Chapter 2

All the evidence brought before the Committee indicates that abortion is exceedingly frequent in New Zealand.

It is quite impossible to assess the incidence with complete accuracy, for the reason that a very considerable number of these cases do not come under medical or hospital observation, but some definite indication of the frequency is given by the statistics obtained from various hospitals and practices.

In one urban district, for instance, in which the total live births for a two-year period were 4,000, the number of cases of abortion treated in the public hospital alone was 400.

When to this number were added the cases treated in the various private hospitals, those attended by doctors in the patients' homes, and those not medically attended at all, it was computed that a total of 1,000 abortions was a conservative figure. In other words, roughly twenty pregnancies in every 100 terminated in abortion.

Looked at from a somewhat different angle, figures were presented from one hospital showing that in a group of 568 unselected women of child-bearing age, there were 549 abortions in 2,301 pregnancies, or 23 per hundred.

HOW DO THESE CASES ORIGINATE?

It must be explained that a certain number of cases of abortion occur perfectly innocently as the result of some condition of ill health, or, occasionally, as the result of accident. These _spontaneous_ cases constitute an entirely medical problem.

All other cases are artificially produced or _induced_.

A very small number of these are honourably performed by medical practitioners when the mother's life is seriously endangered.

This procedure is termed "_Therapeutic induction of abortion_."

Certain important questions in relation to therapeutic abortion will be discussed at a later stage in this report.

The remainder of the induced cases are unlawfully produced by the person herself or by some other person--_criminal abortion_.

The Committee received much evidence regarding the methods used in the attempt to procure abortion.

In the first instance it was shown that the use of so-called abortifacient drugs was extensively practised and was usually a first resort.

Little need be said about the matter at this stage except to state that the New Zealand evidence entirely supports the opinions expressed elsewhere that drug-taking is rarely effective.

Those tempted to use these drugs should realize the futility of the practice for the purpose intended and the frequency with which disturbances of health are caused by taking them.

Their only value is as a lucrative source of gain to those people who, knowing their inefficacy, yet exploit the distress of certain women by selling them.

It is perfectly clear that the real menace is the instrumentally produced abortion, either self-induced by the person herself or the result of an illegal operation performed by some outside person.

These abortionists include a few unprincipled doctors and chemists, a few women with varying degrees of nursing training, and a number of unskilled people.

It was a matter of considerable importance for the Committee to attempt to determine first the extent to which spontaneous abortions contribute to the total figures: the prevalence of unlawful abortion could then be better realized.

Here again it was found exceedingly difficult to obtain exact figures, but the evidence suggests that probably less than seven pregnancies in every 100 terminate in spontaneous abortion.

Taking the records of one group of 1,095 women where the incentives to interference were probably at a minimum, it was found that out of a total of 2,180 pregnancies only 152, or 6.97 per cent., terminated in abortion, while in a series of 5,337 pregnancies in patients taken from the records of St. Helens Hospitals, 6 per cent. terminated in abortion.

Even assuming that _all_ these were spontaneous (which was probably not the case), the incidence is approximately 6 per cent. to 7 per cent.

If, then, the total abortion rate is 20 per 100, it is clear that the incidence of criminal abortion is at least 13 in every 100 pregnancies.

The Committee believes that this figure can be accepted as a conservative estimate of the prevalence of unlawful abortion in New Zealand. Some of the figures presented suggested a still higher incidence.

Applying the figures given to the whole of New Zealand it means that while in the year ending March, 1936, there were 24,395 live births there were probably 6,066 abortions, of which nearly two-thirds (4,000) were criminally induced.

The impression of the Committee is that this is an underestimate.

Serious as this is on general grounds, the matter is of particular importance in regard to the special problem which led to the setting-up of this Committee of inquiry--the _incidence of septic abortion_.

Septic infection, or blood-poisoning, is the most serious complication which may follow abortion.

Grave concern has been occasioned by a realization of the frequency of septic abortion, the most significant indication of which is the number of women who lose their lives as the result of this complication.

Attention has repeatedly been drawn to this problem by the officers of the Department of Health, the New Zealand Obstetrical and Gynaecological Society, and others interested in maternal welfare.

During the five-year period 1931-35, 176 women died from sepsis following abortion. In the same period there were only 70 deaths from sepsis following full-time child-birth. Some of the distressing repercussions from these tragedies have been revealed in the annual report of the Director-General of Health, 1936, which shows that in that period 338 children were left motherless by the death of 109 married women.

Another serious fact is that, while, owing to the strenuous efforts of those engaged in the direction and practice of midwifery, there has been a most gratifying fall in deaths from post-confinement sepsis from 2.02 per 1,000 live births in 1927 to 0.4 per 1,000 in 1935, deaths from post-abortion sepsis in the same period rose from 0.50 per 1,000 live births in 1927 to 1.73 per 1,000 in 1934, with a fall to 1 per 1,000 in 1935. These figures are illustrated by the following graph and accompanying table:--

_Maternal Mortality._

Showing the number of deaths and the death-rate per 1,000 live births from certain causes, 1927 to 1935.

+----+----+----+----+----+----+----+----+----- |1927|1928|1929|1930|1931|1932|1933|1934|1935 --------------------------+----+----+----+----+----+----+----+----+----- Maternal mortality, | | | | | | | | | _including_ septic | | | | | | | | | abortion-- | | | | | | | | | Number | 137| 134| 129| 136| 127| 101| 108| 118| 101 Rate |4.91|4.93|4.82|5.08|4.77|4.08|4.44|4.85|4.21 | | | | | | | | | Maternal mortality, | | | | | | | | | _excluding_ septic | | | | | | | | | abortion-- | | | | | | | | | Number | 123| 120| 110| 106| 98| 75| 82| 76| 78 Rate |4.41|4.42|4.11|3.96|3.68|3.02|3.37|3.12|3.25 | | | | | | | | | Puerperal septicaemia-- | | | | | | | | | Number | 56| 42| 30| 27| 18| 13| 14| 17| 8 Rate |2.01|1.54|1.12|1.01|0.68|0.52|0.58|0.70|0.33 | | | | | | | | | Septic abortion-- | | | | | | | | | Number-- | | | | | | | | | Married |} | | {| 26| 26| 24| 16| 29| 17 |} 14| 14| 19{| | | | | | Single |} | | {| 4| 3| 2| 10| 13| 6 Rate |0.50|0.51|0.71|1.12|1.09|1.04 1.07|1.73|0.96 --------------------------+----+----+----+----+----+----+----+----+-----

One of the unfortunate features of this matter from the public health point of view is the extent to which this increase in deaths from abortion sepsis is counterbalancing and masking the very real improvement which has been achieved by the obstetrical services in the work for which they may justly be held responsible.

According to the international system of recording, these cases are included in the total maternal mortality.

Actually in New Zealand in the five-year period mentioned, abortion sepsis was responsible for one-quarter of the total maternal deaths.

In the larger urban areas the position is even more unfortunate, as the following instance will indicate:--

_Maternal Mortality in Urban Areas for the Five-year Period, 1930-34._

| | | | |Maternal | | Death- | | | | | Death- | | rate | | Total |Maternal|Maternal |rate per | Deaths | from | | Mater-| Death- | Deaths | 1,000 | from | Septic Urban Area | Live | nal |rate per|excluding| Live | Septic |Abortion |Births.|Deaths.| 1,000 | Septic | Births |Abortion| per | | | Live |Abortion.|excluding| | 1,000 | | |Births. | | Septic | | Live | | | | |Abortion.| | Births. ------------+-------+-------+--------+---------+---------+--------+-------- Auckland |14,290 | 81 | 5.67 | 55 | 3.85 | 26 | 1.82 Wellington |11,690 | 61 | 5.22 | 32 | 2.74 | 29 | 2.48 Christchurch| 9,599 | 51 | 5.31 | 29 | 3.02 | 22 | 2.29 Dunedin | 5,960 | 24 | 4.03 | 17 | 2.96 | 7 | 1.17 | | | | | | | Total, four |41,539 | 217 | 5.22 | 133 | 3.20 | 84 | 2.02 urban areas| | | | | | | | | | | | | | Total, |58,623 | 273 | 4.66 | 204 | 3.48 | 69 | 1.18 remainder | | | | | | | of Dominion| | | | | | | ---------------------------------------------------------------------------

In the case of the four urban areas deaths from septic abortion account for approximately two-fifths of the total maternal mortality.

With these cases excluded, the maternal mortality associated with child-birth proper was 3.20 per 1,000 live births.

Clearly, any comparison between different maternity services should be made on the basis of these latter figures alone.

WHAT IS THE CAUSE OF THIS HIGH INCIDENCE OF DEATHS FROM SEPTIC ABORTION.

The evidence offered to the Committee by medical witnesses indicates conclusively that sepsis, and death from sepsis particularly, is almost entirely due to illegal instrumental interference.

Spontaneous abortion, provided that proper medical care is given, rarely results in sepsis. Therapeutic abortion, done with all the safeguards of modern surgical practice, is associated with very little acute sepsis.

But criminal abortion is associated with an extremely high sepsis rate.

The reasons are not far to seek: the surreptitious nature of the operation and the lack of skill and surgical cleanliness so frequently shown by the operator make this result almost inevitable.

HAS THE PRACTICE OF ABORTION INCREASED IN RECENT YEARS?

In so far as the deaths from septic abortion can be taken as a comparative indication of the occurrence of abortion generally--and the Committee believes this is a fair index--there seems little doubt that there has been a marked increase.

A reference to the graph already given will indicate this rise.

There is reason to hope that the fall in 1935 means an improvement in the general situation.

Professor Dawson, giving evidence regarding admissions to the Dunedin Hospital, showed that in the five-year period 1931-35 there was an increase of 23.7 per cent. in the cases of abortion as compared with the previous five-year period.

The evidence of other medical witnesses was practically unanimous on this point.

HOW DOES NEW ZEALAND COMPARE WITH OTHER COUNTRIES IN THIS MATTER?

According to the report of the British Medical Association Committee on the Medical Aspects of Abortion (1936), the position in Great Britain would appear to be very similar to that existing in New Zealand.

In that report it is stated that the incidence of abortion is generally reckoned at from 16 per cent. to 20 per cent. of all pregnancies.

The spontaneous-abortion rate is suggested as probably about 5 per cent. of all pregnancies.

The evidence set before that Committee suggested that there has been an increase in criminal abortion in the last decade.

In England and Wales 13.4 per cent. of the total maternal deaths were due to abortion.

That Committee concludes that "illegal instrumentation contributes to an overwhelming degree to the mortality from abortion."

One of the most interesting investigations into this aspect of the subject is reported by Parish[1] in a study of 1,000 cases of abortion treated as in-patients in St. Giles's Hospital, Camberwell, during the years 1930 to 1934.

[1] "The Journal of Obstetrics and Gynaecology of the British Empire," December, 1935, p, 1107. T. M. Parish.

In 374 of these cases where instrumentation was admitted the febrile rate was 88.2 per cent., and the death rate 3.7 per cent., while in 246 cases with no history of interference and presumably spontaneous the febrile rate was 5.7 per cent. and the mortality rate _nil_.

The following table compiled by the Government Statistician shows New Zealand's position in comparison with eleven other countries:--

_Puerperal Mortality per 1,000 Live Births in Eleven Countries, 1934._

| | | Total Puerperal | | | Mortality. | | Puerperal |------------------- Country. | Septic | Sepsis |Including|Excluding |Abortion.| following | Septic | Septic | |Child-birth.|Abortion.|Abortion. ------------------------+---------+------------+---------+--------- Norway | 0.47 | 0.57 | 2.75 | 2.28 Netherlands | 0.30 | 0.73 | 3.20 | 2.90 New Zealand | 1.73 | 0.70 | 4.85 | 3.12 Switzerland | 0.73 | 0.82 | 4.58 | 3.85 England and Wales | 0.49 | 1.53 | 4.60 | 4.11 Australia | 1.45 | 0.90 | 5.76 | 4.31 Irish Free State | 0.07 | 1.73 | 4.68 | 4.61 Canada | 0.58 | 1.23 | 5.26 | 4.68 United States of America| 1.02 | 1.30 | 5.93 | 4.91 Union of South Africa | 0.67 | 2.03 | 5.99 | 5.32 Scotland | 0.38 | 2.30 | 6.20 | 5.82 Northern Ireland | 0.32 | 1.85 | 6.27 | 5.95 -------------------------------------------------------------------