2004 U.S. Briefs 1144, *; 2005 U.S. S. Ct. Briefs LEXIS 527, **

KELLY A. AYOTTE, ATTORNEY GENERAL OF NEW HAMPSHIRE, Petitioner, v. PLANNED PARENTHOOD OF NORTHERN NEW ENGLAND, ET AL., Respondents

No. 04-1144

SUPREME COURT OF THE UNITED STATES

2004 U.S. Briefs 1144; 2005 U.S. S. Ct. Briefs LEXIS 527

 
August 8, 2005

 [**1]  On Writ of Certiorari to the United States Court of Appeals for the First Circuit.

BRIEF AMICI CURIAE OF AMERICAN ASSOCIATION OF PRO LIFE OBSTETRICIANS AND GYNECOLOGISTS, CHRISTIAN MEDICAL ASSOCIATION, CATHOLIC MEDICAL ASSOCIATION, ALLIANCE DEFENSE FUND, NATIONAL ASSOCIATION OF EVANGELICALS, CONCERNED WOMEN FOR AMERICA AND CHRISTIAN LEGAL SOCIETY IN SUPPORT OF PETITIONER

Steven H. Aden, (Counsel of Record), CENTER FOR LAW & RELIGIOUS FREEDOM OF THE CHRISTIAN LEGAL SOCIETY, 4208 Evergreen Lane, Suite 222, Annandale, Virginia 22003, Tel.: (703) 642-1070.
 
Counsel for Amici Curiae.  [*i] 

 View Table of Contents

 View Table of Authorities

 [*1]  STATEMENTS OF INTEREST OF AMICI CURIAE n1



n1 Amici curiae file this brief by consent of the parties, and copies of the letters of consent are on file with the Clerk of the Court. Counsel for Amici authored this brief in its entirety. No person or entity, other than the amici curiae, their supporters, or their counsel, has made a monetary contribution to the preparation or submission of this brief. Amici wish to gratefully acknowledge the contributions of Steven R. Zielinski, M.D., J.D., who served as principal medical consultant for this brief.

American Association of Pro Life Obstetricians and Gynecologists ("AAPLOG") is a national organization of over 2,500 obstetricians and gynecologists who reaffirm the unique value and dignity of individual human life in all stages of growth and development from conception onward.

The Christian Medical Association ("CMA") was founded in 1931 and today represents over 16,000 members--primarily practicing physicians representing the entire range of medical specialties. These members, who include physicians licensed to practice in the State of New Hampshire, share a common commitment to the principles of biblical faith and the integration of those principles with professional practice. Among other functions, the CMA Medical Ethics Commission coordinates member experts in the field of medical ethics who formulate positions on vital issues. These positions are subsequently voted upon for adoption, amendment, or rejection by over 100 elected representatives to the national convention of the Association. CMA's members have an interest in the case before the Court because it raises the prospect of a constitutional rule that may result in poorer access to family support structures necessary for providing medical care in the best interests of their patients.

 [*2]  The Catholic Medical Association is a professional association of American and Canadian physicians, who seek to respond to the unique responsibility which belongs to all health-care personnel as guardians and servants of human life and human dignity. Its members are conscious of the fact that their patients entrust themselves to the knowledge acquired by physicians. This suggests an important tension. As John Paul, II noted in On Faith and Reason, "On the one hand, the knowledge acquired through belief can seem an imperfect form of knowledge, to be perfected gradually through personal accumulation of evidence; on the other hand, belief is often humanly richer than mere evidence, because it involves an interpersonal relationship and brings into play not only a person's capacity to know but also the deeper capacity to entrust oneself to others...." This capacity to entrust oneself to others lies at the heart of the patient-physician relationship, and at the heart of this case. The Catholic Medical Association has an interest in assisting the Court in properly understanding that relationship.

Alliance Defense Fund ("ADF") is a not-for-profit public interest organization that provides strategic planning, funding, and training to attorneys and organizations to reform American law so that all human life will be respected and protected from conception to death. Its membership includes hundreds of lawyers and numerous public interest law firms. ADF has advocated for the rights of Americans in hundreds of significant cases throughout the United States, having been directly or indirectly involved in at least 500 cases and legal matters, including cases before this Court regarding life issues such as Vacco v. Quill, 521 U.S. 793 (1997), and Washington v. Glucksberg, 521 U.S. 702 (1997).

 [*3]  The National Association of Evangelicals ("NAE") is a nonprofit association of evangelical Christian denominations, local churches, para-church organizations, and individuals, and includes more than 50,000 local churches from 51 denominations, as well as over 250 other religious ministries. NAE serves a constituency of over 30 million people. The Association believes that human life is sacred, that civil government has no higher duty than to protect human life, and the duty is particularly applicable to the life of unborn children because they are helpless to protect themselves.

Concerned Women for America ("CWA") is the nation's largest public policy organization for women. Located in Washington, D.C., CWA is a non-profit organization that provides policy analysis to Congress, state and local legislatures and assistance to pro-family organizations through research papers and publications. CWA seeks to inform the news media, academic community, business leaders and the general public about marriage, family, cultural and constitutional issues that affect the nation. CWA has participated in numerous amicus curiae briefs in the United States Supreme Court, lower federal courts and state courts.

CWA's vision statement calls for women and like-minded men to come together to restore the family to its traditional purpose because this allows each family member to realize their God-given potential and be more responsible citizens. The inalienable right to life documented in the Declaration of Independence and shored up by strong families is a touchstone of liberty. CWA's defense of minors' ability to rely on the protection and wisdom of their parents is a long-standing part of CWA's educational and grassroots efforts.

 [*4]  The Christian Legal Society ("CLS"), founded in 1961, is a nonprofit interdenominational association of Christian attorneys, law students, judges, and law professors with chapters in nearly every state and most law schools. Since 1975, the Society's legal advocacy division, the Center for Law and Religious Freedom, has worked for the protection of human life from conception to natural death.

SUMMARY OF ARGUMENT

In imposing a constitutional standard for parental notice statutes that mandates a broadly interpreted "health" exception, the Circuit Court of Appeals has relied precipitously upon the testimony of one physician-Plaintiff in the case. The Court's Amici seek to bring to the Court's attention supplemental medical authority that suggests that none of the acute medical complications of pregnancy cited by the Court of Appeals or Respondents and their amici necessarily mandates immediate termination of pregnancy by abortion as the accepted standard of practice. Moreover, Respondents' assertion that abortion is a relatively "safe" medical procedure relies upon maternal mortality [**6]  data that is unintended for that purpose and unsuitable to it.

ARGUMENT

i. INTRODUCTION.

In 2003, the New Hampshire legislature enacted the "Parental Notification Prior to Abortion Act" to require parental notification before abortions may be performed on unemancipated minors. 2003 N.H. LAWS 173, codified at N.H. REV. STAT. ANN. ("RSA") 132:24-28 (2003); see Planned Parenthood of Northern New England v. Heed, 390 F.3d 53, 55  [*5]  (1st Cir. 2004). The Act provides:
No abortion shall be performed upon an unemancipated minor or upon a female for whom a guardian or conservator has been appointed pursuant to RSA 464-A because of a finding of incompetency, until at least 48 hours after written notice of the pending abortion has been delivered in the manner specified in paragraphs II and III.

 
RSA 132:25; 390 F.3d at 55. Written notice must be addressed to the parent at the usual place of residence; notification by certified mail is permitted. Id. However, notice is not required in the fashion provided by the statute if the person entitled to notice certifies they have received it, or if the physician certifies that abortion is necessary [**7]  to prevent the minor's death and there is insufficient time to provide the requisite notice. RSA 132:26; 390 F.3d at 55.

The District Court held the Act facially invalid pursuant to this Court's decisions in Planned Parenthood of Southeastern Pa. v. Casey, 505 U.S. 833 (1992) and Stenberg v. Carhart, 530 U.S. 914 (2000). 390 F.3d at 56-57; Planned Parenthood of Northern New England v. Heed, 296 F. Supp.2d 59, 64-65 (D. N.H. 2003). The District Court found the Act unconstitutional due to the lack of an explicit exception to protect the health of the minor and the narrowness of the Act's exception for abortions necessary to prevent the minor's death. 390 F.3d at 56-57; 296 F.Supp.2d at 65 (health exception) and 67 (death exception). The lower court relied upon the affidavit of the only physician plaintiff in the case, Dr. Wayne Goldner, who listed five specific conditions that, in his view, could require abortion to protect a minor's health. 390 F.3d at 56, n.2; 296 F. Supp.2d at 56. Although the District Court did not discuss these conditions  [*6]  in its opinion,  [**8]  they were cited by the Court of Appeals as examples of medical conditions that may require an abortion to preserve a minor's health:
Dr. Wayne Goldner listed in his unopposed declaration five specific conditions that could require abortion to protect a minor's health: pre-eclampsia, eclampsia, premature rupture of the membranes surrounding the fetus, spontaneous chorioamnionitis, and heavy bleeding during pregnancy.

 
390 F.3d 53, 56, n.2. The Court's Amici, who include thousands of obstetricians, gynecologists, surgeons and internal physicians, respectfully take issue with the courts' reliance upon Dr. Goldner's assertions. In the case of each of these pregnancy complications, as well as in the case of most if not all other recognized complications, immediate termination by abortion is not only not indicated, in many cases it is actually contraindicated. See Appendix A to Brief of Amici ("Comparison Chart: Pregnancy Complications and Treatments"). Amici submit that the medical-legal issue for the Court to consider in the circumstances contemplated by the New Hampshire parental notification act is not whether a particular complication may necessitate consideration [**9]  of termination as a therapeutic response generally, but whether Respondents have adequately demonstrated (primarily through Dr. Goldner's assertions) that immediate termination within 48 hours in the primary clinical setting of Respondent women's health centers is indicated for such complications. In Amici's view, accepted medical authority directly contradicts Respondent's position.

I. NEW HAMPSHIRE'S PARENTAL NOTIFICATION LAW WILL NOT INCREASE MATERNAL MORBIDITY AND MORTALITY AMONG THE STATE'S  [*7]  TEENAGERS.

Teenage pregnancy, while not desirable, does not result in excess maternal mortality provided the mother receives proper prenatal care. Numerous studies support the value of proper prenatal care as essential to the well-being of the adolescent mother and child. n2 "Women without any prenatal care were almost twofold at increased risk for maternal death  [*8]  relative to those who received prenatal care." n3 Nothing in the growth or physiology of an adolescent specifically contraindicates pregnancy. n4 In fact, the opposite is true, as "women aged 35-39 years carry a 2.6-fold increased risk of maternal death and those >/= 40 years have a 5.9 fold increased risk." n5 [**10]  This is reflected in New Hampshire's own recent experience; State Health Department statistics demonstrate that for the period 1999 to 2002, New Hampshire has recorded no deaths due to pregnancy, childbirth and the puerperium for patients under 22 years of age. See Appendix B, Health Statistics and Data Management Section of the Bureau of Disease Control and Health Statistics, Department of Health and Human Services, Table, NH Female Leading Causes of Deaths from 1999 to 2002.



n2 The quantity and quality of prenatal care have a direct and significant effect on the pregnant woman and her offspring. The most striking examples of the value of prenatal care occur in teenage pregnancies. The unique medical problems of the pregnant teenager can be controlled and the results of proper prenatal care prove to be no different from that in the general population. Israel and Woutersz, Teenage Obstetrics, 85 AM. J. OBSTET. GYNECOL. 869 (1963); Anderson, Comprehensive Management of the Pregnant Teen-ager, 7 CONTEMPORARY OB/GYN 75 (1976); Briggs, Herren, et. al., Pregnancy in the Young Adolescent, 84 AM. J. OBSTET. GYNECOL. 436 (1962); Dwyer, Managing the Teenage Pregnancy, 12 OB-GYN OBSERVER 2 (1975); Webb, Briggs, Brown, A Comprehensive Adolescent Maternity Program in a Community Hospital, 84 AM. J. OBSTET. GYNECOL. 442 (1962); Houde and Conway, Teen-age Mothers: a Clinical Profile, 7 CONTEMPORARY OB/GYN 71 (1976); Sarrel and Klerman, The Young Unwed Mother, 105 AM. J. OBSTET. GYNECOL. 575 (1969); Dott and Fort, Medical and Social Factors Affecting Early Teenage Pregnancy, 125 AM. J. OBSTET. GYN-ECOL. 532 (1976); Clark, Wong, et al., The Pregnant Adolescent, 142 ANN. N.Y. ACAD. SCI. 813 (1970); Zaeckler, Adelman, et al., The Young Adolescent as an Obstetrical Risk, 103 AM. J. OBSTET. GYNECOL. 305 (1969). These results show the benefits of proper pre-natal care for the pregnant teenager. There are no studies indicating any medical benefits of abortion for the pregnant teenager, nor is abortion recommended as the form of treatment. Many health problems prevalent among teenagers can be diagnosed and treated concurrently with pregnancy; such treatment may not occur should the patient choose abortion. [**11] 
 


n3 Dildy, G. (Ed.), et al., CRITICAL CARE OBSTETRICS 6 (4th ed. 2003), citing Atrash, H.K., et al., Maternal and Perinatal Mortality, 4 CURR. OP. OBSTET. GYNECOL. 61 (1992).


n4 Seeley, et al., ANATOMY AND PHYSIOLOGY 937-955 (5th ed. 2000).


n5 CRITICAL CARE OBSTETRICS at 6.

Physicians have long known that an excessive reliance on abortion as a treatment for adolescent pregnancy was unfounded. The Court should be extremely wary of abortion as a treatment for the health problems of teenagers since severe, long-term complications and handicaps have developed due to such abortions. n6 Further, since an individual's first pregnancy may also be her only one and existing health problems in an adolescent only tend to worsen over time, n7 an adolescent should not be hastily  [*9]  rushed into an abortion when future child bearing may be placed at greater risk. As adolescents are not fully developed with regard to future planning and risk assessment, n8 parental notification, knowledge and involvement are essential to ensure positive overall outcomes.



n6 Bulfin, A New Problem in Adolescent Gynecology, 72 SOUTHERN MED. J. 967-968 (Aug. 1979).


n7 Most constitutional illnesses, e.g., diabetes, hypertensive and vascular disorders, rheumatological disorders and genetic disorders tend to worsen an individual's health over time. See generally Habermann, T. (Ed. in Chief), MAYO CLINIC INTERNAL MEDICINE BOARD REVIEW 2002-2003. [**12] 
 


n8 See generally John J. Mitchell, THE NATURAL LIMITATIONS OF YOUTH: THE PREDISPOSITIONS THAT SHAPE THE ADOLESCENT CHARACTER (Ablex Pub. Co. 1998).

II. MEDICAL COMPLICATIONS OF PREGNANCY DO NOT REQUIRE ABORTION AS A TREATMENT IN THE CIRCUMSTANCES CONTEMPLATED BY THE NEW HAMPSHIRE STATUTE.

Respondents evidence a fundamental misunderstanding of the proper role of the physician in the care of the high risk pregnant adolescent. Proper medical care mandates evaluation and diagnosis prior to undertaking life altering surgical procedures. Such action is not only prudent from the medical perspective, it is essential in the context of induced abortion, since the pregnant adolescent is likely to be at risk in any future pregnancies and the best opportunity to have offspring might be her first and only pregnancy.

All of the potentially catastrophic medical conditions cited by opponents would also mandate care in an advanced medical facility. Specialized units have been developed for the provision of such care. n9 Such care would, of necessity, go beyond the immediate abortion procedure and would likely involve complex decision-making. Prudent medical care and planning would therefore [**13]  consistently involve parental involvement and consultation, if not outright  [*10]  consent. Encouraging parental knowledge and involvement at the earliest opportunity would serve to protect the adolescent in difficult circumstances, particularly when the adolescent cannot advocate for herself. n10



n9 CRITICAL CARE OBSTETRICS at 13-16.


n10 The confidentiality advocated by Respondents is designed to keep the information only from the parent. Since pregnancy in an otherwise unemancipated adolescent raises at least the question of statutory rape or child sexual abuse, the unnecessary allegiance to confidentiality may only serve to maintain the adolescent in an abusive situation or allow others with knowledge of the adolescent's history to use the threat of exposure for continued coercion or abuse.

The Court's Amici believe that the litany of complex medical complications of pregnancy cited as necessitating a health exception, including Eisenmenger's Syndrome, n11 Pulmonary Hypertension, Pre-Eclampsia/Eclampsia, Premature Rupture of the Membranes/Chorioamnionitis, Placenta Previa and Abruptio Placenta, and Marfan's Syndrome, n12 do not necessarily warrant immediate abortion [**14]  as the primary therapeutic response, for the reasons discussed herein.



n11 See Brief Amici Curiae of Society for Adolescent Medicine, et al., in Support of Appellees at 11.


n12 Id.

Eisenmenger's Syndrome is a form of cyanotic heart disease which involves severe pulmonary hypertension originating from a left to right shunting of blood. n13 As the pulmonary hypertension worsens, the shunt reverses, forcing unoxygenated blood to bypass the heart. While Eisenmenger's Syndrome is considered a contraindication to  [*11]  pregnancy and some authorities might advocate termination early in a pregnancy, nothing in the medical literature requires emergent or even urgent termination. The vast majority of deaths occur peri-partum (i.e., during delivery) and post-partum.



n13 Atrial septal defect, ventricular septal defect and patent ductus arteriosis can all be sources of the original left-to-right shunt. Epstein, P. (Ed. in Chief) and Foster, E. (Ed.), MEDICAL KNOWLEDGE SELF-ASSESSMENT PROGRAM 89 (13th ed. 2003).

The accepted treatment for Eisenmenger's Syndrome in pregnancy is supplemental oxygen, bed rest, early hospitalization with close hospital monitoring, decreased cardiac [**15]  workload and maintenance of venous return, appropriate vascular volume and right ventricular filling. n14 In fact, some studies indicate increased maternal mortality with surgical intervention in the latter half of pregnancy compared to vaginal delivery. n15



n14 Burrow, et al. (Eds.), MEDICAL COMPLICATIONS DURING PREGNANCY 110-111 (6th ed. 2004); CRITICAL CARE OBSTETRICS at 257.


n15 CRITICAL CARE OBSTETRICS at 257.

Several points regarding Eisenmenger's Syndrome are important to consider. First, the occurrence of late stage Eisenmenger's Syndrome with significant pulmonary hypertension in the adolescent population is extremely rare. Eisenmenger's syndrome does not develop spontaneously. "Over many years, the prolonged presence of high flow and pressure in the pulmonary arteries causes the pulmonary vessels to constrict and thicken." n16 "These are exceedingly rare conditions." n17



n16 http://tchin.org/resource_room/c_art_06.htm (emphasis added).


n17 T. Murphy Goodwin, M.D., Medicalizing Abortion Decisions, 61 FIRST THINGS 33-36 (March 1996).

Second, hormonal changes secondary to pregnancy may provide some protective effect by decreasing pulmonary  [*12]  vascular [**16]  resistance. n18 The loss of these protective hormones by surgical abortion may have significant adverse consequences.



n18 CRITICAL CARE OBSTETRICS at 257.

Third, since the vast majority of complications are periand post partum, the existence of Eisenmenger's Syndrome is highly unlikely to produce adverse health consequences during the period when parental notification, under the New Hampshire law, will be at issue.

Fourth, no responsible physician would undertake the care of a pregnant Eisenmenger's patient, whether for surgical abortion or delivery, outside of the hospital setting. For an adolescent patient, close contact and consultation with the parents or other responsible guardian would be essential for appropriate immediate treatment, case management and follow-up care.

Finally, delivery of an adolescent mother, while problematic, may be preferable from a health standpoint compared to the risk of a later pregnancy which is likely to occur in the same mother only with a worsened cardiovascular status. Complex decisions regarding potential termination in a setting where future pregnancy is contraindicated are best done in a careful, well planned manner with appropriate [**17]  familial and medical support. The New Hampshire law is consistent with such appropriate parental involvement.

Pulmonary Hypertension in pregnancy carries with it similar concerns to those noted for Eisenmenger's Syndrome. Recent medical advances (e.g., epoprostenol, n19  [*13]  inhaled nitric oxide n20) may prove beneficial in decreasing morbidity and mortality in these patients regardless of the planned clinical outcome. For both Eisenmenger's Syndrome and Pulmonary Hypertension, appropriate clinical evaluation and initial stabilization therapy will provide more than ample time for either parental notification or judicial bypass.



n19 See generally http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/203429.html.


n20 CRITICAL CARE OBSTETRICS at 258.

Cardiac surgery during pregnancy is not absolutely contraindicated, but should be optimized as to time, place, gestation and level of care. n21 However, surgical abortion as a treatment for certain cardiovascular conditions, such as congestive heart failure, has long been known to carry severe inherent risks:


For the patient who is not in cardiac failure there is no need to terminate and if she is in failure termination [**18]  is next door to manslaughter . . .

On no account may obstetrical intervention be undertaken until the patient's cardiac failure is under control, although the situation may seem so grim that one may be tempted to interfere. To do so would simply seal the patient's fate. Once failure has been controlled, however, the need to intervene in the pregnancy has passed. n22





n21 MEDICAL KNOWLEDGE SELF-ASSESSMENT PROGRAM at 96-97. For peripartum cardiomyopathy, "Treatment is supportive and includes standard treatment for congestive heart failure." MEDICAL KNOWLEDGE SELF-ASSESSMENT PROGRAM at 100. See generally id., at 99 (discussing benefits and risks of continuing or interrupting pregnancy in cardiac patients).


n22 Donald, I., PRACTICAL OBSTETRIC PROBLEMS 169-170 (5th ed. 1979) (emphases added).

 [*14]  Pre-eclampsia is a disease unique to pregnancy and pregnancy related conditions. n23 Pre-eclampsia is defined as maternal hypertension, proteinuria and edema beginning after the 20th week of gestation. n24 Optimal treatment consists of bed rest, blood pressure monitoring and control, regulation of fluid intake and output, close hospital monitoring and medication [**19]  for neurologic indications. n25 Treatment for pre-eclampsia has been fairly standardized for decades, n26 and newer anti-hypertensive medications have improved treatment and control. n27 Early delivery, not necessarily abortion, is considered if the condition worsens after attempts at medical control. n28



n23 MEDICAL COMPLICATIONS DURING PREGNANCY at 45. Eclampsia, which involves maternal seizures in the setting of pre-eclampsia, is included here. "The incidence of eclampsia has declined since the 1920s, largely because of the greater availability of prenatal care." MEDICAL COMPLICATIONS DURING PREGNANCY at 46.


n24 MEDICAL COMPLICATIONS DURING PREGNANCY at 45-47.


n25 MEDICAL COMPLICATIONS DURING PREGNANCY 54-56; CRITICAL CARE OBSTETRICS at 438.


n26 CRITICAL CARE OBSTETRICS at 438-39; MAYO CLINIC INTERNAL MEDICINE BOARD REVIEW 2002-2003 at 553.


n27 CRITICAL CARE OBSTETRICS at 441-444.


n28 "When severe pre-eclampsia is diagnosed, immediate delivery, regardless of gestational age, has generally been recommended." National High Blood Pressure Education Program Working Group (1990), quoted in CRITICAL CARE OBSTETRICS at 438.

While some authorities advocate [**20]  outpatient monitoring and expectant management for pre-eclampsia, n29 such care is not likely to be appropriate in the setting of adolescent pregnancy, particularly in the absence of parental notice and  [*15]  involvement. n30 It would be difficult, if not impossible, to imagine a situation where the adolescent would receive appropriate medical management in a suitable clinical setting, n31 regardless of the intended pregnancy outcome, without parental notice and parental involvement. Further, the health risks and concerns for the adolescent do not terminate merely because the pregnancy does n32 and follow-up in a supportive environment would be essential to prevent any late complications.



n29 E.g., CRITICAL CARE OBSTETRICS at 438-439.


n30 MEDICAL COMPLICATIONS DURING PREGNANCY at 55. Optimal outpatient management would include twice weekly fetal monitoring, ultrasound evaluations and frequent laboratory and clinical evaluations.


n31 See CRITICAL CARE OBSTETRICS at 438-439 ("...intensive maternal and fetal monitoring in a tertiary care center").


n32 MEDICAL COMPLICATIONS DURING PREGNANCY at 56 ("Late postpartum eclampsia has also been observed, the seizures occurring after the first postpartum week."). [**21] 

Placenta Abruptio and Placenta Previa are conditions that often present with significant vaginal hemorrhage. Placental abruption is defined as the premature separation of a normally situated placenta, and may be partial or complete. n33 In placenta previa, a portion of the placenta may partially or completely cover the internal cervical os. n34 In the setting of vaginal blood loss, appropriate initial management includes bed rest, close hospital monitoring, fluid resuscitation, and transfusion as needed. "Resuscitation with fluid, blood, and correction of coagulopathy must be urgently undertaken, and invasive monitoring may be necessary." n35 Should the clinical condition of the mother permit, ultrasound evaluation and testing for pregnancy  [*16]  viability may be considered. But the appropriate treatment is not abortion, since "...prompt delivery prevents further decompensation of both mother and fetus." n36 "If the fetus is alive and of viable gestational age at presentation, urgent delivery by caesarean section is indicated unless vaginal delivery is imminent." n37



n33 CRITICAL CARE OBSTETRICS at 298.


n34 ANATOMY AND PHYSIOLOGY at 964.


n35 CRITICAL CARE OBSTETRICS at 298. [**22] 
 


n36 CRITICAL CARE OBSTETRICS at 298.


n37 CRITICAL CARE OBSTETRICS at 298.

To undertake such care in anything less than a full service hospital would be risky. To undertake such care in a free-standing clinic or with mid-level health practitioners would be unthinkable. n38 Parental notification can be easily accomplished as part of transfer to an appropriate medical care facility or during the period of stabilization at that facility. Parental consultation may be essential, since the distressed adolescent may be unable to advocate for herself or provide for the needs of her newborn.



n38 Amici note with concern that Respondent Planned Parenthood of Northern New England admits that "Using mid-level practitioners reduces costs for patients and enables us to reach more women." http://www.ppnne.org/site/PhotoAlbumUser?view=UserPhotoDetail&PhotoID=68499&position=3&AlbumID=7528 (last viewed 08/06/05).

Premature Rupture of Membranes surrounding the unborn child may lead to an infectious condition known as Chorioamnionitis. Most infections are caused by bacteria in the cervical and vaginal flora. n39 Treatment requires prompt administration of antibiotics and delivery. n40 Since [**23]  the required antibiotics are administered intravenously and would be required regardless of intended pregnancy outcome, hospitalization, monitoring of drug levels and close  [*17]  observation are mandatory. n41 As noted throughout this brief, parental notification, consultation and support would be essential to a positive outcome for the adolescent.



n39 MEDICAL COMPLICATIONS DURING PREGNANCY at 314.


n40 MEDICAL COMPLICATIONS DURING PREGNANCY at 315.


n41 Id.

Marfan's Syndrome is an autosomal dominant genetic disease that produces abnormalities in connective tissue. Individuals with Marfan's Syndrome are at risk for aortic dissection and other cardiovascular complications.


Pregnancy should be discouraged in these individuals. Maternal activity should be limited, and prophylactic B-adrenergic blocking therapy should be applied during pregnancy. Ideal monitoring includes blood pressure analysis and serial echocardiographic studies. If there is progressive aortic root dilation or if the aortic root diameter exceeds 5.5 cm, necessary surgical repair can be carried out during pregnancy with good outcomes. n42

 
Cesarean section is advised in certain circumstances.  [**24]  n43



n42 MEDICAL COMPLICATIONS DURING PREGNANCY at 112, citing Elkayam, U., et al., Cardiovascular Problems in Pregnant Women with the Marfan Syndrome, 123 ANN. INTERN. MED. 117 (1995).


n43 Id.

In summary, pregnancy complications in the adolescent do not require a rush to abortion. Prudent medical management requires an appropriate evaluation and an effort at stabilization which would allow for beneficial parental notification and involvement. See Appendix A to Brief of Amici ("Comparison Chart: Pregnancy Complications and Treatments").

III. STATISTICAL COMPARISONS OF ABORTION RISKS  [*18]  AND MATERNAL MORTALITY RISKS MAY GIVE A FALSE IMPRESSION OF ABORTION SAFETY.

Respondents urge that abortion is "an extremely safe medical procedure." Declaration of Wayne Goldner 2, P3. Dr. Goldner claimed in the District Court that "Both in terms of mortality (death) and morbidity (serious complications short of death) abortion is many times safer than continuing pregnancy through to childbirth." Id. Complaint at 7. However, this argument depends upon a fallacious comparison of maternal mortality and live birth data. While defining maternal mortality relative to live births may be [**25]  statistically convenient, it improperly represents the true population at risk while including deaths from unrelated groups. According to the Centers for Disease Control and Prevention,
The maternal mortality rate is computed as all maternal deaths per 100,000 live births. In contrast, the measure used for abortions is a case-fatality rate which is computed per 100,000 abortions. These measures are conceptually different and used by CDC for different public health purposes.

 
Appendix C, Letter of July 20, 2004 from Julie L. Gerberding, M.D., M.P.H., Director, to Walter M. Weber, American Center for Law & Justice, p. 1.

Moreover, the Maternal Mortality Rate (MMR) is commonly defined as the Total Maternal Deaths (TMD) divided by the number of Live Births (LB). Each component suffers from multiple defects that make the overall MMR an inappropriate means for comparison to the Abortion Mortality Rate (AMR).

 [*19]  First, the TMD is defined as all deaths attributable to pregnant women during the period of their pregnancy and for a year after delivery. n44 Such deaths might occur in women of all races, n45 across the entire age range in which pregnancy can occur, n46 [**26]  in all states of underlying health conditions, n47 by all causes n48 and without regard to whether or not the woman is under a physician's care. Each element noted above has implications that make the TMD number increase, thereby increasing the MMR, but which are not considerations as likely to occur in a population of women seeking abortion. Women seeking induced abortions tend to be younger, healthier, from favorable socioeconomic circumstances, of white (Caucasian) race and all, by definition, are under a physician's care. Those with underlying medical conditions who succumb, in whole or in part, to the stresses of an induced abortion procedure, may have their deaths attributed to the underlying medical condition or a subsequent condition which developed, rather than the abortion procedure. n49 Being under a physician's care during a pregnancy has been shown to be a significant factor in the  [*20]  prevention of maternal mortality. n50



n44 Centers for Disease Control and Prevention, Pregnancy Related Mortality Surveillance -- United States, 1991-1999 (MMWR), February 21, 2003, available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5202a1.htm.


n45 Minorities are more commonly represented in the population of women continuing their pregnancies and have poorer outcomes. CRITICAL CARE OBSTETRICS at 4 ("Black maternal race confers a relative risk of 3.7 fold for maternal death compared to White women."); CRITICAL CARE OBSTETRICS at 6. [**27] 
 


n46 Id. ("women aged 35-39 years carry a 2.6-fold increased risk of maternal death and those >/=40 years have a 5.9 fold increased risk").


n47 See generally MEDICAL COMPLICATIONS DURING PREGNANCY; CRITICAL CARE OBSTETRICS.


n48 CRITICAL CARE OBSTETRICS at 6.


n49 CRITICAL CARE OBSTETRICS at 6.


n50 Id. ("Women without any prenatal care were almost twofold at increased risk for maternal death relative to those who received prenatal care.").

Second, the calculation of MMR based on the number of live births falsely underestimates the population of women who are at risk for the complications of pregnancy either wholly or in part. Women who experience miscarriages, stillbirths, pre-partum intrauterine deaths and deaths from other causes may be added to the TMD without ever having the likelihood of a live birth.

Confidentiality issues also impact the accuracy of reporting of maternal deaths, since a pregnant or recently pregnant woman may have the evidence of her pregnancy objectively determined, but whether her abortion is natural or induced cannot so easily be assumed. Many women withhold the fact of their induced abortion. Should such women suffer severe morbidity [**28]  or mortality, prior to disclosure, their deaths might be attributed to complications of pregnancy instead of the true cause, which is induced abortion. n51 Further, confidentiality issues preclude the proper and objective collection and interpretation of morbidity and mortality data in induced abortion. n52 While  [*21]  maternal deaths, whether from pregnancy or induced abortion, generally occur in the hospital setting, induced abortions are performed in freestanding clinics not subject to reporting laws. n53 Death and injury following an induced abortion procedure often occurs at another location without complete knowledge of the previous induced abortion. Follow-up on induced abortion morbidity and mortality is incomplete and haphazard. Provider bias, including concerns about potential malpractice or public image, may significantly impact what is reported.



n51 Id. ("...infections were the leading cause of abortion related maternal deaths").


n52 In fact, New Hampshire is one of only 5 states that do not mandate abortion providers to submit epidemiologically valuable reports relative to abortion and, of course, its complications. Planned Parenthood, among other organizations, has opposed efforts by the New Hampshire State Department of Health and Human Services to require abortion providers to report such data. Saul, Rebekah, "Abortion Reporting in the United States: An Examination of the Federal-State Partnership," in Family Planning Perspectives, Vol. 30, Number 5, Sept./Oct. 1998. [**29] 
 


n53 See Thornburgh v. Amer. College of Obstet. & Gyn., 476 U.S. 747 (1986).

Respondents and their amici raise claims of increased mortality and morbidity from any restriction of immediate access to abortions for adolescents. Past claims of increased morbidity and mortality, including claims by allegedly impartial government agencies, have proven groundless. With regard to the Hyde Amendment, which restricted governmental funding for abortions, Dr. Willard Cates, representing the Centers for Disease Control Abortion Surveillance Branch, predicted a total of 77 excess deaths to women who would seek illegal abortions and an additional 5 excess deaths due to delays in seeking abortion. n54 The same department would later admit that no such increase in mortality or morbidity had occurred. n55 Even Dr. Cates would later admit, "The 'bloodbath' many predicted simply is not happening..." n56 The Court should not be swayed by  [*22]  false claims of abortion safety compared to pregnancy or statistical claims of excess mortality or morbidity.



n54 Pettiti and Cates, Restricting Medicaid Funds: Projection of Excess Mortality, 67 AMER. J. PUB. HEALTH 860-62 (Sept. 1977). [**30] 
 


n55 Centers for Disease Control, Morbidity and Mortality Weekly Report, Vol. 28, No. 4, Feb 2, 1979.


n56 Cates, Willard, M.D., Centers for Disease Control, Interview in The Washington Post, February 16, 1978.

CONCLUSION

Parental involvement in a teenager's decision to continue or terminate her pregnancy is not only desirable, but beneficial to the overall mental and physical health of the teenage mother.
In this case, however, we are concerned only with minors who according to the record range in age from children of twelve years to 17-year-old teenagers. Even the latter are less likely than adults to know or be able to recognize ethical, qualified physicians, or to have the means to engage such professionals. Many minors who bypass their parents probably will resort to an abortion clinic, without being able to distinguish the competent and ethical from those that are incompetent or unethical.

 
Bellotti v. Baird, 443 U.S. 622, 641 (1979). Moreover,
The medical, emotional, and psychological consequences of an abortion are serious and can be lasting; this is particularly so when the patient is immature. An adequate medical and psychological [**31]  case history is important to the physician. Parents can provide medical and psychological data, refer the physician to other sources of medical history, such as family physicians, and authorize family physicians to give relevant data.

 
H.L. v. Matheson, 450 U.S. 398, 411 (1981); accord Ohio v. Akron Ctr. for Reproductive Health, 497 U.S. 502, 518-19  [*23]  (1990).

The teenager may have significant medical needs following the abortion procedure that further validate the desirability and benefits of early parental involvement. (Risks of infection, mental and physical trauma, hemorrhage, perforation, undetected ectopic pregnancy, etc.) Further, parental involvement can ensure the continued involvement and responsible management of qualified health professionals who might otherwise be unaware of or unavailable for the continuing medical needs of the teenager.

New Hampshire's plan for parental certification is a safe and effective means of assuring that the mother receives treatment in a timely manner without risking exposure to dangerous procedures and unscrupulous providers. Should the parents be notified and fail to act in the best interest of their [**32]  teenage child, the physician has ample recourse either through emergency bypass or through termination of parental rights in a child welfare proceeding.

For the reasons set forth hereinabove, the Court's Amici respectfully submits that the decision of the First Circuit Court of Appeals should be reversed.

Respectfully submitted,

Steven H. Aden, (Counsel of Record), CENTER FOR LAW & RELIGIOUS FREEDOM OF THE CHRISTIAN LEGAL SOCIETY, 4208 Evergreen Lane, Suite 222, Annandale, Virginia 22003, Tel.: (703) 642-1070,  [*24]  Counsel for Amici Curiae
 
August 8, 2005

 [*1]  Appendix A

COMPARISON CHART: PREGNANCY COMPLICATIONS AND TREATMENTS
Condition Requiring Standard Medical Respondent's
Treatment Treatment Treatment Plan
Teenage Pregnancy Proper Prenatal Care n1 Immediate Abortion n3
Social and Support
Services
Treatment of Existing
Health
Conditions n2
Parental notification,
Consultation and Support
Eisenmenger's Syndrome Oxygen n4 Immediate Abortion n5
Bed Rest
Close Hospital Monitoring
Optimize Cardiovascular
   Function
Post-Partum Observation
General Cardiac Surgery Not Immediate Abortion n7
Conditions Contraindicated n6
Optimize Cardiovascular
   Function
Pulmonary Hypertension See Eisenmenger's Immediate Abortion n9
Syndrome, supra.
Medication to decrease
   Pulmonary Vascular
   Resistance. n8
Preeclampsia/Eclampsia Bed Rest n10 Immediate Abortion n12
Blood Pressure Monitoring
   & Control
Regulation of fluid
   intake and
   output
Close Hospital Monitoring
Medication for Neurologic
   Complications
Early Delivery if
   needed n11
Abruptio Placenta Prompt Delivery n13 Immediate Abortion n14
Fluid Resuscitation
Blood Transfusion
Hospital Monitoring
Bed Rest
Ultrasound and Lab (HCG)
   Evaluation
Placenta Previa Fluid Resuscitation n15 Immediate Abortion n16
Blood Transfusion
Hospital Monitoring
Bed Rest
Ultrasound and Lab (HCG)
   Evaluation
Cesarean and Early
   Delivery If
   needed
Premature Rupture of Monitor for signs of Immediate Abortion n18
Membranes infection n17
Chorioamnionitis Intravenous Antibiotic
Therapy
Fluid Support
Delivery if needed
Marfan's Syndrome Blood Pressure Analysis Immediate Abortion n21
n19
Frequent
Echocardiographic
   Evaluation
B-Blocker Therapy
Surgery if needed n20
 [**33] 



n1 Israel and Woutersz, Teenage Obstetrics, 85 AM. J. OBSTET. GYNECOL. 869 (1963); Anderson, Comprehensive Management of the Pregnant Teen-ager, 7 CONTEMPORARY OB/GYN 75 (1976); Briggs, Herren, et. al., Pregnancy in the Young Adolescent, 84 AM. J. OBSTET. GYNECOL. 436 (1962); Dwyer, Managing the Teenage Pregnancy, 12 OB-GYN OBSERVER 2 (1975); Webb, Briggs, Brown, A Comprehensive Adolescent Maternity Program in a Community Hospital, 84 AM. J. OBSTET. GYNECOL. 442 (1962); Houde and Conway, Teen-age Mothers: a Clinical Profile, 7 CONTEMPORARY OB/GYN 71 (1976); Sarrel and Klerman, The Young Unwed Mother, 105 AM. J. OBSTET. GYNECOL. 575 (1969); Dott and Fort, Medical and Social Factors Affecting Early Teenage Pregnancy, 125 AM. J. OBSTET. GYN-ECOL. 532 (1976); Clark, Wong, et al., The Pregnant Adolescent, 142 ANN. N.Y. ACAD. SCI. 813 (1970); Zaeckler, Adelman, et al., The Young Adolescent as an Obstetrical Risk, 103 AM. J. OBSTET. GYNECOL. 305 (1969).


n2 The only time an adolescent may present for ongoing medical care will be during the period of her pregnancy.


n3 See generally Complaint; Brief Amicus Curiae of Society for Adolescent Medicine, etc., in Support of Appellees. [**34] 
 


n4 Burrow, et al., MEDICAL COMPLICATIONS DURING PREGNANCY 110-111 (6th ed. 2004).


n5 Brief Amicus Curiae of Society for Adolescent Medicine at 11.


n6 E. Foster and Paul E. Epstein, Eds., MEDICAL KNOWLEDGE SELF-ASSESSMENT PROGRAM - Part A, Book 2 96-97 (13th Ed. 2003).


n7 Brief Amicus Curiae of Society for Adolescent Medicine at 11.


n8 Epoprostenol, Inhaled Nitric Oxide, for example.


n9 Brief Amicus Curiae of Society for Adolescent Medicine at 11.


n10 MEDICAL COMPLICATIONS DURING PREGNANCY at 54-56; Dildy, et al., CRITICAL CARE OBSTETRICS 438 (4th ed. 2003).


n11 "When severe pre-eclampsia is diagnosed, immediate delivery, regardless of gestational age, has generally been recommended." National High Blood Pressure Education Program Working Group (1990), quoted in CRITICAL CARE OBSTETRICS at 438.


n12 Complaint at 8.


n13 CRITICAL CARE OBSTETRICS at 298.


n14 Brief Amicus Curiae of Society for Adolescent Medicine at 12; Complaint at 8.


n15 CRITICAL CARE OBSTETRICS at 298.


n16 Brief Amicus Curiae of Society for Adolescent Medicine at 13; Complaint at 8.


n17 MEDICAL COMPLICATIONS DURING PREGNANCY at 314-315.


n18 Brief Amicus Curiae of Society for Adolescent Medicine at 12; Complaint at 8. [**35] 
 


n19 "Pregnancy should be discouraged in these individuals. Maternal activity should be limited, and prophylactic [beta] -adrenergic blocking therapy should be applied during pregnancy. Ideal monitoring includes blood pressure analysis and serial echocardiographic studies. If there is progressive aortic root dilation or if the aortic root diameter exceeds 5.5 cm, necessary surgical repair can be carried out during pregnancy with good outcomes." MEDICAL COMPLICATIONS DURING PREGNANCY at 112, citing U. Elkayam, et al., Cardiovascular Problems in Pregnant Women with the Marfan Syndrome, 123 ANN. INTERN. MED. 117 (1995).


n20 Cesarean section is advised in certain circumstances. MEDICAL COMPLICATIONS DURING PREGNANCY at 112.


n21 Brief Amicus Curiae of Society for Adolescent Medicine at 11.

 [*1]  Appendix B
 
NH Female Leading Causes of Deaths From 1999 To 2002
Leading Cause of 0 to 4 05 to 14 15 to 24 25 to 34 35 to 44
Death Description
Unknown 22 5 5 11 48
Accidents 7 12 44 15 46
Acute bronchitis 0 0 0 0 0
and bronchiolitis
Alzheimer's disease 0 0 0 0 0
Anemias 0 1 0 0 0
Aortic aneurysm and 0 0 1 0 2
dissection
Assault (homicide) 3 0 2 4 4
Atherosclerosis 0 0 0 0 0
Cerebrovascular 0 0 1 2 7
Diseases
Certain conditions 60 0 0 0 0
originating in the
perinatal period
Cholelithlasis and 0 0 0 0 0
other disorders of
gallbladder
Chronic liver 0 0 1 5
disease and
cirrhosis
Chronic lower 0 0 2 0 3
respiratory
diseases
Complications of 0 0 1 0 3
medical and
surgical care
Congenital 20 0 1 5 3
malformations,
deformations and
chromosomal
abnormalities
Diabetes mellitus 0 1 0 2 7
Diseases of 0 0 0 0 0
appendix
Diseases of heart 1 0 3 7 28
Essential (primary) 0 0 1 0 1
hypertension and
hypertensive renal
disease
Hernia 1 0 0 0 0
Human 0 0 0 1 7
immunodeficiency
virus disease - HIV
In situ neoplasms, 2 1 2 2 0
benign neoplasms
and neoplasms of
uncertain or
unknown behavior
Infections of 1 0 0 0 0
kidney
Inflammatory 0 0 0 0 0
diseases of female
pelvic organs
Influenza and 2 0 1 1 2
pneumonia
Intentional 0 2 7 17 24
self-harm (sulcide)
Malignant neoplasms 4 5 9 16 119
Meningitis 0 0 0 0 0
Nephritis, 1 0 0 1 4
nephrotic syndrome
and nephrosis
Nutritional 0 0 0 0 1
deficiencies
Parkinson's disease 0 0 0 0 0
Peptic ulcer 0 0 0 0 0
Pneumoconloses and 0 0 0 0 0
chemical effects
Pneumonitis due to 0 0 0 0 0
solids and liquids
Pregnancy, 0 0 1 5 1
childbirth and the
puerperium *
Septicemia 0 0 0 2 2
Tuberculosis 0 0 0 0 0
Viral hepatitis 0 0 0 0 1
NH Age Group Death 124 27 81 92 318
Totals
* Included ICD10 codes (O00 through O99).
 [**36] 

Leading
Cause
Leading Cause of 45 to 54 55 to 64 65 to 74 75 to 84 85 plus Total
Death Description
Unknown 78 104 259 489 801 1,822
Accidents 28 27 29 75 86 369
Acute bronchitis 0 0 0 2 5 7
and bronchiolitis
Alzheimer's disease 1 4 25 165 409 604
Anemias 1 0 1 2 17 22
Aortic aneurysm and 2 2 12 47 42 108
dissection
Assault (homicide) 3 2 2 1 2 23
Atherosclerosis 2 2 12 35 76 127
Cerebrovascular 25 32 110 412 671 1,260
Diseases
Certain conditions 0 0 0 1 0 61
originating in the
perinatal period
Cholelithlasis and 1 0 0 6 16 23
other disorders of
gallbladder
Chronic liver 13 28 29 30 9 115
disease and
cirrhosis
Chronic lower 27 74 211 340 263 920
respiratory
diseases
Complications of 1 2 3 5 5 20
medical and
surgical care
Congenital 3 3 0 7 4 46
malformations,
deformations and
chromosomal
abnormalities
Diabetes mellitus 16 33 89 171 139 458
Diseases of 1 0 0 1 0 2
appendix
Diseases of heart 102 183 474 1,259 2,282 4,339
Essential (primary) 5 1 11 29 61 109
hypertension and
hypertensive renal
disease
Hernia 1 1 0 3 7 13
Human 0 0 0 0 0 8
immunodeficiency
virus disease - HIV
In situ neoplasms, 3 2 12 33 46 103
benign neoplasms
and neoplasms of
uncertain or
unknown behavior
Infections of 0 0 0 0 0 1
kidney
Inflammatory 0 0 1 0 0 1
diseases of female
pelvic organs
Influenza and 2 7 30 84 208 337
pneumonia
Intentional 23 8 5 7 1 94
self-harm (sulcide)
Malignant neoplasms 332 514 851 1,035 626 3,511
Meningitis 0 0 1 1 1 3
Nephritis, 3 10 35 57 78 189
nephrotic syndrome
and nephrosis
Nutritional 1 3 10 14 29
deficiencies
Parkinson's disease 0 0 12 38 35 85
Peptic ulcer 0 4 1 10 22 37
Pneumoconloses and 0 0 0 1 0 1
chemical effects
Pneumonitis due to 1 2 3 16 33 55
solids and liquids
Pregnancy, 0 0 0 0 0 7
childbirth and the
puerperium *
Septicemia 5 13 22 38 27 109
Tuberculosis 0 0 0 2 0 2
Viral hepatitis 1 3 1 0 0 6
NH Age Group Death 680 1,062 2,244 4,412 5,986 15,026
Totals
* Included ICD10 codes (O00 through O99).
 [**37] 
 
Rates based on fewer than 10 events are not computed because they do not meet standards of reliability.
 
NH Pregnancy-Related Cause of Death Compared to Total Deaths By Age Group 1999 To 2002
NH
Cause of Pregnancy-Related
Death Pregnancy-Related Death % of
Age Group Total Deaths ** Total
15 to 24 81 1 1.2
25 to 34 92 5 5.4
35 to 44 318 1 0.3
** No deaths were under 22 years of age.


 [*1]  Appendix C

JUL 20
 
Mr. Walter M. Weber
Senior Litigation Counsel
American Center for Law & Justice
201 Maryland Avenue, N.E.
Washington, D.C. 20002
 
Dear Mr. Weber:
 
We appreciate your interest in the Centers for Disease Control and Prevention's (CDC) efforts to collect and publish maternal mortality statistics (including those related to abortion). CDC makes every effort to identify all such deaths and to present maternal mortality statistics using established scientific methods.
 
The maternal mortality rate is computed as all maternal deaths per 100,000 live births. In contrast, the measure used for abortions is a case-fatality rate which is computed per 100,000 legal abortions. These measures are [**38]  conceptually different and are used by CDC for different public health purposes.
 
CDC calculates the maternal mortality rate per 100,000 live births for the following reasons:
1. To maintain comparability in long term trends for the United States. Estimates of the number of pregnancies (including live births, miscarriages or stillbirths, and induced abortions) in the United States have been published only since the 1970s.
2. The live birth component of the pregnancy estimates is highly reliable. Virtually all births are counted in every year. Estimates of all abortions are based on CDC's abortion surveillance system, which relies on state abortion reporting systems. Estimates of stillbirths, ectopic pregnancies, and miscarriages are based on survey data and are subject to significant sampling error, particularly for smaller population subgroups. Estimates of stillbirths and miscarriages are based on pregnancy history data from the National Survey of Family Growth (NSFG). The NSFG is conducted periodically, every 5 to 7 years. The data are subject to sampling error, particularly for smaller population subgroups. For information on the estimation methodology, see http://www.cdc/.  [**39]  gov/nchs/data/series/sr_21/sr21_056.pdf.
3. To maintain international comparability. Many other countries cannot adequately estimate the number of pregnancies, especially those in which abortion is illegal. Information on miscarriage and stillbirth also varies considerably in completeness. In the interest of international comparability, the World Health Organization has specified that the number of live births should be used for the denominator of the maternal mortality rate.

 
 [*2]  Adjusting the maternal mortality rate for gestational stage is not statistically feasible, because this requires data that are not currently completely available. The Pregnancy Mortality Surveillance System (PMSS) relies primarily on death certificates which do not typically provide this information. Gestational age may be available for some maternal deaths in cases where linkage with other records (e.g., birth certificates, fetal death reports) is possible. Information on gestational age for induced abortions is available in about 42 states or jurisdictions.
 
CDC recognizes that despite efforts to count all maternal deaths (including those abortion-related) in the United States, some remain [**40]  uncounted. The death itself is reported but accurate information on the cause may not be provided. CDC estimates that maternal deaths in general are underreported by 30 to 150 percent (see www.cdc.gov/mmwr/preview/mmwrhtml/ss5202al.htm). The nature of the surveillance systems make it difficult to obtain complete data. The PMSS compiles data from 50 states, the District of Columbia, and New York City. Abortion surveillance involves data from 47 states, District of Columbia, and New York City. These systems are voluntary (CDC does not provide remuneration for data) and rely primarily on death certificate data which may or may not provide information that indicates the death was maternal or abortion-related. In the case of deaths associated with induced abortion, CDC also uses searches of computerized print media databases (Lexis-Nexis) to identify additional cases.
 
At CDC we are very committed to improving data collection systems and providing the most accurate and reliable data on all aspects of maternal and infant health. I hope this information is helpful.

Sincerely,

Julie Louise Gerberding, M.D., M.P.H.

Director

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