In Which The Guttmacher Institute Continues to be Awful

One of the more exciting hobbies of The Guttmacher Institute — besides receiving annual donations from Planned Parenthood — is demanding greater legal access to abortion in countries where abortion is restricted. This demand blooms from studies of these countries — usually Guttmacher’s — which consistently find high numbers of illegal abortions and abortion-related maternal deaths.

Their message is simple: Legalize abortion, for there exists a massive need for it, and women are dying in their attempt to meet that need with unsafe, illegal abortion. And for the past thirty years or so, we’ve all nodded dutifully, thanked Guttmacher for their hip-as-all-get-out videos explaining this, worked up compassionate faces, and legalized abortion.

Here’s the issue: The methods with which The Guttmacher Institute and researchers of the same vein use to procure these drastic numbers are decisively moronic.

A study published today by Koch et al. in the International Journal of Women’s Health entitled “Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases” — which I will be quoting from — politely points this out.

The Guttmacher Institute determines the number of induced abortions in a given country through the use of surveys.

First, they pass out what’s called a Health Facilities Survey to subjects who work in — you guessed it — healthcare facilities, asking them “to remember the total number of women who received post-abortion care ‘in the average month and in the past month.’” Once this recalled number is obtained, they move on to stage two — the Health Professionals Survey.

Guttmacher surveys healthcare professionals “selected on the basis of their professional affiliation, training, experience and specialization on the subject.” (1) Who these people are remains unavailable, as do their qualifications (what counts as specialization?), as do the questions asked in the survey (and whether those questions contain any relative bias), thus rendering the survey unrepeatable — an issue for any scientist. But the Guttmacher Institute is resolute, well-funded, and undeterred by such trifles. The Health Professionals Survey is used to estimate “an expansive multiplier of abortion rates (x3, x4, x5, etc)”, which is then applied to the numbers obtained by the Health Facilities Survey. Voila, the number of abortions.

Even a layman like myself can see why this is iffy at best. As Koch et al. state, such “estimation methods are subjective in nature and extremely subject to selection and recall bias”, that is, to the intentional or unintentional manipulation of answers by those biased on the issue of legalized abortion. Furthermore, there is no information on how the subjects of the Health Professionals Survey were selected, and if the sample size is enough to represent the total population of medical professionals in Mexico.

Don’t take my word for it though. The numbers show how drastically this survey-method of “counting” abortions overestimates reality.

Guttmacher — using their surveys — estimated that for the year 2006 in the Federal District of Mexico (Mexico DF) there were between 137,145 and 194,875 induced abortions. Normally their word would have been taken as gospel truth, but because Mexico DF offers abortion on request to any woman up to 12 weeks into a pregnancy — one of the few Mexican states in which abortion is legal — there exists another way of counting abortions in the same area — actually counting abortions via the required reporting of abortion rates by hospitals.

The number of recorded abortions in 2007 — the year abortion was legalized in the Mexico DF — was 10,137. This number, for those interested, is less than 137,145 and 194, 875. We are left with two options.

Option 1: Either immediately upon abortion being legalized in the Federal District of Mexico, from 2006 to 2007, the abortion rate experienced an epic, up to 2000% decrease. This would be bizarre, given that, as Stanley Henshaw of the Guttmacher Institute itself has explained, “In most countries, it is common after abortion is legalized for abortion rates to rise sharply for several years” (2) and that it defies common sense.

It wouldn’t be a bad argument to make that, since legal abortion was new in the year 2007, there were still illegal abortions taking place, abortions that would have been included in the Guttmacher surveys but missed by the actual counting of legal abortions. However, as the study points out:

 …the figure of legally induced abortions carried out in the five cumulative years from April 2007 until April 2012 (ie, a period of time probably long enough to replace illegal abortion with legal procedures in Mexico DF) was 78,544; which is nearly 50% of the original estimate by the [Guttmacher Institute] for only a single year [2006].

We move, therefore, to Option Two: The survey method of obtaining abortion rates is inaccurate, verging on ridiculous. Yet still it continues:

[The Guttmacher Institute] have recently conducted another study insisting on the use of the same methodology and showing figures of induced abortion overestimated by approximately 1000% for 2009 (ie, estimating 122,455 induced abortions instead of the actual figure of 12,221 for Mexico DF in 2009) despite the existence of epidemiological surveillance on this matter by an independent non-governmental agency.

Which, by and large, was dumb. Now that legal abortion is available in Federal District of Mexico, and has been legal long enough so as to make illegal abortions a negligible percentage of total abortions, the Guttmacher Institute still demands we believe that abortion rates are 1000% higher than reported. There have been problems with underreporting regarding the recording of legal abortion rates, but there is no serious consideration that underreporting could be this low. As Koch et al point out:

We acknowledge that underreporting of legal abortions may limit the reliability of estimations based on actual records in Mexico DF. Nevertheless, Mexican health authorities have been actively working towards decreasing the underreporting of maternal mortality statistics which, at least in terms of MMR, have decreased to a negligible percentage since 2003. Even if such efforts have yet to be translated into a decrease in the potential underreporting of legal abortion records in Mexico DF, especially within the private sector, the figures proposed by [the Guttmacher Institute researchers] would still be overestimated. For instance, speculatively assuming an underreporting of 1- to 3-fold, the figure proposed by these authors would be overestimated by 2.5 to 5 times.

Now there is a similar issue with the method by which researchers currently determine induced-abortion-related mortality, that is, the number of women who die from abortions.

Abortion-related mortality is determined by dividing the number of abortion-related deaths by the number of live births.

The International Classification of Diseases considers abortion-related mortality to include deaths by “all pregnancies with abortive outcome”. While this may sound straightforward enough, the reality is complicated, for death by all “pregnancies with abortive outcome” does not necessarily indicate death by botched illegal abortions, but refers to “causes of death ranging from abnormal products of conception to unspecified, and other abortions.” This, as Koch et al show, includes such complications as miscarriage, “hydatidiform mole [and] ectopic pregnancy”.

Again, the study does the universe a favor by pointing out the obvious:

[These] should not be included in the assessment of abortion mortality, particularly when the focus of the study is to address the influence of illegal abortion on maternal health. For example, if one wanted to measure the deleterious effects of alcoholism on the liver, one would want an indicator specific to alcoholism. If that indicator instead included liver damage caused by fulminant hepatitis, Wilson’s disease, and drug-related liver damage, then the specific damage attributable to alcohol would be obscured. Similarly, if one wants to determine mortality from induced abortion, then deaths from other causes (such as hydatidiform mole or ectopic pregnancy) should be excluded.

But studies such as Schiavon et al, “Analysis of maternal and abortion related mortality in Mexico over the last two decades” do include these “abortion-related deaths”. Thus their frightening conclusion, that “[u]nsafe abortion continues to represent a significant proportion of all maternal deaths in Mexico” is rendered a skeptical one.

When Koch et al. removed the “abortion-related deaths” that were not specific to induced abortion — which, after all, is what was being studied — and looked at the numbers again, they found the following:

When taking this into consideration, even though the AMR shown by Schiavon et al displays discrete changes between 1990 and 2008, unspecified abortion (O06) combined with other abortion (O05) between 2002 and 2008 shows a downward trend, with a 22.9% overall decrease from 1.44 to 1.10 deaths per 100,000 live births. This observation further supports the notion that the apparent lack of progress in abortion-related maternal mortality in Mexico is likely to be related to causes other than unspecified abortion (O06) and other abortion (O05), and therefore seems to be unrelated to illegal induced abortion. (Emphasis my own.)

The study goes on to suggest that the apparent lack of progress in abortion-related maternal mortality seems more strongly correlated with an increase in violence against pregnant women in Mexico.

Obviously, there is much more to the study, including recommended alternatives to Guttmacher’s surveys and the the general use of ICD codes to determine abortion-related mortality. But these two points represent a paradigm shift in the way we view the legalization of abortion. If the primary method of establishing abortion rates in countries that restrict abortion is flawed, producing impossibly exaggerated numbers, the oft-repeated argument that legalizing abortion is a dire necessity is rendered null. If the primary method by which researchers determine the number of women dying from illegal abortions is flawed, including deaths that are not the result of induced abortion, then the oft-repeated emotional argument that women are dying from the lack of legalized abortion is similarly called into question. In fact, the argument sidetracks the conversation, and detracts resources away from the issues that truly do effect maternal mortality, such as the “adequate medical treatment of conditions such as hemorrhage, gestational hypertension, eclampsia, and indirect causes of maternal death, mainly characterized by pre-existing chronic diseases.”

The importance of this study cannot be understated. The lessons of Mexico should, at the very least, curb our enthusiasm for the widespread legalization of abortion.

1. Singh & Bankole, Ginecol Obstet Mex 2012;80(8):554–561. Article in Spanish

2. Stanley Henshaw, Guttmacher Institute (16 June 1994)

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