By Randall K. O’Bannon, Ph.D., NRL-ETF Director of Education and Research
When Elard Koch and his colleagues published his study showing that abortion limits do not lead to increases in maternal mortality, they upset more than few apple carts. Chief among them was the Guttmacher Institute, which has for years published “studies” claiming the exact opposite.
Koch et al’s study, “Women’s Education Level, Maternal Health Facilities, Abortion Legalisation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007,” which appeared in the May 2012 edition of the journal PloS ONE, followed 50 years of government statistics. Chile made abortion illegal in 1989, yet maternal mortality rates continued to drop, showing that abortion limits are not associated with increases in maternal mortality, contrary to claims long made by Guttmacher and others.
Koch et al’s carefully documented conclusion was that better education and improved medical care were the sort of factors which led to decreased maternal mortality, not abortion.
Though Guttmacher’s claims were not the focus of Koch’s article, Guttmacher recognized the threat posed by the Chilean study and responded aggressively, defending its own claims and its methods. In an advisory published on its website, Guttmacher claims that the Chilean study “has several serious conceptual and methodological flaws that render some of its conclusions pertaining to abortion and maternal mortality invalid”
Though Guttmacher does not specify what the technical “methodological” errors might be, it does offer four basic criticisms of the Koch study: 1) That Chile’s abortion laws before 1989 were already restrictive, so that no conclusions could be drawn from the change; 2) That authors rely on a narrow, unreliable database; 3) The conclusion of the Chilean study on abortion’s impact “is not supported by the existing body of evidence”; 4) The authors underestimate the incidence of hospitalizations for complications of “unsafe” abortions in Chile. None of their claims hold weight.
Guttmacher argues that research indicates the drop in maternal mortality rates in Chile is due to “greater access to and use of contraceptives” and the private use of chemical abortifacients like misprostol. (Misoprostol is the prostaglandin used in conjunction with RU486 in the United States but is capable of inducing an abortion on its own by stimulating powerful uterine contractions to expel the unborn child.)
Despite the considerable evidence obtained by Koch and his colleagues, Guttmacher maintains in the end that “The evidence on abortion laws, unsafe abortion and maternal health indicates that further reductions in Chile’s maternal mortality and morbidity could be achieved by such strategies as liberalizing the country’s abortion law and giving women meaningful access to safe and legal abortion services.”
In an interview with Steve Weatherbe, a reporter for National Catholic Register, lead researcher Elard Koch responded to Guttmacher’s charges in some detail (www.ncregister.com/daily-news/new-study-rejects-claim-that-where-abortion-is-illegal-maternal-mortality-I). The point-by-point rebuttal Koch offered in the interview can be found in Weatherbe’s blog at faithvictoria.wordpress.com/2012/05/20/a-chilean-study-disproves-a-pro-abortion-article-of-faith.
Koch describes as “major misinformation” the claim that Chile’s abortion policy was nearly as restrictive before prohibition as after. Though abortion was allowed for “therapeutic reasons” prior to 1989 (permitted after three physicians or one physician and two witnesses from 1931 to 1967, allowed based on opinion of just two physicians from 1967 to 1989), Koch says that in practice this was interpreted very broadly, with physicians authorizing abortions for socioeconomic reasons, “mental health reasons,” or simply “on request.”
Koch notes that at just one hospital in Santiago, over 3,000 abortions were performed “on request” in 1973, giving just a hint of how liberally this condition was interpreted and how many thousands of unborn lives slipped through the loophole.
The new law does not have this wiggle room, Koch argues. While the language allows the delivery of a pre-viable fetus when the object is to save the life of the mother, the word “therapeutic” is no longer in the statute, and statistics before and after 1989 are indicative of a real change.
Koch told Weatherbe that in the 1960s, abortion (both spontaneous–that is, miscarriage–and induced) was the leading cause of maternal mortality, and over 40% to 50% of all abortion related hospitalizations were attributable to clandestine abortions. Between 2001 and 2008, only 12% to 18% of abortion hospitalizations are attributable to complications from these clandestine abortions.
Abortion mortality generally decreased in line with decreasing general maternal mortality, challenging the suggestion that women simply turned to illegal methods and had their deaths miscoded after failing to seek medical help. Of this claim, Koch says “given the strengths and integrity of the Chilean registry of maternal deaths and live births, as well as the widely acknowledged credentials of the Chilean INE [National Institute of Statistics], it is highly unlikely that maternal deaths of any kind (including those caused by complications of any kind of abortion) are misrepresented or under-reported.” That they had data from the 1960s showing high numbers of maternal deaths due to abortion was, in fact, evidence of the quality of their data.
Koch thus argues that the Chilean team’s reliance on the country’s vital statistics was not a weakness of their study, as Guttmacher claims, but a strength.
Koch goes into some detail outlining the rigorous statistical methods used to collect, measure, and check the study data. Those wanting such detail are free to read his lengthy response on the faithvictoria blog linked above.
Suffice it to say that Koch and his colleagues relied on broad, consistent, hard scientific data on vital statistics that has been recognized by both the United Nations and the World Health Organization as among the world’s best.
The Guttmacher criticism is all the more remarkable given that Guttmacher customarily relies on “surveys of women and surveys of health professionals” to generate its international estimates. Of these, Koch says that while they may have some anecdotal value, these indirect methods are “flawed from an epidemiological viewpoint,” and can lead to under or overestimations. And because of the “subjective nature of opinion surveys,” Koch notes, these “can be extremely biased.”
Koch gives the examples of Mexico and Guatemala. In 2006, using these survey methods, Guttmacher estimated there were between 700,000 and 1,000,000 illegal abortions being done in Mexico each year. This figure was used to raise the specter of a crisis in the government and on the streets of Mexico, leading to the legalization of abortion there on April 24, 2007. Yet since legalization, the number of abortions reported in Mexico has only been a fraction of that, ranging from 13,404 in 2008 to just 20,314 in 2011. Even taking the highest figure and Guttmacher’s lowest estimate, that would mean that Guttmacher overestimated by a factor of more than thirty!
Researchers from Guttmacher estimated that there were over 400,000 abortions a year in Colombia, yet when added to the 715,453 live births recorded in Colombia for 2008, Koch points out that this “leads to a figure of pregnancies beyond the empirically possible reproductive rate for that country.”
This is something to consider when assessing the “existing body of evidence” that Guttmacher has collected in support of its claim that abortion limits are associated with high maternal mortality and that abortion legalization leads to lower rates of maternal mortality. Koch gives numerous counterexamples where countries like Chile, Ireland, Malta, and Poland which protect unborn children have declining maternal mortality rates while countries allowing abortion such as the U.S. and Canada show increases.
There are countries, Koch admits, like Nicaragua and El Salvador which limit abortion and still have high maternal mortality rates as well as countries like Guyana who show no decrease in maternal mortality rates following legalization, arguing against any sort of broad generalization of the sort made by Guttmacher. Koch argues, based on his own findings, that education, rather than abortion policy, is a better predictor of maternal mortality rates.
Guttmacher tries to argue that the highest maternal mortality rates are found in subregions with high “unsafe abortion rates and abortion-related maternal deaths, while such deaths are low or non-existent in countries with “liberal abortion laws.” Koch points out that the subregions Guttmacher refers to that have both abortion limits and high maternal mortality rates are typically undeveloped or underdeveloped countries “exhibiting fundamental deficiencies such as high illiteracy rates of the mothers, poor access to maternal health facilities, low proportion of childbirth delivered by skilled attendants, malnutrition, insufficient access to clear water and sanitary sewer, etc.”
In light of those deficiencies, Koch says, “it is not possible to do a causal assumption from circumstantial or purely descriptive data without taking into account these major factors identified to substantially decrease maternal mortality.”
Koch has little trouble answering the remaining charge– that Chile’s low maternal mortality rates were due, not to the factors cited in the Chilean study, but increased contraceptive use and the black market dissemination of misoprostol. Koch and his colleagues acknowledged in their paper that Chile’s contraceptive program had helped reduce abortion rates, although Koch says their data indicated that fertility reduction was not limited to the use of artificial contraceptive means alone.
As for the claim that abortion has merely shifted to private chemical means like misoprostol, Koch labels this “speculation unsupported by our epidemiological data.”
Koch points out that misoprostol didn’t hit the Chilean black market until the late 1990s, long after maternal mortality rates had already significantly dropped. Furthermore, Koch notes, misoprostol is not sold over the counter in Chile and prescriptions are audited month-by-month by the Chilean Institute of Public Health, making it difficult to prescribe for purposes other than the approved use of addressing ulcers.
Having invested so much in the twisted thesis that a country must legalize abortion in order to save lives, the fervency of Guttmacher’s attack on Koch’s study and defense of its own research is not surprising. Yet after all is said and done, the Chilean study and its conclusions still stands, and the most careful and rigorous research still shows that you don’t reduce maternal mortality by legalizing the slaughter of unborn children.
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