d of birth control. 4 In 1988, one in ten w o m e n a g e d 15-44 at risk o f u n w a n t e d p r e g n a n c y w e r e not using any contraceptive method. Almost twice the p e r c e n t a g e of p o o r w o m e n , as c o m p a r e d to w o m e n above the poverty line, r e p o r t e d no contraceptive use. 21 Mo r eo v er , use of the m o r e effective forms of birth control (the pill, IUD, and sterilisation) has b e e n appreciably l o w er a m o n g US w o m e n than a m o n g m a n y of their E u r o p e a n counterparts. 4,7 Thus, the 1988 abortion rate for the US was 27 p er 1,000 w o m e n o f reproductive age, m o r e than five times the Netherlands rate of 5 p er 1,000.12 In Russia - which did not officially adopt a family planning policy until 1991 - wide availability of legal abortion coupled with low availability of reliable contraceptive methods and inadequate family planning services have resulted in even higher abortion rates, which are t h o u g h t to be a m o n g the highest in the world. 22,23 • In Russia knowledge of family planning and contraception is scant; m o d e r n reliable methods of contraception are generally unavailable; and supplies of m o d e r n methods are irregular. '22 As a result, a 1990 survey revealed that only 22 per cent of all Russian w o m e n of reproductive age used contraceptives regularly. 23,24 This situation has been attributed largely to a 20-year 'antipill' campaign, w h i ch has led w o m e n to perceive oral contraceptives to be ' d a n g e r o u s to their health' and a m o n g the least effective methods, along with spermicides and the diaphragm. E v e n in 1990, Russian w o m e n believed c o n d o m s and withdrawal to be the m o s t effective methods, yet the quality and availability of S o v i et - p r o d u ced co n d o m s left m u c h to be desired. 23,24 Moreover, most abortion providers 'offer little contraceptive counselling, are often
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unaware of technical advances published in other languages, and are seldom motivated to change their practices. '12 Although it has begun to change, birth control in Russia, as in the other republics of the former Soviet Union, has thus been based primarily on abortion. W o m e n h a v e a v e r a g e d six or m o r e abortions during their reproductive years, 12 and some are r e p o r t e d to have h a d as many as 25 abortions. 25 The legal abortion rate for the 1980s, reported in 1987, was at least 112 abortions p er 1,000 w o m e n of reproductive age, which is considerably h i g h e r than the rate for the US and the Netherlands. 12,22 Eastern European countries likewise reflect the access to and use of contraceptives. 12A4,26,27
PUBLIC HEALTH BENEFITS OF SAFE, LEGAL A B O R T I O N Although a comprehensive family planning prog r a m m e and increased contraceptive use will reduce abortion rates, contraceptives cannot and do not eliminate the need for abortion. 12,28 F o r the vast majority of women, abortion is a necessary back-up method for use w h e n contraception fails, is not available or has not been used, and in cases of rape and incest w h e r e w o m e n have no opportunity to p r o t e c t them~ selves f r o m u n w a n t e d pregnancy. F o r some, abortion m ay be a p r ef e r r e d m e t h o d of birth control due to particular social or personal situ~ ations, or inadequacies in contraceptive m e t h o d s or health care delivery systems. 32 Liberalisation of abortion laws has been shown to be a significant factor in decreasing mortality rates f r o m unsafe abortion. W h e n abortion services are normalised as a standard c o m p o n e n t of w o m e n ' s health care, the quality of service tends to increase, and associated medical risks are minimised. 3° Early abortion by v a c u u m aspiration is one of the safest of all surgical procedures. Up to the 16th week of pregnancy, abortion is ten times safer than childbearing, and the risk of death from abortion r em ai n s l o w e r than the risk of death from childbirth t h r o u g h o u t most of the second trimester. 31,32 The risk of an abortionrelated death in W e s t e r n E u r o p e is generally less than 1 per 100,000 abortions, c o m p a r e d with about 5-7 m a t e r n a l deaths p e r 100,000 live births. 14
In the United States, abortion b e c a m e legal in all states following a S u p r e m e Court ruling in 1973. 33 In the years b e f o r e the Court's decision, illegal abortion acco u n t ed for approximately 17 p e r cent of all deaths attributable to p r e g n a n c y and childbirth. 34 By 1985, mortality from legal abortions d ecr eased m o r e than flvefold to 0.4 deaths p er 100,000 procedures. I m p r o v e d training and physician skills, safer methods, and earlier termination of p r e g n a n c y due to imp r o v e d access to safe services contributed to this dramatic reduction. 35 M a n y other countries, such as Hungary, Ro m an i a and the f o r m e r Czechoslovakia, ex p er i en ced similar declines in their abortion-related mortality rates following legalisation of abortion. 12,14,26,27 Liberalisation of abortion laws alone, however, does not g u a r a n t e e the availability of safe abortion services. In the United States, federal health care r e i m b u r s e m e n t p r o g r a m m e s do not c o v er abortion unless the w o m a n ' s life is in danger, or in the event of rape or incest. Independent state funding for abortion, absent a threat to a w o m a n ' s life, is available in only a fraction of the states. 14,36 A b o u t half the w o m e n having abortions after 15 weeks of p r e g n a n c y have been delayed by the n e e d to make financial arrangements to pay for the procedure. 35 Inadequate information leads m a n y w o m e n to poorly trained, low quality providers, often at inflated cost. a7 In addition, 83 p er cent of all counties in the US have no abortion provider, forcing many w o m e n to travel long distances at significant expense to obtain an abortion. 35,36 Moreover, there is a g r o w i n g s h o r t a g e of physicians and hospitals w i r i n g to p r o v i d e abortion services. 38 Such circumstances lead to delayed abortions, thus exposing w o m e n to i n cr eased health risks associated with later procedures. Generally, maternal morbidity and mortality from abortion increases with 9estational age. 14 Moreover, w o m e n w h o face such obstacles have an even m o r e difficult time finding a provider; only 25 per cent of US providers will p e r f o r m an abortion b e y o n d the 16th week of pregnancy. 35 In the f o r m e r Soviet Union, legal abortion also has not resulted in optimal quality abortion services for w o m e n . In state abortion clinics, w o m e n describe 'assembly-line' abortions, p e r f o r m e d without anaesthesia, with up to eight w o m e n having p r o c e d u r e s in the same r o o m at the same time. 24,25 Figures for 1988 reveal 3.4
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deaths p er 100,000 legal abortions in state hospitals in the Soviet Union, and the situation is even w o r s e outside the state health sector. 24 The c u m b e r s o m e administrative p r o c e d u r e s and low quality of care in hospitals and clinics lead m a n y Russian w o m e n to seek illegal abortions. 12 In 1989, one-fifth of all abortions in w o m e n without children w e r e illegally performed. 23] "Illegal p r o c e d u r e s are responsible for 68 p er cent of all deaths due to abortion; and 31 p er cent of all maternal deaths in 1989 resulted from complications of criminal abortions. '23 Illegal procedures, typically p e r f o r m e d by physicians after regular hours, cost b e t w e e n one-fourth to one-half of w o m e n ' s a v e r a g e monthly income. 12 These "handsome fees" for unauthorized abortion p r o c e d u r e s have b e e n cited as a powerful but hidden motivation for biases against and lack of availability o f contraceptives. 39 The available evidence demonstrates that public health objectives are seriously undermi ne d unless abortion services are available a m o n g the panoply of r e p r o d u c t i v e health services offered to women. In fact, countries that have legalised the p r o c e d u r e , and taken other steps to make abortion services m o r e accessible, have wi t n es s ed a dramatic i m p r o v e m e n t in w o m e n ' s health. 14 It should be n o t e d that, in the p r e s e n c e of strong family planning initiatives, liberalisation of abortion laws has not increased the overall rate of abortion in the long term. 7,~2,4° For example, the Netherlands, a country with one of the most liberal abortion laws, also has one of the lowest abortion rates in Europe.
SPECIAL NEEDS OF ADOLESCENTS G o v e r n m e n t - f u n d e d contraceptive information and supplies are especially i m p o r t a n t for teenagers, the population often at highest risk for u n w a n t e d pregnancy. 41,42 Indeed, a 1990 international study concluded that '[i]n Scandinavia and Engiish-speaking countries, especially the United States, the m o s t im p o r t a n t prerequisite for r e d u c i n g unintended p r e g n a n c y and abortion is an i m p r o v e m e n t in contraceptive use a m o n g young, u n m a r r i e d w o m e n . '14 In line with this observation, a 1988 study found t e e n a g e abortion rates to be lowest in countries w h e r e contraceptive services w e r e widely available to teenagers, confidential, free
or very inexpensive, and w h e r e timely information about sexuality and contraception was p r o v i d e d t h r o u g h the schools or media. 4 The Netherlands's low t een ag e birth and abortion rates can be in part attributed to its o p e n p r e s e n t a t i o n and discussion o f matters relating to sexuality and birth control. 13,2° '[S]ex education begins in early school years and is considered a lifelong effort, p r o m o t e d at all levels of society, including health professionals and the media. '12 In addition, t e e n a g e r s w h o prefer anonymity may visit family planning clinics, m a n y of w h i c h are open evenings and weekends. In fact, delivery of contraceptive services to teenagers - a g r o u p singled out by the g o v e r n m e n t as n e e d i n g special attention - is a p r i m a r y focus of the largest n e t w o r k of clinics. Visits by adolescents are government-subsidised. Additionally, a n e t w o r k o f counselling centres are available to pr o v i d e guidance, information and referrals related to sexuality and birth control. 13 In contrast, w h e r e t e e n a g e r s face obstacles in obtaining contraceptive information and services, adolescent fertility and abortion rates are higher. The comparatively high t een ag e birth and abortion rates in the United States have been attributed to a lack of openness about sexual matters. US t e e n a g e r s often lack access to contraceptive and abortion information and free or low-cost contraceptives, a° The decision w h e t h e r and h o w to teach about contraceptive met h o d s is left up to individual schools or local authorities. 4,2° There are no national guidelines on the content or quality of sex education programmes, and state and local guidelines have been described as 'purposely v ag u e to assure m a x i m u m c o m m u n i t y flexibility."41 In addition, family planning clinics are not tailored to the special needs of teenagers. Some teens avoid clinics, v i ew i n g t h e m as places "where only welfare clients 9o." 20,43 Consequently, in the US, one in five t e e n a g e r s exposed to the risk of p r e g n a n c y in 1988 w e r e not using any form of birth control. 21 W o m e n below the age of 25 account for 61 p e r cent of total abortions, as c o m p a r e d with 40 p e r cent in the Netherlands. 4 Studies have pointed to a n u m b e r of approaches that m i g h t help reduce t een ag e p r e g n a n c y rates. These include u p g r a d i n g family planning clinics to provide free or low-cost contraceptive services to teenagers; establishing special clinics for adolescents, p er h ap s as-
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sociated with schools, to provide confidential c o n t r a c e p t i v e s e r v i c e s as p a r t o f g e n e r a l h e a l t h care; e n c o u r a g i n g local s c h o o l d i s t r i c t s t o p r o vide s e x e d u c a t i o n p r o g r a m m e s ; a n d r e l a x i n g restrictions on advertising of non-prescription c o n t r a c e p t i v e s s u c h as c o n d o m s a n d s p e r m i cides. 2° Recent efforts to improve contraceptive use a m o n g t e e n a g e r s in t h e U S h a v e h a d s o m e success. B e t w e e n 1982 a n d 1988, t h e p r o p o r t i o n of a d o l e s c e n t s a g e d 15-19 w h o h a d e v e r h a d s e x u a l i n t e r c o u r s e , i n c r e a s e d f r o m 47 p e r c e n t to 53 p e r cent. Yet t h e p r e g n a n c y r a t e o f w o m e n o f t h e s a m e a g e g r o u p r e m a i n e d c o n s t a n t . 21 T h e r e a s o n w a s u n d o u b t e d l y a n i n c r e a s e in c o n t r a c e p t i v e use. F o r e x a m p l e , t h e p r o p o r t i o n o f w o m e n a g e d 15-19 w h o u s e d a m e t h o d t h e first t i m e t h e y h a d i n t e r c o u r s e i n c r e a s e d f r o m 48 p e r c e n t t o 65 p e r cent. 21 N e v e r t h e l e s s , c o n t r a c e p t i v e n o n u s e a n d failure rates remain somewhat higher among teen ~ a g e r s . 43-45 I n a r e c e n t s t u d y b a s e d o n 1988 d a t a , t h e failure r a t e f o r all c o n t r a c e p t i v e m e t h o d s f o r w o m e n u n d e r 20 w a s 26 p e r c e n t , in c o n t r a s t to 14 p e r c e n t f o r all w o m e n . 45 T h u s , i n t e g r a t i o n o f free o r l o w - c o s t safe, l e g a l a b o r t i o n s e r v i c e s i n t o family p l a n n i n g p r o g r a m m e s is p a r t i c u l a r l y critical f o r a d o l e s c e n t s . O f p a r t i c u l a r i m p o r t a n c e to p o l i c y m a k e r s a r e t h e life c o n s e q u e n c e s o f u n w a n t e d t e e n p a r e n t h o o d . T h e h e a l t h , e c o n o m i c , a n d social c o s t s of a d o l e s c e n t p r e g n a n c y a n d c h i l d b e a r i n g h a v e b e e n well d o c u m e n t e d . 46,47 P r e g n a n t t e e n a g e r s h a v e h i g h e r r a t e s of c o m p l i c a t i o n s , m a t e r n a l morbidity and mortality, and more premature and/or low birthweight babies. Early childbear-
References
i n g also h a s a d e t r i m e n t a l i m p a c t o n e d u c a t i o n a l a t t a i n m e n t w h i c h , i n p a r t , c o n t r i b u t e s to l o w e r work status and income. Thus, 'women who e n t e r p a r e n t h o o d as t e e n a g e r s a r e a t g r e a t e r risk o f l i v i n g in p o v e r t y , b o t h in t h e s h o r t a n d l o n g term." In a d d i t i o n , c h i l d r e n o f t e e n a g e m o t h e r s h a v e b e e n s h o w n t o face i n c r e a s e d h e a l t h risks, c o g n i t i v e deficits a n d s o c i o - e m o t i o n a l p r o b l e m s . 46 A c c e s s t o a b o r t i o n is e s s e n t i a l to e n a b l e t e e n a g e r s w h o so c h o o s e to a v o i d unwanted parenthood.
CONCLUSIONS T h e c o n c l u s i o n s a r e clear. T h e p o o r e r t h e q u a l i t y o f c o n t r a c e p t i v e p r o v i s i o n a n d use, t h e h i g h e r t h e levels o f u n w a n t e d p r e g n a n c y a n d a b o r t i o n . Illegal a n d u n s a f e a b o r t i o n l e a d s to a h i g h r a t e o f m a t e r n a l m o r t a l i t y . I n b o t h cases, t h e h e a l t h o f w o m e n suffers. T h u s , g o v e r n m e n t p o l i c i e s p r o m o t i n g b r o a d a c c e s s to q u a l i t y f a m i l y p l a n n i n g s e r v i c e s - i n c l u d i n g safe, l e g a l a b o r t i o n - a r e t h e b e s t m e a n s o f e n s u r i n g g o v e r n m e n t o b j e c t i v e s as well as t h e h e a l t h a n d r i g h t s o f w o m e n .
Note The author would like to thank Lori F Fischler for her assistance in preparing this paper. This paper is adapted from a Brief Amici Curiae, filed in the German Constitutional Court in 1992 in support of the compromise German abortion legislation, on behalf of a number o f organisations. The brief, co-authored with Julie A Mertus, was written in close consultation with Stanley K Henshaw of the Alan Guttmacher Institute.
and Notes
1. Rinehart, W et al, 1984. Healthier mothers and children through family planning, Population Reports. Series J, 27:657-96. 2. Rosenfield, A, 1986. Birthspacing and health: an overview. International Family Planning Perspectives. 12(3):69-70.
3. Miller, J E, 1991. Birth intervals and perinatal health: an investigation of three hypotheses. Family Planning Perspectives. 23(2):62-70.
4.
Jones, E F et al, 1988. Unintended pregnancy, contraceptive practice and family planning services in developed countries. Family Planning Perspectives. 20(2):5367. The countries surveyed included Australia, Austria, Belgium, Canada, Denmark, Finland, France, West Germany, Greece, Ireland, Italy, the Netherlands, New Zealand, Norway, Portugal, Spain,
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Sweden, Switzerland, the United Kingdom, and the United States. 5. Jamieson, D J and Buescher, P A, 1992. The effect of family planning participation on prenatal care use and low birth weight. Family Planning Perspectives. 24(5):214-18. 6. ArM, S O et al, 1986. Screening for sexually transmitted diseases by family planning providers: is it adequate and
Pine
appropriate? Family Planning Perspectives. 18(6):255-58. 7. Ketting, E and van Praag, P, 1985. Schwangerschafts-
abbruch, gesetz und praxis im internationalen vergleich. DGVT-Verlag, Tubingen. 8. See for example: Harlap, S e t al, 1991. Preventingpregnancy,
protecting health: a n e w look at birth control choices in the United States. Alan Guttmacher Institute, New York. 9. The IUD likewise received significant adverse public attention. Forrest, J D, 1986. The end of IUD marketing in the United States: what does it m e a n for American w o m e n ?
Family Planning Perspectives. 18(2):52-57. 10. Henshaw, S K et al, 1984. Abortion services in the United States, 1981 and 1982. Family Planning Perspectives. 16(3): 11927. 11. Ketting, E, 1982. Contraception and fertility in the Netherlands.
International Family Planning Perspectives. 8(4):141-47. 12. David, H P, 1992. Abortion in Europe, 1920--1991: A public health perspective. Studies in Family Planning. 23(1):1-22. 13. Torres, A and Jones, E F, 1988. The delivery of family planning services in the Netherlands.
Family Planning Perspectives. 20(2):75-79. 14. Henshaw, S K, 1990. Induced abortion: a world review 1990.
Family Planning Perspectives. 22(2):76-89. While Czechoslovakia, Hungary, a n d the GDR kept fairly accurate abortion statistics during this time, Romania and the Soviet Union did not. The actual abortion rates in these latter countries are likely to be m u c h higher. 15. Dutch g o v e r n m e n t aid to family planning reduces abortion use.
International Family Planning Perspectives. 7:117. 16. Ketting, E and Schnabel, P, 1980. Induced abortion in the
Netherlands: a decade of experience 1970-80. Studies in Family Planning. 11(12):385-394. 17. Rademakers, J, 1990. Abortus in Nederland. Stimezo, Utrecht. 18. Bumpass, L A and Westoff, C F, 1970. The 'perfect contraceptive' population. Science. 169:1177. 19. Apparently, in W e s t Germany, the national health care p r o g r a m m e pays for the doctor's visit but not the pills themselves. See Jones, E F et al, 1989. Pregnancy, contraception,
and family planning in industrialized countries. Yale University Press, New Haven. 20. Jones, E F et al, 1985. Teenage p r e g n a n c y in developed countries: determinants and policy implications. Family Planning Perspectives. 17(2):5363 21. Forrest, J D and Singh, S, 1990. The sexual and reproductive behavior of American w o m e n 1982-1988. Family Planning Perspectives. 22(5):206-14. 22. Popov, A A, 1993. Contraceptive knowledge, attitudes, and practice in Russia during the 1980s. Studies in Family Planning. 24(4):227-35. 23. Popov, A A, 1993. A short history of abortion and population policy in Russia.
Planned Parenthood in Europe. 22(2):23-25 24. Benkelman, S, 1993. Russia's culture of abortion/sex in Russia: 'whatever happens, happens.' Long Island Newsday. A u g u s t 31. 25. Gray, F du Plessix, 1989. Soviet
Women: Walking the Tight Rope. A n c h o r Books, Doubleday, New York. 26. Frejka, T, 1983. Induced abortion and fertility: a quarter century of experience in Eastern Europe. Population and Development Review. 9:494. 27. Hord, C et al, 1991. Reproductive health in Romania: reversing the Ceausescu legacy. Studies in Family Planning. 22(4):231-40.
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28. Frejka, T, 1985. Induced abortion and fertility.
International Family Planning Perspectives. 11(4):125-29. 29. Dixon-Mueller, R, 1993. Abortion is a m e t h o d of family planning. Four Essays on Birth
Control Needs and Risks. International W o m e n ' s Health Coalition, New York. 30. Blinkin, A J, 1986. Trends in induced legal abortion morbidity and mortality. Clinical
Obstetrics and Gynecology. 13:83/90. And: Grimes, D A and Schulz, K F, 1985. Morbidity and mortality from second trimester abortions. Journal o f Reproductive Medicine. 30: 505-14. 31. Tietze, C and Henshaw, S K, 1986. Induced abortion: a world review 1986. Alan Guttmacher Institute, New York. 32. Cares Jr, W e t al, 1982. Mortality from abortion and childbirth: are the statistics biased? Journal
of American Medical Association. 248:192/196. 33. Roe v. Wade, 410 U.S. 113 (1973) 34. Mortality, Vital Statistics o f the United States, 1965. II(A). US National Center for Health Statistics, 1967. 35. Council on Scientific Affairs, American Medical Association, 1992. Induced termination of p r e g n a n c y before and after Roe v Wade: trends in the mortality and morbidity of women.
Journal of American Medical Association. 268(22):3231-39. 36. Henshaw, S K, 1991. The accessibility of abortion services in the United States. Family Planning Perspectives. 23(6):24652/263. 37. Bernstein, E M, 1993. A lesson in one w o m a n ' s decision: knowledge is key in choosing clinics for abortions. N e w York Times. July 19, B1/B4. 38. Who will provide abortions?
Ensuring the availability o f qualified practitioners. Recommendations from a NAF/ACOG National
Reproductive Health Matters, No 2, November 1993
Symposium, October 25-26, 1990. National Abortion Federation, 1991. 39. Russia's women face a new reign of fear. The Financial Times. August 21722, 1993, II:I/XVIII. 40. Simons, M, 1989. Abortion fight has new front in Western Europe. N e w York Times. June 28, A1. 41. David, H P e t al, 1990. United States and Denmark: different approaches to health care and family planning. Studies in Family Planning. 21(1):1719. 42. Rademakers, J, 1991. Study of teenagers gives pointers for better sex education. Entre Nous. 17:6. 43. Winter, L and Breckenmaker, L C, 1991. Tailoring family planning services to the special needs of adolescents. Family Planning Perspectives. 23(1): 24-30. 44. Henshaw, S K et al, 1991. Characteristics of US women having abortions 1987. Family Planning Perspectives. 23(2): 75-81. 45. Jones, E F and Forrest, J D, 1992. Contraceptive failure rates based on 1988 NSFG. Family Planning Perspectives 24(1): 12-19. 46. Risking the future: adolescent sexuality, pregnancy, and childbearing. National Research Council. National Academy Press, Washington DC, 1987. 47. Furstenberg Jr, F F et al, 1990. The children of teenage mothers: patterns of early childbearing in two generations. Family Planning Perspectives. 22(2):54~61.
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