Abortion and Maternal Mortality

Thomas W. Strahan Memorial Library
Index
Standard of Care for Abortion
Abortion Decision-Making
Psychological Effects of Abortion
Social Effects and Implications
Physical Effects of Abortion
Abortion and Maternal Mortality
Adolescents and Abortion
Definition of Terms
Women's Health After Abortion
Material Yet to be Cataloged
Strahan Summary Articles

Sub-Index
Physical Effects
Abortion Technique Risks
Short Term Complications
Immediate Complications
Pain in Women
Organ or System Failure
Infections Related Complications
Impact on Later Pregnancies
Cancer Risks

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Maternal Death from Abortion

Review Article

'Deaths associated with abortion compared to childbirth: a review of new and old data and the medical and legal implications. Reardon DC, Strahan TW, Thorp JM, Shuping MW.The Journal of Contemporary Health Law & Policy 2004; 20(2):279‑327.'

The best available evidence now contradicts the “established medical fact,” relied upon in Roe v Wade, claiming that the maternal mortality rate for abortion is lower than that of childbirth. Recent analyses of large medical databases linked to death certificates have now shown that when mortality rates associated with abortion and childbirth are examined using a single uniform standard, significantly higher mortality rates are associated with abortion. These record linkage studies have demonstrated that pregnancy-associated deaths are actually two to four times higher for aborting women compared to delivering women.

This is an important paper examining why previous evidence was flawed and what objective record based studies really show.

Record Based Studies

'Deaths associated with pregnancy outcome: a record linkage study of low income women. Reardon DC, Ney PG , Scheuren FJ, Cougle JR, Coleman, PK, Strahan T. Southern Medical Journal, August 2002, 95(8):834-841.'

BACKGROUND: A national study in Finland showed significantly higher death rates associated with abortion than with childbirth. Our objective was to examine this association using an American population over a longer period.

METHODS: California Medicaid records for 173,279 women who had an induced abortion or a delivery in 1989 were linked to death certificates for 1989 to 1997.

RESULTS: Compared with women who delivered, those who aborted had a significantly higher age-adjusted risk of death from all causes (1.62), from suicide (2.54), and from accidents (1.82), as well as a higher relative risk of death from natural causes (1.44), including the acquired immunodeficiency syndrome (AIDS) (2.18), circulatory diseases (2.87), and cerebrovascular disease (5.46). Results are stratified by age and time.

CONCLUSIONS: Higher death rates associated with abortion persist over time and across socioeconomic boundaries. This may be explained by self-destructive tendencies, depression, and other unhealthy behavior aggravated by the abortion experience.

'"Chili Study"'

Preliminary findings by a prominent biomedical researcher examining the dramatic decrease in maternal mortality, over the past fifty years in the Latin American nation of Chile, appear to undercut claims by global abortion lobbyists that liberal abortion laws are necessary to reduce maternal mortality rates.

According Dr. Elard Koch, an epidemiologist on the faculty of medicine at the University of Chile, Chile's promotion of "safe pregnancy" measures such as "prenatal detection" and accessibility to professional birth attendants in a hospital setting are primarily responsible for the decrease in maternal mortality. The maternal mortality rate declined from 275 maternal deaths per 100,000 live births in 1960 to 18.7 deaths in 2000, the largest reduction in any Latin country.

This news follows a report from the World Economic Forum in December which showed that countries with restrictive abortion laws are often the leaders in reducing maternal mortality. Ireland, which is under pressure to change its Constitutional protection of the unborn child, leads the world in maternal health performance, with 1 death for every 100,000 live births. Poland, which has tightened its abortion law, ranks 27 on the WEF list with 8 deaths per 100,000. In the United States, where there are virtually no restrictions on abortion, the ratio is 17 deaths per 100,000. C-FAM cites other examples from its analysis of the WEF report which prove the point.

"Pregnancy-associated deaths in Finland 1987-1994-definition problems and benefits of record linkage," M Gissler et al, Acta Obstet Gynecol Scand 76:651-657, 1997.

Death certificates of all women of child-bearing age were linked to birth, abortion, and other pregnancies to identify women who had been pregnant during the last year of their life. Only in 22% of the death certificates was pregnancy or its end mentioned. The mortality rate was 27 per 100,000 live births, 48 per 100,000 miscarriages or ectopic pregnancies, and 101 per 100,000 abortions. After abortion, the mortality risk was increased for accidents, suicides, and homicides.

"Suicide Deaths Associated with Pregnancy Outcome: A Record Linkage Study of 173,279 Low Income American Women," DC Reardon et al, Clinical Medicine & Health Research2001030003, April 25, 2001.

A record-linkage study of low income women eligible for state-funded medical insurance in California identified all paid claims for abortion or delivery in 1989. These were linked to the state death registry. Compared to women who delivered, those who aborted had a significantly higher age adjusted risk of dying from all causes (1.62), from suicide (2.54), accidents (1.82), and non-violent causes (1.44), including AIDS (2.18), circulatory diseases (2.87), and cerebrovascular disease (5.46). The results remained significant over an eight year period and over four of six age groups examined.

"Hidden From View: Violent Deaths Among Pregnant Women in the District of Columbia, 1988-1996," CJ Krulewitch et al, J Midwifery & Women's Health 46(1): 4, Jan/Feb 2001.

From 1988-1996 the District of Columbia officially reported 21 maternal deaths using standard definitions for pregnancy-related death, but did not include women who died from pregnancy associated but not pregnancy related causes. Thirty additional deaths were identified from autopsy reports , which documented evidence of pregnancy. Of these 30 deaths, homicide was documented as the manner of death in 13 cases (43.3%). Three out of four women with evidence of pregnancy who died from homicide were in their first 20 weeks of pregnancy.

"Enhanced Surveillance for Pregnancy-Associated Mortality- Maryland, 1993-1998," IL Horon and D Cheng, JAMA 285(11):1455, March 21, 2001.

A study of pregnancy-associated deaths in Maryland found that among all deaths occurring up to one year after delivery or termination, it was found that homicide (50 deaths) was the most frequent cause of death, with deaths from cardiovascular disorders the second leading cause of death (48 deaths). Death certificates only accounted for 67 out of 247 deaths. Record linkage and medical examiner records provided the balance of the information.

Other Peer Reviewed Studies

Pregnancy-Associated Death: A Qualitative Systematic Review of Homicide and Suicide Shadigian EM; Bauer ST; Obstetrical & Gynecological Survey 60:183-190, 2005.

(abstract) A systematic review of the literature on maternal homicide and suicide was performed to understand the causes of pregnancy-associated death. Forty-four studies examined homicide and/or suicide and pregnancy-associated death (defined as the death of a woman, from any cause, while she is pregnant or within 1 year of termination of pregnancy) (1). Of these studies, 747 homicides and 349 suicides were identified. All studies were included except duplicate datasets, case reports of less than 3 events, suicide attempts, unpublished manuscripts, review articles, or non-English studies. Homicide is a leading cause of pregnancy-associated death and suicide is also an important cause of death among pregnant and recently pregnant women. Healthcare providers should understand that homicide is a leading cause of pregnancy-associated death, most commonly as a result of partner violence. Therefore, screening for both partner violence and suicidal ideation are essential components of comprehensive medical care for women during and after pregnancy.

"Legal abortion in the U.S.: trends and mortality," HK Atrash, HW Lawson, JC Smith, Contemporary OB/GYN 35:58, Feb. 1990

Abortion-related deaths are defined as deaths (1) resulting from a direct complication; (2) an indirect complication caused by the chain of events initiated by the abortion, or (3) an aggravation of a pre-existing condition by the physiologic or psychologic effects of the abortion. Any death attributable to abortion is considered abortion related regardless of how long it occurred after the abortion. Ed Note: there are a number of definitions of abortion-related deaths or pregnancy related deaths. This is one of them.

"Abortion Mortality. United States, 1972 through 1987," H.W. Lawson et. al. Am. J. Obstet. Gynecol. 171: 1365-1372,1994.

The Centers for Disease Control reported that 240 U.S. women died from legal induced abortion between 1972-1987 with a decreasing overall rate of 4.1 per 100,000 abortions in 1972 to 0.4 per 1000 abortions in 1987. Those at increased risk of death from legal induced abortion included women 40 years old or more, black women and those of the minority races, abortions at 16 weeks gestation or greater and use of general anesthesia.

"Pregnancy-Related Mortality in the United States. 1987-1990." C.J. Berg et. al, Obstet. Gynecol. 88: 161-167,1996.

The Centers for Disease Control reported that the pregnancy-related mortality ratio of deaths per 100,000 live births increased from 7.2 in 1987 to 10.0 in 1990. A higher risk of pregnancy-related death was found with increasing maternal age, increasing live birth order, no prenatal care, and among unmarried women. The leading causes of pregnancy- related death were hemorrhage, embolism, and hypertensive disorders of pregnancy. The CDC reported a total of 1453 pregnancy-related deaths during this period including 797 deaths where there was a live birth, 103 deaths with stillbirth, 156 deaths from ectopic pregnancy, 81 deaths from abortion (spontaneous or induced), 6 deaths from molar pregnancy, 112 deaths where the baby was undelivered and 198 deaths where the outcome of the pregnancy was unknown.

"Pregnancy-Related Mortality Surveillance-United States, 1987-1990," LM Koonin et al, MMWR 46(SS-4): 17-36 (August 8, 1997).

The causes of pregnancy-related death where there is a live birth are: hemorrhage (21.1%), embolism (23.4%), pregnancy-induced hypertension (23.8%), infection (12.1%), cardiomyopathy (6.1%), anesthesia complications (2.7%) The causes of pregnancy- related deaths where there is an abortion (induced or spontaneous) are: hemorrhage (18.5%), embolism (11.1%), pregnancy-induced hypertension (1.2%), infection (49.4%), anesthesia complications (8.6%).

"An Assessment of the Incidence of Maternal Mortality in the United States," T. Smith, J. Hughes, P. Pekow and R. Rochat, Am. J. Public Health 74: 780-783, 1984

The incidence of maternal mortality is higher than vital statistics reports indicate. The person certifying the cause of death may not know that a woman had a recent pregnancy. Also, the definition of maternal death can greatly affect the reported incidence of maternal mortality.

"Legal Abortion Mortality in the United States: 1972 to 1982," H. Atrash, H.T. MacKay, N. Binkin and C. Hogue, American Journal Obstetrics and Gynecology, 156(3): 611, March 1987.

Although there is no certainty that all legal abortion-related deaths from 1972 to 1982 were reported to the Center for Disease Control [CDC], it is believed that the use of multiple reporting sources decreases the likelihood that deaths are missed. A study of maternal deaths in the U.S. between 1974-1978, relying only on vital records, identified only 141 abortion-related deaths, 63 of which were related to legal abortion. See "Causes of Maternal Mortality in the U.S." Kaunitz, et al., Obstet. Gynecol. 65:605-612, 1985. In comparison, CDC's surveillance of abortion [maternal] mortality identified 188 abortion- related deaths during the same period, 92 of which were related to legal abortion.

"Causes of Maternal Mortality in the United States," A. Kaunitz, J. Hughes, D. Grimes, J. Smith, R. Rochat and M. Kafrissen, Obstetrics and Gynecology 65: 605-612, May 1985.

From 1974-1978, the most common causes of maternal deaths, excluding other unspecified causes, were embolism (191), hypertensive disease of pregnancy (421), obstetric hemorrhage (331), ectopic pregnancies (254), obstetric infection (199), cerebro vascular accident (107) and anesthesia/analgesia complications (98). There were 135 deaths from upper genital tract infections among the deaths for obstetric infection. Among deaths due to obstetric hemorrhage 33 were from retained placenta and 19 from placenta previa. Ed. Note - Prior induced abortion may have been an implicating factor in some of these deaths.

"Legal Abortion in the U.S.: Trends and Mortality," H.K. Atrash, H. Lawson and J. Smith, Contemporary Ob/Gyn 35(2):58-69 Feb 1990.

According to the Centers for Disease Control the relative risk of death for black women and other minorities increased from 2.4 per 100,000 abortions during 1972-1978 to 2.9 per 100,000 abortions during 1979-1985). (The cause of death from legal abortion during 1979-1985 was hemorrhage (22.2%); infection (13.9%); embolism (15.3%); anesthesia (29.2%) and other (19.4%).

"Fatal Hemorrhage from Legal Abortion in the United States," D. Grimes, et al., Surgery, Gynecology and Obstetrics, 157: 461-6, November 1983.

From 1972-1979, hemorrhage was the third most frequent cause of death from legal abortion, accounting for 15% of deaths. If abortions are performed in free-standing clinics, the capability for rapid transportation to a nearby well-equipped hospital must be assured. Inordinate delays while waiting for an ambulance contributed to several deaths. The back- up hospital must have the ability to begin a laparotomy quickly and to transfuse large amounts of blood products.

"Legal Abortion Mortality and General Anesthesia," H. Atrash, Am. J. Obstet and Gynecol 158:420-424(1988).

The percentage of deaths from legal abortion caused by general anesthesia complications increased from 7.7% between 1972-75 to 29.4% between 1980-85. At least 23 of the 27 deaths were due to hypoventilation and/or loss of airway resulting in hypoxia.

"Anesthesia or Analgesia Related Deaths of Women from Legal Abortion: The Need for Increased Regulation," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change Research Bulletin 12(1):1-8, Nov/Dec 1997.

"Economic Consequences of Pelvic Inflammatory Disease in the United States," James Curran, American Journal of Obstetrics and Gynecology, 138(7):848-851, Part 2, December 1,1980.

Between 1970 and 1975, an average of 897 women hospitalized for PID died each year. Fifty percent of the morbidity and deaths from ectopic pregnancy can be attributed to PID. The extent to which induced abortion may have contributed to these deaths was not stated.

"Abortion Related Maternal Mortality: An In-Depth Analysis," T. Hilgers and D. O'Hare, in New Perspectives on Human Abortion, ed. T. Hilgers, D. Horan and D. Mall, (Frederick MD: University Publications of America, 1981).

Analyzes state and national statistics and concludes that the legalization of abortion has had no effect on the already existing downward trend in the maternal mortality rate. Prior maternal deaths for criminal abortion have been replaced by maternal deaths for legal abortion. Maternal mortality rates are generally expressed as the number of maternal deaths which occur during the entire course of pregnancy and the first three to six months following completion of the pregnancy per 100/000 live births.

"Fatal Ectopic Pregnancy After Attempted Legally Induced Abortion," G. Rubin, W. Cates, J. Gold, R. Rochat and C. Tyler, Journal of the American Medical Association, 244(15): 1705-1708 October 10, 1980.

Ten cases of death caused by ruptured ectopic pregnancy after attempted legal abortion were identified by the Center for Disease Control [seven blacks, three whites, five nulliparous] from 1973 to 1978. In seven cases tissue obtained at the abortion was sent for outside pathological exam, but results came back too late. The study concluded that an important factor in preventing fatal ectopic pregnancy is the identification of products of conception at the time of the abortion while patient is still available for re-examination. Deaths occurred from one to 44 days following the attempted abortion. See also "Missed Tubal Abortion," Burrows, et al., American Journal of Obstetrics and Gynecology, 136(5): 691-92, March 1,1980; "Ectopic Pregnancy and First Trimester Abortion," Schonberg, Obstet. Gynecol. (Supp.), 49:73 (1977). Planned Parenthood reported only 11 cases of tubal pregnancy among 41,753 women presented for elective, first-trimester abortions, only two of which were diagnosed prior to rupture.

"Fatal pulmonary embolism during legal induced abortion in the United States from 1972 to 1985," H.W. Lawson, H.K. Atrash, A.L. Franks, Am.J. Obstetrics and Gynecology, 162: 986-990,1990.

Of the 213 deaths from legal abortion from 1972-1985, 21 % were due to air, blood clot or amniotic fluid embolism. The risk of death from embolism was higher among minority women and women aged 34-44 years and abortion at later stages of pregnancy.

"Cluster of Abortion Deaths at a Single Facility," M.E. Kafrissen, D.A. Grimes, C.J.R. Hogue, J.J. Sacks, Obstetrics and Gynecology 68: 387,1986.

Four abortion related deaths at a single facility were reported from 1979 to 1983. Two abortion deaths occurred when an unlicensed person performed the abortions. It was recommended that prompt treatment of abortion complications and community-based surveillance of serious morbidity should be done.

"Ectopic Pregnancy in the United States. 1970-1986," H. Lawson, H. Atrash, A. Saftlas and E. Finch, Centers for Disease Control, Morbidity and Mortality Weekly Report, 38(SS- 2) Sept. 1989.

Ectopic pregnancy rose from 17,800 cases in 1970 to 73,700 cases in 1986. Nearly 800,000 women have been hospitalized for ectopic pregnancy since 1970. Thirty-six women reportedly died from ectopic pregnancy in 1986.

"Mortality From Abortion and Childbirth," (letter), M. Lanska D. Lanska and A. Rimm, JAMA 250(3): 361-362 July 15, 1983.

Maternal mortality following a cesarean section is approximately 100 per 100,000 births which is roughly 10-20 times greater than the maternal mortality following vaginal delivery. Cesarean sections, while accounting for only 10% of the deliveries, account for 90% of the maternal mortality associated with childbirth. The results suggest that the mortality rate among women who have had abortions (1.9 per 100,000 legal abortions) is almost twice as high as maternal mortality rates for women who have had vaginal deliveries (1.1 per 100,000 live births.

"Trends in the United States cesarean section rate and reasons for the 1980-1985 rise," S. Taffel, P. Placek and T. Liss, Am. J. Public Health 77: 955 (1987).

Deliveries by cesarean section in the U.S. increased from 5.5% in 1970 to 16.5% in 1980 and to 27.7% of all deliveries in 1985.

"Maternal Mortality in the United States: Report From the Maternal Mortality Collaborative," R. Rochat, L. Koonin, H. Atrash, J. Jewett, Obstetrics and Gynecology 72: 91 1988.

Of the leading causes of direct maternal deaths during 1980-85,45.5% were known to have been associated with delivery by cesarean section. It was concluded that maternal deaths from childbirth and abortion are under-reported.

"Ectopic pregnancy concurrent with induced abortion: Incidence and mortality," H.K. Atrash, Am. J. Obstet. Gynecol. 162(3):726-730, March 1990.

From 1972-1985, 24 women who underwent an induced abortion died as a result of a concurrent ectopic pregnancy. The death-to-case rate was 1.3 times higher in ectopic pregnancy concurrent with induced abortion than for women not undergoing induced abortion. Most of the deaths of women with ectopic pregnancy who underwent abortion were attributed to the failure to diagnose ectopic pregnancy before the women left the facility. Tissue examination to assure there is a product of conception at the time of the abortion is necessary.

"Centers for Disease Control, Abortion Surveillance, 1981," U.S. Dept. of Health and Human Services, Public Health Services, November 1985 p. 9

Between 1972 and 1981 the Centers for Disease Control reported that 21 deaths from ectopic pregnancy occured soon after an attempted legally induced abortion. In the 1978 abortion surveillance report the CDC considered such deaths as abortion-related and included them as a separate subcategory of legal induced abortion. In 1979 the CDC began the independent surveillance of ectopic pregnancy-related mortality and published its first ectopic pregnancy surveillance report in 1982. In the abortion surveillance report of 1981 (and apparently in years following), the CDC excluded all deaths associated with ectopic pregnancies.

General Literature

Post Moretem: Death Investigation in America -- (February, 2011) An NPR News investigation in partnership with ProPublica and PBS Frontline explores the nation's 2,300 coroner and medical examiner offices, and finds a troubled system that literally buries its mistakes.

This expose underscores the unreliability of relying on death certificates to quantify deaths associated with abortion and childbirth

Permissive Abortion Laws May Be Hazardous To Mothers' Health, Per New Report

The Global Gender Report, 2009 from the World Economic Forum (WEF) shows that countries with restrictive abortion laws are often the leaders in reducing maternal mortality, and those with permissive laws often lag. According to the report, the pro-life nation of Ireland has topped the global rankings once again with the best maternal health performance.

"An examination and comparison of several countries included in the WEF survey show that legal abortion does not mean lower maternal mortality rates. 


"Both Ireland and Poland, favorite targets of the abortion lobby for their strong restrictions on abortion, have better maternal mortality ratios than the United States. Ireland ranks first in the survey with 1 death for every 100,000 live births. In recent years Poland has tightened its abortion law and ranks number 27 on the list with 8 deaths per 100,000. In the United States where there are virtually no restrictions on abortion, the maternal mortality ratio is 17 out of 100,000 live births."

Lime 5. Exploited by Choice, Mark Crucher, (Denton, Texas: Life Dynamics, Inc., 1996) 135-155

Describes the reporting of flawed data on maternal deaths by the Centers for Disease Control. Examples include: lack of information in medical records, failure to recognize that there was a recent abortion, improper classification, differing definitions of maternal death, confidentiality, lack of cooperation between various government agencies, CDC officials connected to the abortion industry.

Communication dated Tune 5. 1987 from Commissioner of Health, City of New York to All Gynecologists, Anesthesiologists, Administrators and Others Concerned with the Provision of Abortion Services in Victims of Choice, Kevin Sherlock, (Akron, Ohio: Brennyman Books, 1996)

The New York City Health Department, apparently relying on data likely to have been provided by the Alan Guttmacher Institute, reported that 146 women died from legal abortion between 1981-1984, yet the Centers for Disease Control reported only 42 deaths from legal abortion during that same period. Ed Note: This is a good example of the underreporting of deaths from legal abortion.

Victims of Choice, Kevin Sherlock, (Akron, OH: Brennyman Books, 1996)

In an investigation and subsequent analysis of 87 abortion-related deaths of U.S. women between 1980-1989 in 28 states, 47 were classified as unspecified abortion, 33 as legal abortion, and 7 did not include a code classification. Death certificates or coroner reports used 27 different terms or phrases to describe abortion. If the term abortion, septic abortion, induced abortion or incomplete abortion was used on death certificates or coroner/medical examiner reports, deaths were classified as unspecified abortion. Where the term termination of pregnancy or elective abortion was used, about 2/3 were classified as legal abortion deaths. Where the term therapeutic abortion was used, virtually all were classified as legal abortion deaths. Ed Note: It appeared that most, if not all, of these abortion-related deaths were from legal abortion. The wide range of terms used to describe abortion appeared to be a major factor in misclassification.

"Induced Abortion as a Contributing Factor in Maternal Mortality or Pregnancy- Related Death in Women," Thomas Strahan, Association for Interdisciplinary Research in Values and Social Change 10(3): 1-8, Nov/Dec, 1996.

Prior induced abortion is a cause of complications in subsequent pregnancies including placenta previa, retained placenta, abrupdo placentae, premature rupture of membranes, and obstetrical infections. Also, induced abortion increases the incidence of suicide compared to other pregnancy outcomes, as well as ruptured ectopic pregnancy. Induced abortion does not provide the protective effect of childbirth and increases the incidence of hypertensive disorders of pregnancy. All of these increase the incidence of maternal mortality.

"Brief of Amicus Curiae Feminists for Life of America. Women Exploited by Abortion, etc," Christine Smith Torre, Webster v. Reproductive Health Services 88-605 1988 at p. 22

The state of California reported no deaths from abortion during 1982 and 1984, yet there was incontrovertible evidence from death certificates, police reports, coroner's reports and other sources that at least four women and teenage girls died from legal abortions in Los Angeles County alone during 1983 and 1984.

Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Press, 1987) 109.

In an investigation of four Chicago-based abortion clinics (out of more than 20 in the state), investigative reporters for the Chicago Sun-times uncovered 12 abortion deaths that had never been reported. Even when abortion-related deaths such as these are uncovered, they are not generally included in the "official" total since they were not reported as such on the original death certificates. Citing "The Abortion Profiteers," Pamela Zekeman and Pamela Warrick, Chicago Sun-Times, November 12, 1978 (Special Reprint December 3,1978); Abortion: Questions and Answers J. Willke and B. Willke ( Cincinnati: Hayes Publishing, 1985); "Medical Hazards of Abortion," Thomas Hilgers, in Abortion and Social Justice. ed. T. Hilgers and D. Horan, (New York: Sheed and Ward, 1972)

"Before and After Legalization," in Aborted Women: Silent No More, David C. Reardon, (Chicago: Loyola Press, 1987) 282-300.

Examines reporting of abortion related deaths before and after legalization. Abortion related deaths were much more likely to be reported when it was still a criminal act. Numerous factors, including the lack of a formal reporting mechanism, render post- legalization assessments of abortion related deaths unreliable.

"The Cover-Up: Why U.S. Abortion Mortality Statistics are Meaningless," David C. Reardon, The Post-Abortion Review 8(2):4, April-June 2000. Posted at www.afterabortion.org/PAR/V8.

This article identifies examples of documented abortion related deaths that have been excluded from government figures. The rules regarding coding cause of death using the International Classification of Diseases preclude identifying medical procedures as the cause of death. This coding rule contributes to the lack of good statistics on abortion related deaths.

Abortion, Health, and the Law N Engl J Med 2004; 350:1908-1910 April 29, 2004

Greene and Ecker's interesting exploration of difficulties in risk–benefit analyses with regard to therapeutic abortions (Jan. 8 issue)[1] is, unfortunately, flawed by the use of disparate comparisons. For example, they cite sources that use dissimilar definitions, populations, and means of case identification to calculate comparative death rates for abortion and childbirth. This approach is problematic, since efforts to track deaths associated with pregnancy and abortion are hampered by inaccurate death certificates and inconsistent definitions.[2] Citing the only two record-based, case–control studies that directly compared death rates associated with abortion and childbirth would have been more informative.[2,3] Both reveal significantly higher mortality rates associated with abortion than with other outcomes of pregnancy. The one-year age-adjusted odds ratio for death among pregnant women as compared with nonpregnant women was 0.50 for those who gave birth, 0.87 for those who had a miscarriage, and 1.76 for those who had an abortion.[2] The authors also fail to note that couples in which the woman undergoes a therapeutic abortion have high rates of psychiatric sequelae and divorce.4 Although it is known that elective abortion is more strongly associated with subsequent psychiatric hospitalization than is childbirth,[5] there have been no comparative studies of therapeutic abortion. Therefore, case–control studies are required to support the authors' risk–benefit analysis.

1. Greene MF, Ecker JL. Abortion, health, and the law. N Engl J Med 2004;350:184-186
2. Gissler M, Kauppila R, Merilainen J, Toukomaa H, Hemminki E. Pregnancy-associated deaths in Finland 1987-1994 -- definition problems and benefits of record linkage. Acta Obstet Gynecol Scand 1997;76:651-657
3. Reardon DC, Ney PG, Scheuren F, Cougle J, Coleman PK, Strahan TW. Deaths associated with pregnancy outcome: a record linkage study of low income women. South Med J 2002;95:834-841
4. Lloyd J, Laurence KM. Sequelae and support after termination of pregnancy for fetal malformation. Br Med J (Clin Red Ed) 1985;290:907-909
5. Reardon DC, Cougle JR, Rue VM, Shuping MW, Coleman PK, Ney PG. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ 2003;168:1253-1256

Benefits of Childbirth

In addition to the record based studies from Finland showing lower mortality rates for childbearing women compared to non-pregnant women, additional research shows that women who have larger families have greater longevity.

Childbearing history and late-life mortality: the Dubbo study of Australian elderly Leon A. Simons, Judith Simons, Yechiel Friedlander and John McCallum.

Objective: to examine the association of parity with mortality in later life.

Design: a longitudinal, community-based study.

Setting: semi-rural town of Dubbo, NSW, Australia.

Subjects: a total of 1,571 women and 1,233 men 60 years and older first examined in 1988–89.

Outcome measures: all-cause and cause-specific mortality rates analysed over 16-year follow-up. Hazard ratios obtained from proportional hazards models employing conventional predictors, potential confounders and measure of parity.

Results: increasing parity in women was weakly associated with overweight, diabetes and hypertension. All-cause mortality fell progressively with increasing parity in women (hazard ratio and 95% confidence intervals): childless, 1.00; 1 child, 1.03 (0.75–1.43); 2 children, 0.83 (0.61–1.11); 3 children, 0.80 (0.60–1.08); 4 children, 0.91 (0.66–1.25); 5 children, 0.70 (0.49–1.01); 6+ children, 0.60 (0.43–0.85) (trend for parity P < 0.002). This result was similar whether or not hypertension, diabetes and overweight were included in multivariate models adjusting for social variables and other confounders. The reduction in all-cause mortality was accompanied by a parallel reduction in deaths from cancer and respiratory conditions, while coronary heart disease mortality increased 60–111% in all parous women.

Conclusion: there was increased all-cause mortality in later life in childless women, accompanied by reduced mortality as parity increased. Underlying mechanisms are unclear but findings may have public health importance.