Abortion laws and maternal mortality rates – deconstructing the anti-choice spin

(This is an edited and condensed version of a piece I originally wrote for the Choice Ireland website in early 2010. I thought it was worth dusting off in view of the hysterical response by the anti-choice movement to today’s Universal Periodic Review examination, in which Ireland’s abortion policies were sharply criticised by a number of UN member states. The anti-choice criticism has been almost entirely focused on the issue of maternal mortality rates.)

Listening to the Irish anti-abortion movement, you’ll notice certain mantras that slip into every public comment. All those recent surveys indicating a shift in attitudes toward abortion? They’re meaningless, you’ll hear, because they don’t distinguish between “medical interventions” necessary to save a woman’s life and, you know, real abortions. Their own polls, of course, also ignore some important distinctions, but it is rare to hear them challenged on this – frustratingly so, since it would be so easy to do.

The latest mantra that seems to pop up whenever they speak has to do with Ireland’s maternal mortality rate (MMR). It’s the lowest in the world, apparently, and they consider this crucially significant in the abortion debate. The first few times I heard them mention it, I dismissed it as being too obviously irrelevant to merit further discussion – after all, who ever suggested that our abortion ban was killing women? Pro-choicers have always pointed to the numbers of women travelling to Britain or further afield (statistics, incidentally, which the anti-choice movement prefers to ignore) as demonstrating our hypocrisy in using another country’s laws as our safety net so that Irish women don’t die from illegal abortions. We have never claimed that they are somehow dying anyway. So what exactly is their point?

As their use of this statistic increased, two themes began to emerge. The first was the claim that our low MMR was somehow indicative of a “culture of life” or “how Ireland values life”. This is, of course, utter nonsense, as is shown by our mortality figures in other categories. For example, we have a relatively high (for Europe) perinatal mortality rate;[1] the cervical cancer death rate has steadily increased here while declining elsewhere in Europe;[2] and our youth suicide rate is fifth highest in the EU.[3]Surely the fact that we don’t even have universal primary healthcare, unlike nearly every other developed country in the world, puts the final nail in the “culture of life” coffin.

The second theme took a little longer to deconstruct but ultimately turned out to be just as flawed. In this one, the anti-choicers try to use international statistics to show a correlation between legalised abortion and high MMRs, or inversely between abortion bans and low maternal mortality. In other words, they argue that the Irish statistic isn’t a fluke but part of a pattern of greater survival rates for pregnant women in countries that outlaw abortion. A typical example is an article titled “UN Health Data Show Liberal Abortion Laws Lead to Greater Maternal Death”[4], which compares the MMR in Mauritius to those in Ethiopia and South Africa; Chile to Guyana; and Sri Lanka to Nepal; and finds that in all these cases, the World Health Organisation death rate for pregnant women in the former (abortion-restrictive) country is far lower than in the latter (more liberal) country. Is there any truth in this?

The answer, unsurprisingly, is yes and no. The anti-choicers aren’t making these figures up – but they aren’t giving the full story behind them, either. For one thing, they’re assuming that “legal” equates to “widely accessible”, which is something we know isn’t always true. The United States, for example, has among the most liberal abortion laws in the world and yet there is no abortion provider in 87% of its counties[5] – not an insignificant obstacle in a large, sprawling country with poor public transport infrastructure, and where workers lack statutory rights to paid medical or personal leave. It certainly does not follow that less-developed countries have only to remove legislative barriers to abortion and suddenly any woman who wants a (legal) one can get it.

But we don’t need to rest on generalisations; let’s look at some of those countries where legal abortion is assumed to be widely available. Though Nepal relaxed its laws in 2002, it was only last summer that poor Nepalese women – thanks to a lawsuit by the Center for Reproductive Rights and the Forum for Women, Law and Development – obtained the right to state-funded abortions. And, in a country that ranks 144th out of 182 in the UN’s Human Development Index[6] – the fourth-lowest in all of Asia – there are a lot of really poor women. How exactly do the anti-choicers think these women were accessing legal abortions? Of course, there is also the matter of Nepal’s decade-long armed conflict, which led to the destruction of much of what that country had in the way of infrastructure – including healthcare facilities and how to get to them. The strong likelihood is that the change in abortion laws has had little impact for a large proportion of Nepalese women.

The situation is only somewhat better in South Africa. In 2004, the Durban Mercury newspaper reported[7] that healthcare workers were invoking moral grounds to refuse women abortions in spite of their legal rights – with the predictable consequence of dangerous backstreet abortions. A 2006 report[8] found that one-third of sexually active women attending public health clinics in one province did not even know that abortion was legal. A 2005 study[9]of forty-six women who had illegal abortions in another province found that 54% were unaware of their rights, while an additional 15% knew the law but didn’t know where to find a provider. Clearly, there are still a lot of backstreet abortions going on. The legal right to abortion is not yet an effective right – and thus it is simply disingenuous to claim that pregnant South African women are dying at a higher rate because abortion is legal.

Now if South Africa – one of that continent’s wealthier nations – can’t guarantee its women access to legal abortions, how could anyone imagine that a country like Ethiopia can? It is, after all, one of the most underdeveloped countries in the world, a place where women and children still have to walk many miles a day just to fetch water. It almost seems pointless to go looking for references on the actual availability of abortion since the law was relaxed in 2006. Fortunately, I don’t have to, because in this case the anti-choicers’ argument falls at the first hurdle: the WHO report they cite, although published last year, cites data from 2005. I’ll graciously assume they simply didn’t notice this.

I’m less inclined to be generous about their selectivity with the WHO statistics. As eager as they are to highlight those parts of the world where the MMR seems to back up their position, they’re curiously silent about those parts of the world where it doesn’t. They don’t tell you, for example, that the lowest rate in North America is in Canada, which abolished all abortion restrictions in 1988; or that in East Asia, the safest country for pregnant women is liberal Japan. And of course, while they point out that South Africa has a higher MMR than Mauritius, they conveniently ignore that both places are left for dust by countries like Niger and DRC, where abortion is pretty much totally illegal.

The anti-choicers could have a valid argument if they were using these facts and figures to show that the link between illegal abortion and maternal mortality is more complex than it may initially seem. That would be fair enough. But this is something the pro-choice side has always recognised. Even the Guttmacher Institute[10] implicates unsafe abortion in only 13% of the world’s annual maternal deaths – which means that 87% of them are caused by something else. (In real terms, of course, 13% is still a significant number, representing approximately 70,000 women per year, and a more telling statistic would be the proportion of these particular maternal deaths that occur in countries without an effective legal right to abortion. The anti-choice movement, however, doesn’t seem very interested in that. I wonder why.)

When it suits them, of course, they’re happy to acknowledge that maternal mortality is a function of a number of elements. Take the example of Chile. Family and Life recently cited a study that, in their words,[11] shows that “maternal mortality in Chile declined over the last century whether abortion was legal or illegal” [emphasis added]. In other words, factors particular to Chile other than the legal status of abortion had the most significant impact on the MMR – which is exactly the argument the pro-choice side would make. Apparently, Family and Life didn’t get the memo that they were supposed to credit the abortion ban for the decline. Neither did the Pro-Life Campaign, judging by its 23rd April 2010 newsletter: it approvingly cites a recent Lancet article[12] which attributes the worldwide decline in maternal mortality to a number of different factors, none of them relating to either the legalisation or criminalisation of abortion. Remember that the next time you hear it claimed that Ireland’s low rate is because of our restrictive laws.

But if Chile is a country whose historical MMR shows no discernible link to the status of abortion, there are plenty of others where the opposite is true – and some of the anti-choicers’ favourite examples feature prominently on that list. In South Africa, for example, a 2005 study[13] found that the MMR declined by anywhere from 51.3 to 94.8 per cent after abortion was legalised (the large range is due to the difficulty in ascertaining the number of abortion-related deaths in the pre-legalisation era). In Nepal, which legalised abortion in 2002, by 2006 the MMR had fallen by almost 48%.[14] There’s not much information available on Guyana, but one telling record is that hospital admissions for septic and incomplete abortion fell 41 percent after legalisation.[15] These statistics are not incontrovertible proof of a link between MMR and the law (especially given the already-discussed gap between what the law says and what’s actually available), but they’re a lot more persuasive than crude cross-country comparisons – and they certainly put the lie to any suggestion that legalisation increases maternal mortality.

So to summarise, the anti-choice movement is correct to point out that countries with legal abortion don’t necessarily have lower maternal mortality than countries without it, or the other way around. But they’re absolutely wrong in suggesting the existence of a pattern in their favour. If anything, the opposite is true – a big-picture evaluation of the data reinforces the pro-choice side, in that the majority of countries with high MMRs impose strict limits on abortion while the majority of countries with low MMRs do not. In picking out the exceptions and highlighting them as if they were actually the rule, the anti-choicers are a bit like the climate change deniers (not surprising, since they tend to spring from the same gene pool) who think the miserable summers we’ve had in Ireland for the past couple years prove that there isn’t a global warming trend. And they’re equally wrong.

But there’s something really offensive at the heart of this anti-choice argument, and it doesn’t actually depend on whether or not they’re right about the link between maternal mortality and the law. Even if they were, they would still be showing up their hypocrisy in pretending that their opposition to abortion rights was somehow motivated by concern for women’s well-being. These, after all, are the same people who believe that nothing short of the woman’s death (if that) should be sufficient to entitle her to an abortion. The same people who see nothing wrong with bogus crisis pregnancy agencies inflicting huge psychological damage on women in order to prevent them making that choice. We’re seeing this kind of hypocrisy being played out in the United States at the moment, where their latest tactic is to target the black abortion rate with cries of “genocide”. It wasn’t so long ago that many of the same people (i.e., white conservatives) were accusing black women of having too many babies (for the welfare cheque, of course) – and not so long before that that they were forcibly sterilising black women. They may feign concern for the women now, but it’s nothing more than a propaganda tool.

Just to emphasise the point, I did a trawl through the Family and Life and Irish Times archives, to try to find some comment from them about those 70,000 deaths per annum. Some reference to the fact that, rates and rankings aside, women are dying as a direct result of unsafe illegal abortions (and no doubt, many others die of complications from unwanted pregnancies that they would have aborted given the option). Some explanation as to how they propose to address this particular tragic consequence of the abortion laws in those countries, the laws that they support and want to see brought in everywhere else. I found nothing – which shows pretty conclusively that the life of a pregnant women isn’t really their concern. The woman in the abortion scenario has value to them only when they think they can advance their agenda by portraying it as being in her interest. And this is something the pro-choice side needs to point out in our own public statements, because at the end of the day, whatever about opinion polls and statistics, this is what distinguishes us from them: we care about women’s lives, and they don’t.

Let that be our mantra.

1. ESRI, Perinatal Statistics Report 2007, published September 2009
2. Comber H, Gavin A , “Recent trends in Cervical Cancer Mortality in Britain and Ireland: the Case for Population-Based Cervical Cancer Screening”;. British Journal of Cancer (2004) 91 (11):1902-4
3. National Office for Suicide Prevention Annual Report 2008.
4. http://www.lifesitenews.com/ldn/2009/aug/09081310.html
5. Henshaw SK, Finer LB. “The accessibility of abortion services in the United States, 2001”. Perspectives on Sexual and Reproductive Health. Jan-Feb 2003;35(1):16-24.
6. United Nations Human Development Report 2009
7. Akhona Cira and Latoya Newman, “Backstreet abortions take their toll”, 9th September 2004
8. Chelsea Morroni, Landon Myer and Kemilembe Tibazarwa, “Knowledge of the abortion legislation among South African women: a cross-sectional study”; Reproductive Health 2006, 3:7
9. Jewkes RK, Gumede T, Westaway MS, Dickson K, Brown H, Rees H: “Why are women still aborting outside designated facilities in Metropolitan South Africa?”, International Journal of Obstetrics and Gynaecology 2005, 112:1236-1242.
10. Singh S et al., Abortion Worldwide: A Decade of Uneven Process, New York: Guttmacher Institute, 2009.
11. “Chilean Maternal Mortality Study Refutes Pro-Abortion Assertions”, 1st March 10
12. “Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5”, 12 April 2010
13. Jewkes R, Rees H: “Dramatic decline in abortion related mortality due to the Choice on Termination of Pregnancy Act”, South Africa Medical Journal 2005, 95(4):250
14. Nepal: Maternal Mortality and Morbidity Study 2008/09, Nepal Department of Health
15. Nunes F, Delph Y. “Making abortion law reform work: steps and slips in Guyana”, Reproductive Health Matters 9 (1997), pp. 66–76