Philippa Taylor

Maternal mortality: is there a link with abortion legislation or not?

Philippa Taylor is Head of Public Policy at CMF. She has an MA in Bioethics from St Mary’s University College and a background in policy work on bioethics and family issues.
The views expressed do not necessarily reflect those of CMF.

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The question of whether restrictive laws on abortion lead to fewer maternal deaths, or more maternal deaths, is hotly debated.

Those who are ‘pro-life’ and want to see more restrictive abortion laws say that fewer abortions leads to fewer maternal deaths, with Northern Ireland providing one example close to home: ‘Ireland and Northern Ireland show a low incidence of maternal and infant conditions known to be abortion sequelae: still birth…and maternal deaths. Liberalisation of abortion laws in Ireland and Northern Ireland can be expected to result in higher abortion rates and a corresponding deterioration in respect of these conditions affecting the health of women.’

Those who are ‘pro-abortion’ argue that where laws on abortion are more restrictive, more illegal (‘back street’) abortions take place leading to more complications and deaths. So, where abortion is safe, legal and accessible, maternal mortality drops: ‘Evidence demonstrates that liberalising abortion laws to allow services to be provided openly by skilled practitioners can reduce the rate of abortion-related morbidity and mortality.

Into this debate comes some interesting research by Elard Koch, published in BMJOpen a few months ago, based on analysis carried out across 32 states in Mexico.

Koch does not take ‘sides’, instead making a simple, but important, claim based on his research in Mexico, that that differences in abortion legislation do not correlate ultimately with maternal mortality ie. abortion laws do not make the difference in women’s mortality rates (in Mexico).

This is useful. There has been a well funded (see here too) campaign for many years by pro-abortion groups pushing for all national abortion laws to be more permissive (using the euphemism ‘reproductive rights’), even within those countries culturally and legally opposed to abortion. It is argued that restrictive abortion laws are harmful to women. Maternal mortality rates and maternal health are both key to these claims.

This new analysis shows that such arguments are not tenable:

  • Permissive abortion laws do not reduce maternal morbidity and mortality;
  • Restrictive abortion laws do not harm women’s health and increase abortion-related mortality rates;
  • States with restrictive laws do have lower maternal mortality rates, but this was not explained by abortion legislation itself.

Instead, not unsurprisingly, most of the differences (up to 88%) in maternal mortality between the Mexican states were largely explained by factors such as women’s literacy, maternal healthcare, emergency obstetric care, individual-level risk factors, clean water, sanitation, fertility rate and intimate-partner violence against women.

It is worth briefly explaining why this research in Mexico is particularly useful.

Each of the 32 Mexican states has its own political constitution, criminal code and abortion legislation. Some are more restrictive and some more permissive. Mexico therefore provides a unique epidemiological scenario to test the impact of abortion legislation on maternal mortality in a population that shares the same history and culture and (importantly) that has a homogeneous healthcare system. The authors were also able to use virtually complete official vital statistics of live births and maternal deaths in the 32 Mexican states between 2002 and 2011.

Koch and colleagues have since published in the BMJ (August 2015) an even more detailed analysis, in response to criticism of their research by a pro-abortion activist. They claim their research is: ‘Methodologically sound, with perhaps an uncomfortable result.

They tackle directly the argument that: ‘Theoretically, in Mexican states exhibiting less permissive legislation, maternal mortality should have been higher because the practice of unsafe abortion should be more frequent.’

Instead, they found that: ‘Paradoxically, over a 10-year period, those states almost univocally exhibited lower figures for maternal mortality ratio (MMR), MMR with any abortive outcome and induced abortion mortality ratio.’

Nevertheless, despite this correlation, Koch et al do not attribute the cause to abortion legislation, but instead they say that the differences can be explained by other independent factors known to influence maternal health.

The main conclusion by Koch is that addressing disparities in these other factors – such as women’s literacy, maternal healthcare, water, sanitation, fertility rates and violence against women – will most likely facilitate a transition towards low maternal mortality rates in developing countries.

There is more to Koch’s work however.

In his rebuttal to criticism, he mentions a few other associations with reproductive health outcomes, which I found of interest (not related to Mexico or maternal mortality). For example:

  1. Klick et al. assessed gonorrhoea incidence rates and found that, compared with very restrictive abortion laws, a switch to more permissive abortion laws is associated with large increases in gonorrhoea incidence. According to Klick, economic theory predicts that abortion laws affect sexual behaviour since they change the marginal cost of having high-risk sex (when barrier contraception is not used) leading to a higher risk for both STD acquisition and unintended pregnancy: ‘these results are consistent with a story whereby increased access to abortion leads people to engage in more risky sex.
  2. In a Spanish study over 10 years Duenas et al. reported an increase in the use of contraceptives (49% in 1997 to 80% in 2007), but at the same time an increase in the abortion rate (5.52 to 11.49 per 1,000 women), especially in young women, who reported engaging in high-risk sex more frequently. Interestingly, a Russian Longitudinal Monitoring Survey report begins by stating that: ‘Internationally, high abortion rates often are considered an indication that women’s access to effective contraceptives is inadequate’ yet these authors found that the availability of abortion was one of the reasons specifically cited for women not using contraceptives.
  1. The prevalence of Down syndrome at birth is higher in settings with less permissive abortion laws: Chile (2.47 per 1,000), Argentina (2.01 per 1,000) and Ireland (2.1 per 1,000 in Dublin). The converse of this is that prenatal screening and more permissive laws of abortion have a strong impact on Down syndrome, decreasing the prevalence at birth to less than 1 per 1,000 in Europe.

But back to my title question, the answer to which is ‘yes’ and ‘no’. There appears to be a link, in that restrictive state laws have lower maternal mortality rates, but this is NOT explained by abortion legislation itself, according to this research.

If, therefore, the key determinants of maternal mortality are actually education, maternal health, sanitation and drinking water etc, then the implications for international policy are clear. But, as Peter Saunders has questioned here, will the lavishly funded birth control and abortion industry take note?

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