maternal health

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Anti-choice researchers recently published a dangerously flawed study that examined various factors associated with Chile’s declining maternal mortality rate, and concluded — incredibly — that the legal status of abortion has no influence on maternal deaths in Chile, a country that completely prohibited abortion for any reason in 1989.

The study, published in full online at PLoS ONE, is entitled “Women’s Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007.” It looks deceptively like a professional mainstream study. However, the lead author is Dr. Elard Koch of Chile’s Universidad Católica de la Santísima Concepción (Catholic University of the Most Holy Conception), who is clearly anti-choice and has been arguing for years that legalizing abortion does not improve maternal health, against all evidence to the contrary. The second author is John Thorp, an anti-choice doctor from North Carolina and member of the “Law of Life Project,” which sought to intervene last fall in a lawsuit by abortion providers against the state’s “Woman’s Right to Know Act.” The other five co-authors are all from Chile and appear to be Catholic doctors or researchers.

Koch et al.’s justification for their bizarre conclusion that criminalized abortion does not kill women, appears to be that unless official abortion numbers can be obtained from governments or hospital records, illegal abortion does not occur and can be simply disappeared under the rug, along with any concern for the safety and lives of women who resort to illegal abortion. The authors’ dismissal of pretty much anything other than official “vital statistics” obfuscates the glaring fact that illegal abortions, by definition, are clandestine and not reported, and that most would never come to the attention of any authorities.

Estimating the incidence of illegal unsafe abortion as well as the resulting deaths and complications is of course a challenging task. A variety of methods must be used to carefully piece together a picture that is as reliable as possible. For Koch et al. to simply toss out all such methods as “speculative” or “unsupported” is itself both those things. It is disingenuous and unwarranted for the authors to limit acceptable evidence to “vital statistics,” which provide only a fragment of the evidence-based picture around the incidence of illegal abortion.

The Guttmacher Institute has published an excellent “evidence check” against the Koch et al. paper, and while Dr. Koch has responded, his long-winded reply still fails to adequately address the criticisms, contains numerous factual errors and distortions, and continues to dismiss other evidence besides official statistics as “speculative assumptions.” For example, Koch states: “So far, we are unaware of empirical data demonstrating a causal link between prohibiting abortion and an increase in maternal mortality.” This is an astonishing claim given the well-known example of Romania, where under the Ceausescu regime of criminalized abortion (1964-1989), 87 per cent of maternal mortality in 1989 alone was attributed to unsafe, illegal abortion. Strong evidence that criminalized abortion leads to more maternal deaths is also available from other countries, including the U.S., South Africa and Nepal. (Koch makes many other fallacious claims in his rebuttal that I don’t have the space to address, but some are refuted in more detail here.)

Incidentally, Koch and some of his co-authors have also recently published a piece in Spanish, in which they claim that the Guttmacher Institute — a highly respected researcher on global reproductive health issues for the last 40 years — has grossly inflated their numbers of illegal abortions in many countries in Latin America by using poor methodology and biased assumptions. But what’s more difficult to believe — that Guttmacher, along with the World Health Organization, United Nations, and other global human rights organizations working for decades in the field of reproductive health and rights, are all scientifically incompetent or irresponsible? Or that a small group of Catholic doctors and researchers might be motivated by anti-choice ideology?

I suggest that the hidden hypothesis behind both of these Koch et al. studies is the preposterous anti-choice dogma that criminalizing abortion somehow stops abortion. Those who want to keep abortion illicit must justify their stance by “proving” that illegal unsafe abortion doesn’t happen, at least nowhere close to the estimates of highly regarded researchers and organizations. This mission has been on the anti-choice agenda for years already, including in Canada. The study authors demonstrate a key way to further that mission — by largely ignoring historical experience and global comparisons in the context of abortion practice, which provide overwhelming evidence that women around the world have always had abortions, whether legal or not.

To help obfuscate the incidence and consequences of illegal abortion, Koch et al. present as their main conclusion (in the PLoS ONE study) that women’s educational level is the primary factor leading to the decline in maternal deaths in Chile. This is hardly groundbreaking, since higher education has long been correlated with better health outcomes the world over. Other key factors cited by the authors, such as the availability of clean water and skilled birth attendants, are also blatantly obvious predictors of improved maternal health outcomes, but help dress up the study as scientific and untainted by anti-choice ideology. Of course, the factors influencing maternal health and mortality in Chile and elsewhere are complex and varied. The legal status of abortion is only one aspect that can easily get obscured by other competing factors, and this is exactly what the study authors have attempted to do. But the bottom line is that if abortion was safe and legal in Chile, the country’s maternal morbidity and mortality rates would be even lower than they are.

Another well-established global fact is that good availability of contraception significantly reduces unintended pregnancies and thus abortions. Therefore, the key factor in Chile’s declining maternal mortality rates since the 1960s is far more likely to be the country’s family planning program introduced at that time — but this rates only a passing mention by the study authors.

To counter the large body of evidence that legalizing abortion decreases maternal mortality, the authors cite Ireland, Malta and Poland as other countries with illegal abortion and low maternal mortality, ignoring the fact that women in all three countries routinely travel to nearby countries to obtain safe, legal abortions — a near-impossible alternative for Chilean women, since abortion is criminalized in neighbouring Latin American countries. (To be fair, Dr. Koch concedes this point in his response to Guttmacher).

Further, many studies have demonstrated that abortion is frequently underreported or misreported by women and health-care workers, especially in regions where it’s criminalized. Even without that direct evidence, the stigma and illegality of abortion, and the fear of shaming or prosecution, make this an obvious commonsense conclusion that cannot be denied.

The Koch et al. article has been distributed widely through anti-choice circles since its publication, which helps explain why it’s the second most viewed study on women’s health on the PLoS ONE website (as of this writing). The study will undoubtedly serve as a key source for anti-choice lobbyists trying to influence the policy decisions of governments. For example, it could lead to decreased funding for reproductive health programs in developing countries — such as what happened in Canada in 2010, or further restrictions on abortion despite current laws that still kill 47,000 women a year and injure over 8 million. By rendering those women invisible, the study becomes a dangerous weapon that threatens to slow down the global decrease in maternal mortality and continue allowing women to suffer and die unnecessarily.

Joyce Arthur is the founder and Executive Director of Canada’s national pro-choice group, the Abortion Rights Coalition of Canada (ARCC), which protects the legal right to abortion on request and works to improve access to quality abortion services.


Joyce Arthur

Joyce Arthur is the founder and Executive Director of the Abortion Rights Coalition of Canada, a national pro-choice group in Canada.