C. Counter arguments against APB risk posed and answered
Chapter B should have convinced an objective reader that the
evidence for the APB (Abortion-Preterm-Birth) risk is very credible.
In a malpractice suit in which the plaintiff claims that she was put
at increased risk for preterm birth resulting in a handicapped child
she had after prior elective induced abortions, the defense would
like to demonstrate that the APB risk is not credible. Good 'LUCK' to
such defense counsel!! How can defense counsel show that there is
not one 'gold standard' APB study finding such a risk, when there are
over forty such studies? How likely is it that defense counsel can
demonstrate that top preterm birth experts such as Barbara Luke,
Judith Lumley, and Emile Papiernik are not highly regarded experts
in the field of prematurity risk? However, arguments to discredit
the APB evidence will be presented. Here are some (not all!) of the
arguments that could be presented, along with responses:
1. 'Recall Bias' - in any medical 'case-control' study it is possible
, if interviews are used to collect data, that 'cases' (people
with a particular disease) will be more accurate in recalling key
information than are 'controls' (people without the particular
disease). For example, if women with breast cancer are much more
likely to admit to previous induced abortions than women without
breast cancer, then one of 2 abortion-breast-cancer risks might be
much less than researchers believe. (There is no strong evidence
to support the contention that there is significant 'recall bias'
for abortion-breast-cancer studies). Can doubters of the APB risk
claim that 'recall bias' explains apparent risk and that there is
no real risk? There is at least one (1) large population study that
eliminated the possibility of 'recall bias' by using, not inter-
views, but an abortion registry to ascertain induced abortion
history.1 It is well known that in Greece there is no strong
stigma against women with prior abortions.; ie. there is no good
reason to believe that APB studies done in Greece are substantially
affected by 'recall bias'. There are three (3) 'gold standard'
Greek studies.9,15,18 How about the other 50+ 'gold standard' APB
studies and 'recall bias'? The burden of proof is on the doubters
to provide substantial evidence of 'recall bias'; a very heavy
burden. Proving 'recall bias' for the APB risk is nearly an imposs-
ible task. It is also possible for 'control' women in a case-
control study to be more accurate in recalling reproductive events
than are 'cases', in which situation the estimate of risk is too
low, not too high! This possibility is virtually never mentioned
by those supporting the health 'benefits' of induced abortion.
2. 'Socio-economic status' - if it is true that lower 'socio-economic
status' women have more abortions than high SES women, then
perhaps it is not the abortions that are responsible for PB risk,
but low SES. This possibility was examined by preterm birth expert
Judith Lumley (PhD) and discarded as very unlikely (20):
Lumley reported the following relative risks of VPB from abortions:
# prior induced % inc. in # prior spon. % inc. in relative
abortions relative abortions risk of VPB
VPB (<28 wks) (<28 weeks' gestation)
risk
1 55% 1 66%
2 146% 2 194%
3 458% 3 489%
Lumley wrote, "These last four relative risks [2.46, 2.94, 5.58, 5.89
] are substantially greater than any of those associated with maternal
age, marital status, parity or socio-economic status: that is the
association is most unlikely to be explained by confounding factors of
a sociodemographic kind."20 Let doubters argue with a highly regarded
PB expert, Judith Lumley (Director: Centre for the Study of Womens'
and Children's Health, Victoria, Australia)
3. APB has not been conclusively proven - this is probably true but is
irrelevant, since for an elective procedure, warnings of risk must
be given once there is credible evidence of risk. For example it
has not been conclusively proven that hormone replacement therapy
increases risk of breast cancer, but a doctor recommending this
therapy must legally warn women (in particular, women with a family
history of breast cancer) of the POSSIBLE breast cancer risk. In
1954 there was credible but not conclusive evidence that smoking
cigarettes boosted lung cancer risk. No one would deny that warnings
of POSSIBLE lung cancer risk should have been issued in 1954 by
cigarette makers. Not warning until conclusive (or causal) evidence
is produced is termed by some the 'Joe Camel' defense.
4. APB is not even an accepted PB risk - the APB risk is accepted by
the author of the classic book in prematurity prevention, Prof.
Barbara Luke.26 Two other giants in this field, Judith Lumley and
Emile Papiernik have published results showing substantial APB risk.
10,19 No one denies that incompetent cervix boosts PB risk; incompe-
tent cervix is a known risk of induced abortion surgery. Infection,
particularly vaginal and intrauterine, is strongly suspected as a PB
risk.26-31
5. Some APB review articles do not support the risk - a review article
will take an overview of many previous studies. The claim of review
articles not supporting APB is not true unless one takes the 'Joe
Camel' position that conclusive proof must be found for there to be
risk. Consider the 1999 study where the subjects were over 60,000
Danish women.1 The authors of this article in the respected medical
journal Obstetrics and Gynecology wrote the following: "Three
reviews ... concluded that dilation and evacuation increased the
risk of preterm delivery."1
6. Some specific studies found no APB risk. The 'counter' to this type
of argument is best demonstrated via example. Let's say defense
council claims that the 1996 'Lang' study found no increased PB risk
from precisely one previous induced abortion.3 The plaintiff, let's
say, had precisely one previous induced abortion before she gave
birth to a 'preemie' with a handicap. The 1996 'Lang' study found
an increased risk of PB from one previous induced abortion of 10%
but 'Lang' was not at least 95% confident of increased risk; in
'medical talk' this risk was reported as RR [Relative Risk] 1.1 (.8-
1.5); the first number in the parentheses, .8, is below 1.0 and tells
one that the researchers were not at least 95% confident of higher
risk. So, how can anyone say that there is no increase in risk
according to 'Lang'? This is a common 'flippancy' in medical reports
, since what researchers should honestly say is, "If there is indeed
an increase in risk from factor X, then our study had too few sub-
jects to be at least 95% confident of increased risk." Instead of
an honest statement, what is often written is, "No increase in risk
from factor X." However, the 'Lang' study did find a 90% increase
in PB risk for women with two previous induced abortions (RR 1.9 (1.
1-3.0)); here the first number, 1.1, in parentheses is greater than
1.0, so for two induced abortions the 'gold standard' of at least
95% confidence was achieved. So what is the 'counter' to 'study xyx'
found no APB risk? The counter is the following question: "What
was the relative risk (RR) reported in this study?" The odds are
high that either they do not know or if they can supply the RR
number, it EXCEEDS 1.0 (i.e. increased risk). The comeback is, "So
the researchers did report increased PB risk, but the study had too
few subjects for them to be at least 95% confident of increased risk
." Since some of the 40+ 'gold standard' studies required 2 or 3
prior induced abortions for the researchers to be at least 95% con-
fident of elevated risk, the 'ideal' plaintiff will have had at
least two or three abortions before the 'preemie' with handicaps was
born. Large population studies found significantly higher risk of PB
with just one prior induced abortion.1,10,17
7. There are approximately 60 PB risk factors, so how can researchers
be sure that the other 59 factors do not account for this risk?26
'Sure' is a 'code word' for a demand for conclusive proof of risk.
It is clear that surgical induced abortions boost the risk of incom-
petent cervix and infection, PB risk factors. Some consent forms
admit to incompetent cervix (e.g. 'lacerated cervix') and many if
not most forms admit to higher risk of infection. 'End of story'.
8. Studies finding APB did not properly adjust for all the other possi-
ble risk factors - This means that perhaps there were differences
between 'cases' (women with PB infants) and 'controls' (women with-
out PB infants) other than abortion history that the researchers
were unable to adjust for. There has never been a medical study that
adjusted for all possible risk factors. Should one reject studies
linking smoking to higher lung cancer risk, because differences in
diet, exercise, location (urban vs. rural), marital status, ethnic
background, reproductive history, etc. between 'cases' and 'controls'
were not recorded and 'adjusted for'? No. If there were actually no
PB or LBW (Low Birth Weight) risk from previous induced abortions,
what are the odds that 40+ 'gold standard' studies would all find
increased risk? What are the odds of fifty-nine flips of a two headed
coin would result in all 'heads'? Ans: less than one in a trillion.
Luke, Lumley, and Papiernik, three world class PB experts, reported
elevated risk of PB from previous induced abortions.
9. Induced abortion techniques of the 1960's and 1970's may have
caused PB risk, but vacuum aspiration does not - NICE TRY! Consider
one recent (1999) study of over 60,000 Danish women.1 This study
used an Induced Abortion Registry (started in 1973) and thus so-
called 'recall bias' is not a possible explanation for a finding of
APB risk. For vacuum aspiration the following risks were found(1):
# previous vacuum relative increase 95% confidence
aspiration in preterm birth interval
abortions risk
1 82% (1.63,2.04)*
2 145% (1.90,3.17)*
3 100% (1.13,3.54)*
* - all three finding achieved at least 95% confidence of increased
PB risk
So much for the theory that vacuum aspiration abortions carry no PB
risk.1,10,17
10. Unless the relative APB risk is at least double (ie. RR 2.0), the
risk can not be considered proven by a court. This is the 'cult of
2.0'. For an elective medical procedure, merely credible (not proven
, conclusive, definitive, causal) proof of risk need be provided.
For judges converted to the 'cult of 2.0', remind them of results
that do surpass this 'magic' number. E.G. the 1998 German study
results for VPB (Very Preterm Birth risk for gestations under 32
weeks')(17):
# previous induced relative increase in
abortions VPB risk
1 150% (RR 2.5)*
2 460% (RR 5.6)*
3 510% (RR 6.1)*
(all three results exceeded a doubling of PB risk; * all three
results achieved the 'gold standard' of at least 95% confidence)
11. No major medical organization recognizes APB risk - the Centers
for Disease Control (Atlanta, Georgia) recognizes induced abortion
as a risk factor for urinary/genital tract infection. Vaginal
infection is a recognized risk for PB.26 Incompetent cervix is a
recognized side-effect of induced abortion and incompetent cervix
is a PB risk factor.26 Major U.S. medical organizations have been
ineffective in stopping the continuing increases in U.S. PB rate,
which is currently about 11 percent. Emile Papiernik (MD) was the
head of a French program that reduced PB risk by 52% between 1972
and 1989 and a study he participated in found that abortions boost
PB risk.19 For the fifty+ (50+) 'gold standard' studies reporting
increased APB risk, consider some of the prestigious journals that
these reports appeared in:
New England Journal of Medicine (3 reports), British Medical
Journal (2 reports), Obstetrics & Gynecology, American Journal
of Public Health, American Journal of Epidemiology, American
Journal of Obstetrics and Gynecology, Epidemiology, European
Journal of Obstetrics & Gynecology and Reproductive Biology (3
reports)
......................................................................
SUMMARY:
Some of the counter medical arguments against the APB risk have
been presented, Clearly, the APB risk remains very credible. If
the APB risk is not credible, then highly esteemed PB experts must
demand that the New England Journal of Medicine expose THREE 'gold
standard' studies published in it as invalid.4,5,6 Three world
renowned PB experts, Luke, Lumley, and Papiernik must renounce
their APB findings. Abortion clinics must remove warnings about
incompetent cervix risk and infection risk from their consent
forms. All of these actions must be taken for APB to lose substant-
ial credibility, but none of them is likely to happen. APB is not
merely a credible risk, it is a VERY credible risk for an ELECITVE
(!!) medical procedure.
copyright Brent Rooney ( [email protected] )