News Abortion

In Latin America and the Caribbean, Unmet Need for Contraception and Unsafe Abortion Are Widespread

IPPFWHR

January 22nd marked the 39th anniversary of one of the most significant legal decisions of the 20th century, Roe v. Wade. This landmark ruling from the United States Supreme Court legalized abortion and changed the course of history for women in this country. Yet women in Latin America and the Caribbean continue to struggle for this basic reproductive right.

January 22nd marked the 39th anniversary of one of the most significant legal decisions of the 20th century, Roe v. Wade. This landmark ruling from the United States Supreme Court legalized abortion and changed the course of history for women in this country. Yet women in Latin America and the Caribbean continue to struggle for this basic reproductive right.

According to a report released by the Guttmacher Institute this week, 95 percent of abortions in Latin America are unsafe. In places where abortion is illegal, women often turn to inadequately trained practitioners who employ unsafe techniques or attempt to self-induce abortion using dangerous methods. In Latin America and the Caribbean, nearly one million women are hospitalized each year because of complications from unsafe abortion, and the World Health Organization estimates that one in eight maternal deaths in the region result from unsafe abortion. Poor and rural women are disproportionately affected.

Fear of legal consequences, social stigma, high cost, and lack of access to trained health professionals are major barriers to obtaining safe abortions. Banning abortion does not reduce the numbers of women who attempt it; in fact, the abortion rate is much higher where it is illegal.

Despite these disturbing facts, only 6 of the 34 countries in the region allow abortion without restriction. These countries account for less than 5 percent of the region’s women ages 15–44.

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Over the last decade, gains have been made throughout the region to address unsafe abortion and advocate for decriminalization. In 2007, for example, the Mexico City government lifted the ban on abortion during the first 12 weeks of pregnancy. IPPF/WHR’s Member Association in Mexico, MEXFAM, plays a leading role in providing safe abortion services to women and adolescents. In addition to providing legal abortion services in Mexico City, MEXFAM also works to reduce the public health impact of unsafe abortion in states where the law is more restrictive. MEXFAM’s work to reduce maternal mortality was highlighted just last month by ABC’s “20/20.”

Nearly half of sexually active young women in Latin America and the Caribbean have an unmet need for contraception. Fulfilling this need will not only reduce the number of unplanned pregnancies, but also empower women by giving them the freedom to choose when and if they have children. Fulfilling the unmet need for contraception worldwide would avert 188 million unintended pregnancies, which would in turn result in 112 million fewer abortions.

Meeting the unmet need for sexual and reproductive health services helps create healthier communities and is a crucial step towards achieving the Millennium Development Goals by 2015.

Image from The World’s Abortion Laws Map 2011

Originally published at IPPF/WHR

Commentary Media

Anti-Choicers Are Trying to Convince Us That Reproductive Care Isn’t a Legitimate Need—and the Media Is Helping

Amanda Marcotte

Two of the major anti-Planned Parenthood talking points, which anti-choicers have disseminated through mainstream media, are about advancing the idea that any sexual health services that aren't about making babies doesn't count as real health care.

This summer, the anti-choice movement clearly had one goal: to see how far it could get in using lies and deceptive rhetoric to convince America that reproductive health care, particularly the service offered by Planned Parenthood, isn’t a real medical need.

This was all kicked off with a lie that got a surprising amount of traction for being a self-evident right-wing fantasy—that Planned Parenthood is somehow profiting off selling fetal body parts. Still, using that deception to try and snooker people into believing reproductive services aren’t legitimate is an enormous undertaking. Nearly all women, including religious conservatives themselves, use the kinds of health care in question: contraception, cancer screenings, STI testing and treatment, well-woman visits, you name it. Women know for a fact that these things are, indeed, health care. So anti-choicers have concocted a number of lies and confusing rhetorical ploys to try and overcome this well-established fact. And unfortunately, they’ve had some assistance from mainstream media outlets, which too often hesitate to correct right-wing misinformation out of fear of being accused of bias.

Conservative efforts to call into question the necessity of reproductive health care have taken two forms: Deny that there’s any reason women would need access to specialized gynecological care and imply that any gynecological care that is not prenatal care must therefore be “abortion.” (Obviously, abortion is also legitimate health care, but anti-choicers have been denying that for a long time. This is about everything that is not abortion.)

The first point is largely being accomplished by arguing that women don’t need Planned Parenthood because they can go to a “community health center.” In order to bolster this claim, the Susan B. Anthony List is circulating a map of these centers where women can go for alternative health care, a talking point that many legislators have brought up as well.

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Unsurprisingly, it all turns out to be utter nonsense. Community health centers are often already overworked and dumping a bunch of patients seeking gynecological care on them will mean less care for everyone. Jennifer Frost and Kinsey Hasstedt of the Guttmacher Institute dug into this claim even more deeply and found that when it comes to contraception in particular, there is simply no replacing Planned Parenthood:

In 68 percent of counties with a Planned Parenthood site (332 counties out of 491), these sites serve at least half the women obtaining publicly supported contraceptive services from a safety-net health center. And in 21 percent of counties with a Planned Parenthood site (103 counties), Planned Parenthood serves all of the women obtaining publicly supported contraceptive services from a safety-net health center.

Others have pointed out before that defunding Planned Parenthood results in a surge of unintended pregnancies due to unmet contraception needs, and were met with indifferent shrugs by anti-choicers.

It’s clear that anti-choicers aren’t circulating this map of “alternative” clinics—clinics that are usually good clinics, but are often overtaxed and not equipped for the levels of specialized care Planned Parenthood can offer—because they truly want women to get contraception somewhere else. They know women likely won’t be able to. So circulating the map is about creating the facile appearance of concern while actually implying that there’s no need for widespread specialized gynecological care at all: that services meant to allow women to have sex safely without getting pregnant should not be considered health care in the first place.

This is made even more evident by talking point number two: the claim, floated again by the SBA List, that 94 percent of “pregnancy-related” services at Planned Parenthood are abortion. Imani Gandy of Rewire thoroughly debunked this claim, and I recommend reading her takedown in its entirety. In addition to her analysis, what should jump out at you is the hidden premise that SBA List is floating with that statistic, which is that the only legitimate gynecological care for women is “pregnancy-related.” Cancer screenings, STI treatment, well-woman visits, pregnancy prevention, even just treatment for anemia? (Which is one of the things Planned Parenthood treated me for in college.) All of that is considered so unimportant that SBA List couldn’t even bother to take it into consideration. If a woman isn’t currently gestating, she apparently doesn’t even rate as a person deserving health care. Women are treated, openly, like nothing but baby buckets. If you aren’t pregnant, your care doesn’t matter enough to even be counted.

Unfortunately, the Washington Post’s response to this number was to run a “both sides do it” story debunking the SBA List’s statistical methods, but also arguing that Planned Parenthood was somehow underestimating their abortion services with their standard claim that it’s only 3 percent of what they do. (Gandy challenged the Post’s rebuttal, as well.) It’s a lot of fun with numbers, but what goes unquestioned is the extremely different assumptions bundled with each statistic. By pointing out that abortion is only 3 percent of their services, Planned Parenthood is trying to argue that their preventive services—contraception, STI testing, you know the drill—are legitimate forms of health care. By focusing strictly on abortion, prenatal care, and “adoption referrals,” SBA List is suggesting that non-pregnant women have no legitimate interest in sexual health care. It’s not a story of both sides “fudging the numbers” at all; it’s a very strong difference in opinion over whether the woman who surrounds the uterus is a person with any value beyond making babies.

This kind of false equivalence was also all over a recent episode of the Diane Rehm show, which aimed to broadly cover the various attacks on Planned Parenthood. The episode had anti- and pro-choice voices, but little effort was actually made to weigh the claims of either side against facts. New York Times reporter Jackie Calmes did point out, briefly, that the SBA List’s 94 percent number blatantly ignores the fact that women have sexual health-care needs even when not pregnant, but beyond that, the anti-choice voice, Carol Tobias, was able to push her myths hard without much fear of Rehm pointing out that she was, by an objective and truth-based standard, being deceptive.

For instance, Tobias claimed “the money that would have gone to Planned Parenthood would go to other health service centers that would provide the same care.” But she then went on to argue, “We have thousands of pregnancy centers all over this country who will help women with the pregnancy, with whatever services she needs.” She is almost certainly talking about crisis pregnancy centers (CPCs), almost none of which are actual clinics. Most CPCs don’t offer any useful services at all, but simply provide a pregnancy test you could buy at the drugstore and a lecture about how abortion and birth control are evil.

Unfortunately, none of the journalists on the show pointed out that a pamphlet telling you to abstain from sex is not an adequate replacement for actual medical care provided by actual doctors and nurses. Because of this, listeners who don’t know much about the issue might actually walk away thinking there’s nothing Planned Parenthood offers that women can’t readily get elsewhere. Imagine if Tobias was challenged on her nonsense! She might admit to believing that she disapproves of health care for women who want to have sex without getting pregnant. She might admit that she was just trying to bamboozle people by implying that a CPC is anything like an actual medical clinic. Members of the public might have learned that anti-choice activists have an ugly anti-sex agenda way outside of mainstream views. Instead, she went unchallenged, and listeners likely walked away incorrectly believing that these attacks on Planned Parenthood don’t represent the threat to reproductive health care that they actually do.

It’s hard challenging anti-choices lies and anti-choice radicalism. Anti-choicers whine and they fuss about being held accountable to even basic truths, much less being challenged on their values assertions. They lie so often that it’s exhausting just trying to keep up with it all. But audiences deserve to know what’s really going on with this debate over Planned Parenthood, and serving their interests—and serving the truth—means abandoning this attachment to narratives that treat both sides as equivalent, and equally factual, points of view.

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.