PBA330H: Maternal Mortality

Abortion advocates sometimes claim that “abortion is safer than childbirth” or “without legal abortion, women will die.” How can we respond?

The detailed answer is that advances in medicine and proper maternal healthcare are what make pregnancy safe, not abortion. This is a bit of a deep dive on the statistics and case studies so that we have the background to understand why abortion is not the answer to reducing maternal mortality.

this content is good, but it needs to be explained in a more accessible way, otherwise people get lost in the stats and don't get the bigger point. Some slides/visuals to illustrate the points? Or more of a concise summary? Perhaps changing the flow - this starts out deep in the weeds and slowly works towards a succinct conclusion, instead of maybe answering the question up front and then elaborating?

A related argument is that abortion should be legal or ethically permitted in order to defend the health of women who might die from illegal abortions.

Dr. Bernard Nathanson¹⁾:

How many deaths were we talking about when abortion was illegal? In NARAL we generally emphasized the drama of the individual case, not the mass statistics, but when we spoke of the latter it was always “5,000 to 10,000 deaths a year.” I confess that I knew the figures were totally false, and I suppose the others did too if they stopped to think of it. But in the “morality” of our revolution, it was a useful figure, widely accepted, so why go out of our way to correct it with honest statistics?

• Prior to the legalization of abortion, deaths from abortion decreased dramatically throughout the 20th century
  • e.g. National Center for Health Statistics reported 1231 abortion deaths in 1942 and 120 in 1972
  • Medical advances such as the use of sulfa, penicillin, and safer abortion techniques - not legalization - resulted in fewer deaths²⁾
  • Legalization does not necessarily make abortion safe, as there are many examples of women who die from legal abortions³⁾

• Dr. Byron Calhoun's article: “The Maternal Mortality Myth in the Context of Legalized Abortion”
  • Responds to the claim that “the risk of death associated with childbirth is approximately 14 times higher than with abortion”
  • Calhoun argues that there is no credible scientific evidence to support this claim
  • For your own background information, we're going to spend a bit of time understanding the abortion death rate and the maternal mortality rate, and why it's not possible to draw such a conclusion
• Understanding the Maternal Mortality Rate:
  • The maternal mortality rate is the number of deaths from pregnancy per 100,000 live births
    • The number of deaths resulting from pregnancy is difficult to determine because there is lack of consensus regarding the time line
    • Should a death within a month, six months, or a year after birth be attributed to pregnancy?
    • The numerator of maternal deaths includes deaths from ectopic pregnancies, molar pregnancies, miscarriage, and still births - none of which fall into the category of live births
      • “40 percent of the deaths are never represented in the denominator, resulting in a dramatically over-inflated maternal mortality rate”
      • “Moreover, the majority of women who survive ectopic pregnancies, miscarriage, and stillbirth will not be in the data at all since their pregnancies do not result in live birth”
  • Women who are aware they are pregnant “have already survived beyond the period of pregnancy's greatest risk” - Kaczor believes Calhoun is talking about tubal ectopic pregnancies
    • 19.7 cases per 1000 pregnancies in North America, and the leading cause of maternal mortality in the first trimester
    • While these deaths are tragic, they are not relevant for the discussion of elective abortion - “despite some controversy about particular ways of treating ectopic pregnancy, everyone agrees that the general treatment of ectopic pregnancy is morally and legally legitimate… even though a developing human being will die as a side-effect of the medical treatment”⁴⁾
    • Furthermore, abortion actually increases the likelihood of future ectopic pregnancy, according to several studies - “more abortions lead to more ectopic pregnancies; more ectopic pregnancies lead to more maternal deaths”⁵⁾
• Determining the risk of abortion cannot be done with precision, at least in the US
  • Lack of consensus on the time line
    • e.g. What if an abortion causes a woman to have an ectopic pregnancy two years later? Her death would not be attributed to abortion, but to pregnancy!
  • In order to know how dangerous abortion is, it is also necessary to know both how many abortions take place and the number of deaths and complications that result from these abortions.
    • If either the numerator or the denominator of this ratio is unknown, it is impossible to determine the risk of death from abortion.
    • If we cannot determine the risk of death from abortion, we cannot compare this risk to the risk of childbirth.
      • Although we do have reliable statistics on maternal death from pregnancy, we do not have reliable statistics on maternal deaths from abortion⁶⁾
        • There is simply no uniform, mandatory, and consistent way of tracking deaths from abortion in the US, which relies on voluntary reporting methods when it comes both to the numbers of abortions and the numbers of maternal fatalities from abortion⁷⁾
  • (skip) NOTE: There's a comparison to be made here about the difficulty of determining the cause of death with the COVID-19 comorbidity questions, except be careful not to be ridiculously ignorant about it - there might be more confusion than benefit in making this analogy because of the ignorance and internet misinformation, especially on the right…

Conclusion / Broader Point: We simply don't have an apples to apples comparison of the death rate from pregnancy and the death rate from abortion. There are problems in determining either rate individually, nevermind being able to make a fair comparison.

Other problems:

• Calhoun notes that at least seven different definitions of “abortion related deaths” are used, some of which do not distinguish between spontaneous abortions (involuntary miscarriages), elective abortions, and therapeutic abortions (such

as ectopic pregnancy)⁸⁾

• Many women sufferings from complications of abortion are treated by emergency room doctors who may not be made aware of the prior abortion. Deaths in these cases may be attributed only to the most immediate cause, such as sepsis or hemorrhage, without indication that it was an abortion which brought about the sepsis or hemorrhage.
• Another factor compounding the difficulty of finding reliable data is the impact of substance abuse, depression, and suicide resulting from abortion and leading to death.

The claim that childbirth is more risky than abortion depends upon a comparison of two ratios: the risk of giving birth and the risk of getting an abortion. Reliable data for either ratio is not available. Arguments for legalization or ethical permissibility of abortion cannot justifiably rely on the claim that giving birth is more risky than getting an abortion.

Is legalized abortion a boon for women’s health? One way to examine this question is to compare countries where abortion is legal to countries where it is not?

Based on study of 42 years of comparing England, Wales, Scotland, with Northern Ireland and the Republic of Ireland, they found that the countries with legal abortion actually had higher maternal mortality rates.

Calhoun concludes, “the legal status of abortion had no relationship to the reduction in maternal mortality. Rather, the reduction in maternal deaths during pregnancy was related to the better education and obstetrical care for women available in the different time periods”

We can see this pattern across several countries that are good test cases for the question. If we can't compare MMR with AMR because the numbers are not reliable or comparable, we can at least compare changes if those measurements over time in countries where there has be legalization or criminalization of abortion.

Chile liberalized abortion laws in 1931 and then later banned virtually all abortions in 1989 (permitting abortion only to save the life of the mother, such as ectopic pregnancy).

• The maternal mortality ratio (MMR) dropped throughout the years from 1909 through 2009
  • During this 100 year span, abortion was decriminalized and then recriminalized
• When Chile liberalized abortion laws in 1931, there was no significant decrease in MMR
  • the highest peak of the MMR occured in 1937. In fact, there's a 32 percent increase in MMR between 1931 and 1937.
• When Chile banned virtually all abortions in 1989, this did not lead to an increase in the MMR
  • After criminalization, the MMR as well as the number of women dying from abortions both continued to drop
    • The abortion mortality rate decreased over 96 percent after abortion banning in 1989 from 10.0 to 0.039 per 100,000 live births

Why is this?

The factors that made the biggest difference in lowering maternal mortality per capita were clean water, increasing female education achievement, systematic prenatal care, and complementary nutrition programs for children and pregnant women — not the legal status of abortion

Poland had state funded abortion for decades and then criminalized most abortions after the 1989 Solidarity revolution of independence from communism. Poland provides a test case of how illegalization of almost all abortion and women’s health are related.

As of 2000:

To everyone’s surprise, there have been 25% fewer miscarriages and 30% fewer women dying compared with what it had been while abortion was legal

Examining the other side of the coin, the legalization of abortion in Guyana in 1995 did not reduce maternal mortality. Indeed, Koch notes, the maternal mortality ratio increased after legalization of abortion (Koch 2013, p. 159). What matters for improving women’s health, Koch argues, is increased female education, nutrition programs for mothers and children, access to prenatal health services, advances in emergency obstetrics, and advanced sanitation.

• When abortion was illegal in Ireland, Ireland still had lower maternal morbidity rates than Scotland and England, where abortion was legal⁹⁾

Very few women died from illegal abortion in the 1960s and early 1970s - before changes to the laws. In fact, a key argument in Roe v. Wade was that abortion prohibitions were outdated because the laws were meant to protect women because abortion was dangerous, but since abortion was no longer dangerous, the legal prohibition was no longer needed. And many of the same physicians were performing abortions when it was illegal and then legalized, e.g. Morgentaler.

The legal status of abortion has no real connection with maternal mortality. Rather, it's proper medical care that changes the MMR, regardless of the legal status of abortion. Looking at proper examples like Chile, Ireland, Poland and Guyana provide the data needed to answer that question.

Abortion advocates often point to developing countries or oppressive totalitarian regimes in the middle east where abortion is illegal and the MMR is high compared to developed countries where abortion is legal. This is not a fair comparison if these countries have lower quality medical care, education, clean water, etc. We don't know what the MMR would look like in those same countries if only one variable was change: the abortion law. However, when we look at countries like Poland, Ireland, Chile, and Guyana we can see accurate comparisons - we can actually measure what happened when that one variable was changed.

It's medical care that makes the difference - not the legal status of abortion.

Let's look at the MMR data from 2017:

• Canada: 10 (2017)
• United States: 19 (2017)
• Ireland: 5 (2017)
• Poland: 2 (2017)

dialogue example of comparing the US and Ireland before 2018. “Abortion was totally illegal in Ireland before 2018, yet Ireland had one of the lowest MMRs in the world, lower than the US where abortion was legal. Abortion is almost entirely illegal in Poland, and Poland has a lower MMR than the United States as well. If legal abortion is what reduces the MMR, why would a country like Ireland and Poland have fewer maternal deaths even when abortion is illegal? Lower than even Canada? The answer is that the MMR depends on the quality of healthcare available, not the legal status of abortion.”

But, let's pretend abortion was safer than childbirth.

The argument about the relationship between women’s health and abortion is an important one, but it is only one aspect of a larger conversation. Let’s suppose that giving birth were more risky for a woman’s health than getting an abortion. Let’s suppose that legalized abortion did lead to lower overall rates of maternal mortality. Would it follow that abortion is morally permissible? Would it follow that abortion should be legalized? It seems clear that a few other questions must also be answered in order to come to a balanced and holistic judgment. These questions include, is the human being in utero someone who has intrinsic worth and equal basic dignity? Is it permissible to intentionally kill one human being (one’s own son or daughter) in order to lower the likelihood of adverse effects for oneself? It is permissible to use one person simply as a means, indeed to destroy this person’s life, in order to achieve some worthwhile end? It is also relevant to mention that abortion may be more or less risky for the woman involved but it is always fatally risky for the fetus involved. Abortion may or may not leave one injured, but it always leaves one dead.

The key to the response:

• Compare Canada/US to Ireland/Poland - it can't be legal abortion that's necessary to save lives
• Bring it back to the central question: _Every_ successful abortion kills a human being. If we add the abortion deaths of the children who are killed by the abortion, it's clear that abortion is not the safer option.

Bonus, information on the debate about the Texas MMR:

• https://www.youtube.com/watch?v=BPzhk-rdv7M
• https://www.youtube.com/watch?v=1nHGH96YHkQ
  • https://lozierinstitute.org/new-study-maternal-mortality-in-texas-rose-earlier-than-previously-claimed/