Incomplete or Inaccurate Reporting of Information on 47 Death Certificates of U.S. Women who Died from Confirmed or Suspected Legal Abortion: 1972-1992
A.I.R.V.S.C.
Thomas W. Strahan, J.D.
Association for Interdisciplinary Research in Values and Social Change
Vol. 17, No. 4 September/October 2003
Reproduced with Permission
Those who support legal abortion claim that the incidence of death of women from legal abortion is lower than the incidence of death of women from childbirth. This claim has been the subject of considerable criticism. Information on death certificates is an important source of information to determine the cause of death. This study was designed to attempt to find out to what sorts of errors or omissions may occur in death certificates of women who died from a confirmed or suspected legal induced abortion which may understate the incidence of death of women from legal abortion.
Introduction
All 50 states plus New York City and Washington D.C. collect death certificates. Information from death certificates may be used to determine the underlying cause of maternal deaths.1
The most important element in assigning the correct element in assigning the correct underlying cause of death is the information recorded on the death certificate. If this information is inaccurate or incomplete, the codes subsequently entered will not reflect an accurate description of events that led to the death and will result in a misclassification of the cause of death.2 Various studies have documented the fact that physicians frequently sign death certificates containing various errors or omissions. In one study, 59% of death certificates contained errors because only the mechanism of death was reported and not the cause of death. The authors pointed out that this would lead to considerable statistical misinformation.3 If a woman of reproductive age dies in New York City, the certifying physician is required to fill out a section on the death certificate stating whether or not the woman had been pregnant within the last six months. Yet, a study of death certificates found that 40% of the certifying physicians failed to do so.4 A survey of the 52 vital statistics registration areas in the United States found that at least 23 did not fulfill the minimum cause of death query guidelines recommended by the National Center for Health Statistics.5
In the case of identifying abortion deaths, the value of vital statistics as a source depends on the physician's determination of the cause of death on the death certificate. In order that abortion be mentioned on the death certificate, the certifying physician must know that an abortion has taken place, must warrant it important enough to be mentioned, and then must actually list it on the certificate.6 Vital statistics information has been found to contain a smaller number of reported abortion deaths than actually take place. Inadequate physician documentation on the death certificate has been identified as a primary reason for this.7 Abortion-related deaths are defined by the Centers for Disease Control (CDC) as deaths resulting from the direct complication of an abortion, an indirect complication of an abortion caused by the chain of events initiated by the abortion, or an aggravation of a preexisting condition by the physiologic or psychological effects of the abortion. Any death attributable to abortion is considered by the CDC to be abortion-related regardless of how long it occurred after the abortion.8 Legal abortion is defined by the CDC as an abortion performed by a licensed physician, or someone acting under the supervision of a licensed physician. The CDC has acknowledged that all states do not report on each variable.9
Study Design
This study was done in order to examine the nature of inaccurate or incomplete information on abortion death statistics. In order to determine whether or not death certificates were accurate or complete, the names, date of death and place of death of women who were confirmed or suspected of having died from legal abortion were obtained from available complications based on coroner reports, press reports, disciplinary proceedings, criminal investigations, wrongful death/malpractice suits, journal articles, and other information available to the public. From these compilations, 47 death certificates10 were obtained covering the period from 1972-1992 which included 27 deaths in California, 14 in Illinois, 4 in Michigan, and 2 in Oklahoma. Forty-three (43) of the 47 death certificates were certified copies. There were at least five years between the date of death and the time of obtaining the death certificates. Twenty-four (24) of the death certificates had been amended at least once and 22 of the amended certificates involved deaths which occurred in California.
A review of the death certificates revealed that an autopsy was performed on 43 women, no autopsy for 3 women with one certificate not checked. Twenty-two (22) of the 43 death certificates where an autopsy had been performed indicated that the results of the autopsy had been relied upon in determining the cause of death, 4 were not checked one way or the other and 17 death certificates did not ask the question and therefore provided no information.
Demographic Information
| Table 1 | ||||
|---|---|---|---|---|
|
Analysis of 47 Death Certificates of Suspected or
Conflrmed Death of Women from Legally Induced Abortion |
||||
| Age of Death | 19 or Under | 20-29 | 30 or Higher | |
| California | 8 | 11 | 8 | |
| Illinois | 3 | 6 | 5 | |
| Michigan | 1 | 3 | ||
| Oklahoma | 2 | |||
| Totals | 12(26%) | 22(47%) | 13(28%) | |
| Race | White | Black | Hispanic | Asian |
| California | 7 | 10 | 7 | 3 |
| Illinois | 2 | 12 | ||
| Michigan | 1 | 3 | ||
| Oklahoma | 1 | 1 | ||
| Totals | 11(23%) | 26(55%) | 7(15%) | 3(6%) |
| Marital Status | Married | Never Married | Divorced | Not Listed |
| California | 6 | 15 | 5 | 1 |
| Illinois | 6 | 5 | 3 | |
| Michigan | 2 | 2 | ||
| Oklahoma | 1 | |||
| Totals | 15(32%) | 22(47%) | 8(17%) | 2(4%) |
The vast majority of the women were minorities (26 Black/Negro, 7 Hispanic, 3 Asian and 11 White women)11 (Table 1); Twelve (12) were 19 years of age or younger at the time of their death, 22 were between 20-29, and 13 were age 30 or higher (Table 1). Fifteen (15) of the women were listed on the death certificate as married, 22 were never married, 8 were divorced and 2 did not list marital status (Table 1). Twelve (12) of the women were listed as students on the death certificate, 10 were housewives or homemakers, 4 were housekeepers/cleaning, 4 were teachers' aides or assistants, 3 were medical assistants or nurses' aides, 3 were clerks or cashiers with 2 listed as secretary or receptionist followed by a variety of other occupations (Table 2).
| Table 2 | |
|---|---|
|
Occupation of Women Listed on Death Certificates
of Confirmed or Suspected Death of Women from Legal Abortion 47 Deaths 1972-1992 |
|
| Occupation | No. |
| Student | 12 |
| Housewife/Homemaker | 10 |
| Housekeeping/Cleaning | 4 |
| Teacher Aide/Assistant | 4 |
|
Medical Assistant/
Nurses Aide |
3 |
| Nurse/L.P.N. | 2 |
| Clerk/Cashier | 3 |
| Secretary/Receptionist | 2 |
| Hostess | 1 |
| Restaurant Manger | 1 |
| Data Entry | 1 |
| Computer Analyst | 1 |
| Phone Operator | 1 |
| Laborer | 1 |
| Unknown | 1 |
Causes of Death Listed on Death Certificate
The cause of death as stated on the death certificates which included any amendments, was therapeutic abortion (11), abortion or saline abortion (9), elective abortion (4), septic abortion (1), post-abortal (1), elective termination of pregnancy (1), dilatation and curettage (1), dilatation and extraction of fetus (1), ruptured ectopic pregnancy (3), tubal ligation procedure (1), retained products of conception (1), perforation of uterus (1) and necrosis of uterus or hepatic necrosis (2). Other causes of death as stated on a single death certificate included lung abscess and broncopneumonia, cardio-respiratory arrest, chriocarcinonoma of uterus, pulmonary edema, urinary tract infection, acute septicemia, septic shock and peritonitis, and undetermined (Table 3).
| Table 3 | |
|---|---|
|
Cause of Death as Listed on 47 Death
Certificates Including Any Amendments |
|
| Cause of Death | No. |
| Therapeutic Abortion | 12 |
| Elective Abortion | 4 |
| Elective Termination of Pregnancy | 1 |
| Abortion, Saline Abortion | 9 |
| Septic Abortion | 1 |
| Post-Abortal | 1 |
| Dilation and Curettage | 1 |
| Dilation and Extraction of Fetus | 1 |
| Retained Products of Conception | 1 |
| Perforation of Uterus | 1 |
| Necrosis of Uterus or Hepatic Necrosis | 2 |
| Septic Shock/Peritonitis | 1 |
|
Septic Shock/Congenitally Elongated
Pedicle |
1 |
| Acute Septicemia | 1 |
| Lung Abscess and Broncopneumonia | 1 |
| Cardio-Respiratory Arrest | 1 |
| Chriocacinonoma of Uterus | 1 |
| Pulmonary Edema | 1 |
| Urinary Tract Infection | 1 |
| Ruptured Ectopic Pregnancy | 3 |
| Tubal Ligation Procedure | 1 |
| Undetermined | 1 |
A review of the terms used to describe the cause of death indicates that, in many instances, the mechanism or manner of death was actually being described, but not the cause of death. This defect tended to understate the underlying cause of death, which was frequently legally induced abortion. Many death certificates also used phrases such as "abortion, dilatation and curettage, products of conception, or septic abortion, which would indicate that there had been a recent pregnancy, but which were likely to be too vague and non-specific to be identified as a death from a legal abortion for vital statistics purposes.12 Death certificates which had been amended once or twice were more likely to mention the word abortion (74%) compared to death certificates which had not been amended (50%). Amended death certificates were also much more likely to use the phrase "therapeutic abortion" as the cause of death (39%) compared to non-amended death certificates (5%) which would increase the likelihood that vital statistics data would indicate that the woman's death had occurred as a result of legal abortion.(12)
Coroner/Medical Examiner Reports
In some instances, information which was part of the coroner's report was not disclosed on the death certificate. For example, one coroner report disclosed that the woman expired after an elective abortion in a hospital at 24 weeks gestation. Yet, the death certificate merely stated the cause of death as "dilation and extraction of fetus". Another death certificate made no mention of abortion and merely said there had been an "operation", yet the coroner/medical examiner report clearly stated "therapeutic abortion-sepsis". Still another autopsy report stated "sepsis subsequent to saline abortion; recent, therapeutic abortion". The death certificate listed the woman's death as a "therapeutic accident" and stated that the cause of death as "saline abortion". If the cause of death had been stated as due to a therapeutic abortion it is more likely that it would have been coded for vital statistics purposes as a death from a legal abortion.(12)
Information Regarding Place of Injury
One important reason why more death certificates did not mention abortion was because 18 of the 47 death certificates (38%) contained no information about the place where the injury occurred, although this was a question on all of the death certificates. No death certificates asked the question relative to who caused the injury. This is a considerable limitation on the value of death certificates to identify women who died from legal abortion because the injury resulting in death from abortion must be as a result of an abortion performed by a licensed physician or someone acting under the supervision of a licensed physician.
In addition, 18 other death certificates (38%) provided only sketchy information such as hospital, clinic, woman's hospital or private medical clinic to describe the place of the injury. Only one certificate stated that the injury occurred at an abortion facility. In only 6 instances (l2%) were the place of injury and the place of death listed as the same location although this figure could have been somewhat higher if additional information had been available. Thus, in many instances, a review of any medical records by the coroner or medical examiner or other physician signing the death certificate most likely would not have included medical records or other information from the facility where the abortion may have been performed. Without this information it would be most unlikely that the person(s) who caused the abortion injury would be identified. This information is essential if one is to determine whether or not death occurred as a result of a legal abortion.(9)
Questions Relative to Recent Pregnancy
Only 7 of the 47 death certificates (15%) examined included a question regarding whether or not the woman who died had been recently pregnant. This question was only included on Illinois death certificates beginning in the 1980's where it was asked if the decedent had been pregnant in the last three months. In one instance the answer to the question was not checked. The failure to respond to the question did not misrepresent the cause of death because, on that certificate, it was listed as due to elective abortion. In another instance where the cause of death was listed as due to a ruptured ectopic pregnancy, both yes and no were checked. In another instance, the signer of the death certificate checked no in response to the question, but a subsequent malpractice/wrongful litigation against the abortion facility and the doctors involved revealed that the woman had had a recent induced abortion. In yet another instance, the signer of the death certificate checked yes but the cause of death was listed as undetermined. In still another instance, the signer checked yes and stated that the cause of death was due to halothane toxicity. However, the fact that the halothane was being used as anesthesia in connection with an induced abortion was not included on the death certificate. This fact was subsequently revealed in a malpractice/wrongful suit brought by the next of kin of the decedent.
Type and Place of Death
A11 47 death certificates listed a place of death. In 41 of the certificates the name of a hospital or medical center was entered. In three of these instances the certificate entered the letters D.O.A. next to the name of the hospital or medical center. One certificate listed surgical center as the place of death and one certificate listed only an address without specifically designating the specific location. Three certificates listed home or residence as the place of death, and one certificate listed vehicle. Only 6 certificates listed the same location for the place of injury and the place of death.
Death certificates a]so have a space to characterize the type of death; i.e. natural, accidental, homicide or suicide. Among the 47 death certificates examined 14 listed accident, 6 listed therapeutic accident, 8 listed natural, 2 listed homicide, none listed suicide, 6 listed undetermined, and the remaining certificates left the space blank. A11 47 death certificates listed the date of death but only 29 clearly listed the date of injury. In 13 instances the date of death and date of injury were the same, in 5 instances death occurred the next day after the injury, in 3 more instances death occurred within 7 days. Two additional instances were listed where death occurred within 15 days, 1 at 19 days and 5 between 4 weeks to 9 weeks after the injury.
Civil Law Suits
Of the 47 women who died, there were 24 law suits identified which were filed by the next of kin of the deceased women in the county in which the women died and where the abortion facility was located. In virtually all instances, the suits were based on wrongful death/malpractice claims against the abortion facility and the medical doctors involved. Although not previously considered by public health officials for purposes of vital statistics(8)(9)(11), this source of information helped to establish death from legal abortion in eleven (ll) instances where there had been no mention of abortion on the death certificate. It helped to establish death by legal abortion in three (3) instances where the word abortion was used on the death certificate but most likely would have been classified as death from unspecified abortion. In five (5) instances the law suits helped reinforce a most likely finding that death resulted from a legal abortion because the phrase "therapeutic abortion" was stated to be the cause of death on the death certificate. In two (2) instances information from law suits helped to confirm that death occurred from a ruptured ectopic pregnancy after an attempted abortion, and in one instance helped to confirm the fact that death occurred following a postabortion sterilization. For statistical purposes, the law suits need not prove that the abortion facility or the medical doctors involved were negligent. All that would be required to demonstrate that a women's death occurred by legal abortion is that the place of the abortion injury be identified and that the abortion was performed by a licensed medical doctor or by someone under the supervision of a medical doctor.
Press Reports and Disciplinary Proceedings
Press reports are a potentially valuable source of information to identify deaths of women from induced abortion. In this study, there were at least 14 press reports involving the death of the women. Several deaths of women from induced abortion in Illinois were disclosed in a Chicago-Sun Times investigation of abortion practices where their death certificates had not mentioned abortion. A coroners inquest or disciplinary proceedings against medical doctors frequently coupled with press reports also helped to identify deaths of women from legal abortion in at least 4 instances.
Press reports also identified the death of a California woman as being due to abortion under circumstances where it was likely an illegal abortion had occurred because the facility and staff worker involved were identified in the article as being unlicensed. In that instance, the death certificate stated that "etiology was undermined" with no mention of abortion. At least two deaths of women related to induced abortion were investigated as possible homicides. As a result of one inquest the death was ruled to be a homicide due to gross negligence. In another abortion-related death of a woman it was listed on the death certificate as a homicide, and there was a criminal trial in which the abortionist was acquitted of criminal wrongdoing. However, it was clear that her death was caused by a legally induced abortion. In that instance, the death certificate used the phrase "post-abortal" which was probably not sufficient to report the death as a death from legal abortion for vital statistics purposes.(12)
Summary and Conclusions
In summary, death certificates resulting from deaths of women who died from legal abortion were most often inaccurate or incomplete as to the cause of death, for a variety of reasons. These included not having a question on the death certificate as to who caused the abortion injury and stating the mechanism of death instead of the cause of death. Frequently, the precise location of the injury was not known and therefore not recorded and the place of death was frequently different from the place of injury which makes it likely that records from the place of abortion injury would not be considered. There was also evidence of not fully recording what was included in the coroner/medical examiner reports about the circumstances of the abortion injury onto the death certificate.
Death certificates which had been amended were more likely to disclose the fact that the woman had died from an induced abortion compared to death certificates which had not been amended. Law suits by next of kin against the abortion facility and the medical doctors involved were particularly helpful in identifying the place of injury and establishing death from legal abortion. Press reports, disciplinary proceedings, coroner inquests, and criminal investigations also identified additional deaths of women from legal abortion. Based on these findings, the reliance on information provided on death certificates where there are abortion-related deaths of women provides an inaccurate and incomplete picture of its incidence and it is an unreliable basis for vital statistics information on which to base public policy.
Footnotes
1 Differences in Maternal Mortality Among Black and White Women- United States, MMWR 44/No.1:6, January 13, 1995 [Back]
2 An Assessment of the Incidence of Matemal Mortality in the United States, JC Smith et al, Am J Public Health 74(8):780, 1984 [Back]
3 Incorrect death certification. An invitation to obfuscation, RE Zumwalt and MR Ritter, Post Graduate Medicine 81(8): 245, 1987 [Back]
4 Ascertainment of Maternal Deaths in New York City, MH Allen et al, Am J Public Health 81(3):380, 1991 [Back]
5 Survey of Cause-of-Death Query Criteria Used by State Vital Statistics Programs in the US and the Efficacy of the Criteria Used by the Oregon Vital Statistics Program, DD Hopkins et al, Am J Public Health 79(5):570, 1989 [Back]
6 Deaths After Legally Induced Abortion, JD Shelton and AK Schoenbucher, Public Health Reports 93(4):375, 1978 [Back]
7 Assessment of Surveillance and Vital Statistics Data for Monitoring Abortion Mortality, United States, 1972-1975, W Cates, Jr. et al, Am J Epidemiology 108(3): 200, 1978 [Back]
8 Legal abortion in the US:trends and mortality, HK Atrash et al, Contemporary OB/GYN 35:58, 1990 [Back]
9 Legal abortion mortality in the United States, HK Atrash et al, Am J Obstet Gynecol 156:605, 1987 [Back]
10 Abortion Surveillance - United States, 1996, MMWR 48/No. 55-4, July 30, 1999 Table 19 (CDC reported 297 deaths from legal induced abortion from 1972-1992) [Back]
11 Abortion Mortality, United States, 1972 through 1987, HW Lawson et al, Am J Obstet Gynecol 171:1365, 1994 (The rate of death from legal abortion among white women was reported by the CDC to be 0.9 per 100,000 abortions compared to 2.3 per 100,000 abortions for black women and women of other races.) [Back]
12 A separate analysis of phrases used on 87 death certificates or coroner/medical examiner reports of suspected or confirmed death of U.S. women from legal abortion in 28 states from 1980-1989, found that only 2 out of 10 deaths were coded as death from legal abortion when the word "abortion" was used; among 15 deaths from "septic abortion", none were coded as deaths from legal abortion; among 3 deaths which used the phrase "dilation and curettage" or " dilation and extraction ", none were coded as deaths from legal abortion; among 7 deaths which used the phrase "elective abortion", 4 were coded as death from legal abortion; among 16 deaths which used the phrase " therapeutic abortion, 14 were coded as death from legal abortion. [Back]
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