Transcript Maternal Mortality and the myth of “safe” abortion Donna J. Harrison, M.D. Director of Research and Public Policy American Association of Pro-Life Obstetricians and Gynecologists www.aaplog.org Life.

Maternal Mortality and the myth
of “safe” abortion
Donna J. Harrison, M.D.
Director of Research and Public
Policy
American Association of
Pro-Life Obstetricians and
Gynecologists
www.aaplog.org
Life. It’s Why We Are Here.
Photo by Geezaweezer
Photo by Jim Epler
Mothers are important.
Photo by Neils Photography
• When mothers die,
• the whole family suffers,
• the extended family suffers,
• the community suffers.
• So, saving the life of and improving the
health of mothers is an important part of
improving the life and health of the entire
community.
Photo by Justin Vidamo
How can Maternal Health be improved?
• Eliminate what sickens and kills mothers
raising children.
• Make childbearing safer.
Photo by Tosimasha Ishibashi
Photo by Mrs. Joan Chandler
Photo by Praziquantel
The Global Burden of Disease 2004 W.H.O.
The Global Burden of Disease 2004 W.H.O.
How many mothers
die each year?
• Hogan et Al. 2010 Lancet
• 342,900 maternal
mortalities worldwide.
• In the absence of HIV,
there would have been
281,500 (243,900–327,900)
maternal deaths
worldwide in 2008.
[Compare to 500,000
claimed by UNFPA]
How many mothers
die each year?
• Hogan et Al. 2010 Lancet
• More than 50% of
maternal deaths occur
within 6 countries.
• (India, Nigeria, Pakistan,
Afghanistan, Ethiopia,
and the Democratic
Republic of the Congo)
What kills mothers?
• “Haemorrhage and
hypertensive disorders
are major contributors
to maternal deaths in
developing countries.”
Making Motherhood safe
• Enemies:
• Preeclampsia
• Postpartum
hemorrhage
• Infection
• HIV
• Physical obstacles to
access care.
• Improving maternal
health by:
• Improved prenatal care
• Safe delivery facilities
adequately staffed and
equipped
• Transportation
• Female literacy
Safe motherhood?
• 1987: Beginning of the
“Global Safe Motherhood
Initiative”
• Resulted in forming the “IAG”
(Inter-Agency Group for Safe
Motherhood).
• 2000. UN General Assembly
announced the formation of
the MDG’s
Safe motherhood?
• 1987: Beginning of the
“Global Safe Motherhood
Initiative”
• Resulted in forming the “IAG”
(Inter-Agency Group for Safe
Motherhood).
• 2000. UN General Assembly
announced the formation of
the MDG’s
Safe motherhood?
• 2002-5 Donors
pressured consolidation
of the Safe Motherhood
Initiative with UNICEF
and UNFPA
• Major source of
disagreement:
Feminists supported
UNFPA, but refused to
support “Safe
Motherhood”
• Disagreements included
the discussions on
“unsafe abortion” and
who gets the money to
fund what projects.
• Point of agreement:
Mothers dying are a
tragedy.
• Point of disagreement:
How do we solve it?
Women Deliver London 2007
• September 2007
• Marked a triumph of
the feminist (UNFPA)
part of the partnership
over the Safe
Motherhood part of the
partnership.
• “Abortion First”
Women Deliver: Obstacles to be
eliminated
#1 Obstacle:
• The presence of Protestant
Missionaries in the health
care system in Africa and
Asia, and the presence of
the Roman Catholic Church
in the health care system in
Latin America.
Photo by Seattle Municipal Archives
Women Deliver: Obstacles to be
eliminated
#2 Obstacle:
• The idea of health care
workers “Rights of
Conscience” which allows
health professionals to
refuse to do abortions.
Photo by Vera Kratochvil
Women Deliver: Obstacles to be
eliminated
#3 Obstacle:
• The use of ultrasound in
obstetrics, which
“unfortunately” turns the
mind of the woman to the
“possible” humanity of the
fetus.
Women Deliver: Obstacles to be
eliminated
#4 Obstacle:
• The people themselves do
not want abortion…
John Ragai
Photo by Neils photography
Photo by Tom Maisey
Photo by Janine and Jim Eden
Photo by Devin
Making Motherhood Safe
vs. Preventing motherhood
• Enemies:
• Pregnancy itself.
• The solution
• “Comprehensive”
reproductive rights
• “safe” abortion
Controversy about the role of legalizing induced
abortion and the effect on maternal mortality.
❧ One of the most controversial subjects in international health has been
the effect of abortion laws on maternal health, particularly where a
country has prohibited abortion in order to safeguard women’s health,
motherhood and the unborn human life.
❧ During the last three decades, numerous international agencies, public
health actors, politicians and several research groups claim that
countries which restrict or prohibit elective abortion promote “unsafe”
abortions. These advocates of abortion claim that prohibiting abortion
results in a higher rate of maternal morbidity and mortality from “unsafe”
abortion. This theoretical threat of increasing maternal mortality is used
to pressure nations into overturning laws and legalizing abortion.
❧ However, there is no direct scientific evidence of any potentially
deleterious cause-effect relationship between abortion restrictive laws
and maternal health.
AAPLOG Annual Research and Strategy Meeting
Washington DC, February 2013
Defining “Safe” and “Unsafe” Abortion
• The word “safe” implies
certainty of outcome,
usually means risk-free.
• But abortions are lethal for
the unborn child, and may
carry greater short and
long term risks for the
mother than giving birth.
• Yet, WHO mixes legal and
medical definitions to
imply “legal” = “safe” and
promote abortion
legalization worldwide.
Defining “Safe” and “Unsafe” Abortion
•
Sedgh, et. al. Induced abortion:
estimated rates and trends
worldwide. Lancet Oct, 2007.
• “For estimation purposes,
safe abortions were defined
as those that meet legal
requirements in countries in
which abortion is legally
permitted under a broad
range of criteria.”
Defining “Safe” and “Unsafe” Abortion
•
Sedgh, et. al. Induced abortion:
estimated rates and trends
worldwide. Lancet Oct, 2007.
• “Unsafe” = abortion by
unskilled, not meeting
minimum medical
standards.
• “These include abortions
in countries with
restrictive abortion
laws…”
Defining “Safe” and “Unsafe” Abortion
•
Sedgh, et. al. Induced abortion:
estimated rates and trends
worldwide. Lancet Oct, 2007.
• So, regardless of the • “Unsafe” = abortion by
medical safety, an
unskilled, not meeting
abortion performed minimum medical
in a country where
standards.
abortion is illegal is • “These include abortions
by WHO definition
in countries with
an “unsafe”
restrictive abortion
abortion.
laws…”
Defining “Safe” and “Unsafe” Abortion
• “When
performed
within the legal
framework, the safety
of the procedure will
depend on the
requirements of the
law, and the resources
and medical skills
available.”
Defining “Safe” and “Unsafe” Abortion
• “In some countries, lack
of resources and
possibly skills may
mean that even
abortions that meet
the legal and medical
requirements of the
country would not
necessarily be
considered sufficiently
safe in high-resource
settings.”
Defining “Safe” and “Unsafe” Abortion
• “In some countries, lack
• So, a procedure
of
resources
and
labeled as a “safe”
possibly skills may
abortion in the
mean that even
developing world
abortions that meet
the legal and medical
would not be a
requirements of the
medically acceptable
country would not
abortion in the
necessarily be
resource rich nations. considered sufficiently
safe in high-resource
settings.”
Policy Implications of the terms
“safe” and “unsafe” abortion
• If a country simply
legalizes abortion then:
Policy Implications of the terms
“safe” and “unsafe” abortion
• If a country simply
legalizes abortion then:
• Poof! The total number
of “UNSAFE” abortions
magically decreases.
• Because most abortions
now “meet legal
requirements” which is
the W.H.O. definition of
a “SAFE” abortion
Policy Implications of the terms
“safe” and “unsafe” abortion
• If a country simply
legalizes abortion then:
• Poof! The total number
of maternal deaths from
“UNSAFE” abortion also
magically decreases
because most abortions
now “meet legal
requirements.”
• But the women still die.
Policy Implications of the terms
“safe” and “unsafe” abortion
• If a country simply
legalizes abortion then:
• …the women still die.
• And women die in greater
numbers, because the
total number of abortions
dramatically increase in
every nation where
abortion has been
legalized.
Policy Implications of the terms
“safe” and “unsafe” abortion
• If a country simply
legalizes abortion then:
• … the women still die.
• But now these women’s
deaths become invisible
to the official statistics,
because they are deaths
from “safe” abortion.
• “Safe” abortion deaths
are not tracked.
• Brilliant legal strategy.
• Heinous medical care.
What are the risks of “safe” abortion?
•
•
•
•
•
•
•
Immediate:
Hemorrhage
Infection
Surgical complications
Incomplete abortion
Ongoing pregnancy
Death
• Long term:
• Preterm birth in
subsequent pregnancies
(136+ studies)
• Increase in adverse
psychological outcome:
-Suicide
-Depression
-Substance Abuse
*Premenopausal Breast Ca
[abort 1st preg + delay term
preg = proliferation of
lobular cells with failure of
maturation]
Immediate risks of 1st trimester abortion
•
•
•
•
All women in Finland 2000-2006
</=63 days gestation
N= 42, 619 women
Follow-up for 42 days
• “The overall incidence of
adverse events was
fourfold higher in the
medical compared with
the surgical abortion
cohort.
• Medical=20% of patients
• Surgical= 5.6% of patients
• P<0.001
Immediate risks of 1st trimester abortion
• [ p<0.001 for all given]
• Risk of Hemorrhage
• medical = 15.6%
• surgical = 2.1%
• Risk of incomplete abortion
• medical = 6.7%
• surgical = 1.6%
• Risk of emergency surgery
• medical = 5.9%
• surgical = 1.8%
Immediate risks of 1st trimester abortion
• There were 2 deaths in
the medical abortion
cohort of 22,368
women.
• There were 4 deaths in
the surgical abortion
cohort of 20,251
women.
Abortion Mortality
• A Clinicians Guide to
Medical and Surgical
Abortion, Chapter 15.
Abortion Mortality
Abortion Mortality
• “The risk of death
increased exponentially
by 38% for each
additional week of
gestation.”
Abortion Mortality
• “Compared with women
whose abortions were
performed at or before 8
weeks of gestation,
women whose abortions
were performed in the
second trimester were
significantly more likely to
die of abortion-related
causes.”
Abortion Mortality
• Compared with abortion
at <13 weeks, the relative
risk of abortion-related
mortality was
• RR=14.7 at 13-15 weeks
(95%CI 6.2-34.7)
• RR=29.5 at 16-20 weeks
(95%CI 12.9-67.4)
• RR= 76.6 >20 weeks
(95%CI 32.5-180.8)
Abortion Mortality
Livebirth mortality U.S.
What are the risks of “safe” abortion?
•
•
•
•
•
•
•
Immediate:
Hemorrhage
Infection
Surgical complications
Incomplete abortion
Ongoing pregnancy
Death
• Long term:
• Preterm birth in
subsequent pregnancies
(136+ studies)
• Increase in adverse
psychological outcome:
-Suicide
-Depression
-Substance Abuse
*Premenopausal Breast Ca
[abort 1st preg + delay term
preg = proliferation of
lobular cells with failure of
maturation]
Abortion and
Breast Cancer
“Pregnancy, and especially
first pregnancy, appears to
represent a critical window
in determining future breast
cancer risk. The occurrence
of a first completed
pregnancy and age at first
pregnancy are among the
strongest known predictors
of breast cancer risk.”
Abortion and
Breast Cancer
“A significant elevation of
risk was associated with a
history of induced abortion
but not spontaneous
abortion.”
Abortion and
Breast Cancer
“Risk of Breast Cancer
among Young Women:
Relationship to Induced
Abortion”
Daling J, Malone K, et Al. J
Natl Cancer Inst 1994 Nov
2: 86 (21): 1584-92
• Methods:
• 845 cases identified
through the tumor
registry of NCI.
• 961 matched controls
Abortion and
Breast Cancer
• Results: Highest risks
were observed when
the abortion was done
at ages younger than 18
years- particularly if it
took
place
after
8
Daling J, Malone K, et Al. J
weeks gestation-or at
Natl Cancer Inst 1994 Nov
30
years
of
age
or
2: 86 (21): 1584-92
older.”
“Risk of Breast Cancer
among Young Women:
Relationship to Induced
Abortion”
Abortion and
Breast Cancer
• “among women who
had been pregnant at
least once, the risk of
breast cancer in those
who had experienced
an
induced
abortion
Daling J, Malone K, et Al. J
was 50% higher than
Natl Cancer Inst 1994 Nov
among
other
women
by
2: 86 (21): 1584-92
age 45.”
“Risk of Breast Cancer
among Young Women:
Relationship to Induced
Abortion”
Abortion and
Breast Cancer
• “Teenagers under age
18 and women over 29
years of age who
procure an abortion
increase their breast
cancer
risk
by
more
Daling J, Malone K, et Al. J
than 100% by age 45.”
Natl Cancer Inst 1994 Nov
2: 86 (21): 1584-92
“Risk of Breast Cancer
among Young Women:
Relationship to Induced
Abortion”
Abortion and
Breast Cancer
• “Teenagers with a family
“Risk of Breast Cancer
history of breast cancer
among Young Women:
who procure an abortion
Relationship to Induced
face a risk of breast
Abortion”
cancer that is incalculably
high”.
Daling J, Malone K, et Al. J • All 12 women in the study
Natl Cancer Inst 1994 Nov
with this history were
2: 86 (21): 1584-92
diagnosed with breast
cancer by the age of 45.
Abortion and
Breast Cancer
• “Additionally, hazard ratio
(HR) show an association
between incomplete
pregnancies and a higher
BC risk, which reached
2.39 (95% CI=1.28-4.45)
among women who had
at least three incomplete
pregnancies when
compared with women
with zero incomplete
pregnancies.”
Abortion and
Breast Cancer
• “This increased risk
appeared to be
restricted to incomplete
pregnancies occurring
before the first FTP
(HR=1.77, 95% CI=1.192.63).”
Abortion and
Breast Cancer
•
Dolle 2010 Univ. of Washington Seattle,
and National Cancer Institute. 897 women
(age 20-45) with invasive breast cancer
• “Specifically, older age,
family history of breast
cancer, earlier
menarche age, induced
abortion, and oral
contraceptive use were
associated with an
increased risk for breast
cancer”.
Abortion and
Breast Cancer
• “Induced abortion
increases the risk of
breast cancer by 40%”.
• Triple Negative Breast
Cancer.
What is a “safe” abortion?
• “safe” is a legal
term.
• “Safe” abortions
carry real risks of
harm to women,
often greater
harm than giving
birth
• But a question
remains:
• Will making abortion
illegal increase
maternal mortality in a
nation?
• What is the evidence?
The Chilean “natural experiment”
❧ Chile offered a unique opportunity to test the hypothesis that the legal
status of abortion was related to maternal health through what is called a
“natural experiment”. This study was possible due to several
interventions in education, public health and legislation implemented
during the last century:
INTRODUCTION OF ANTIBIOTICS
INTRODUCTION OF SYNTHETIC OXYTOCIN
1900
2010
1920
Mandatory
Elementary School
1931
Authorization of
therapeutic abortion
1938
Implementation of
the “Mother-Child
Law”
Prenatal control and
complementary
nutrition program
1989
Abortion ban
2003
Mandatory School
up to 18 y-o.
1965
Mandatory 8 years of
Elementary and Middle School
1963-1965
Extension of the “Mother-Child Law”
with a family planning component
AAPLOG Annual Research and Strategy Meeting
Washington DC, February 2013
Maternal mortality trend in Chile (1957-2007)
Koch et al (2012) PLoS ONE
AAPLOG Annual Research and Strategy Meeting
Washington DC, February 2013
Koch et al (2012) PLoS ONE
20
23.4
2009
2008
2007
2006
2005
2004
2003
2002
61.6
2009
2008
2007
2006
2005
2004
2003
2002
15
2001
2000
Abortion ban
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
30
1999
1998
1997
1996
1995
1994
1993
1992
1991
20
1990
60
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
50
1989
1988
1987
1986
1985
1984
1983
1982
1981
25
1980
1979
MMR per 100,000 live births
70
1980
1979
AMR per 100,000 live births
Maternal and abortion mortality trend in Chile
(1979-2009)
A
-58.5%
40
40.8
23.6
16.9
10
0
B
Abortion ban
-96.3%
10
10.8
5
0
0.4
YEAR
AAPLOG Annual Research and Strategy Meeting
Washington DC, February 2013
Synergistic effects of education
+ Education
Effect
+35
+30.1
Maternal Deaths per 100,000 Live Births
The “fertility paradox”
Women
Education
(every year)
Skilled
attendant
delivery
Clean
water
(for each
5%)
(for each
5%)
Sanitation
(for each 5%)
0
-3.7
-9.9
-12.5
-22.9
-29.7
-35
Koch et al (2012) PLoS ONE
-10.8
Primiparous 30
or more years
old
(for each 1%)
-13.9
+ Education
Effect
+8.1
+ Education
Effect
+ Education
Effect
AAPLOG Annual Research and Strategy Meeting
Washington DC, February 2013
Current profile of maternal mortality
in Mexico and Chile
Koch et al (2012) In J Women Health
AAPLOG Annual Research and Strategy Meeting
Washington DC, February 2013
Trend of maternal mortality in Mexico and Chile
(1957-2010)
Koch et al (2012) In J Women Health
AAPLOG Annual Research and Strategy Meeting
Washington DC, February 2013
Trends in Pregnancy-Related Mortality
in the United States, 1987–2008