WHO: Excessive Dilatation May Affect Later PregnancySource: Family Planning Perspectives, Vol. 9, No. 3 (Jun., 1977), pp. 134-135Published by: Guttmacher InstituteStable URL: http://www.jstor.org/stable/2134525 .

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DK3EST While these data certainly reflect the

changing life-styles and attitudes about children in U.S. culture, they must be viewed with some caution. In a paper presented at the 1977 annual meeting of the Population Association of America, Princeton demographers Charles F. Westoff and Norman B. Ryder stated that they "are skeptical of the predictive va- lidity of reproductive intentions."2 In the 1975 National Fertility Study (NFS) of which they are codirectors, 2,361 women surveyed in the 1970 NFS were reinterviewed. All were white women of reproductive age in intact first marriages.

The investigators found that although 40.5 percent of the women interviewed in 1970 said they planned to have more children, only 34.0 percent actually had more. "In other words," the authors ob- served, "had intentions been taken at face value, . . . the result would have been an overshooting of the outcome by some 16 percent." The authors noted, however, that their data showed "a much stronger disposition to change positive intentions [toward future childbearing] downward than to change negative in- tentions upward." Thus, while more than three in 10 women who had planned to have another child had not

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done so five years later, only slightly more than one in 10 women who had planned not to have a child had given birth in that period.

'Ideal' Number of Children

A 1977 Gallup poll of a representative sample of the U.S. population also re- flects the trend toward smaller families in the country.3 Only 13 percent of re- spondents said that four or more chil- dren is their "ideal" family size, com- pared to 41 percent as recently as 1968.

Seventy-two percent of those inter- viewed said that they consider two or three children ideal, while only two per- cent indicated one child and another two percent said they wanted no children. (Eleven percent of those questioned had no opinion on this subject.)

'While it is still true in the United States that Roman Catholics prefer large families (four or more children) more of- ten than do Protestants, the relative de- cline in this preference since 1968 has been greater among Catholics (31 per- centage points compared to 24 percent- age points). As in 1968, the proportion of the total sample polled preferring small families increased with education and decreased with age. In both years, some- what more women than men said large families are ideal.

An international poll conducted by the Gallup organization in 300 localities in 1977 shows that the popularity of large families varies widely among regions.4

In Western Europe, large families are even less popular than in North America (see Table 1). Only one in 10 people in Western Europe consider four or more children ideal, compared to almost two in 10 North Americans.

In the Far East, three in 10 people prefer large families, as do four in 10

Table 1. Percent of persons polled world- wide who believe four or more children to be the ideal number of children per family, by geographic area, 1977*

Geographic area Percent Western Europe 10 North America

(Canada and the U.S.) 18 Far East 30 Latin America 39 Africa 79 *The percents are based on interviews with 1,591 adults aged 18 and older in 300 localities during the pe- riod Feb. 18-21. Source: See reference 3.

Latin Americans. Twice as large a pro- portion of Africans, eight in 10, prefer four or more children.

While future fertility cannot be pre- dicted from these data, they do corre- spond to current fertility levels: The lower the birthrate, the lower the popu- larity of large families. According to the Population Reference Bureau, the birth- rates in the areas polled are: Western Eu- rope, 13 per 1,000 population; North America, 15; Asia, 33; Latin America, 37; and Africa, 46.5

References

1. U. S. Bureau of the Census, "Prospects for Ameri- can Fertility: June 1976 (Advance Report)," Current Population Reports, Series P-20, No. 300, 1976. 2. C. F. Westoff and N. B. Ryder, "The Predictive Validity of Reproductive Intentions," paper present- ed at the annual meeting of the Population Associa- tion of America, St. Louis, Apr. 21-23, 1977. 3. G. Gallup, "Big Families Out of Style in U.S. and Europe," news release, The Gallup Poll, Princeton, N.J., Mar. 24, 1977. 4. Ibid.

5. Population Reference Bureau, " 1976 World Popu- lation Data Sheet," Washington, D.C., 1976.

WHO: Excessive Dilatation May Affect Later Pregnancy Preliminary data from an eight-country collaborative study coordinated by the World Health Organization (WHO) sug- gest that there may be an association be- tween induced abortion and the outcome of subsequent pregnancy.'

The preliminary data point to an in- creased risk of spontaneous abortion, "attributable probably mainly to D&C [dilatation and curettage], particularly associated with [cervical] dilatation of greater than 12 mm," as well as to a rela- tively short interval between the in- duced abortion and subsequent concep- tion. There is also a suggestion of an in- creased risk of bearing a low-weight in- fant. However, both of these associa- tions are also affected by smoking, a "major factor affecting birth weight, the effect possibly being so great as to over- shadow the effect of abortion." These observations were reported by Mark Bel- sey, a WHO medical officer, at a recent conference on the risks and benefits of contraception sponsored by the Program for Applied Research on Fertility Regu- lation (PARFR).

The WHO Task Force on Sequelae of Abortion is collecting data from a variety

134 Family Planning Perspectives

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of institutions, including maternal health centers, antenatal clinics and hos- pitals, in eight countries where abortion is legal: Denmark, Finland, Hungary, Poland, South Korea, Sweden, the Unit- ed Kingdom and Yugoslavia.

The study participants were recruited from among pregnant women making their first visit to a participating health institution for prenatal care. Those who agreed to join were questioned about their age, education, occupation (and that of their partner), marital status and medical and reproductive history, in- cluding abortion. Women who reported having had an induced abortion in the last pregnancy were compared with women who had not had one in the last pregnancy on the basis of age (within five-year age groups), social status and parity. Women who had had multiple births or who had diabetes were exclud- ed from the study, since these factors are known to influence pregnancy outcome. Also excluded were women who did not know the date of their last menstrual pe- riod. As of March 1976, more than 30,000 women had entered the study; about 1,200 reported having obtained an abortion in the last pregnancy.

Findings

While the data suggest an association be- tween induced abortion and unfavorable outcome in subsequent pregnancies, Belsey stressed that the data are only preliminary and that further analysis is necessary to control for other contribut- ing factors, since the study groups and the abortion procedures vary greatly. For example, he noted, the proportion of women in the European centers who smoked ranged from 13 to 48 percent; al- most none of the women in the Korean group smoked. (The differences between the European and Korean centers are of such magnitude, he explained, that un- der no circumstances have their data been pooled.) Smoking, education, occu- pational status and the planning status of the pregnancy all appear to affect the pregnancy outcome, the investigators found.

In some of the European groups stud- ied, Belsey pointed out, there was no significant difference in pregnancy out- come between women who had had abortions and women who had not; while in other groups, significant differ- ences were found. This variation may be due to the abortion procedures em-

ployed, he explained. In Copenhagen, for example, rates of spontaneous abor- tion were similar for the abortion and control groups, whereas in Stockholm, women who had had an induced abor- tion had a significantly higher rate of spontaneous abortion than the control group. Smoking did not appear to be the crucial factor, since the prevalesnce of smoking was similar in the two centers. However, there was a great difference in the procedures which had been used to terminate pregnancy. Eighty percent of the abortions reported by the women in Copenhagen had been performed in the first trimester by suction, compared to only one-third of the abortions reported by the women in Stockholm. Another third of the abortions reported by the Stockholm women had been first-trimes- ter procedures performed by D&C, and the remaining third had been second- trimester procedures.

Pooling the data from the European centers, the investigators found that the rate of spontaneous abortion was more than twice as high for women who had had an abortion by D&C (8.2 percent) as for women who had had an abortion by suction (3.3 percent). From this they "hypothesize that the extent of cervical dilatation relates to the risk of an adverse outcome [in a later pregnancy]." A dila- tation of the cervix of more than 12 mm, they believe, poses the greatest risk.

In the Korean group, a history of in- duced abortion did not increase the risk of adverse pregnancy outcome. The in- vestigators suggest that the reason for this may be that the proportion of nul- liparous women who reported having had an abortion was much lower than in the European samples. In the pooled European data, about one-half of women whose last pregnancies were terminated by induced abortion were nulliparous.

Interval and Smoking

A short interval between induced abor- tion and the next conception also ap- peared to increase the risk of spontane- ous abortion. Among European women who had had an induced abortion less than 27 weeks before conceiving again, the proportion who had a spontaneous abortion (7.3 percent) was more than twice as great as the proportion among women who conceived 27 or more weeks after their induced abortion (3.3 per- cent).

Smoking, the authors believe, may

have "a stronger association than abor- tion with lower birth weight [lower than 2,500 grams] and shortened gestation." Among the European women, not only did those who smoked have higher rates of these unfavorable pregnancy out- comes than nonsmokers, but for smok- ers, a history of induced abortion had only a barely significant (and, in some centers, no significant) effect.

Previous Conflicting Reports

The WHO study was instituted after conflicting reports on the effects of abor- tion on future fertility appeared in the literature. In an analysis of these reports presented at the PARFR conference, Carol Hogue of the University of North Carolina points out that the designs of many of the studies were flawed, and that some of the reports of unfavorable effects came from countries where abor- tion was illegal.2 From this she con- cludes that the "evidence [published] to date does not meet the criteria for estab- lishing causal linkages between preg- nancy termination and . . . subsequent fertility complications." The final results of the WHO study, which should be- come available by the end of the year, may provide the needed data.

References

1. WHO Task Force on the Sequelae of Abortion, "The Association of Induced Abortion with Adverse Outcome in the. Subsequent Pregnancy," paper pre- sented at the "Workshop on Risks, Benefits and Con- troversies in Fertility Control," sponsored by the Program for Applied Research on Fertility Regula- tion, Arlington, Va., Mar. 13-16, 1977; and M. A. Belsey, personal communication, Mar. and Apr. 1977.

2. C. J. R. Hogue, "Review of Postulated Fertility Complications Subsequent to Pregnancy Termina- tion," paper presented at the "Workshop on Risks, Benefits and Controversies in Fertility Control," Mar. 13-16, 1977.

In United States, No Large Fertility Increase Is Likely A substantial increase in fertility in the United States is unlikely during the next few years, even if young married women have all the children that they say they expect to have; this seems especially probable in the face of continuing ad- verse economic conditions, according to Campbell Gibson, chief of the Cen- sus Bureau's Population Projections Branch.l Publishing in Science, Gibson disputes the forecast made in the same

Volume 9, Number 3, May/June 1977 135

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