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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Lisa Bourne

‘You can’t have’ marriage equality ‘without polygamy’

Lisa Bourne
By Lisa Bourne

July 3, 2015 (LifeSiteNews) – Motivated by the U.S. Supreme Court ruling legalizing homosexual “marriage,” a Montana polygamist has filed for a second marriage license, so he can be legally wed to two women at once.

"It's about marriage equality," said Nathan Collier, using homosexual advocates’ term to support marriage redefinition. "You can't have this without polygamy."

Collier, who has has appeared on the TLC reality show Sister Wives with his legal wife Victoria, and his second wife Christine, said he was inspired by the dissent in the Supreme Court decision.

The minority Supreme Court justices said in Friday’s ruling it would open the door to both polygamy and religious persecution.

“It is striking how much of the majority’s reasoning would apply with equal force to the claim of a fundamental right to plural marriage,” wrote Chief Justice John Roberts.

Collier and his wives applied for a second marriage license earlier this week at the Yellowstone County Courthouse in Billings, a report from the Salt Lake Tribune said.

Collier, who was excommunicated from the Mormon Church for polygamy, married Victoria in 2000 and had a religious wedding ceremony with Christine in 2007. The three have seven children between them and from previous relationships.

"My second wife Christine, who I'm not legally married to, she's put up with my crap for a lot of years. She deserves legitimacy," Collier said.

Yellowstone County officials initially denied the application before saying they would consult with the County Attorney and get him a final answer.

Click "like" if you want to defend true marriage.

Bigamy, the holding of multiple marriage licenses, is illegal all 50 states, but Collier plans to sue if his application is denied. Officials expect to have an answer for him next week.

While homosexual “marriage” supporters have long insisted legalization of same-sex unions would not lead to polygamy, pro-life and family advocates have warned all along it would be inevitable with the redefinition of marriage.

“The next court cases coming will push for polygamy, as Chief Justice John Roberts acknowledged in his dissent,” said Penny Nance, president of Concerned Women for America, after the Supreme Court ruling. “The chief justice said “the argument for polygamy is actually stronger than that for ‘gay marriage.’ It’s only a matter of time.”

In a piece from the Washington Times, LifeSiteNews Editor-in-Chief and the co-founder of Voice of the Family John-Henry Westen stated the move toward legal polygamy is “just the next step in unraveling how Americans view marriage.”

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Chris Christie: Clerks must perform same-sex ‘marriages’ regardless of their religious beliefs

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By Ben Johnson

TRENTON, NJ, July 3, 2015 (LifeSiteNews) – Chris Christie is not known for nuance. This time, he has turned his fiery personality loose on county clerks and other officials who have religious objections to performing same-sex “marriages.”

In a tone usually reserved for busting teachers' unions, Christie told clerks who hold traditional values, “You took the job, and you took the oath.” He would offer no exemption for an individual whose conscience would not allow him to participate in a union the vast majority of the world's religions deem sinful.

“When you go back and re-read the oath it doesn’t give you an out. You have to do it,” he said.

He told a reporter that there “might” be “individual circumstances” that “merit some examination, but none that come immediately to mind for me.”

“I think for folks who are in the government world, they kind of have to do their job, whether you agree with the law or you don’t,” the pugnacious governor said.

Since the Supreme Court voted 5-4 to legalize homosexual “marriage” last Friday, elected officials have grappled with how to safeguard the rights of those who have deeply held religious beliefs that would not allow them to participate in such a ceremony.

Christie's response differs markedly from other GOP hopefuls' responses to the Supreme Court ruling. Mike Huckabee, for instance, has specifically said that clerks should have conscience rights. Louisiana Gov. Bobby Jindal signed an executive order granting such rights and ordered clerks to wait until a pending court case was fully adjudicated before any clerk issues a marriage license to a homosexual couple.

Christie gave up a legal appeal after a superior court judge struck down his state's voter-approved constitutional marriage protection amendment. New Jersey is the only state where such a low court overturned the will of the voters.

The decision to ignore conscience rights adds to the growing number of Christie's positions that give conservatives pause.

The natural locus of support for a Christie 2016 presidential run is the Republican's socially liberal donor class, for personal as well as political reasons. His wife works on Wall Street, and some of the GOP's high-dollar donors – including Paul Singer – have courted Christie for years.

However, this year Jeb Bush, Marco Rubio, and to a lesser degree Scott Walker have eclipsed Christie as the preferred candidates of the boardroom donors – who sometimes prefer Democrats to Republicans.

Christie also used language during a speech before the Republican Jewish Coalition last year, which concerned some major GOP donors.

Christie is reportedly spending this weekend with Mitt Romney and his family at Romney's New Hampshire home. Romney declined to enter the 2016 race himself and may be able to open his donor list to Christie's struggling campaign.

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After having a girl with Down syndrome, this couple adopted two more

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By Ben Johnson

LINO LAKE, MN, July 3, 2015 (LifeSiteNews) – For most people, having five biological children would have been enough. In fact, for many Americans, large families are treated as a scandal or a burden.

But one family made the decision, not just to have a large family, but to give a home to some of the most vulnerable children in the world: Girls born overseas with Down syndrome.

Lee and Karen Shervheim love all seven of their children, biological or otherwise. Undeterred by having twin boys – Daniel and Andrew, 18 – they had Sam four years later.

They now have three daughters who are all 11 years old. All three have Down syndrome.

And two of them are adopted.

About the time their eight-year-old son, David, was born, Lee and Karen decided to adopt a child with Down syndrome to be a companion to their daughter, Annie.

They made the further unexpected choice to adopt a child from Eastern Europe with the help of Reece's Rainbow, which helps parents adopt children with Down syndrome.

“Between my wife and I, we couldn’t get it out of our heads,” Lee told the Quad City Press. “So many children need families and we knew we could potentially do something about it.”

After originally deciding to adopt Katie, they spent six weeks in Kiev, visiting an orphanage in nearby Kharkov. While there, they decided they may have room in their heart, and their home, for another child.

When they saw a picture of Emie striking the same pose as their biological daughter in one of their photographs, they knew they would come home with two children.

Both girls were the same age as their Annie. She would not lack for companionship, as they worried.

Lee said after the Ukrainian government – finally – completed the paperwork, they returned to the United States, when the real challenges began.

“The unvarnished truth,” Lee told the Press, is that adopting the Russian-speaking special needs children “was really disruptive to our family. They came with so many issues that we had not anticipated.”

After teaching them sign language and appropriate behavior, they moved to Lino Lake, Minnesota and found a new support group in Eagle Brook Church. There they found personal assistance and spiritual solace.

Every year in the past seven years has been better and better, they say.

“I think my girls can do almost anything they want to do,” he said, “and that’s what I want to help them become.”

The family's devotion is fueled by their faith, and it informs the sense of humor Lee showed in a tweet during the 2014 midterm elections:

It takes a special person to believe in the potential of the “mentally retarded,” as they were once labeled. Today, 90 percent of all babies diagnosed with Down syndrome in the womb will be aborted. The percentage is higher in some countries. Some have even spoken of "a world without people with Down syndrome."

Their God, and their experience, tell them that every child has infinite worth and potential, Lee told local media, and he would encourage anyone to follow his footsteps and adopt a Down syndrome child – or two.

“The message is that it really doesn’t matter where you started or where you came from,” Lee said. “There are endless opportunities for everyone, whether they have disabilities or not. They deserve a shot.”

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