Elard Koch

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A ground-breaking abortion study from Chile

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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Planned Parenthood closes Iowa abortion facility because of low business

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DUBUQUE, Iowa, May 3, 2016 (LifeSiteNews) – Planned Parenthood closed an Iowa abortion facility on Friday, noting low business that left the facility unsustainable from a financial standpoint.

Although Planned Parenthood of the Heartland announced in January that it planned to close the Dubuque, Iowa, office, pro-life sidewalk counselors were overjoyed on Friday to read the sign in the window that read: “Our office is closed, effective April 28, 2016.”

The office did not perform surgical abortions but did provide medication abortions to the community of about 58,000.

“Rejoice with us for the lives of unborn children saved!” Iowa Right to Life said in a statement after the closure.

As with numerous other closures, Planned Parenthood, which styles itself a provider of “care no matter what,” emphasized it was closing its doors to preserve its bottom line.

“After assessing the shifting health care landscape, changing demographics, and the challenges of operating in areas with low patient volumes, we made the tough decision to close the Dubuque Health Center,” the group said in an announcement. “This change allows us to expand hours and see more patients in Cedar Rapids, where there is unmet demand due to lack of clinician hours.”
“While we regret making this change, we know it is a necessary step in order to continue our mission to provide, promote and protect reproductive and sexual health through health services, education and advocacy. Patients have been notified, and if they wish, they can receive a broader array of services at our health center in Cedar Rapids, where we have expanded hours to accommodate more patient,” Planned Parenthood said.

American Life League’s vice president, Jim Sedlak, remembers speaking to the county right to life group nine years ago.

“I told them at the time that they needed to protest outside Planned Parenthood at least once a week,” he said. “They told me they would do better than that. Over the last eight years, these dedicated pro-lifers were outside Planned Parenthood every hour it was open. And now...it’s closed for good.”

That aligns with advice that David Bereit, the founder of 40 Days for Life, once told young people who wanted to know how to end abortion.

Be loving and compassionate, he said.

Your peaceful, loving presence out there flies in the face of all the stereotypes they want to throw onto us,” he added. “When you show them love instead of condemnation, when you show them peace and joy instead of anger and judgment, that will begin to break down the walls.”

Iowa Right to Life credited just such tactics with closing an office in Red Oak that performed webcam abortions. “Planned Parenthood shut down in Red Oak in large part because of the constant, prayerful presence outside their clinic,” the group said.

Upon hearing of the latest abortion facility shuttering, the Dubuque County Right to Life said that Planned Parenthood isn't the only group that will move its base of operations. “We will probably put our efforts in Cedar Rapids and will continue to spread the pro-life message,” said Executive Director Marian Bourek.



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Ted Cruz confronted by mom who supports aborting disabled babies…just like hers

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MARION, Indiana, May 3, 2016 (LifeSiteNews) – Senator Ted Cruz was met on the campaign trail by a mother who strongly opposed a state pro-life law that would have protected children with birth conditions – like her own.

Andrea DeBruler, a 41-year-old nurse, confronted the presidential hopeful in the city of Marion as Cruz campaigned with Gov. Mike Pence.

DeBruler first asked Cruz, then Pence, about House Bill 1337, which bans abortions performed due to the child's race, sex, or disability, such as Down syndome.

DeBruler held up a picture of her daughter, Jania, who was born with cerebral palsy. “This was a choice,” she said.

She asked Sen. Cruz if he supported the bill, which made Indiana the second state in the nation to ban abortion for Down syndrome, after North Dakota.

“I'm not Governor Pence,” he replied. “But I'll tell you this: I believe in protecting human life.”

Pence, who endorsed Cruz in today's make-or-break Indiana primary, listened to her objections.

“I'm not here as a Republican, I'm not here as a Democrat. I'm here as a woman, a woman with choices, choices that you guys should not make,” DeBruler said.

After hearing that she felt many families lacked sufficient resources to care for children, especially in an area like Marion, Gov. Pence offered to connect her with social services.

“God bless her,” he said, looking at Jania's picture, “and God bless you.”

Though it may be unusual to encounter a woman arguing for the right to abort her own child, the governor handled it calmly. Pence had specifically reflected on “precious moments” he spent with “families of children with disabilities, especially those raising children with Down syndrome” when he signed the bill into law in March.

"We are truly thankful for the passage of this historic legislation by the Indiana House and applaud the new civil rights protections this bill creates for unborn children, as well as the new provisions this bill establishes for the humane final disposition of aborted babies," Indiana Right to Life President Mike Fichter said at the time.

DeBruler told the UK media outlet The Independent that H.B. 1337 “means you can no longer have an abortion based on deformity. I’m against this law, because I think it should be a woman’s choice” to abort for any reason.

Congressional Democrats made similar statements during hearings last month for Rep. Trent Franks' federal Prenatal Nondiscrimination Act (PRENDA), with Congressman John Conyers saying the bill is “patently unconstitutional,” because a woman has the right to abort a child before viability for any reason.

Both leading contenders for the Democratic nomination expressed their displeasure with the law, which protects unborn children from racial or sexual discrimination, as well as discrimination on the basis of an inborn trait like mental capacity.

When Gov. Pence signed the law, Sen. Bernie Sanders tweeted:

Hillary Clinton later said, “I commend the women of this state, young and old, for standing up against this governor and this legislature.”

DeBruler told The Independent, despite her comment about not being a Democrat or a Republican, she is in fact a Democrat and will vote for Hillary Clinton in today's primary. 



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This year, as Notre Dame prepares to confer an honor on Vice President Joe Biden, the silence from the Catholic hierarchy is deafening. Drop of Light / Shutterstock.com
Phil Lawler

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The moral challenge to Cardinal Wuerl in pending Notre Dame outrage

Phil Lawler

Ask Notre Dame not to honor pro-abortion Vice President Joe Biden. Sign the petition!

May 3, 2016 (CatholicCulture) -- In 2009, when the University of Notre Dame invited President Barack Obama to deliver a commencement address, dozens of American bishops lodged loud public protests. Yet this year, as Notre Dame prepares to confer an even greater honor on Vice President Joe Biden (together with former House Speaker John Boehner), the silence from the hierarchy is deafening.

Back in 2009, Cardinal Daniel DiNardo of Houston said that Notre Dame’s invitation to President Obama was “very disappointing,”, while then-Archbishop Timothy Dolan termed it a “big mistake.” The late Bishop John D’Arcy, then leader of the Indiana diocese in which the university is located, spoke of “the terrible breach which has taken place between Notre Dame and the Church.” For the first time in his 25 years of service to the Fort Wayne-South Bend diocese, Bishop D’Arcy declined to attend the Notre Dame commencement exercises; instead he addressed a protest rally organized by pro-life students, faculty, alumni, and staff.

These prelates and others explained their dismay by referring to the statement “Catholics in Political Life,” released in 2004 by the US Conference of Catholic Bishops. In that document, the bishops reflected on the need to maintain a consistent public witness in defense of human life, and therefore to distance themselves from public officials who support legal abortion. The statement set forth a clear policy that Catholic institutions should not give public honors to “pro-choice” politicians:

The Catholic community and Catholic institutions should not honor those who act in defiance of our fundamental moral principles. They should not be given awards, honors or platforms which would suggest support for their actions.

By giving President Obama an honorary degree and offering him an opportunity to speak at graduation, Notre Dame clearly violated that policy. University officials could offer only garbled partial defenses, claiming that they were honoring Obama not because he supports unrestricted abortion, but because he is President of the United States.

This year the university cannot offer even that lame defense of the decision to award the Laetare Medal to Vice President Biden. Unlike Obama, Biden is a Catholic, and by granting him this award the university is explicitly saying that the Vice President has “illustrated the ideals of the Church and enriched the heritage of humanity.” In other words, Notre Dame is honoring Vice President Biden as a Catholic political leader despite his unwavering support for abortion and same-sex marriage.

Give credit to Bishop Kevin Rhoades, the current leader of the Fort Wayne-South Bend diocese, for raising a lonely voice of protest. “I believe it is wrong for Notre Dame to honor any ‘pro-choice’ public official with the Laetare Medal, even if he/she has other positive accomplishments in public service,” Bishop Rhoades said. But if any other bishops have joined him in that rebuke to Notre Dame, I must have missed their public announcements.

Some observers, of liberal political sympathies, have argued that it is wrong to honor John Boehner, too, because the former Speaker disagreed with the US bishops’ stand on immigration. This is a tired old argument, conflating disagreement with the bishops on a prudential political decision with defiance of Church teaching on a fundamental moral principle. But it is noteworthy that Notre Dame officials saw fit to make a joint award, no doubt in a cynical effort to dodge political criticism by choosing one honoree from each side of the political spectrum.

“We live in a toxic political environment where poisonous invective and partisan gamesmanship pass for political leadership,” said Father John Jenkins, the president of Notre Dame, in announcing the Laetare Award recipients. (Notice the pre-emptive suggestion that those who criticize the school’s choices may be engaged in “poisonous invective.”) He went on to make a tortured argument that although Notre Dame is honoring two politicians, it is not honoring them for what they have done in their political careers:

In recognizing both men, Notre Dame is not endorsing the policy positions of either, but celebrating two lives dedicated to keeping our democratic institutions working for the common good through dialogue focused on the issues and responsible compromise.

By now we all know the familiar dodges. The politician claims to oppose abortion personally, but to feel a delicate reticence about imposing his views on others. He says that we must be willing to compromise (even on life-and-death decisions). He insists that he is not “pro-abortion” but “pro-choice.”

That last bubble of rhetoric was unceremoniously burst by Cardinal Donald Wuerl of Washington, DC, when he celebrated Mass at Georgetown after Planned Parenthood president Cecile Richard had delivered a lecture there. “The word ‘choice’ is a smokescreen,” he said, “behind which those killing unborn children take refuge. Every chance you get, blow that smoke away!”

Now Cardinal Wuerl himself has a chance to “blow that smoke away.” As things stand, he is scheduled to celebrate Mass at the Notre Dame commencement, and to receive an honorary degree. He could pull out; he could absent himself from the ceremonies, to ensure that he does not become part of an event that pays homage to a “pro-choice” Catholic politician.

And there is a precedent. Back in 2009, the Harvard legal scholar (and former US ambassador to the Holy See) Mary Ann Glendon was chosen to receive the Laetare Award. But when she learned that President Obama would be speaking, she announced her decision to decline the award. Clearly annoyed that her presence might be used to quiet the critics of the honor for Obama, Ambassador Glendon wrote that she did not want to be used as a counterweight, nor did she see the Notre Dame commencement as an appropriate venue for a genteel debate about legal abortion:

A commencement, however, is supposed to be a joyous day for the graduates and their families. It is not the right place, nor is a brief acceptance speech the right vehicle, for engagement with the very serious problems raised by Notre Dame’s decision—in disregard of the settled position of the U.S. bishops—to honor a prominent and uncompromising opponent of the Church’s position on issues involving fundamental principles of justice.

Could Cardinal Wuerl do this year what Ambassador Glendon did in 2009? Even at this late date, his withdrawal would send a powerful message of support for the right to life: an unmistakable rebuke to politicians who hide behind the smokescreen that the cardinal himself identified. To be sure, if he did withdraw, the cardinal would be caught in an avalanche of public criticism; he would suffer for his public witness. But there is a reason why cardinals wear red.

Phil Lawler has been a Catholic journalist for more than 30 years. He has edited several Catholic magazines and written eight books. Founder of Catholic World News, he is the news director and lead analyst at CatholicCulture.org. Reprinted with permission from Catholic Culture.



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