CORRESPONDENCE

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Abortion rates still rising

SIR, - A recent report from the Office of Population
Censuses and Surveys' has been widely quoted in
the press,2 3and was reported by Ms Luisa Dillner,4
as indicating that the abortion rate has tripled in
the past 20 years in England and Wales. Detailed
analysis of these figures, however, shows that
requests for abortion have remained remarkably
constant since 1972 (figure).
The initial rapid rise from 3-5/1000 women aged
15-44 in 1968 (the first year when abortions were
notified) to a level rate of 11 0/1000 in the 1970s
probably reflects the increasing availability of legal
termination of pregnancy and corresponds to a
decrease in illegal abortion. Much of the modest
increase since then (35%) can be explained by
demographic changes rather than a profound
change in women's requests for abortion. Women
born during the "baby boom" of 1960-5 reached
sexual maturity during the 1980s, and hence a
larger proportion of the female population is at risk
of unwanted pregnancy. The Office of Population
Censuses and Surveys calculated that because
there has been an increase in the proportion of
women aged between 16 and 29 (a group that has a
higher termination rate than older women) without
any change in the age specific termination rates the
number of terminations would have been expected
to increase by 14% between 1972 and 1989.
The remaining increase is likely to be due mainly
to a gradual change in the attitudes of doctors,
and particularly gynaecologists, to therapeutic
abortion in certain parts of the country. In Scotland
there were appreciable regional differences in the
abortion rate in 1972, with the rate in the west
being half that in the north and east. Though the
rates in the east and north have remained fairly
constant over the past 20 years (for example, that
in Grampian), the rate in Greater Glasgow has
doubled to reach the national average. These
differences probably reflect the influence of two

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1970 1974 1976

1980 1984

1988

Abortion rate among women aged 1544 in Grampian

region, Greater Glasgow, Scotland, and England and
Wales, 1970-88
*Figures for North East Scotland Regional Hospital Board. tFigures

for West ofScotland Regional Hospital Board.

BMJ

VOLUME 303

7 SEPTEMBER 1991

eminent senior gynaecologists. My father, Sir

Dugald Baird, who worked in Aberdeen, played an
important part in supporting the change in the
Abortion Law in 1967; Professor Ian Donald in
Glasgow was vehemently opposed to therapeutic
abortion. Though religious and social factors may
have had some role, it seems unlikely that the rise
in abortion rate in Glasgow is totally unrelated to
the retiral of Professor Donald in 1976. Similar
regional differences in attitudes existed throughout
England and Wales, and hence the increase in the
abortion rate nationally probably reflects the
gradual levelling out of provision of abortion
services rather than an increased resort to abortion
as a means of controlling fertility.
A major factor determining the demand for
abortion is the provision of contraceptive services.
The abortion rate in Scotland (9-8/1000 women
in 1989) is lower than that in most European
countries and less than one third that in the United
States' partly because contraception is widely
available to all sections of the community from the
NHS. Recent attempts by many health authorities
to limit the provision of "social" sterilisations and
to reduce budgets for family planning services may
lead to a rise in the incidence of unplanned and
unwanted pregnancies. The consequent increase
in the demand for therapeutic abortion would be
very undesirable at a personal level and would put
increasing strain on medical services.
DAVID T BAIRD

Centre for Reproductive Biology,

Department ot Obstetrics and Gynaccology,
University of Edinburgh,
Edinburgh EH3 9EW
I Office of lopulation Censuses and Surveys. 'I'rends in abortion.
In: Population trends 64. London: Government Statistical
Service, 1991:19-29.
2 Fletcher D. Abortion rate has trebled in 20 years. Daily Telegraph
1991 June 19:4(col 1).
3 Hunit L. Abortions on the increase. Independent 1991 June
19:4(col ).
4 Dillner L. Abortion rates still rising. BMJ 1991;302:1559-60.
(29 June.)
5 Henshaw SK. Induced abortion: a world review. Family
Planning Perspecti'ves 1990;22:76-89.

Vital statistics of births

SIR,-The measurement of maternal mortality
is important enough that a minor point in Dr
Geoffrey Chamberlain's excellent paper' deserves
mention. The denominator for maternal mortality
in a given year is either the total number of births
or the number of live births during that year, not
the number of maternities-the term maternities is
ambiguous. The World Health Organisation's
definition states that "A 'maternal death' is defined
as the death of a woman while pregnant or within
42 days of termination of pregnancy, irrespective
of the duration and the site of the pregnancy,

from any cause related to or aggravated by the

pregnancy or its management, but not from
accidental or incidental causes" and goes on to
say that "the denominator used for calculating
maternal mortality should be specified as either
the number of live births or the total number of
births (live births plus fetal deaths). Where both
denominators are available, a calculation should be
published for each."2
To allow for an extension of the period during
which deaths can be related to pregnancy or its
outcome, the 1989 international conference for the
tenth revision of the International Classification of
Diseases introduced the concept of late maternal
death: "A 'late maternal death' is defined as the
death of a woman from direct or indirect obstetric
causes more than 42 days but less than one year
after the termination of pregnancy."2
Similarly, the conference has introduced the
concept of "pregnancy related death" to permit
classification of deaths of women while pregnant
or when recently delivered, even though local
facilities may not allow the cause of death to be
identified as "related to or aggravated by the
pregnancy or its management." A pregnancy
related death is thus defined as "the death of a
woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the cause
of death." It. is likely, for instance, that some
homicides and suicides of pregnant or recently
pregnant women fall into this category, and
accidents may also be considered in this light,
in so far as fatigue or reduced mobility in advanced
pregnancy affects ability to avoid or survive
accidents.'
A C P' L'HOURS
M C THURIAUX

Division ot Epidemiological Surveillance and

Health Situation and Trend Assessment
Strengthening of Epidemiological and
Statistical Services,
World Health Organisation,

1211 Geneva,
Switzcrland
I Chamberlain G. Vital statistics of births. BMJ 1991;303:178-8 1.
(20 July.)
2 International conference for the tenth revision of the International
Classification of I)iseases, Geneva, 26 September-2 October
1989. Wttrld Health Statistics Quarterly 1990;43:204-45.
3 Fortney JA. Implications of the ICD-I( definitions related to
death in pregnancy, childbirth or the puerpwrium. World
Health Statistics Quarterly 1990;43:246-8.

Nursing: an intellectual activity

SIR,-For doctors to comment on matters concerning nursing risks touching a raw nerve-the
"doctor's handmaiden" nerve-but the forthright
views of June Clark, a professor of nursing,
deserve discussion.' Doctors and nurses need each
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