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The Epidemiology of Abortion and Its Prevention in Chile, 79(5) Rev Gene Gene Start Gene End Motif Start Motif End Motif Strand Exon Start Exon End HS Start HS End Distance NLGN4X 5808082 6146706 5821352 5821364 gtggccacggcgg ‑ 5821117 5821907 5811910 5813910 7442 AFF2 147582138 148082193 148048477 148048489 ccaccatcacctc + 148048319 148048609 148036319 148040319 8158 NLGN3 70364680 70391051 70386983 70386995 gtggatatggtgg + 70386860 70387650 70371089 70377089 9894 MECP2 153287263 153363188 153296166 153296178 gtggtgatggtgg ‑ 153295685 153296901 153306976 153308976 10798 FRMPD4 12156584 12742642 12739916 12739928 ccaccatggccgc + 12738647 12742642 12721454 12727454 12462 PHF8 53963112 54071569 54012352 54012364 ccaccatgtcctc ‑ 54012339 54012382 54025089 54033089 12725 RAB39B 154487525 154493852 154493567 154493579 cctccatggccgc ‑ 154493358 154493852 154478566 154480566 13001 FRMPD4 12156584 12742642 12736309 12736321 ggggcaagggagg + 12735619 12736909 12721454 12727454 14867 GRPR 16141423 16171641 16170710 16170722 cctccgtggccac + 16170378 16171641 16208454 16211454 37732 AFF2 147582138 148082193 148079262 148079274 cccccgtcaccac + 148072740 148082193 148036319 148040319 38943 SH3KBP1 19552082 19905744 19564111 19564123 cctccttatcctc ‑ 19564039 19564168 19610454 19614454 46331 PDZD4 153067622 153096003 153070331 153070343 cccccttctcctc ‑ 153067622 153070355 153013976 153018976 51355 SLC6A8 152953751 152962048 152960611 152960623 ccaccctgacccc + 152960528 152962048 153013976 153018976 53353 FMR1 146993468 147032647 147026533 147026545 gaggacaaggagg + 147026463 147026571 147083193 147085193 56648 HNRNPH2 100663120 100669128 100668241 100668253 gtggttatggtgg + 100666923 100669128 100725023 100727023 56770 HNRNPH2 100663120 100669128 100668229 100668241 gtggttatggagg + 100666923 100669128 100725023 100727023 56782 HNRNPH2 100663120 100669128 100667689 100667701 gagggtatggagg + 100666923 100669128 100725023 100727023 57322 FMR1 146993468 147032647 146993528 146993540 gcggtgacggagg + 146990948 146993748 147083193 147085193 89653 CXCR3 70835765 70838367 70837189 70837201 gtgggcagggcgg ‑ 70835765 70837309 71057089 71064089 219888 AR 66763873 66944119 66765398 66765410 ccgccgtggccgc + 66763873 66766604 68319089 68321089 1553679 permissive abortion laws lead decrease in fertility (from 5.0 to 1.8 5.0 to decreasein fertility(from increased live births (Figure 1). This scientific fact challengesbirths the live (Figure deaths to abortion related abortion After pregnancy). excluding ectopic type, phenomenonexceptionally rare in epidemiological to summarizeattempt will — whichI inthis institute exception tothis rule. In fact, Chile has been the (2014). remains a key objective akey remains Chile. most relevant torial, The Epidemiology of Abortion and Its Prevention in Chile, of Abortion and ItsPrevention torial, TheEpidemiology Health, MELISAInstitute,Concepción, Chile.Reprintedwithpermission.Originallypublished as pregnant womenpregnant of fertile of epidemiologicaldata greater mortalityassociatedwithabortion. greater challenges thecommonnotionthatlesspermissive abortionlawsleadto 10.8to0.39per100,000livebirths.Thisscientificfact from to decrease toabortioncontinued After abortionbecameillegalin1989,deathsrelated 100,000 lifebirthsforabortionofanytype,excludingectopicpregnancy). cal terms womenoffertileageor0.4per (ariskof1in4millionpregnant phenomenoninepidemiologi abortion hasbecomeanexceptionallyrare past fiftyyearsinChile.Infact,maternalresult ofaninduced death asa the over continuously decreased by abortionhas Mortality ABSTRACT: The Epidemiology ofAbortion * Epidemiologist, Director of Research, CenterofExperimentalEmbryonic MedicineandMaternal ofResearch, Epidemiologist,Director Mortality byMortality abortion has continuouslydecreased Several factors Several likely contributed to this of thelegalstatus abortion, of Regardless And Its Prevention inChile [3] In fact, maternal accessfamily planningmethods to starting in1964, factors that havebeenrecent studies identified in and recent research — someour which conductedat of research — recent and in most of the western world, age or0.4 per 100,000 live births for abortion of any continued todecrease 10.8 to 0.39 per 100,000 from death as a result of an induced abortion has becomeof aninduced as a result death an Elard Koch,M.P.H.* _________________ to greater mortality associatedwithabortion. greater to children per woman per this children 50 over 71 phenomenon observed in Chile. The The phenomenon observed Chile. in 79(5) prevention ofinducedabortion prevention subject of an interesting series subject ofan interesting terms (a risk of 1 in 4million terms (ariskof R E becamein illegal 1989, V editorial. C over thepast 50 years in commonnotion thatless [1,2] HIL and Chile is not an and Chileisnot . O BST [8] appear tobethe E T . G the increase in the increase ‑ IN year period), EC OL . 351 [3,5 ‑ 7] ‑ Edi 360 [4] ‑ - 72 Issues in Law & Medicine, Volume 30, Number 1, 2015 women’s education (from an average of 3.5 to 12 years over this 50‑year period), a progressive expansion of emergency obstetric care, early access to pregnancy man‑ agement and post‑abortion care.[9,10] It should be noted that the increase in female education showed synergistic effects influencing other variables.[10] Likewise, the evidence suggests that a dynamic lex artis, together with a prudential medical ethical practice applied on a case–by–case basis, [11] have prevailed in Chilean obstetric medical practice, making it unnecessary to return to a particular law for extreme cases of vital maternal compromise. It could even be the case that such legislation would lead to regressive results, depending on the law’s scope, interpretation and use, as has occurred historically with previous abortion laws.[12,13] Of interest is a time series examining 100 years of official records[3] that confirm that the global maternal mortality ratio increased during the first seven years of the first therapeutic abortion law of 1931, reaching a historical peak of 989.2 deaths per 100,000 live births in 1937, the highest in the history of Chilean maternal health during the 20th century (Figure 2). According to official statistics, abortion‑related morbidity has also decreased.[9] For example, the number of hospital discharges in 1965 for abortion of any type (spontaneous or induced) was 56,130 (i.e., 18.6% of all live births that year), which corresponds to a third of the obstetric bed occupancy at that time.[14] Currently, abortion‑related discharges number approximately 30,000 each year (i.e., 12% of the total live births), which corresponds to 10% to 15% of the obstetric bed occupancy. Over the last decade (2001‑2011), despite a steady rate of obstetric hospitalizations and deliveries (33% of the total hospital discharges for women), an important decrease in the rate of abortion‑related hospital discharges has been observed (Figure 3). Upon disaggregating the nine diagnostic codes of the O group for abortive causes or outcomes using the 10th revision of the Statistical Classification of Diseas- es and Related Health Problems Diseases (ICD‑10), it can be observed that ectopic pregnancy (O00), molar pregnancy and other abnormal products of conception (O01, O02 and O08) and spontaneous abortion (O03) have remained at remark‑ ably constant rates, representing 70% of the total abortion‑related hospital dis‑ charges in the last year of the series. As highlighted by a recent review of the use of ICD‑10 codes for the documentation of abortive outcomes,[15] none of these codes has been related to illegal abortions. For example, code O02 is used (among others) to classify an anembryonic pregnancy[16] that is terminated with curettage, which is frequent in Chile due to the high ultrasound and surgical obstetrical medicalization, especially within the private sector. It is a prevalent error[17,18] to consider code O02 to be an estimate of illegal abortions, an assumption that would mistakenly inflate the numbers. The Epidemiology of Abortion and its Prevention in Chile 73 352 REV CHIL OBSTET GINECOL 2014; 79(5) 352 REV CHIL OBSTET GINECOL 2014; 79(5) FigureFigure 1. Maternal 1. Maternal mortality ratiomortality by abortion ratio (deaths by abortion per 100,000 (deaths live births, per excluding 100,000 ectopic live pregnancy) births, between 1979 and 2009 in Chile [3]. After 1989 (the year in which the health code authorizing therapeutic abortion endorsedexcluding by two ectopicphysicians pregnancy)was repealed), thebetween mortality ratio1979 continued and 2009 to decrease in Chile (96% [3]. in 20After years). 1989 (the year in which the health code authorizing therapeutic abortion endorsed by two physicians was repealed), the mortality ratio continued to decrease (96% in 20 years). Figure 1. Maternal mortality ratio by abortion (deaths per 100,000 live births, excluding ectopic pregnancy) between 1979 and 2009 in Chile [3]. After 1989 (the year in which the health code authorizing therapeutic abortion endorsed by two physicians was repealed), the mortality ratio continued to decrease (96% in 20 years). Figure 2. Maternal mortality ratio in Chile, 1924 – 1938 [3]. FigureFigure 2. Maternal 2. Maternal mortality mortality ratio in Chile, ratio 1924 in – Chile,1938 [3]. 1924 – 1938.[3] 74 Issues in Law & Medicine, Volume 30, Number 1, 2015 In contrast, Figure 3 shows that the combined ratio of hospital discharges for other abortions (O05), unspecified abortion (O06), and failed attempted abortion (O07) had a significant downward trend of 2% per year or 1.73 per 1000 live births per year (r=0.94; ‐=1.74; p<0.001).
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