Obstetricians seek recognition for Chinese pioneers of safe abortion

Chinese, Australian, and UK obstetricians have organised the translation of a pioneering research paper on abortion by vacuum aspiration, in an attempt to get recognition for its authors 50 years after it was first published.

The research ultimately led to the technique becoming the world’s commonest and safest obstetric procedure. As a result it has probably been responsible for saving thousands of women’s lives.

The first English translation of the classic paper is published online this week in the news section on bmj.com, in the hope of gaining recognition for the researchers, two Shanghai obstetricians called Yuantai Wu and Xianzhen Wu.

“There can be few, if any, surgical procedures that have alleviated more human suffering, morbidity, and mortality than vacuum aspiration abortion,” said Roger Short, who, with Chinese colleagues, translated the 1958 paper, originally published in the Chinese Journal of Obstetrics and Gynaecology.

Although there is some dispute over whether Drs Wu and Wu were the first to come up with vacuum aspiration abortion, there is no doubt that their paper brought the technique to the world’s attention.

David Paintin, emeritus professor in obstetrics and gynaecology at St Mary’s Hospital, London, and former chairman of the Birth Control Trust, said that the old curettage technique was “quickly abandoned” once clinicians tried suction termination in early pregnancy.

“Prior to suction termination, if you were pregnant and of less than 12 weeks’ gestation, anaesthetic would be administered to the cervix, the cavity stretched, a series of metal rods introduced, and the cervix further stretched up to 12 mm. Using a metal loop, with an edge like a dinner knife [a curette], the doctor would scrape the pregnancy out through the vagina canal.”

But there were flaws, said Professor Paintin. “The disadvantage was that you did not always get a complete abortion. Some product did not come through, so a pair of narrow forceps was inserted into the uterus, which was then opened and turned to take out the rest of the fetal tissue.” Because the uterus is a soft organ, there was danger of puncturing it with the surgical instrument.

“In comparison, with the suction dilation procedure you use a cannula made of flexible plastic and with a blunt tip. You insert for limited distance, and then suction is applied. It is very quick. After curettage technique, suction was so much easier.”

Global spread

Suction termination became established first in China, the Soviet Union, Japan, and Bulgaria, years before the idea reached the West. Professor Paintin said, “The communist regime was very keen to reduce population, so both contraception and abortion were widely used—there was considerable emphasis on women having an abortion.”

Progress temporarily halted at eastern Europe, in part because travel between east and west Europe was far less common, and Western obstetricians were distrustful of evidence from behind the Iron Curtain.

In stark contrast to women living under communism, for UK women in the 1950s an unplanned pregnancy was often a disaster. Professor Paintin explained, “In 1958 [the year the Wu and Wu paper was published] very few women had abortions done by doctors. In the NHS, abortion was limited to a very small number of women whose lives were threatened by their pregnancy.

“Consultants would perform only one or two abortions a year. Women who could afford it would pay a private doctor to perform an abortion. But then, generally speaking, they first had to see a psychiatrist, who would need to say that the pregnancy, if it continued, would threaten the patient’s mental health. But for ordinary women this was not possible. These women had to resort to illegal abortionists, usually non-medically qualified nurses or midwives who had had some contact with that world.”

Dorothea Kerslake, from the department of obstetrics in Newcastle, first introduced the idea of suction termination to the United Kingdom in 1967, publishing a study in the United States that further accelerated the technique’s spread (Obstetrics and Gynecology NY 1967;30:35).

As late as the early 1970s, Roger Short was asked by the Department of Health to go to Yugoslavia from the UK to look at contraception.

“In Skopje, I met a professor of obstetrics, and I asked what was the maximum number of abortions performed on one woman. [He said] about 60. I said, ‘You can’t do 60 on one woman very easily.’ He said yes [you can], using the Chinese aspiration technique.”

Refined technique

The vacuum aspiration technique was refined by the US lay psychiatrist Harvey Karnen, who developed a soft flexible tubing that was small enough to avoid the need for cervical dilatation and pliable so it tended to curl up inside the uterus and prevent damage to its wall or risk perforation, which a rigid instrument might cause. It allowed early abortion to be performed with only local anaesthesia or even none at all. The NHS was influenced by this work and moved on from rigid plastic cannulas.

“Karnen in the early 1970s thought vacuum aspiration was so simple that one woman could get a friend to empty [her] uterus,” said Professor Short. Although such a procedure was illegal on both sides of the Atlantic (and in many other places), such a claim illustrates the value of the Chinese technique in reducing the cost and complications of the procedure—giving poorer women access to safe abortion for the first time.

The technique has allowed humane abortion services to develop, said Professor Short, such as one centre in Bangkok, which performs as many as 150 abortions a day, where every woman gets a fresh orchid on their pillow.

But sadly, Professor Short pointed out, the technique has not travelled right around the globe. “Still an enormous [number] of women are dying because of unsafe abortions, and there is this amazingly simple technique. It does need a doctor, a safe place to do it, and something to produce a vacuum.”

Malcolm Potts, from the school of public health at the University of California in Berkeley, said he thought that the first manual vacuum aspiration was carried out by Queen Victoria’s gynaecologist, James Young Simpson. He thought that the Chinese were also pre-empted by Bykov in Russia in 1927. But none of these discoveries went further, unlike with Wu and Wu’s study.

“Only in a field as controversial as abortion would the same idea need to be discovered three times, each independently,” said Professor Potts.

In China, the legacy of Wu and Wu is still a modest one. Joyce Leong, one of the translators from the faculty of medicine at the University of Melbourne, said, “I don’t think people in China are aware of the fact that vacuum aspirations were invented in their country despite its use being so common. It is largely taken for granted.

“Reproductive health in China has always been more forward than in most places because the underlying purpose for any sort of family planning initiative is always to put the nation before oneself. Things like infanticide and abortion have never been openly discussed although they were openly performed because there was never much public emotion tied to these things, and everyone knew, expected, and accepted the realities of controlled fertility.

“These things happen, but quietly, and everyone moves on, none the wiser.”