The author is a family physician who spent eight years in obstetrics.
Georgi Boorman’s article from Sept. 9, “Is Abortion Really Necessary For Treating Ectopic Pregnancies?” is laudable for her willingness to take a hard look at what might otherwise be an unexamined assumption. However, the conclusion she draws is not supported by the evidence, even as presented in her own article. Before responding, it’s important we establish several key points of common ground.
First, abortion is wrong. The fact that we allow children to be slaughtered by the millions for the cause of “choice” is a mark of shame upon our nation and culture. While mothers who are dealing with unexpected pregnancies need our support, the fact that we, as a society, countenance the wholesale murder of children when they are inconvenient is unconscionable.
As a nation, the United States has committed her share of grave sins, but in terms of scale — how exactly does one quantify human suffering? — it would be roughly on the order of slavery (although I pray it won’t last as long as that evil institution did). These and other historical wrongs are not unique to America, of course, but we must be willing to acknowledge and confront our national offenses without sugar-coating them.
Second, medicine is a changing field. As one of my senior residents when I was a still-green, first-year resident, joked, “Truth changes.” The oral polio vaccine was superior to the injection Jonas Salk developed because even though it caused a few cases of polio, it prevented more than it caused — until polio became so rare, the oral vaccine was causing more cases than it prevented. Today, then, all polio vaccines in the United Sates are injected.
Inhaled steroids were considered the best early treatment for chronic lung disease for years. In 2017, however, the internationally respected GOLD guidelines pointed out that, no, the data shows they should be used no earlier than third- or fourth-line.
There is a vigorous debate about the merits of universal screening for prostate cancer with the PSA (prostate specific antigen) test, due to questions about whether it affects rates of prostate cancer deaths (as opposed to more focused testing). In medicine, as in many other fields, the only constant is change.
Third, if it is at all possible to save both pregnant mothers and their children, we should. Nobody who believes in pro-life principles wants to see children die needlessly.
Before we go further, we must also define some terms. An abortion is the term for any time a child dies before delivery. If the child died of natural causes, this is a spontaneous abortion, also known as a miscarriage. (This has led to heartbreaking misunderstandings for mothers who received emergency treatment for a miscarriage, only to learn later that their condition was diagnosed as an “abortion.”)
Other subcategories — threatened abortion, incomplete abortion, missed abortion — are beyond the scope of this discussion. This is, of course, distinct from an elective abortion, which is when a child is actively killed for any reason other than to preserve the life of the mother. An abortion that is performed explicitly to save the life of the mother is a therapeutic abortion. Yes, to pro-life ears this sounds like a fingernails-on-chalkboard oxymoron, but that is the technical term.
Boorman’s Data Is Problematic
Now, to address Boorman’s article. She begins by introducing her topic and stating the perspective she plans to critique. She then cites a 2017 report in Obstetrics and Gynecology that between 2011 and 2013, 54 maternal deaths occurred from ectopic pregnancy. She then calculates a 0.023 percent death rate from ectopic pregnancies. To do this, she takes the figure of 11,838,612 total pregnancies (supplied in her footnote), multiplies it by 2 percent as the percentage of ectopic pregnancies, and divides this number (236,772.2) into the 54 reported deaths, supplying the number of 0.023 percent.
Here’s the problem: What she has calculated is not the rate of death from all ectopic pregnancies. It’s the rate of maternal death from ectopic pregnancies with current treatment. As she notes, the doesn’t tell us “what the rate would be if abortion weren’t employed.” This is a critical distinction, as we will see.
She also says it would help to have further data to clarify why the deaths occurred, citing delayed treatment and misdiagnosis as two possibilities. However, this is beside the point. When a mother dies from an ectopic pregnancy, it was the ectopic pregnancy that killed her, not a delay in treatment. Just as if a patient were to die from a missed heart attack, the physician who missed it might be preparing for a discussion with his malpractice attorney, but it was still the heart attack that killed the patient.
She discusses autotransfusion (“suctioning out the hemorrhaged blood, filtering it, and reinserting it via IV”) as an option that can prevent maternal death if employed in a timely manner. This is certainly an option worth considering, but to offer it as the best alternative to abortion is not responsible.
The study she cites showed a single death out of 632 cases. Unfortunately, if a study is investigating a particular undesirable outcome and there is only a single instance of that outcome, this means the study was too small to achieve statistical power. Interestingly, if we apply the 0.023 percent rate she cited earlier to the 632 patients in this study, we have a fatality rate not of 1 but of 0.144. Boorman’s numbers suggest that with a therapeutic abortion, that one patient need not have died. That’s another reason to suspect her calculation is off.
Look at it another way: How many medical interventions are there in which it would be considered acceptable to allow one out of every 600 patients to die?
Promoting Unnecessary Fatalities
Two other problems arise with using this study to argue against therapeutic abortion to save a mother’s life. One is that there is no mention of a control group. A study without a control group really doesn’t provide any useful information.
The second is a little more complex. While the study is too small to be statistically valid, let’s use it for the sake of argument. One out of 632, as Boorman points out, gives a maternal fatality rate of 0.16 percent. If we apply this to the 2 percent of pregnancies mentioned earlier (approximately 236,772), this yields 374.6. In other words, according to Boorman’s own numbers, using autotransfusion for every mother with an ectopic pregnancy between 2011 and 2013 would have yielded not 54, but 374 maternal fatalities. That’s 320 women who would have died unnecessarily.
She notes that some also cite concern for fallopian tube damage and future fertility as a reason to abort in an ectopic pregnancy. I cannot speak to those for whom this is a driving concern, but for me, saving the life of the mother is paramount.
Might the child in the ectopic pregnancy die anyway, and there be no need for an active intervention to abort? He might. Boorman’s data says that in one sample, between 47 and 82 percent died spontaneously. That means that between 18 and 53 percent continued to grow, potentially threatening the life of the mother.
This is unacceptable. This is not simply a case of “Doctors don’t want to be sued for malpractice if a pregnancy develops complications.” To wait for a life-threatening hemorrhage because you want to see whether a condition will resolve on its own is malpractice.
The Shortcomings of Current Technology
What about the child? Boorman cites several reports spanning multiple decades with one example, which she admits is questionable, going all the way back to 1917. In doing so, she inadvertently highlights the problem with these anecdotal reports: They are so incredibly rare as to be nigh unto miraculous when they occur.
If there were evidence that these are not rare, then that would be another matter and worthy of serious reexamination. I am aware of no such evidence, however. To rely on these cases to inform medical care, without statistical evidence to back it up, is wishful thinking.
One instance Boorman cites, Heidi and Halle, represents a special case: the heterotopic pregnancy. In these cases (rare, but they happen), twins are conceived, but only one implants in the uterus, while the other implants in the fallopian tube. With current technology, the only way to save the the mother and the child in the uterus is to remove the other one. Or, rather than shy away from it, we should call the thing what it is: The only way to save two lives is to kill one. Sometimes, you don’t get any good choices; you just have to pick the least awful one.
Now, make no mistake: If a technique for transferring a viable embryo from the fallopian tube (or elsewhere) to the uterus were to be developed, this would be a godsend. I pray such a thing would come to pass — without a 1-in-600 chance of killing both mother and child — because it would have profound implications for early pregnancy care. However, what can be explored in research medical centers with highly skilled surgeons, obstetrical nurses, neonatologists, and the dizzying array of skill sets that extremely specialized care involves is starkly different from what is the standard of care out on the front lines.
Save the Life You Can Save
The weakest line in Boorman’s argument is this: “Take note: This near-universal refusal to save tiny lives is a consequence of legal abortion, which promotes the idea that only one patient’s welfare – the larger, older one – must be considered when her health is at risk.” The glib dismissal of medical professionals, some of whom are among the most fiercely pro-life people I know, is disappointing coming from a writer as skilled and sensitive as Boorman.
The sad fact is that with the current state of medical technology, in an ectopic pregnancy, nothing can save the life of that child. Nothing. To focus on the life of the mother is not to say she is more important than the child she carries. The better understanding is that of triage: You save the life you can save. You don’t have to like it, but when you are faced with a choice between one death and two, you do what you can to make it one.
Boorman’s final assertion, that abortion is never the answer, is difficult to address because in just about any other conceivable instance, I would agree with her. However, there are other occasions in which a behavior may be prohibited in the vast majority of circumstances but allowed under very limited conditions.
It’s wrong to ask a person to take off all her clothes and lie down on a table, and then cut her open – but that is a surgeon’s job. I cannot take a drill to someone’s mouth – but my dentist can. Likewise, to kill the child growing inside a mother is wrong – unless it is the only way to save the mother from significant risk of death.
Boorman is to be applauded for asking a tough question, and for challenging the status quo. However, as a closer look at her own numbers demonstrates, when the question is whether abortion is necessary to save the life of a mother with an ectopic pregnancy, the answer, sadly, is yes.
This article offers no medical advice for specific cases; in such circumstances, always consult your doctor.
