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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Indiana Gov. Mike Pence signs the state's Religious Freedom Restoration Act.
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Indiana faces backlash as it becomes 20th state to protect religious liberty

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By Ben Johnson

INDIANAPOLIS, IN, March 27, 2015 (LifeSiteNews.com) – On Thursday, Indiana became the 20th state to prevent the government from forcing people of faith to violate their religious beliefs in business or the public square.

Gov. Mike Pence signed the Religious Freedom Restoration Act (SB 101) into law, saying the freedom of religion is a preeminent American value.

“The Constitution of the United States and the Indiana Constitution both provide strong recognition of the freedom of religion, but today, many people of faith feel their religious liberty is under attack by government action,” Pence said.

Gov. Pence, a possible dark horse candidate for president in 2016, cited court cases brought by religious organizations and employers, including Catholic universities, against the HHS mandate. “One need look no further than the recent litigation concerning the Affordable Care Act. A private business and our own University of Notre Dame had to file lawsuits challenging provisions that required them to offer insurance coverage in violation of their religious views.”

The new law could also prevent Christian business owners from being compelled to bake a cake or take photographs of a same-sex "marriage" ceremony, if doing so violates their faith. In recent years, business owners have seen an increased level of prosecution for denying such services, despite their religious and moral beliefs.

The state's pro-life organization applauded Pence for his stance. "Indiana's pro-life community is grateful to Gov. Mike Pence for signing the Religious Freedom Restoration Act into law,” said Indiana Right to Life's president and CEO Mike Fichter. “This bill will give pro-lifers a necessary legal recourse if they are pressured to support abortion against their deeply-held religious beliefs.”

“RFRA is an important bill to protect the religious freedom of Hoosiers who believe the right to life comes from God, not government,” he said.

The state RFRA is based on the federal bill introduced by Sen. Chuck Schumer, D-NY, and signed into law by President Bill Clinton in 1993. The Supreme Court cited the federal law when it ruled that Hobby Lobby had the right to refuse to fund abortion-inducing drugs, if doing so violated its owners' sincerely held religious beliefs.

In signing the measure – similar to the one Arizona Gov. Jan Brewer vetoed – Pence and the state of Indiana have faced a torrent of venom from opponents of the bill, who claim it grants a “right to discriminate” and raises the spectre of segregation.

"They've basically said, as long as your religion tells you to, it's OK to discriminate against people," said Sarah Warbelow, legal director of the Human Rights Campaign, a national homosexual pressure group.

The Disciples of Christ, a liberal Protestant denomination based in the state capital, has said it will move its 2017 annual convention if the RFRA became state law. The NCAA warned the bill's adoption “might affect future events” in the Hoosier state.

Pence denied such concerns, saying, "This bill is not about discrimination, and if I thought it legalized discrimination in any way I would've vetoed it."

The bill's supporters say that, under the Obama administration, it is Christians who are most likely to suffer discrimination.

"Originally RFRA laws were intended to protect small religious groups from undue burdens on practicing their faith in public life,” said Mark Tooley, president of the Institute on Religion and Democracy. “It was not imagined there would come a day when laws might seek to jail or financially destroy nuns, rabbis or Christian camp counselors who prefer to abstain from the next wave of sexual and gender experimentation. And there's always a next wave.”

The bill's supporters note that it does not end the government's right to coerce people of faith into violating their conscience in every situation. However, it requires that doing so has to serve a compelling government interest and the government must use the least restrictive means possible. “There will be times when a state or federal government can show it has a compelling reason for burdening religious expression – to ensure public safety, for instance,” said Sarah Torre, an expert at the Heritage Foundation. “But Religious Freedom Restoration Acts set a high bar for the government to meet in order to restrict religious freedom.”

Restricting the ability of government to interfere in people's private decisions, especially their religious decisions, is the very purpose of the Constitution, its supporters say.

"Religious freedom is the cornerstone of all liberty for all people,” Tooley said. “Deny or reduce it, and there are no ultimate limits on the state's power to coerce."

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Fight pornography. Beat pornography. And join the ranks of those who support their fellow men and women still fighting.
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Porn is transforming our men from protectors into predators. Fight back.

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By Jonathon van Maren

Since I’ve gotten involved in anti-pornography work, I’ve met countless men who struggle, fight, or have beaten pornography. Each person seems to deal with the guilt and shame that accompanies porn use in a different way—some deny that it’s “all that bad,” others pretend that they could “stop whenever they want,” many insist that “everyone is doing it,” and most, when pressed, admit to a deep sense of self-loathing.

One worry surfaces often in conversation: What do my past or current struggles with pornography say about me as a man? Can I ever move past this and have a meaningful and fulfilling relationship?

I want to address this question just briefly, since I’ve encountered it so many times.

First, however, I’ve written before how I at times dislike the language of “struggling” with pornography or pornography “addiction,” not because they aren’t accurate but because too often they are used as an excuse rather than an explanation. It is true, many do in fact “struggle” with what can legitimately be considered an addiction, but when this language is used to describe an interminable battle with no end (and I’ve met dozens of men for whom this is the case), then I prefer we use terminology like “fighting my porn habit.” A semantic debate, certainly, but one I think is important. We need to stop struggling with porn and start fighting it.

Secondly, pornography does do devastating things to one’s sense of masculinity. We know this. Pornography enslaves men by the millions, perverting their role as protector and defender of the more vulnerable and turning them into sexual cannibals, consuming those they see on-screen to satisfy their sexual appetites.

What often starts as mere curiosity or an accidental encounter can turn into something that invades the mind and twists even the most basic attractions. I’ve met porn users who can’t believe the types of things they want to watch. They haven’t simply been using porn. Porn has actively reshaped them into something they don’t recognize and don’t like. 

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Porn is this generation’s great assault on masculinity and the role of men in society. It is essential that we win this battle for the sake of society’s survival. Contrary to what the gender-bending and family-morphing progressive elites claim, good husbands and good fathers and good church leaders are necessary for a healthy society. But pornography is destroying marriages, creating distant and disconnected fathers, and, metaphoricaclly castrating men, hindering their ability and desire to make a positive difference in the society around us.

So, with this sobering set of facts in mind let’s return to the question: what do pornography struggles, past and present, say about a man?

The proper way to respond is with everything that is good about masculinity. We have to fight pornography as men have fought countless evils throughout the ages. We need to fight pornography to protect women, and wives, and children, and our society at large. This is how pornography threatens society, by castrating men, and turning them from protectors into predators. Rooting out the evil in our own lives allows us to better fulfill the role we are called to perform in the lives of others. Battling our own demons enables us to battle the wider cultural demons. Every day without porn is another bit of virtue built. Virtue is not something you’re born with. Virtues are habits that you build. And one day without porn is the first step towards the virtue of being porn-free.

Many men ask me if men who have had past porn addictions are cut out for being in a relationship or working in the pro-life movement or in other areas where we are called to protect and defend the weak and vulnerable. And the answer to that is an unequivocal yes. Our society needs men who know what it means to fight battles and win. Our society needs men who can say that they fought porn and they beat porn, because their families and their friends were too important to risk. Our society needs men who rose to the challenge that the evils of their generation threw at them, and became better men as the result. And our society needs men who can help their friends and their sons and those around them fight the plague of pornography and free themselves from it, too—and who can understand better and offer encouragement more relevant than someone who has fought and been freed themselves?

So the answer to men is yes. Fight pornography. Beat pornography. And join the ranks of those who support their fellow men and women still fighting. Lend them support and encouragement. We cannot change the fact that porn has left an enormous path of destruction in its wake. But we can change the fact that too many people aren’t fighting it. We can change our own involvement. And we can rise to the challenge and face this threat to masculinity with all that is good about masculinity.

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Red Alert!

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I don’t like having to do this, but we have always found it best to be totally upfront with our readers: our Spring fundraising campaign is now worrying us! 

You see, with just 6 days remaining, we have only raised 30% of our goal, with $125,000 still left to raise. That is a long ways to go yet.

We have no choice but to reach our minimum goal of $175,000 if we are going to be able to continue serving the 5+ million readers who rely on us every month for investigative and groundbreaking news reports on life, faith and family issues.

Every year, LifeSite readership continues to grow by leaps and bounds. This year, we are again experiencing record-breaking interest, with over 6 million people visiting our website last month alone!

This unprecedented growth in turn creates its own demand for increased staff and resources, as we struggle to serve these millions of new readers.

And especially keep this in mind. As many more people read LifeSite, our mission of bringing about cultural change gets boosted. Our ultimate goal has always been to educate and activate the public to take well-informed, needed actions.

Another upside to our huge growth in readers is that it should be that much easier to reach our goal. To put it simply: if each person who read this one email donated whatever they could (even just $10) we would easily surpass our goal! 

Today, I hope you will join the many heroes who keep this ship afloat, and enable us to proclaim the truth through our reporting to tens of millions of people every year!

Your donations to LifeSite cause major things to happen! We see that every day and it is very exciting. Please join with us in making a cultural impact with a donation of ANY AMOUNT right now. 

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