Red Medicine: Socialized Health in Soviet Russia

The Problem of Abortion

A SPECIAL chapter on abortion appears to be called for, in view of the unique official attitude adopted by the Soviet Government. We confine ourselves strictly to a statement of facts, so far as we could ascertain them. This chapter might have been placed in the later medical section; but it is placed here in view of the intimate relation of abortion to married life and economic conditions.

In most countries the purposeful production of abortion except for medical reasons is regarded as murder. The Soviet Government in 1920 repealed the existing laws against abortion and legalized it under certain specific conditions. This law contained the provisions summarized below, which are more fully stated in Mrs. Field's Protection of Women and Children in Soviet Russia.

1. Abortion must be undertaken only by a licensed surgeon. Midwives are prohibited from performing abortions.(1)

2. It must, as a rule, be the result of a surgical operation, and not of drugs.

3. The patient must afterwards remain in bed in the hospital or place of operation for three full days.

4. She must not be allowed to go to work for two weeks after the operation.

5. For a first pregnancy an abortion must not be performed unless childbirth would seriously endanger the mother's life.'

6. Abortion is forbidden if the pregnancy has lasted for more than two and a half months.

7. A doctor cannot refuse an application for abortion, except as stated under 5 and 6. He may, however, discourage it in any way he thinks fit.

8. It is recommended that all abortions be performed in those State hospitals which have a division for this purpose. An insured woman or the wife of an insured man can claim abortion free of charge in a State hospital. For others a small charge may be made.

9. A private doctor or anyone else producing an abortion which results in death can be tried for manslaughter. Women cannot be punished for performing on themselves.

10. The doctor is recommended to discourage a woman from abortion if there are no social, economic, or medical reasons for it, and particularly if she has fewer than three children, or has adequate means for supporting another child.

It is stated that few abortions are asked for by women desiring to conceal illicit relations. Under the circumstances set out in Chapter 11 the significance of such relations has largely disappeared; and the prohibition of abortion for first pregnancies also bears on this point.

In Mrs. Field's valuable volume it is stated that since 1920 less than one per cent (0.74) of abortions performed in State hospitals resulted in death.

Dr. Alexandre Roubakine, of Moscow University, informed us that of 11,000 abortions induced in the Moscow hospitals in 1925 not a single case proved fatal. In the same year, he said, there was not a single fatal case out of 2,366 abortions in Saratov.

The experience of other countries would suggest that these figures are either too favorable even when the operation is performed in a good hospital and by a surgeon having special skill, or they do not tell the whole story. The experience of gynecologists in other countries would almost certainly show a higher fatality rate than this, even when the utmost skill is utilized.

The figures given doubtless refer to hospitals in which the surgeons have specialized in operations for abortion. The majority of abortions would occur outside the cities if they were distributed according to population. Although this is not the case, a high proportion of abortions must be induced under relatively unskilled management, and serious complications cannot be very infrequent.

In one city we were informed that mothers preferred the few minutes' pain of abortion to the frequent efforts at contraceion! Charges, if made, are according to wages; never more than 40 rubles. Social insurance covers the charges for women who are insured or whose husbands are insured, which, as will be seen in Chapter XV, accounts for all the women of the proletariat.

Dr. Genss informed us that in twelve years legalized abortion had saved the lives, of 300,000 women and he considered that hygienists should from this viewpoint strongly support it. He added that special skill has been developed in the operation, which now occupies only three to five minutes, instead of half an hour as formerly, all the patients being treated by specialists in hospitals. Each patient stays three days in the hospital and can resume work in ten days.

No difficulty has arisen because of the unwillingness of women to come to hospitals for this purpose. No distinction is drawn between married and unmarried women. In an earlier year all the available hospital accommodation was exhausted, and experience showed that patients refused at the hospital went to inexperienced midwives. So a system of payment for treatment was introduced, and the payments were used for providing additional accommodation. The position as to payment now varies, some clinics retaining it.

In Moscow the usual procedure appears to be that the woman desiring abortion applies to the special consultation centre of her own district. There are now fifty of these in Moscow. Her application, we were informed, is examined by a special committee for this purpose at each centre, the committee comprising three women, namely, a doctor, a representative of the Commissariat of Health, and a secretary. However, Doctors Hamant and Cuenot,(2) who especially investigated the subject in Moscow, regard this. inquiry as "illusory," since consent is given, for instance, when a woman is about to travel, or is going in for an examination, or is about to be divorced, or because the last confinement was painful. But as already indicated, the will of the patient, except in the first pregnancy, is the governing factor.

Consent being given, the woman is referred to one of the thirteen special abortariums in Moscow. The process adopted is curetting, usually without an anesthetic. According to the above reporters, of 52,412 abortions, 50,283 were followed by no untoward incident.

These writers quote Lippermann as stating that in Germany 50,000 deaths (or 5 per cent) have occurred in a million abortions. Sternberg gives 3.3 per cent of deaths in 2,617 abortions.

According to the official statistics of Moscow, which may be taken as being the city in which abortion is probably practised to the greatest extent, the total births (confinements at term plus abortions) increased between 1922 and 1929 threefold, from 43,289 to 133,076, while confinements at term only increased from 35,520 to 51,059, or about 43 per cent. Total abortions became from ten to eleven times as frequent in 1929 as in 1922. The official figures distinguish between induced and spontaneous abortions. The proportion between the two varieties of abortion is shown below, the number of spontaneous abortions each year being stated as too:

1922 1923 1924 1925 1926 1927 1928 1929
Base for spontaneous abortions 100 100 100 100 100 100 100 100
Induced abortions 114 73 131 402 417 695 894 1,240

The proportion of abortions intentionally produced has increased enormously; according to Doctors Hamant and Cuenot, total abortions in Moscow are now much more numerous than confinements at the end of a normal pregnancy. In 1929 they were 61 per cent in excess of normal births.

It must be remembered, of course, that the statistics given refer to recorded abortions and not to those secretly performed. There can be no doubt that secret abortions have greatly decreased in number during the same period that the recorded number has increased.

The experience of Moscow is almost certainly exceptional as regards the amount of abortion; and it is evident that the practice of contraceion, notwithstanding the facilities provided by advice concerning it at most of the maternity centres seen by us, remains exceptional. This is confirmed by the national birth rate (see page 202) which although lower than in the past is still higher than in non-Catholic countries.

The decision of the Soviet Government to legalize abortion appears to have been determined by several considerations. In Soviet Russia as in other continental countries there was a vast amount of unskilled abortion, with terribly serious results in the destruction or damage of maternal health and life.(3) This partially explains the public abortion exhibitions, of which we saw an example at Rostovon-Don. The primary object of this exhibition was to warn all members of the public of the danger to health and life of unskillfully induced abortion, and it doubtless did this. Some of the exhibits in this exhibition were unsuitable for unrestricted display; but if there is still a large amount of unlicensed abortion the need for warning of its dangers is evident. It may be that although provision is made for obtaining officially sanctioned abortion, this provision is still defective in scattered districts, and that much suffering results from unskilled intervention.

The Soviet policy was possibly also determined by the consideration that as abortion could not be prevented by deterrent punishment, it should be regarded, like irregular sexual intercourse, as not being a crime. We need not animadvert on the differences between these two.

Occupational requirements have also had much influence in determining the Soviet policy on abortion.

Seventy per cent of the women in Russia between the ages of eighteen and fortyfive are workers, although in some districts this proportion may be only 30 per cent. If a woman who is a worker already has living children, pregnancy is a to make her wish to have an abortion.

Dr. Genss (see page 21) impressed upon us the official view that abortion is a necessary evil, and that it is hoped eventually to "liquidate" abortion by preventing conceion, when this is desired. At present, he stated, there is no completely dependable method of contraceion, though he thinks such a method, without mechanical appliances, may soon be within reach.

It will be understood that in this volume the authors are abstaining from expressions of opinion in respect of either abortion or contraceion; they are recorders of momentous social facts, concerning which each reader will form his own judgment, in the light of his hygienic and social outlook and his ethical attitude.

(1) Margaret I. Cole in Twelve Studies in Soviet Russia (London, Victor Gollancz, 1933) states: "Abortion is absolutely illegal unless performed in Government hospitals or clinics, and if performed outside is punishable by three years' imprisonment." She adds that "in the case of a first pregnancy, abortion is very vigorously discouraged," implying that it is not strictly forbidden.

These statements appear to us, in the light of our visits, to be more nearly in accord with present practice than the corresponding statements under the enumerated headings in the text.

(2) "Etat Actuel de la Medecine Anti-Conceionale en U.S.S.R." in Gynecologie et Obstetrique, Revue Mensuel, October, 1932.

(3) See, for instance, the figures given for Berlin on page 142, Volume I, of International Studies on the Relation Between the Private and Official Practice of Medicine by Sir Arthur Newsholme.