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Fax: 571-312-0544

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Charlotte Lozier Institute

Phone: 202-223-8073
Fax: 571-312-0544

2776 S. Arlington Mill Dr.
#803
Arlington, VA 22206

Maternal & Public HealthAbortion

Fact Check: “Abortion is 14 Times Safer than Childbirth”

 

Myth: Abortion is 14 times safer than childbirth.

Fact: Studies from countries with better data show that a woman is at least three times as likely to die from any cause following abortion than after childbirth.

 

The false claim that abortion is 14 times safer than childbirth arose from a 2012 journal article by two vocal abortion advocates, Elizabeth Raymond and David Grimes (henceforth “R&G”).[1] Despite being debunked in the dozen years since,[2] it continues to be repeated by pro-abortion media advocates. Following are numerous reasons this statement is false and not data-driven.

 

1. This comparison is made using four disparate numbers, none of which can be calculated accurately (abortion-related deaths, legal abortions, maternal deaths, and live births).

Different denominators are being compared: Abortion-related deaths are compared to 100,000 legal abortions, whereas all maternal deaths are compared to 100,000 live births. The relevance of these facts to the R&G myth will be clarified below.

 

2. Even the former director of the Center for Disease Control and Prevention (CDC), Dr. Julie Louise Gerberding, demonstrated that a comparison between the two statistics is inappropriate. In 2004, she wrote that maternal mortality ratios and abortion mortality rates “are conceptually different and are used by CDC for different public health purposes.”[3]

 

3. The number of legal abortions in the U.S. is unknown.

  • The estimated number of legally induced abortions is voluntarily provided by local and state health departments to the CDC. In 2020, the CDC documented 620,327 abortions.[4]
  • The number of abortions is also estimated by the Guttmacher Institute, which directly surveys abortion providers, but a large disparity is seen between the two sources. In 2020, the Guttmacher Institute documented 930,160 abortions,[5] nearly 50% more abortions than the CDC reported.
  • R&G used Guttmacher-derived legal abortion numbers for their denominator rather than CDC numbers (even though they used CDC numbers for abortion-related deaths), allowing the larger numbers in the denominator to dilute the numerator.

 

4. Abortion-related deaths are undercounted. (See CLI paper “Handbook of Maternal Mortality” for extensive discussion.)

  • The CDC relies primarily upon death certificate documentation or deaths that happen to come to its attention in order to detect abortion-related deaths, but there are many reasons that these deaths may not be documented.
    • Due to private payment for most abortions and women’s tendency to hide an abortion history, a prior abortion is often not known by the certifier.[6]
    • Abortion complication reporting is not required by federal law and ideologically driven individuals may misrepresent, hide, or fail to report abortion-related deaths.[7]
    • Deaths from mental health causes (suicide, homicide, accidents due to high risk-taking behavior, substance and alcohol abuse and overdose) are rarely documented as abortion-related on death certificates,[8] even though several meta-analyses have documented increased risks of mental health complications such as anxiety, depression, substance and alcohol abuse, and self-harm following abortion compared to childbirth.[9]

 

5. The total number of pregnancies in the U.S. is unknown because early pregnancy losses are not recorded.

  • Thus, the CDC uses the denominator of 100,000 live births because this is measured by mandatory birth certificates. This becomes a “maternal mortality ratio,” not “maternal mortality rate,” because the denominator does not include all the “at-risk” individuals (those who have experienced a pregnancy).
  • This causes maternal deaths that are associated with early pregnancy events (miscarriages, ectopic pregnancies, gestational trophoblastic disease, and induced abortions) to be represented in the numerator but not the denominator, artificially inflating the numerator. Only 2/3 of maternal deaths are associated with a live birth or fetal death (beyond 20 weeks of gestation).[10]
  • It should also be noted that an abortion-related death is counted in both statistics.

 

6. Maternal mortality data is also inaccurate.[11]

  • There are several disparate maternal mortality reporting systems in the U.S. using different methods of data collection and different temporal definitions.
    • CDC’s National Vital Statistics System (NVSS) determines pregnancy-related deaths based on death certificate ICD-O coding during or within six weeks of a pregnancy.[12]
    • CDC’s Pregnancy Mortality Surveillance System (PMSS) determines pregnancy-related death based on death certificate documentation of pregnancy within one year and review of the woman’s medical records to determine “pregnancy-relatedness” – that is, whether it was caused or exacerbated by the pregnancy or its management.[13]
    • Not surprisingly, given differing data sources and timelines, there is little correlation between the statistics reported by NVSS and PMSS.[14]
    • Using death certificates as the initial source of detecting pregnancy-associated deaths does not cast a broad enough net, because at least 38-50% of all U.S. maternal deaths are not documented on death certificates.[15]
    • In order to improve detection of pregnancy-associated deaths, the CDC recommended adding a “pregnancy check-box” to death certificates, but this was variably implemented by the states over a prolonged period, leading to non-comparable statistics for over a decade. Although more maternal deaths were detected, false positives were also noted to be frequent, leading to continued data deficiencies.[16]
    • Additionally, Maternal Mortality Review Committees (MMRC) have convened at local, state, regional, and federal levels to comprehensively review reported maternal deaths. Although these multidisciplinary committees will likely provide better quality data, the most recent collaborative report from 2019 only included the analysis of 36 such committees (failing to include data from 14 states and the District of Columbia), so a complete analysis of U.S. data from all states remains elusive.[17]

 

7. Higher quality data can be obtained from records-linkage studies since all abortions can be detected (usually through single-payer insurance coverage in European countries) and compared to all subsequent deaths within one year in reproductive aged women. R&G chose not to include international data and ignored the one U.S. study using this methodology. These better-quality studies demonstrate far more deaths in the year following abortion than childbirth, providing strong evidence that abortion is not safer than childbirth.

  • A records-linkage study of California Medicaid recipients found that a woman was 62% more likely to die from any cause in the years following abortion compared to childbirth, 82% more likely to die in an accident, and 154% more likely to commit suicide.[18]
  • A number of large studies from Finland found that the maternal mortality rate following abortion was 3-4 times the maternal mortality rate following birth.[19] The rate of suicide following abortion was six times the rate following birth, the rate of accidental death was five times the rate following birth, and the rate of homicide was over ten times the rate following birth.[20]
  • The Finnish data demonstrate the inherent unreliability of utilizing death certificate documentation to detect maternal deaths. Despite meticulous record-keeping in that country, death certificate documentation alone detects only 26% of deaths after a live birth or stillbirth, 12% of deaths following miscarriage or ectopic pregnancy, and just 1-6% of deaths following induced abortion.[21]
  • Additionally, two international Systematic Reviews comparing all available studies were available at the time R&G published their paper but were not referenced by these researchers.[22]
  • A 2017 meta-analysis of available records-linkage studies documented the increased risk of death after abortion compared to birth. One study included in the meta-analysis documented a dose-effect, as each additional abortion increased a woman’s risk of dying by around 50%.[23]
  • A records-linkage study using Danish data from 1980-2004 revealed that after a first-trimester induced abortion, a woman had twice the likelihood of death within 180 days, and a 331% increased likelihood of death within 180 days for second-/third-trimester abortion compared to childbirth.[24]

 

8. In the politically polarized climate following the Supreme Court’s decision in Dobbs v. Jackson Women’s Health, reversing Roe v. Wade and allowing legislatures to regulate abortion, some have falsely stated that doctors may not be able to provide quality care for obstetric complications, even though all states with pro-life protections allow an exception if abortion is necessary in life-threatening emergencies. (See CLI articles, “Abortion Policy Allows Physicians to Intervene to Protect a Mother’s Life” and “Pro-Life Laws Protect Mom and Baby: Pregnant Women’s Lives are Protected in All States” for more discussion.)

 

9. Allegations have arisen that state limits on abortion will increase maternal mortality. Fortunately, there are many reasons to expect abortion restrictions to decrease, rather than increase, maternal mortality. (See CLI articles “Twelve Reasons Women’s Health and Maternal Mortality Will Not Worsen, and May Improve, in States with Abortion Limits” and “Response to Media Allegations that Abortion Restrictions Cause Maternal Mortality and Female Suicides” for more discussion.)

 


[1] Raymond EG, Grimes DA. The comparative safety of legal induced abortion and childbirth in the United States. Obstet Gynecol 2012;119:215–219.

[2] Calhoun B. Systematic Review: The maternal mortality myth in the context of legalized abortion. The Linacre Quarterly. 2013;80(3):264-276; Reardon DC, et al. Deaths associated with abortion compared to childbirth-A review of new and old data and the medical and legal implications. The Journal of Contemporary Health Law and Policy. 2004;20(2):279-327.

[3] Letter from Julie Louise Gerberding to Walter Weber, July 20, 2004. http://afterabortion.org/pdf/CDCResponsetoWeberReAbortionStats-Gerberding%20Reply.pdf.

[4] Kortsmit K, Nguyen AT, Mandel MG, et al. Abortion Surveillance — United States, 2020. MMWR Surveill Summ 2022; 71(No. SS-10):1–27. DOI: http://dx.doi.org/10.15585/mmwr.ss7110a1.

[5] Jones RK, Kirstein M, Philbin J. Abortion Incidence and Service Availability in the United States, 2020. Nov 2022. Perspectives on Sexual and Reproductive Health 54(4):128-141. Available at https://onlinelibrary.wiley.com/doi/10.1363/psrh.12215.

[6] Desai S, Lindberg LD, Maddow-Zimet I, Kost K. The Impact of Abortion Underreporting on Pregnancy Data and Related Research. Matern Child Health J. 2021;25(8):1187-1192. doi:10.1007/s10995-021-03157-9; Udry JR, Gaughan M, Schwingl PJ, van den Berg BJ. A medical record linkage analysis of abortion underreporting. Fam Plann Perspect. 1996;28(5):228-231.

[7] Grossman D, Perritt J, Grady D. The Impending Crisis of Access to Safe Abortion Care in the US. JAMA Intern Med. 2022;182(8):793-795. doi:10.1001/jamainternmed.2022.2893

[8] Gissler M, Kauppila R, Meriläinen 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(7):651-657. doi:10.3109/00016349709024605; Walker D, Campero L, Espinoza H, et al. Deaths from complications of unsafe abortion: misclassified second trimester deaths. Reprod Health Matters. 2004;12(24 Suppl):27-38. doi:10.1016/s0968-8080(04)24019-8

[9] Coleman PK. Abortion and mental health: quantitative synthesis and analysis of research published 1995-2009. Br J Psychiatry, 2011;199:180-186; Fergusson DM, Horwood LJ, and Boden JM. Does abortion reduce the mental health risks of unwanted or unintended pregnancy? A re-appraisal of the evidence. Aus NZ J Psych, 2013;47(9):819-827; Fergusson DM, Horwood LJ, Boden JM. Abortion and mental health disorders: evidence from a 30-year longitudinal study. Br J Psychiatry. 2008;193(6):444-451; Sullins DP. Abortion, substance abuse and mental health in early adulthood: Thirteen-year longitudinal evidence from the United States. Sage Open Medicine. 2016;4:1-11; Sullins DP. Affective and Substance Abuse Disorders Following Abortion by Pregnancy Intention in the United States: A Longitudinal Cohort Study. Medicina (B Aires) [Internet]. 2019;55(11):1–21.

[10] Horon IL. Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. Am J Public Health 2005;95:478-482

[11] M.F. MacDorman, et al., “Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends from Measurement Issues,” Obstetrics & Gynecology 128:3 (2016): 447-455; Horon IL. Underreporting of maternal deaths on death certificates and the magnitude of the problem of maternal mortality. Am J Public Health 2005;95:478-482; Deneux-Tharaux C, Berg C, Bouvier-Colle MH, et al. Underreporting of pregnancy-related mortality in the United States and Europe. Obstet Gynecol 2005;106(4):684-692; Joseph KS, Lisonkova S, Boutin A, et al. Maternal mortality in the United States: are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance? Am J Obstet Gynecol. doi:10.1016/j.ajog.2023.12.038

[12] Hoyert DL. Maternal mortality rates in the United States, 2021. NCHS Health E-Stats. 2023. doi:10.15620/cdc:124678

[13] Pregnancy Mortality Surveillance System. Centers for Disease Control and Prevention. Updated March 23, 2023. Accessed April 3, 2024. https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm

[14] MacKay A, Berg CJ, Duran C, et al. An assessment of pregnancy-related mortality in the United States. Pediatric & Perinatal Epidemiology 2005;19:206–214; Hoyert DL. Maternal Mortality and Related Concepts. Vital & Health Statistics. Series 3, Analytical and Epidemiological Studies. 2007;33:1-13. Available at https://europepmc.org/article/med/17460868, accessed August 9, 2022.

[15] Horon IL, Cheng D, Chang J, et al. Underreporting of Maternal Deaths on Death Certificates and the Magnitude of the Problem of Maternal Mortality. AJ of Public Health. 2005;95:478-82; Dye TD, Gordon H. Retrospective maternal mortality case ascertainment in West Virginia, 1985 to 1989. Am J Obstet Gynecol. 1992;167(1)72-6.

[16] Hoyert DL, Minino AM. Maternal mortality in the United States: Changes in coding, publication, and data release, 2018. National Vital Statistics Reports; vol 69 no 2. Hyattsville, MD: National Center for Health Statistics. 2020; Joseph KS, Lisonkova S, Boutin A, et al. Maternal mortality in the United States: Are the high and rising rates due to changes in obstetrical factors, maternal medical conditions, or maternal mortality surveillance? Am J Obstet Gynecol. doi:10.1016/j.ajog.2023.12.038

[17] Trost SL, Beauregard J, Njie F, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US states, 2017-2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022. Available at: https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc.html.

[18] Reardon DC, Ney PG, Scheuren FJ, Cougle JR, Coleman, PK, Strahan T. Deaths associated with pregnancy outcome: a record linkage study of low income women. Southern Medical Journal, 2002;95(8):834-841.

[19] Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Pregnancy-associated mortality after birth, spontaneous abortion, or induced abortion in Finland, 1987-2000. Am J Obstet Gynecol. 2004;190(2):422-427. doi:10.1016/j.ajog.2003.08.044; Gissler M, Kauppila R, Meriläinen 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(7):651-657. Doi:10.3109/00016349709024605.

[20] Gissler M, Hemminki E, Lönnqvist J. Suicides after pregnancy in Finland, 1987-94: register linkage study. BMJ. 1996;313(7070):1431-1434. doi:10.1136/bmj.313.7070.1431; Gissler M, Berg C, Bouvier-Colle MH, Buekens P. Injury deaths, suicides and homicides associated with pregnancy, Finland 1987-2000. Eur J Public Health. 2005;15(5):459-463. doi:10.1093/eurpub/cki042; Gissler M, Kauppila R, Meriläinen 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(7):651-657. doi:10.3109/00016349709024605

[21] Reardon DC, Thorp JM. Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis. SAGE Open Med. 2017;5:2050312117740490. Published 2017 Nov 13. doi:10.1177/2050312117740490

[22] Reardon DC, Strahan TW, Thorp JM, Shuping MW. Deaths associated with abortion compared to childbirth: a review of new and old data and the medical and legal implications. The Journal of Contemporary Health Law & Policy 2004; 20(2):279-327; Shadigian EM; Bauer ST. Pregnancy-Associated Death: A Qualitative Systematic Review of Homicide and Suicide. Obstetrical & Gynecological Survey. 2005. 60:183-190.

[23] Reardon D, Thorp J. Pregnancy associated death in record linkage studies relative to delivery, termination of pregnancy, and natural losses: A systematic review with a narrative synthesis and meta-analysis. Sage Open Medicine. 2017;5:1-17.

[24] Reardon DC, Coleman PK. Short and long term mortality rates associated with first pregnancy outcome: Population register based study for Denmark 1980-2004. Med Sci Monit 2012;18(9):71-76; Coleman PK, Reardon DC, Calhoun BC. Reproductive History Patterns and Long-Term Mortality Rates: A Danish population-based record linkage study. Eur J of Public Health. 2013;23(4):569-574.


Ingrid Skop, M.D., F.A.C.O.G., is Vice President and Director of Medical Affairs for the Charlotte Lozier Institute.

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