Categories
Medical Public Health Reproductive Health Women's Issues

Update on Abortion

Many years ago I worked for three weeks in Swaziland, South Africa. A memory still haunts me.

Most mornings we saw one or two young women through the emergency ward. Almost all of these women were from surrounding communities, were “visiting an auntie” and they hadn’t eaten breakfast. All were carrying early pregnancies and reported bleeding. Indeed, on examination there was blood and the cervix had started to open.

Bleeding and cervical dilatation in pregnancy usually ends up as a miscarriage, and can lead to a serious infection unless a D&C is done to empty the uterus.

Another doctor told me this pattern had been happening for a long time. We surmised that some doctor in this city was using instruments to make it appear that these patients were about to miscarry. It would be easy to instrument the cervix, tell the young woman to go to our hospital in the morning—and to skip breakfast. “I hope all goes well tomorrow at the hospital. And have your boyfriend wear a condom next time,” I can imagine that doctor saying.

In Swaziland abortion is only legal to save a woman’s life. The physician who opened the cervix was taking a big risk, allowing him to charge an outrageous fee.

Don’t laws that prohibit abortion decrease its frequency? No, apparently not. Norway, known for its excellent medical statistics, found that the incidence of abortion did not rise when it was legalized in 1978. This finding was borne out by a recent article in the world’s premier medical journal, Lancet.

The study looked at all the world’s countries. 84 have liberal abortion laws; the remaining nations (like Swaziland) prohibit abortion, with few or no exceptions.

Outlawing abortion does not prevent women from terminating unwanted pregnancies. Where it is illegal, however, women are subjected to unsafe procedures and risk their health and very lives. Surprisingly, this study found the incidence of abortion is higher in places where it is outlawed. This may be because these are also places where women are not esteemed, and where contraception is difficult to obtain.

Wherever laws permit safe abortion, two observations are made. Maternal mortality from unsafe abortions decreases drastically, and women are treated with more respect.

More surprises are to be found in another research paper from England. It is an exacting review of the psychological effects of abortion. Although many studies in this field are of poor quality, the researchers found 44 high quality studies.

To reduce the possibility of bias and to ensure transparency, the reviewers sent out a request for comments. Several anti-abortion (as well as pro-choice) organizations responded, and their comments influenced the final report.

The questions the multi-faceted panel of experts set out to answer are: How prevalent are mental health problems in women who have an induced abortion? What factors cause poor mental health outcomes after an abortion? Are mental health problems more common in women who have an abortion compared with women who deliver an unwanted baby?

The report’s findings are summarized:

•            Unwanted pregnancies are associated with an increased risk of mental health problems, and the rate of problems is the same whether women had an abortion or gave birth.

•            The most reliable predictor of post-abortion mental health problems was having a history of mental health problems before the abortion.

•            There are additional factors associated with an increased risk of mental health problems specifically related to abortion, such as pressure from a partner to have an abortion and negative attitudes towards abortions in general.

The study recommends:

“…it is important to consider the need for support and care for all women who have an unwanted pregnancy because the risk of mental health problems increases whatever the pregnancy outcome. If a woman has a negative attitude towards abortion, shows a negative emotional reaction to the abortion or is experiencing stressful life events, health and social care professionals should consider offering support, and where necessary treatment, because they are more likely than other women who have an abortion to develop mental health problems.”

We are lucky in La Plata County to have wonderful assistance for women carrying unintended pregnancies. The Pregnancy Center supports women who plan to deliver, while Planned Parenthood provides access to safe, compassionate abortions. I am concerned, however, that the people who demonstrate outside Planned Parenthood may not provide accurate information to women who are considering abortion. The demonstrators may have a negative influence on those women who are at risk for mental health problems.

© Richard Grossman MD, 2012

Categories
Carrying Capacity Environment Global Conflict Population

Realize the Tragedy of Demographic Entrapment

Last month’s column was on the “tragedy of the commons”—when people use more than their share of a common resource, leading to the resource’s destruction. An example is overgrazed fields, where unpalatable weeds replace nourishing plants. Overgrazing is a disaster for shortsighted ranchers, because depleted fields can support very few animals.

Can a similar calamity happen to humans?

Yes, that is exactly what devastated Somalia recently. That country in the Horn of Africa is generally arid, and rainfall has been made scarcer by climate change. Human actions make the situation even worse, because cutting firewood leads to deforestation that reduces rainfall.

During the region’s frequent droughts, food production drops below what is necessary for human survival. Tens of thousands died in Somalia during 2011 from starvation.

Unstable politics in Somalia make the situation much worse. Gangs victimize the poor, robbing them of what little food they have. The Somali government is too weak to enforce any sort of rule of law.

Can we help by sending food? That sounds like the compassionate thing to do, but there is a hitch. Food aid arrives at distribution centers in cities so hungry people must leave their land to collect food. Their fields are abandoned and crops die. With no reason to return to their fields, these destitute people are forced into a cash economy. When the short-term food aid ceases these now landless peasants are caught with no money, no skills to make money, and (once again) no food.

This sad situation is made worse by the rapid growth rate of Somalia. Its Total Fertility Rate is 6.4—the average woman will bear more than six children. Only one country in the world has a higher TFR! In a wet year the harvest is good enough to feed all mouths, but not when the monsoon rains don’t come.

But, you might say, what about countries that far exceed their human population carrying capacity? For example the island of Singapore has the world’s highest population density and little land to grow food. Singapore imports its food, paying with money from manufacture and trade.

There are historical examples of human populations that outgrew the land’s ability to support them. I am part Irish, and suspect that my ancestors came to the USA to escape the Great Potato Famine in the mid 19th century. Ireland had become dependent on a single crop—potatoes—for most of its sustenance. This New World tuber allowed the population of Ireland to expand significantly—until a crop failure (from potato blight) caused an estimated million people to starve to death. Another, luckier million were able to emigrate from Ireland—many to the USA.

“Demographic entrapment” is the term applied to human overuse of their land’s carrying capacity. Dr. Maurice King, a British physician who has spent many years working in Africa, has tried to warn people about this tragedy.

Demographic entrapment occurs when a country has a population larger than its carrying capacity, when the country exports too little to be able to import food and when emigration is impossible. Dr. King suspects that much of sub-Saharan Africa will become entrapped soon.

An example of entrapment occurred in Rwanda in 1994. The genocide is generally blamed on tribal conflict, but starvation may have been the real reason. James Gasana, a former Minister in the Rwandan government, has excellent support for this theory. He found that, before genocide, ethnic strife was most likely to happen in areas where people were famished. Violence only occurred where people consumed less than 1500 calories each day. For comparison, the average person in the USA eats more than 2500 calories daily.

“Collapse”, Jared Diamond’s book, gives other examples of societies that outgrew their resources—the Romans, Mayas and Ancestral Puebloans. An intriguing video of Collapse can be found on YouTube in seven parts.

What is the best way to prevent demographic entrapment? There are very few under-populated countries, so massive emigration is unlikely. The poor countries of Africa are unable to compete on the world market, so exports cannot save them. The best way to head off violence similar to Rwanda’s is with small families.

Dr. King has not made friends by publicizing the concept of demographic entrapment. It is so frightening that many people are not willing to contemplate it. To ignore demographic entrapment, however, will not solve the problem. Sticking our heads in the sand could have tragic consequences, sentencing millions of people to death by starvation or by violence.

© Richard Grossman MD, 2012