In These “Times”

Debbie Nathan

What is The New York Times' problem with abortion? The editorial page consistently supports sex education, birth control, and the right to legally end unwanted pregnancy. The rest of the Times, however, often seems uncomfortable with concrete applications of these principles.

What is The New York Times' problem with abortion? The editorial page consistently supports sex education, birth control, and the right to legally end unwanted pregnancy. The rest of the Times, however, often seems uncomfortable with concrete applications of these principles. Not a season goes by that a news item or magazine feature doesn't imply that women who get abortions are acting with egotism, unhealthiness, and cruelty.

The most recent instance of this is Annie Murphy Paul's "The First Ache," in last Sunday's Magazine. "When does the experience of pain begin?" the subtitle asks. "Anti-abortion activists aren't the only ones to argue that it may be in the womb."

Paul's article, which runs over 5,000 words, begins with a doctor in Arkansas claiming that fetuses as immature as 20 weeks after gestation suffer agonies when prodded and cut during, say, prenatal surgery. And–the point of the piece–when they're aborted.

But then other doctors start discussing the Arkansas physician's claim, and their opinions are all over the map. One insists that fetuses feel no pain until at least 29 weeks. Another pushes the pain date all the way forward to 18 weeks. Someone else says that even born babies can't feel pain until they're one year old. Clearly, there's no consensus on the issue. But the lack of agreement is lost amid the article's looming intimation that women who end their pregnancies are hurting their fetuses. Paul never specifies that the vast majority of abortions–more than 96 percent–are performed before 18 weeks' gestation, the earliest date being claimed for the beginning of fetal pain. Nor does she mention that American women are getting abortions earlier and earlier in their pregnancies: The rate occurring in the first eight weeks has increased sharply in recent years, with many now done in the sixth week of pregnancy or earlier. Without these statistics, the article's main effect is to make female readers feel guilty and confused about abortion.

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Paul's is not the only problem piece to run in the Sunday Magazine. Another, by Slate senior editor Emily Bazelon, appeared last January and looked at "post-abortion syndrome" (PAS). A takeoff on PTSD (post-traumatic stress disorder), PAS is not recognized by the psychiatric or psychotherapy establishment because there's no scientific evidence it exists. But moral conservatives out to overturn Roe v. Wade have popularized the purported malady among women who've had abortions. And last year, the Supreme Court cited affidavits submitted by people claiming they've suffered from PAS. The court said the risk to women of contracting the risk of "severe depression and loss of esteem" was one reason to ban "dilation and extraction"–better known as "partial birth" abortion. If for no other reason than this politicking, PAS is well worth exploring.

Problem is, Bazelon skips lightly over politics, focusing instead on fuzzy profiles of self-described PAS sufferers. One is Rhonda Arias, an evangelical minister who runs PAS-support groups in Texas women's prisons. Bazelon follows Arias as she holds forth in one facility, reading from the New Testament, playing gospel music, and handing dolls to inmates who weep as they mourn their aborted offspring. Then Arias asks these prisoners to send her testimonies about their PAS to her so she can submit them to places like the Supreme Court. Read on…

Read the rest of Debbie Nathan's discussion of abortion politics at the New York Times here, on The New Republic's site.

Analysis Science

‘False Witnesses’ Publish Deeply Flawed Study on Abortion Mortality in Mexico

Joyce Arthur

Written by ten anti-choice authors, the new study poses an unacceptable risk to public health because it could be used to advocate the criminalization of necessary health care for women.

A recent study in the British Medical Journal Open that looked at the effect of abortion laws on maternal mortality in Mexico is egregiously flawed and biased. Written by ten anti-choice authors, it poses an unacceptable risk to public health because it could be used to advocate the criminalization of necessary health care for women.

The study purports to show that Mexican states with more restrictive abortion laws have lower maternal mortality rates than states with more permissive laws. Although the authors refrain from hypothesizing a causal link between criminalized abortion and better maternal health outcomes, that preposterous implication comes through nonetheless. It’s even clearer in the authors’ press release about the study.

BMJ Open is an open access journal that offers easier and quicker publication of studies, but its website also states (emphasis added): “Our aim is to provide a home for all properly conducted medical research to be fully reported, after a rigorous and transparent peer review process.”

So what happened? Why did BMJ Open accept this study without subjecting it to greater scrutiny? Some anti-abortion language even slipped through—on page three of the study, the authors characterize the Mexican states’ constitutional amendments protecting the “unborn” from conception as “progressive changes.” The study was peer-reviewed by two medical doctors, but neither appears to have expertise in abortion research or Mexico. One of the reviewers refuses to prescribe birth control to his patients, while the other specializes in safe driving education and injuries from agricultural accidents.

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Credibility of Authors in Question

Four of the ten co-authors of the BMJ Open study were named as “False Witnesses” in an investigative series carried out last year by Rewire. The investigation found that those four researchers “pushed false information designed to mislead the public, lawmakers, and the courts about abortion” in their previous research or public statements. Those co-authors are:

  • Elard Koch (lead author of the BMJ Open study)
  • John Thorp (final author, which usually means the principal investigator or main writer)
  • Monique Chireau (second author)
  • Byron Calhoun (sixth author)

Five of the six other authors have published previously with lead author Koch on abortion-related research. The remaining author, Joseph Stanford, signed the Dublin Declaration that denies the need for legal abortion even to save a woman’s life. In fact, all of the other co-authors signed this anti-choice declaration as well, with the sole exception of Fernando Pliego.

Lead author Koch and co-authors Chireau and Calhoun are members of the group We Care, a group of anti-abortion researchers and doctors that formed around 2011 to publish their own research in mainstream venues, in an apparent effort to put a gloss of scientific respectability on their anti-abortion stance. Indeed, the current BMJ Open study suffers from repeated citations of their own past writings on abortion (over a dozen different citations from Koch and various co-authors), as if their work is equally legitimate to mainstream research. The effect is to create a false picture of scientific confusion and conflicting data in the abortion field.

The methodology of previous Koch-led studies related to abortion (in Chile, Colombia, and Mexico) has been shown to be seriously flawed and biased, rendering their conclusions invalid. My blog has a compendium of rebuttals of Koch et al.’s previous work from both professional and lay sources.

For example, in 2012, Ipas-Mexico published an analysis of maternal and abortion-related mortality in Mexico from 1998 to 2008, showing that one in 13 maternal deaths were from abortion. Koch and some co-authors then published a rebuttal to this, and Ipas responded with a statement that referred to the Guttmacher Institute’s previous rebuttals to Koch et al.’s work. Guttmacher had explained and defended widely accepted scientific methodologies for estimating numbers of illegal abortions and resulting maternal mortality rateswhich Koch et al. had grossly underestimated.

Fatal Flaw #1: Data Dredging to Find an Association

The BMJ Open study concludes that “maternal and abortion-related mortality ratios were lower in states with less permissive abortion legislation compared with states with more permissive legislation.” However, this is based on arbitrarily dividing Mexican states into two categories using a variable with little significance for maternal mortality: those that ban abortion for reasons of “serious genetic or congenital conditions” in the fetus, and those that don’t. It’s worth quoting the authors in full to expose the nature of their error:

In exploratory analyses, segregating states by the number of exemptions provided in criminal codes did not result in detectable differences in sensitivity analyses, with the exception of abortion allowed by genetic or congenital fetal malformations. The remaining seven exemptions were distributed differentially in almost every state or very few states, thus offering no discrimination potential. Therefore, to differentiate between states with more or less permissive abortion legislation in subsequent statistical analyses, states allowing pregnancy termination due to serious genetic or congenital conditions were considered more permissive (14 states) while the remaining states were considered less permissive (18 states).

In other words, the authors subjected each legal exemption to a “sensitivity analysis”—which checks all the data to look for patterns among variables—until they found a variable that happened to show a detectable difference in maternal mortality. They then presented this as the primary finding. This error is called “data dredging” because chance associations between just about any two things are easy to find if you crunch enough numbers. To make their random association sound more meaningful, the authors manipulated the definition of “states with less permissive legislation” into something it didn’t actually mean at all.

Twelve Mexican states actually have a more liberal exemption allowing abortion in cases of serious risk to the woman’s health, yet nine of those states ended up in the study’s category of “less permissive.” This demonstrates the arbitrariness of the chosen exemption factor of fetal anomaly, and indicates that the study could well have come to the opposite conclusion if the health exemption had been chosen as the dividing criterion instead. (All Mexican states allow abortion in cases of rape. Otherwise, abortion is mostly or completely illegal in all states except Yucatán, where it is allowed for economic or social reasons, and the Federal District of Mexico City, which allows abortion on request up to 12 weeks.)

The selected exemption for fetal anomaly cannot possibly by itself show any trends or differences in abortion mortality rates between states. That’s because abortions due to fetal abnormality are always a tiny minority of abortions in any country. In Britain for example, only 1 percent of abortions are carried out for reasons of fetal anomaly, and the numbers are similarly tiny for other countries. Further, almost all abortions for fetal abnormality occur later in pregnancy because the anomaly cannot usually be detected until then.

In settings like Mexico, the numbers of abortions for fetal anomaly will likely be far smaller than 1 percent regardless of legality, because of stigma and other obstacles. Indeed, here’s a study showing that most Mexican geneticists advise against abortion when the fetus has a genetic or chromosomal disorder. And there’s no reason to assume that the average Mexican woman would even know that abortion might be legally available for reasons of fetal abnormality, let alone that she would have the means, resources, or courage to pursue that option. In other words, abortions for reasons of fetal abnormality must be very rare throughout Mexico, and cannot possibly serve as a proxy for tracking trends in maternal mortality due to abortion.

This fatal flaw renders the study meaningless and the conclusion invalid, because it relies solely on a rarely occurring variable that would not have any noticeable statistical effect on maternal mortality.

Fatal Flaw #2: Mistaking Legal Abortion for Accessible Abortion

Similarly, the study assumes that because about half of Mexican states tightened their already strict laws against abortion after 2007by passing a constitutional amendment protecting “the unborn” from conception—this would have a measurable effect on death from unsafe abortion. There is absolutely no basis for this assumption. Criminal laws restricting most abortions were already in effect everywhere outside Mexico City, so women would not be driven to unsafe abortion in any greater discernible numbers.

This helps expose the second major flaw in the study: the authors’ assumption that abortion law accurately predicts abortion practice. In reality, few Mexican women actually obtain abortions under the legal exemptions due to fear and stigma, lack of resources or knowledge, and refusals by anti-abortion doctors.

One study (in Spanish) by the Mexico City-based Group on Reproductive Choice (GIRE) showed that between 2007 and 2012, only 39 women in Mexico actually got a legal abortion under the country-wide rape exemption, out of a total of 120 who had applied for one. Why would so few apply? First, most states lack sufficient administrative mechanisms for seeking out a legal abortion under any of the exemptions, which means there’s simply no way to even apply for an abortion. Second, abortion is highly stigmatized in Mexico, and it takes courage to apply for one—or seek medical attention after an illegal abortion. At least 679 women in Mexico were reported or sentenced for having an illegal abortion between 2009 and 2011. Mexico is one of at least seven countries in the world that imprisons women for having illegal abortions. From 2007 to 2012, 127 women were put on trial for abortion in Mexico, and in one particularly conservative state, Guanajuato, dozens of women have been prosecuted for abortion since 2000, with some of them receiving sentences of up to 30 years in prison.

Oddly, Koch et al. never mention such shocking facts, nor do they mention the deeply rooted stigma and shame surrounding abortion in Mexico, the judgmental attitudes of many health-care workers, or indeed any of the social, economic, or logistical difficulties that may inhibit women from even attempting to exercise their legal right to abortion in Mexico. Instead, the study’s methodology and conclusion depend on the unspoken assumption that legal exemptions for abortion mean that all or most of those exempted abortions are actually taking place as needed. Nothing could be further from the truth.

Failing to Account for Underreporting and the Impact of Safer Medical Abortion

Koch et al. fail to acknowledge that “do-it-yourself” medical abortions have increased substantially over the last decade or more, with pills to end pregnancy now widely available in Mexico and most other Latin American countries. In fact, the words mifepristone and misoprostol never appear once in the BMJ Open study, which is a serious oversight. Clandestine use of the drug misoprostol is generally accepted as being much safer than traditional and more dangerous methods (for example, significantly reducing the rate of infection), even when women misuse it or misinterpret its effects because they don’t have instructions on how to use it or what to expect.

In one of Koch’s 2012 rebuttals to the Guttmacher Institute, he asserted that “no study currently exists to date that seriously supports a decline in maternal mortality associated with the use of abortifacient drugs such as misoprostol in Chile.” But he ignored several studies from countries such as Brazil and Mexico that showed significant declines in the severity and number of abortion-related complications and sometimes mortality over the same periods in which misoprostol use has grown.

In the BMJ Open study, Koch and his co-authors follow the same pattern as in a previous Koch-led study on Chile: They underestimate the number of abortions and associated maternal mortality by relying only on official statistical sources, while failing to consider that large numbers of illegal abortions are not accounted for in these sources, and that related complications and deaths may often be misclassified. In a criminalized and stigmatized environment, many women will not admit to having an abortion, and many health professionals will not officially report complications or deaths as caused by abortion, either through ignorance of the real cause, or out of compassion for women and their families.

Koch et al. claim there is no reason for health-care professionals in Mexico to “misreport deaths from a suspected illegal abortion” due to the existence of separate reporting codes for various types of abortions, including for an unknown cause. This overlooks the fact that issues with miscoding have become more common with misoprostol-related complications. For example, it can be challenging for doctors to distinguish medical abortion from miscarriage or other obstetrical complications. Further, Koch et al.’s analysis ignores the effects of fear and abortion stigma on how abortion occurs in illegal settings and whether complications or deaths resulting from them are reported as such.

Using Reduced Maternal Mortality to Mask Abortion Deaths

It’s already well established—practically self-evident—that maternal mortality can be significantly reduced by educating women, upgrading health systems, and improving access to contraception, skilled birth attendants, clean water, sanitation, and so on. Yet, this study and previous Koch-led studies seem to treat such factors like their own new discovery that obviates any need to reform abortion laws.

Unsafe abortion is just one of many factors that affect maternal mortality rates, though it’s among the top five causes. An estimated 13 percent of maternal mortality globally is due to unsafe abortion. It is simply not possible to try to take into account a lot of contributing factors to maternal mortality and conclude that restrictive abortion laws have little or no effect, because the other factors can easily swamp the effect of unsafe abortion on maternal mortality rates. Is it possible that the anti-abortion authors of the BMJ Open study are using such factors as a smokescreen to cover up the effect of unsafe abortion on maternal mortality?

Mexico still has a relatively high maternal mortality rate compared to other countries—about 45 per 100,000 live births, compared to 28 for the United States, 13 for Canada, and four for Sweden. In Latin America, where abortion is mostly illegal, it’s 22 for Chile and 69 for both Brazil and Argentina (2013 data). It’s likely that the declines Mexico has been seeing in maternal mortality would be even steeper if abortion was safe, legal, and accessible, and the same goes for Chile.

Estimating the incidence of illegal, unsafe abortion as well as the resulting deaths and complications is of course a challenging task. Such abortions are unreported and usually never come to the attention of authorities, so vital statistics can only provide a fragment of the evidence-based picture. A variety of methods must be used to carefully piece together a picture that is as reliable as possible. These include, for example, surveys of women, surveys of specific health-care facilities, and interviews with knowledgeable health-care workers.

Such methodologies are embodied in the Abortion Incidence Complications Method (AICM), which was developed about 20 years ago. The AICM has been widely used in studies appearing in peer-reviewed journals, and is recognized by experts around the globe, including the World Health Organization. Despite this, Koch has simply tossed out the AICM on the basis that it uses “imaginary numbers.” Not only is this dismissal disingenuous and unwarranted, it amounts to a gratuitous slur against the hundreds of reputable scientists and researchers who spend large amounts of time carefully gathering, comparing, and adjusting abortion-related data under challenging circumstances.

Real World Absent From Study

The BMJ Open study has an important focus on maternal mortality, but unfortunately that focus tends to disguise certain facts that never see the light of day in the study:

  • More than a million (1,026,000) abortions take place in Mexico each year, the large majority of them illegal.
  • About 159,000 women were treated at public hospitals for abortion complications in 2009.
  • An estimated 36 percent of all women who have illegal abortions develop complications that need medical treatment.
  • One-quarter of those do not seek treatment, putting them at risk of lasting negative health consequences.

The question that Koch et al. need to answer is this: Even if the study did demonstrate that restrictive abortion laws are associated with lower maternal mortality, does that make it acceptable to let a million desperate Mexican women, year after year, suffer the distress and trauma associated with risking their lives, health, and freedom to obtain an illegal abortion?

Koch et al.’s studies, including the current one in BMJ Open, are promoted widely on the Internet by anti-abortion groups and individuals. Because the studies appear professional and are published in reputable journals, there is a real danger that they can be used to influence policy decisions of governments. For example, they may play a role in decisions to decrease or cut funding for reproductive health programs in developing countriessuch as what occurred in Canada in 2010—or to further restrict abortion, despite current laws that still kill 47,000 women a year and injure over eight million.

By rendering those women invisible, such studies become dangerous weapons that threaten to slow down the global decrease in maternal mortality and continue allowing women to suffer and die unnecessarily. The BMJ Open study is the latest contribution to this ideological battle disguised as science, one that poses a grave public health risk to women.

Author’s note: I would like to thank the Guttmacher Institute for its past work, cited in this article, exposing the serious methodological flaws in Elard Koch’s work and debunking his false claims.

News Abortion

Anti-Choice “Medical Experts” Play Increasing Role in Abortion Legislation Testimony

Robin Marty

They aren't always doctors, but they play them in your legislature.

As anti-choice state legislators introduce more and more abortion restrictions, the testimony for and against such bills is becoming increasingly important in influencing final votes. In some cases, such as the recent Indiana medication abortion law hearing, the divide between real science and anti-choice “science” is clear when anti-choicers are unable to find even one practicing medical professional to show up to defend the bill, while opponents are able to recruit numerous doctors to discuss its problems.

To combat the fact that anti-choice “science” isn’t accepted by the general medical profession, anti-choicers now are working feverishly to stack their testimonies with “experts” who engage in one-sided debates to give the appearance that they represent true mainstream medical thought. As part of his ongoing attempt to restrict abortion access to low-income women, Alaska Sen. John Coghill recently video conferenced national medical professionals to testify in a recent committee hearing; they all claimed abortion is never medically necessary and is harmful to a woman’s physical and mental health. His “experts” included Priscilla Coleman, who, along with David Reardon, is responsible for most of the studies claiming abortion is harmful for women, many of which have either been debunked or are based on self-selected biased samples; Dr. John Thorp, who works with Matercare International, a “nonprofit international organization of Catholic health professionals” and who testified against so-called partial birth abortion in 2006; and Susan Rutherford, who is most active as a “Christian physician” and spokesperson against assisted suicide in Washington state.

In a clear reminder that these people don’t actually represent mainstream medicine, Rutherford was questioned about why her belief that abortion causes cancer contradicts that of the rest of the medical profession. The Anchorage Daily News reported:

[Sen. Bill Wielechowski] asked Susan Rutherford, a maternal-fetal medicine doctor at EvergreenHealth Medical Center in Washington, whether she had written a paper linking abortion to breast cancer.

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No, she said.

Do you believe there’s a link? he asked.

“You know there’s some compelling evidence that it could be,” Rutherford said. She mentioned a pro-choice breast cancer expert who found an increased risk, particularly for women who had abortions as teens.

That contradicts the National Cancer Institute, Wielechowski said.

There are flaws in medical literature, Rutherford responded.

As the only Democrat on the committee, Wielechowski was left with the formidable challenge of rebuking all of the experts during the hearing. Medical experts testifying against new rules about what constitutes a “medically necessary abortion” will not be heard until Monday, a ploy that will allow the legislative record to appear to give equal weight to both sides of the issue, despite the fact that one argument is waged by a handful of religious medical professionals and the other supported by facts and the medical establishment.

The anti-choice movement has become highly adept at managing the public record through a variety of means, regardless of how far in the minority their medical experts are. In New York state, where anti-choice advocates are fighting a rare case of legislators trying to reaffirm reproductive rights access, an unnamed faith-based doctor’s group has been positioning itself as speaking for all doctors in opposition of Gov. Andrew Cuomo’s Reproductive Health Act. According to NBC News, members of the group who spoke out against the proposal at a press conference were “doctors of different faiths who deliver babies and work with women after abortions, [and who] said its opposition to the governor’s bill is based on medical experience, not their religious beliefs.” Yet the speakers’ backgrounds contradict the claim that there is no religious agenda at play—from Dr. Miriam Grossman’s fixation on abstinence until marriage and traditional gender roles to Dr. Anne Nolte’s work at the National Gianna Center for Women’s Health and Fertility, a family planning and alternative infertility clinic that follows the “ethical and religious directives for Catholic health-care services.”

How “medically sound” are these doctors’ beliefs? Nolte told the National Review Online that when it comes to a later abortion, it is probably safer for a woman to undergo an unnecessary cesarean section to potentially save the fetus than to have the abortion. “The risk of physical complications from a surgical abortion increases, the later in pregnancy that these procedures are performed. If the ‘termination’ of a pregnancy after 24 weeks is required to protect a woman’s health, this can be accomplished by inducing labor or performing a c-section—options that are safer than late-term abortion when a woman’s life or health is truly at risk and that preserve the life of the infant,” she told NRO’s Kathryn Jean Lopez.

Missing from Nolte’s analysis isn’t just the risks that come from any surgery, especially when it may not be necessary, but the additional risks that could come from future pregnancies and surgeries due to having a prior c-section.

These are the voices of medical “experts” disagreeing publicly with the standards of care that the vast majority of health professionals follow. Whether women or families wish to follow their medical advice or directives is a choice that should be left up to them. But to allow them to not only have equal weight when it comes to discussing issues surrounding a woman’s health, but create and support legislative bills that will enforce their beliefs on all medical practitioners and their patients isn’t “allowing both sides to be heard.” It is enforcing religious beliefs contrary to medical best practices.