Research Methods · Measurement and Statistics
Abstract
Recently, the Guttmacher Institute estimated a number of 400,400 clandestine abortions for Colombia. Because of the strong implications that such brief could have in different areas of interest, a full revision of the methodology of estimation was performed. The methodology used by the Guttmacher Institute was as follows: first, the authors estimated the losses from spontaneous and induced abortions from the opinion of 289 subjects who work in an equal number of Colombian health institutions through the opinion survey entitled "Health Facilities Survey". Subsequently, an expansive multiplier (x3, x4, x5, etc.) was applied to the numbers obtained by this survey that also emerges from a subjective opinion of another 102 respondents of the "Health Professional Survey" selected by convenience. There is no objective data based on real vital events, the whole estimate is based on imagining/numbers underlying mere opinions. Even as public opinion survey, the sampling technique introduced serious selection bias in the gathering of information. Valid epidemiological methods using standardized rates, choosing the paradigmatic cases of Chile and Spain as standard populations, it was observed that Guttmacher Institute methodology overestimates more than 9 times the complications due to induced abortion in hospital discharges and more than 18 times the total number of induced abortions. In other Latin American countries where the same methodology was applied including Argentina, Brazil, Chile, Mexico, Peru, Guatemala, and Dominican Republic, the number of induced abortions was also largely overestimated. These results call for caution with this type of reports that alarm public opinion.
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EARLY-PREG: A preconception longitudinal cohort of women seeking pregnancy to investigate maternal-embryonic molecular signalling during the peri-implantation window
Koch ES et al., 2025 · medRxiv (preprint) · Free to read
Abstract BACKGROUND Maternal-embryonic signalling involves intense and complex molecular exchange between the maternal reproductive system and the early embryo. This interaction begins after fertilisation but is poorly understood before implantation. EARLY-PREG is structured as a bidirectional prospective–retrospective preconception open cohort designed to characterise time-dependent molecular signatures of maternal–embryonic communication during the earliest stage of pregnancy. The cohort supports a dynamic and structured longitudinal biobank of maternal biological fluids, cells and tissues-derived samples collected during the peri-implantation window. STUDY DESIGN Participants were recruited in three rolling waves from 2017 to 2024 so far, in Concepcion, Chile. Healthy women trying to conceive were enrolled and completed a survey with health, lifestyle, and sociodemographic data. Menstrual cycles were prospectively monitored with ovulation and fertile window ascertainment (ultrasound, fertility monitor, and/or LH strips) and followed for a maximum of six consecutive cycles or until implantation of a viable embryo exposure occurred. Each cycle was synchronised within a longitudinal repeated-measures design incorporating systematic day-by-day sampling anchored to ovulation (day 0). Biological samples include cervicovaginal fluid (CVF), urine, saliva, and blood. In addition, cervical brushings were collected during the peri-implantation window (days 12–14 post-ovulation) and on day 21 post-ovulation. Retrospective temporal alignment of ovulation and defined physiological windows was performed using hormonal curves (LH, oestradiol, progesterone and beta-hCG) measured in stored blood and urine samples. RESULTS TO DATE At present, 1,183 women have been contacted, of whom 223 met all eligibility criteria. Among participants trying to conceive, 129 completed at least one full longitudinal repeated-measures cycle; 35 achieved full-term pregnancies and 17 experienced early pregnancy loss (ELP). In addition, 40 abstinent and 5 sterilised women completed the protocol. To date, 292 menstrual cycles have been fully documented and sampled. 52 cycles correspond to conception cycles and 240 cycles to the absence of embryo implantation. Among the latter, 31 cycles were classified as non-conception counterfactual cycles and 209 to non-counterfactual cycles. The biorepository encompasses maternal biological samples collected during the first 2 weeks after ovulation across all documented cycles. Biospecimen collection compliance exceeded predefined protocol thresholds for most sample types. CURRENT AND FUTURE DIRECTIONS The cohort currently supports longitudinal proteomic analyses within a within-individual counterfactual framework, comparing the exposure to a viable embryo implantation (conception cycle) with the absence of embryo implantation (non-conception cycle) to characterise time-dependent molecular signatures of early pregnancy. Additional outcomes of the cohort include implantation failure and early pregnancy loss. A fourth rolling recruitment wave is planned for 2026 to characterise time-dependent immunophenotypic variation in maternal peripheral blood mononuclear cells (PBMCs) during early pregnancy stages. STUDY FUNDING This work forms part of the EARLY-PREG preconception open cohort and has been supported by research grants awarded by Fundación de Investigación San Ramón (FISAR), Chile. The pilot study and first recruitment wave were supported by grants #MEL109112011 and #MEL109112011R4 awarded to E.S.K., C.V., and J.F.S. The second recruitment wave was supported by grants #MEL109112011R5 and #MEL131032017R1 awarded to E.S.K. The third wave was supported by grant #MEL205062018 awarded to E.S.K. and M.H. Current funding for the fourth recruitment wave and mass spectrometry research on maternal CVF is supported by grant REH042024-01 awarded to M.H., G.N., and E.S.K. TRIAL REGISTRATION NUMBER NCT07358026.
Effects of emerging SARS-CoV-2 on total and cause-specific maternal mortality: A natural experiment in Chile during the peak of the outbreak, 2020-2021
Enriquez Y et al., 2024 · PLOS global public health · Free full text on PubMed Central
This study estimated the effects of the COVID-19 pandemic on maternal mortality in Chile between 2020 and 2021. A natural experiment was conducted using official data on maternal deaths and live births (LBs) between 1997 and 2021. The effects of the SARS-CoV-2 outbreak were evaluated using interrupted time series (ITS) and an autoregressive integrated moving average (ARIMA) model to forecast the expected rates on MMR and 95% confidence intervals (95% CI). In Chile, following World Health Organization suggestions, maternal deaths aggravated by SARS-CoV-2 are assigned to code O98.5 (non-respiratory infectious indirect) accompanied by code U07.1 or U07.2, depending on confirmation of the presence or absence of the virus. ITS analysis revealed that the SARS-CoV-2 outbreak impacted the MMR due to indirect causes, with a greater increase in indirect nonrespiratory causes than respiratory causes. The ARIMA forecast was consistent with ITS, showing that the expected MMR for indirect causes (3.44 in 2020 and 1.55 in 2021) was substantially lower than the observed rates (9.65 in 2020 and 7.46/100.000 LBs in 2021). For nonrespiratory indirect causes, the observed values of the MMR for 2020 (8.77/100.000 LBs) and 2021 (7.46/100.000 LBs) were double the predicted values of 4.02 (95% CI: 0.44-7.61) and 3.83 (95% CI: -0.12-7.79), respectively. A lower effect was observed on direct obstetrical deaths. During 2020-2021, there was a rise in the MMR in Chile attributable to SARS-CoV-2. The pandemic contributed to an escalation in the MMR due to indirect causes, particularly nonrespiratory and infectious causes. MMR due to direct obstetric causes were less affected. This suggests that the pandemic disproportionately affected maternal health by exacerbating conditions unrelated to pregnancy, childbirth, or postpartum, more than those directly linked to obstetric complications.
Impact of emerging virus pandemics on cause-specific maternal mortality time series: a population-based natural experiment using national vital statistics, Argentina 1980-2017
Critto ME et al., 2021 · Lancet regional health. Americas · Free full text on PubMed Central
Emerging pandemic viruses may have multiple deleterious effects on maternal health. This study examines the effects of a pandemic influenza virus on cause-specific maternal mortality time series, using Argentinian vital statistics. We conducted a population-based natural experiment from national vital records of maternal deaths between 1980 and 2017. Joinpoint regression models were used to model time series of the maternal mortality ratio (MMR). The sensitivity of the registry to detect the effects of the pandemic H1N1 2009 influenza virus on cause-specific MMR was analysed using a panel of parallel interrupted time series (ITS). Over this 38-year study, the MMR decreased by 58·6% (69·5 to 28·8 deaths/100,000 live births), transitioning from direct obstetric causes (67·0 to 21·1/100,000 live births; 68·4% decrease) to indirect causes (2·6 to 7·7/100,000 live births; 196·2% increase). The regression analysis showed an average reduction of -2·2%/year (95% CI: -2·9 to -1·4) with 2 join points in the total trend (1998 and 2009). Parallel ITS analyses revealed the pandemic H1N1 virus had an increasing effect on mortality from the respiratory system- and sepsis-related complications (level change 4·7 and 1·6/100,000 live births respectively), reversing after the outbreak. No effect was found on MMR from hypertensive disorders, haemorrhage, abortive outcomes, other direct obstetric causes, and indirect non-respiratory comorbidities. The Argentinian maternal death registry appears sensitive to detect different effects of emerging infectious epidemics on maternal health. In a population-based natural experiment, pandemic H1N1 virus impacted maternal mortality almost exclusively from the respiratory system- and sepsis-related complications. Supported by FISAR www.fisarchile.org.
Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: a natural experiment in 32 Mexican states
Koch E et al., 2015 · BMJ open · Free full text on PubMed Central
To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. Population-based natural experiment. Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence. Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=-0.061 to -1.100), skilled attendance at birth (β=-0.032 to -0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=-0.566 to -0.962), clean water (β=-0.048 to -0.730), sanitation (β=-0.052 to -0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=-14.329) and MMRAO (β=-1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R(2)) 51-88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates. Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.
Related research
Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases
Koch E et al., 2012 · International journal of women's health · Free full text on PubMed Central
In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.
Complications and adverse outcomes related to induced abortion in female from the Ukrainian-Russian military conflict regions: A multicentre study
Salmanov AG et al., 2025 · Wiadomosci lekarskie (Warsaw, Poland : 1960)
To provide an overview of complications and adverse outcomes related to induced abortion in female from the Eastern and Southern Ukrainian-Russian military conflict regions. Material and This are a multicentre combined retrospective and prospective cohort study. All women who underwent induced abortion in Eastern and Southern Ukrainian-Russian military conflict regions between 2022 and 2024 are included in the study. A total of 14,196 induced abortion were performed, 10,630 (74.9%) complications cases were observed. The most complication were infections (71.1%), cervical injury (6.6%), incomplete abortion (5.4%), hemorrhage (5.2%), and uterine perforation (4.9%). The most common infection related to induced abortions was endometritis (21.6%), cervicitis (17.8%), vaginal cuff infections (16.3%), peritonitis (12.3%) and pelvic abscess (10.7%), followed by adnexa utery (8.1%), parametritis (6.7%), salpingitis (5.1%), sepsis (1.3%) and other (0.2%) infections. The main risk factors was increased maternal age, surgical abortion approach, increased gestational age, prior cesarean delivery, presence of a bleeding disorder, fetal demise before the abortion, lack of healthcare facilities, lack of essential medication, lack of personnel and equipment, and surgical inexperience. This study findings demonstrate the high rate of complications related to induced abortion in the Ukrainian-Russian military conflict regions. The ongoing war has led to a decline in the quality of healthcare services and main reason for the high rate of complications and adverse outcomes related to induced abortion in female from the military conflict regions.
Impact of reproductive laws on maternal mortality: the chilean natural experiment
Koch E, 2013 · The Linacre quarterly · Free full text on PubMed Central
Improving maternal health and decreasing morbidity and mortality due to induced abortion are key endeavors in developing countries. One of the most controversial subjects surrounding interventions to improve maternal health is the effect of abortion laws. Chile offers a natural laboratory to perform an investigation on the determinants influencing maternal health in a large parallel time-series of maternal deaths, analyzing health and socioeconomic indicators, and legislative policies including abortion banning in 1989. Interestingly, abortion restriction in Chile was not associated with an increase in overall maternal mortality or with abortion deaths and total number of abortions. Contrary to the notion proposing a negative impact of restrictive abortion laws on maternal health, the abortion mortality ratio did not increase after the abortion ban in Chile. Rather, it decreased over 96 percent, from 10.8 to 0.39 per 100,000 live births. Thus, the Chilean natural experiment provides for the first time, strong evidence supporting the hypothesis that legalization of abortion is unnecessary to improve maternal health in Latin America.