Education, not abortion, reduces maternal mortality, study suggests

The research entitled "Women's Education Level, Maternal Health Facilities, Abortion Legislation and Maternal Deaths: a Natural Experiment in Chile from 1957 to 2007" was conducted on behalf of the Chilean Maternal Mortality Research Initiative (CMMRI) and published in the May 4 issue of PLoS ONE.

Using 50 years of official data from Chile's National Institute of Statistics (1957-2007), the authors looked at factors likely to affect maternal mortality, such as years of education, per capita income, total fertility rate, birth order, clean water supply, sanitary sewer, and childbirth delivery by skilled attendants. They also analyze the effect of historical educational and maternal health policies, including legislation that has prohibited abortion in Chile since 1989, on maternal mortality.

During the fifty-year study period, the overall Maternal Mortality Ratio or MMR (the number of maternal deaths related to childbearing divided by the number of live births) dramatically declined by 93.8%, from 270.7 to 18.2 deaths per 100,000 live births between 1957 and 2007, making Chile a paragon for maternal health in other countries.

"In fact, during 2008, the overall MMR declined again, to 16.5 per 100,000 live births, positioning Chile as the country with the second lowest ratio in the American continent after Canada and with at least two points lower MMR than United States" said Koch.

One of the most significant findings is that, contrary to widely-held assumptions, making abortion illegal in Chile did not result in an increase in maternal mortality. In fact, after abortion was made illegal in 1989, the MMR continued to decrease from 41.3 to 12.7 per 100,000 live births (69.2% reduction). "Definitively, the legal status of abortion is unrelated to overall maternal mortality rates" emphasized Koch.

The variables affecting this decrease included the predictable factors of delivery by skilled attendants, complementary nutrition for pregnant women and their children in the primary care clinics and schools, clean facilities, and fertility. But the most important factor and the one which increased the effect of all others was the educational level of women. For every additional year of maternal education there was a corresponding decrease in the MMR of 29.3 per 100,000 live births.

The picture for Chile includes a transition of leading causes of death along with an accelerated decline of fertility and delayed motherhood. Koch explained that direct causes -those directly attributable to pregnancy condition- were the rule before 1980, but from then, indirect causes -i.e. non-obstetric chronic conditions such as hypertension and diabetes among others- rise as the most prevalent, hindering the decline on maternal mortality.

"This study uncovers an ongoing 'fertility paradox' in maternal health: education is the major modulator that has helped Chile to reach one of the safest motherhood in the world, but also contributes to decrease fertility, excessively delaying motherhood and puts mothers on risk because of their older age." Thus, an emerging problem nowadays "is not a question of how many children a mother has, but a question of when a mother has her children, specially the first of them" concluded Koch.