Chile study challenges the "safe abortion" myth
One of the great scandals of today's global village is the deaths of hundreds of thousands of mothers each year simply because they are carrying or giving birth to a child. The last reliable estimate, from 2008, indicated nearly 343,000 of these maternal deaths. The scandal lies in the fact that most of them are easily preventible with basic health care, as the West discovered more than a century ago.
The West, as we know from many statements from the World Health Organisation and reproductive health groups, is anxious to reduce this awful statistic, which is an important aim of the Millennium Development Goals. Unfortunately, this altogether worthy goal is entangled with another: the reduction of fertility in the developing countries, by the quickest means possible. This means that, often before other basic medical and social improvements are in place, there must be universal access to birth control technology -- not only contraception but abortion.
Abortion, however, must be safe for the woman -- that is, provided by medically qualified people or by medically certified means -- and to be safe it must be legal. Where it is illegal it will happen anyway but it will be unsafe, and often lethal. States which persist in keeping abortion illegal or severely restricted (and not the agents who are pushing this form of birth control) are thus contributing to the dire maternal mortality statistics. And states which ban abortion after it has been legal are similarly putting women's lives at risk. That, as they say, is the narrative.
There's just one problem with the drift of this story: there is no proof that it is true. The only hard evidence that we have on the subject of restrictive abortion laws and maternal mortality rates (MMR) is very new and it points in the opposite direction.
Research from Chile published a few days ago shows that, when therapeutic abortion was banned in 1989 after a long period when it had been legal in that country, there was no increase in maternal mortality. None at all. On the contrary, maternal deaths continued to decline. Chile today has one of the lowest maternal mortality rates in the world (16 per 100,000 live births), outstripping the United States (18) and, within the Americas, second only to Canada (9). Rather than the rogue violator of women's reproductive health that the UN makes it out to be, Chile is looking this week like a model for countries that really want to save the lives of mothers.
Figure 1. Trend for maternal mortality ratio, Chile 19572007.
It's important to note here what the study, Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007, does not claim. It does not say that making abortion illegal caused a decline in maternal deaths. But it shows, importantly, that the 1989 law did not increase mortality. It continued to decline substantially, although other factors were at work in the decline -- notably, the education of women and their ability to shape their own reproductive behaviour. (The latter does not mean quite what birth control fundamentalists mean, as we shall see.)
The study, published in the open access online journal PLoS One, is the work of Chilean and American researchers led by Dr Elard Koch, epidemiologist and a professor at the University of Chile and Universidad Católica de la Santísima Concepción (UCSC). The group, who formed the Chilean Maternal Mortality Research Initiative (CMMRI) for the purpose of the study, had access to exceptionally good data: 50 years of official records from Chile's National Institute of Statistics, 1957 to 2007. These provide the basis of what the authors call a "natural experiment" in fertility and abortion policy.
What these records show is a dramatic decline in MMR from 1965, when abortions were numerous and abortion was the main cause of mortality, through to 1981; a continuing but slower reduction from 1981 to 2003; and a steady state from 2003 to 2007. To explain this pattern the researchers analysed social policies and trends likely to influence maternal mortality. Here are the key ones, especially for the first phase:
- Delivery by skilled birth attendants. For each 1 per cent increase in the number of deliveries performed by skilled attendants there was an estimated decrease of 4.58 maternal deaths per 100,000 live births. Clean water and other sanitary improvements also played a part.
- Access to maternal healthcare services. Nutrition programmes for mother and child, coupled with the distribution of fortified milk at primary care clinics created new opportunities for pregnancy and birth care for both mother and child. This strategy practically eradicated malnutrition, increased birth weight and contributed to the noteworthy reduction in infant mortality observed in Chile, 3.1/1000 live births for infants 28 days to 1 year of age.
- Women's educational level. This, says Koch, is the most important factor, and the one which increased the effect of all other factors. Educating women enhances a woman's ability to access existing health care resources and directly leads to a reduction in her risk of dying during pregnancy and childbirth. Data showed that for every additional year of maternal education in Chile there was a corresponding decrease in the MMR of 29.3/100,000 live births.
Boosting female education did something else: it brought down the fertility rate (currently the TFR is 1.87). To return to a point mentioned earlier, the authors point out that "education promotes higher autonomy in women, allowing them to take control of their own fertility" using the method they prefer. Interestingly, a majority of Chilean women do not prefer artificial contraceptives. The authors note:
"Although the primary care system currently provides universal access to a variety of contraceptives methods, actual use of hormonal contraceptives and intrauterine devices in Chile reaches approximately 36% of women of reproductive age. Therefore, as in developed nations, other factors not limited to the use of artificial contraceptives seem to be contributing to the reduction in TFR in Chile. One such factor could be women's increasing level of education."
And here the news stops being good. At this point Chilean woman meets North American and European and Antipodean woman in a pattern of delayed motherhood -- and pathologies associated with that delay. Koch and colleagues describe this "fertility paradox" as follows:
Although a strong correlation did exist between the decline on the MMR and the reduction on total fertility rate (i.e. the average number of children that would have been born to a woman over her reproductive lifetime), the increase in the number of first pregnancies at advanced ages was directly associated with an increase on maternal deaths. For every 1% increment in primiparous women giving birth older than 30 years of age, an increase of 30 maternal deaths per 100,000 live births was estimated. Thus, when the total fertility decreases and produces a delayed motherhood it can also provoke a deleterious effect on maternal health via an increase of the obstetric risk associated with childbearing at advanced ages.
Before 1980 the causes of MMR in Chile were on the whole directly related to pregnancy and birth. From then on the underlying health problems of "aging pregnancy" began to take over in the mortality stakes: hypertension, diabetes and obesity among others. The problem now, there and here in the developed world, "is not a matter of how many children a mother has, but a matter of when."
Did the reproductive health brigade get that? Delayed motherhood can be literally deadly. At a certain point, the gains of education and good health and social services are taken too far and recoil upon the modern woman. With the greater part of the world, including many developing countries, now below replacement TFR, maternal mortality from social progress is set to climb before deaths from deprivation have been thoroughly, and one could say properly, addressed.
Koch's study shows that the custodians of reproductive health profoundly misunderstand the remedy for maternal mortality in developing countries. Will they do any better when they try to come to grips with the fertility paradox?
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