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June 25, 2019
Paula M. Lantz
| Early View, Opinion
A recent “Fact Checker” piece in the Washington Post took to task a claim made by Planned Parenthood President Dr. Leana Wen that “thousands of women died each year” before the 1973 Roe v. Wade ruling that made abortion legal in all 50 states. Glenn Kessler, after assessing “musty academic literature,” gave Dr. Wen’s claim Four Pinocchios, concluding that “even given the fuzzy nature of the data and estimates, there is no evidence that in the years immediately preceding the Supreme Court’s decision, thousands of women died every year in the United States from illegal abortions.”1
Fact checking dramatic claims made by advocates and politicians serves a useful public purpose because numbers and evidence are too often misused in the policy process. However, the intentional misrepresentation of data and statistics for advocacy purposes or political gain is quite different from the challenge of raising awareness about a serious, clandestine problem in the absence of high-quality, accurate data. It is unfair for Kessler to shout “Liar!” when the exact number of abortion-related deaths over five decades ago is unknowable and there is credible evidence of a significant toll before 1967, when states started to legalize abortion under certain circumstances.2 The obvious and valid point being made by Dr.Wen is that when abortion is illegal and unsafe, women can and do die.
Kessler’s exercise is also misguided because it myopically focuses on the past. A more important question is how many women will die or experience devastating health and social welfare outcomes because of a new policy regime that makes most abortions illegal and severely restricts its access? The public policy landscape regarding women’s reproductive health services is changing rapidly.3 Instead of worrying about how best to count deaths from the distant past, public health experts should quickly agree upon and implement the best scientific methods for documenting the effects of a new wave of restrictive reproductive health policies.
Some very important and common public health problems are extremely hard to measure at a population level. Examples include the incidence of intimate partner violence, the prevalence of depression and homelessness, and deaths from secondhand smoke and medical errors. Public health researchers have the responsibility to design rigorous approaches for producing valid estimates, and in doing so, to be transparent about the methods used (including the assumptions and limitations) and the degree of confidence around the results.
The recent controversy regarding the number of deaths in Puerto Rico from Hurricane Maria in 2017 provides a relevant lesson. The initial government death estimate for the island was 64, while recognizing the challenges of counting deaths in the absence of electricity, communication systems, and coroner services. However, an independent assessment conducted by public health researchers put the death toll at 2,975 in the six months after the storm.4 While the Trump administration criticized the methodology as biased and the findings as partisan, the official estimate from the Puerto Rican government was eventually revised to 2,975.
An ad hoc committee, convened through the National Academy of Medicine and composed of experts from multiple disciplines, is currently preparing a consensus report that reviews the current state of the science and identifies best methodological practices assessing mortality and significant morbidity following large-scale disasters.5 In the chaotic aftermath of a natural disaster, having scientific guidance from a nonpartisan entity should serve to produce better data and estimates, improve disaster relief responses, and reduce politically driven controversy.
Such a consensus process is also needed for best practices in assessing the mortality and significant morbidity resulting from public policies that severely restrict the parameters for legal abortion. All 50 states are expected to consider some type of new abortion legislation during 2019. Through May 2019, eight states had passed bans on abortion after detection of a fetal heartbeat or had otherwise significantly lowered the gestational age for pregnancy termination, and Alabama had in effect, enacted a total ban.3 In addition, the March 2019 new “Final Rule” for the Title X Family Planning Program prohibits any funded entity—including Planned Parenthood clinics—to perform, promote, discuss, or refer for abortion.
All of these policies are currently facing lengthy court challenges and some might not stand.3 Even so, there is no question that women’s access to abortion and other important reproductive health services is under siege, and that many of the more than 2 million US women who find themselves in the situation of an unintended pregnancy each year will face restricted legal access to an abortion.
It is highly unlikely that the number of deaths due to new abortion prohibitions will reach the levels from prior to Roe v. Wade.2 However, deaths from abortion are certainly probable through multiple mechanisms stemming from unsafe/underground procedures and/or lack of timely and appropriate medical attention to complications because of fear of investigation and prosecution. This includes risks from uterine perforation/puncture, cervical tears, blood clots, hemorrhaging and infection from multiples causes, and complications from medication abortions which could also lead to death. Suicide among women unable to obtain a legal abortion, although rare, is possible.
In addition, reduced financial and physical access to the important services provided by Title X program clinics that refuse to comply with the new rules—including sexually transmitted infection/HIV screening and treatment, breast and cervical cancer early detection services, family planning, and intimate partner violence counseling—also will lead to significant morbidity and some mortality among women. Efforts should be made to include a wide range of health outcomes in the surveillance and evaluation of restrictive reproductive health policies.
There is an important literature on research methods for estimating maternal mortality in developing countries, of which unsafe abortion is a leading cause.6 In a 2013 systematic review of 36 studies of mortality related to unsafe abortions, Gerdts, Vohra, and Ahern found a lack of standardization of terms across studies, and research challenges related to inadequate reporting systems and data availability, quality, and access.6 Despite significant limitations, the research efforts to date from countries with a high prevalence of unsafe abortion will be instructive for efforts to estimate abortion-related morbidity and mortality in the United States.
Assessing the burdens, opportunity costs, and unintended consequences of public policies is a standard practice inherent in good policy analysis and evaluation. Therefore, it is in society’s best interest for experts to convene and reach consensus on the best methods for producing nonbiased, valid estimates of the death and severe morbidity toll from restrictive abortion policies in the United States. This is critically important because we know that when abortion and other reproductive health services are severely restricted, women do suffer and die. Their families and communities suffer as well. The numbers represent real people, are important regardless of ideology, and deserve to be known, believed, and respected.
Paula Lantz, PhD, MS, MA, is the associate dean for academic affairs and a professor of public policy at the Ford School of Public Policy at the University of Michigan. She also holds an appointment as professor of health management and policy in the School of Public Health. Lantz teaches and conducts research regarding the role of social policy in improving population health and reducing health inequities. She is currently leading a project regarding the potential for and challenges associated with using social impact bonds to finance interventions aimed at upstream social determinants of health. An elected member of the National Academy of Social Insurance and the National Academy of Medicine, Lantz received an MA in sociology from Washington University, St. Louis, and an MS in epidemiology and PhD in social demography from the University of Wisconsin.
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