Delegates at the 1983 Life Conference heard Mr. John Murphy, MD, FRCPI, MRCOG, of the National Maternity Hospital, Dublin, present a fascinating and important paper: Maternal mortality – is there ever a case for abortion?
Mr. Murphy’s hospital is the largest obstetric unit in Great Britain and Ireland, indeed, one of the largest maternity hospitals in the developed world. Patients are referred from a wide catchment area, which means that it handles a concentration of problems likely to result in maternal death.
Accurate record-keeping is a feature of the hospital, with especial focus on data concerning maternal death. Mr. Murphy was able to present conclusions based on data collected over a ten-year period from 1070-1979 (inclusive).
During the decade there were 74,317 births in the Hospital at more than 28 weeks gestation. 21 women died, giving a maternal mortality rate of 0.28 per thousand. It is those 21 deaths that Mr. Murphy and his colleague examined to see whether any of them could have been prevented by so-called therapeutic abortions.
No suicides
It is important to note that the age, parity and social class of the 21 mothers was in line with the general population and included one unmarried mother. It is also important to emphasize that not one of the maternal deaths was from suicide.
Mr. Murphy explained that there are three categories of maternal death: those unrelated to pregnancy itself though occurring during pregnancy, such as death in a plane or road crash; those directly resulting from pregnancy, i.e. deaths which would not have happened if the woman had not been pregnant; and those indirectly resulting from pregnancy of women in whom some chronic disease is present and where it could be argued that pregnancy makes the condition worse.
Unrelated causes
Seven deaths were from unrelated causes – that is the cause of death had nothing to do with the pregnancy. Their causes of death were:
Malignant disease 3
Cerebrovascular accident 2
Weil’s disease 1
Road traffic accident 1
Two of the deaths from malignant disease were caused by carcinoma of the colon, and one from carcinoma of the breast. The two deaths from cerebrovascular accident (bleeding into the brain) could not have been anticipated.
Abortion would not have averted any of these deaths. So we can set these seven cases aside.
Eleven of the 21 deaths were the direct result of a complication of pregnancy. If these women had not been pregnant they would not have died.
The causes of death were:
Infection 4
Embolism 3
Haemorrhage
Eclampsia 1
Spontaneous rupture of the liver 1
Could any of these have been saved by therapeutic abortion? The answer is ‘no’.
These eleven women suffered from complications of pregnancy that could not have been foreseen. So the question of therapeutic abortion could not have arisen. For example, the mother who died of a ruptured liver had no known chronic condition, was aged 29, and had 4 children. Her pregnancy had gone smoothly. She was delivered at 39 weeks of a healthy baby, but died soon after the delivery from a very rare complication of pregnancy that could not be foreseen. Similarly nine others in this group had no chronic disease which could have been regarded as an ‘indication’ for abortion. Their complications of pregnancy were all unpredictable because the mothers did not differ from other mothers in the early stages of pregnancy.
Three cases
Only one of the mothers in this category of maternal death had a known condition, that of mild high blood pressure that was treated at the end of pregnancy. She was admitted because of her blood pressure at 35 weeks and surgical induction was performed at 37 weeks. Four hours later she had an eclampsic convulsion and was at once delivered by caesarian section under general anaesthesia. She did not regain consciousness and died. Autopsy revealed no cause of death other than eclampsia.
The remaining three deaths were of patients with chronic medical diseases of whom it could be said that the pregnancy might have made the disease worse. There was one case of phaeochromocytoma, one case of bronchial asthma and one case of congenital heart disease.
The argument in favour of therapeutic abortion depends almost entirely on cases like these.
No reason to diagnose
The mother who died of phaeochromocytoma would, some would argue, have been saved by abortion. But could she? She was aged 36 (no particular risk), she had 4 children (again, no particular risk), was of middle economic group (not a risk), and very fit. She went through the first 30 weeks of pregnancy with no difficulty. She admitted herself in labour at 30 weeks, and her baby was safely delivered. Unfortunately her placenta remained stuck in the womb and had to be manually removed under general anaesthetic, during which she died. At the autopsy she was found to have an unsuspected chromocytoma, a correctable condition if diagnosed. But there was no reason to diagnose it.
The mother who died of respiratory failure was a known asthmatic, aged 35 years, with 5 children and of socio-economic group 5. Her asthma gave no cause for concern until 28 weeks pregnancy, when her condition worsened considerably. She was found to have a large cyst on her lung and was put on a ventilator, but she died of respiratory failure without delivering her baby. She suffered from a common chronic condition, but one at a terminal stage which would have been reached whether or not she had been pregnant. There were no indications for abortion early in pregnancy – and later abortion would not have saved her life.
So the case for therapeutic abortion to save the mother’s life comes down to one out of 21 maternal deaths over a period of 10 years and over 74,000 births.
In this case the mother had Eisenmenger’s Syndrome (hole in the heart) since birth. She was 26 years old, of social/economic group 1, she had had one previous pregnancy delivered at 28 weeks by caesarian section and the baby died. She chose to become pregnant again and to continue with pregnancy. So the question of abortion did not arise with her – her freedom was to choose to be pregnant. She spent most of her pregnancy in the National Maternity Hospital, was delivered at 33 weeks by caesarian section and the baby survived. The mother survived the operation, but died five days later of cardiac failure.
Conclusion
The conclusion drawn by Mr. Murphy was that therapeutic abortion would have had no effect on maternal mortality in the National Maternity Hospital in the 1970s. Put another way – women do not die in childbirth because therapeutic abortion is not available (as, of course, it was not and is not in that hospital).
This conclusion is the answer to the question: surely you would not let a woman die when her doctor has warned her that she should not become pregnant? The conclusion is that therapeutic abortion to save the mother’s life is a thing of distant past, not of the 1980s.
