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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PBS defends decision to air pro-abortion documentary ‘After Tiller’

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By Dustin Siggins

Under pressure for showing the pro-abortion documentary "After Tiller" on Labor Day, PBS' "POV" affiliate has defended the decision in response to an inquiry from LifeSiteNews.

The producers of the film say their goal with the documentary, which tells the stories of four late-term abortion doctors after the killing of infamous late-term abortionist George Tiller, is to "change public perception of third-trimester abortion providers by building a movement dedicated to supporting their right to work with a special focus on maintaining their safety.” 

POV told LifeSiteNews, "We do believe that 'After Tiller' adds another dimension to an issue that is being debated widely." Asked if POV will show a pro-life documentary, the organization said that it "does not have any other films currently scheduled on this issue. POV received almost 1000 film submissions each year through our annual call for entries and we welcome the opportunity to consider films with a range of points of view."

When asked whether POV was concerned about alienating its viewership -- since PBS received more than $400 million in federal tax dollars in 2012 and half of Americans identify as pro-life -- POV said, "The filmmakers would like the film to add to the discussion around these issues. Abortion is already a legal procedure."

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"This is an issue that people feel passionately about and will have a passionate response to. We are hopeful that the majority of people can see it for what it is, another lens on a very difficult issue." 

In addition to the documentary, POV has written materials for community leaders and teachers to share. A cursory examination of the 29-page document, which is available publicly, appears to include links to outside sources that defend Roe v. Wade, an examination of the constitutional right to privacy, and "a good explanation of the link between abortion law and the right to privacy," among other information.

Likewise, seven clips recommended for student viewing -- grades 11 and beyond -- include scenes where couples choose abortion because the children are disabled. Another shows pro-life advocates outside a doctor's child's school, and a third is described as showing "why [one of the film's doctors] chose to offer abortion services and includes descriptions of what can happen when abortion is illegal or unavailable, including stories of women who injured themselves when they tried to terminate their own pregnancies and children who were abused because they were unwanted."

Another clip "includes footage of protesters, as well as news coverage of a hearing in the Nebraska State Legislature in which abortion opponents make reference to the idea that a fetus feels pain." The clip's description fails to note that it is a scientifically proven fact that unborn children can feel pain.

The documentary is set to air on PBS at 10 p.m. Eastern on Labor Day.

Kirsten Andersen contributed to this article.

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He defended ‘real’ marriage, and then was beheaded for it

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By Pete Baklinski

A Christian man was executed during the night by a high-profile ruler after making an uncompromising defense of real marriage.

The Christian, who was renowned for his holiness, had told the ruler in public that his relationship with his partner was “against the law” of God. The Christian’s words enraged the ruler’s partner who successfully plotted to have him permanently silenced.

John the Baptist was first imprisoned before he was beheaded. The Catholic Church honors him today, August 29, as a martyr and saint.

While John’s death happened a little less than 2,000 years ago, his heroic stance for real marriage is more pertinent today than ever before.

According to the Gospel of Mark, the ruler Herod had ‘married’ his brother’s wife Herodias. When John told Herod with complete frankness, “It is against the law for you to have your brother’s wife,” Herodias became “furious” with him to the point of wanting him killed for his intolerance, bullying, and hate-speech.

Herodias found her opportunity to silence John by having her daughter please Herod during a dance at a party. Herod offered the girl anything she wanted. The daughter turned to her mother for advice, and Herodias said to ask for John’s head on a platter.

Those who fight for real marriage today can learn three important lessons from John’s example.

  1. Those proudly living in ungodly and unnatural relationships — often referred to in today’s sociopolitical sphere as ‘marriage’ — will despise those who tell them what they are doing is wrong. Real marriage defenders must expect opposition to their message from the highest levels.
  2. Despite facing opposition, John was not afraid to defend God’s plan for marriage in the public square, even holding a secular ruler accountable to this plan. John, following the third book of the Hebrew Bible (Leviticus 20:21), held that a man marrying the wife of his brother was an act of “impurity” and therefore abhorrent to God. Real marriage defenders must boldly proclaim today that God is the author of marriage, an institution he created to be a life-long union between one man and one woman from which children arise and in which they are best nurtured. Marriage can be nothing more, nothing less.
  3. John did not compromise on the truth of marriage as revealed by God, even to the point of suffering imprisonment and death for his unpopular position. Real marriage defenders must never compromise on the truth of marriage, even if the government, corporate North America, and the entire secular education system says otherwise. They must learn to recognize the new “Herodias” of today who despises those raising a voice against her lifestyle. They must stand their ground no matter what may come, no matter what the cost.

John the Baptist was not intolerant or a bigot, he simply lived the word of God without compromise, speaking the word of truth when it was needed, knowing that God’s way is always the best way. Were John alive today, he would be at the forefront of the grassroots movement opposing the social and political agenda to remake marriage in the image of man.

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If he were alive today he might speak simple but eloquent words such as, “It is against God’s law for two men or two women to be together as a husband and wife in marriage. Marriage can only be between a man and a woman.” 

He would most likely be hated. He would be ridiculed. He would surely have the human rights tribunals throwing the book at him. But he would be speaking the truth and have God as his ally. 

The time may not be far off when those who defend real marriage, like John, will be presented with the choice of following Caesar or making the ultimate sacrifice. May God grant his faithful the grace to persevere in whatever might come. St. John the Baptist, pray for us!

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The Wunderlich family Mike Donnelly / Home School Legal Defence Association
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German homeschoolers regain custody of children, vow to stay and fight for freedom

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By Thaddeus Baklinski

One year to the day since a team of 20 social workers, police officers, and special agents stormed a homeschooling family’s residence near Darmstadt, Germany, and forcibly removed all four of the family’s children, aged 7 to 14, a state appeals court has returned custody of the children to their parents.

The reason given for the removal was that parents Dirk and Petra Wunderlich continued to homeschool their children in defiance of a German ban on home education.

The children were returned three weeks after being taken, following an international outcry spearheaded by the Home School Legal Defense Association.

However, a lower court imposed the condition on the parents that their children were required to attend state schools in order for them to be released, and took legal custody of the children in order to prevent the family from leaving the country.

In a decision that was still highly critical of the parents and of homeschooling, the appeals court decided that the action of the lower court in putting the children in the custody of the state was “disproportional” and ordered complete custody returned to the parents, according to a statement by the HSLDA.

The Wunderlichs, who began homeschooling again when the court signaled it would rule this way, said they were very pleased with the result, but noted that the court’s harsh words about homeschooling indicated that their battle was far from over.

“We have won custody and we are glad about that,” Dirk said.

“The court said that taking our children away was not proportionate—only because the authorities should apply very high fines and criminal prosecution instead. But this decision upholds the absurd idea that homeschooling is child endangerment and an abuse of parental authority.”

The Wunderlichs are now free to emigrate to another country where homeschooling is legal, if they choose, but they said they intend to remain in Germany and work for educational freedom.

“While we no longer fear that our children will be taken away as long as we are living in Hessen, it can still happen to other people in Germany,” Dirk said. “Now we fear crushing fines up to $75,000 and jail. This should not be tolerated in a civilized country.”

Petra Wunderlich said, "We could not do this without the help of HSLDA,” but cautioned that, “No family can fight the powerful German state—it is too much, too expensive."

"If it were not for HSLDA and their support, I am afraid our children would still be in state custody. We are so grateful and thank all homeschoolers who have helped us by helping HSLDA.”

HSLDA’s Director for Global Outreach, Michael Donnelly, said he welcomed the ruling but was concerned about the court’s troubling language.

“We welcome this ruling that overturns what was an outrageous abuse of judicial power,” he said.

“The lower court decision to take away legal custody of the children essentially imprisoned the Wunderlich family in Germany. But this decision does not go far enough. The court has only grudgingly given back custody and has further signaled to local authorities that they should still go after the Wunderlichs with criminal charges or fines.”

Donnelly pointed out that such behavior in a democratic country is problematic.

“Imprisonment and fines for homeschooling are outside the bounds of what free societies that respect fundamental human rights should tolerate,” he explained.

“Freedom and fundamental human rights norms demand respect for parental decision making in education. Germany’s state and national policies that permit banning home education must be changed.

"Such policies from a leading European democracy not only threaten the rights of tens of thousands of German families but establish a dangerous example that other countries may be tempted to follow,” Donnelly warned.

HSLDA Chairman Michael Farris said that acting on behalf of the Wunderlichs was an important stand for freedom.

“The Wunderlichs are a good and decent family whose basic human rights were violated and are still threatened,” Farris said.

“Their fight is our fight," Farris stressed, "and we will continue to support those who stand against German policy banning homeschooling that violates international legal norms. Free people cannot tolerate such oppression and we will do whatever we can to fight for families like the Wunderlichs both here in the United States and abroad. We must stand up to this kind of persecution where it occurs or we risk seeing own freedom weakened.”

Visit the HSLDA website dedicated to helping the Wunderlich family and other German homeschoolers here.

Contact the German embassy in the U.S. here.

Contact the German embassy in Canada here.

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