From: hsims@vax.clarku.edu
Newsgroups: talk.abortion
Subject: Romania (repost)
Date: 9 Nov 92 20:25:47 GMT
Organization: Clark University

From the American Journal of Public Health, October 1992, volume 82, number 
10, pages 1328-1331.  Reprinted without permission.  All typos mine.

COMMENTARY: THE PUBLIC HEALTH CONSEQUENCES OF RESTRICTED INDUCED ABORTION - 
LESSONS FROM ROMANIA

Patricia Stephanson, ScD, Marsden Wagner, MD, MSPH, Mihaela Badea, MD, and 
Florina Serbanescu, MD. 

INTRODUCTION
	Abortion policy is being debated in a number of countries in which 
abortion is currently legal and women have access to safe abortion, performed 
by qualified practitioners, through the health care system.  Some political or 
religious groups in Hungary, Poland, Germany, Spain, Sweden, and the United 
States seek to ban abortion or at least to restrict it as much as possible.
	Both proponents and opponents of legal abortion debate the issue in 
the abstract terms of women's rights, fetal rights, religious theories, or 
constitutional principles.  However, those who ultimately decide this question 
will sooner or later have to come to terms with the concrete reality of what 
can happen to women and children when and if the right to safe abortion is 
taken away.

SAFE ABORTION AND MATERNAL MORTALITY
	When access to safe abortion has been introduced in a country, 
maternal mortality has decreased.  In the United States during the 1960s, as 
some states began to change their laws on abortion and hospital abortion 
policies became less restrictive, gradual decreases in maternal mortality were 
noted.  After the US Supreme Court decision in 1973 guaranteeing women the 
right to safe abortion, national maternal mortality rates decreased further.  
In England and Wales there were no deaths due to unsafe abortion in the 
triennium 1982 to 1984, compared with 75 to 80 such deaths per triennium prior 
to the Abortion Act of 1967 (which gave free access to safe abortion).[1]  
Although it is reasonable to conclude that these trends are due to the changes 
in the abortion laws, one can never completely rule out the possible 
simultaneous effects of other factors.  
	More instructive is what happens in a country when abortion is made 
illegal and access to safe abortion is taken away.  Before 1966, Romanian 
women - like their neighbors in other Eastern European countries - had access 
to safe abortion through the country's health care system.  In 1966 Romanian 
President Nicolae Ceaucescu introduced pronatalist policies, outlawed abortion 
and contraception, and took measures to enforce the law.  Mandatory pelvic 
examinations at places of employment were imposed on women of reproductive 
age.  Informers for the security police were stationed in maternity hospitals. 
 Doctors could be prosecuted for performing unauthorized abortions, and nurses 
were to make unannounced supervisory visits to new mothers to determine 
whether they were taking proper care of their infants.  
	The consequences of this policy and its enforcement are presented in 
Figures 1 through 3, through data from the Romanian birth and death 
registration system and the nationwide, ongoing maternal mortality audit 
system. (World Health Organization site visits from 1991 to 1992 have found 
that these systems are comparable to those of Western Europe in terms of 
completeness of reporting and the reliability of data [2].  Romanian vital 
data systems and maternal mortality reports use ICD-9 CM definitions and 
diagnostic classifications.)  After a brief rise, the crude birth rate fell 
and continued to fall (Figure 1).  Thus the policy intended to increase the 
birth rate failed.
	Before the 1966 law went in to effect, the Romanian maternal mortality 
rate was similar to those of other Eastern European countries.  Afterward, 
abortion-related maternal mortality increased to a level 10 times that of any 
other European country (Figures 2 and 3).  For the decade 1980 to 1989, the 
average Romanian maternal mortality rate was 150 maternal deaths per 100,000 
live births. [6] Many women obtained abortion illegally, and every year 
approximately 500 otherwise healthy women of childbearing age died from 
postabortion hemorrhage, sepsis, abdominal trauma, and poisoning.
	Precise figures on the Romanian prevalence of postabortion morbidity 
are not available.  The country's most common cause of obstetrical death were 
postpartum hemorrhage and infection, [3] complications that could be 
associated with unsafe abortion.  In Romania, local health professionals 
report that unsafe abortion - as performed by the woman herself or by 
untrained persons - may involve very dangerous techniques, such as scraping 
the uterus with a rubber tube or other instrument, uterine lavage with water 
or a caustic fluid, introduction of foreign bodies into the uterus, or 
external trauma.  Such methods often result in damage to the uterine cervix, 
chronic infection, and severe anemia that, in turn, increase the risk of 
postpartum hemorrhage and infection, infertility, preterm birth, and low 
birthweight. [7,8]

THE SOCIAL IMPACT OF RESTRICTED ABORTION

	Legions of Romanian children in institutions are another sad legacy of 
the years of the Ceaucescu pronatalist policy.  Some women who did not have 
illegal abortions bore children after unwanted pregnancies and placed the 
children in institutions because they and their families simply could not find 
the means or motivation to care for them. [9]  Although the number of children 
institutionalized before the overthrow of the Ceaucescu government is unknown, 
shortly after the revolution approximately 150,000 to 200,000 children were in 
institutional care. [10]  Warehousing of children in institutions overwhelmed 
the health care system and reduced the standard of care. [9]  Present programs 
have returned many institutionalized children to their families or have 
attempted to place them in adoptive homes. [9]  However, several thousand 
severely retarded and handicapped children are likely to remain in 
institutions for the rest of their lives. [9]

CONCLUSIONS

	After the December 1989 Romanian revolution, one of the provisional 
government's  first acts abrogated the 1966 law banning abortion and 
contraception.  This was done as an emergency public health measure to try to 
decrease maternal mortality due to unsafe abortion.  Since then, more and more 
induced abortions have been performed by qualified doctors in hospitals or 
clinics; the maternal mortality rate fell by 50% in the first year following 
the change in the law.  It continues to fall as more and more women avail 
themselves of safe abortion.  New admissions to children's institutions have 
decreased in spite of severe economic conditions. [9]
	The Ro,manian experience demonstrates the futility and folly of 
attempts to control reproductive behavior through legislation.  A law that 
forbids abortion does not stop women from aborting unwanted pregnancies.  In 
Ireland today, where abortion is illegal, some 4,000 women each year travel to 
Britain for the procedure.  Nor can laws concerning reproductive behavior be 
effectively enforced.  The extreme pronatalist policies in Romania did not 
succeed in sustaining the desired levels of reproduction and natural increase 
(Figure 1).
	To reduce or eliminate abortion, the rational approach is to promote 
contraception.  To paraphrase the position of the 1984 International 
Conference on Population, the solution to the abortion question is to prevent 
unwanted pregnancy. [7]  The outlawing of abortion and contraception is not 
pronatalist by antinatalist in that the results are likely to be fewer 
healthy, fertile women who might have children, reduced fertility from 
widespread gynecological infection, the birth of more damaged babies, and, in 
sum, not more but fewer healthy citizens for the future.
	In the 23 years of its enforcement, the antiabortion law in Romania 
resulted in over 10,000 deaths of women from unsafe abortion.  The pronatalist 
policy as a whole resulted in the untoward institutionalization of thousands 
of children and in an elevated rate of infant deaths.  In effect, it also 
turned otherwise law-abiding women and their partners into criminals; women 
learned to fear the government and its representatives.  Doctors and other 
health care providers were victims as well because they were forced to carry 
out the policies of the state.  Working today to improve and strengthen 
women's health servicesm Romanian doctors report that many women remain 
fearful of contact with the health care system.
	The lessons of the Romanian experience hit home for those of us who 
remember how it was in our own countries prior to the legalization of 
abortion.  Those who could afford to fly to other places could obtain legal, 
safe abortion, while those who could not made due with "backstreet" procedures 
or relinquished their unwanted children to orphanages.  Perhaps we have come 
so far and accomplished so much that we have forgotten the public health 
consequences of restricting access to safe abortion.
	In light of those consequences, it does not matter whether, as health 
professionals, we believe that life begins at conception or whether 8-week-old 
fetuses should have equal protection under the law.  Policy on abortion is 
being formulated in the rarified atmosphere of legislatures and parliaments, 
meeting halls and court room.  Let us hope that policy makers accept their 
responsibility for protecting the health and lives of women and children.

REFERENCES

1.  United Kingdom Department of Health, Report of Confidential Enquiries into 
Maternal Deaths in England and Wales, 1982-1984.  Report on Health and Social 
Subjects 34. London, England, 1990.

2.  World Health Organization, European Regional Office, Maternal and Child 
Health Unit, Report of an MCH Mission to Romania, january 1991.

3.  Birth and Death Register, Bucharest, Romania, 1992.

4.  Maternal Mortality Audit System, Bucharest, Romania, 1992.

5.  Health for All Database, WHO, Denamrk, 1991

6.  Tabulated Birth and Death Statisticsm 1991, Ministry of Health of Romania, 
1992.

7.  WHO, Maternal and Child Health Unit and Family Planning Division of Family 
Health, Abortion: A Tabulation of Available Data on the Frequency and 
Mortality of Unsafe Abortion, WHO, 1990

8.  Royston, E, Armstrong,S, Preventing Maternal Deaths, WHO, 1989.

9.  The Children's Health Care Collaborative Study Group, The Causes of 
Institutionalization in Romanian Leagane and Sectii de Distrofici: Report of a 
Populatio-based Study with Recommendations, Bucharest, 1991.

10.  Report of a UNICEF Mission to Develop Emergency Assistance Programme for 
Institutionalized Children in Romania, New York, United Nations Children's 
Fund, 1990.
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