Global Problems of Population Growth

MCDB 150 - Lecture 21 - Global Demography of Abortion

Chapter 1. Abortion Data [00:00:00]

Professor Robert Wyman: We're coming to the end of the course, and the last couple of lectures, the last few are social issues and then we'll have a very short time for environment, unfortunately. Today we're going to talk about abortion. It's kind of a unique topic in the sense that in the United States it's--if you have a global perspective, in most of the world abortion is not a big controversial issue. In the United States it's just gone sky high as kind of the central issue in the American debate on values. It has tremendous political significance. Large numbers of people vote for a candidate for, say president, based solely on whether they are pro-choice or pro-life.

One of the things you've got to figure out, or try to, is why has this become so important an issue. I think one of the reasons is that it encapsulates diametrically opposed views of our roles in everyday life. People perceive it as an everyday kind of issue. What are the roles that I'm talking about? Sex roles, work roles, husband and wife roles, motherhood and fatherhood roles; all of those--how you perceive yourself in those roles will very much determine how you feel about the abortion debate.

For instance, both sides in the debate agree that the issue is about murder. A pro-lifer sees images of a three month old fetus, which even though only about the size of your finger they see--they're having visuals of blown up photographs and I'm sure you've all seen those things and it already looks quite baby like, and thinks of it of being dismembered and murdered.

A pro-choicer also sees it about murder, but she, in her mind, sees a young woman, maybe herself, in a back alley abortion, being butchered and possibly murdered. Almost everyone of the older generation of pro-choice women has either themselves had an abortion, or has had a friend who has had an abortion, and they perceived it as lifesaving, or if it was a back alley, unsuccessful one, as a life depriving situation.

Both sides agree that the issue is about babies and motherhood. A pro-life mother thinks that babies are so precious that whenever they come they will be loved and wanted. There is no such thing as an unloved or unwanted baby. A pro-choice mother thinks that babies are so precious that they should only be had when the woman really wants the baby and is in the situation in life where they have resources to take care of the baby.

Both sides agree that the issue is about sex. A pro-life woman thinks that sex is so special that it should be guarded by strong religious and social controls so that it always has an almost sacred character. A pro-choice woman thinks sex is so special that it should be freed from worry about pregnancy and disease so that it can be enjoyed as a unique sharing of intimacy.

Both sides agree that the issue is about the status of women. Pro-life women think that women are so important that their special life role of motherhood must be protected. Pro-choice women think that women are so important that they should have every bit as much control over their life roles as men have.

Just viewed in that way, one of the interesting things about this abortion debate is that the two sides on--if you really get down to what the fundamental values of the two sides are, they're not different. They apply them differently. They're thinking of different instances, of different real situations in which to apply these rather same kinds of fundamental human values.

All right, well obviously this is not a philosophy course and not in the slightest set up to debate the pros and cons of abortion, and that's also a kind of sterile debate. Anybody--has anybody changed their mind about abortion since they were knee high to a grasshopper, in the class? I don't want to know which direction you went. One has changed her mind, two have changed their mind. That's a high ratio. Does anybody know anybody who's changed their minds, except for yourself of course, one or two more people; three another one.

I mean there's so much about abortion out there and yet people's attitude toward it is set very early in life, by again, these very fundamental images of what we're talking about when we're talking about abortion. No matter how it's argued, people basically don't change their opinions. I'm not going to debate pros and cons at all. I'm going to give you as many facts about abortion as I can explain to you: the demography, and the biology, and the statistics, and all of that kind of stuff.

There are a number of important things that you should know about abortion. The first is that induced abortion is common; it's a very frequent situation in the world. There's one abortion for every 3.2 live births, so that's 1 in 3. Each year about 3% of women in childbearing ages have an abortion, and if you consider a 30 year reproductive lifespan with each woman having a 3% chance each year that's 90%. That means that, in the world, the average woman has a 0.9 chance, very close to one. Basically, for every woman in the world, there's one abortion in her reproductive lifetime. Of course this is an average, some women have many more, and some women have none.

There are three, actually three or four standard ways of measuring and expressing the frequency of abortion. One is simply the number of abortions in the world, or in the country, or whatever you want. The latest estimate, all of these latest estimates come from 2003. About every five years people try to tally up abortion statistics from around the world and that's a very difficult job because wherever its illegal, you have very great difficulty getting statistics.

In many places--especially where there's religious opposition to abortion they--the statistics include it as 'menstrual regulation.' That means a woman has missed her menses and, of course, everyone knows that's a good thing, so you have to restore the menses and you do exactly what's an abortion. Everybody in the country will understand what's going on, but the statistic is menstrual regulation. Depending on what's happening in the country, you usually have to add one part of the government statistics about menstrual regulation to another part which says abortion.

Anyway, there are lots of problems in collecting these numbers but they're probably fairly decent because they're very sophisticated--demographically very sophisticated people are the ones that try to make these best estimates. The number of abortions in the world is now considered to be 42 million per year and the number has stayed in that range, the 40 to 50 million range, for at least the last two decades, when there's fairly good collection of the statistics. So that's the number.

The abortion rate is defined as the abortions per 1,000 women in reproductive ages which is usually taken as 15 to 44, or 15 to 49. For the world it's 29 per 1,000. So, every year, per 1,000 women, 29 have an abortion. That's the 3% that I mentioned earlier; if it was 30 it would be exactly 3%. Both the highest rate and the lowest rates are found in Europe. Western Europe has 12 abortions per 1,000 women per year; Eastern Europe has four times as many, 44 per 1,000 women per year. It's interesting that of the whole world, within Europe, which we sometimes consider a cultural entity, it isn't with respect to abortion, the highest and lowest numbers are found in Europe.

Another way of expressing it is the abortion ratio which is the abortions per 100 live births, and that's what I told you before. One abortion for every 3.2 live births. In the world, that comes out to 31 per 100 and this ranges from 12 in middle Africa, it's a low rate, to 105 in Eastern Europe, again Eastern Europe has the highest in the world. Note that 105; we're talking about abortions per live births. When you have 105 abortions per 100 live births, there are more abortions than live births. So, at 100 per 100, half of pregnancies are terminated with an abortion.

Interestingly, the abortion rate is the same, is very closely the same, independent of whether you're in a developing country or a developed country. The rate in developed countries is 26 per 1,000 and in developing countries it's 29 per 1,000; not a huge difference. China, which everyone worries about the forced abortions there, has about 20% of the world's population and has about 20% of the world's abortions.

Another--the last number that I'll tell you about that people calculate, is what's called the total abortion rate, which is calculated exactly in the same way as the total fertility rate. You take the age specific abortion rate and add it up, and it's the number of abortions that the average woman would have in her lifetime if she continues with the rates that are present at the time you collect the statistics. Again, I mention this, in the world it's 0.9 very close to 1, the average woman will have 1 abortion in her lifetime. It ranges from a low of 0.2, one abortion per every five women in several countries, to a high of 1.7 in Cuba, almost two abortions per woman in Cuba. Well I'll talk later about a very interesting situation in Cuba.

Chapter 2. Country Level Abortion Data [00:11:22]

Over time, as I said, the number of abortions is really, on the big scale, a couple of decades, staying pretty constant. But, from the last compilation in 1995, the estimate was 46 million abortions and now it's down to 42 million abortions. There has been a very small drop in the number of abortions. Where do you think all of that drop has occurred? Eastern Europe; again they had an extremely high abortion rate, it was the mechanism of contraception there, and they're gradually becoming accustomed to contraception so their abortion rate is going down, three-quarters of the change in the whole world is all due to Eastern Europe.

The United States looks pretty much like the rest of the world. There's 1 abortion for every 3.2 live births here which is exactly the number that is the average for the world. In the United States there are 1.3 million abortions in again 2003, the last time those statistics were collected. The rate is 21.3 abortions per 1,000 women. If you look per woman, the U.S. looks a little better than per births, that the total abortion rate for the United States is 0.64 per woman, that's mean two-thirds of--the average is two-thirds of women will have an abortion during their lifetime, whereas, the world is closer to one. So, we have a somewhat lower rate, and again, the difference is the use of contraception and I'll talk about that later.

The United States, although somewhat better than the world average in this, is not nearly as good as 0.2; remember I said ours is 0.64. Belgium, Germany and Switzerland all are down at 0.2, so less than a third of the number of abortions per woman that we have. A cohort of 1,000 women going through their reproductive life will have 639 abortions, and that's assuming, we currently have been having a reducing rate of abortion, here it presumes that that rate will stay down.

Expanding out to the world again, abortion can be a major method of fertility control, especially when a country first goes through its fertility transition. One of the fastest fertility transitions in the world was in Japan, of all places. Where they halved the birthrate--the birthrate in Japan was cut in half between 1947 and 1957, in ten years it went down to half, from 34 per 1,000 women to 17, and it's remained at that level more or less until 1979 and now it's getting even lower.

Here is--this is the interesting case of Japan. This is the years 1949--remember MacArthur, the U.S. Administration of Japan was still sort of tailing down at that time and we're looking at a ten year span. This is the number of pregnancies, which is births plus abortions, and you'll notice that during this time, during this ten year time, the number of pregnancies really does not change an awful lot; notice 2,700 to 2,900, 2,600, 2,800, 2,800, 2,600. So the number of pregnancies does not change.

But look what happens to abortion. It gets legalized here and very rapidly it goes from 100 to ten times as much. Correspondingly, the births go down, so abortion goes from an insignificant fraction of births to a very--so much, much closer to the number of births. In this case, it was legalization of abortion that sort of, boom. caused the Japanese birthrate to fall. There was no coercion involved it was purely a legalization step.

In many places, abortion is the method of birth control. So, in the Soviet Union, the official statistics, before it fell apart, were that there five to eight abortions lifetime per woman. In the Ukraine it was ten to 12 abortions per woman. The immigrants that come to America say that's nonsense. That it was 20 to 30 that everybody they know had 20 to 30 abortions lifetime.

Japan also, because, although they legalized abortion very early, they didn't legalize the pill until just a few years ago. They legalized it when Viagra came out and the men demanded to get Viagra. -- They have a very good national health plan, it's all free and very careful and very good, and men wanted free Viagra. Then it became politically impossible to keep the women from having the pill, but pay for men's Viagra. So Japan legalized it very recently, the pill, and their abortion rate has always been extremely high.

In some special circumstances the abortion rates have gone sky high. In 1966, in Romania, there were 408 abortions for every 100 live births, four abortions for every one live birth. The history of that is very, very interesting. In the whole Soviet Bloc it was a complex of issues. Contraception was legal, it was kind of available but the manufacturing was terrible. They had condoms in the various Soviet bloc countries but they were so poorly made that the people called them galoshes, they just didn't fit. Plus, the doctors were working for the government and not paid very well, but they could privately, outside the government statistics, they could privately do abortions and make money on it. So, the doctors were all pushing abortion and for a variety of other reasons. We'll talk more about countries in which abortion is by far the dominant means of birth control.

Legal and medically performed abortion, by a trained doctor, is one of the safest methods of birth control known. Here is the statistics on this, this on this, this is from the--do you know the Physician's Desk Reference? For many years all of the birth control pills had to have this graph in it. What do you see here? This is the annual deaths--four women per 100,000 non-sterile women who are either using or not using birth control. What you notice, the really high category, was the only super duper high, is women over 40 who smoke; bad idea, and use the pill--smoke and use the pill. That's the pill--the pill is their method of contraception and they smoke. If you're over 40 and you smoke, don't use the pill, that's not a healthy thing to do.

For every other category of woman, the white bars are larger than any of the other bars, and the white bar is not using contraception at all. What this tells you is, if they're not using contraception, they're going to get pregnant and that the mortality dangers, this is deaths, so this is mortality, that the mortality dangers from pregnancy are a good bit higher than any of the methods of birth control.

Student: What year was that from?

Professor Robert Wyman: What?

Student: What year was this from?

Professor Robert Wyman: This is, I think, about 1990 and hasn't--well what has changed is that--let me finish and I'll tell you what's changed since then. The safest is these little black bars, which you can hardly see, which is traditional contraception which is condoms is what they're talking about, backed up by abortion. That is the safest of all methods, and then the other methods like diaphragm and condom, IUD, pills for non-smokers, abortion only, are all sort of low but intermediate. The story is, with the exception of older women who smoke, the worst thing you can do is not use any method. That's dangerous. The best thing you can do is use a condom backed up by abortion. That's surprising because there's so much popular myth out there that misconstrues these facts.

Now what has changed is that this data was taken in the earlier days of birth control pills which were high dose, and you've probably heard about this. They used to have very high dose because it was new, they didn't know about it, and they wanted to be sure. The main thing was to prevent pregnancy. Then they realized they could get away with lower and lower doses and the pills nowadays have much lower doses so there are much less side effects. All of these columns would probably be way, way down from what they were, and that's what's changed.

When you go the developing world, this is United States data, when you go to the developing world of course pregnancy itself is much more dangerous. Childbirth is much more dangerous so what you see is these white bars go an awful lot higher depending on the country. If you're in the middle of Africa they're very high, if you're in other places they're pretty much like the United States level.

Student: These are deaths associated with deaths while giving birth or these are deaths from side effects of the contraceptives?

Professor Robert Wyman: Both, both, both, all of the above.

Chapter 3. Abortion Rates: Health, Safety, Religion and Legality [00:21:59]

Okay not only--so this just shows you immediate mortality and it's clear what's going on. Abortion apparently has no long term clinical effects whatsoever. There's no physical affects, again we're talking about proper medically done abortions, sterile abortions, properly done, and there are no long term clinical effects, neither physical nor psychiatric. It doesn't make women sterile, doesn't increase the chance of sterility, it doesn't cause you to go crazy later; none of that stuff is statistically true. Of course there are women who either having an abortion or not having an abortion, go through all these bad events but statistically they're the same.

The number of women who've had an abortion and eventually go sterile would be the same as those who have not had an abortion and eventually go sterile. Now that's medical sequelae. What the emotional content of having an abortion is, that varies tremendously by country. We'll talk about some countries where it's absolutely like a non-event, having an abortion, and other places, and other individuals where if their own ethics, their own morality, their own desire for a child, their religion, if it really is opposed to abortion, then there can be a lot of emotional difficulty with it. But that's not a thing to do with the abortion itself, it's to do with the, shall we say, the moral context in which that woman perceives the abortion to have been done.

Along with this the--So, you have these generally quite high rates of abortion around the world and the question is, what are the determinants of that rate? What makes the rate higher? What makes the rate lower? Many people believe that religious proscription, that the religion of the country is what is the determining factor, but it's not. For instance, in Europe among Catholic countries, Belgium has one of the lowest rates in the world 6.8 per 1,000, and Hungary another Catholic country has one of the highest 34.7 per 1,000 so you span the whole range.

Among Muslim countries, Bangladesh has one of the lowest rates 3.8 while Turkey has six or seven times that rate. Again, the Bangladesh rate is a little confused because of--they use a lot of menstrual regulation there. The U.S.,a largely, though not-exclusively, Protestant country, has about the same rate as Turkey. Turkey is essentially all Muslim, of course. People believe that the Catholic Church, of course, teaches that abortion is a mortal sin, its murder. But, in the U.S. the abortion rate for Protestants which is 17 per 1,000 is lower than for Catholics, 24 per 1,000. As far as one can tell, Catholics, because of the church, slightly underuse birth control, so, as compensation, they slightly overuse abortion. The error bars in all these basically mean that there's a barely detectable difference between say Protestants and Catholics within America, within any one country. There are two issues of why the Catholic rate is higher. Yeah.

Student: Are these lines per person or per 1000?

Professor Robert Wyman: This is per 1,000. Those are numbers per 1,000; per 1,000 women of reproductive age not per 1,000 babies.

The Catholic thing is most--most of the difference in that statistic is that there's a large Hispanic population in America which happens to Catholic and has a higher abortion rate than native born women, so that is the most of the reason why the Catholic rate is higher.

It's also--you can't tie it down to legal proscription, whether abortion is legal or not legal. You can't tie that down as a determining factor in abortion either. About half of the abortions in the world are illegal. The old statistics used the word illegal, but now there is such a variety of legal rules and such a variety of situations in each country where it's legal or not. Now different states in different countries, like in Mexico, Mexico City has one law, each state can have a very different law, so it gets to be difficult to describe legality and that's all tied in with the safety which we'll come back to. You see sometimes statistics about safe abortion, sometimes statistics about legal abortion, and--usually they fit right on top of each other.

About half of abortions in the world are illegal, the other half are legal, and so for instance in Europe abortion is generally legal everywhere under a very wide range of conditions, and its abortion rate is 28 per 1,000. In Africa where it's illegal almost everywhere it's 29, so again, no difference. The lowest rates in the world are in western--in northern Europe where abortion is accessible with few restrictions so the total--basically the total legality of abortion is in a place where the rates are very low.

Up to 2007 abortion was banned in Mexico, so it was totally illegal everywhere Mexico. Nevertheless, the number of abortions rose by 50% between 1990 and 2006 with a constant legal situation of illegality. In 2006, Mexico's abortion's rate was 40% higher than the U.S. rate next door. Here you have three countries that are all in a line Canada, the U.S., and Mexico. Canada has much lower, and the United States is in the middle and Mexico--those two are legal; in Mexico it's illegal and it has the highest rate of all.

Of course I should warn you, and you probably realize it, that saying that abortion doesn't--you can't--the legality is not the determining factor, these intercontinental comparisons, or country comparison are not terribly informative because so many--between say Mexico and the United States, or between Africa and Europe, there are so many variables, so many socioeconomic variables, education, medical care, standard of living, all of this varies tremendously. The difference in abortion rates is not to be found in the legal or illegal nature, but in some of those other characteristics.

In most countries abortion is legal, and as of a few years ago, 61% of the world's people lived in countries where abortion is permitted, basically without restriction or for a wide range of reasons. Only 25% live in places where abortion is largely illegal. These are largely Latin America, some of the Muslim countries, and Sub-Saharan African countries.

Abortion is becoming legal in more places. From 1985 to 1998, 19 nations significantly liberalized their abortion laws and only Poland de-legalized abortion, which had to do with its independence basically from the Soviet Union at the time. That was 1985 to 1998. From 1998 to 2007, again the latest data, 16 nations liberalized their abortion laws and two territories and one state in Australia liberalized its abortion laws, and in Mexico I mentioned. Mexico City has now made abortion in the first 12 weeks legal and that was in 19--2007 I believe, and than a few states in Mexico has followed that, so Mexico is now a split place.

In this 1998 to 2007 time frame El Salvador and Nicaragua, which already had a very restrictive abortion laws went to absolute, under no circumstances, abortion is totally--no rape, no death--health of the mother, no exceptions in Nicaragua and El Salvador.

Chapter 4. Abortion: Legality and Health [00:30:40]

In contrast to the safety of legal abortion, where abortions--when it's legal it's almost always in a proper medical situation. When it's illegal, it's an extremely dangerous procedure. There's something like 67,000 abortion related deaths a year and that leaves 220,000, a quarter million children without their mothers. As you may know, when it's illegal, the main procedure is inserting something up the uterus and scraping around to try to dislodge the endometrium and the fetus.

Well, if you're scraping around in there with a pointed stick or a hangar or something, you're liable to puncture the uterine wall and make a hole between the inside of the uterus, which is open through the vaginal canal to the outside, and the peritoneal cavity, the inside of your body and so infection gets through that and so the main route isn't--the main reason why abortion--illegal abortion is so dangerous is that non-sterility of whatever it is that's inserted, plus it's pointed usually, and they break right through the uterine wall.

In addition, you may know that the fallopian tube is open into the peritoneal cavity because the ovary, which releases the egg is--it sits right on top of the fallopian tube and the egg is released into the peritoneal space, the body fluid here and it's supposed to drop down into the fallopian tube and cilia push it down. That's an opening so if you get something unsterile into the womb and then the bacteria can swim upstream and get into the body and then you're into sepsis and you very likely die. It's a very dangerous procedure when done not properly.

There are very good statistics showing that the main determinant of the maternal death rate from abortion is its legal status. Here again, although I don't think I showed this slide, so here is places where abortion is legal, here's the abortion rate, this goes back to saying that the legal situation doesn't determine the rate of abortion. Here are various abortion legal places and the rate is about 6 to 26, and here it's illegal and you have the range of 23 to 52, so ballpark double or triple this rate, so it's illegal. These are all South America. This is all Europe, Japan, Australia, United States, very developed countries. Countries that are partially developed shall we say.

The illegality correlates with the abortion rate but it's almost certainly not the cause, certainly being illegal is not causing these high abortion rates. Now when you go over and look at the maternal deaths you see that there are ten, the developed regions have an average of ten, whereas in Latin America you have up in the 100 and 200, and even up to 300 range. You go to Africa it's 650. There the illegality really does make a difference in the maternal death rate, that's the dominant effect of making something illegal is--doesn't change the abortion rate and we have a number of examples, but it changes the maternal death rate very, very clearly.

The most extreme example of this and the clearest example of this is from Romania. Romania had during--after World War II when it was a Soviet puppet state, as I told you, the abortion rate was extraordinarily high, like four abortions for every one live birth. Because--well they had a dictator then, Nicolai Ceausescu, who you've undoubtedly have heard of, and he decided that for the glory of greater Romania there should be more Romanians, he wanted a big strong state, so he went on a pronatalist campaign.

Abortion was immediately criminalized, contraceptives became very hard to get hard, they wouldn't import them, they didn't manufacture them. So what he did was that all women between 18 and 45 were rounded up at their workplace, remember this is a socialist state so almost all the women worked, they were rounded up at their workplace, and subjected to a gynecological examination. If they were not pregnant they had to explain to the government why they were not pregnant. It was about as intrusive a pronatalist campaign as you can imagine. It's somewhat the mirror image of China's anti-birth campaign, and Romania had the plus campaign.

Anyway, what happened immediately--so previously 80% of pregnancies had been ending--had been terminated with abortion. Abortion disappears, and was legal, abortion had been legal, and boom the birthrate does indeed go up; nothing like by a factor of five but something like a factor two as I remember but I want--should--check that. Then, very rapidly, women set up networks of illegal abortion providers and the birth rate goes up and the birth rate comes back down and it ends up somewhat higher than it had been beforehand, but not enormously higher.

The maternal death rate is what changed. It rose to 200 per 100,000 live births, from a number in a developed country that was something in the tens or twenties. It ranged up to ten times that amount. The infant mortality rate, because these mothers didn't want these children, presumably, the infant mortality rate rose to 83 deaths per 1,000 from--Japan's rate is 4.8, the U.S. is 8.9, so it rose to 83. So again, something like a ten times increase in infant mortality. The main effect of de-legalizing abortion was a temporary rise in the number of births but a long term increase in maternal mortality and infant mortality, a massive increase.

By the time abortion--of course when they got free of the dictator--it was legalized again and then, by that time, things had come back a little to normal. But still, the maternal death rate, as soon as they legalized abortion, the maternal death rate dropped by a factor three, so that's Romania's nice example.

In South Africa, more recently, this was in the late 1960s, the Romania story. In South Africa the abortion law was liberalized and the incidence of maternal infection due to abortion dropped in half. In all cases the major effect of making abortion illegal is an increase in complications. You don't change the abortion rate, but medical complications, death of the mother, and death of the infants.

The fundamental--we've been going through things that are not the cause of the high abortion rates, it's not the religion, it's not the legality. The fundamental causes of--kind of obvious--is unintended pregnancy. You may remember that these--there are very high rates of unintended pregnancy. --Here is a comparison of two regions, almost all legal in the developed countries and in almost all of Africa it's illegal and the death rate's an enormous, enormous difference there.

You may remember these statistics, just to refresh your memory, about unwanted fertility. This is 71% of living women want to stop having children. Yet, as I showed you before, they have more--they continue to have children because they're not using contraception, they don't have enough contraception. That's Bolivia. This is from the previous lecture around the world, remember this is the line where people--this is how many children people are having, this is how many they want, this is the line where they're equal. All countries, all developing countries are having more children than they want. There's a large amount of unmet need in the world. The estimate for the world is 108 million women. Since there's an unmet need, these women who don't want to have more children yet do, that results in some 51 million unintended pregnancies. Of those using contraception, another 25 million happen as a result of incorrect, inconsistent use of contraception or method failure. You have something like 80 million unwanted pregnancies.

In the world there are 210 million pregnancies annually, and about 40% of them are unplanned. About a quarter of--We know, from a lot of places, that when there's an unplanned pregnancy about a quarter of them end in abortion. The main sequence is: unwanted pregnancy and then high abortion rate. Most unintended pregnancies in the world--most unintended pregnancies are in the [un]developed counties. So there's a difference here between developed and undeveloped countries. Contraception is very available and highly used in the developed world, so in the developed world most unintended pregnancies are people who are using contraception, and using it fairly accurately, but there's a method failure, the contraception just fails.

You have to remember that a woman is fertile for say 30 years of her life. She has 12 monthly cycles in a year, a little bit more actually, a cycle is 28 days in principle, but that's close enough. In order to not have an unintended pregnancy her contraception must be perfect for 30 years, 12 cycles a year, that's an awful lot to expect of a contraceptive, and contraceptives are just not that good. So, in developed countries also, the main reason for unintended pregnancy, it's very heavily--married women who are using contraception. They usually have several children already, and the contraception fails. That's the main reason in developed countries. In developing countries where contraception use is less prevalent, the main reason is non-use of contraception.

Chapter 5. Contraception and Abortion [00:42:25]

There is a very strong relationship between contraception and abortion. -- So, we have a country, most countries, with this unmet need; women, before you start collecting statistics, want fewer children than they're having but it's not a big deal. Then something changes, could be a mechanism that we've discussed the reasons of cultural change, and economic change, or whatever, and people really start wanting to have fewer children.

This happened around 1964 in Korea and you read--and I gave you one of the stories about how an example of how this happens in Korea. What happens is as women--as the whole culture changes from wanting sort of the maximum rate of fertility to wanting a lower rate of fertility, the contraception--the abortion rate takes off first because in all these countries abortion is the traditional method, the women know it, and are moderately comfortable with it, so you see first the abortion rate starts going up. Then, with a short lag, the contraception rate goes up, because all the countries establish national family planning programs.

What happens is people use more abortion, use more contraception, so they're reducing their fertility, but the rate of drop of desired fertility can be so fast that even the sum of contraception and abortion can't keep up with it, so both rates keep rising. Eventually you peak. Abortion peaks and starts falling down, contraception continues upward. This is the time when the demand to have less fertility is more than either method alone can cope with.

Eventually women--and abortion is easier because the post--it's an after the fact method, but eventually women learn to use contraception--learn to use it and learn to use it properly and so then the abortion rate declines as the contraception rate continues on up to very high levels, and most of the difference here is women who want to get pregnant or something.

You have this trade off. You have, in an early stage, both of them rise together and at a later stage they do very divergent things. You'll see when you get a polemicized discussion of this, what you'd hear is right to life people say, 'contraception is no good, abortion rises with contraception' and they use statistics from this half on down. People who are pro-choice say 'no, no, no or are pro-contraception no, no, no it goes this way and the use this half of the graph. But you get both of these things.

Korea is one example. Here is another example of the relationship between contraception and abortion in Bangladesh. Here is--remember Matlab--you read about Matlab where they chose some villages and got a very strong family planning program and then other villages which they left as a control region. They had family planning because they had the government program, but the government program wasn't any near as good as the intervention program.

Here's the control region and a lot to see here. First of all this is desired fertility and that starts at this level and drops down to somewhat more than half; desired fertility in the Matlab region starts at about the same level and falls about the same amount. The difference between the two regions is not desired fertility. The actual fertility rate drops here, starts higher and drops a little faster here, so that it ends up not very different. Again, the difference is not the actual amount of fertility, which the number of births isn't enormously different between the two regions.

In Matlab--in the experimental region, the region where they had the good program, the contraceptive prevalence goes very high or goes rapidly very high from something like 30%, more than doubles to 70%. Whereas, in the other--in the non-control region you have--it starts much lower--this rises very rapidly, this doesn't change at all for a number of years, then the government--actually the government improves its program, it jumps up a little bit. So it's the contraceptive, this is a really big difference, the contraceptive prevalence is much lower in the control region than in the experimental region. The result is: here's the abortion ratio in the region where the contraceptive prevalence is very high and here the abortion ratio goes crazy where they don't have--they're not using contraception efficiently.

Again here you can see in those two regions the same country, the same time, neighboring villages, neighboring districts that the--there's this tradeoff. They either use contraception or they use abortion. Both places, they're wanting fewer children as time goes on, but in one case they use contraception and in the other case they use abortion.

Here's another example of this, rather different in Shanghai. This is a more complicated, somewhat interesting case. This is the one-child policy comes in. They're only allowed one child, so they have that child and then they try to do something to avoid the second child, and what they use is contraceptive methods and they don't work, they start with very--let me get this straight here. They start with a low use of IUD which is a really secure method of contraception and the abortion rate is very high and they rather rapidly learn that IUD is the only really secure way of not getting pregnant and then the abortion rate falls down, so it's another rather different situation in which again the abortion rate and the effective contraceptive rate are mirror images of each other.

When you have a high rate of effective contraception you have a low rate of abortion. Latin America shows this same pattern. In Latin America abortions have been practiced for centuries. It was certainly practiced by the Incas and the Aztecs. In 1551 the Bishop of Venezuela reported to the King of Spain that the natives did not want their children to become slaves, so they aborted them, 1551.

Chile has very good medical statistics. At the beginning of Chile's fertility transition in the 1960s 23% of Chilean women voluntarily admitted to having an induced abortion. Again, remember Chile is very heavily a Catholic country and this is not really delving into medical records or making any corrections. This is just asking the women, Have you had an abortion?' and a quarter of them say, yes I've had an abortion. Not only did they have an abortion but most of them had more than one abortion, up to three, 8.4% of the women had more than seven abortions. This is early on.

Ten years later in the 1970s now it's--where women are really into their fertility decline, they don't want the children, the average woman has almost three abortions, lifetime, so that goes up. Again, those are the openly admitted numbers and the real numbers must have been much higher. Again, as in elsewhere, in Chile almost all the women were married, almost all middle class women, and they already had had four to six pregnancies, they already had children, and experience with pregnancy. In terms of socioeconomic levels, middle class women had more abortions than working class women. Married women had a greater abortion rate than those living in temporary unions, and in all--through all this time abortion was completely illegal in Chile and it still is.

Going next door to Peru, in Lima in the 1970s, again the time when the fertility was going down, when people were wanting fewer children in Peru, the yearly increase in the abortion rate was 24%, every year there was a 24% increase in abortion. In any given year a quarter to a third of the reproductive age women would have abortions, that's one out four, one out of three women every year would have an abortion. Again, it's in this--the really high abortion rates are when women are--or families are starting to want fewer children and haven't yet really figured out how to use contraception.

In contemporary Latin America abortion, although it's illegal almost everywhere and it's almost universally a Catholic place, abortion is very widespread. Latin America as a whole has 1 abortion for every 2 live births; remember worldwide and in the U.S. it's 1 per 3.2, Latin American has 1 for every 2 live births. Eventually there's a generational change and the younger women start using contraception and then the abortion rate starts to fall.

The Philippines, another example--in the Philippines have a very interesting situation of the politics. There's a strong inter-relationship between the politics of the country, the Catholic Church, and the citizen's use of contraception. When Fidel Ramos was President, one of the early very populist president's, he supported family planning and a quarter of the Filipino women were using the modern method. Since then the desired fertility has gone down in the Philippines and now more than half of Filipino women want some form of birth control.

But the presidency has changed and a woman, Gloria Arroyo Macapagal, came in and since Ferdinand Marcos was a strong dictator and they had strong presidencies but then, when he was kicked out for massive corruption and dictatorial means, they now have democratic elections and the governments have been quite weak. They don't have much popular support and so the government needs to get legitimacy from somewhere and in this case they get legitimacy from the Catholic Church because, again, the Philippines is a very Catholic country.

A fairly open deal was made between Macapagal and the archbishop of the Philippines that the church will support you if you make abortion illegal and get rid of the family planning programs. Now the government--and that was taken and she got elected -- and now the government only supports the traditional family planning method, which is withdrawal basically. This had an effect. So from 1993 to 1998 in the five, six year period, the use of traditional methods went up by 50% while the use of modern methods didn't--actually didn't change much.

When the government pushes something it often goes up and all those traditional methods just plain don't work. The result was that the number of abortions in the Philippines in these years increased by 19% from 400,000 which was already high--from 400,000 it went up to basically a half a million abortions. They're all illegal of course.

Chapter 6. Abortion as a Controversy [00:55:14]

As I said in the beginning, in America abortion is a great source of controversy. This is not always the case in a lot of places, so there's a lot of literature now on what they call the culture of abortion. Those countries for whom abortion has a non-controversial place as a mechanism for fertility control just as contraception has a more or less non-controversial place as a form of fertility control in say Europe and America.

I got invited a few years back to talk to the women's health class about abortion and--it was one of the things we talked about, and afterwards I was talking with some students and a professor with the next class walks in and he turned out to be from Russia and he asked us what are you talking about? The students had started asking me questions about--something about abortion. He was really puzzled; he said 'abortion, why is anybody interested in that?'

Because in Russia it's just an ordinary, absolutely ordinary kind of thing; in places like Romania, and I'm sure this is to some degree true in probably the whole of eastern Europe. Remember, I mentioned to you the old theory that the health of the body depends on the humors, that you've got four humors of bile, and choler, and all this other stuff and it's the balance that's important. You have to reestablish--What the menstrual period does, everyone knows the worst fluid is menstrual fluid, and so you've got to get rid of that and if you don't--if you're not periodically getting rid of menstrual fluid, the bad spirits humors, fluids, build up in you and you get unhealthy. In places like Romania, many people, older less educated people, believe that it's good to have an abortion every so often. Having nothing to do with pregnancy even, it's just good to do that to get rid of this evil humor.

That has persisted as well as a lot of other really unbelievable--almost unbelievable to us, medical myths and is part of the reason for that very, very high abortion rate in Romania. In the Ukraine, when the Soviet Union fell apart, the family planning programs that they had also fell apart, and so the whole area was left without effective family planning. The International Planned Parenthood Federation, their nearest office was in Bangkok and so they couldn't help very much. What they did is, they said, we'll take just the city of Moscow because it's most cost effective to work in a city, a lot of people, we don't have geographic access, but, we'll try to provide some contraception in Moscow.

That left all the other Soviet Bloc countries with nothing. The Planned Parenthood Federation of Connecticut here, I was associated with them at the time, got in contact with the Ukraine--the whole Ukraine was left like bereft of contraception. Got in touch with the main--the head and the university in Kiev, the head of the OB/GYN Department, a very nice woman, and started to help her provide--buy contraceptives here and ship them abroad.

Actually we buy them internationally, very cheap, a cycle of pills is $.80 on the world market. A condom is like a penny and a half, diaphragm is $1.25. So, if you buy them in the United States they're expensive. If you buy them in India or wherever they're made, the things are a lot of cheaper, so we could really help Ukraine. What they wanted first was--because you can't use any of these things if there's pelvic infections so they wanted Monistat and other treatments for vaginal infections as a first line and than they could start dealing with contraception.

Anyway, this program went on but it wasn't very successful and the reason was, the women were using abortion and were quite happy with it. They didn't see anything wrong with it; they were used to it, and no problems, so why should we change? One of the things that they did, and we helped them, was we got some of these right-to-life films, which show, in the goriest way, what the fetus looks like and what an abortion is like and you know are really are way, way off the deep end and shipped them to them so they could show their patients and say, 'see an abortion is not just this sort of nothing kind of event.'

The most interesting case might be Cuba which has one of the highest abortion rates in the world, 78 per 1,000 women per year, compared to Canada which has 15.5, for instance, again that's the two sides of the United States. Almost 60% of what they call known pregnancies are terminated by abortion.

So they have a long history. Before 1938 they were very much tied culturally to Spain, and Spain was very conservative. That was the Franco era; a very, very right wing fascist, Catholic dictatorship and so--in the Spanish law all forms of abortion, induced abortion were illegal, and Cuba just used that same law. It was up until 1938, and in 1938 they liberalized a little bit for rape, likelihood of death of the mother, or severe fetal malformation issues. Despite these restrictions it was the mechanism of birth control in Cuba and it was used widely by all the social classes. Well, I'll tell you an exception to that, and by poor people and it was used in the cities and in the countryside. So abortion was it.

Contraception starts coming in but it's a foreign product and it's expensive, and you need some medical knowledge to use it, so only the upper class uses contraception, at this time, used contraception in Cuba. At that time a very, very--few people owned all the sugar plantations and everyone else was basically a slave on the sugar plantations, so the social gulf between the rich people using contraception and the poor people using abortion was enormous and they didn't talk to each other. So there was no social diffusion of the ideas of contraception, so the people just continued using abortion.

1959 Fidel Castro has his revolution and he takes over, and in the beginning he's anti-abortion, he still is, and a lot of events happened and I'm simplifying a complicated history. By 1962 the United States places an embargo on Cuba, including medical supplies, and guess what the Cubans can't get? Contraception, because the United States was their source of supply, so abortion gets more entrenched. The embargo might have done the biggest thing to raise Cuban rates; no one has good statistics on that.

While abortion is legal in Cuba, the government really wants to reduce it. In 1998 the Pope visited Cuba as you probably may remember from all the headlines and he talked against abortion, then, shortly after that, Castro gave a seven hour lecture, worse than me, a seven hour lecture condemning abortion as a method of birth control. He said it was his duty as a public figure and a revolutionary leader to oppose widespread abortion. It didn't have any effect on the people, and it's very interesting, there is now a wonderful article which I actually should have assigned to you about what's going on in Cuba. You have too much reading already.

The medical--the government and the medical establishment want to get people--wean people off abortion. In these interviews one of the things they ask the respondents, who are women of all ages and men of all ages, 'well what have you heard from doctors and healthcare professionals.'

'Well that's it's dangerous, that you can die from it. Just imagine'--that's what she's heard from the professionals--'but just imagine if you had to give birth every time you got pregnant. I got pregnant and had an abortion when I was 15 even though I was on the pill. I also got pregnant earlier when I was using an IUD.' This was a woman, who at the time of the interview was age 30, and she had--this is after her fourth abortion. The people's perception is very different than what they're hearing from the medical establishment and the government establishment. It's an absolutely unremarkable subject for discussion.

One male who is now age 49 said, 'I was about ten years'--they ask what have you--do you hear about abortion? Is it discussed? He says, 'sure, I was about ten years old, I heard about abortion from people on the street, also in my house my mom talked about it with her friends in front of me.' Another respondent: 'Around the streets abortion is a common thing people talk about. It's an everyday thing.' A male aged 23.

"Do you know anyone in your family, among your friends who's had an abortion?" 'Yes, an aunt of mine.' "What did she tell you?" 'That you don't feel anything, that they give you the anesthetic and stuff, everything goes fine.' That was a woman of 18 who's just had her first abortion. Another respondent, 'yes friends of mine, they told me that they had it done and that you don't feel anything.' Now that was a 15 year old girl with her first abortion.

Another respondent, 'my cousin had an abortion, she told me that nothing out of the ordinary happened, that everything went well.' This is a female aged 21 on her second abortion. Another respondent, 'when I was in school, a friend of mine had an abortion; she was fairly young around 13 years old because we were in the eighth grade.' "What did she tell you, how did it go?" 'She told me it went well and said the anesthetic was fine, girls talk about that kind of stuff.' This was a 31 year old woman on her fourth abortion.

Another respondent--to the question, have you heard much talk about abortion? 'Oh yes, among girls at school. They don't use anything,' meaning they don't use any contraceptives, 'so when they get pregnant the go to get an abortion. They talk about it like it's nothing; it's like drinking a glass of water. Some people have problems when they get an abortion but most people don't. Almost always the procedure goes fine.' That's a 17 year old girl after her first abortion.

It's a very interesting case because while they're experienced, they're hearing one thing from the government, the same thing from the medical community but they know lots and lots of people who have had abortions, a common subject, and they're not hearing about any difficulties from it, or very rarely are they. The government's pushing contraception and they use contraception, 92% of the Cuban women have used contraception. That's some time--even among adolescent girls who are obviously having a very rich sex life because they're getting pregnant all the time, 84% have used some form of contraception.

It doesn't mean anything to them, because they're just as happy with abortion. So, they're not worried about getting pregnant so they sometimes use contraception, they sometimes don't, and the reports of when they use it are almost totally haphazard. They'll use it for a while, they'll stop using it, they'll start again and they change methods. It doesn't even have any--of course women go through periods and men too, when they're in a relationship having sex or just having a lot of casual sex, and the woman will tell you this and the use of contraception did not correlate at all with periods when the women were having sex.

It's just a total disconnect and undoubtedly the reason is that they're perfectly happy with abortion and it's a fine backup so they don't have to be terribly careful about using contraception. In fact, much as they're hearing that abortion is no big deal, they're hearing that the other forms of other contraception are really not very pleasant. Here are more answers to survey questions. 'I don't like the pill because of extra hormones in the woman's body,' a male aged 19 says that. This is a woman: 'No, I don't use any IUD because my body can't support it. It falls out of place.' "You have used an IUD in the past?" 'Yes, I had an IUD two different times and both times it fell out place. I have problems with IUDs.' That's a 37 year old woman on her second abortion.

IUD causes pain to women. 'After my first pregnancy I had an IUD inserted, but I had to have it removed because it was causing pain. I started having problems with my period and a lot of inflammation, and when I had sex it was painful, so I had the IUD removed,' female aged 35 her first abortion. 'I had an IUD before, I had it for two years, but I had it removed because I had abnormal menstrual bleeding,' a 42 year old woman, fourth abortion.

Another woman, 'sometimes I'll use protection but the condom broke. You explain these things to the doctors and they say that--this doesn't happen but I'm telling you it's not a lie. Sometimes condoms are bad and they break,' a 19 year old girl on her third abortion. At the time of the survey 88% were practicing contraception at the time of the survey, and again, among adolescents 68% were using condoms at the time of the survey. Yet, the contraception, they didn't like it, it wasn't effective, and they were apparently just as happy with abortion.

It's a very interesting thing and this is repeated in basically all of the east European countries, where again, they have long experience with abortion and they don't particularly see any benefit to contraception. Now the standard thing that you'll hear in America from everybody, independent of their--they can be right to life or pro-choice. Their thing is that--the idea is, and I've been sort of saying that here, the idea is to replace abortion with contraception, that contraception is a better method of birth control than abortion. It's controversial--but now it's controversial.

Actually, what started me really looking into this was a number of years ago I was giving a lecture, and I was saying very overtly, that well it's progress when contraception replaces abortion. Now it's not so obvious because I showed you this one, that the safest method is condoms backed by abortion. It's very--it was very hard--one student asked me this question about why is--why do you think that contraception is better than abortion and it's a very, very hard question to answer and I won't even try to do this today. It's a very difficult kind of issue.

The final thing that I should tell you is that one of the things we worry about is the population growth rate. Abortion makes a huge difference in the global rate of population growth. As I told you, there's ballpark 75 million increase in the world now. If the abortion rate is about somewhere between 40 and 50 million, that means the rate of world population increase goes up by 75% or something. Because abortion is such a large fraction of the birthrate, if abortion disappears and is not replaced by contraception, the population growth rate goes crazy.

In the world, as it is now, there's probably not any chance of stabilizing world population without abortion. Just on time, we will continue with the biology of abortion and some of the history and philosophical considerations in the next lecture.

[end of transcript]