Abortion and Maternal Mortality

In response to my previous post about feminism, someone wrote (in part) why she supports abortion:

And wanting to dismantle those structures is why I support reproductive rights. In a different world, abortion would be unnecessary. Women’s lives would never be endangered by a pregnancy, no woman would ever be forced to get pregnant by her abusive partner, no woman would ever be raped, 10-year-olds would not get pregnant, there would be comprehensive sex education and free and unlimited access to birth control and free high-quality daycare and a year of paid maternity leave. These are, to me, highly feminist goals.

But we don’t live in that world; in this world, unintended pregnancies occur and a myriad of forces conspire to cause them and punish women for them. A system in which abortion is criminalized does nothing to help women; it makes their lives worse. If the only goal is to have somewhat fewer abortions, then banning abortion is probably an effective thing to do. There will still be abortions, of course: women with money will always find access to them, and women with less money will sometimes find a way, safe or unsafe, to access abortions; and sometimes they won’t, and those are the abortions the ban will have prevented. But it will also be causing maternal deaths (unsafe abortion is one of the top five causes of maternal death around the world, and causes an especially large percentage of maternal deaths in Latin America), and their fetuses won’t be carried to term; and when women are caught and prosecuted (and those will almost certainly be the women with less money), their other children will suffer (as so many women seeking abortions already have children). There is an excellent article about the consequences of what a full abortion ban looks like, as El Salavdor actively enforces one. It doesn’t seem like a good solution to me. To me, the feminist act is to dismantle the structures that make pregnancies unwanted, and that hurt women in myriad other ways as well.

Because this is an important topic (and because I recently read about Chile’s maternal mortality rate and abortion laws), I wanted to repost my answer here, slightly expanded:

The El Salvador link didn’t come through; you can re-post it if you want. It’s been some time since I’ve thought of El Salvador, but I remember being in a discussion some time ago in which I found out that they have an abortion ban in place which would prohibit abortions even for ectopic pregnancies as long as the fetus/embryo is still alive. Once fetal/embryonic death is confirmed (or the tube bursts), an abortion or other surgery can be performed to save her life. I think this is a bit too stringent, with the probability of a diagnosed ectopic resulting in a life-threatening if not a life-taking situation for the mother. In abortion cases such as these, the intent is to save the life of the mother, *not* to take the life of the child. It is the unfortunate inevitable result that the baby dies; but the likelihood (probably 99% or greater) is that the baby could never survive, so it is saving one life instead of taking two.

And, yes, I agree that we should be looking at ways to make pregnancy wanted. Often, when faced with an unwanted pregnancy/child, the solution offered is to get rid of the child. Most pro-life people would say that we need to get rid of the “unwanted” portion of the equation instead.

However, there is some equivocation about abortion. Often, “unsafe abortion” is juxtaposed against “legal abortion,” as if the two were opposite or mutually exclusive, when that is not the case. There are numerous unsafe legal abortions, as there are numerous safe illegal ones. [Safe for the mother, anyway.] Just recently, a woman in New York City died from an abortion when the abortionist lacerated her cervix during the procedure and she apparently bled to death. Legal, but unsafe. Ireland has the lowest maternal mortality rate in the world, and it also has strict laws against abortion. Illegal, but safe.

The reality is, that often in countries where abortion is illegal, health services in general and maternity services in particular are horrible, with high rates of death and disease from things that barely raise a blip on the radar of developed nations. I can’t speak for the current climate in these other countries, but I know that in America, about 90% of all illegal abortions were performed by a doctor or midwife, with most of the remainder being performed by someone else who had some medical training (veterinarian, nurse, etc.), and only a small minority being either self-induced abortions or by a complete amateur. [The term “back-alley abortion” does not refer to the place of the abortion, but rather that the pregnant woman would enter the doctor’s office through the back door in the alley, often at night, so as not to be seen and raise suspicion.] These abortions were unsafe, not because they were illegal nor because they were done by unqualified personnel, but because they were unsafe by their very nature. Up until the development of antibiotics, if a woman got sepsis from childbirth or abortion, there was precious little that could be done for her. Maternal mortality dropped like a rock with the advent of sulfa drugs and penicillin, because it gave doctors for the first time the ability to fight infection. Maternal mortality dropped below 600/100,000 in 1934, and was in a free-fall for decades after, dropping to 75/100,000 in 1951 when abortion was still quite illegal, and continuing to fall to 18.8 in 1972, the year before Roe and Doe were decided. Legalizing abortion did not alter its safety; good health practices did. [In highlighting antibiotics, this does not exclude other advances, such as safer anesthesia, better technology in recognizing and treating maternal illness, a higher standard of living, etc.] MMR did fall below that, but is now on the upswing again — all with abortion still very legal. In countries where antibiotics and other health-saving measures are not easily available, we still see high rates of preventable deaths from all sorts of reasons, including abortion.

Here are abortion laws by country for 2007. As you can see, El Salvador does not allow for abortion for any reason. It has a maternal mortality rate of 170/100,000. However, what you may not have noticed from those same sources is that Chile also does not allow abortion for any reason, even to save the life of the mother, yet its maternal mortality rate is 16/100,000 — about the same as the United States’ rate.

While one might say (as is often said of Ireland), that women are merely going across the border to neighboring countries where abortion *is* legal, I would point out that their neighbors (Argentina, Bolivia and Peru) all have abortion restricted only for the life and health of the mother, and sometimes for rape. Plus, all three of these countries have *much* higher MMRs than does Chile: 77, 290, and 240/100,000 respectively. In fact, as you can see, El Salvador has a much lower maternal mortality rate than Bolivia and Peru, which both have abortion legal in the case of saving the mother’s life and health. Somehow, even with a full abortion ban, Chile enjoys an MMR comparable to that of the United States.

9 Responses

  1. Here’s the direct El Salvador article link: http://www.nytimes.com/2006/04/09/magazine/09abortion.html

    I don’t think it’s really so great that Chile’s MMR is nearing the U.S. MMR (in 2005, Chile was at 16/100,000 and the U.S. 11/100,000), given that we’re not exactly setting any benchmarks for the world there. Like other countries considered “developing” or “second world”, Chile might best the U.S. if abortion was safe and legal (see for example, Slovenia with an MMR of 6/100,000), given that abortion is the 3rd leading cause of maternal mortality in Chile (http://www.thefreelibrary.com/Maternal+mortality+in+Chile.-a0179570903). Yes, as Chile has shown, you can absolutely lower the MMR while keeping abortion illegal (although almost certainly not eliminating it, as we can see from the maternal mortality stats above), but that doesn’t make deaths from abortion disappear; in fact, it tends to bump them up in the list of leading causes, because you’re reducing everything but.

    I absolutely agree with you on the following points: Yes, good health practices make abortion safer and contribute to the drop in MMR both from abortion-related mortality and from general mortality. Yes, legal abortions can still lead to death; that’s an informed risk a woman takes when she decides to have one, just as she does with getting in a car, going skydiving, or giving birth.

    My argument is that illegal abortions are likely to be less safe, thus leading to increased maternal mortality from abortion. Is your argument that if we make abortions illegal, they will be just as safe? That if they’re still going to happen safely, they might as well be illegal? That’s an odd argument to make but maybe I’m reading this wrong.

    On the topic of reducing the “unwanted” part of “unwanted pregnancy”: I am frustrated that many anti-abortion groups campaign so hard against comprehensive sex ed. and increased access to contraception, because that seems like a no-brainer to reduce unwanted pregnancy. (That is, in fact, one of the ways Chile has so effectively reduced its MMR, and likely to some extent its MMR from abortion as well.)

    • I’m saying that safety and legality are not as closely connected as many abortion proponents would like others to believe. Often, the argument is made (as in your previous comment), “Illegal abortion kills women, while legal abortion saves women’s lives”; or, “Low maternal mortality is not possible with restricted abortion,” or “Look at El Salvador to see what a total abortion ban looks like”; when many countries have low maternal mortality *and* restricted abortion, and many countries have high maternal mortality *and* unrestricted abortion. I’m saying that we can save women’s lives *without* also taking the lives of millions of unborn children.

      Here is one reason why contraception and comprehensive sex-ed don’t necessarily work. And this 2004 Chilean study concluded, “Chile achieved the objective of the Regional Plan of Action for the Reduction of Maternal Mortality in the Americas, with a decrease of more than 50% in maternal mortality in the 1990–2000 period. That reduction is due mainly to the decline in maternal mortality from hypertension, abortion, and puerperal sepsis. “

      • And I agree with you. We can save women’s lives without high abortion rates. Look at the Netherlands: the lowest abortion rate in the world, and low maternal mortality. And as Chile shows, lowering maternal mortality is possible even with restricted abortion. But the lowest possible maternal mortality is probably not something you’re going to get with restricted abortion. As one of the other commenters said, Ireland is one of the few examples of very low maternal mortality + illegal abortion, and isn’t a good one as abortion is still fairly accessible to Irish women.

        Questions: If abortion were outlawed in every country in the world – if there was no legal access to abortion – do you think maternal mortality would be affected? That maternal mortality from abortion would be affected? If it increases, should we consider that collateral damage, only aim to reduce maternal mortality from other causes besides abortion? I ask these as real questions. I truly believe that you have to choose whether you’re going to prosecute something or make it as safe as possible; it’s very hard to do both at the same time.

        The link you gave, I think, is by someone who doesn’t understand how rates work. Young educated women had lower rates of abortion – proportionally, they had fewer abortions than others. That they had the highest number of abortions doesn’t really mean anything if you don’t have a denominator. If we follow the presumption that young educated women have better access to/knowledge of contraception, then yes, those did work in reducing their abortion rate, although there’s nothing that indicates the report actually assessed contraception use/knowledge.

        And I should have made this connection more clearly: contraception reduces abortion rates (by preventing unwanted pregnancies). It also reduces MMR (by preventing unwanted pregnancies that lead to mortality-related abortion). The better contraception access you have, the fewer abortions you have, so the fewer opportunities you have to die from abortion. That Chile reduced maternal deaths from abortion seems likely to be at least partially related to good birth control services.

        (Somewhat related, contraception also reduces MMR by reducing unwanted pregnancies that are not terminated, but still result in poor health outcomes. The fewer pregnancies you have period, the fewer opportunities you have to die from any maternal-related causes.)

        • This arguement always annoys me. Abortion has been shown, over and over again, to be MORE dangerous to a women’s health than pregnancy/birth. Yes, on very rare occassions (like ectopic) an abortion can be a life saving medical procedure that has the unfortunate affect of not being able to save the baby as well as the mother. But the actual medical reasons that abortion is necessary to save the mother’s life are extremely rare, and so are abortions done because of them (HELLP, eclampsia, ectopic, placenta abruptia before viability, or massive injury due to accident is pretty much the whole list). In fact, most studies show that only around 18% of abortions are even done for the ‘health’ of the mother or baby. In actuality this number is grossly inflated because this includes not only abortions preformed for legitament medical reasons like the mother has a form of cancer that must be treated immediately and treatment will kill the baby or the baby has grown without an organ that is necessary for viability outside the womb but abortions preformed for anything that could be claimed to be ‘health’ related such as the mother tells the doctor the pregnancy is depressing her or the baby has down syndrome or a hare lip.
          Not only does every single abortion kill a baby, but almost every single women killed by an abortion (excepting those that actually needed the abortion to survive and ended up dying of complications anyway) is a death that was unnecessary. Same thing with morbidities. And you can’t just look at the direct number of women who, for instance, bled out after some ‘reputable’ doctor perferated her womb or infection, but at the aftereffects like a greatly increased suicide and substance abuse rate, an increased risk of breast cancer, an increased risk of complications with future pregnancies, and an increased risk of domestic violence. Abortion destroys women’s lives, and there is no excuse for it. As for the ‘hard’ cases, you wouldn’t kill a man’s infant if he was convicted of murder, why would you kill his infant in utero if he was a rapist? I can understand that a women might not want to keep the baby (although statistics on actual rape victims show this is the minority, most women who become pregnant through rape, which is very rare anyway, want the child and find the child to be a healing experiance, something good that came from something horrible), but there are alternatives to raising the child. Yes, the mother has to carry the child for 9 months, one of the reasons rape is so horrible is it removes a women’s choice, but its not the child’s fault, and a women shouldn’t have any more legal ability to destroy the child in utero as she should if she gives birth to it and then, on its second birthday, decides she wants to kill it. Yes, a 12 year old who is pregnant is a sad commentary on society, but studies on early maternity (mother’s between 12-16) show they have a LOWER rate of maternal death than more normal aged mothers, probably because they usually have much more attentive prenatal care due to their rarity and the sensationalism that tends to surround their pregnancies. And, just like the rape victim (and incest victims) they should by no means be required to keep the baby but there is no more reason to kill the baby as there would be to kill a baby born into that situation at its second birthday.
          As for why people who are pro-life rail against ‘comprehensive sex ed’, there are two main reasons. One, some forms of ‘birth control’ are really early term abortions (the definition of ‘pregnant’ being redefined for marketing reasons in the 80’s to describe implantation instead of the medical beginning of pregnancy, still used in all medical textbooks and research, of conception), and people are being lied to about this, so they are not able to truly make an informed choice to use them or not, especially teenagers. And two, so called comprehensive sex ed has been show, again in repeated studies around the world, to INCREASE sexually risky behavior in teens and young adults (and one assumes adults but fewer studies on that, only some out of Africa). Teenagers subjected to comp. sex ed have a higher likelihood of engaging in sex at a younger age, a higher likelihood of std infection (and complications from lack of treatment), a higher rate of premarital pregnancy, and a higher rate of abortion. Comprehensive sex ed does two basic things, makes teens sexually active and increases the profits of birth control and abortion companies.
          Want to lower women mortality rates (since many abortion deaths are not counted as ‘maternal’ mortality statistics), ‘unwanted’ pregnancies, and teenager sexual activity? Ban abortion except to save the life of the mother, teach the actual statistics for failure rate of birth control/condoms and the actual infection rates for sex outside of monogamous marriage, and give pregnant women (weather its their first pregnancy or their tenth) the love and support of a carrying, family first community.

          • Your approach seeks to control people and dictate how and with whom they should have sex. Best of luck with that approach; I don’t think it’s particularly effective. If you actually want to reduce abortions, why argue with what works? The states in our country that use comprehensive sex ed have some of the lowest rates of teen pregnancy. The states that use abstinence only education – including inaccurate information on the “real” failure rate of birth control (so why bother using it if you do have sex?) – have the highest rates. I think we should follow in the footsteps of countries like the Netherlands & Sweden that use comprehensive sex ed and good contraception access to achieve low abortion rates, low teenage birthrates, and low maternal mortality. Again, why argue with what works?

            I won’t address all the distorted statistics, but suffice it to say, that’s not such good information you’re using. Among other things, there’s no demonstrated increased breast cancer risk with abortion.

  2. there is an article on RH Reality Check on this, with some good comments. http://www.rhrealitycheck.org/blog/2010/02/10/abortion-leads-maternal-mortality-prolife-blog-claims

    e.g.: “People who care about maternal health can find common ground with people who care about protecting the unborn since it serves both goals to improve health care. The women in India, Nicaragua and the Philippines have poor access to health care and both maternal health and the unborn suffer as a result. Women in Ireland, France and the Netherlands have excellent access to quality health care and not only to they have superior rates of maternal health they also have lower abortion rates than the poorer countries.”

    Being Irish, I’m not all that enthused about using Ireland as an illegal abortion => low MMR example (as discussed in the comments on the above article), as Irish women with some means can access legal (and safe) abortion in the UK or buy misoprostol online relatively easily in comparison to women in e.g.: El Salvador.

  3. First of all, the U.S. has one of the highest maternal mortality rates in the developed world, so I wouldn’t say Chile “enjoys” that rate. It sucks and needs to be improved.

    Second, I hope you were being facetious when you said that the El Salvador ban, which does not allow abortion in cases of ectopic pregnancy unless the fetus has already died, is “a bit” too strict. We’re talking about not allowing a lifesaving surgery when a woman’s life is in immediate danger and her fetus has no chance of survival. That’s not “a bit too strict” that’s criminally derelict.

    There’s a lot more I really want to say in response to this but I’m going to wait and see if someone else can find a nicer way to say it than I could.

  4. You’re right, doctors performed abortions when it was “illegal” – my grandmother had two in the early 40s (her health and therefore her life was at stake with the consecutive pregnancies she had been facing). Of course then if the doctor deemed it a medical necessity it was not illegal, but then again there was no birth control available to her nor was “no” acceptable in marriage.

    I also know that even when abortion is legal illegal ones occur – like my cousin puncturing her uterus when giving herself an abortion, there is legal and there is accessible. Most women in this country do not have access to abortions, my own great grandmother advocated deciding when to be pregnant via using one’s knitting needles, I assume whale bone knitting needles were safer then metal as they have some give – perhaps that’s why most women in my family knit too.

    As with any medical field there are doctors who should not practice, and there are times when accidents occur – like if a woman has very friable tissues it’s hard to know until you are in the middle of it.

    The bottom line is maternal mortality in this country has a lot to do with our poor health and how we measure maternal mortality – we count all reasons for maternal death even unrelated biologically to birth for the reasons of death, the #1 reason for maternal mortality is murder by the hands of a loved one (http://www.jrrobertssecurity.com/security-news/security-crime-news0043.htm), kind of changes the statistics if we look at how the deaths are counted.

    The goal is to keep abortion legal for there are reasons that we need it, keep it accessible for the same reason, but most of all help women decide when they become pregnant first and foremost – in the line of domestic violence abusers are known to interfere with birth control in order to get their partner pregnant, again to use it against them (http://abcnews.go.com/Health/Wellness/domestic-abuse-abusive-men-sabotage-birth-control/story?id=9639340). I don’t believe that violent men should ever be allowed to reproduce, I just don’t.

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