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CMMRI

The Chilean Maternal Mortality Research Initiative

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Response to Guttmacher Institute criticisms by Koch et al. on the Impact of Abortion Restrictions on Maternal Mortality in Chile
Elard Koch, John Thorp, Miguel Bravo, and Sebastián Gatica, on behalf of the CMMRI

On May 23rd, the Alan Guttmacher Institute (GI) released an advisory comment entitled “Review of a Study by Koch et al. on the Impact of Abortion Restrictions on Maternal Mortality in Chile” [1]. Following a short background on maternal mortality, this document contains several criticisms that attempt to debunk some conclusions of our article recently published in PLoS ONE entitled “Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007” [2]. After carefully reviewing the document released by the GI [1], we think it contains erroneous and misleading information, which may influence public opinion into disregarding important findings revealed in our article. The following commentary presents a point-by-point rebuttal that will clarify several issues and will help readers to make their own conclusions. For simplicity purposes, we excluded the references within quotes of both our article and the document by the GI. GI: “Assessing a new study from Chile A new study by Koch et al. asserts that the expansion of abortion restrictions in Chile in 1989 did not lead to an increase in the incidence of abortion-related mortality. The study concludes that ‘making abortion illegal is not necessarily equivalent to promoting unsafe abortion.’ However, as detailed below, the study has several serious conceptual and methodological flaws that render some of its conclusions pertaining to abortion and maternal mortality invalid:” [1] Author’s reply: Which are exactly the serious “methodological flaws” of our study? The single conclusion that they challenge appears to relate only to the null effect of abortion ban on maternal mortality trend in Chile. More seriously, GI experts do not present any actual evidence in support of any ‘serious’

prohibition of abortion in Chile did not influence the downward trend in the maternal mortality ratio. as the GI affirms ―although we understand how delicate this matter is. Thus. over 3. abortion was simplified and allowed based on the opinion of two physicians. after permission of three physicians or one physician and two witnesses. including women’s educational level. until 1989. or simply “on request”. six months immediately before the Chilean coup d'état. For instance. located in the south sector of Santiago. as a chronicle ironically entitled “La vía chilena hacia el aborto” (literally in English “The Chilean way to abortion”) [3]. Regarding the legal status of abortion. better access to maternal health care facilities and professionals. so no conclusions can be drawn about impact of a change from liberal to restrictive laws:” [1] Author’s reply: This is a major misinformation. the term “therapeutic” was loosely interpreted by Chilean physicians. In Appendix S1 of our article [2]. it is clear that abortion ban in Chile meant a major transition from a partially restrictive to a fully restrictive law in . in 1973. Moreover. among others.000 abortions were conducted “on request” in “Hospital Barros Luco Trudeau”. From 1967 to 1989.” [2] GI: “1. we realize more clarification is needed: our main goal was not assessing “the consequences of abortion”. expansion of sanitary services. we assessed the impact of different factors thought to influence maternal mortality. Abortion was legal in Chile from 1931 to 1967. It is relatively well documented that. we clearly describe that the Chilean law allowed abortion for “therapeutic reasons” with the respective notes. Chile’s pre-1989 abortion law was already highly restrictive. it is inaccurate to affirm that: “Chile’s pre-1989 abortion law was already highly restrictive” [1]. This case is very well documented and was recently reported in the Chilean newspaper “The Clinic”. 2 Therefore. Flexible interpretation of the practice of “therapeutic” abortion was progressively restricted and prosecuted until the definitive derogation of all types of abortion in 1989. In fact. The legal status of abortion was no more than another factor subjected to analysis. the legal status of abortion does not appear to be related to overall rates of maternal mortality. Rather. an undetermined number of elective abortions were conducted by several physicians utilizing the latter law in different regions of the country. Thus. complementary nutrition programs.CMMRI The Chilean Maternal Mortality Research Initiative methodological flaw in our study. we conclude at the end of our article: “Finally. allowing abortions to be performed for socioeconomic or mental health reasons.

maternal mortality ratios steadily decreased over the last fifty years. For clarification purposes. Article 19 was replaced by the text “no podrá ejecutarse ninguna acción cuyo fin sea provocar un aborto” (literally in English “no action can be performed whose purpose is to cause an abortion”). allowed conducting an undetermined number of elective induced abortions in Chile. This conclusion remains unaltered even after the GI criticism. In practical terms. when the life of the mother is at risk. To the letter of the law. In terms of Chilean medical practice. because it is interpreted as a medical ethics decision and abortion is not the primary purpose. Chile was already among the countries where abortion is highly restricted. In fact. “Only for therapeutic purposes a pregnancy can be terminated. medical ethics is sufficient to settle the matter. . This means that on the spectrum of abortion restrictions. But even if the argumentation by the GI experts stating that “Chile was already among the countries where abortion is highly restricted” [1] was correct. In other words. and the interruption of a pregnancy intended to save the life of the mother is not a legal issue in Chile. it is absolutely possible for developing countries to decrease maternal and abortion mortality without requiring any liberal law of abortion. In other words. current law does not prohibit the pre-viable delivery of a fetus to save the life of the mother. As stated previously and because of the evident ambiguity of the word ‘therapeutic’. Carrying out this intervention will require the documented opinion of two physicians”). Para proceder a esta intervención se requerirá la opinión documentada de dos médicos cirujanos” (literally in English. are ethically solved by applying the principle of double effect and the concept of indirect abortion [4]. this does not invalidate one of the main conclusion of the Chilean natural experiment: abortion restrictive laws did not influence maternal mortality trends. the Spanish word “terapéutico” is literally translated to “therapeutic”. exceptional cases. The further tightening of these already severe restrictions in 1989 then put Chile firmly in the group of countries with the most restrictive laws—those where abortion is banned under any circumstances” [1] 3 Author’s reply: As pointed out above. this is an error or misinterpretation of the Chilean abortion law –probably related to misinformation– by the GI. the interpretative use – and abuse– of this law. the Chilean law (Article 19 of the Chilean Sanitary Code) was redacted in the following terms: “Sólo con fines terapéuticos se podrá interrumpir un embarazo.CMMRI The Chilean Maternal Mortality Research Initiative practical terms. In 1989. abortion was legal in Chile only to save a woman’s life (the law was sometimes interpreted to allow abortion if a woman’s health was threatened). GI: “Before 1989.

the proportion of all abortions that were illegal did not increase substantially” [1] Author’s reply: We think this question has already been addressed in our previous rebuttal comments. when the leading cause of mortality was abortion. As we already discussed in our article. restrictive laws may have a restraining effect on the practice of abortion ―similar to restrictions on tobacco smoking or alcohol consumption that are hypothesized to cause a dissuasive effect on the population― when combined with adequate policies improving women’s . More research is required to accurately address the factors related to the parallel decrease in complications and hospitalizations from abortion in Chile. In the last decade. the Chilean experience shows that it is absolutely possible for developing countries to lower maternal mortality rates. It is a matter of scientific fact in our study. over 80% of all hospitalizations from abortion are related to miscarriages or spontaneous abortions. These data suggest that throughout time. the fifty–year natural experiment conducted in Chile strongly supports that abortion legalization is unnecessary to decrease maternal mortality and reach the millennium development goal 5 (MDG-5). only 12-19% of all hospitalization from abortion can be attributable to complications from clandestine abortions between 2001 and 2008. Nowadays. In other words. All the argumentation carried out by the GI is flawed because of serious misinformation and misinterpretations regarding the Chilean abortion law. it is not surprising (and should in fact be expected) that after Chile’s law was further tightened in 1989. We appreciate that the GI’s acknowledges: “the proportion of all abortions that were illegal did not increase substantially” [1]. “in 1960. there were 287. In fact. this proportion decreased rapidly in the following decades. GI: “Relatively few legal abortions are performed to save the life of the mother or to protect the mother’s health. The decline of maternal mortality and abortion mortality in Chile occurred in parallel with the decrease of number of hospitalizations attributable to complications from clandestine abortions: while over 40% to 50% of all abortionrelated hospitalizations were attributable to complications from clandestine abortions during the 1960’s decade.063 live births and 57. we observed a continuous reduction from the 1970’s. Thus.CMMRI The Chilean Maternal Mortality Research Initiative 4 Finally. indeed. when we considered the hospitalizations for any kind of abortion in Chile.368 hospitalizations from abortion (whether spontaneous or induced). representing a 5:1 ratio. the ratio between live births and hospitalizations from abortion has remained relatively stable at approximately 7:1” [2]. without requiring the legalization of abortion.

displaying 92. all this information has been included in our publication at PLoS ONE and it is already available to be utilized by the scientific and medical community interested in maternal health research utilizing long time series or different historical periods at least from 1950’s decade. The work was not exclusively limited to describe the trend on maternal deaths. In fact. clean water supply.” [1] Author’s reply: On the contrary. 8. birth order. However. In fact. concretely we standardized the ICDs version 7. ours is the first in-depth analysis of a large and parallel time series. To accurately assess the trend in maternal deaths causes.1% accumulated decrease over fifty years. 5 GI: “2. including years of education of women in reproductive age. It is not a matter of circumstantial or anecdotic evidence or indirect estimates. The authors rely on a far too narrow. their exclusive reliance on Chile’s vital registration system to assess the incidence and consequences of abortion in a setting where the procedure is highly restricted—and therefore largely clandestine—is a critical methodological weakness.CMMRI The Chilean Maternal Mortality Research Initiative educational level and access to maternal health care. a rigorous statistical analysis controlled by multiple confounders was performed. of maternal deaths and the simultaneous assessment of their determinants at a country level. To the best of our knowledge. it is a unique natural experiment conducted in a developing country. Furthermore. a homologation of four codes of International Classification of Diseases (ICDs) was needed. per capita income. In addition. Now. childbirth delivery by skilled attendants. and a pathway regression using a robust autoregressive procedure (ARIMA). by definition maternal mortality ratio (MMR) is the main indicator to monitor the MDG- . total fertility rate. but rather a matter of scientific data representing actual vital events ―and every case representing a real woman dying from maternal-related or abortion-related causes― whose methodology has been published for the first time in a independent and external peer-reviewed scientific journal. 9 and 10 to analyze maternal death causes from the original ICD. and different historical policies. this is a major strength in our study. In this sense.3% decrease from 1989 and 99. sanitary sewer. a segmented regression. unreliable evidence base: The authors state that they are using ‘empirical evidence’ as a basis for their claims regarding the incidence of abortion and abortion-related mortality in Chile. More research to assess this important hypothesis emerging after the Chilean natural experiment is required. Chile exhibits today one of the lowest abortion-related maternal deaths in the world. this is the first study counting with sufficient data and time points to simultaneously conduct a multiple time-series regression. year-by-year.

In fact. from an epidemiological viewpoint they are flawed to accurately quantify the number of induced abortions: these are purely indirect approaches that may lead to under.or overestimations. In this context. in strict scientific rigor. Furthermore. Moreover. A body of research using data sources such as surveys of women and surveys of health professionals has been developed. it is necessary to probe much further. you need to compare the reliability of the data. GI: “To properly understand the impact of a clandestine practice. . controlling for each other variable including changes or breaks in the observed trends. in 2006. especially when we consider that the Chilean natural experiment seriously challenges. In contrast. we chose PLoS ONE after editors of The Lancet rejected even conducting a peer-review of our article. for the first time. Practically the totality of the studies conducted by the GI over the last two decades is based on indirect estimates. with figures estimated with the methodology developed by the GI: employing this methodology. Although we grant that some anecdotic and qualitative value can be drawn from such instruments. almost to the point of abuse. Finally. as we pointed out. Thus. the Chilean study is very transparent and all the information was made available at PLoS ONE. because our extremely controversial finding related to the null impact of the illegal status of abortion.CMMRI The Chilean Maternal Mortality Research Initiative 6 5. the manuscript was intensively peerreviewed by independent scientists. We explored the serious methodological flaws by the GI in a recent independent peer-reviewed publication [5]. and due to the subjective nature of opinion surveys. peer reviewed and published in scientific journals in recent decades specifically to address the severe limitations of registration systems in measuring the incidence and consequences of unsafe abortion. Moreover. studies based on indirect estimates are substantially more exposed to bias than studies based on actual data. several reports ―most of them based on indirect estimates of induced abortions in developing countries by researchers from the GI― published in this prestigious medical journal over the last decade. such as Mexico. We found that the GI grossly overestimated abortion rates in all analyzed countries. This is not surprising.” [1] Author’s reply: “Surveys of women and surveys of health professionals” have been long used by researchers of the GI. we precisely analyzed the impact of the each predictor on MMR over a fiftyyear period. Overestimation by this methodology can also be observed by contrasting actual figures of abortion from countries with liberal abortion laws. they are largely based on opinion surveys whose scientific validity is unknown. when you are looking to compare different studies. the scientific validity of these methodologies is unknown. they can be extremely biased.

812. The case of Mexico allows making four important conclusions: First. In fact. not independently peer-reviewed journal [6] ―and therefore we consider that publication bias cannot be ruled out. in Colombia. elective abortions have shown a clear upward trend year-by-year.937. the Ministry of Health of Spain keeps a precise registry of elective abortion since 1987. this study was pivotal for the legalization of abortion in Mexico FD on April 24th. after abortion legalization. This leads to a figure of pregnancies beyond the empirically possible biological reproductive rate for that country. These epidemiological observations based on actual data directly contradict one of the main conclusions by the GI researchers over the last decades: liberal laws do not control the problem of induced abortion. what has really happened in Mexico FD since then? The case of this country provides a “natural” laboratory to assess what occur after abortion legalization. from 16.000 clandestine abortions per year in Mexico and published this finding in their own in-house. the methodology based on surveys conducted by the GI leads to at least a 30-fold overestimation in the number of induced abortions conducted before abortion legalization in 2007 (i. Group of Information in Elective Reproduction) [7]. The number of elective induced abortions registered since abortion legalization until 2011 inclusive totals 71. again publication bias cannot be ruled out [9]. using valid .000. and therefore. But.766 to 115. this large “black figure” of induced abortion triggered the alarm in the government and the public opinion.404 in 2008 to 20. from 13. This is not surprising and has been well documented in developed countries that have legalized abortion. Third. according to the GIRE (Grupo de Información en Reproducción Elegida. Moreover. abortion registry in Mexico suggests that abortion legalization is promoting a continuous increase in the number of induced abortions.314 in 2011 [7].314 in 2011). In fact. they just increase its incidence. in English. Obviously. For instance.400 abortions in another in-house journal without independent peer-review. since the methodology employed by the GI is indirect and mainly based on opinion surveys. 700. and researchers from the GI estimated 400. In fact. 715.e. 2007. calculating figures of abortions comparable to the number of live births. For instance. a year after its legalization in this country [8]. such as occur in a modern epidemic. Second. elective induced abortion figures from Spain have steadily increased between 1987 and 2008. even though some degree of under-report in the number of elective abortions may occur in Mexico at the present.000 and 1.453 live births were observed during 2008. it can lead to overestimations that reach beyond what is empirically plausible.CMMRI The Chilean Maternal Mortality Research Initiative 7 researchers from the GI estimated between 700.000 according to the GI versus the actual figure of 20.

For the same reason. GI: “Abortion as a cause of death is often misreported or underreported in countries where the procedure is illegal under all or most circumstances. fails to reflect reality. this subject has been already discussed in the Limitations section of our article and was intensively and critically evaluated during the external and independent peer review process at PLoS ONE [2]. Chile.400 versus 21. conclusions by analysis purely based on opinion surveys appear inconsistent and biased: in strict scientific rigor. physicians treating women for postabortion complications may misreport (or not report at all) deaths and injuries from unsafe abortion to protect their patients from criminal sanctions. the “body of research”. and Dominican Republic [12]. Chile is classified in the A list by the United Nations regarding vital statistics information from a long time ago. reporting elevated ―and overestimated in a similar way to the case of Mexico and Colombia [5]― numbers of clandestine abortions. In Appendix 2 of the WHO report [15]. 8 Finally. In contrast. The current registry of maternal death causes has 100% integrity and practically null misclassification due to active epidemiological surveillance and mandatory notification and constant audit of maternal death causes under strict rules of confidentiality [16]. we observe that the opinion-based methodology by the GI researchers overestimated by a factor of 18 the possible number of induced abortions (400. women who suffer complications after undergoing unsafe abortions are highly unlikely to admit to these actions given possible criminal sanctions (including prison sentences for having obtained abortions). In fact. In Chile. In Chile. Brazil. Live births registry is corrected by the method of delayed registry (1 to 7 . many women may not seek medical help for abortion-related complications. Peru. Chile appears along with 63 countries with civil registration data characterized as complete with good attribution of cause of death. trends of maternal mortality observed in most of these countries show significant progress over the last two decades [13].978) in Colombia [5]. similar studies carried out by researchers from the GI have been conducted in Argentina [10]. Our recently published article [5] supports these assumptions. even though “published in scientific journals in recent decades”. integrity and medical certification of global deaths is practically 100% and misclassification is between 2% and 4% considering the general registry of all death causes [14]. In this scenario.” [1] Author’s reply: This speculative assumption by GI experts is not likely to be a relevant factor influencing the results in the Chilean case.CMMRI The Chilean Maternal Mortality Research Initiative epidemiological methods of estimation. Guatemala [11]. Likewise.

While it is true that Malta.CMMRI The Chilean Maternal Mortality Research Initiative years). We grant that it is possible that travelling to nearby countries may be easier for women from Malta.8% of live births occur in maternities at the Chilean hospitals. since most European countries allow elective abortion.5 and 1%.” [1] Author’s reply: The first problem with the GI statement is that it doesn’t appear to be a rule regarding the legal status of abortion. makes it difficult for Chilean women to seek and perform abortions abroad. In fact. the authors cite low maternal mortality ratios in Ireland. if not going up. Thus. Moreover. In fact. The report of the high number of maternal deaths due to abortion in the early 1960’s is further evidence of the high quality of the Chilean registry [17]. an analysis of . possibly due to public policies similar to those promoting the decrease of maternal mortality in Chile. Chilean INE is the technical referent entity for the Organization for Economic Cooperation and Development (OECD) in Latin America. Nowadays. as well as the widely acknowledged credentials of the Chilean INE. Poland) these ratios were already low at the time of passing restrictive abortion laws. To test this hypothesis. Thus. Moreover. 9 GI: “The argument that restrictive abortion laws do not have a negative impact on women’s health is not supported by the existing body of evidence: In addition to their own study. this registry is also characterized as complete (Appendix S1 [2] details this information).g. and Poland. in some of them (e. The correction method is carried out by the National Institute of Statistics (INE) and released as an official year-by-year publication. it went down. it is unlikely that the decrease in abortion mortality in Chile is explained by ‘safe abortion’ procedures in more liberal countries. Ireland. and Poland currently exhibit very low MMR. you would expect to find abortion mortality at least plateauing in Chile. however. it is highly unlikely that maternal deaths of any kind (including those caused by complications of any kind of abortion) are misrepresented or under-reported. these countries are exceptions to the rule. the extent of abortion restriction is variable among different countries. Currently. Ireland. Abortion prohibition in most Latin America. 99. if the causal assumption by GI were correct. given the strengths and integrity of the Chilean registry of maternal deaths and live births. Malta and Poland as evidence that restrictive abortion laws are safe for women. This may be acting as a confounder difficult to control. This is not surprising since currently. Therefore. But women in these countries are known to travel to nearby countries with liberal abortion laws to terminate pregnancies or seek postabortion care. delayed registry is between 0.

We think the statement that “almost all of the countries with the highest maternal mortality rates have highly restrictive abortion laws” is essentially mistaken given the cases of Chile. Nevertheless. GI: “Almost all of the countries classified as having the lowest maternal mortality rates in the world allow legal abortion on broad grounds. we call the same rigor in causal associations from other scientists. and Poland and the decreasing trends on maternal mortality observed in most of Latin American countries with restrictive abortion laws. Moreover. Ireland. there is a collection of anecdotic information that has yet to be analyzed in-depth to test that postulate. according to the latest independent global reports on maternal deaths by Hogan et al. Canada and the US. We simply state that maternal mortality trends are uninfluenced by the illegal status of abortion. developed countries such as Spain. the statement “Almost all of the countries classified as having the lowest maternal mortality rates in the world allow legal abortion on broad grounds” is another generalization without a real causal link. Likewise. similar to that made with Chilean data. we are concerned about making causal associations that are not firmly founded on empirical data. such analysis was also lacking for Chile before our publication. So far. As scientists. There are. Guyana legalized abortion in the early 1990’s showing no sign of decreasing MMR. and almost all of the countries with the highest maternal mortality rates have highly restrictive abortion laws. we are unaware of empirical data demonstrating a causal link between prohibiting abortion and an increase in maternal mortality. these countries are progressing rapidly to improve maternal health. the evolution of maternal mortality in Poland. and Ireland is yet to be analyzed in depth in the formal biomedical literature. On the other hand. is required. Finally. Malta. [13] and may benefit from the Chilean example of public policies leading to better access to education and maternal health facilities. Rather. In fact. such El Salvador and Nicaragua. developing countries with restrictive abortion laws that still exhibit high MMR.” [1] Author’s reply: This is a harmful and risky generalization. Therefore. It is just a speculative assumption .CMMRI The Chilean Maternal Mortality Research Initiative 10 maternal mortality data from this country. show an increase in maternal deaths over the last decade. This is why we do not make a causal association between prohibition of abortion in Chile in 1989 and the following decrease in maternal mortality. Our experiment in Chile shows that both maternal mortality trend and illegal status of abortion are not causally related in one way or another. however. Malta.

GI: “In countries that have liberalized their abortion laws over the past two decades. according to data from the World Bank [20].2%. For example. the improvement in maternal health facilities and other significant confounders that may be influencing the decrease in maternal mortality. Therefore. 11 As our study [2] shows. such as Ethiopia. and 2009. 17.5 to 4.4.4%. education influenced the effect of all other factors analyzed in our study. the evidence is beginning to demonstrate that abortion law reforms are associated with improved health outcomes for women. 34. 2001. as our study shows. it can be argued that the decrease in maternal mortality may be accounted for by the improvement in the educational level of women in Nepal.9%. Recent studies on maternal mortality conducted in Nepal [18] and Ethiopia [19] were not controlled by the change in women’s educational level. nutrition.CMMRI The Chilean Maternal Mortality Research Initiative based on purely descriptive data or indirect estimates. and not by legalization of abortion.9% for the years 1981.000 live births. Nepal shows an important improvement in the educational level of women of reproductive age: an increase of the average schooling years from approximately 1. 1991. to the best of our knowledge. women’s educational level should be considered as a major confounder when studying the effect of abortion policies. there were 121 maternal deaths per 100. no other study has taken into account such confounder when analyzing trends in maternal mortality. in addition. and 46. the 2010 report of the World Health Organization for South Africa suggests an increase in maternal mortality over the last two decades: in 1990. Unfortunately. between 1990 and 2010 (just between 2000 and 2010 this figure increased from 2. sanitary services (clean water and sanitary sewer) may help developing countries to reach MDG-5 without having to resort to legalization of abortion. it is likely that an improvement in women’s education level. exhibiting figures of 9.” [1] Author’s reply: Our study [2] shows that women’s educational level is the main factor influencing the decrease in Chilean maternal mortality rate: for every additional year of maternal education there was a corresponding decrease in the MMR of 29.4).000 live births while in 2008 this . likely by promoting behavioral changes in and the utilization of maternal health facilities by the female population. and all of them should be taken into account when analyzing their effect on maternal mortality trends. there are several factors influencing MMR in a country. maternal health facilities. Furthermore.3/100.5 to 4. the literacy rate of women over 15 years-old has steadily increased. respectively. Thus. On the other hand. Nepal and South Africa. In light of our data.

and 8% of the viable conceptions end as clinical spontaneous abortions. it is worth noting that the authors seem to have underestimated the incidence of induced abortion complications treated in hospitals. is necessary when making conclusions from indirect estimates for maternal mortality or when they are based on hospital records. from the actual number of live births of a particular year. GI: “The authors underestimate the incidence of hospitalization for complications from unsafe abortion in Chile: Though it does not affect the estimated trends in abortion mortality. Biological probabilities are widely acknowledged. Therefore. [21]. Thus. approximately 66% of the viable conceptions end in a live birth. and independently corroborated by Wang et al. The detailed methodology is already published in an independently peer reviewed journal [5]. within Table S8 of our article in PLoS ONE [2]. it is very difficult to reach any strong conclusion regarding the progress in maternal health of these countries. early pregnancy loss was excluded from calculations of the expected number of clinical spontaneous abortions. By contrast. Caution. they rely on an unpublished methodology developed by the first author of the current paper. we calculated the number of expected clinical spontaneous abortions as 8% of the total number of expected viable conceptions. by overestimating the proportion of all abortion cases that are the result of spontaneous abortions (miscarriages). Since these studies are likely to be conducted on the basis of partial and incomplete information. Using this approach. It is necessary to note that quality and reliability of hospital records and vital statistic figures from these countries are questionable according to the World Health Organization [15].” Author’s reply: We think the experts from the GI misunderstood the methodology employed to estimate the number of ‘Expected clinical spontaneous abortions’. [22]. GI: “To estimate the numbers of cases that are due to spontaneous abortions. only 28% . they estimated that 88% of all abortions were spontaneous abortions. however. making an overestimation very unlikely. 25% of the viable conceptions end as early pregnancy loss.CMMRI The Chilean Maternal Mortality Research Initiative 12 figure has increased to 237 [15]. to the point of being repeatedly used in clinical trials to assess the effectiveness of hormonal contraceptives. according to an approach that has been peer reviewed numerous times and published in a range of scientific journals. or to causally associate them to the legal status of abortion. it is possible to calculate the number of expected viable conceptions for that same year. According to Wilcox et al. Then. but the following summarizes the method: we used biological probabilities to calculate the expected number of total viable conceptions on the basis of the number of live births observed in a particular year.

The methodology employed by GI experts is likely to be overestimating the number of clandestine abortions in Chile and other Latin American countries. Misoprostol. as well as the use of less dangerous clandestine abortion methods. which correspond to a review published in-house by the GI [24] and an in-house journal [23]. as already pointed above.8%) and theirs (28%). the latter figure was not calculated on the basis of the number of observed abortion hospitalizations. largely published in peer-reviewed journals. With regard to the ‘approach that has been peer reviewed numerous times and published in a range of scientific journals’ [1].CMMRI The Chilean Maternal Mortality Research Initiative of hospitalized abortion cases in Chile in 1990 were spontaneous abortions. is legally and widely available in . as we have reported in our recent article [5].8% when compared to the actual number of observed abortion hospitalizations. there are gross differences between our expected figure of clinical spontaneous abortions out of observed abortion hospitalizations in terms of percentage (80. the experts of the GI cite only 2 references. This is entirely different from stating. the difference is most likely due to gross overestimations by the GI experts since they use a flawed methodology based on opinion surveys. and not 28% as estimated by experts from the GI using opinion surveys in 1990 [23]. This number corresponds to approximately 8% of total viable conceptions. GI experts are probably confused by the fact that 80. respectively. a drug that can be used to induce nonsurgical abortions.” [1] 13 Author’s reply: The article describing our methodology was in press at the time of publication in PLoS ONE and it has just been published on Friday. both without independent external peer-review ―and once more publication bias cannot be ruled out. As we pointed out above.9% to 87.9% to 87. but from the actual number of live births. GI: “A body of research. the calculation relies on widely acknowledged studies by Wilcox et al. makes clear that the decline in maternal morbidity and mortality from unsafe abortion in Chile in the past decades coincides with greater access to and use of contraceptives. the experts from the GI seem confused in terms of the methodology used for calculating the expected number of spontaneous clinical abortions. [21] and Wang et al. Again.9% to 87. [22]. Not surprisingly. May 18th [5]. which is unlikely to be explained by the difference in the years cited: 2001 to 2008 in our case and 1990 in theirs.8% of “Observed abortion hospitalizations” were explained by “Expected clinical spontaneous abortions” from 2001 to 2008 [2]. It just turns out to be 80.” As explained above. which observe that early pregnancy loss and clinical spontaneous abortion represent approximately 25% and 8% of all viable conceptions. “88% of all abortions were spontaneous abortions. Nevertheless.

duodenal ulcer disease or prophylaxis to avoid gastric ulcer provoked by NSAIDs. i. This was well before the development and commercialization of misoprostol. legally distributed misoprostol in Chile is strictly regulated and controlled by Chilean sanitary authorities. Indeed. The use of misoprostol as an abortifacient is associated with a lower risk of severe health consequences than the use of illegal surgical procedures. GI: “By helping to reduce unintended pregnancy. Moreover. 26] correspond to mere opinions without any epidemiological evidence or quantitative data supporting such claims. Contraceptive use has increased substantially in Chile since the 1960s. family planning programs also help to reduce recourse to unsafe abortion. Any other conclusion regarding the legal distribution of misoprostol in Chile is a harmful misleading piece of information by experts of the GI. misoprostol is not sold to the public as an over-thecounter drug in Chile. The prescription is retained by the pharmacist and audited month-by-month by the Chilean Institute of Public Health (ISP). Therefore. Clearly. Its sale is conditioned to a prescription by a physician and solely for the treatment of gastroenterological conditions.” [1] Author’s reply: Regarding the role of contraception we stated in our Article: “It is well documented that the Chilean program providing contraceptive methods after clandestine abortion was effective in decreasing abortion rates. that seriously supports a decline in maternal mortality associated with the use of abortifacient drugs such as misoprostol in Chile. women’s groups have helped make misoprostol available to women seeking abortions. Thus.e. In addition. no study currently exists to date. the methods used to conduct clandestine abortions at present may have lower rates of . and is considered an important explanatory factor in the decline in abortion-related deaths in the past two decades.” [1] Author’s reply: Explaining the decrease of maternal mortality ratio in Chile as a result of using drugs such as misoprostol is speculation unsupported by our epidemiological data. The two quoted articles by GI experts [25. this is just a speculative assumption. misoprostol was introduced in the Chilean black market in the late 1990s. The initial rise in contraceptive use ushered in an extended decline in the incidence of unsafe abortion and abortion-related hospitalizations. making it extremely unlikely that its introduction had any important influence on overall rates of maternal mortality. our study shows that global maternal mortality ratio ―as well as mortality by abortion― steadily decreased from 1965-1967. This extensively limits its prescription for purposes other than its only indication approved by the ISP. which were already significantly reduced at that time. In fact. and abortion providers and women themselves have been using the drug to terminate pregnancies since the 1990s.CMMRI The Chilean Maternal Mortality Research Initiative 14 Chile.

Nevertheless. as we pointed out in our article.’ [2] We additionally found that “For every 1% increment in primiparous women giving birth older than 29 years of age.’ [2] Therefore. allowing them to take the control of their own fertility using the method for fertility regulation of their preference. We termed this phenomenon as a “fertility paradox”. a conclusion of our study is that women’s educational level is influencing both MMR and TFR in Chile. The decrease in TFR strongly correlated with the decrease in maternal mortality. hindering a further decrease in MMR.000 live births was estimated.9 between 1957 and 2007. These results suggest that the fertility reduction is not limited to the use of artificial contraceptive methods. We found a significant decrease in Chilean TFR from 5. and other factors may be intervening such as the dramatic increase of the educational level of women from 1965 [2]. A likely explanation for this phenomenon is that increasing education levels would favor utilization of available maternal health facilities. Our findings suggest that an important shift in the reproductive behavior of women is likely taking place.” [2] In other words.CMMRI The Chilean Maternal Mortality Research Initiative 15 severe complications than the methods used in the 1960s. possibly linked to the increasing levels of education that . This may be a consequence of the increased obstetric risk associated with childbearing at advanced ages. an increase of 30 maternal deaths per 100. This phenomenon also seems to be related to joint-effects between increasing educational level and changes on the reproductive behaviour of Chilean women. ‘when the number of years of education of the female population is included in the explanatory model. Therefore. the strong correlation between TFR and maternal mortality reduction is substantially attenuated. Health policies implemented during the analyzed period in Chile have gradually increased the access to a variety of contraceptive methods through the primary care system. mainly based on highly invasive self-conducted procedures. and especially in women older than 29 years of age [2]. the delayed motherhood trend in Chile is accompanied by a deleterious effect on maternal health. Noteworthy. we analyzed the impact of total fertility rate (TFR) as an indicator of the reproductive behavior of Chilean women. as well ‘as higher autonomy to women.0 to 1. the actual use rate of hormonal contraceptives and intrauterine devices in Chile reaches approximately only one-third of women at reproductive age (36%) and is lower than developed nations [2.” [2] In addition. the practically null abortion mortality observed in Chile nowadays can be explained by both a reduced number of clandestine abortions and a lower rate of severe abortionrelated complications. 16]. an observation that requires further research. together with an increase in the total percentage of primiparous women.

because abortion restrictive law in Chile is unrelated to maternal mortality and this country reached one of the lowest rates of maternal-related and abortion-related deaths of the world (at the present.000 live births. respectively) without legalizing abortion. O98). it is imperative to remark that. 1 (2.” Author’s reply: As stated in our article in PLoS ONE [2]. Review of a Study by Koch et al.2%) respectively.3%) and 13 (30. no matter how controversial the finding might be. Retrieved from: . REFERENCES 1. on the Impact of Abortion Restrictions on Maternal Mortality in Chile. Finally. especially in developed nations where maternal mortality is increasing over the last decade. Guttmacher Advisory. unrelated to abortion complications. Accordingly. GI: “The evidence on abortion laws.6%). This remains for further research to fully understand its implications. May 2012. for the first time. abortion (code O06). 16.9 per 100.000 live births (43 deaths) and the figures of indirect causes (codes O99. we cannot understand how the GI experts intend to further decrease MMR in Chile by legalizing abortion: this conclusion does not make any sense.CMMRI The Chilean Maternal Mortality Research Initiative 16 produce a change on reproductive behavior. that a liberal law of abortion is unnecessary to improve maternal health: it is a matter of scientific fact in our study.9%). “According to the most recent report published by INE.39 per 100. this fifty-year natural experiment provides strong evidence.9 and 0.” This profile of maternal mortality causes suggests the apparition of a more complex residual pattern of maternal morbidity. 11 (25. the MMR for 2009 was 16. We think this should be recognized by a scientific community guided by principles of honesty and objectivity in science. decreasing fertility and delaying motherhood. unsafe abortion and maternal health indicates that further reductions in Chile’s maternal mortality and morbidity could be achieved by such strategies as liberalizing the country’s abortion law and giving women meaningful access to safe and legal abortion services. and other direct obstetric causes were 18 (41. O15). gestational hypertension and eclampsia (codes O14.

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