Abortion and Maternal Mortality

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Review Articles Relative to Maternal Death from Abortion

The risk of cardiovascular disease in women with a history of miscarriage and/or stillbirth. Asgharvahedi F, Gholizadeh L, Siabani S. Health Care Women Int. 2019 Oct;40(10):1117-1131. doi: 10.1080/07399332.2019.1566332. Epub 2019 Apr 5.

Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in women worldwide. Apart from the well-established risk factors, some adverse pregnancy outcomes have been found to be associated with increased risk of CVD in women. We reviewed the literature on the risk of CVD in women with a history of pregnancy loss (miscarriage and/or stillbirth). Electronic databases including MEDLINE and CINAHL were searched for English language articles published from 2000 to July 2016. Following the application of study inclusion and exclusion criteria, we selected seven studies for review. Women with history of miscarriage and/or stillbirth are more likely to develop coronary heart disease (CHD), but not stroke in their later life compared with women without these conditions. The risk is particularly greater in women with multiple miscarriages or stillbirths. Health professionals should be aware of the risk associated with miscarriage and stillbirth, and use maternal history to identify, refer, closely monitor, and engage these high risk women in healthy lifestyle and risk factor modification programs.

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. Reardon DC, Thorp JM. SAGE Open Med. 2017 Nov 13;5:2050312117740490. doi: 10.1177/2050312117740490. eCollection 2017.

OBJECTIVES: Measures of pregnancy associated deaths provide important guidance for public health initiatives. Record linkage studies have significantly improved identification of deaths associated with childbirth but relatively few have also examined deaths associated with pregnancy loss even though higher rates of maternal death have been associated with the latter. Following PRISMA guidelines we undertook a systematic review of record linkage studies examining the relative mortality risks associated with pregnancy loss to develop a narrative synthesis, a meta-analysis, and to identify research opportunities.
METHODS: MEDLINE and SCOPUS were searched in July 2015 using combinations of: mortality, maternal death, record linkage, linked records, pregnancy associated mortality, and pregnancy associated death to identify papers using linkage of death certificates to independent records identifying pregnancy outcomes. Additional studies were identified by examining all citations for relevant studies.
RESULTS: Of 989 studies, 11 studies from three countries reported mortality rates associated with termination of pregnancy, miscarriage or failed pregnancy. Within a year of their pregnancy outcomes, women experiencing a pregnancy loss are over twice as likely to die compared to women giving birth. The heightened risk is apparent within 180 days and remains elevated for many years. There is a dose effect, with exposure to each pregnancy loss associated with increasing risk of death. Higher rates of death from suicide, accidents, homicide and some natural causes, such as circulatory diseases, may be from elevated stress and risk taking behaviors.
CONCLUSIONS: Both miscarriage and termination of pregnancy are markers for reduced life expectancy. This association should inform research and new public health initiatives including screening and interventions for patients exhibiting known risk factors.

'The maternal mortality myth in the context of legalized abortion. Calhoun B. The Linacre Quarterly, Volume 80, Number 3, August 2013 , pp. 264-276(13)'

It was quoted recently in the literature that “The risk of death associated with childbirth is approximately 14 times higher than with abortion.” This statement is unsupported by the literature and there is no credible scientific basis to support it. A reasonable woman would find any discussion about the risk of dying from a procedure as material, i.e., important and significant. In order for the physician‐patient informed consent dialogue to address this critical issue, the physician must rely upon objective and accurate information concerning abortion. There are numerous and complicated methodological factors that make a valid scientific assessment of abortion mortality extremely difficult. Among the many factors responsible are incomplete reporting, definitional incompatibilities, voluntary data collection, research bias, reliance upon estimations, political correctness, inaccurate and/or incomplete death certificate completion, incomparability with maternal mortality statistics, and failing to include other causes of death such as suicides. Given the importance of this disclosure about abortion mortality, the lack of credible and reliable scientific evidence supporting this representation requires substantial discussion.

'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.

'Therapeutic abortion: the medical argument. Murphy JF, O'Driscoll K. Irish Medical Journal. 1982 Aug;75(8):304-6.'

Editors note: There is no evidence that abortion can be used to actually reduce maternal mortality rates because there is no evidence that those women at risk of dying during a pregnancy are at less risk of dying from an abortion.
Abstract:This document analyzes all cases of maternal death between 1970-79 at the National Maternity Hospital, Dublin, Ireland, and speculates as to the number of lives which might have been saved by therapeutic abortion. 74,317 births were considered; there were 21 deaths, or a mortality rate of 0.28/1000. 7 women died for reasons that had nothing to do with pregnancy: 3 cases of malignant disease, 2 of cerebrovascular accident, 1 of road accident, and 1 of Weil's disease. Therapeutic abortion would not have altered the outcome of pregnancy in these cases. 11 women died of pregnancy complications, 4 of infection, 3 of embolism, 2 of hemorrhage, 1 of eclampsia, and 1 of liver rupture. These deaths, however, could not have been prevented by therapeutic abortion, since these complications could not have been foreseen. 3 women died of diseases which could be said to have made pregnancy more dangerous. However, in the 1st case no disease was suspected until necropsy demonstrated the lesion; in the 2nd case the fatal outcome was interpreted as the terminal state of a chronic process which would have occurred whether or not the woman had been pregnant. Only in the 3rd instance a reasonable case could have been made in favor of therapeutic abortion. However, the woman in question had purposely sought pregnancy for the 2nd time in 2 years, fully aware of the risk involved; she would not have accepted a therapeutic abortion. Thus, the conclusion seems to be that, in the series presented, therapeutic abortion would not have saved a single life. The most recent publication on therapeutic abortion, bearing on 57,228 deliveries at the Mount Sinai Hospital in New York between 1953-64, indicates that in over 69 cases of therapeutic abortion the degree of risk to the mother's life was debatable.

'Public Health Impact of Legal Termination of Pregnancy in the US: 40 Years Later Thorp JM. Scientifica Volume 2012 (2012), Article ID 980812.':

Includes a review of record linkage studies showing higher rates of mortality after abortion and identifies failures in systematic tracking of abortion related deaths in the United States.

'Breast Cancer and Pregnancy WebMD'

"Pregnancy termination will not improve the mother's chances of surviving breast cancer. In addition, there is no evidence that breast cancer can harm the baby. What may harm the baby are some of the treatments for breast cancer."
See also: Breast cancer in pregnancy. Rovera F, Frattini F, Coglitore A, Marelli M, Rausei S, Dionigi G, Boni L, Dionigi R. Breast J. 2010 Sep-Oct;16 Suppl 1:S22-5.

Record Based Studies

Identifying maternal deaths with the use of hospital data versus death certificates: a retrospective population-based study. Aflaki K, Park AL, Nelson C, Luo W, Ray JG. CMAJ Open. 2021 May 21;9(2):E539-E547

Background: Accurate identification of maternal deaths is paramount for audit and policy purposes. Our aim was to determine the accuracy and completeness of data on maternal deaths in hospital and those recorded on a death certificate, and the level of agreement between the 2 data sources.

Methods: We conducted a retrospective population-based study using data for Ontario, Canada, from Apr. 1, 2002, to Dec. 31, 2015. We used Canadian Institute for Health Information (CIHI) databases to identify deaths during inpatient, emergency department and same-day surgery encounters. We captured Vital Statistics deaths in the Office of the Registrar General, Deaths (ORGD) data set. Deaths were considered within 42 days and within 365 days after a pregnancy outcome (live birth, miscarriage, ectopic pregnancy or induced abortion) for all multiple and singleton pregnancies. We calculated agreement statistics and 95% confidence intervals (CIs).

Results: Among 1 679 455 live births and stillbirths, 398 pregnancy-related deaths in the ORGD data set were mapped to a birth in CIHI databases, and 77 (16.2%) were not. Among 2 039 849 recognized pregnancies, 534 pregnancy-related deaths in the ORGD data set were linked to CIHI records, and 68 (11.3%) were not. Among live births and stillbirths, after pregnancy-related deaths in the ORGD data set not matched to a maternal death in the CIHI databases were removed, concordance measures between CIHI and ORGD records for maternal death within 42 days after delivery included a κ value of 0.87 (95% CI 0.82–0.91) and positive percent agreement of 0.88 (95% CI 0.83–0.94). The corresponding measures were similar for maternal death within 42 days after the end of a recognized pregnancy. When unlinked pregnancy-related deaths in the ORGD data set were retained, agreement measures declined for death within 42 days after a live birth or stillbirth (κ = 0.68, 95% CI 0.62–0.74). For maternal death within 365 days after a live birth or stillbirth, or after the end of a recognized pregnancy, the concordance statistics were generally favourable when unlinked pregnancy-related deaths in the ORGD data set were removed but were substantially declined when they were retained.

Interpretation: Maternal mortality cannot be ascertained solely with the use of hospital data, including beyond 42 days after the end of pregnancy. To improve linkage, we propose including health insurance numbers on provincial and territorial medical death certificates.

Increased risk of premature death following teenage abortion and childbirth-a longitudinal cohort study. Jalanko E, Leppälahti S, Heikinheimo O, Gissler M. Eur J Public Health. 2017 May 16. doi: 10.1093/eurpub/ckx065.

Abstract: Teenage pregnancy is associated with an increased risk of premature death. However, it is not known whether the outcome of pregnancy, i.e. induced abortion or childbirth, affects this risk. A Finnish population-based register study involving a cohort of 13 691 nulliparous teenagers who conceived in 1987-89; 6652 of them underwent induced abortion and 7039 delivered. The control group consisted of 41 012 coeval women without teenage pregnancy. Follow-up started at the end of pregnancy and lasted until 6th June 2013. Women with teenage pregnancy had a higher risk of overall mortality vs. controls (mortality rate ratio [MRR] 1.6, [95% CI 1.4-1.8]) and were more likely to die prematurely as a result of suicide, alcohol-related causes, circulatory diseases and motor vehicle accidents. A low educational level appeared to explain these excess risks, except for suicide (adj. MRR 1.5, [95% CI 1.1-2.0]). After adjusting for confounders, the childbirth group faced lower risks of suicide (adj. MRR 0.5, [95% CI 0.3-0.9]) and dying from injury and poisoning (adj. MRR 0.6, [95% CI 0.4-0.8]) compared with women who had undergone abortion. A low educational level is associated with the increased risk of premature death among women with a history of teenage pregnancy, except for suicide. Extra efforts should be made to encourage pregnant teenagers to continue education, and to provide psychosocial support to teenagers who undergo induced abortion.

'Reproductive history patterns and long-term mortality rates: a Danish, population-based record linkage study. Coleman PK, Reardon DC, Calhoun BC. Eur J Public Health. 2012 Sep 5.'

BACKGROUND: Inconsistent definitions and incomplete data have left society largely in the dark regarding mortality risks generally associated with pregnancy and with particular outcomes, immediately after resolution and over the long-term. Population-based record-linkage studies provide an accurate means for deriving maternal mortality rate data.
METHOD: In this Danish population-based study, records of women born between 1962 and 1993 (n = 1 001 266) were examined to identify associations between patterns of pregnancy resolution and mortality rates across 25 years.
RESULTS: With statistical controls for number of pregnancies, birth year and age at last pregnancy, the combination of induced abortion(s) and natural loss(es) was associated with more than three times higher mortality rate than only birth(s). Moderate risks were identified with only induced abortion, only natural loss and having experienced all outcomes compared with only birth(s). Risk of death was more than six times greater among women who had never been pregnant compared with those who only had birth(s). Increased risks of death were 45%, 114% and 191% for 1, 2 and 3 abortions, respectively, compared with no abortions after controlling for other reproductive outcomes and last pregnancy age. Increased risks of death were equal to 44%, 86% and 150% for 1, 2 and 3 natural losses, respectively, compared with none after including statistical controls. Finally, decreased mortality risks were observed for women who had experienced two and three or more births compared with no births.
CONCLUSION: This study offers a broad perspective on reproductive history and mortality rates, with the results indicating a need for further research on possible underlying mechanisms.

'Short and long term mortality rates associated with first pregnancy outcome: Population register based study for Denmark 1980-2004. Reardon DC, Coleman PK. Med Sci Monit. 2012 Aug 30;18(9):PH71-76.'

BACKGROUND: There is a growing interest in examining death rates associated with different pregnancy outcomes for time periods beyond one year. Previous population studies, however, have failed to control for complete reproductive histories. In this study we seek to eliminate the potential confounding effect of unknown prior pregnancy history by examining mortality rates associated specifically with first pregnancy outcome alone. We also examine differences in mortality rates associated with early abortion and late abortions (after 12 weeks).
METHOD: Medical records for the entire population of women born in Denmark between 1962 and 1991 and were alive in 1980, were linked to death certificates. Mortality rates associated with first pregnancy outcomes (delivery, miscarriage, abortion, and late abortion) were calculated. Odds ratios examining death rates based on reproductive outcomes, adjusted for age at first pregnancy and year of women's births, were also calculated.
RESULTS: A total of 463,473 women had their first pregnancy between 1980 and 2004, of whom 2,238 died. In nearly all time periods examined, mortality rates associated with miscarriage or abortion of a first pregnancy were higher than those associated with birth. Compared to women who delivered, the age and birth year adjusted cumulative risk of death for women who had a first trimester abortion was significantly higher in all periods examined, from 180 days (OR=1.84; 1.11 <95% CI <3.71) through 10 years (1.39; 1.22 <95% CI <1.61), as was the risk for women who had abortions after 12 weeks from one year (OR=4.31; 2.18 <95% CI <8.54) through 10 years (OR=2.41; 1.56 <95% CI <2.41). For women who miscarried, the risk was significantly higher for cumulative deaths through 4 years (OR=1.75; 1.34 <95% CI <2.27) and at 10 years (OR=1.48; 1.18 <95% CI <1.85).
CONCLUSIONS: Compared to women who delivered, women who had an early or late abortion had significantly higher mortality rates within 1 through 10 years. A lesser effect may also be present relative to miscarriage. Recommendations for additional research are offered.

'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.
NOTE: The elevated risk from death from circulatory diseased and cerebrovascular disease may be partially explained by a finding that abortion is associated with elevated rates of metabolic syndrome which is a cause of increased cardiovascular disease. See: Association between history of abortion and metabolic syndrome in middle-aged and elderly Chinese women. Xu B, Zhang J, Xu Y, Lu J, Xu M, Chen Y, Bi Y, Ning G. Front Med. 2013 Mar;7(1):132-7.

'"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.

Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: A Natural Experiment in Chile from 1957 to 2007 Koch E, Thorp J, Bravo M, Gatica S, Romero CX, et al. (2012) PLoS ONE 7(5): e36613.

An analysis of maternal mortality rates in Chile over a 50 year period shows that the decline 93% in mortality rates during that time was not hindered by the 1989 laws prohibiting abortion.

The Chilean abortion paradox: Even when prohibited by law, abortion rates decrease

Abortion-related mortality has steadily declined in Chile after its prohibition by law in 1989: "Chile displays a continuous decreasing trend of hospital discharges due to complications of abortions suspected to be illegally induced -represented by specific codes of the World Health Organisation classification- at a rate of 2% per year since 2001. In contrast, a decreasing trend was not observed in hospital discharges due to other types of abortion, such as spontaneous abortion or ectopic pregnancies, which have remained constant during the same period. The high quality of Chilean vital statistics indicates these findings are unlikely to be the result of an artifact of the registry system. Rather, a decrease in hospital discharges due to complications from illegal abortion appears to explain virtually all the reduction in hospital discharges due to any type of abortion in Chile during the last decade."

Women's education level, maternal health facilities, abortion legislation and maternal deaths: a natural experiment in Chile from 1957 to 2007. Koch E, Thorp J, Bravo M, Gatica S, Romero CX, Aguilera H, Ahlers I (2012) PLoS ONE 7(5):e36613. DOI:10.1371/journal.pone.0036613.

Background: The aim of this study was to assess the main factors related to maternal mortality reduction in large time series available in Chile in context of the United Nations' Millennium Development Goals (MDGs).
Methods: Time series of maternal mortality ratio (MMR) from official data (National Institute of Statistics, 1957–2007) along with parallel time series of education years, income per capita, fertility rate (TFR), birth order, clean water, sanitary sewer, and delivery by skilled attendants were analysed using autoregressive models (ARIMA). Historical changes on the mortality trend including the effect of different educational and maternal health policies implemented in 1965, and legislation that prohibited abortion in 1989 were assessed utilizing segmented regression techniques.
Results: During the 50-year study period, the MMR decreased from 293.7 to 18.2/100,000 live births, a decrease of 93.8%. Women's education level modulated the effects of TFR, birth order, delivery by skilled attendants, clean water, and sanitary sewer access. In the fully adjusted model, for every additional year of maternal education there was a corresponding decrease in the MMR of 29.3/100,000 live births. A rapid phase of decline between 1965 and 1981 (−13.29/100,000 live births each year) and a slow phase between 1981 and 2007 (−1.59/100,000 live births each year) were identified. After abortion was prohibited, the MMR decreased from 41.3 to 12.7 per 100,000 live births (−69.2%). The slope of the MMR did not appear to be altered by the change in abortion law.
Conclusion: Increasing education level appears to favourably impact the downward trend in the MMR, modulating other key factors such as access and utilization of maternal health facilities, changes in women's reproductive behaviour and improvements of the sanitary system. Consequently, different MDGs can act synergistically to improve maternal health. The reduction in the MMR is not related to the legal status of abortion.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states. Koch E, Chireau M, Pliego F, Stanford J, Haddad S, Calhoun B, Aracena P, Bravo M, Gatica S, Thorp J. BMJ Open. 2015 Feb 23;5(2):e006013. doi: 10.1136/bmjopen-2014-006013.

OBJECTIVE: To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.
DESIGN: Population-based natural experiment.
SETTING AND DATA SOURCES: Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011.
MAIN OUTCOMES: Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR).
INDEPENDENT VARIABLES: Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence.
MAIN RESULTS: Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates.
CONCLUSIONS: Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.

NOTE: A critique of the above study by Darney et al. titled Maintaining rigor in research: flaws in a recent study and a reanalysis of the relationship between state abortion laws and maternal mortality in Mexico was itself so flawed that the journal Contraception retracted it.

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. Koch E, Aracena P, Gatica S, Bravo M, Huerta-Zepeda A, Calhoun BC. Int J Womens Health. 2012;4:613-23. doi: 10.2147/IJWH.S38063. Epub 2012 Dec 5.

Abstract: In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.

"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.

'Increased mortality among patients admitted with major psychiatric disorders: a register-based study comparing mortality in unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia. Laursen TM, Munk-Olsen T, Nordentoft M, Mortensen PB. J Clin Psychiatry. 2007 Jun;68(6):899-907.'

CONTEXT: Persons suffering from severe mental disorder have an excess mortality compared to persons with no mental disorder. However, the magnitude of the excess mortality differs from one mental disorder to another, and the impact on mortality if a first-degree family member suffers from a mental disorder has never been examined in a population-based study.

OBJECTIVE: Our objective was to examine and compare mortality rates after admission with schizophrenia, schizoaffective disorder, unipolar depressive disorder, or bipolar affective disorder and to examine the impact of family history of psychiatric admission on mortality.

METHOD: We established a register-based cohort study of 5.5 million persons born in Denmark who were alive on or born after January 1, 1973 and alive on their 15th birthday. Mortality rate ratios were estimated by survival analysis, using Poisson regression.

RESULTS: Unipolar depressive disorder, bipolar affective disorder, and schizoaffective disorder were associated with the same pattern of excess mortality. Schizophrenia had a lower mortality from unnatural causes of death and a higher mortality from natural causes compared to the 3 other disorders. Family history of psychiatric admission was associated with excess mortality.

CONCLUSION: Patients suffering from the 4 disorders all had an excess mortality, but the pattern of excess mortality was not the same. There was an excess mortality associated with mental disorder in a first-degree family member, but this only explained a small part of the general excess mortality associated with the 4 mental disorders examined.

Death after legally induced abortion. A comprehensive approach for determination of abortion-related deaths based on record linkage. J D Shelton, A K Schoenbucher Public Health Rep. 1978 Jul-Aug; 93(4): 375–378.

Shelton linked data from the state of Georgia covering an average of eight months after 19,877 abortions. In that case, ten deaths were found, of which eight were related to violent causes (three suicides, two homicides, and three accidents of which one may have been a suicide). The expected number of deaths due to violent causes was 5.7.
The finding of a heightened risk of death from violent causes reported in this small CDC were dismissed by the authors, but in retrospect are consistent with the findings of the Gissler and Reardon studies.
This study did not include a full year follow-up and used a very small sample (only 10 deaths) compared to the thousands of deaths examined by Gissler and Reardon.

Increased mortality among patients admitted with major psychiatric disorders: a register-based study comparing mortality in unipolar depressive disorder, bipolar affective disorder, schizoaffective disorder, and schizophrenia. Laursen TM, Munk-Olsen T, Nordentoft M, Mortensen PB. J Clin Psychiatry. 2007 Jun;68(6):899-907.

Persons suffering from severe mental disorder have an excess mortality compared to persons with no mental disorder. In this study of the population of Denmark, unipolar depressive disorder, bipolar affective disorder, and schizoaffective disorder were associated with the same pattern of excess mortality. Family history of psychiatric admission was associated with excess mortality.

This finding is consistent with the hypothesis that the mental health effects associated with abortion may contribute to the higher rates of mortality associated with abortion.

Childlessness, parental mortality and psychiatric illness: a natural experiment based on in vitro fertility treatment and adoption. Agerbo E, Mortensen PB, Munk-Olsen T. J Epidemiol Community Health. 2013 Apr;67(4):374-6.

Childlessness increases the risk of premature mortality and psychiatric illness. The crude death rate ratio in women who become mothers to a biological child is 0.25 (95% CI 0.16 to 0.39). In other words, childless women seeking in vitro experience a fourfold higher rate of death, that is, 4.02 (2.56 to 6.31). The analogous death rate in fathers is approximately halved: 0.51 (0.39 to 0.68) and 0.55 (0.32 to 0.96) associated with having a biological child and an adopted child, respectively. With substance use disorders being the exception, none of the crude rates of psychiatric illness in parents of a biological child were statistically distinguishable from the rates in the childless.

Childlessness, parental mortality and psychiatric illness: a natural experiment based on in vitro fertility treatment and adoption. Agerbo E, Mortensen PB, Munk-Olsen T. J Epidemiol Community Health. 2013 Apr;67(4):374-6. doi: 10.1136/jech-2012-201387. Epub 2012 Dec 5.

While this study did not examine mortality associated with abortion, it did report a four fold higher risk of death among childless women...which may be affected by abortion rates. Additional analyses is warranted to look at mortality rates among the childless relative to exposure to abortion and miscarriage compared to to women with no pregnancy history.

Legal restrictions and complications of abortion: insights from data on complication rates in the United States. Rolnick JA, Vorhies JS. J Public Health Policy. 2012 Aug;33(3):348-62.

Abstract: Although US federal law requires all American states to permit abortion within their borders, states retain authority to impose restrictions.We used hospital discharge data to study the rates of major abortion complications in 23 states from 2001 to 2008 and their relationship to two laws: (i) restrictions on Medicaid – the state insurance programs for the poor – funding, and (ii) mandatory delays before abortion. Of 131 000 000 discharges in the data set, 10 980 involved an abortion complication. The national rate for complications was 1.90 per 1000 abortions (95 per cent CI: 1.57–2.23). Eleven states required mandatory delays and 12 restricted funding for Medicaid participants. After controlling for socioeconomic characteristics and the pregnancy complication rate, legal restrictions were associated with lower complication rates: mandatory delays (OR 0.79(0.65–0.95)) and restricted Medicaid funding (OR 0.74 (0.61–0.90)). This result may reflect the fact that states without restrictions perform a higher percentage of second-trimester abortions. This study is the first to assess the association between legal restrictions on abortion and complication rates.

Elevated Risk of Death in Later Pregnancies

Marmian (2000): "The Placenta Accreta Spectrum (PAS) includes placenta accreta, placenta increta, and placenta percreta. In 1950, the incidence of PAS was 1:30,000 deliveries, but in 2016, the incidence was reported to be 1:272 deliveries (Mogos et al. 2016). This 110-fold increase in incidence raises the risk of pregnancy-related mortality. Occurring in women with a history of uterine surgery, including induced abortion (Baldwin et al. 2018), PAS can cause massive hemorrhage, and deaths occur even in tertiary hospitals (Klemetti et al. 2012).

Loss of Woman-Years Estimate

According to Gissler (1997), the total age-adjusted mortality rate per 100,000 for a one year period was 58.8 for nonpregnant women, 103.2 for abortion, and 29.4 for birth. Assuming an average life expectancy of 76 for women, and the average premature death occurring at age 28, yields a loss of 2,131 woman-years per 100,000 abortions compared to non-pregnant women, and 3,542 woman-years per 100,000 abortions compared to delivering women. These lost woman-year estimates, however, capture only the losses stemming from excess deaths within the first year of an abortion.

Reardon (2002) examines an eight year period after pregnancy outcome, reporting approximately 300 excess premature deaths per 100,000 women who had abortions (compared to those who delivered) over an eight year period, with an average age of at death of 28. Deducted from the average life expectancy (around 76), this translates to 48 woman years lost per death or a loss of 14,400 woman-years per 100,000 abortions.

Reardon (2012) examines a ten year period following first pregnancy outcomes. This study reports that the excess number of deaths within 10 years was 230 per 100,000 abortions of a first pregnancy. The average age of death was 27.4. Ignoring deaths after the 10 year window, and assuming an average life span of 76 years, this translates to 11,178 woman years lost per 100,000 abortions.

Projecting the latter (11,178 per 100,000) on the estimated 60 million abortions in the United States since 1973, yields an estimated loss of 6,706,800 woman-years.

Projected on the worldwide estimated number of 1.5 billion, yields an estimated loss of 167.7 million woman-years.

Other Peer Reviewed Studies

'The Comparative Safety of Legal Induced Abortion and Childbirth in the United States. Obstetrics & Gynecology. Raymond, Elizabeth G.; Grimes, David A. 119(2, Part 1):215-219, February 2012.'

This is an old-style comparison of nationally reported rates for abortion deaths (absent any standardized method for identifying abortion associated deaths) to nationally reported maternal deaths, which concludes that abortion is 14 times safer than childbirth. Notably, the authors carefully constructed their "review" of the literature to ignore all of record based studies (see above) which contradict their claim that mortality rates associated with abortion are lower than those associated with childbirth. A more complete criticism of this "review" is found in "Rehash of Abortion Safety Claim Ignores All Inconvenient Evidence to the Contrary."

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.

Mortality Elevated by Substance Use & Other Abortion Associated Mental Health Maladies

[http://archpsyc.jamanetwork.com/article.aspx?articleID=2474998&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMAPsychiatry%3AOnlineFirst12%2F23%2F2015 Association of Mental Disorders With Subsequent Chronic Physical Conditions World Mental Health Surveys From 17 Countries] Scott KM, et al. JAMA Psychiatry. Published online December 23, 2015. doi:10.1001/jamapsychiatry.2015.2688

Objective To investigate associations of 16 temporally prior DSM-IV mental disorders with the subsequent onset or diagnosis of 10 chronic physical conditions.
Design, Setting, and Participants Eighteen face-to-face, cross-sectional household surveys of community-dwelling adults were conducted in 17 countries (47 609 individuals; 2 032 942 person-years) from January 1, 2001, to December 31, 2011. The Composite International Diagnostic Interview was used to retrospectively assess the lifetime prevalence and age at onset of DSM-IV–identified mental disorders. Data analysis was performed from January 3, 2012, to September 30, 2015.
Main Outcomes and Measures Lifetime history of physical conditions was ascertained via self-report of physician’s diagnosis and year of onset or diagnosis. Survival analyses estimated the associations of temporally prior first onset of mental disorders with subsequent onset or diagnosis of physical conditions.
Results Most associations between 16 mental disorders and subsequent onset or diagnosis of 10 physical conditions were statistically significant, with odds ratios (ORs) (95% CIs) ranging from 1.2 (1.0-1.5) to 3.6 (2.0-6.6). The associations were attenuated after adjustment for mental disorder comorbidity, but mood, anxiety, substance use, and impulse control disorders remained significantly associated with onset of between 7 and all 10 of the physical conditions (ORs [95% CIs] from 1.2 [1.1-1.3] to 2.0 [1.4-2.8]). An increasing number of mental disorders experienced over the life course was significantly associated with increasing odds of onset or diagnosis of all 10 types of physical conditions, with ORs (95% CIs) for 1 mental disorder ranging from 1.3 (1.1-1.6) to 1.8 (1.4-2.2) and ORs (95% CIs) for 5 or more mental disorders ranging from 1.9 (1.4-2.7) to 4.0 (2.5-6.5). In population-attributable risk estimates, specific mental disorders were associated with 1.5% to 13.3% of physical condition onsets.
Conclusions and Relevance These findings suggest that mental disorders of all kinds are associated with an increased risk of onset of a wide range of chronic physical conditions. Current efforts to improve the physical health of individuals with mental disorders may be too narrowly focused on the small group with the most severe mental disorders. Interventions aimed at the primary prevention of chronic physical diseases should optimally be integrated into treatment of all mental disorders in primary and secondary care from early in the disorder course.

Mortality and life expectancy of people with alcohol use disorder in Denmark, Finland and Sweden. Westman J, Wahlbeck K, Laursen TM, Gissler M, Nordentoft M, Hällgren J, Arffman M, Ösby U. Acta Psychiatr Scand. 2015 Apr;131(4):297-306. doi: 10.1111/acps.12330. Epub 2014 Sep 20

"People hospitalized with alcohol use disorder have an average life expectancy of 47-53 years (men) and 50-58 years (women) and die 24-28 years earlier than people in the general population."

Mortality and potential years of life lost attributable to alcohol consumption in Canada in 2005. Shield KD, Taylor B, Kehoe T, Patra J, Rehm J. BMC Public Health. 2012 Jan 31;12:91. doi: 10.1186/1471-2458-12-91.

Alcohol-attributable mortality and years of potential life lost in Chile in 2009. Castillo-Carniglia A, Kaufman JS, Pino P. Alcohol Alcohol. 2013 Nov-Dec;48(6):729-36. doi: 10.1093/alcalc/agt066. Epub 2013 Jul 5.

Alcohol-attributable mortality in France. Guérin S, Laplanche A, Dunant A, Hill C. Eur J Public Health. 2013 Aug;23(4):588-93. doi: 10.1093/eurpub/ckt015. Epub 2013 Mar 4.

Alcohol-attributable mortality in Switzerland in 2011--age-specific causes of death and impact of heavy versus non-heavy drinking. Marmet S, Rehm J, Gmel G, Frick H, Gmel G. Swiss Med Wkly. 2014 May 20;144:w13947. doi: 10.4414/smw.2014.13947. eCollection 2014.

Excess mortality, causes of death and life expectancy in 270,770 patients with recent onset of mental disorders in Denmark, Finland and Sweden. Nordentoft M1, Wahlbeck K, Hällgren J, Westman J, Osby U, Alinaghizadeh H, Gissler M, Laursen TM. PLoS One. 2013;8(1):e55176. doi: 10.1371/journal.pone.0055176. Epub 2013 Jan 25.

Associations between substance use disorder sub-groups, life expectancy and all-cause mortality in a large British specialist mental healthcare service. Hayes RD, Chang CK, Fernandes A, Broadbent M, Lee W, Hotopf M, Stewart R. Drug Alcohol Depend. 2011 Oct 1;118(1):56-61. doi: 10.1016/j.drugalcdep.2011.02.021. Epub 2011 Mar 26.

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 Simons LA, Simons J, Friedlander Y, McCallum J. Age Ageing. 2012 Mar 29.

Overall, the more kids a woman had, the less likely she was to die during this time.

Compared with women who were childless, death ratesin women with two kids were 17 per cent lower. Death rates were 30 per cent lower among women with five children, and 40 per cent lower in those with six or more kids.

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.