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Chapter 7 CONTRACEPTION AND ABORTION This chapter examines the possibility that women who would otherwise use contraception may begin to rely instead on abortion after restrictive abortion laws are relaxed. A major interest in this possibility stems from its implications for repeated abortions and their potential long-term medical complications. An examination of the substitution question is followed by data on the prior patterns of contraceptive use of women obtaining abortions (including repeated abortions), especially teenage women who often have had little experience with contraception. Finally, there is a discussion of the effect of contraceptive counseling on post-abortion contraceptive use, and on the importance of providing contraceptive devices along with counseling services at the time of the abortion. The Substitution of Abortion for Contraception Because contraceptive practice and induced abortion share the common objective of regulating fertility and preventing unwanted births, it has been suggested that legalization of abortion could lead to a growing reliance on abortion rather than contraception to control fertility.Tj In the United States, only very limited data exist for an analysis of this substitution effect primarily because abortion has been widely available only since January 1973. Moreover, the relationship between abortion and contraception as alternate means of fertility regulation is sufficiently complex as to preclude definitive conclusions at this time. What evidence is available on substitution phenomena comes primarily from New York City for the period July 1970 through June 1972. As discussed in Chapter 2, Tietze has estimated that the increment in the number of legal abortions obtained by resident women in New York City could account for less than 40 percent of the decline in the number of births from 1971 to 1972. His conclusion was that "overal1, contraceptive practice improved markedly between the first and second years of the liberalized abortion law."2/ Consistent with this finding, reports from 115
116 the Harlem Hospital Center indicate that the initiation of a voluntary abortion program at the Center was accompanied not by a reduction in demand for family planning services but by an increase of about 25 percent in patient visits for family planning during the next 12 months.V On a nationwide basis, Planned Parenthood has indicated that there continues to be a strong increase in demand for contraceptive services at all of its family planning clinics.4/ Such trend data, though, do not necessarily indicate that abortion is not being relied on as a substitute for contraception in some instances. It is possible, for example, that the demand for family planning services might have increased at an even greater rate if abortion were not easily available. All that may be accurately stated is that where legal abortion has been readily available, there has been no documented decline in the demand for contraceptive services. An examination of a possible substitution effect must be made within the context of the U.S. preference for contraception rather than abortion as the primary means of limiting unwanted births.5/ At very least, the reasons for this preference include traditions, cultural values, convenience, and moral or ethical considerations. The relative availability of abortion and contraception also weigh in the choice of each; family planning and abortion services are not uniformaly distributed geographically and are not of equal cost or legality. That is, in some instances, the "choice" of abortion or contraception may be based on circumstances over which the woman has no control.6/ The data in Table 19 suggest that the U.S. preference for contraception is not tied exclusively to health considerations. The lowest mortality is incurred when legal abortion is used to back up failures of only moderately effective contraception (i.e., condom or diaphragm), while a greater mortality accompanies the exclusive use of highly effective contraception (i.e., the pill or IUD) with no abortion backup.TJ
117 Table 19 Estimated Annual Number of Pregnancies and Pregnancy-Related Deaths Per 100,000 Women a/ For Selected Combinations of Abortion and Contraception Methods used Number of pregnancies Number of deaths expected expected No contraception, no induced abortion 40,000-60,000 8-12 Use of moderately effec- 14,300 0.4 tive contraception; induced abortion for all pregnancies Use of highly effective 100 3 contraception, no induced abortion a/ Incudes only women of reproductive ages (15-44) in fertile unions. Source: Christopher Tietze. "Mortality with Contraception and Induced Abortion," Studies in Family Planning 45: 6-8, September 1969. A similar comparative analysis of the medical complications associated with varying combinations of contraception and abortion is also possible, and clearly related to health. However, because of the extensive and somewhat inconclusive literature on medical complications associated with contraceptive use, this topic will not be addressed here.8/ Repeated Abortions as an Indicator of Substitution A more specific measure of the substitution of legal abortion for con- traception use is the incidence of repeated abortions. If abortion rather than contraception is increasingly relied on for birth contro1, one would expect the number of recorded repeated abortions to rise rapidly. Though U.S. data on this subject are scanty, a recent New York report provides some evidence of trends in the frequency of repeated abortions. During the period July 1, 1970 to June 30, 1972, 2.5 percent of the abortions
118 obtained by New York City residents were repeated abortions.* If that two-year period is divided into six-month periods, repeated abortions as a percent of the total rose from 0.01 percent in the first period, to 0.95 percent in the second, 2.27 percent in the third, and 6.02 percent in the fourth period. This increase may be due in part to a substi- tution effect, but it also may result from an improved reporting system and more truthful disclosure of previous abortions. From a statistical standpoint, the number of repeated abortions can be expected to increase along with the increase in the number of women who have obtained legal abortions and the amount of time they are at risk of another unwanted conception. And, since none of the current contraceptive methods is completely failure proof, nor likely to be used with maximum care on all occasions, there is a minimum level of repeated abortions that is expected to occur for reasons of contraceptive failure alone.10/ A recent study by Rovinsky (1972) of a group of 82 women seeking repeated legal abortions at a New York hospital between January and August 1971 attempted to classify the reasons for the additional unwanted preg- nancies. All of the women had obtained their prior abortions at the same facility and had received contraceptive counseling and contraceptive methods at that time. The reasons they offered to explain their subsequent pregnancy were classified into three categories. The "patient failure" groupâ61 percent of the sampleâincluded women who had difficulty practicing effective contraception for various psychological or emotional reasons. Reported "method failures" accounted for an additional 24 percent of the pregnancies. "Institutional failures" accounted for 15 percent of pregnancies; and included procedural problems in obtaining con- traception from the hospital or difficulties in obtaining a preferred method. Interviews with the women disclosed no evidence of reliance on abortion rather than contraception to regulate fertility. Laxity in contraceptive use seemed to be based more on personality or circumstantial factors than on a new or increasing dependency on abortion for birth control.ll/ Until more complete data are available, definitive conclusions cannot be made concerning the possible substitution of abortion for contraception, particularly as measured by the incidence of repeated abortions. There are some data from abroad on the relationship of contraceptive practices and induced abortion, but the lack of comparability in cultural, economic, and social factors limits the applicability of those findings to the United States.12/ *"Repeated abortions" refers to repeated legal abortions. Data on repeated illegal abortions or legal abortions preceded by illegal abortions are unavailable.
119 Prior Contraceptive Use Patterns of Women Obtaining Abortions A number of studies have attempted to identify the contraceptive histories of women obtaining abortions. As might be expected, most of these women report sporadic or no contraceptive use during the month that conception occurred. However, the vagueness with which they relate their contraceptive experience and the inaccuracies of memory yield data that are generally inadequate. Moreover, the distinction between "using contraception" and "not using contraception" is a some- what artificial division of behavior that in reality exists on a continuum. Contraception can be "used" but used carelessly, and "no contraception" often means a haphazard use of the rhythm method, which still can be interpreted as some attention to birth control. Such problems notwithstanding, data collected from the various studies agree that most women obtaining abortions have become pregnant due to poor contraceptive vigilance rather than to contraceptive failure. In his review of the literature on contraceptive use prior to abortion, Lerner notes that most studies quote between 40 and 80 percent as the proportion of women obtaining abortions who were not using any means of contraception at the time they became pregnant.1^/ For example, a study of 1,022 women obtaining abortions at a proprietary hospital in a suburb of New York City in 1971-1972 found that only 46 percent of the sample had used any method of contraception during the prior 12 months.L4/ At the time of conception, less than 20 percent of the total sample was practicing any form of contraception.L5/ This unusually low figure is probably explained by the fact that the sample was disproportionately young and with no living children. Teenage Contraceptive Use Contraceptive use is closely related to age, in that younger women are less likely to have practiced contraception at al1, or if they have used some method, to have used it less carefully and consistently than older women. As shown in Figure 6 more than 31 percent of all induced abortions in the United States during 1973 were obtained by women less than 20 years old. Recent information confirms the general impression of poor contraceptive use among young women. Using data collected in 1971 by means of a national probability sample survey of 4,611 females 15-19 years of age, Zelnik and Kantner reported that 30 percent had engaged in premarital intercourse. 1J>/ Among this group of sexually active women, only 47 percent had used any kind of contraception the last time they had intercourse, and among the 15-year-olds, only 29 percent had used any contraception during their last sexual encounter. The proportion of sexually experienced teenagers who consis- tently used contraception was even lowerâ19 percent,l7_/ And further, nearly three of every 10 teenage women in the sample who engaged in premarital intercourse experienced a premarital first pregnancy. Although some of these conceptions were intended, the majority (73 percent) were not. The study found that of those pregnant
120 teenagers who did not intend to become pregnant, only about 15 percent had used any kind of contraception to avert it.18/* A recent survey by Lubin-Finkel (1974) of 421 male adolescents revealed that patterns of contraceptive use in this group are also uneven, though seemingly better than the Kantner-Zelnik reports on teenage women. Within this group, 69 percent reported themselves to be sexually experienced. At last intercourse, 29 percent of the sexually active young men reported use of birth control methods which are regarded as poor methods (withdrawa1, douche); 29 percent used a condom at last coitus, 18 percent reported that their partner had used some method, and 24 percent claimed that no birth control was used at all by either partner.20/ Even a preli- minary profile of male contraceptive use is important in that it calls atten- tion to the joint responsibility for birth control. Traditional emphasis has been on female use of contraception, but both female and male roles in the decision and use processes need to be explored if a complete picture of adolescent contraceptive use is to emerge. Many reasons have been offered to explain the poor use of contra- ception, particularly among teenagers. Ignorance about conception and the human reproductive cycle is one factor contributing to unintended teenage pregnancy.^l/ In addition, a wide variety of psychological and psychosocial variables relating to adolescent development influence fertility behavior. The lack of family planning services for teenagers is also a factor in the volume of teenage pregnancy and, ultimately, the number of teenage abortions. Morris has estimated that in 1972-1973, between 1.3 and 2.2 million teenagers were in need of contraceptive services. Although some private physicians, several public facilities and Planned Parenthood affiliates are providing services for teenagers, an estimated 70-80 percent of the need is still unmet.22] This lack of services for teenagers persists notwithstanding a June 1972 Gallup Organization national survey which indicated that nearly three-fourths of those questioned believed "professional birth control information, services and *As has been indicated above, many teenagers have chosen abortion to deal with unwanted pregnancy. In Zelnik and Kantner's survey 35 percent of the women surveyed who experienced a premarital first pregnancy married before the outcome of that pregnancy. Among white teenagers, 51 percent married prior to delivery; among blacks nine percent married. Twenty percent of those who did not marry obtained abortions. Among white teenagers, the percent was 42 percent; among blacks it was 6 percent,19/ However, at the time of the survey (1971) abortion was not readily available in all states, and certainly not to most minors. The impact that the 1973 Supreme Court decision has had on the number of premaritally pregnant teenagers who do not marry and seek abortion is still unknown.
121 counseling should be made available to unmarried teenagers who are sexually active.'\23/ If teenage-centered family planning services were increased, it is possible that the number of teenagers obtaining abortions would decline. As the situation now exists, however, a certain proportion of teenage women are introduced to contraception through the instruction and devices provided them at the time of their abortion. For many, this interaction serves as the primary entry point into the system of fertility regulation, an entry otherwise denied them by virtue of relatively inaccessible or unavailable services. The Impact of Contraceptive Counseling Many facilities providing abortions offer some form of contraceptive counseling and, more importantly, supply contraceptive methods to their patients in order that they may avoid future unwanted pregnancies. Several recent studies have attempted to evaluate the impact of these services on subsequent contraceptive use. For example, a major study on this subject was conducted in 1972 at Preterm, an abortion and vasectomy clinic in Washington, D.C. that emphasizes a contraceptive counseling program. In a sample of 303 women obtaining first-trimester abortions, Margolis et al. found that 93 percent obtained a method of contraception at the time of their abortion, and 91 percent reported they were still using contraception six months later. The follow-up interview found that nearly four-fifths of the women were using a technically effective method (pil1, IUD). More dramatic was the continued use of effective contraception among single teenagers. Only 56 percent of those less than 20 years of age had indicated they had used any contraception before their abortion; at follow-up, 86 percent were still using some method, and 75 percent were using the pill or IUD. The Preterm study also noted, however, that the use of contraception at some time prior to the abortion by 84 percent of the total sample calls for caution in attributing the high level of post-abortion contraceptive use to the pregnancy, abortion, or counseling experience.24/ There also are defects in the design of the study that seriously limit the utility of its conclusions. From an original pool of 664 women only 303 (46 percent) participated in the follow-up phase. These follow-up subjects were self-selected in that only those women who con- sented at the time of their abortion to be interviewed and were successfully reinterviewed several months later were included in the study. Also, the women who were available for the subsequent phone interview were dis- proportionately older, married women, who were more likely to have used contraception previously and to have had children.2^5_/ The most signifi- cant drawback of this study, though, and others like it (for example, Lai et^ ajL^, 1973 26/) is the absence of a control group. Without a group for comparison, there is no way of determining whether observed behavior changes were due to the abortion itself, contraceptive counseling, or some other unknown variable.
122 A study by Daily et al. of women experiencing repeated (legal) abor- tions in New York City provides additional data on the effect of contracep- tive counseling. In an examination of 355 women obtaining repeated abortions in the first half of 1972 at 12 of the 14 New York City muni- cipal hospitals that were performing abortions, the authors found that nearly 90 percent of these women had received contraceptive counseling at the time of their previous abortion and, since then, had increased their use of contraception substantially (i.e. while only 47 percent of the women sampled had used contraception in the year before their previous abortion, 74 percent had practiced some form of birth control in the period between abortions).^/ More significant, though, is that in spite of the earlier contraceptive counseling, nearly half of the women in the repeated abortion sample were not using any contraception at all in the menstrual cycle immediately before the latest conception, and 26 percent had failed to use birth control at any time in the interval between abort ions.28/ The investigators explain this circumstance, in part, by reporting that the provision of contraceptives immediately following the abortion was inadequate. Although 86 percent of the respondents requested contraceptives at the time of their previous abortion, 59 percent were discharged without having been started on their requested method. Nearly half were given no method at al1, and an additional 13 percent were given a less effective method than they requested. Of the 31 women who requested tubal ligation, only three were sterilized and 19 received no method. Half of those requesting lUDs did not receive them.29/ These findings gain importance in light of recent research indicating that many women are able to conceive again very soon after an abortion and therefore require immediate attention to contraceptive protection. Boyd and Holmstrom studied the ovulation patterns of 61 women following abortion and found that all but one of them ovulated within five weeks of the termination. Although the average number of days was 22, the earliest verified ovulation occurred ten days following the abortion.^)/ These figures suggest that abortion facilities should be equipped to provide contraceptive devices themselves, or to refer their patients to effective family planning services within one week after the abortion to prevent the risk of repeated conception before contraceptives are obtained. Rovinsky has suggested that the critical variable in preventing future unwanted pregnancies is not contraceptive counseling, but the actual provision of the contraceptive devices themselves.31/
123 A report by Lerner et al. on the level of contraceptive services for abortion patients in New York City argues that the importance of providing methods of contraception immediately after abortion has not been realized by many institutions. In 18 New York City freestanding clinics and 60 hos- pitals reporting data in 1972, only seven clinics and 31 hospitals provided comprehensive family planning services at no extra cost to their abortion patients. Four clinics and 13 hospitals had reduced programs, and an addi- tional four clinics and three hospitals provided information only. Private patients had even fewer opportunities to obtain family planning services at the abortion facility and were presumably dependent upon their private physician for contraceptive advice. Whether or not this situation has improved since 1972 is not known.32/ Summary Data on the relationship of contraception to abortion are limited, and preclude firm conclusions on many aspects of the topic. What information is available on the possible substitution of abortion for contraception indicates no documented decline In the U.S. demand for family planning services as abortion has become more readily available. When the substitution effect is assessed on the evidence of repeated abortions, limited data suggest that although there may be an increase in the number of repeated abortions being reported (in New York City, specifically), many explanations other than substitution could plausibly account for the trend. A review of information on the contraceptive use of women obtaining abortions reveals poor patterns of effective birth control practice, especially among teenagers. These data underscore the importance of abortion facilities paying greater attention to the future contra- ceptive needs of their patients. The timing of such post-abortion contraceptive services is particularly significant, since some data suggest that ovulation usually occurs within five weeks of an abortion and may occur as early as 10 days later. The behavioral impact of contraceptive counseling was also reviewed, but in this area, the information is particularly inconclusive. The psychological and motivational issues associated with contraceptive use and with the abortion choice are sufficiently complex that no studies have yet defined their exact relationship when both are equally available and accessible.
124 REFERENCES 1. Betty Sarvis and Hyman Rodman. The Abortion Controversy, 2nd ed., New York: Columbia University Press, 1974, p. 150. 2. Christopher Tietze. "Two Years' Experience with a Liberal Abortion Law: Its Impact on Fertility Trends in New York City," Family Planning Perspectives 5: 41, Winter 1973. 3. Donald P. Swartz. "The Harlem Hospital Center Experience," in H. Osofsky and J. Osofsky eds. The Abortion Experience: Psychological and Medical Impact, Hagerstown, Maryland: Harper and Row, 1974, p. 114. 4. Personal Communication from Frederick S. Jaffe, President, The Alan Guttmacher Institute, May 1974. 5. Sarvis and Rodman, p. 150. 6. Emily Campbell Moore-Cavar. International Inventory of Information on Induced Abortion, New York: International Institute for the Study of Human Reproduction, Columbia University, 1974, p. 559. 7. Christopher Tietze. "Mortality with Contraception and Induced Abortion," Studies in Family Planning 45: 6-8, September 1969. 8. The morbidity of various contraceptive methods has been addressed by such articles as: Marshall E. Schwartz. "The Dalkon Shield: Tale of a Tai1," Family Planning Perspectives 6: 198-201, Fall 1974; Nariyandada G. Shaila e^t^ al. "A Comparative Randomized Double-blind Study of the Copper-T200 and Copper-7 Intrauterine Contraceptive Devices with Modified Insertion Techniques," American Journal of Obstetrics and Gynecology 120: 110-116, September 7, 1974; Oral Contraceptives and Health, an interim report from the Oral Contraception Study of the Royal College of General Practitioners. London: Pitman Publishing Corporation, 1974. 9. Edwin F. Daily, Nick Nicholas, Frieda Nelson and Jean Pakter. "Repeat Abortion in New York City: 1970-72," Family Planning Perspectives 5: 89, Spring 1973. 10. Christopher Tietze. "The Problem of Repeat Abortion," Family Planning Perspectives 6: 148-150, Summer 1974. 11. Joseph J. Rovinsky. "Abortion Recidivism," Journal of Obstetrics and Gynecology 39: 649-659, May 1972.
125 12. The possible substitution relationship between abortion and contra- ception in countries outside of the United States has been addressed in such articles as: B. Viel. "Results of a Family Planning Program in the Western Area of the City of Santiago," American Journal of Public Health 59: 1898-1909, 1969; A. Girard and E. Zucker. "Une Enquete aupres du Public sur la Structure Familiale et la Prevention des Naissances," Population 22: 439-454, May-June 1967; N. H. Fisek. "Epidemiological Study on Abortion," I. Nazer ed. Induced Abortion: A Hazard to Public Health. Beirut: International Planned Parenthood Federation, 1972, pp. 264-283; S. B. Hong. Induced Abortion in Seoul, Korea. Seoul: Dong-A Publishing Company, 1966. 13. Raymond C. Lerner, Judith Bruce, Joyce R. Ochs, Sylvia Wassertheil- Smoller, and Charles B. Arnold. "Abortion Programs in New York City: Services, Policies and Potential Health Hazards," The Milbank Memorial Fund Quarterly: Health and Society 52: 30, Winter 1974. 14. Michael B. Bracken, Gerald Grossman, and Moshe Hachamovitch. "Contracep- tive Practice Among New York Abortion Patients," American Journal o^ Obstetrics and Gynecology 114: 969, December 1, 1972. 15. Ibid., p. 975. 16. Melvin Zelnik and John F. Kantner. "The Resolution of Teenage First Pregnancies," Family Planning Perspectives 6: 75, Spring 1974. 17. John Kantner and Melvin Zelnik. "Contraception and Pregnancy: Experience of Young Unmarried Women in the United States," Family Planning Perspectives 5: 21-22, Winter 1973. 18. Zelnik and Kantner (1974), p. 76. 19. Ibid., p. 76. 20. M. Lubin-Finkel. "Male Adolescent Sexual Behavior; Policy Implications." A paper presented at the annual meeting of the American Public Health Association, New Orleans, 1974. 21. Harriet B. Presser. "Early Motherhood: Ignorance or Bliss?" Family Planning Perspectives 6: 11, Winter 1974. 22. Leo Morris. "Estimating the Need for Family Planning Services Among Unwed Teenagers," Family Planning Perspectives 6: 96, Spring 1974. 23. Richard Pomeroy and Lynn C. Landman. "Public Opinion Trend: Elective Abortion and Birth Control Services to Teenagers," Family Planning Perspectives 4: 54, October 1972.
126 24. Alan Margolis, Ronald Rindfuss, Phyllis Coghlan and Roger Rochart. "Contraception after Abortion," Family Planning Perspectives 6: 56-60, Winter 1974. 25. Ibid. 26. Shirley Lai et^ a]L "Contraceptive Practice Before and After Out-patient Termination of Pregnancy," Family Planning 23: 4-7, April 1974. 27. Daily et^al., pp. 91-92. 28. Ibid., pp. 92-93. 29. Ibid., p. 93. 30. E. Forrest Boyd and Emil G. Holmstrom. "Ovulation following Therapeutic Abortion," American Journal of Obstetrics and Gynecology 113: 469, June 15, 1972. 31. Rovinsky, pp. 649-659. 32. Lerner e£ ail., pp. 23-24.
APPENDICES
