Elard Koch

A ground-breaking abortion study from Chile

Elard Koch
By Elard Koch
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A groundbreaking study of abortion in Chile published last week in the scientific journal PLoS One found that illegal abortion is not associated with maternal mortality. At a time when access to legal abortion is deemed absolutely necessary for women’s health, this shatters long-standing assumptions. In this exclusive interview, Dr Elard S. Koch (pictured below), the lead author of the study, defends his findings.


MercatorNet: Chile is not alone in restricting abortion. Poland, Malta and Ireland also have very restrictive rules and a low maternal mortality rates. But this has been known for years. Has no one studied it before?

Elard Koch: The Chilean study is the first in-depth analysis of a large time series, year by year, of maternal deaths and their determinants, including years of education, per capita income, total fertility rate, birth order, clean water supply, sanitation, and childbirth delivery by skilled attendants, and including simultaneously different historical policies.

In this sense, it is a unique natural experiment conducted in a developing country. Thus, a first difference between the data from Chile and data from Poland, Malta and Ireland is that, in the case of Chile, there is a rigorous analysis controlled by multiple confounders. It is not a matter of circumstantial or anecdotal evidence, but a matter of scientific data representing real, vital events whose methodology has been published for the first time in a peer-reviewed scientific journal.

A second consideration relates to the degree of abortion prohibition in the different countries. Taking into account the countries in your question: in Chile, all types of abortion were prohibited in 1989. In Malta, abortion is banned in all cases but it is not prosecuted when pregnancy threatens the life of the mother. In Ireland, abortion is illegal except in cases of substantial risk to the mother, including the threat of suicide. Finally, in Poland, abortion is prohibited except in the case of danger to the mother’s health, when the pregnancy is the result of a criminal act, or when the foetus is seriously malformed.

It is worth noting that since most European countries allow elective abortion, it may be easier for women from Malta, Ireland, and Poland to travel for an abortion and this may be acting as a confounder which is difficult to control.

In contrast, due to abortion prohibitions in most Latin American countries, it is unlikely that a significant number of abortions can be performed by Chilean women abroad.

In addition, for Poland maternal mortality rates were already low at the time of passing restrictive abortion laws, possibly due to public policies similar to those promoting the decrease of maternal mortality in Chile. To test this hypothesis, analysis of maternal mortality data from this country is required, possibly in a similar manner to the one published for Chilean data.

Finally, the evolution of maternal mortality in Poland, Malta, and Ireland is yet to be analyzed in depth in the formal biomedical literature. In fact, such analysis was also lacking for Chile before our publication.

MercatorNet: Chile’s National Women’s Service (Sernam), estimates that at least 10 percent of maternal deaths are caused by complications from attempted abortions. Abortion is the fourth most common cause of maternal death in Chile. Your comment?

Elard Koch: This constitutes a harmful misinformation spread by Sernam. Indeed, according to the tenth revision of the International Codes of Disease (ICD), in 2008 5 deaths were attributed to codes O00-O07 out of 41 total maternal deaths (codes O00-O99)—12% of maternal deaths. Knowledge of and familiarity with the ICD-10 revision quickly orientates interpretation and correct translation. Maternal mortality comprises codes O00 to O99. Codes O00-O08 are labelled “pregnancy with abortive outcome”. In Spanish this should be translated as “Embarazo con desenlace abortivo”, and not “Embarazo terminado en aborto” (literally: pregnancy ended in abortion) as the Chilean Ministry of Health depicts.

To declare that abortion is present in all these pregnancies is misleading, because it is then interpreted as induced abortion and actually means that “10 percent of maternal deaths are caused by complications from attempted abortions”.

In fact, of the 5 cases that took place in 2008, 3 were ectopic pregnancies and 2 were actually unspecified abortions, presumably attributable to clandestine abortion. Thus, a more precise statement should be that 2 out of 41 cases were attributable to complications of abortion. This means 4.87% and not more than 10% of the total maternal deaths registered that year.

Moreover, due to the very low maternal mortality exhibited by Chile, it is inappropriate to use percentages to refer those causes that only have 1 or 2 cases. The risk of maternal death by abortion in Chile was 1 in 2,000,000 women at fertile age in 2008 and 1 in 4,000,000 women at fertile age in 2009.

In other words and from an epidemiological perspective, when the numerators are very low, the proportions and rates are very unstable for comparison purposes because 1 or 2 cases make a big change in the proportion or rates.

As discussed in our article, according to the most recent report published by Chilean National Institute of Statistics, the maternal mortality ratio for 2009 was 16.9 per 100,000 live births (43 deaths) and the figures for indirect causes (codes O99, O98), gestational hypertension and eclampsia (codes O14, O15), abortion (code O06), and other direct obstetric causes were 18 (41.9%), 11 (25.6%), 1 (2.3%) and 13 (30.2%) respectively.

MercatorNet: Some critics argue that the decline is mostly attributed to women’s increasing use of misoprostol and mifepristone, which are far safer than other clandestine methods. What will eventually be the effect of widespread use of RU-486 and other do-it-yourself abortion drugs?

Elard Koch: Explaining the decrease of maternal mortality ratio in Chile as a result of using drugs such as misoprostol, mifepristone or RU-486 is speculation unsupported by our epidemiological data. As a scientist, I am concerned about actual empirical data supporting any causal assumption. It is a matter of scientific facts supported by real vital data. Clearly, no study currently exists which seriously supports a decline in maternal mortality associated with the use of abortifacient drugs such as misoprostol or mifeprestone in Chile.

Therefore, this is just a speculative assumption. Indeed, our study shows that global maternal mortality ratio—as well as mortality by abortion—steadily decreased from 1965-1967. This was before the development and commercialization of the abovementioned drugs with abortifacient effects.

In fact, these drugs were introduced in the Chilean black market in the late 1990s, making it extremely unlikely that their introduction had any important influence on overall rates of maternal mortality, which were already significantly reduced at that time.

In addition, and as discussed in our article, the methods used to conduct clandestine abortions at present may have lower rates of severe complications than the methods used in the 1960s, mainly based on highly invasive self-conducted procedures. Therefore, the practically null abortion mortality observed in Chile nowadays can be explained by both a reduced number of clandestine abortions and a lower rate of severe abortion-related complications. This phenomenon also seems to be related to joint-effects between increasing educational levels and changes in the reproductive behaviour of Chilean women, an observation that requires further research.

We also discuss the fact that the practically null abortion mortality observed does not imply that there are no illegal or clandestine abortions in Chile nowadays.

Rather, the current abortion mortality ratio and recent epidemiologic studies of abortion rates in this country suggest that clandestine abortion may have been reduced in parallel with maternal mortality and may have currently reached a steady state based on stable ratios between live births and hospitalizations by abortion.

It is to be expected that any major increase in the magnitude of clandestine abortions will necessarily be followed by an increase in abortion hospitalizations. But our analysis shows that Chile exhibits a steady decrease in abortion-related hospitalizations over the last four decades, suggesting a decrease in clandestine abortions. In consequence, by observing the current Chilean registry of hospitalization for any kind of abortion, we can monitor possible changes in the trend of clandestine abortions, whatever the method used.

MercatorNet: In hindsight, was the 1989 ban justified? Did it save lives?

Elard Koch: In Chile, therapeutic abortion was prohibited in 1989 since it was considered unnecessary for protecting the life of the mother and her baby. From the perspective of the Chilean medical practice, the exceptional cases in which the life of the mother is at risk are regarded as a medical ethics problem to be solved by applying the principle of double effect and the concept of indirect abortion.

Thus, in Chile, exceptional problems that require medical intervention to save the life of the mother are considered a decision of medical ethics and not a legal issue. Therefore, any kind of directly provoked abortion was prohibited in 1989, in agreement with Article 19 of the Chilean Constitution which protects the life of the unborn.

The second question—does it save lives?—is very complex and important. We can address this important issue from different perspectives.

First, from a public health view, restrictive laws are hypothesized to cause a dissuasive effect on the population, similar to restrictions on tobacco or alcohol consumption. We observed that reduction of maternal mortality in Chile was paralleled by the number of hospitalizations attributable to complications of clandestine abortions. While over 50% of all abortion-related hospitalizations were attributable to complications of clandestine abortions during the 1960s, this proportion decreased rapidly in the following decades.

Indeed, only 12-19% of all hospitalization from abortion can be attributable to clandestine abortions between 2001 and 2008. These data suggest that over time, restrictive laws may have a restraining effect on the practice of abortion and promote its decrease. In fact, Chile exhibits today one of the lowest abortion-related maternal deaths in the world, with a 92.3% decrease since 1989 and a 99.1% accumulated decrease over 50 years.

Second, from the perspective of human life, especially if a developing country is looking to simultaneously protect the life of the mother and the unborn child, a plausible hypothesis after the Chilean study is that abortion restriction may be effective when is combined with adequately-implemented public policies to increase educational levels of women and to improve access to maternal health facilities. A restrictive law may discourage practice, which is suggested by the decrease of hospitalizations due to clandestine abortions estimated in Chile.

Third, from the perspective of protecting human life from the very beginning, obviously, abortion restriction saves many lives, in contrast to countries where elective—on demand—abortion is allowed, because in these countries all the unborn lose their lives.

Finally, it is necessary to remark that our study confirms that abortion prohibition is not related to overall rates of maternal mortality. In other words, making abortion illegal does not increase maternal deaths: it is a matter of scientific fact in our study.

Nevertheless, although our study definitively ruled out any deleterious influence of abortion prohibition on the maternal mortality trend, it cannot be immediately concluded that solely making abortion illegal is a direct causal factor for decreasing maternal mortality by itself.

The reduction in the maternal mortality trend in Chile is controlled by other factors, especially the educational level of women that positively influences other key variables, such as access to maternal health facilities, sanitary services and reproductive behaviour.

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Elard S. Koch is an epidemiologist from the Department of Family Medicine, Faculty of Medicine, University of Chile. This article reprinted from Mercatornet.com under a Creative Commons license.


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Jonathon van Maren Jonathon van Maren Follow Jonathon

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Arguments don’t have genitals

Jonathon van Maren Jonathon van Maren Follow Jonathon
By Jonathon van Maren

“As soon as he grows his own uterus, he can have an opinion.”

That was a comment left on The Abortion Rights Coalition of Canada’s Facebook page by a woman who presumably opposes men speaking out against misogyny, domestic abuse, rape culture, and female genital mutilation as well. Apparently, you see, male genitals disqualify people from speaking out on various human rights issues deemed by women who define themselves by their uteruses while protesting angrily against being defined by their uteruses as “women’s issues.”

Which abortion isn’t, by the way. It’s a human rights issue.

To break it down really simply for our confused “feminist” friends: Human beings have human rights. Human rights begin when the human being begins, or we are simply choosing some random and arbitrary point at which human beings get their human rights. If we do not grant human rights to all human beings, inevitably some sub-set of human beings gets denied protection by another group with conflicting interests. In this case, of course, it is the abortion crowd, who want to be able to kill pre-born children in the womb whenever they want, for any reason they want.

Science tells us when human life begins. Pro-abortion dogma is at worst a cynical manoeuvre to sacrifice the lives of pre-born human beings for self-interest, and at best an outdated view that collapsed feebly under the weight of new discoveries in science and embryology. But the abortion cabal wants to preserve their bloody status quo at all costs, and so they make ludicrous claims about needing a uterus to qualify for a discussion on science and human rights.

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In fact, feminists love it when men speak up on abortion, as long as we’re reading from their script, which is why the carnivorous feminists have such a support system among the Deadbeat Dads for Dead Babies set and the No Strings Attached Club.

Male abortion activists have even begun to complain about “forced fatherhood,” a new cultural injustice in which they are expected to bear some responsibility for fathering children with women they didn’t love enough to want to father children with, but did appreciate enough to use for sex. Casual fluid swaps, they whine, should not result in custody hearings.

This is not to mention a genuine social tragedy that has men forcing or pressuring women to have abortions or abandoning them when they discover that the woman is, indeed, pregnant.

Or the fact that abortion has assisted pimps, rapists, and misogynists in continuing the crimes of sex trafficking, sexual abuse, and sex-selection abortion.

And coming against these disgusting trends are thousands of men in the pro-life movement who believe that shared humanity means shared responsibility, and that when the weak and vulnerable are robbed of their rights, we have to stand up and speak out.

We are not at all convinced by the feminist argument that people should think with their reproductive organs or genitals. We think that the number of people currently doing that has perhaps contributed to the problems we face. And we refuse to be told that protecting the human rights of all human beings is “none of our business” and “outside of our interests.”

Arguments don’t have genitals, feminists. It’s a stupid argument trying to protect a bloody ideology.

Reprinted with permission from CCBR.


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Rachel Daly

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Gvmt strikes UK Catholic school admission policy that prefers Mass attendees

Rachel Daly
By Rachel Daly

St. Joseph's Catholic Primary School in Epsom, England, was ordered to change its admissions policy after it was ruled discriminatory by the nation's Office of Schools Adjudicator, according to Your Local Guardian. St. Joseph's reportedly had been granting preferred acceptance to students whose families attended Mass at the affiliated church.

St. Joseph’s School is for students from age 4 to 11 and describes itself as “enjoy[ing] a high level of academic success.” The school furthermore places high priority on its Catholic identity, affirming on its homepage that “We place prayer and worship at the center of everything we do.”

The school states in its current admissions policy that it was "set up primarily to serve the Catholic community in St Joseph’s Parish" and that when the applicant pool exceeds 60 students, its criteria for prioritizing students includes "the strength of evidence of practice of the faith as demonstrated by the level of the family's Mass attendance on Sundays." 

Opponents of this policy reportedly argue that since donations are asked for at Mass, it could allow donation amounts to influence acceptance, and that forcing non-accepted local students to seek education elsewhere imposes a financial burden upon their families. 

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As Your Local Guardian reports, the adjudicators dismissed claims that donation amounts were affecting school acceptance, given that it is impossible to track donations. Nonetheless, the adjudicators maintained that "discrimination ... potentially arises from requiring attendance at the church rather than residency in the parish."

The Office of Schools Adjudicators, according to its website, is appointed by the United Kingdom’s Secretary of State of Education, to perform such functions as mediating disputes over school acceptances. The Office's ruling on St. Joseph's will require the school to release a revised admissions policy, which is expected in the next few days.

Reprinted with permission from the Cardinal Newman Society.


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Carolyn Moynihan

African women at risk of HIV, hostages to birth control

Carolyn Moynihan
By Carolyn Moynihan

Which should be the priority for a health organisation: preventing an incurable disease, or preventing a natural function that might have adverse physical consequences?

Preventing the disease, you would think. But the World Health Organisation would rather expose African women to HIV-AIDS than withdraw its support from a suspect method of birth control, arguing that childbirth is also risky in Africa. Riskier, apparently, than the said contraceptive. And at least one of WHO’s major partners agrees.

This is one of the stories you will not have read in coverage of the International AIDS Conference held in Melbourne last week, despite the fact that WHO made an announcement about it during the conference and the findings of a highly relevant study were presented there.

The story is this: there is increasing evidence that the method of contraception preferred by family planning organisations working in Africa (and elsewhere) facilitates the transmission of HIV. The method is the progesterone injection in the form of either DMPA (Depo Provera, the most common) or NET-En (Noristerat).

Millions of women in sub-Saharan Africa receive the injection every three months. The method overcomes problems of access. It can be given by nurses or health workers. A wife need not bother her husband for any special consideration; the teenage girl need not remember to take a pill.

But for 30 years evidence has been accumulating that, for all its “effectiveness” in controlling the number of births, the jab may also be very effective in increasing the number of people with HIV.

Three years ago at another AIDS conference in Rome, researchers who had analysed data from a number of previous studies delivered the disturbing news that injectables at least doubled the risk of infection with HIV for women and their male partners.

That study had its weaknesses but one of the experts present in Rome, Charles Morrison of FHI 360 (formerly Family Health International, a family planning organisation that also works in AIDS prevention), considered it a “good study” and subsequently led another meta-analysis that addressed some of the issues with previous research.

Last week at the Melbourne conference he presented the results. His team had re-analysed raw data on the contraceptive use of more than 37,000 women in 18 prospective observational studies. Of these women, 28 percent reported using DMPA, 8 percent NET-En, 19 percent a combined oral contraceptive pill, and 43 percent no form of hormonal contraception. A total of 1830 women had acquired HIV while in a study.

The analysis showed that both injectables raised the risk of infection by 50 percent:

Compared to non-users [of any hormonal contraceptive], women using DMPA had an elevated risk of infection (hazard ratio 1.56, 95% CI 1.31-1.86), as did women using NET-En (1.51, 95% CI 1.21-1.90). There was no increased risk for women using oral contraceptives.

Similarly, comparing women using injections with those using oral contraceptives, there was an elevated risk associated with DMPA (1.43, 95% CI 1.23-1.67) and NET-En (1.30, 95% CI 0.99-1.71).

Morrison also noted:

The results were consistent in several subgroup and sensitivity analyses. However, when only studies which were judged to be methodologically more reliable were included, the increased risk appeared smaller.

Morrison acknowledged that observational studies such as the FHI analysis depended on have their limitations. He is looking for funding to conduct a randomised controlled study – something that, after 30 years of suspicions and evidence, still has not been done.

So what is his advice to the birth control industry? Stop using this stuff in regions with a high prevalence of HIV until we are sure that we are not feeding an epidemic?

No.

One reason is that FHI is at least as interested in contraception as it is in HIV prevention. Though its website reflects a broad range of development activities, its core business is integrating birth control programmes with HIV prevention. The WHO – one of its partners -- describes the US based, 83 percent US government funded non-profit as “a global health and development organization working on family planning, reproductive health and HIV/AIDS.”

Another reason is that FHI 360 has a vital stake in precisely the kind of contraceptives that are under suspicion. Its annual report refers to:

Our trailblazing work in contraceptive research and development continues, as we develop and introduce high-quality and affordable long-acting contraceptives for women in low-income countries. Research is under way to develop a new biodegradable contraceptive implant that would eliminate the need for removal services. We are also working with partners to develop an injectable contraceptive that would last for up to six months. Currently available injectables require reinjections monthly or quarterly, which can be challenging where health services are limited.

That project is funded by the Bill and Melinda Gates Foundation and USAID.

So Morrison did not argue in Melbourne for restrictions on the use of injectables, and neither did the WHO, whose representative at the conference outlined the UN body’s new guidelines on contraception and HIV. Mary Lyn Gaffield said a review of studies up to – but not including Morrison’s – did not warrant a change to WHO’s policy that DMPA and NET-En should be available, without restriction, in areas of high HIV prevalence.

The most WHO will advise is that women should be informed of the risk:

“Women at high risk of HIV infection should be informed that progestogen-only injectables may or may not increase their risk of HIV acquisition. Women and couples at high risk of HIV acquisition considering progestogen-only injectables should also be informed about and have access to HIV preventive measures, including male and female condoms.”

Condoms? How do they defend such cynicism? By equating the risk of HIV with the risks of motherhood – complications of pregnancy or childbirth, maternal death and the effect on infants... And yet motherhood remains risky precisely because 90 percent of the world’s effort is going into contraception!

Seven years ago a meeting of technical experts convened by WHO to study the injectables-HIV link showed the reproductive health establishment worried about that issue, to be sure, but also concerned that funding was flowing disproportionately to HIV-AIDS programmes, setting back the cause of birth control. The integration of family planning and HIV prevention spearheaded by FHI 360 looks like they have found an answer to that problem.

Whether African women are any better off is very doubtful. They remain pawns in a game that is, above all, about controlling their fertility. They and their partners are encouraged to take risks with their health, if not their lives, while researchers scout for funds to do the definitive study.

FHI had an income of $674 million last year, most of it from the US government. Couldn’t it give Charles Morrison the money to do his research today?

Reprinted with permission from Mercatornet.com.


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