Bulletin of the History of Medicine

Sources and Methodology

The main source for this analysis is the journal Ginekologia Polska, a space where representations of expertise, research, and practice intersected. The journal was established in 1922 and, apart from a nine-year interruption (1939–47) during and immediately after World War II, has continued publication to the present day, with twelve issues each year since 1965. As well as research articles, descriptions of medical cases, reports, clinical and experimental studies, and reviews, since 1970 the editors have invited commentaries relating to themes they deemed crucial to Polish gynecology and obstetrics. Summaries of foreign medical literature have also appeared, including articles published in the Soviet Akusherstvo i Ginekologiya, as well as Western journals, such as Journal of Obstetrics and Gynaecology of the British Empire and American Journal of Obstetrics and Gynecology. Opinion pieces have been uncommon; the discussion around the idea of legislating a total abortion ban in 1989 and 1990 was a rare circumstance in which the editors published exchanges of opinion, although with explicit reluctance.

Established by the Gynaecological Societies of Cracow, L’viv and Poznań, and later run by the Polish Gynaecological Society,⁸ Ginekologia Polska was the most important print platform for Polish gynecology as a medical specialty throughout the twentieth century, and a fundamental resource for the reinforcement of Polish gynecologists’ professional identities.⁹ As the journal’s chief editors have been renowned professors of gynecology and obstetrics, including Ireneusz Roszkowski (1962–82), Tadeusz Pisarski (1982–89), and Zbigniew Słomko (1989–98), the journal’s contents have been defined by key Polish academic centers for research and teaching in gynecology and obstetrics. These centers have been responsible for roughly three-quarters of all publications in Ginekologia Polska, a proportion of which remained relatively stable between the late 1950s and the late 1970s.¹⁰

The journal thus has exhibited not only peer-validated expertise but also representations of elite practice developed in the main academic centers, which, with early access to new technologies and international knowledge, were establishing standards and aspirations for the rest of the [End Page 87] country. While archival material and medical textbooks could also provide valuable insights into normative debates on abortion among Polish experts and providers, systematic historiographic analysis of a public and periodic source such as Ginekologia Polska enables me to trace, both quantitatively and qualitatively, long-term shifts in expert debates on abortion, and particularly in (expected) providers’ self-positioning with regard to abortion practice.

My compiling process was based on a manual review of issues published between 1922 (when the journal was established) and 1993 (when abortion for “social” reasons became illegal in Poland). With the assistance of Endnote software, I registered 1,214 articles on topics linked to reproductive health and gynecological practice in Poland, 1,140 of which were published between 1956 and 1993. Abortion (understood as artificial termination of pregnancy) was discussed or mentioned in 171 articles between 1922 and 1993; the 127 published in the period between 1956 and 1993—when abortion was legal for “social” reasons—constitute the basic corpus for my analysis. The following discussion focuses on three interconnected themes I identified in this material as fundamental and defining for the abortion debate in expert circles in postwar Poland: the procedure’s indications, its (dis)connection to health, and the patient-doctor relationship. Meanings contained in these categories were in some cases stable, and in others shifted—radically at times—during the period under discussion. Simultaneous analysis of these themes has enabled me to explicate the history of abortion expertise in state-socialist Poland.

My analysis is contextualized and historicized through a number of additional sources, including publications in other medical journals, such as Wiadomości Lekarskie, Zdrowie Publiczne, and Polski Tygodnik Lekarski; popular medical literature on family planning published by the state publisher Państwowy Zakład Wydawnictw Lekarskich; articles on abortion and contraception published in women’s magazines, such as Przyjaciółka and Kobieta i Życie; and archival material produced by the state-sponsored family planning organization Society for Conscious Motherhood (Towarzystwo Świadomego Macierzyństwa; established in 1957, in 1970 renamed Towarzystwo Planowania Rodziny and in 1979 Towarzystwo Rozwoju Rodziny).

Regulating and Providing Abortion

This section traces the legal regulation of abortion in Poland during the second half of the twentieth century in relation to shifts in state-socialist population policy and the changing relationship between the party-state and the Catholic Church, an important social and political agent in a [End Page 88] country where over 93 percent of the population was Catholic in the early 1970s, rising to almost 96 percent by 1987.¹¹ I also discuss registered abortion figures during this period, thereby contextualizing my subsequent analysis of debates about abortion among (potential) providers.

Abortion for medical and criminal reasons was first legalized in Poland in 1932.¹² In 1956, in response to regional trends and local demand, state-socialist authorities added another indication: “difficult life circumstances.”¹³ Neither the 1956 law nor its first executive order published by the Ministry of Health in May of that year provided advice on how to interpret “difficult life circumstances.” Initially, a doctor approached by a woman seeking abortion referral who remained unconvinced by her description of economic and social adversity was obliged to investigate her claims, but the second executive order to the law in 1959 removed this obligation.¹⁴ Thereafter, the doctor referring a woman for abortion merely “took note of her declaration in the medical history and obtained her signature.”¹⁵ Historian Aleksandra Czajkowska has argued that the simplification of this procedure was a response to demands the burden be lifted from an overloaded gynecological sector.¹⁶

Further, and perhaps more importantly, the legalization of abortion and liberalization of access in the second half of the 1950s, together with the launching of an extensive public health campaign to popularize family planning, were essential components of the party-state policy, which historian Sylwia Kuźma-Markowska interpreted as moderate antinatalism.¹⁷ This policy remained in place throughout the 1960s.¹⁸ In the 1970s, under the new first secretary of the Polish United Worker’s Party, Edward Gierek, in [End Page 89] office between 1970 and 1980, the population policy began to shift toward incentivizing rather than limiting births.¹⁹ This shift was applauded by the Catholic hierarchy,²⁰ which, from the late 1960s onward, had intensified the popularization of its own population policy: pronatalism based on an unconditional rejection of abortion and “artificial” contraception. Promotion of these ideas intensified through, for instance, the mainstreaming of institutionalized Catholic marriage preparation courses informed by the encyclical Humanae Vitae, which itself reiterated the ban on “nonnatural” family planning methods for the Catholic community.²¹

From the mid-1970s onward, arguments against liberal abortion access and in favor of “natural family planning” appeared in a number of popular magazines, both Catholic and secular.²² Some, such as the popular women’s magazine Przyjaciółka, devoted increasing space to natural family planning presented by Catholic doctors who, without revealing their religious identities, seeped Catholic anti-contraception and anti-abortion doctrine into the mainstream media.²³ Historian and literary scholar Katarzyna Stańczak-Wiślicz has attributed this intensification to attempts by the Catholic Church to change the language of the abortion debate in Poland, framing the practice as a threat to the nation and the state.²⁴

Despite the alignment of demographic goals between the party-state and Catholic Church in the 1970s, the legal regulation of abortion [End Page 90] remained unchanged until the beginning of the next decade. The Catholic Church’s influence on social and political life in Poland had been enhanced by the 1978 election of Karol Wojtyła as Pope John Paul II, who was extremely vocal in his condemnation of abortion and contraception. The emergence and institutionalization of the Solidarity movement in 1980, some leaders of which had strong links to the Church and fervently promoted a change in abortion legislation, further boosted the public prominence of anti-abortion discourse in Poland.

In November 1981, weeks before the introduction of the martial law that remained in place until 1983, the Ministry of Health together with the Ministries of Communication, Defense, and the Interior—a collaboration that signified and staged the importance of the issue—released a new instruction on the application of the 1956 law. A doctor should now request a thorough explanation of why a woman was seeking a termination, while also informing her about the associated health risks, especially for a first pregnancy, and “attempt to convince the woman not to terminate.”²⁵ This instruction reinclined the power balance from women to doctors, who were once again, as in 1956, entitled and explicitly instructed to enquire into patients’ motivations as well as encouraged to undermine a woman’s decision to terminate. Legal scholar Małgorzata Fuszara has argued that it is unclear whether this was a response to opponents of the procedure, including the Catholic lobby, or an attempt to deflect threats to the 1956 abortion law, which itself remained unchanged.²⁶ I would suggest that it fulfilled both aims, as, while apparently tightening control over abortion provision in public health care, it kept control of the procedure between a woman and her doctor.

The 1981 instruction, however, preceded further and deeper restrictions to abortion access during the democratic transition. The fourth executive order to the 1956 law (1990) redefined the protocol for terminations in public health care, promoting counseling against abortion from a recommendation to a legal obligation.²⁷ Furthermore, women were required to receive a second medical opinion and a psychological [End Page 91] evaluation before proceeding. This trajectory of protocolized obstacles to abortion access in public health care was therefore implemented years before the ban on socioeconomic abortion materialized in 1993. “Abortion on demand,” however, remained accessible in private surgeries and medical cooperatives, which, at least from the 1980s onward, were already the first-choice abortion providers for many Polish women.

The 1993 abortion law, which restricted legal terminations to public health care,²⁸ pushed private abortions underground and further accelerated what anthropologist Agata Chełstowska has argued was the simultaneous process of commercialization and stigmatization of abortion services.²⁹ Official registers (Figure 1) show that the number of abortions performed in public hospitals remained around 150,000 per year until the aforementioned decrease during the 1980s. This suggests the process of commercialization had actually started in the 1980s and may have been linked to the increasing barriers within the public sector encouraging women to seek private providers. In fact, during the 1980s, demographers assessed the total number of terminations as much higher than the official figures, amounting to between 300,000 and half a million per year, with most private terminations unreported.³⁰ What is beyond doubt, however, is that the 1993 ban caused a dramatic increase in the cost of commercial abortions, therefore exacerbating economic and mobility-based inequalities in abortion access.³¹

Shaping and Interpreting Abortion Indications

In this section I analyze debates about abortion indications in state-socialist and early democratic Poland. I argue that the idea that women could and were entitled to define their own “social” abortion indications persisted in expert debates during this period, leading to a gradual eradication of the conceptualization of therapeutic abortion motivated by the preservation of women’s health and well-being. There were two motives [End Page 92]

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Figure 1.

Registered abortions in Polish public hospitals, 1957–99. Sources: Czajkowska, “O dopuszczalności przerywania ciąży” (n. 7); Rada Ministrów, “Sprawozdanie Rady Ministrów z realizacji w roku 1999 Ustawy z dnia 7 stycznia 1993 roku o planowaniu rodziny, ochronie płodu ludzkiego i warunkach dopuszczalności przerywania ciąży,” http://orka.sejm.gov.pl/Rejestrd.nsf/wgdruku/2136/$file/2136.pdf.

driving this eradication: first, classifying an abortion as “social” rather than “therapeutic” was easier for providers; second, this conformed with the dominant framing of abortion as a potential threat to health, which I discuss in the next section. However, from the 1970s onward, “therapeutic” abortion reemerged when fetal abnormalities were detected or suspected. Finally, from the mid-1980s onward, the patient-doctor relationship in relation to indications started to be represented in terms of conflict, and nationalistic anti-abortion arguments surfaced in expert discourse.

Figure 2 shows the number and distribution of articles on abortion published between 1927 (when this topic was first discussed) and 1993. It also shows the proportion of articles in which abortion indications were the principal focus (forty-four articles). Many implicitly reflected upon abortion indications, including a number of case reports on the practice of terminations at a particular clinic. As can be seen, the periods in which theoretical debates around indications intensified rarely coincide with changes in abortion law.

This disconnection can be explained by the value that gynecological expertise has been afforded in legislative debates. A concentration of these articles in the late 1920s reflects the leading role the specialty was assigned in discussions relating to abortion during elaboration of the post–World War I penal code. From 1932 onward, this code set the penalty for abortion, self-induced or induced by others, at three years of imprisonment, but, as mentioned, decriminalized terminations performed by doctors [End Page 93]

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Figure 2.

Abortion indications versus other themes in Ginekologia Polska, 1927–93. Source: Author’s elaboration.

for medical reasons (to preserve the health of the pregnant woman—art. 233) or when the pregnancy itself was a consequence of sexual abuse, rape, incest, or sexual relations with a minor under fifteen (arts. 203–6).³²

The debate that took place on the journal pages in 1927, reflecting a scientific meeting organized in March 1927 by the Warsaw Gynaecological Society, was specifically about delimiting what, if any, medical indications existed. As prominent gynecologist and at that time president of the society, Professor Adam Czyżewicz underlined in the introduction to the special issue that “unblemished doctors” would find support within the pages for their aspiration to “remain clean in the swamp that surrounds them.”³³ Through eleven articles, the entire issue, doctors from various specialties, including obstetrics, psychiatry, neurology, and ophthalmology, presented their opinions on indications. Zofia Garlicka—the only female physician to feature here—explicitly blurred the boundaries between “social,” “medical,” and “criminal” indications and claimed that rape was the only indication that justified a medically approved termination. She did propose two social indications: pregnancy out of wedlock and when a working woman was the sole breadwinner. Garlicka also insisted [End Page 94] that under no circumstances should women be penalized for having a termination.³⁴

The lack of a similar discussion around the legalization of abortion in Ginekologia Polska during 1956, or relating to the second executive order of 1959, indicates a possible disconnect between the medicalization of abortion as a public health venture and the position of gynecological elites, who viewed the prewar legislation, restored after the war, as sufficient or even exhibited a clear anti-abortion position. When such discussions happened, however, they took place outside the professional journal for gynecology and in other forums. One example was the journal Służba Zdrowia, which covered themes relating to medical workplaces and health care provision, and became a platform for an exchange of opinions about abortion during the second half of the 1950s. As Sylwia Kuźma-Markowska has shown, this exchange was initiated by an “Open Letter to our Colleagues, Gynaecologists” published in autumn 1956, in which doctors from various specialties called on gynecologists to respect the new law for the good of their patients. Proclaiming themselves as representatives of the profession, a group of Warsaw-based Catholic gynecologists responded by claiming that abortion inflicted irreparable harm to health.³⁵ This framing of abortion, which become more commonplace on the pages of Ginekologia Polska in the 1970s, was largely absent during the 1950s and 1960s, as I will discuss in the next section. Similarly absent were discussions about abortion indications during the years immediately following enactment of the 1956 law, perhaps due to the removal of medical authority to set these indications.

On the pages of Ginekologia Polska, the fact that women “defined” the indications for abortion—without validation by doctors—was often linked to the progressive disappearance of those indications labeled as “medical” or “therapeutic” and therefore authorized by gynecological expertise. This process was a reversal of that taking place in contexts with punitive or partially decriminalized abortion legislation. In Britain, the 1967 Abortion Act had installed doctors’ authority over whether “continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family,” and the idea of undesired pregnancy as a disruptor of women’s health solidified among practitioners over the decades the act was in place.³⁶ Similarly, in Spain between 1985 [End Page 95] and 2010, partial decriminalization of abortion led to legal terminations to safeguard women’s health; private clinics used a broad interpretation of “health” to provide abortion services.³⁷ Therefore, in these contexts, the meanings of “therapy” stretched to embrace a variety of bodily, social, and personal circumstances, often discursively validated through the World Health Organization’s (WHO) definition of health as not only an absence of disease but a state of holistic well-being.³⁸ Historians have shown similar trends in “therapeutizing” oral contraception in countries where birth control has been prohibited, such as Spain (1942–78) and Ireland (before 1979). In such circumstances, the oral contraceptive pill has often been officially prescribed as a “menstrual regulator” rather than contraception and any prophylactic properties represented as side effects of the “therapy.” This “therapeutization,” however, has been shaped by the prescriber’s ideologies and the patient-doctor relationship, which often included payment in exchange for services, as in private gynecological surgeries in Spain that coexisted with the public health care system.³⁹

From the late 1950s through to the mid-1970s, however, Polish gynecologists noted that the use of “therapeutic” indications decreased as the term “social” came to be understood by both women and professionals to mean “on demand.” A number of gynecologists recognized their own role in driving this change, emphasizing the time-saving advantages of classifying abortion as “social” and therefore dependent on a woman’s statement alone, as opposed to “therapeutic” and requiring a more comprehensive justification. In 1968, Zbigniew Sternadel, together with Witold Wendolowski and Zdzisław Jabłoński, published a report on ten years of abortion practice in the First Clinic of Obstetrics and Women’s Diseases of Warsaw Medical School, the first and most important teaching clinic for gynecology and obstetrics in the country, established in 1920: “As the years passed after pregnancy termination had been legalized, our clinic as well as others noted a systematic decline in [reported] medically indicated abortions. It would be a mistake to attribute this to an actual decline [End Page 96] in the incidence of such indications. Their downward trend—or a trend to disappear—is in fact caused by the fact that it is much easier to certify social indications than medical ones.”⁴⁰ Six years later, in a follow-up report with Anna Pęksa and Andrzej Łysikiewicz, Sternadel estimated that reported medical indications accounted for 0.5 percent of all abortions and again insisted this figure was artificially lowered due to the simplicity of classifying the procedure as “social.”⁴¹

Other contemporary commentators on the pages of Ginekologia Polska, however, viewed the low proportion of abortions classified as “therapeutic” as a reflection of social and medical reality. A 1972 report by Kazimierz Waszyński on abortion practice in Warsaw between 1957 and 1968— roughly the same period as that covered in the 1968 report by Sternadel, Wendolowski, and Jabłoński—claimed that once the 1959 executive order had removed the need for certificates attesting to a “difficult living situation” and given women “complete freedom in terminating an undesired pregnancy,” “therapeutic” indications became limited to “real” ones: the author did not specify what these “real” ones were.⁴²

During the 1970s, the professional forum for Polish gynecologists became a space for the definition and construction of a new indication: fetal malformation. This had not been considered for the 1956 law, as the technologies that increased detection and proliferated in the West from the 1950s onward,⁴³ began to circulate in Poland only from the mid-1960s. This coincided with production of the first Polish ultrasound devices to be used in gynecology and obstetrics,⁴⁴ followed by a boom in articles dedicated to the subject in Ginekologia Polska from 1970 onward. Between 1970 and 1993, the journal published almost a hundred articles covering various applications for ultrasound in Polish gynecological clinics. As in the West, the irruption and spread of technologies for fetal viewing, diagnosis, and monitoring had a profound impact on gynecological practice, becoming an essential element and strengthening practitioners’ authority. At the same time, as feminist scholars have argued, the proliferation [End Page 97] of these technologies transformed the experience of childbirth and pregnancy itself, subjecting it to new forms of scrutiny and self-scrutiny.⁴⁵

Prenatal diagnosis became a prominent topic on the pages of Ginekologia Polska from the 1970s onward, having first been broadly discussed in a 1971 editorial by W. L. Whitehouse from the London hospitals of Westminster and Queen Mary’s. The editorial’s title was translated into Polish as “Preventing Damage in Fetuses and New-Borns,”⁴⁶ indicative of the discursive framing of prenatal diagnosis and its links to “therapeutic” abortion in the decades to follow. Prenatal diagnosis was represented as preventive, protecting healthy fetuses from unnecessary abortions, a framing similar to that which sociologist Radka Dudová detected in contemporaneous Czechoslovakian expert debates on abortion.⁴⁷

However, as techniques for the detection of fetal defects—chiefly amniocentesis and ultrasound—were employed only at around twenty weeks of pregnancy, the prognosis of such defects did not automatically lead to abortion. Although not legally stipulated until 1990, abortion in the public health care system upon woman’s request was generally limited to the first trimester. According to two reports on medical malpractice published in Ginekologia Polska in 1984, later on-demand terminations were available in private practice but were far riskier procedures often performed in ill-equipped surgeries; the majority of abortion-related fatalities analyzed in these two articles resulted from private, beyond-first-trimester terminations.⁴⁸

A diagnosis of fetal malformation in later in pregnancy, which experts represented as both a “therapeutic” and “social” indication, could entitle the pregnant woman to an elective termination in a public hospital. The dual possibility of this indication was discussed in a 1974 article, “Preventing Genetic Diseases through Prenatal Diagnostics,” by Henryk Hubner and Helena Szlojdo from the Military Medical School in Łódź:

A question arises whether detecting a serious genetic disease of the fetus is a medical, or a social indication for abortion. If the decision of termination is [End Page 98] made because serious chromosomal anomalies or biochemical alterations in the fetus have been detected, this speaks in favor of medical indications. Our legislation, however, does not contemplate termination because of the condition of the fetus. Classifying it as such could stand in conflict with the law. We can also see it conflicting with the basic duty of a doctor—that of protecting human life. But, from a society’s point of view, it does make a difference whether the new-born will be a fully-able (pełnowartościowy) citizen or will require hospital or nursing home care for the rest of their life. It could be postulated, then, that a genetic disease detected in a fetus is a social indication for abortion.⁴⁹

Tinted with neo-eugenic ideas contrasting “fully-able” and “valid” citizens with those who would be a burden to society, the intensification of which during the 1970s and 1980s in state-socialist Hungary and Czechoslovakia has been documented by Eszter Varsa and Vera Sokolová, respectively, this discourse persisted in the 1980s, with prenatal diagnosis viewed as a measure to prevent both unnecessary births and unnecessary abortions.⁵⁰ By highlighting that terminating a pregnancy contradicted the medical ethos of protecting human life, the author also assumed—and contributed to—the humanization of the fetus.

In a 1981 article on the possibilities and methods of prenatal screening, Przemysław Czerski and Ewa Manikowska-Czerska, based at one of the pioneering Polish centers of prenatal diagnostics, the Area of Genetics at the Mother and Child Institute in Warsaw, explained that “it enables the parents to give birth [sic] to a healthy child.”⁵¹ The authors framed the possibility of termination at around twenty weeks if malformation was diagnosed as preventing abortion of a potentially healthy fetus, one that parents may have demanded earlier in pregnancy because of fears produced by a previous child with Down syndrome or a neural tube defect.⁵² [End Page 99] In this realm, many experts emphasized the agency of women and (prospective) parents in deciding whether to carry to term what historian Ilana Löwy has termed an “imperfect pregnancy.”⁵³ By the late 1980s, “genetic indications” had been accepted by most Polish gynecologists despite a lack of explicit legal support. In a 1988 article on the ethical aspects of abortion, the first to be published in Ginekologia Polska, Zbigniew Szawarski claimed “genetic” and “social” were the only indications that existed in Poland at that time: therapeutic indications relating to women’s health had disappeared.⁵⁴

While for some gynecologists “social” and “therapeutic” indications had merged, the questioning of both became explicit in the pages of Ginekologia Polska during the last decades of Polish state socialism. This was fueled by a number of factors, including increasing censorship of “immoral and obscene publications” and the aforementioned intensifying diffusion of anti-abortion arguments based on fetal personhood into public discourse.⁵⁵ In Ginekologia Polska, the appearance of “natural” Catholic family planning, presented as an ideologically neutral and scientifically justified system for the “natural regulation of conceptions,” began in the mid-1970s through articles by one of the main proponents of fertility awareness-based contraception in Polish professional forums, the gynecologist Włodzimierz Fijałkowski.⁵⁶ As I have argued elsewhere, the expanding spaces carved out in these forums for Catholic systems of family planning contributed to the increasing dissemination of anti-abortion ideas based on fetal personhood.⁵⁷ [End Page 100]

These debates intensified in Ginekologia Polska as “social” indications for abortion became increasingly controversial and calls for urgent revision emerged during the 1980s. Paradoxically, authors contributing to this debate did not always wish to restrict women’s agency in deciding the fate of their own pregnancies. One example of such ambiguous representations of “social” indications is a 1984 article published by Lidia Hirnle from the Department and Clinic of Obstetrics at Wrocław Medial School. She concluded that “neither the health risks, nor religious beliefs or legal bans” would prevent a woman from terminating a pregnancy that could produce “a child that would complicate her current family life or would discredit her in the eyes of society.”⁵⁸ An editorial on medical errors by Zdzisław Marek from Cracow Medical School’s Department of Forensic Medicine published that same year similarly stated that “it is the woman herself that defines the indications [for termination].” At the same time, Marek speculated about the consequences of a prospective abortion ban: “The legal ban on abortion (because of doctors’ moral dilemmas) limits the woman’s [possibility] to decide on the things that interest her intensely, therefore violating her basic rights. But in regard to the formal and legal side of things, the doctor cannot refuse to perform an abortion in a hospital unless there are medical indications for such refusal. On the contrary, the refusal may cause the doctor to be accused of acting against the law and face consequences.”⁵⁹ Marek’s analysis offers another meaning of “therapeutic” (counter)indications for abortion: as the only legal possibility for a public health care doctor to veto the procedure, an instrument that could act as a replacement for conscientious objection, not sanctioned as physicians’ right in communist Poland. The editorial also demonstrates that a possible abortion ban was discussed by Polish professionals in the mid-1980s and that the relationship between women and their abortion providers had begun to be represented as one of conflict, not cooperation.

Toward the end of the 1980s, proposals that access to abortion should be restricted for nationalistic reasons began to appear in the journal. In 1988, an editorial on the ethical aspects of abortion by the ethicist Zbigniew Szawarski leaned toward defending the ultimate right of women to decide the fate of their own pregnancies, concluding that “each women’s moral duty to give birth to the child depends on her own interpretation of this duty.”⁶⁰ A reply to Szawarski was published in a 1990 issue featuring [End Page 101] several articles discussing abortion, together with the position of the Polish Gynaecological Society in the early democratic abortion debates, which I will discuss more in the next section. In relation to abortion indications, however, one article was especially emblematic. Józefa Dzban, a female physician who did not describe herself as a gynecologist, argued that “social indications bring shame upon the couple, the society and the State. Every child is the nation’s priceless treasure, thus killing it—is a crime, and every act in favor of abortion is an act against the human being, the society and nature.”⁶¹ Although Dzban’s anti-abortion argument was fundamentally demographic and nationalistic, the addition of the emotionally charged phrase “killing a child” exemplifies the Catholicization of public debates on abortion during the final decades of Polish state socialism.

In a 1989 interview, Ireneusz Roszkowski, one of the most renowned Polish postwar gynecologists and editor of Ginekologia Polska between 1962 and 1982,⁶² also depicted abortion as “destruction of life” and a threat to the nation:

During the 20 years I was editor of Ginekologia Polska, I ensured that all the articles published in the journal were linked to the creation, not the destruction of life. Speaking of destruction—in 1956 the law on legal pregnancy termination was dictated, but thanks to me it only started to be put into practice in 1960. I counted that, because of these 4 years, the nation owes me at least 750,000 [citizens] that I managed to save from destruction. I did it as a Pole for my country.⁶³

The nationalistic and demographic anti-abortion rationale this extract exemplifies had been present in Catholic anti-abortion rhetoric since 1956 and proliferated in public discourse from the 1970s onward. As I will discuss in the next section, this extract suggests that such discourse also operated in Ginekologia Polska in a more implicit way, promoting representations of abortion as inherently risky and unhealthy, and limiting the exposure of research on how to increase the safety and comfort of abortion procedures. [End Page 102]

Between “Health” and “Sickness”: Defining Abortion Risks and Procedures

In this section I discuss intersecting representations of abortion and health in Polish expert discourse. I argue that while the dominant framework for this representation was that abortion was a potentially risky surgery, from the mid-1950s to the late 1960s this framework was nuanced through concurrent representations of legal abortion as an ally in combating maternal mortality. In the 1970s, however, abortion began to be linked to infertility, often in simplistic cause-and-effect terms, despite poor supporting evidence. At the same time, systemic causes of the risks in abortion, such as limited supplies of drugs and a lack of less trauma-inducing technology, were often ignored.

Over the two decades after abortion was legalized, the dominant framing of legal abortion in Ginekologia Polska was as a protection against an unsafe and unhealthy termination, a framing very similar to that detected by Radka Dudová in Czechoslovakian expert discourses on abortion following national legalization in 1957.⁶⁴ In articles discussing maternal mortality in the mid-1950s, abortion occupied a prominent place in causality. A 1954 report on fatalities from air embolism at Łódź Medical School described several cases of women who claimed they had “fallen” from a haystack or down the stairs, therefore possibly delaying diagnostics and the appropriate treatment.⁶⁵ A 1957 report from the same university but in the new legal context underlined that doctors were obliged to inform patients that the 1956 law removed all criminal responsibility from women procuring an abortion themselves or with the help of others, thereby preventing the patient from lying and “[she] can be saved.”⁶⁶

From the late 1950s onward, it was relatively common to represent (legal) abortion in terms of protecting, rather than damaging women’s health and fertility, a rhetoric aligned with the arguments used by the communist authorities to defend 1956 abortion law reform.⁶⁷ This rhetoric continued in reports on the advances of Polish gynecology in professional journals published in the mid-1960s. In one 1965 report, the prominent gynecologist Wojciech Gromadzki framed the legalization of “social” abortions in public health care as diminishing injuries resulting from illegal [End Page 103] terminations.⁶⁸ In a contemporary report on the clinical practice of abortion in the II Clinic of Obstetrics and Women’s Diseases at Gdańsk Medical School, Tadeusz Lakomy emphasized that not a single abortion-related death had occurred in that clinic since legalization.⁶⁹ Other authors emphasized how fatalities from illegal abortion had dramatically diminished, radically changing the panorama of maternal mortality in Poland.⁷⁰

Other gynecologists classified abortion as a “minor surgery,”⁷¹ or underlined the (relative) safety of the procedure. In a 1978 article, Mieczysław Cisło and Marian Gryboś from the Institute of Gynecology and Obstetrics at Wrocław Medical School (a pioneering medical center in the development of new contraceptive and abortion technologies, the IUD and vacuum aspiration) highlighted the low incidence of complications resulting from abortions performed by “qualified doctors in a clinical setting” and added that “new methods of termination [performed early in pregnancy] further enhance safety.” This was followed by the customary warning that “despite their low incidence there still might be immediate or long-term complications,” an aphorism that appears to have been a compulsory addition to any discussion on abortion in Ginekologia Polska. However, Cisło and Gryboś mitigated this warning by reminding readers that such complications could also take place when a curettage was performed after miscarriage.⁷²

During the 1970s, such nuances and mitigations became the exception. In a political climate increasingly shaped by the alignment of the state’s and the Church’s populational goals, and increasing party-state anxieties about the deceleration of population growth—attributed to, among other factors, extensive access to abortion⁷³—Ginekolgia Polska shifted focus from abortion indications to counterindications.⁷⁴ In particular, the termination [End Page 104] of a first pregnancy began to be explicitly framed as a counterindication, symptomatic of the trend to represent abortion as universally and unequivocally linked to infertility.

During this decade, Ginekologia Polska published a number of research papers linking abortion away from health and toward pathology, all concluding that an association between terminating a pregnancy and becoming unable to conceive or bring pregnancy to term did exist. These papers by Polish gynecologists were disseminated not only in Ginekologia Polska but also in other Polish and German gynecological journals and would be widely cited over the following decades. One example is Stanisław Lembrych’s “Problems of Fertility in Women with a History of Induced Abortion in the First Pregnancy,” published in Ginekologia Polska in 1979. Lembrych, based at a Regional Mother and Child Hospital in Opole, a midsize town without its own medical school, had published his research on the negative consequences of terminating a first pregnancy seven years earlier in Zentralblatt für Gynäkologie, a leading German journal for gynecology and obstetrics.⁷⁵ Together with Janusz Kubicki, Lembrych presented a sample of fifty-two women who had terminated their first pregnancy between ten and fifteen years earlier. The authors concluded that 51.7 percent of these women, some of whom had undergone more than one abortion, had no complications in subsequent pregnancies. However, the remaining twenty-six women had experienced problems and six were now believed to be infertile. The authors attributed all complications directly to the fact the women had terminated their first pregnancies, concluding that this caused “infertility, miscarriage or bleeding in pregnancy in around 50% of cases.”⁷⁶ This generalization of a cause-and-effect relationship was not supported by the actual data presented in the article, taken from an extremely small group of patients.

Similar conclusions based on a higher number of cases were presented by another author, Maria Renkielska, based at a women’s clinic attached to an enamelware factory in Olkusz. Renkielska studied a group of 341 [End Page 105] patients during the first half of 1976: 241 had undergone abortion (158 once, 83 twice or more); the remaining 100 women who had not had terminations served as a control group. According to her analysis, abortion had a detrimental impact on women’s fertility and generated complications in future pregnancies: 17.8 percent of women who had abortions suffered from ovarian inflammation versus 9 percent in the control group; 14.5 percent had experienced cervical trauma versus 3 percent of those who never had abortions; and 36 percent had experienced complications during childbirth, when in the control group this proportion was less than 20 percent. Renkielska noted, however, that there was no “proportional increase in morbidity in [women who had] more than one abortion.” Similarly, the rate of spontaneous miscarriage among women who had an abortion and the control group was similar.⁷⁷

While the risks of legal abortion had become the subject of research, it was unusual to associate these with the provision of health services. However, a 1989 report did examine the complications that women with Rh-negative blood could face in future pregnancies if not given an immunoglobulin injection after a termination. This history of the prevention of RH incompatibility in Poland by Professor Zbigniew Słomko explained that in the city of Poznan before 1979 supplies of immunoglobulin had been too low to include women undergoing abortion in prevention schemes, and even during the mid-1980s only small numbers of women having terminations in a limited number of facilities would be offered the injection.⁷⁸

Likewise, Ginekologia Polska devoted almost no space to the abortion technique itself. An explicit plea for the use of less traumatic abortion techniques by the Polish Gynaecological Society was published in the journal only in 1990, in the context of the early democratic debates about a total abortion ban.⁷⁹ This plea demonstrates that such risks had been recognized by professionals, but perhaps the dominant frame of the discourse of abortion as inherently unhealthy—nuanced and diversified in the early postlegalization years, but solidified from the 1970s onward—censored or contributed to self-censorship about technological innovations that could diminish the dissuasive health risks. [End Page 106]

Historians have shown that in a number of state-socialist regimes, innovation in abortion technology was a significant medical and political endeavor. Yugoslavian doctors, as Branka Bogdan has demonstrated, were pioneers in the transnational knowledge flows about vacuum aspiration during the 1960s and 1970s.⁸⁰ This technique was also adopted in the Soviet Union during the 1960s and was endorsed by communist authorities in the 1980s.⁸¹ Radka Dudová has argued that the emergence of vacuum aspiration technology in Czechoslovakia was linked to the 1980s liberalization of the country’s 1957 abortion law. Considered safer and less traumatic, this procedure could be performed only early in pregnancy, at around eight to ten weeks, but the requirement for abortions to be authorized by Abortion Commissions prolonged the administrative procedure and meant many women could not opt for vacuum aspiration. As safety became a priority, Abortion Commissions were removed in 1986.⁸²

In contrast to other countries in the region, however, expert debates on abortion technology were practically nonexistent in Poland before the 1970s, and during that decade focused heavily on prostaglandins and their use in after-first-trimester abortions, which authors linked to fetal malformation. While vacuum extraction frequently appeared in the context of assisting birth on the pages of Ginekologia Polska, use of the vacuum in abortion was broadly discussed in only one research article, published in 1965. Stanisław Krzysztoporski, previously based in Wrocław but at that time affiliated with Łódź Medical School, described a vibratory dilation device he had begun to use with a vacuum aspirator. As the title of the article declared, this presented “a modified technique of eliminating the fetal egg”: only the English abstract explicitly referred to the device being used in cases of “interruption [sic] of pregnancy because of social or medical indications.”⁸³ Such stylistic choices could be a consequence of (self-) censorship by the author or the journal; Krzysztoporski’s paper is a rare example in which the “potential and immediate health consequences” of abortion do not appear. The fact that another article on vacuum aspiration abortion I located was published not in Ginekologia Polska but in the aforementioned German Zentralblatt für Gynäkologie could also be a symptom of this censorship. In this 1966 article, Mieczysław Cisło, Kazimierz Nowosad, and Andrzej Reszczyński—the latter two key names in the development of the Polish IUD, Spiran, in the late 1960s—described the [End Page 107] vacuum aspiration device they had used (metal cannulas with diameters between nine and thirteen millimeters) to successfully terminate three hundred pregnancies in the First Department and Clinic of Obstetrics and Women’s Disease at Wrocław Medical School. Unsurprisingly, most of these procedures were carried out for “social” reasons. They reported that the technique was less traumatic and painful than earlier methods and, in their experience, entirely free from complications.⁸⁴ The extent to which this technique spread through Poland merits investigation, as does the fact these authors chose a German medium to publish their results. Unlike the previously discussed article by Stanisław Lembrych on links between the termination of a first pregnancy and fertility problems, first published in the Zentralblatt für Gynäkologie and later in Ginekologia Polska, this article was not transferred to the Polish journal.

Ginekologia Polska did, however, host numerous articles and summaries on prostaglandins, the uptake in use of which coincided with the journal’s interest in fetal diagnostics during the mid-1970s. Knowledge flows about prostaglandins as a labor-inducing technology in abortions later in pregnancy linked Polish gynecologists with their Soviet and East-Central Europe counterparts, as well as the WHO. Most summaries about these drugs published in Ginekologia Polska from 1974 onward originated from the Soviet Akusherstvo i Ginekologiya and concerned their use in inducing abortions, with considerable discrepancies in opinions about their safety.⁸⁵ Stefan Soszka and Roman Czekanowski, Polish professors of gynecology, reported on their participation in a seminar on “prostaglandins and fertility regulation” held in Moscow in September 1974, and referred to the possibility of also using these drugs to induce an early termination;⁸⁶ in 1978 the journal published three summaries by WHO on the same theme. [End Page 108] In a 1981 report on his visit to several East German gynecological clinics, Edmund Waszyński highlighted the use of prostaglandins as a standard technique for inducing abortion, often followed by a curettage.⁸⁷ Reports on local clinical practice that mentioned prostaglandins during the 1980s always associated the drugs with “medically indicated” abortion beyond the first trimester, almost exclusively in the context of fetal malformation.⁸⁸

One possible interpretation of the considerable presence of debates on prostaglandins in the main Polish professional forum, alongside the absence of such discussions on vacuum aspiration as an abortion technology, could be the different values attached to first-trimester on-demand abortion and later abortion due to fetal malformation. The first were defined by women, with gynecologists legally obliged to provide the surgery, although in the final decades of state socialism the power balance was shifting, with doctors instructed to convince women not to terminate and increasing challenges to the concept of “social” indications. Gynecologists who detected fetal indications passed the information to women or couples, who would then decide whether to carry the pregnancy to term.

However, while Ginekologia Polska gave little space to abortion technology, it did occasionally publish articles on other aspects of the procedure that would enhance comfort and safety. Most of these contributions focused on anesthesia and other drugs administered before, during and after surgery. One such 1970 article by Jerzy Higier and colleagues from the Postgraduate Education Institute of Warsaw Military Medical School looked at the use of drugs to diminish bleeding during abortion. In the introduction, in addition to the already discussed cautionary adage (“as with every surgery, [abortion] carries some risk of early and late complications”), the authors stated that abortion was one of the most frequently performed gynecological procedures and it was therefore imperative to ensure it was as safe as possible.

In regard to pain relief, research articles by Polish gynecologists as well as summaries of articles published in foreign journals emphasized that [End Page 109] anesthesia was an essential part of the procedure.⁸⁹ Some even argued that the use of anesthesia was essential to the procedure’s safety, such as a 1964 article by Aleksy Jurewicz from Warsaw Military Medical School’s Clinic of Women’s Diseases and Obstetrics, at that time directed by the aforementioned Jerzy Higier. Published in a journal for physicians, Wiadomości Lekarskie, this article highlighted that most women undergoing termination were “afraid of pain and requested a painless surgery.” Although anesthesia carried its own risks, and many practitioners believed the short procedure could be successfully performed without the drug, Jurewicz and others working at the Clinic of Women’s Diseases and Obstetrics disagreed: “It is considered that even a short surgery should be painless. . . . A non-anesthetized patient could react to pain with an abrupt movement, and this could lead to harming the uterus, especially a pregnant one.”⁹⁰

Further, Jurewicz added, screams from the patient could unsettle the physician performing the procedure and increase the likelihood of mistakes. In anticipation of these risks, the Clinic of the Warsaw Military Medical School had protocolized the routine use of various forms of anesthesia to make terminations safer and more comfortable. This article illustrates not only practitioners’ interest in improving these aspects of abortion, but also how this interest was a product of patient demand. Publication in Wiadomości Lekarskie could be interpreted as either a desire to broaden readership or the fact that such framing of abortion was not acceptable in Ginekologia Polska.

Conclusion

This analysis of debates about abortion in the primary Polish journal for gynecology and obstetrics provides insight into historical and contemporary engagements with pregnancy termination by Polish gynecologists and the ways in which they defined and redefined indications for terminations. Shortly after the 1956 abortion law was enacted, the overwhelming majority of terminations began to be classified as “social,” with women’s [End Page 110] agency in determining these “social” indications not only recognized and promoted by the Ministry of Health but normalized in the pages of Ginekologia Polska. From the 1970s onward, “therapeutic” abortion began to refer to that of a fetus with diagnosis or suspicion of malformation, although, in absence of legal regulation of fetal indications for terminations, an emphasis on the social and personal consequences of raising an “imperfect” child blurred the lines between “social” and “therapeutic.” The fetal indication brought doctors back into the decision-making process, although women’s agency—and responsibility—was still evident. This process, however, facilitated the subsequent dematerialization of women-related health indications during state socialism, and the predomination of the narrow interpretation of women’s “health,” omitting personal, social, and corporal well-being, that followed the partial recriminalization of abortion in 1993.

While dire warnings about the risks of abortion were a mandatory attachment to almost all discussion concerning this procedure in expert forums, an unnuanced emphasis on the dangers during the 1970s, and extremely limited space given to safe abortion technologies, also contributed to the positioning of (legal) abortion as “unhealthy,” and not, as had been represented in the late 1950s and 1960s, a solution to maternal mortality. Debates about the risks of abortion among Polish gynecologists exemplify social and cultural constructions of safety and danger as two ends of a spectrum. Experts’ positions on this continuum were deeply rooted in their preexisting ideas about abortion, as well as women’s agency and reproductive autonomy. The growing presence of nationalistic arguments against abortion from the 1970s onward showcases the progressive saturation of Polish gynecological debate by such discourses, or at least their public visibility and legitimization. In this sense, it is fair to speculate that, apart from state censorship, various forms of (self-)censorship operated in professional forums, permanently marginalizing some themes and research (such as safe abortion technology) and freezing and thawing others (such as abortion risks). During the 1970s, a time of increasing public anxieties about (de)population and an alliance between the party-state and Catholic Church in Poland, the unnuanced representation of abortion as unhealthy, paired with the beginning of the restitution of gynecologists’ unquestioned authority in the abortion decision-making process, infiltrated the professional cultures of abortion providers. This contributed to an increasing deauthorization of those who normalized abortion as part of reproductive health care in their research and practice. [End Page 112]