Study Still Dead After Resurrection Attempt Fails

Published at BMJ Open on October 26.
The version below is longer and uncut.

The August 11 response of Dr. Elard Koch and several co-authors fails to rectify the two major flaws in their study that I exposed in my April 9 rebuttal, and in fact, further confirms those flaws. Their very lengthy response also ignored many of my arguments and repeated many of their disputed points.

This reply explains why those two major errors remain fatal to their study’s conclusions. I then address the question of anti-abortion bias, which I believe played a key role in the flawed design of the study. To be fair, I also address my own biases. Finally, I deal with several ancillary issues arising from Koch et al.’s response (for those interested to read on).

Fatal Flaws Are Still Fatal

My rebuttal had explained that abortion law was not related to abortion practice in Mexico, and that this invalidates the study’s methodology and conclusion. That’s because you can’t hypothesize a possible effect on abortion mortality based on the existence or absence of various legal exemptions across Mexican states, when those exemptions don’t even work. In practice, few Mexican women can access abortions under the legal exemptions. In response, Koch et al. confirmed this flaw by saying: “…between states, legal permissiveness may be the same, but accessibility may differ by multiple unmeasured factors. We do not say nor have we stated that we are using this term as a proxy for greater or less accessibility to pregnancy termination…” But their failure to account for the difference between law and practice is the flaw. Their methodology implicitly assumed that abortion restrictions reflect abortion practice, but since they now concede that’s not the case, their conclusion that maternal mortality is unrelated to the presence or absence of certain abortion restrictions is meaningless.

I had shown that it was arbitrary and erroneous to select, in particular, the legal exemption for abortion in cases of genetic or congenital malformation as the criterion for assigning Mexican states to the categories of “more permissive” or “less permissive” abortion legislation, depending on whether the state had that exemption. The rarity of abortion for fetal abnormality makes this variable useless as a proxy, because the miniscule numbers of maternal deaths that may result would be impossible to detect statistically in order to compare states with and without the exemption. The authors’ only response is to argue that such abortions may be slightly less rare than I claim, based on the low prevalence of Down syndrome at birth in several other countries. But that has nothing to do with Mexico or the fact that abortions for any kind of serious fetal abnormality are in the range of 1% of all abortions in countries where abortion is widely legal. So their error remains, especially since abortions due to fetal abnormality are likely even rarer in Mexico than in western countries because of its restrictive laws, inaccessibility of legal abortion under the exemptions, profound stigma, and physician refusals.

The authors say that exploratory analyses are “valid and valuable tools to avoid an arbitrary categorization.” But somehow, that’s exactly what they ended up with. The authors confirm their flaw by explaining that they selected the legal exemption for fetal abnormality as the main variable because it was the only one that yielded an association with maternal mortality, as well as the only one where the 32 Mexican states had a roughly equal distribution in terms of whether they had the exemption or not. In other words, the variable was arbitrarily selected on the basis of convenience and because it happened to yield an association that I’ve already shown is meaningless. (Correlation does not equal causation.) A random association is easy to find if you conduct a fishing expedition for one amongst a host of variables, but one should not then base an entire study on it and draw conclusions from it.

Author Bias

My April rebuttal in the BMJ Open was incomplete because I removed a section entitled “Credibility of Authors in Question” at the request of the editors. However, the full version had already been published at RH Reality Check and I linked to it in my BMJ Open response. Koch et al. appear to have ignored this version, which also has more links to references.

After reading Koch et al’s reply, it became even more apparent to me that an anti-abortion bias had infected the study’s methodology and conclusion. This bias must be addressed, despite the authors’ efforts to take sanctuary under the mantle of scientific objectivity. In fairness, I will also disclose and attempt to justify my own biases.

Nine out of ten authors of the BMJ Open study had an undisclosed bias because they are signatories to the “Dublin Declaration.” This document denies the need for legal abortion even to save a woman’s life. Further, Koch himself and three of his co-authors were named as “False Witnesses” last year in an investigative series carried out last year by RH Reality Check, because they had “pushed false information designed to mislead the public, lawmakers, and the courts about abortion” in their previous research or public statements. The peer review process for their BMJ Open study failed to catch the substantive errors in the study because neither peer reviewer had expertise in the subject matter, and one (R. Lieva) appears to hold the same anti-abortion bias as the authors.

The study contains repeated citations (over 30) of the authors’ own past research on abortion and lists over a dozen references from Koch and various co-authors (including peer reviewer R. Lieva), as if their work is equally legitimate to mainstream research. The effect is to create a false picture of scientific confusion and conflicting data in the abortion field. This same pattern is repeated in their reply to me, even though several of their studies have been debunked. (Here’s a compendium of rebuttals to their work.)

Koch et al. have gone to great lengths (in this and other studies) to try and show that factors such as access to emergency obstetric care have the greatest apparent impact on maternal mortality, not abortion laws. But their focus on maternal deaths, while important, obscures all the other suffering and harms that criminal abortion laws cause to women, including high complication rates from unsafe abortion (about 159,000 women are hospitalized annually in Mexico). The implication is that we should accept this human cost as long as good health care systems can save women’s lives in the end. Presumably the authors would disagree, and hopefully their implication was unintentional, but it shows what can happen when bias infects a study.

Based on my reviews of the BMJ Open study and previous Koch-led studies on abortion in Latin America, I believe that the underlying, unstated objective of Dr. Koch and at least some of his co-authors is to promote the idea that abortion does not need to be legal. Although Koch et al. pointed out that they made no recommendation in their study on the legal status of abortion, they don’t need to. The anti-abortion movement does it for them by turning their conclusions into political soundbites claiming that legalizing abortion does not save women’s lives. In effect, their studies serve as a dog whistle to anti-choice activists.

Given the overwhelming global and historical evidence of the danger posed to women by criminal abortion laws, any study conducted by Koch et al. that concludes that restrictive abortion laws do not contribute to maternal mortality should be treated with suspicion.

But let me turn now to the question of my own biases, since Koch et al. would presumably claim that I’m the one who’s biased, as well as unscientific. This is apparent from the authors’ near ad hominem treatment of my criticisms, dismissing them as “based largely on personal opinions or speculative assumptions,” and “not scientifically based.” I’m a writer and pro-choice activist, not a scientist. I do not apologize for my impassioned defense of women’s rights and lives, or for my ability to recognize and expose the authors’ co-opting of scientific methods to disguise an anti-abortion agenda. I’ve been monitoring the anti-choice movement for 25 years and Koch’s work for 3 years.

For the record, I did not have “discomfort” with the study’s findings, because I recognized the study methodology and conclusions were deeply flawed. However, I did feel offended by the study. I object to its very premise and even that it was published in a reputable scientific journal where it does not belong. Please allow me to explain.

I have a bias in favour of the belief that women deserve equality, human rights, and dignity. I also have a bias against criminalizing life-saving healthcare that only women need. Should such biases, if expressed, lessen my credibility or weaken my arguments? If so, it must be because it’s still up for debate whether women deserve human rights and freedoms, including the fundamental right to control their fertility. Koch et al. are ultimately relying on the fact that there’s still significant controversy over women’s rights in many countries – especially abortion rights – and it might explain why they were able to publish such a study in the first place.

The clear message of their study – not stated by the authors of course, but spread by the anti-abortion movement – is that it’s not necessary to legalize abortion in order to reduce maternal mortality.

Well, let’s consider this analogy: What if some researchers had conducted a near-identical study with the same methodology, but instead of looking for a random association between restrictive abortion laws and reduced maternal mortality, they looked for a random association between black segregation and improved health outcomes for black people? Would such a study have been published? I think not. But unlike the near-universal opposition to racism in our societies, sexism is still mainstream.

In my opinion, Koch et al’s study in the BMJ Open is not much different from a study that would document good living conditions in black ghettoes in order to leave the impression that it would be justified to keep black people locked up in them. Such a study would be highly offensive, no matter how scientifically conducted. I find it equally offensive when studies do the same thing to support the continued criminalization of women’s healthcare. And I object to reputable journals publishing studies with the premise that depriving women of their rights may not be harmful and could even be beneficial for them. 

Addendum: Ancillary Issues

Unsafe Abortion as a Contributing Factor to Maternal Mortality:

The authors protest my “unsubstantiated and dissociated” suggestion that they are using other contributing factors to maternal mortality as a smokescreen to cover up the effect of unsafe or illegal abortion. Their objection is largely answered by my points above on author bias.

Further, I believe the authors are being disingenuous when they say they want to emphasize the other factors that contribute to women suffering and dying in childbirth from preventable causes. Rather, they appear to be primarily concerned with abortion. Their study’s title begins with “Abortion legislation” as the key factor. The study objective is: “To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health.” Their press release for the study opens with: “Laws protecting the unborn and therefore, less permissive in regard to abortion, bear a negative …connotation, because induced abortion in clandestinity might increase maternal deaths. However, a new study conducted in 32 Mexican states …challenges this notion…” And most of their other research focuses on abortion.

Of course, many factors contribute to maternal mortality, and many effective ways exist to address it. But as I said in my rebuttal, this range of other factors could swamp the effect of unsafe abortion on maternal mortality rates and make it harder to detect statistically, particularly if a country’s mortality rate from unsafe abortion is relatively low compared to other countries. The study methodology the authors employed was almost guaranteed to find no meaningful association anyway, which allowed them to present their foregone conclusion that abortion laws don’t affect maternal mortality.

Clandestine abortion is still a major cause of maternal mortality in many parts of the world, particularly in Africa and Asia. It is unusual for developing countries with strict bans on abortion to have relatively low maternal mortality rates. In such countries (like Chile and a handful of others in Latin America), other factors indeed play an important role including widespread use of misoprostol – however, maternal mortality would almost certainly be even lower if abortion was legal, safe, and accessible. Regardless, complications from unsafe abortion remain high throughout Latin America and the Caribbean, with over one million women hospitalized annually – 159,000 in Mexico alone during 2009. This demonstrates that restrictive abortion laws continue to pose a great danger to women in Mexico, even if fewer are dying than in the past.

By the way, Koch et al. said they “reanalyzed” the 2012 study by Schiavon et al. that found a significant proportion of maternal mortality in Mexico (7%) was due to unsafe abortion, and claimed it was flawed. But Koch et al. fail to mention that their reanalysis was debunked.

Issues with Vital Statistics for Abortion Deaths:

The authors’ arguments that Mexico does not have a problem with underreporting or misclassification of abortions and associated mortality are unpersuasive. They put a lot of faith in vital statistics from the Mexican government – their only source – but it’s unlikely that government statistics are as robust and accurate as they claim. The authors can only cite their own research as support. I found mentions in several studies (listed below) about the problems of misclassification and underreporting associated with the use of vital statistics when it comes to abortion, even in countries like Mexico that have otherwise high-quality records for maternal mortality.

In settings like Latin America where abortion is mostly illegal and highly stigmatized, women and their families would be more likely to not report or misreport an abortion, and health care personnel would be more likely to misclassify causes of death out of ignorance, fear, or compassion. For example, even with the existence of specific ICD codes for “Abortive Outcomes” (ICD-10 O00 to O08), why should we exclude the possible misclassification of unsafe abortion deaths under the codes for sepsis or hemorrhage in early pregnancy (ICD-10 O20 and O23)?

Vital statistics should not be relied upon alone to determine maternal mortality from unsafe abortion. Reputable studies employ a variety of sources and methods, including studies, hospital data, various types of surveys, and more. For no valid reason, Koch et al. neglect and dismiss these additional methodologies, while their own narrower methodology for estimating abortion incidence has been debunked.

Recent studies on maternal death from unsafe abortion do not support Koch et al’s claim that the rate for Mexico is as low as 3% of all maternal mortality. Before looking at these other figures, it’s important to understand that studies and official statistics on maternal mortality rates and causes do not always distinguish adequately between deaths from induced abortion and spontaneous abortion (miscarriage), or even other “abortive outcomes” such as ectopic or molar pregnancies and other “unspecified” complications. However, we know that maternal deaths from miscarriage, legal abortion, and molar pregnancy are all very rare, at least in settings with reasonable access to health care. While ectopic pregnancies carry a higher risk of death, they are far less common than abortion or miscarriage. Therefore, the majority of officially-recorded abortion deaths in countries with restrictive laws are plausibly due to unsafe induced abortion, including many coded under other “Abortive Outcomes.”

The following studies provide rates of maternal mortality due to abortion in Latin America and/or Mexico. The data for Mexico appear to be sourced from vital statistics only, except for #3, which also cites the WHO Mortality Database (in the study’s Appendix).

1. The Schiavon et al. estimate for Mexico was 7% for 2008.
2. A May 2014 global analysis by the World Health Organization (WHO) provided an estimate of 9.9% for Latin America and the Caribbean. For Mexico, the study shows a rate of almost 8% as denoted on a bar graph in the Appendix, page 37.
3. A September 2014 study by IHME, the Institute for Health Metrics and Evaluation, shows in bar graphs an average rate of about 17.5% for Latin America and the Caribbean in 2013 (Figure 6), and a rate of about 11% for Mexico (Appendix, page 127).

Why are these data from Mexico (7%, 8%, and 11%) higher than Koch et al’s estimate of 3%?  It appears it’s because Koch et al. excluded ICD-10 codes O00, O01, O02, and O08 (respectively: ectopic pregnancy, molar pregnancy, other abnormal products of conception [including missed abortion], and complications following abortion and ectopic and molar pregnancy). Excluding these codes could omit many unsafe abortion deaths that were misreported or misclassified.

Global Rates:  The oft-cited 2008 WHO figure of 13% for global maternal mortality due to unsafe abortion should be retired due to the new WHO analysis (#2 above). That study provides a figure of 7.9% globally for 2003 to 2009, with the reduction due to the use of recent data and improved methods. I would suggest that the reduced figure may also reflect the increased use of safer medical abortion by women in some regions.

Using a somewhat different methodology, the IHME study (#3 above) yields an estimate of about 15% global maternal mortality from abortion in 2013 (see Table 2, page 995). However, that 15% figure includes late maternal deaths (43 days to 1 year after delivery), which the WHO does not include in its unsafe abortion mortality estimate. Excluding late maternal deaths, the IHME figure for global maternal mortality from abortion is actually 18%. The significant variance with the WHO figure of 7.9% is unexplained and it remains unclear which is closer to reality. (The IHME figure is plausible if we hypothesize that the proportion of deaths by unsafe abortion has increased because of far greater reductions in other causes of maternal mortality, compared to unsafe abortion.) An independent review by the Guttmacher Institute (requested by myself) found that the two estimates differed "with respect to data sources used, types of abortions included, analytic methods employed, reference periods to which the estimates refer, and whether adjustments were made for likely underreporting or misreporting of abortion deaths." (Guttmacher Institute, pers.comm, Oct 5, 2015).  [Note: Section in blue added/edited after BMJ Open submission]

Incidence of Unsafe Abortion:  This report was the source for my figures on the significant number of unsafe abortions and complications in Mexico (over a million abortions a year, and 159,000 hospitalizations). These numbers are higher than the estimates from Koch et al. because the latter are based only on vital statistics data, which is insufficient.

Medical Abortion:

The authors state: “It is self-contradictory to say that unsafe abortions have increased substantially over the last decades while observing substantial reductions in deaths from this cause.” Unsafe abortions have increased globally in recent years but not substantially (from 19.7 million in 2003 to 21.6 million in 2008). But in Latin America, unsafe abortions decreased by a third between 1990 and 2008, and maternal mortality went down 70%.

This dramatic reduction in maternal deaths coincides with the widespread availability of medical abortion (using misoprostol) in Latin America over the last two decades. In contrast, maternal mortality from unsafe abortion remains high in regions where misoprostol is not as easily attainable, such as Africa. This suggests that misoprostol plays a significant role in reducing women’s deaths.

Several studies and reports (such as this one) also attribute the reduction in maternal deaths in Latin America to the increased use of medical abortion. This method has largely replaced more dangerous traditional methods, although it can still lead to a high rate of mostly non-lethal complications when used without medical supervision.

Koch et al. are unsatisfied however, and want to see an epidemiologic study with evidence that misoprostol decreases unsafe abortion mortality “independently of other major factors such as access to emergency obstetric care.” This seems to be an unreasonable expectation given the swamping effect those factors would have on the detection of unsafe abortion mortality, especially if the study plugs in artificially low death rates from abortion.

One also wonders at the reluctance of the authors to accept anything but the most rigorous direct evidence for the role of misoprostol in improving the safety of clandestine abortion. Could this be related to Koch et al’s past (discredited) attempts to show that rates of illegal abortion in Latin America have been grossly overestimated? The allegation that the high numbers of illegal abortions are exaggerated or even made-up is common propaganda in the anti-abortion movement. Such a belief would conflict with evidence for a dramatic reduction in maternal mortality due to a switch to a safer clandestine method. Incidentally, it could also motivate anti-abortion researchers to design studies “proving” that restrictive abortion laws don’t increase maternal deaths.

Repeal All Abortion Restrictions

No country needs to regulate abortion via criminal or civil law. All anti-abortion laws and restrictions, throughout the world, should be repealed as unconstitutional violations of women’s rights and equality.

Anti-abortion laws kill and injure women, violate their human rights and dignity, impede access to abortion, and obstruct healthcare professionals. All abortion restrictions are unjust, harmful, and useless because they rest on traditional religious and patriarchal foundations. Only when abortion has the same legal status as any other health procedure can it be fully integrated into women’s reproductive healthcare.

Laws against abortion do nothing to stop abortion.

Every year, about 19 million desperate women seek out illegal abortions, because the countries they live in have banned safe abortion. 68,000 women die every year as a result, and at least five million suffer serious injury or permanent disability.

Countries with strict abortion bans (mostly in the developing world) usually allow an exception to save the woman’s life. Ironically, such bans result in many times more maternal deaths than in countries with more liberal abortion laws. The hypocrisy of laws that pretend to save women’s lives, but which actually slaughter them by the thousands, demands their immediate repeal.

Anti-abortion laws have nothing to do with good healthcare.

Abortion laws around the world vary wildly. While some countries ban abortion totally, others have few or no laws, and many enforce statutes regulating various aspects of the abortion decision and procedure. Such laws are generally not required for any other medical treatment. Examples include mandatory waiting periods, parental consent laws, obligatory counseling, early gestational limits, and other restrictions. Differing legal frameworks also lead to “abortion tourism,” forcing women to travel out-of-country to obtain the care they need, and discriminating against women without the resources to travel.

The sheer diversity of legal situations around the world is proof that abortion laws have nothing to do with quality healthcare, and instead are politically-motivated. Abortion laws are unrelated to women’s real medical needs and concerns, and divorced from the best practices of medical professionals. They are simply holdovers from the days of criminal abortion, or recent products of religious ideology.

In practice, many abortion restrictions impede good medical care, such as delaying treatment unnecessarily and providing false information to patients. This increases the medical risks of abortion and causes psychological and physical distress to women. Also, when abortion is illegal or restricted, it blocks or hampers medical research that's needed to improve abortion care and protect women’s health.

Abortion laws are frequently hollow anyway, because it’s assumed they reduce abortion when they don’t. For example, abortions in the third trimester are very rare and done only in dire circumstances, so passing a law that prohibits late abortions except for health reasons is pointless, as well as insulting to women and doctors. The natural limiting factors for third trimester abortions are the very low demand for them, and the miniscule number of doctors willing and trained to do them.

Anti-abortion laws hurt healthcare professionals.

Anti-abortion laws punish healthcare providers and further reduce access to abortion by:

• marginalizing abortion care and abortion providers outside the mainstream healthcare system
• shifting the focus away from basic healthcare to legal issues
• turning abortion into a political target for legislators and extremists
• disrespecting professional medical judgments made in the patient’s best interests
• interfering in the confidential doctor/patient relationship
• threatening health workers with prosecution

The imposition of anti-abortion laws says, in effect, that legislators can make better medical decisions than doctors. No other medical procedure carries with it the threat of criminal punishment — abortion is singled out for special treatment. But physicians should never work under the shadow of prosecution simply for providing medical care.

Anti-abortion laws institutionalize the stigma of abortion. Laws imply that abortion must be restricted because it is wrong and bad, and people who need or perform abortions are also wrong and bad. But no law will change the fact that a woman desperately needs an abortion, and a doctor wants to help her. As a result, abortion restrictions foster hypocrisy and disrespect for the law because they often force providers to interpret laws loosely, skirt them, or even disobey them.

Anti-abortion laws violate women’s equality.

Women are different than men because of their capacity to bear children. Child-bearing has a much more profound effect on women's lives, than for men. To truly achieve equality with men, women must not be disadvantaged under the law because of pregnancy. There should be no laws regulating pregnancy in any way, because that puts a special obligation on women that is not placed on men. For example, a law that requires women to pay for abortions, but not childbirth costs, is discriminatory.

It’s the uniquely important role of courts to uphold peoples’ constitutional rights by striking down laws that infringe on those rights. Since any restriction on abortion unacceptably limits women’s rights, abortion restrictions can (theoretically) be struck down in a constitutional democracy that protects women’s equality. Likewise, abortion rights should never be subject to a vote by the electorate, and anti-choice laws should never be enacted based on public referendums. That's because we cannot trust citizens to fairly protect the constitutional rights of minorities and disadvantaged groups. In the case of abortion, social opinions are often rooted in stereotypical assumptions about women’s “proper” role as child-bearers, and in religious beliefs about the value of fetal life, at the expense of pregnant women’s lives.

Canada is the only democratic country in the world that has no abortion law or restrictions of any kind, and it has proven that such laws are completely unnecessary. [link goes to expanded version of this article describing Canada's experience] Current abortion care reflects what most Canadians are comfortable with, and women and doctors act in a timely and responsible manner, without regulations. Women’s equality is guaranteed under Canada’s constitution, and it's considered unlikely that any anti-abortion law would withstand a constitutional challenge in Canada today. The courts there have consistently protected women’s right to abortion since 1988, when the old abortion law was struck down by Canada's Supreme Court as violating women’s constitutional rights to “life, liberty, and security of the person,” and “freedom of conscience.”

Even in national constitutions lacking an explicit guarantee of equality for women, there are usually other clauses that will support the repeal of abortion laws. For example, the 14th Amendment in the American constitution says no state can “deny to any person within its jurisdiction the equal protection of the laws.” This clause, and similar clauses in other national constitutions, should require the repeal of abortion laws because they unfairly apply only to women.

Anti-abortion laws hurt and devalue women.

Besides violating women’s equality rights, anti-abortion laws also hurt women by:

• affecting disadvantaged women the most, such as the poor, young, immigrant, and uneducated
• turning women into criminals, or state-controlled baby-making machines
• fostering prejudice against women who need one
• rejecting women's moral reasoning
• distrusting women to make their own decisions about their lives
• protecting fetuses instead of pregnant women
• punishing women for having sex for pleasure
• punishing women for “shirking” motherhood

Abortion restrictions are meant to reduce the incidence of abortion, but instead, they put cruel obstacles in front of a woman. The just and sensible way to reduce abortion is to make contraception universally accessible, teach responsible sex education, and give people positive incentives to raise kids, such as financial bonuses and family support programs.

The state has no legitimate interest in protecting the fetus at any stage, except to provide social and medical resources to pregnant women to ensure good outcomes for their pregnancies. And a good outcome can be an abortion. Pregnant women are in the best position to take care of their fetuses, so we should trust women to make decisions on behalf of their fetuses, not the state.

Anti-abortion laws are rooted in patriarchy and religious tradition.

The following patriarchal myths are the root cause of all abortion restrictions, and form the basis of the anti-abortion viewpoint. The main anti-abortion goal is not to "save babies," it's to keep women in their traditional roles.

• Motherhood is a woman’s highest calling.
• All women should be (and want to be) mothers.
• Women should endure the discomfort and pain of pregnancy and childbirth as their natural duty.
• Women should sacrifice themselves to raise kids.
• Women who have abortions are “bad” or “victims.”
• Women who have abortions suffer psychologically (at least they should).
• Women are irresponsible or too emotional, and need direction and guidance.
• To “protect” women, we must restrict abortion.

Laws against abortion also rely on tradition, for example:

• Pro-natalism — societies have a preference for birth over abortion.
• The right to have babies is unquestioned and unrestricted, but abortion is frowned upon.
• Children are treated like possessions of parents, instead of individuals with rights.
• The Church, God, and Bible are anti-abortion.

This traditional thinking no longer works for our modern society with its focus on human rights. Why should we favour birth over abortion when we live in an overpopulated world; when society will never reach agreement on the moral status of the fetus; when we know that unwilling mothers and unwanted children tend to suffer; and when becoming a parent should be the private decision of the woman and her family? Many people may not be ready or able to provide properly for a child. But children have rights, and they deserve respect, love, and the best chance at a good life. Of course, the right to have a child is fundamental and should not be restricted, but abortion is also a fundamental right on an equal basis.

Churches and religious doctrines should never dictate how we live our lives in a secular society with secular laws. Besides, the Bible is pro-choice. Several passages say it is better to die in the womb than live an unhappy or wicked life.

How to repeal anti-abortion laws.

Here’s some suggested solutions to get rid of harmful anti-abortion restrictions:

• Guarantee women’s equality in countries’ constitutions.
• Collect evidence of laws’ harms, find plaintiffs, and challenge laws in court.
• Lobby government against abortion restrictions (meet with legislators, submit briefs).
• Educate media, government, health professionals, and public about the harm and futility of abortion restrictions.
• Challenge the religious basis of anti-abortion laws, and keep church and state separate.
• Change the rhetoric: Abortion is not a “necessary evil.” Abortion is a moral and positive choice that liberates women, saves lives, and protects families.
• Empower women in society by changing public policies.
• Change patriarchal attitudes about women and motherhood through advocacy and education.
• Prioritize childcare and child-rearing as a universal concern, not a “woman’s issue.”

Some of these proposed solutions are obviously very difficult and would take many years. But one has to start somewhere. Because no country needs laws against abortion. We can trust women to exercise their sensible moral judgment; we can trust doctors to exercise their professional medical judgment, and that’s all we need to regulate the process.