- Email: [email protected]
Inquiries into abortion
1938 report are that in no circumstances should sleeping accommodation be provided in a ward block, there should not be more than one entrance to the hospital site, and that there should be at least one resident male member of the staff in case of emergency. The recommendations set forth for the construction of isolation hospitals will meet with general approval, and follow the best modern practice. Some will wish, however, that the Committee might have given more precise guidance on one or two matters germane to their terms of reference. For example, they have not found it possible to recommend any standard minimum size for isolation hospitals. Though no expression of opinion was made in the Society's Memorandum of Evidence, we believe most medical officers of health would only be in favour of hospitals sufficiently large to warrant the employment of at least one resident medical officer. Again, we think it would have been useful to give some general indication of the proportion of single-bedded wards in relation to the total accommodation of the hospital which it is advisable to provide. Lastly, we note that that Cinderella of institutions, the smallpox hospital, has completely escaped recognition in this otherwise most comprehensive report.
Inquiries into Abortion The ascertainment of the true facts of abortion is notoriously difficult, as the Departmental Committee is probably finding. The fullest recent analysis of the available data in this country is contained in the Report on an Investigation into Maternal Mortality issued by the Ministry in 1937. From this survey it was concluded that abortion is an important factor in puerperal mortality, accounting for about 14 per cent. of the deaths. The trend of mortality from abortion was, if anything, increasing more rapidly than that from other puerperal causes up to 1934, but it is little more than a suggestion. The most satisfactory information as to the frequency of abortion is that gathered in Birmingham by Prof. Beckwith Whitehouse, which indicated that, over a long series of years, there was one abortion to every 4.7 births, i.e. that 17.5 per cent. of all pregnancies ended in abortion. In some areas the proportion is probably higher, and this percentage cannot be assumed to represent even an average for the whole country. In New Zealand 20 per cent. is considered an underestimate.* The Ministry's conclusions on this point are in general terms--that abortion is frequent and appears to be increasing, is more prevalent in some districts than in others and is not restricted to any one class. ¢ Report of the Committee of Inquiry into the Various Aspects of the Problem of Abortion in New Zealand, 1937.
PUBLIC H E A L T H In this state of uncertainty a detailed inquiry into the frequency of abortion in New York and Cincinnati is welcome.t Three groups of women were interviewed, two of which were clients of birth control clinics and one an unselected sample of married wome'n in New York whose pregnancies had terminated recently. The number of pregnancies recorded were (1) (Cincinnati birth control clinic) 7,289, (2) (New York birth control clinic) 3,106 and (3) (New York random sample) 1,525. The percentages ending in abortion were as follows : - Spontaneous* Illegal .. Total ..
(1)
(2)
(3)
8-9 8-0 16-8
7-2 22.1 29-3
9-2 2-9 12.1
* Including therapeutic abortion. When these rates are compared with other American data quoted, the outstanding feature is that t h e " spontaneous " abortion rate is remarkably constant around 9 or 10 per cent., the variation in the total abortion rate, which is considerable as between one place and another, being almost entirely due to differences in the amount of abortion induced illegally. The relatively low spontaneous rate in New York birth control clients is attributed to the exceptionally large amount of deliberate abortion taking place earlier in pregnancy than spontaneous abortion would be expected. Ten per cent. may be taken as a reasonable expectation for the termination of pregnancy in abortion without interference by the woman or any party other than a medical practitioner acting on purely medical grounds. A morbid condition following abortion of such severity as to have impressed itself on the memories of the women themselves was reported in about 10 per cent. of the cases, whether spontaneous or illegal, but sepsis was more than twice as frequent with illegal abortion (2.3 per cent.) as with spontaneous abortion (1.0 per cent.). In both groups the sepsis rate was about five times higher when there had been instrumental interference than when there had not, and a warning is therefore sounded as to the dangers of dilatation and curettage in the treatment of the condition. When the causes of death from abortion are studied, 75 per cent. are found to be due to sepsis (a proportion rather higher than that of England and Wales and New Zealand) ; the percentage of sepsis among deaths from illegal abortion was 97, as compared with about 50 in the spontaneous group (which, it must be remembered, included therapeutically induced cases). t Abortion and the Public Health. By Regine K~ Stix, M.D., and Dorothy G. Wiehl. Am. J. Pub. Health, 1938, 28,621. 291
PUBLIC H E A L T H
JULY
to see that the rate has now fallen to 5-9. The cost of medical extras has increased from 1/9.5d. and 1/9.4d. per patient in the first two periods to 2/0.1d. in the last, this being due to increases both in the number of children under treatment and of chronic cases including the tuberculous, and to a rise in the price of milk; only a small part of the increase is thought to have been due to undue liberality on the part of practitioners. The relations between relieving officers and practitioners are cordial and there are few instances of lax certification. No complaints were received from patients and few exercised their rights of transfer to another doctor. Indeed, Dr. Charles expresses the view that " no other scheme of domiciliary medical service has ever achieved so large a measure of acceptance and popularity amongst those members of the community whom it is intended to serve." Outdoor Medical Assistance Probably it is for this reason that the Council in Newcastle has agreed to raise the remuneration from time A number of the larger authorities have adopted to time. In the first and trial period, a pool of some measure of " open choice" in the provision £1,000 was available for treatment apart from of outdoor medical assistance since the Poor Law certification, confinement and emergency medifunctions were transferred in 1930. Few, how- cines, providing 5-656d. per unit of service. ever, have turned such a keen eye on its operation In the second and third periods fees were on the as the Town Council of Newcastle. The system basis of 5s. per quarter with £ 1 for twelve months came into force on November 8th, 1933, and Dr. if a patient required continuous care over more Charles, M.O.H., has already submitted three than two quarters ; on this basis the cost per unit separate, full and detailed reports on its working, of service has been 11.38d. and 10.6d. respectively. the most recent covering the period March 1st, Since the last period covered by this report, the 1936 to February 28th, 1937. At the commence- basic fee per quarter has been increased by 25 per ment, six of the ten medical relief districts were cent. Dispensing costs have risen from £770 and embraced in the scheme, but gradually it has been £1,474 to £1,637 and administration from £175 extended to include eight. Judged by the average to £362. Including all items the average cost per numbers of persons in receipt of any form of relief, patient was 6/10d., 12/6d. and 11/9.6d. in the the population at risk has fallen by about 2,000, respective periods. The opportunity is taken by Dr. Charles to from 21,395 and 20,687 in the first two periods to 19,115, this decline comprising mostly children. analyse the age and sex distribution and the The number of patients treated has risen from character of the sickness recorded. A separate table 6,360 in the first period of ten months to 8,193 in is devoted to rheumatic diseases. Altogether, this the second year, and to 10,707 in the most recent is a model report on a model scheme. year. It is particularly notable that, in spite of the drop in children at risk, their numbers treated rose Provincial Meeting of the Society from 3,17~6 or 41 per cent. of the total in the The President has decided to call a Provincial second year to 4,654 or 43 per cent. in the year Meeting of the Society in Glasgow for Tuesday under report. The total number of services afternoon, September 27th, the day preceding the rendered in each of the three periods was as first day of the Health Education Conference. follows: November, 1933, to August, 1 9 3 4 - The Society's meeting will be held at 3 p.m. in the ten months-M2,432 (attendances 19,114, visits Burgh Court Hall in the City Chambers, and Dr. 23,318); March, 1935, to February, 1936, 63,113 H. J. Rae, M.O.H. for the City and County of (attendances 40,151, visits 22,962) ; March, 1936, Aberdeen and the County of Kincardine will open to February, 1937, 89,476 (attendances 59,588, a discussion on " Regional Public Health and visits 29,888). Attendances at surgery, it will Hospital Services in Aberdeen." be observed, have increased far more than domiciIt is hoped that a large number of English liary visits. Between the first and second periods M.Os.H. who may be attending the Health there was a rather alarming rise in prescriptions Education Conference will take the opportunity of (which are dispensed at two central dispensaries) attending the Society's meeting also and of renewfrom 4-7 to 7.5 per patient, but it is satisfactory ing acquaintance with the Scottish Branch.
Among recent enquiries in this country one of the most interesting has been conducted by Drs. James Fenton and Violet Russell, the results of which will be published shortly in the M e d i c a l O2fficer. It may be mentioned, however, that 100 of 500 working-class women in Kensington stated that they had a t t e m p t e d to procure abortion during their present or previous pregnancies. Of these, 31 made the attempt during their first pregnancy, 26 in the second, 17 in the third and the remainder in later parities. The overwhelming majority, 89, used drugs for the purpose, while only three admitted commerce with professional abortionists. This inquiry, when published, will be found to contain valuable information both as to the practice of, and reasons for, abortion and contraception.
292
Inquiries into Abortion The ascertainment of the true facts of abortion is notoriously difficult, as the Departmental Committee is probably finding. The fullest recent analysis of the available data in this country is contained in the Report on an Investigation into Maternal Mortality issued by the Ministry in 1937. From this survey it was concluded that abortion is an important factor in puerperal mortality, accounting for about 14 per cent. of the deaths. The trend of mortality from abortion was, if anything, increasing more rapidly than that from other puerperal causes up to 1934, but it is little more than a suggestion. The most satisfactory information as to the frequency of abortion is that gathered in Birmingham by Prof. Beckwith Whitehouse, which indicated that, over a long series of years, there was one abortion to every 4.7 births, i.e. that 17.5 per cent. of all pregnancies ended in abortion. In some areas the proportion is probably higher, and this percentage cannot be assumed to represent even an average for the whole country. In New Zealand 20 per cent. is considered an underestimate.* The Ministry's conclusions on this point are in general terms--that abortion is frequent and appears to be increasing, is more prevalent in some districts than in others and is not restricted to any one class. ¢ Report of the Committee of Inquiry into the Various Aspects of the Problem of Abortion in New Zealand, 1937.
PUBLIC H E A L T H In this state of uncertainty a detailed inquiry into the frequency of abortion in New York and Cincinnati is welcome.t Three groups of women were interviewed, two of which were clients of birth control clinics and one an unselected sample of married wome'n in New York whose pregnancies had terminated recently. The number of pregnancies recorded were (1) (Cincinnati birth control clinic) 7,289, (2) (New York birth control clinic) 3,106 and (3) (New York random sample) 1,525. The percentages ending in abortion were as follows : - Spontaneous* Illegal .. Total ..
(1)
(2)
(3)
8-9 8-0 16-8
7-2 22.1 29-3
9-2 2-9 12.1
* Including therapeutic abortion. When these rates are compared with other American data quoted, the outstanding feature is that t h e " spontaneous " abortion rate is remarkably constant around 9 or 10 per cent., the variation in the total abortion rate, which is considerable as between one place and another, being almost entirely due to differences in the amount of abortion induced illegally. The relatively low spontaneous rate in New York birth control clients is attributed to the exceptionally large amount of deliberate abortion taking place earlier in pregnancy than spontaneous abortion would be expected. Ten per cent. may be taken as a reasonable expectation for the termination of pregnancy in abortion without interference by the woman or any party other than a medical practitioner acting on purely medical grounds. A morbid condition following abortion of such severity as to have impressed itself on the memories of the women themselves was reported in about 10 per cent. of the cases, whether spontaneous or illegal, but sepsis was more than twice as frequent with illegal abortion (2.3 per cent.) as with spontaneous abortion (1.0 per cent.). In both groups the sepsis rate was about five times higher when there had been instrumental interference than when there had not, and a warning is therefore sounded as to the dangers of dilatation and curettage in the treatment of the condition. When the causes of death from abortion are studied, 75 per cent. are found to be due to sepsis (a proportion rather higher than that of England and Wales and New Zealand) ; the percentage of sepsis among deaths from illegal abortion was 97, as compared with about 50 in the spontaneous group (which, it must be remembered, included therapeutically induced cases). t Abortion and the Public Health. By Regine K~ Stix, M.D., and Dorothy G. Wiehl. Am. J. Pub. Health, 1938, 28,621. 291
PUBLIC H E A L T H
JULY
to see that the rate has now fallen to 5-9. The cost of medical extras has increased from 1/9.5d. and 1/9.4d. per patient in the first two periods to 2/0.1d. in the last, this being due to increases both in the number of children under treatment and of chronic cases including the tuberculous, and to a rise in the price of milk; only a small part of the increase is thought to have been due to undue liberality on the part of practitioners. The relations between relieving officers and practitioners are cordial and there are few instances of lax certification. No complaints were received from patients and few exercised their rights of transfer to another doctor. Indeed, Dr. Charles expresses the view that " no other scheme of domiciliary medical service has ever achieved so large a measure of acceptance and popularity amongst those members of the community whom it is intended to serve." Outdoor Medical Assistance Probably it is for this reason that the Council in Newcastle has agreed to raise the remuneration from time A number of the larger authorities have adopted to time. In the first and trial period, a pool of some measure of " open choice" in the provision £1,000 was available for treatment apart from of outdoor medical assistance since the Poor Law certification, confinement and emergency medifunctions were transferred in 1930. Few, how- cines, providing 5-656d. per unit of service. ever, have turned such a keen eye on its operation In the second and third periods fees were on the as the Town Council of Newcastle. The system basis of 5s. per quarter with £ 1 for twelve months came into force on November 8th, 1933, and Dr. if a patient required continuous care over more Charles, M.O.H., has already submitted three than two quarters ; on this basis the cost per unit separate, full and detailed reports on its working, of service has been 11.38d. and 10.6d. respectively. the most recent covering the period March 1st, Since the last period covered by this report, the 1936 to February 28th, 1937. At the commence- basic fee per quarter has been increased by 25 per ment, six of the ten medical relief districts were cent. Dispensing costs have risen from £770 and embraced in the scheme, but gradually it has been £1,474 to £1,637 and administration from £175 extended to include eight. Judged by the average to £362. Including all items the average cost per numbers of persons in receipt of any form of relief, patient was 6/10d., 12/6d. and 11/9.6d. in the the population at risk has fallen by about 2,000, respective periods. The opportunity is taken by Dr. Charles to from 21,395 and 20,687 in the first two periods to 19,115, this decline comprising mostly children. analyse the age and sex distribution and the The number of patients treated has risen from character of the sickness recorded. A separate table 6,360 in the first period of ten months to 8,193 in is devoted to rheumatic diseases. Altogether, this the second year, and to 10,707 in the most recent is a model report on a model scheme. year. It is particularly notable that, in spite of the drop in children at risk, their numbers treated rose Provincial Meeting of the Society from 3,17~6 or 41 per cent. of the total in the The President has decided to call a Provincial second year to 4,654 or 43 per cent. in the year Meeting of the Society in Glasgow for Tuesday under report. The total number of services afternoon, September 27th, the day preceding the rendered in each of the three periods was as first day of the Health Education Conference. follows: November, 1933, to August, 1 9 3 4 - The Society's meeting will be held at 3 p.m. in the ten months-M2,432 (attendances 19,114, visits Burgh Court Hall in the City Chambers, and Dr. 23,318); March, 1935, to February, 1936, 63,113 H. J. Rae, M.O.H. for the City and County of (attendances 40,151, visits 22,962) ; March, 1936, Aberdeen and the County of Kincardine will open to February, 1937, 89,476 (attendances 59,588, a discussion on " Regional Public Health and visits 29,888). Attendances at surgery, it will Hospital Services in Aberdeen." be observed, have increased far more than domiciIt is hoped that a large number of English liary visits. Between the first and second periods M.Os.H. who may be attending the Health there was a rather alarming rise in prescriptions Education Conference will take the opportunity of (which are dispensed at two central dispensaries) attending the Society's meeting also and of renewfrom 4-7 to 7.5 per patient, but it is satisfactory ing acquaintance with the Scottish Branch.
Among recent enquiries in this country one of the most interesting has been conducted by Drs. James Fenton and Violet Russell, the results of which will be published shortly in the M e d i c a l O2fficer. It may be mentioned, however, that 100 of 500 working-class women in Kensington stated that they had a t t e m p t e d to procure abortion during their present or previous pregnancies. Of these, 31 made the attempt during their first pregnancy, 26 in the second, 17 in the third and the remainder in later parities. The overwhelming majority, 89, used drugs for the purpose, while only three admitted commerce with professional abortionists. This inquiry, when published, will be found to contain valuable information both as to the practice of, and reasons for, abortion and contraception.
292