Thursday, October 18, 2007

Legalization as a panacea

Department of awful statistics (HT: JJ)

Prochoicer Megan McArdle looks at the recent lame claims that abortion's legal status has no impact whatsoever on its frequency, just on its safety:

I can't see the Lancet study, which is gated. But the summary does not back up this claim. The study says that abortions are generally high in the developing world, where it is usually illegal, and low in the developed world, where it is usually legal. It also tells you that abortion is relatively unsafe in the developing world.

But it seems mad to extrapolate this to a blanket statement such as "Law does not influence a woman's decision to have an abortion." For one thing, we know of cases where the law absolutely and indisputably did exert such an influence, such as Communist Romania, where abortion bans caused the birth rate to soar. For another, societies where abortion is illegal are probably different from societies where abortion is legal in other ways, such as attitudes towards birth control. Also, enforcement of laws varies even when the laws don't (abortion was technically illegal in Germany for most of the post-war period). And finally, since the variation is almost entirely among developed countries where access to birth control may be spotty for economic, political or social reasons, this would not necessarily tell us much about developed nations. As I understand it, most abortions in America are obtained by women who have had more than one abortion, which seems to indicate that for at least some segment of the population abortion is a substitute for birth control, rather than birth.

Similarly, saying that "making abortion illegal doesn't reduce its incidence, but only makes it more dangerous" is nonsense on stilts when the comparison is largely between developed countries with legal abortion, and developing countries with illegal abortion. Having an abortion in Burundi would be more dangerous than having one in America even if their government legalized the procedure, made it free, and awarded a medal and a complimentary fruit basket to every woman who had one. I am pretty sure that abortion, like almost every other activity, gets more dangerous when it is legally prohibited. But from what I can make out, this study doesn't do a good job of demonstrating that truism.

Cross-country comparisons--what statisticians call latitudinal studies--are fraught with difficulty because of all the differences in law, enforcement, data collection, social norms, political culture, health care systems, and so forth. That's why it's important to also look at longitudinal studies--studies that examine the same place over time. And all the reputable studies I'm aware of, which to be sure are not an exhaustive list, show pretty much the expected result: if you legalize abortion, you get more of it.

Well said.

I also have to say that I think that the safety impact of legalization on the individual woman is gonna be pretty spotty. Yeah, it may make it possible for Susie to go to a nice, clean clinic run by Charlotte Taft. But it may also land Margaret and Carole at a fly-by-night run by Jesse Ketchum, or Wilma and Jeannie at a mill run by Milan Vuitch, or Linda and Yvonne at Benjamin Munson's office. All three of these guys had clean records as criminal abortionists, then got sloppy once legalization banished the fear of going to prison.

So on a case-by-case basis, I'd say that some women would end up with access to abortions that are actually safer than had their abortions been illegal. But others, such as Carole and Margaret, end up with abortions that are actually less safe because their abortionists take chances they'd never have dared had there been the specter of prosecution hanging over their heads.

What we do know for sure is that legalization drives the numbers up, meaning more women are exposed to the risks. Carl Tyler of the Centers for Disease Control and an avid abortion advocate, testified before Congress in the early 1970s, asking for nationwide legalization of abortion-on-demand as a public health measure that he was sure would "eliminate child abuse in a single generation." When quizzed about the expected impact on women, Tyler postulated that the safety of the procedure would increase somewhat for the individual patient, but the number of women exposed to the risk would skyrocket. He estimated that 200 additional women would lose their lives each year. But, Tyler asserted, the total elimination of child abuse was worth the cost in women's lives.

So what actually did happen with legalization? We can see that the abortion mortality trends didn't change much, as evidenced in this chart from the National Center for Health Statistics:

How accurate were their numbers? Pretty good, judging by studies done in California, Minnesota, and Tennessee, in which researchers turned over every rock they could think of to uncover maternal deaths from illegal abortions. Up until Willard Cates and David Grimes left the abortion surveillance area of the Centers for Disease Control in the mid-1970's, public health officials beat the bushes for data on abortion mortality. They contacted public health officials, hospitals, police, funeral directors, ob/gyns, and family doctors, asking if they knew of any suspicious deaths. People who didn't respond got a follow-up letter.

But when Cates and Grimes left (I last noticed them in 1976, but all my Abortion Surveillance Summaries are back home in the states so I'm going from memory here.), what happened? The numbers fell, got erratic, then leveled off:

Let's look at the actual numbers, shall we? You can click below to enlarge this chart from the Centers for Disease Control 2003 Abortion Surveillance Report, the most recent one I could find:

The numbers for illegal abortions were falling, as the numbers for legal abortions were climbing, leaving the total death toll on the same slow, steady downward trend it had been on since 1960 -- seven years before the first states started legalizing abortions for social reasons.

It's hard to credit legalization with a downward trend that had been in place -- except for a brief and inexplicable leveling-off in the 1950s -- for the previous thirty years and more. And the biggest drop after Roe doesn't come until 1976 -- when the CDC changed its data collection technique from an active one (sending out letters and follow-up letters in addition to collecting data sent in to the National Center for Health Statistics) to a passive one (making due with what the NCHS spit their way).

Crediting legalization with the fall in abortion deaths makes no sense, since absolutely nothing changed in the overall trends with legalization. One might with more statistical credibility attribute the fall to my birth in 1961, which at least coincides with the actual mortality drop.

As for what to do about women in developing nations, I'd say that the best thing we could do for them is what we did for ourselves: build an infrastructure that supplies sanitation, clean water, and healthful foods. It's inexcusable to pretend that changing the legal status of abortion will provide these women with basic good health, sanitary medical facilities, and they so desperately need.

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