Refuting Elard Koch’s errors and distortions

Note: This piece contains information supplementing my 2012 article: Anti-choice Researchers in Chile try to disappear illegal abortion - and  women who die from it. It has been updated several times since then, with Addendums appearing at the bottom. 

by Joyce Arthur

First published June 1, 2012 (links updated July 22, 2017)

The following refutes several egregious errors and falsehoods in Dr. Elard Koch's rebuttal to the Guttmacher Institute (published May 25, 2012 at PLOS ONE). 

Illegal abortions still common in Mexico

Koch grossly underestimates the number of abortions in Mexico by playing fast and loose with the facts. He wrongly compares Guttmacher’s previous estimated illegal rates for all of Mexico (between 700,000 and 1 million), to today’s officially reported legal rate for only Mexico City (just over 20,000 in 2011). Mexico City is the only area in the entire country where abortion on request is legal. Less than 20% of Mexicans live in the capital, and most women from other states would be too poor to be able to travel to the capital, which means they are still having unreported illegal abortions in their own communities. But even in Mexico City, legal access is still limited, leading many women there to continue resorting to illegal abortion. Further, only public sector abortions are counted in official numbers, not legal abortions done in the growing private sector.  

Increases in abortion after legalization to be expected

Koch complains that legalization causes an increase in abortions, but this reflects an anti-choice belief that denies the positive and obvious reasons for such increases. It also stems from Koch’s stubborn refusal to acknowledge the prevalence of illegal abortion. Common sense dictates that after legalization, reported legal abortions will begin to replace the previous non-reported illegal abortions. Since it takes time to ramp up services after legalization, of course numbers will increase for a few years as access improves. But if all goes smoothly and especially if contraception also becomes increasingly accessible, legal abortion numbers will eventually stabilize and start to go down. That pattern is now well-documented for most western countries.

Overreliance on official statistics and unwarranted dismissal of evidence that doesn’t fit anti-choice ideology

Koch’s trust in the accuracy of Chile’s maternal death registry is based on faith, not evidence. In a criminalized regime like Chile, there is good reason to believe that many healthcare workers misreport the cause of death when women die in hospital from complications of illegal abortion, since women themselves (or a family member) would be highly motivated to lie to medical personnel about what happened when they arrive at the hospital, to protect themselves from prosecution. Healthcare workers are required to report women who have illegal abortions. While many would likely not ask too many questions and record the complication or death as a result of spontaneous abortion (going along with the woman's story in other words), some women are still being turned in by health workers to face arrest and a possible jail sentence, at least they were as recently as 2007. A 2010 article on abortion in Chile by researchers Shepard & Becerra notes: “More than 99% of abortions are not reported at all, disguised as a different procedure, or reported as spontaneous abortions in public hospitals.” They state the reason for the latter: “To protect both women and hospital staff from prosecution, hospital patient data reported to the Ministry of Health do not differentiate between spontaneous and induced abortion.”

Guttmacher cited this Shepard & Becerra article in its Advisory Review, but Koch dismisses it, as well as another study in Spanish cited by Guttmacher. He refers to them as “mere opinions without any epidemiological evidence or quantitative data supporting such claims.” The context for that comment is a discussion of women's illegal use of misoprostol to induce abortions, in which Koch summarily dismisses the possibility that misoprostol might be contributing to a decrease in maternal mortality, again because of an alleged lack of hard evidence. However, self-use of misoprostol by women is an obvious and highly promising way to reduce abortion-related complications and deaths, because of its relative safety over other traditional clandestine methods. Further, Koch asserts that "no study currently exists to date, that seriously supports a decline in maternal mortality associated with the use of abortifacient drugs such as misoprostol in Chile," while ignoring studies from countries such as Brazil that demonstrate exactly that.

I believe that Koch's practice of rejecting out of hand any data sources he deems invalid reflects an ideological desire to cover up evidence of widespread illegal abortion. For one thing, he chooses to ignore official statistics that don’t fit his ideology. The above-noted Spanish study that he discards as “mere opinion” used the following official sources to determine maternal causes of death: “Clasificación internacional de enfermedades, traumatismos y causas de defunción, CIE-9” (International Classification of Diseases, Injuries and Causes of Death, ICD-9) and the “Anuarios del Instituto Nacional de Estadísticas de Chile” (Yearbooks of the Chile National Institute of Statistics). The latter is apparently the same (and only) source that Koch used for his PLOS ONE study. But based on those two sources, the Spanish study determined that abortion was the second-leading cause of maternal death in Chile between 1990 and 2000, with 19.1% attributed specifically to “induced illegal abortion”, 73.6% to “unspecified abortion,” and 6.2% to “spontaneous abortion.”  Note that these figures are from after 1989, the year Chile's abortion law was tightened to eliminate the exception to save the life of the woman. So even while Chile's maternal mortality rate was still declining in the 1990's, women were still dying from illegal abortion, which simply means that the decline would have been even steeper if abortion was safe and legal.

Koch has not explained why alternative methods of collecting data (besides his preferred statistical sources) on maternal deaths from illegal abortion should be considered entirely worthless. He has no grounds for totally dismissing them, since other ways must necessarily be found to measure the incidence of illegal abortion and resulting deaths and complications (which include for example, surveys of women, surveys of specific healthcare facilities, and interviews with healthcare workers). His dismissal of the data these methods produce amounts to a gratuitous slur against the hundreds of reputable scientists and researchers who spend large amounts of time carefully gathering, comparing, and adjusting such data under challenging circumstances.

Small numbers of pre-1989 legal abortions in Chile. 

Koch asserts that the pre-1989 abortion law in Chile, which allowed abortion only to save the woman’s life, was often interpreted liberally. Yet he can only cite a single documented case of 3,000 abortions being performed “on request” at one hospital in Santiago in 1973. In reality, liberal interpretations of the law did not appear to be common, and Koch himself explains that: "Flexible interpretation of the practice of ‘therapeutic’ abortion was progressively restricted and prosecuted until the definitive derogation of all types of abortion in 1989." A statement in the Koch et al study's AppendixS1 clarifies further: "It is documented that an undetermined number of elective abortions were conducted by several medical doctors utilizing the latter law [in force from 1967-1989], but this practice seemed to be strongly restricted after 1973 by the military government until the definitive derogation in 1989." (emphasis added)  Therefore, Koch has refuted his own conclusion that the 1989 abortion ban “meant a major transition from a partially restrictive to a fully restrictive law in practical terms,” because legal abortion was already very rare many years before 1989. In fact, this falsifies the central claim* in Koch et al’s PLoSONE study, as stated in the final two sentences of the conclusion: "Finally, prohibition of abortion in Chile did not influence the downward trend in the maternal mortality ratio. Thus, the legal status of abortion does not appear to be related to overall rates of maternal mortality." In reality, the new law would not have led to any noticeable difference in maternal mortality rates anyway. The number of reported legal abortions had already dropped to miniscule proportions by 1989, and the illegal abortion rate would have remained about the same as before.

It's also worth noting that since the pre-1989 law allowed abortions only to save the woman’s life and required the approval of two doctors, it’s highly unlikely that large numbers of Chilean women would have even attempted the process, let alone succeeded at it – especially poor, indigenous, uneducated, rural, and other marginalized women with few resources. Such common-sense considerations seem to be beyond Koch, because of his insistence on considering hard data and nothing else.

(* I call this the central claim because we hardly need a study to determine that declines in maternal mortality would be associated with higher education for women, improved access to health facilities and doctors, nutrition programs, clean water, skilled birth attendants, and similar factors. Such findings are already well-documented elsewhere and are pretty much self-evident. Therefore, I believe the authors' focus on those factors serves as a smokescreen to help conceal the study's true agenda, which is political and ideological - part of an anti-choice campaign to ensure that abortion stays criminalized throughout Latin America.)

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One of the most offensive things about Koch’s insistence that illegal abortion does not negatively impact women’s health is that it throws under the bus the most vulnerable groups of women who have little power or voice in society, and who resort to illegal abortion the most. But the most offensive thing of all is that, because maternal deaths from illegal abortion do appear to be quite low in Chile (compared to other developing countries), Koch seems to think it's acceptable that those few should be sacrificed unnecessarily under Chile's harsh criminal laws, and that the rest – anywhere from 40,000 to 200,000 a year according to various estimates – should continue jeopardizing their health and lives, not to mention arrest and imprisonment, and all the upheaval and psychological trauma that these things entail, just because they needed an abortion - an action taken by half of all women around the world to protect their lives, families, and futures. 

In my opinion, based on the above analysis and my published rebuttal, Koch's anti-choice advocacy as a privileged male academic in Chile is an irresponsible abuse of power that puts women's lives and health at risk – not just in Chile, but throughout Latin America wherever abortion is mostly illegal.

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Addendum, July 30, 2012:  Guttmacher has published a rebuttal to Koch et al's attack on Guttmacher's methodology for estimating the number of illegal, unsafe abortions in Latin American countries:   Summary   •   Detailed rebuttal   Guttmacher says: "The Koch et al. critique is characterized by pervasive distortions of Guttmacher's methodology, and their proposed alternative methodology is based on scientifically unsound and illogical assumptions and contains such serious errors that its results are not valid."

Addendum October 2012:  During the CEDAW review of Chile's record on women's rights, including questions to the Chilean delegation on its abortion laws, the Chilean delegation was disingenuous in its claim of a low mortality rate due to abortion, and greatly exaggerated the availability of contraception

On Oct 2, 2012, the UnitedNations Committee on the Elimination of Discrimination against Women (CEDAW)considered the combined fifth and sixth periodic report of Chile on how that country is implementing the provisions of the Convention on the Elimination of All Forms of Discrimination against Women. When questioned by CEDAW experts on its abortion legislation, the Chilean delegation claimed that "Therapeutic abortion was allowed in Chile, and could be carried out by a doctor if the woman’s life was at risk." (emphasis added) The word "could" is a grasping-at-straws hypothetical. In fact, no exceptions are allowed under the law and few doctors would dare risk prosecution by causing an abortion, even if unintended. Moreover, the claim that unintended abortion may occur in order to save a woman’s life rests on the immoral ideology that doctors must wait until a pregnant woman’s life or health is already put at risk or seriously compromised before she receives any healthcare that may endanger the fetus.

The Chilean delegation also claimed (paraphrased in the report): "Maternal mortality due to abortion only amounted to between six to ten women per year. Over 50 per cent of those deaths were due to identifiable causes, and 47 per cent were due to non-identifiable causes. In Chile abortion was illegal so any death due to abortion fell within that 47 per cent. The Government had passed a law to provide contraceptives, including emergency contraceptives, in order to ensure wider distribution guaranteed by law. Any person refusing to provide emergency contraceptives would be committing a criminal offence, and technical guidelines were distributed to health centres on how to help women who had had an abortion, relating to privacy and other related reproductive health services. Although abortion was criminalized there had been no sanctions in the reporting period."

The Chilean delegation is being disingenuous in its claim of a low mortality rate due to abortion. As explained previously, deaths from abortion are almost certainly underreported to at least some degree, while much of the morbidity from induced abortion would be hidden under the "unspecified abortion" loophole in order to protect patients and staff from prosecution. Regardless, even 6-10 deaths a year is 6-10 more than necessary, since these could all be eliminated if abortion was legal.

As for the alleged wide availability of contraception, that too turns out to be a hugely exaggerated claim. An April 2012 article from Chile's Santiago Times [no longer available online] quotes Dr. Beatriz Salgado, a general practitioner at the Department of Public Health at the Universidad de Valparaíso. She explained that sexual health is a taboo topic in Chile, and contraceptive methods are both expensive and often difficult to access. The article states: "In 2008 a constitutional court struck down attempts to make the distribution of the morning after pill free. Two years later Congress finally ruled that the morning after pill had to be freely distributed by the public health system, but young girls who need the pill must be accompanied by one of their parents. Many pharmacies still refuse to stock the morning after pill for religious or moral reasons." Dr. Salgado believes most of the decline in maternal mortality in Chile is due not to good contraceptive use, but because of increasing numbers of women successfully self-administering misoprostol.

Interestingly, the Chilean delegation claims that no one has been prosecuted for abortion during CEDAW's previous two-year reporting period (2010-2012). With at least 40,000 abortions a year (and as many as 200,000), either doctors and patients are becoming very adept at evading the long arm of the law, or Chile is no longer enforcing its criminal abortion law - maybe out of embarrassment after years of being pilloried in the international press for throwing women into jail? 

Addendum, December 14, 2012:  Guttmacher criticizes Koch for recycling his disproven claims about Guttmacher's methodology: Everything Old Is New Again—Debunked Criticism of Guttmacher Methodology Resurfaces 

Addendum November 13, 2014:  Rewire has published a "False Witnesses" series documenting anti-choice activists and researchers who have published false information designed to mislead the public, lawmakers, and the courts about abortion. One piece exposes Elard Koch for his "Signature Falsehood": That making abortion illegal does not result in more maternal deaths.  Rewire says: "The overwhelming evidence from reputable scientists and organizations, including the World Health Organization, is that there is a direct link between illegal abortion and higher maternal death rates."