Abortion is mentioned in ancient medical texts but the effectiveness of the methods described is doubtful. Attitudes varied from apparent disapproval by Hippocrates to open approval in Ancient Rome. In mediaeval times abortion was practised by women in secret and this continued during the 19th and early 20th centuries. Despite being illegal in England induced abortion became more common in Victorian times as the population grew. At the same time the link between criminal abortion and maternal mortality became increasingly clear, and if a woman died after a procedure the abortionist (sometimes a midwife) could be sentenced to death. The law was more tolerant of abortions performed by registered doctors. In the 20th century pressure grew for its legalisation. At the time of the 1967 Abortion Act, abortion was the leading cause of maternal death in the UK but within fifteen years death from illegal abortion had been abolished.
Although induction of abortion has been practised for millennia, accurate information is scanty until the 19th and 20th centuries. This chapter summarises what can be gleaned from older sources and then traces the story in more detail from 1800 onwards, when major changes were taking place in society. It focuses mainly on the UK, where the Lancet was founded in 1823 and the predecessor of the BMJ first appeared in 1840. Both archives have recently been placed on line and these primary sources give graphic accounts of the death toll of criminal abortion and the debate about what should be done about it.
Pre-modern history
Medical methods were used to induce abortion in ancient times but their effectiveness is doubtful. The Ebers papyrus, from Egypt around 1550 BC, includes remedies for a wide range of disorders and recommends honey and crushed dates, introduced vaginally, to end pregnancy. Methods in Chinese texts appear to have involved the use of herbs (again, of doubtful effectiveness) or mercury, which would have been toxic to the woman. In ancient Greece, Plato (428–348 BC) refers to abortion but is vague about the methods used:
“The midwives, by means of drugs and incantations, are able to arouse the pangs of labour and, if they wish, to make them milder, and to cause to bear those who have difficulty in bearing, and they cause abortions at an early stage if they think them desirable.”
Spontaneous miscarriage occurs in about 1 in 6 pregnancies – a high enough proportion to convince women and midwives of the effectiveness of an abortifacient drug or incantation.
The Greek physicians Hippocrates (c 460–370 BC) and Soranus (2nd century AD) taught that physical exercise could cause abortion. Other methods included massage of the uterus or wearing a tight belt, and Soranus advised diuretics, enemas and venesection. In a review of contraception in Ancient Rome, Hopkins consulted 26 medical writers of whom 15 (including Hippocrates) gave methods for abortion. Plants with alleged abortifacient properties included silphium, which was harvested to extinction in Roman times, and hellebore (“Christmas rose”), an ingredient of so-called “abortion wine”. Hellebore has poisonous constituents and can cause death.
There is little evidence of surgical abortion but Soranus’ advice against using sharp instruments suggests that the practice had at least been tried. Tertullian of Carthage states that among surgeons’ tools were an annular blade and a hook for extracting the fetus. “Such apparatus,” he says, “was possessed by Hippocrates .. and even the milder Soranus himself” but they sound more like instruments for treating obstructed labour by extracting the fetus “when lying awry in the orifice of the womb he impedes parturition and kills his mother”. Instructions for instrumental abortion are contained in Persian texts of the 10 th century.
Attitudes to abortion varied. Aristotle wrote that it should be carried out before “sense and life have begun in the embryo” – ie. before quickening (fetal movement) is felt. The ancient Greeks worried that limiting family size would endanger population growth. The Hippocratic Oath appears to oppose abortion, though some argue that it refers to only one specific method. In the early Roman empire the population declined despite an apparently ample food supply, suggesting a highly effective method of fertility control. This decline was restricted to upper-class Romans, according to Hopkins, who concluded that they used effective and ineffective contraceptives in addition to “the unashamed practice of abortion” and perhaps also infanticide
During the Dark Ages the status of women declined and contraception and abortion were contained within a women’s culture. Midwives providing such services were periodically persecuted as “witches”. After the Renaissance, the medical profession in Western Europe became entirely male-dominated and women were excluded from universities. The University of Paris barred women from medicine in 1220, and the University of Cambridge, founded in 1209, did not award degrees to women until 1947.
The secrecy surrounding abortion continued until the modern era. Because of the secrecy, the cost and the ineffectiveness of abortifacients, an unmarried woman might try to keep her pregnancy secret and dispose of the baby. Pregnancy concealment was against the law:
“In the sixteenth century every unmarried woman concealing her pregnancy even, was guilty of felony, and in the reign of James the First an Act was passed by which the jury were obliged to convict on presumptive evidence. This Act continued in force for nearly ninety years. In 1809, the concealment of pregnancy was declared to be merely a misdemeanour, punishable with imprisonment not exceeding two years; and the same proofs as in charges of ordinary homicide were declared to be necessary to convict a woman of child murder.”
Maternal mortality
Little is known about maternal mortality rates (MMR) before the 19 th century. Irvine Loudon, in his classic book “Death in childbirth” gives estimates for 17th century England. In rural parishes the MMR, using the modern denominator “per 100,000 births” ranged from 1250 to 2940, and in London it was 2100. These figures are similar to the MMRs in modern-day Afghanistan or Sierra Leone. They improved to around 800 by the end of the 18th century, which Loudon attributes to the increasing skill of midwives, as obstetricians were still relatively few. Even with this high MMR, maternal mortality accounted for only 20% of all deaths among women aged 25–34.
The 19 th century
Enormous social changes began in the 19th century and abortion increased rapidly in Europe and America. The evidence for this is clear and the reasons are not hard to find.
Demographic change
The need for couples to control their fertility is influenced by their social conditions. As the industrial revolution continued in Victorian times, the population of England increased from 6 million in 1750 to 33 million in 1901. People moved to the cities where housing conditions for many were appalling. The population of Manchester grew from under 330,000 in 1801 to over 2,350,000 in 1901. Large families were the norm for much of the century but this began to change. In 1871 the average woman had 5.5 children but by 1921 this had fallen to 2.4 children. According to a recent review, “whereas previously, delayed marriage and non-marriage were the only factors reducing the number of children borne by each woman, by the late 19th and early 20th centuries the use of traditional methods of birth control (abstinence and withdrawal) within marriage had become more widespread.”
In France the decline in family size had begun almost 100 years earlier and this too is generally attributed to contraception (initially in the form of coitus interruptus). Abortion is believed to have played a large part in the latter part of the 19th century in France and it is now obvious that the same is true in England.
Legal changes
It is commonly stated that abortion became illegal in England in 1803, but the Act of that year simply extended the law to cover surgical as well as medical abortion.
“Formerly .. the crime of foeticide was capital only when drugs were administered to effect it; but by an Act of Parliament brought in by Lord Ellenborough in 1803, the obtaining of criminal abortion by any means is felony. The Act states, “That if any person shall wilfully administer, or cause to be administered, any medicine, drug, or any other substance whatever, or use, or cause to be used or employed, any instrument, with intent to procure the miscarriage of any woman not being, or not being proved to be, quick with child, at the time of committing such thing, or causing such means, then, and in every such case, the person so offending, their counsellors, aiders, and abetters, shall be and are declared guilty of felony, and shall be liable to be fined, imprisoned, set in and upon the pillory, public or privately whipped, or transported beyond the sea for any term not exceeding fourteen years. … The same Act ordains, that administering medicine, drugs, etc, etc, with the intent to procure abortion after quickening , shall be punished with death.”
Reference to the use of instruments suggests that surgical abortion was already being practised in 1803, even though Recamier’s curette and Hegar’s dilators were not introduced into gynaecological practice until much later.
In 1837, Section 58 of the Offences Against the Person Act removed the distinction between pre- and post-quickening abortions and replaced the death penalty with life imprisonment for abortion at any stage of pregnancy. This applied to anyone procuring abortion, including the woman herself. In 1861 the Act was modified by adding the words “whether she be or be not with child”. Thus the intention to procure an abortion became a crime. This law is still in force today, amended by the Abortion Act of 1967. In the USA in the mid-19th century each state had its own statutes, which were inconsistent.
Prevalence of abortion
Although Elizabeth Gaskell (1810-1865) shocked her readers with stories about the seduction, prostitution and suicide of “fallen women” such as “Ruth, “Mary Barton” and “Lizzy Leigh”, abortion was never mentioned. Nonetheless this option was available, as Mrs Gaskell probably knew. In 1831 the Lancet reported a case from Paris in which a woman, pregnant with her fifth child, had injected sulphuric acid into her vagina on the advice of a female neighbour. The pregnancy went to term but with the vagina obliterated, caesarean section was attempted and mother and baby died. In 1843 a patient aged 17 almost died after abortion at around 24 weeks produced by “pills of unknown composition”. She was saved, according to the report, by treatment with mercury, opium and venesection. The father of the pregnancy, who had supplied the pills, was sentenced to 15 years’ transportation. The journal commented:
“The newspapers have been unusually full of late of cases in which the attempt to produce criminal abortion has come under the cognizance of the legal authorities, in consequence of the injurious or fatal consequences to the unhappy females involved; but we cannot help thinking, both from our own experience and from that of many of our professional friends, that the number of instances in which this crime is perpetrated successfully, and without detection, is out of all proportion to the comparatively small number of cases that are found out and punished.”
Some doctors believed that abortifacients were poisons that were as likely to kill the mother as to end the pregnancy, but the journal suggested that in skilled hands they often worked well:
“We have heard of a French hag, living somewhere near Marylebone Lane, who enjoys no small share of fame for her success, the means which she employs consisting in the daily administration of the oils of pennyroyal and savine, with a violent cathartic at intervals of two or three days.”
Indeed, it asserted that many a young girl requested abortion “with as much coolness and naivete as if she wished to be relieved of a troublesome tooth”, but it concluded:
“The opinion that the fetus, for the first two or three months, is an insensate vegetable mass, but that it becomes quick at a definite period, was once held true in medicine, and adopted as the principle of legislation, and, although discarded, it still lingers, like a threadbare garment, amongst the lower orders of society; and it serves, perhaps, to quiet the scruples of some few of the less hardened offenders.”
In 1844, a report of the trial of a medical practitioner for procuring abortion listed fatalities resulting from the use of either savin or ergot of rye and counselled against the use of either medication.
In 1852 the French Academy debated the differences between criminal abortion and abortion induced under medical supervision. Medical indications included pelvic deformity so severe as to make the death of the mother inevitable if the pregnancy went to term, the mortality of Caesarean section being “frightful” at that time. Nevertheless, some doctors argued from moral and religious principles that abortion was still murder, and that the parents of deformed girls should not allow them to marry.
At this time it was hard to tell who was a properly qualified doctor. Death after surgical abortion by “a quack” was reported in 1850 and a prosecution for surgical abortion by “two persons calling themselves surgeons” in 1853 reinforced pleas for a medical register. This was established in 1858, but it did not stop criminal abortion by unqualified men. In 1869 the Lancet records a conviction after a non-medical “abortion-monger ..passed some instrument into the uterus” and in 1885 a Mr Sprow was convicted of procuring abortion: his “terms were £15 a year for any number of operations required to keep a married woman free from children”.
In 1869 an address to the British Medical Association described the frequency of abortion in the USA, where abortifacients were openly advertised, and gave anecdotal but convincing evidence that abortions were easily obtained in England. Infanticide, said the speaker, was also common, with “mill-ponds, in the neighbourhood of factories, that have been made the receptacles for many a new born child”. He suggested that the remedy was “Foundling Hospitals supported by the State.” The frequency of infanticide had been noted thirty years earlier: “bodies of infants are often found in parts of dwelling houses, not unfrequently in privies, or in gardens adjoining houses”. One problem was that there was no legal requirement to register a stillbirth, and in 1873 a deputation from the BMA lobbied for this, asserting that “children killed during birth and after birth are doubtless buried as still-born.” It cited a case “at Plymouth, where one midwife appeared at a cemetery so constantly with the bodies of children for burial as still-born, that suspicion was excited.”
In 1896 a correspondent to the BMJ complained that “no attempt seems to be made to inquire into cases not fatal to the mother.” If the woman died, however, the charge was murder, and in the same year a midwife was sentenced to death for procuring abortion. Suspicion about midwives was given as the reason for the BMA’s opposition to their education and registration. In 1895 a deputation to the General Medical Council (GMC) stated:
“whilst a few years ago … all the practice which tended towards the production of Abortion was written in Latin, it is now customary to teach pupil midwives .. the symptoms and treatment of abortion and miscarriage … this practice is unsound and directly leads to the practice of Criminal Abortion.”
The GMC commented that “the word ‘midwife’ seemed to produce on some members of the Council a somewhat similar feeling to that which a red rag was said to produce on a bull” and the Midwives Act was finally passed in 1902. Stillbirth registration, however, was not introduced in England and Wales until 1927.
Maternal mortality
Registration of maternal deaths began in England and Wales in 1837 but information on the cause of death was unreliable until 1874, when the Births and Deaths Registration Act required the cause of death to be certified by a doctor. During the 19 th century the overall MMR fluctuated considerably, reaching a peak of 693/100,000 in 1874, but was rarely lower than 400/100,000, which means 1 death in 250 pregnancies. An average family size of 5.5 children meant that 1 woman in 45 died as a result of pregnancy.
About 50% of maternal deaths were from puerperal sepsis, usually due to the streptococcus. There was no improvement after the introduction of antisepsis and asepsis, because of asymptomatic carriage of streptococci. Until 1934 the duration of pregnancy was not specified at registration, so “sepsis” included deaths from septic abortion as well as puerperal sepsis. The contribution of abortion to the total MMR is therefore impossible to quantify accurately.
However, the mortality rate of abortion may not have been very high. In 1902 a Dr Blondel of Paris reported 100 cases without a fatality. Of these, 52 had been purposely procured – by a midwife in 22 cases and by the patient herself in 19. The midwife had either passed a sound into the uterus or a gum-elastic catheter through which fluid was injected – “eau d’argent” or the more expensive “eau d’or”. In two cases a patient had used a knitting needle on herself: each already had a prolapse and Dr Blondel believed that without prolapse such self-instrumentation was impossible.
The 19 th century
Enormous social changes began in the 19th century and abortion increased rapidly in Europe and America. The evidence for this is clear and the reasons are not hard to find.
Demographic change
The need for couples to control their fertility is influenced by their social conditions. As the industrial revolution continued in Victorian times, the population of England increased from 6 million in 1750 to 33 million in 1901. People moved to the cities where housing conditions for many were appalling. The population of Manchester grew from under 330,000 in 1801 to over 2,350,000 in 1901. Large families were the norm for much of the century but this began to change. In 1871 the average woman had 5.5 children but by 1921 this had fallen to 2.4 children. According to a recent review, “whereas previously, delayed marriage and non-marriage were the only factors reducing the number of children borne by each woman, by the late 19th and early 20th centuries the use of traditional methods of birth control (abstinence and withdrawal) within marriage had become more widespread.”
In France the decline in family size had begun almost 100 years earlier and this too is generally attributed to contraception (initially in the form of coitus interruptus). Abortion is believed to have played a large part in the latter part of the 19th century in France and it is now obvious that the same is true in England.
Legal changes
It is commonly stated that abortion became illegal in England in 1803, but the Act of that year simply extended the law to cover surgical as well as medical abortion.
“Formerly .. the crime of foeticide was capital only when drugs were administered to effect it; but by an Act of Parliament brought in by Lord Ellenborough in 1803, the obtaining of criminal abortion by any means is felony. The Act states, “That if any person shall wilfully administer, or cause to be administered, any medicine, drug, or any other substance whatever, or use, or cause to be used or employed, any instrument, with intent to procure the miscarriage of any woman not being, or not being proved to be, quick with child, at the time of committing such thing, or causing such means, then, and in every such case, the person so offending, their counsellors, aiders, and abetters, shall be and are declared guilty of felony, and shall be liable to be fined, imprisoned, set in and upon the pillory, public or privately whipped, or transported beyond the sea for any term not exceeding fourteen years. … The same Act ordains, that administering medicine, drugs, etc, etc, with the intent to procure abortion after quickening , shall be punished with death.”
Reference to the use of instruments suggests that surgical abortion was already being practised in 1803, even though Recamier’s curette and Hegar’s dilators were not introduced into gynaecological practice until much later.
In 1837, Section 58 of the Offences Against the Person Act removed the distinction between pre- and post-quickening abortions and replaced the death penalty with life imprisonment for abortion at any stage of pregnancy. This applied to anyone procuring abortion, including the woman herself. In 1861 the Act was modified by adding the words “whether she be or be not with child”. Thus the intention to procure an abortion became a crime. This law is still in force today, amended by the Abortion Act of 1967. In the USA in the mid-19th century each state had its own statutes, which were inconsistent.
Prevalence of abortion
Although Elizabeth Gaskell (1810-1865) shocked her readers with stories about the seduction, prostitution and suicide of “fallen women” such as “Ruth, “Mary Barton” and “Lizzy Leigh”, abortion was never mentioned. Nonetheless this option was available, as Mrs Gaskell probably knew. In 1831 the Lancet reported a case from Paris in which a woman, pregnant with her fifth child, had injected sulphuric acid into her vagina on the advice of a female neighbour. The pregnancy went to term but with the vagina obliterated, caesarean section was attempted and mother and baby died. In 1843 a patient aged 17 almost died after abortion at around 24 weeks produced by “pills of unknown composition”. She was saved, according to the report, by treatment with mercury, opium and venesection. The father of the pregnancy, who had supplied the pills, was sentenced to 15 years’ transportation. The journal commented:
“The newspapers have been unusually full of late of cases in which the attempt to produce criminal abortion has come under the cognizance of the legal authorities, in consequence of the injurious or fatal consequences to the unhappy females involved; but we cannot help thinking, both from our own experience and from that of many of our professional friends, that the number of instances in which this crime is perpetrated successfully, and without detection, is out of all proportion to the comparatively small number of cases that are found out and punished.”
Some doctors believed that abortifacients were poisons that were as likely to kill the mother as to end the pregnancy, but the journal suggested that in skilled hands they often worked well:
“We have heard of a French hag, living somewhere near Marylebone Lane, who enjoys no small share of fame for her success, the means which she employs consisting in the daily administration of the oils of pennyroyal and savine, with a violent cathartic at intervals of two or three days.”
Indeed, it asserted that many a young girl requested abortion “with as much coolness and naivete as if she wished to be relieved of a troublesome tooth”, but it concluded:
“The opinion that the fetus, for the first two or three months, is an insensate vegetable mass, but that it becomes quick at a definite period, was once held true in medicine, and adopted as the principle of legislation, and, although discarded, it still lingers, like a threadbare garment, amongst the lower orders of society; and it serves, perhaps, to quiet the scruples of some few of the less hardened offenders.”
In 1844, a report of the trial of a medical practitioner for procuring abortion listed fatalities resulting from the use of either savin or ergot of rye and counselled against the use of either medication.
In 1852 the French Academy debated the differences between criminal abortion and abortion induced under medical supervision. Medical indications included pelvic deformity so severe as to make the death of the mother inevitable if the pregnancy went to term, the mortality of Caesarean section being “frightful” at that time. Nevertheless, some doctors argued from moral and religious principles that abortion was still murder, and that the parents of deformed girls should not allow them to marry.
At this time it was hard to tell who was a properly qualified doctor. Death after surgical abortion by “a quack” was reported in 1850 and a prosecution for surgical abortion by “two persons calling themselves surgeons” in 1853 reinforced pleas for a medical register. This was established in 1858, but it did not stop criminal abortion by unqualified men. In 1869 the Lancet records a conviction after a non-medical “abortion-monger ..passed some instrument into the uterus” and in 1885 a Mr Sprow was convicted of procuring abortion: his “terms were £15 a year for any number of operations required to keep a married woman free from children”.
In 1869 an address to the British Medical Association described the frequency of abortion in the USA, where abortifacients were openly advertised, and gave anecdotal but convincing evidence that abortions were easily obtained in England. Infanticide, said the speaker, was also common, with “mill-ponds, in the neighbourhood of factories, that have been made the receptacles for many a new born child”. He suggested that the remedy was “Foundling Hospitals supported by the State.” The frequency of infanticide had been noted thirty years earlier: “bodies of infants are often found in parts of dwelling houses, not unfrequently in privies, or in gardens adjoining houses”. One problem was that there was no legal requirement to register a stillbirth, and in 1873 a deputation from the BMA lobbied for this, asserting that “children killed during birth and after birth are doubtless buried as still-born.” It cited a case “at Plymouth, where one midwife appeared at a cemetery so constantly with the bodies of children for burial as still-born, that suspicion was excited.”
In 1896 a correspondent to the BMJ complained that “no attempt seems to be made to inquire into cases not fatal to the mother.” If the woman died, however, the charge was murder, and in the same year a midwife was sentenced to death for procuring abortion. Suspicion about midwives was given as the reason for the BMA’s opposition to their education and registration. In 1895 a deputation to the General Medical Council (GMC) stated:
“whilst a few years ago … all the practice which tended towards the production of Abortion was written in Latin, it is now customary to teach pupil midwives .. the symptoms and treatment of abortion and miscarriage … this practice is unsound and directly leads to the practice of Criminal Abortion.”
The GMC commented that “the word ‘midwife’ seemed to produce on some members of the Council a somewhat similar feeling to that which a red rag was said to produce on a bull” and the Midwives Act was finally passed in 1902. Stillbirth registration, however, was not introduced in England and Wales until 1927.
Maternal mortality
Registration of maternal deaths began in England and Wales in 1837 but information on the cause of death was unreliable until 1874, when the Births and Deaths Registration Act required the cause of death to be certified by a doctor. During the 19 th century the overall MMR fluctuated considerably, reaching a peak of 693/100,000 in 1874, but was rarely lower than 400/100,000, which means 1 death in 250 pregnancies. An average family size of 5.5 children meant that 1 woman in 45 died as a result of pregnancy.
About 50% of maternal deaths were from puerperal sepsis, usually due to the streptococcus. There was no improvement after the introduction of antisepsis and asepsis, because of asymptomatic carriage of streptococci. Until 1934 the duration of pregnancy was not specified at registration, so “sepsis” included deaths from septic abortion as well as puerperal sepsis. The contribution of abortion to the total MMR is therefore impossible to quantify accurately.
However, the mortality rate of abortion may not have been very high. In 1902 a Dr Blondel of Paris reported 100 cases without a fatality. Of these, 52 had been purposely procured – by a midwife in 22 cases and by the patient herself in 19. The midwife had either passed a sound into the uterus or a gum-elastic catheter through which fluid was injected – “eau d’argent” or the more expensive “eau d’or”. In two cases a patient had used a knitting needle on herself: each already had a prolapse and Dr Blondel believed that without prolapse such self-instrumentation was impossible.
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