Abortion in the United States

RICK WEISS: Hello, everyone, and welcome to SciLine’s media briefing on abortion in the United States. I’m SciLine’s director, Rick Weiss.

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One thing you should know about SciLine as we start this briefing in particular is that we don’t venture into policy or politics. Our focus is on scientific evidence around issues in the news. So you might wonder why we’re having a briefing on a topic that sometimes feels like it’s entirely about policy and politics. And the bottom line is that many of you will be crafting stories on the topic of abortion in the weeks and months ahead because of judicial and legislative battles going on. And we believe it’ll be important as you write about the politics of abortion. It will be important for you to have the basic objective facts about abortion, too, so you can include them along with those matters of opinion that will be so much the focus of what you write. So we’re really happy to provide that straight, factual take on the statistical, medical and mental health aspects of abortion, what the research says on those topics to include in the stories that you produce on this topic.

Finally, before we start, a couple of quick logistical details – we have three panelists today, who will make short presentations of about five to seven minutes each, before we get into the Q&A. To enter a question either during or after these presentations, simply hover over the bottom of the Zoom window, select Q&A and enter your name, your news outlet and your question. And if you want to pose that question to a specific panelist, just be sure to note that. A full video of this briefing should be available on our website by tomorrow. And a time-stamped transcript should be available by Monday. But if you’d like a raw copy of the recording more immediately, please just submit a request with your name and email in the Q&A box, and we can send you a link to the video by the end of the day today. You can also use the Q&A box to alert SciLine staff to any technical difficulties.

OK, to get started I’m not going to give full introductions to our speakers. Their bios are on the SciLine website. I’ll just say that we will hear first from Dr. Amanda Stevenson – that’s Stevenson with a V – an assistant professor in sociology at the University of Colorado Boulder, who will give an overview of abortion-relevant statistics and demographics and some of the factors that affect those numbers and trends. Second, we’ll hear from Sarah Prager. Dr. Sarah Prager is a professor of obstetrics and gynecology at the University of Washington, who’s going to look at abortion through a medical lens for us, including an overview of different types of abortion procedures and what’s known about any long-term physical health effects of getting or not getting an abortion. And third, we’ll hear from Dr. Diana Greene Foster – that’s Greene with an E at the end – who is director of research for advancing new standards in reproductive health at the University of California at San Francisco. And she will outline what the research says about mental and physical health impacts of considering or deciding to have an abortion, actually having an abortion or being denied or unable to access abortion services. And with that overview, I’m going to turn it over to you, Dr. Amanda Stevenson, to get us started.

[0:04:42]

AMANDA STEVENSON: Thank you. So I’m going to provide a very brief overview of some statistics about abortion in the United States and the demography of abortion in our country. But before I begin, something very important about abortion in the U.S. is that we have a really huge absence of central public health data collection about abortion in the United States. Reporting abortion statistics to the CDC from the states is voluntary. So some states, including the largest state, California, do not report their statistics to our federal government. As a consequence, official abortion statistics are always wrong and incomplete. And as – and because of that, NGOs have stepped in, or specifically one, the Guttmacher Institute, who fields – intermittently – surveys funded by private organizations that provide us with the only nationally representative data we have about abortion in America. So most of what I’m going to describe today is – comes from two surveys that the Guttmacher Institute intermittently fields. And it’s going to be several years out of date because these are not things that are done every year.

So this is a graph depicting the number and rate of abortions in the United States annually since 1973. You can see the number of abortions in – on the orange line and the rate of abortions, so I’m going to provide a very brief overview of some statistics about abortion in the United States and the demography of abortion in our country. But before I begin, something very important about abortion in the U.S. is that we have a really huge absence of central public health data collection about abortion in the United States. Reporting abortion statistics to the CDC from the states is voluntary. So some states, including the largest state, California, do not report their statistics to our federal government. As a consequence, official abortion statistics are always wrong and incomplete and as a – and because of that, NGOs have stepped in, or specifically one, the Guttmacher Institute, who fields intermittently surveys funded by private organizations that provide us with the only nationally representative data we have about abortion in America. So most of what I’m going to describe today is – comes from two surveys that the Guttmacher Institute intermittently fields, and it’s going to be several years out of date because these are not things that are done every year.

So this is a graph depicting the number and rate of abortions in the United States annually since 1973. You can see the number of abortions on the orange line and the rate of abortions is the number of abortions per reproductive age – per 1,000 reproductive age women in the U.S. over time in the blue line. You can see that the number and rate of abortions increased rapidly after abortion was made legal in the whole U.S. by Roe v. Wade and then stayed relatively stable through the ’80s and then started declining and has been declining since the ’80s. So the last year on this graph is 2017. This is because this is the last year for which we have an estimate of the total number of abortions in the United States provided by the Guttmacher abortion provider surveys.

So this is a survey of abortion providers. This tells us information about how many abortions are provided. It doesn’t tell us about the characteristics of abortion patients. But it does tell us how many abortions happened in the U.S. So you can see that this decline has been happening for a long time, and actually in 2017, we had the abortion rate falling below the rate at which abortions were provided in the first year abortion was legal in the whole U.S. So there’s – abortion has been declining. It’s gotten pretty low. The reasons for this decline are probably many. There are – you know, people get pregnant for lots of different reasons and don’t want to have kids for lots of different reasons. One important thing is that there are probably – these declines are probably not driven by abortion restrictions through 2017. And there looks like – looking at the CDC data, which, like I said, always wrong, it looks like there may have been a sort of attenuation of the decline. So the CDC data actually tick up in the last year for which those data are available, which is 2018. So it’s possible that the decline in abortions has stalled. We don’t know, though, for sure because, like I said, the CDC data are wrong.

Some of the reasons that scholars think that abortion may be declining include improvements in the contraceptive method mix. So people are using more effective methods of contraception now than they were in the past, including IUDs and implants instead of, say, condoms and oral contraceptive pills. There probably have been increases in the – there probably have been increases in people being able to avoid pregnancy when they don’t want to be pregnant – so declines in people becoming pregnant before they want to or after they’ve already completed their family size – declines in pregnancy generally potentially. And there may be – there may be increases in self-managed abortion or increases in abortion stigma, which would both depress the rates at which people have abortions in the United States. So one thing that we know is not associated, like I said, with these declines is the implementation of abortion restrictions by 2017. Abortion rates vary dramatically by U.S. state. This just provides the state level abortion rate. So this is the number of abortions per reproductive – per 1,000 reproductive aged women in 2017; also from the Guttmacher Institute. The variability in abortion rates by U.S. state almost – is almost as broad as the variability in abortion rates by nation of the world. The abortion rate in Wyoming, which has the lowest rate, is almost as low as the rate in countries that completely outlaw abortion. And the abortion rate in some of the states in the northeast is almost as high or as high as countries from the former Soviet – former Soviet republics, which have some of the highest abortion rates in the world. So we have a really huge variation in the rates at which people access abortion care in this country.

People who get abortions, we know about them because the Guttmacher Institute fields an abortion client – abortion patient survey – intermittently, like I said. The last year that this survey was conducted was 2014. So the ages of abortion patients in 2014 are depicted on the right hand side of this graph, and the ages of abortion patients in 2008 for comparison are depicted on the left-hand side. So this is the distribution of people getting abortions by age. Most people who get abortions in the U.S. are in their 20s. A plurality are in their early 20s. And while abortion has been declining for everyone, abortion has declined the most for teenagers. So this is not surprising because pregnancy in general has declined for teenagers. We’ve seen huge declines in teen births over the past 20 years as well. The Abortion Patient Survey that Guttmacher conducts also allows us to describe the characteristics of people who are getting abortion in terms of their race, ethnicity. People of color are overrepresented among abortion clients – and I would be happy to discuss that in a Q&A, as I’m sure would the other panelists. And people who are poor or low-income are overwhelmingly overrepresented in people who are seeking abortion. Most people who get abortions have already got at least one kid. We know about their, people who get abortions, religious affiliations as well, if that’s of interest. Abortion mostly happens very early in pregnancy in the United States. About two-thirds of abortions happen at or before 8 weeks gestation, and this fraction that’s occurring very early in pregnancy has been going up over time as we’ve seen rapid increases in the use of medication abortion among people getting abortions in the U.S. Only about 1.3% of abortions happen after 20 weeks.

Abortion restrictions have been increasing in the past decade. We saw this massive uptick in states introducing new laws and passing those laws into effect in 2011. And we saw a pretty high rate at which states were doing this through the 2010s. And then in 2019, we saw states implementing or introducing and then passing laws that banned abortion at very early gestations. One of those laws, of course, was allowed to go into effect, the one in Texas. And we’ve seen sort of an uptick in these very early gestational age bans in the past year as well. So this is just a count of the number of abortion restrictions that went into effect each year since 1973. And you can see that this sort of period since 2011, highlighted in yellow, has seen a very high rate of these laws going into effect. And then the last few years, we’ve seen these new very early gestational age bans going into effect as well. Those – the abortion restrictions from that yellow period were also very onerous and prevented many people’s access to these services. This is not to say that they weren’t also very serious. OK, so thank you.

[0:12:44]

RICK WEISS: Fantastic. Great introduction. Thank you. And we’ll move here to Dr. Sarah Prager.

[0:12:52]

SARAH PRAGER: Right. Thank you very much. And let me share my screen here. OK. So my task is to really talk to you more about the medical aspects of abortion in the United States. And I want to start, though, by saying language really matters, and you all as reporters know that. How we talk about abortion has really wide implications, both on patients and individuals, those who have abortions, those who might need one in the future. It also has implications on legislation and regulation. So we need to understand more about abortion before we understand how that language is really important and impactful. What is an induced abortion? An induced abortion is the act of doing or taking something to end a pregnancy.

And here is my first point about language. We avoid using the term elective abortion. Not one single patient who gets an abortion considers it elective. It is always indicated, for some reason or another, and providers as well feel that way. So why do we say induced? That is primarily to differentiate it from spontaneous abortion, which is also known as a miscarriage. Medication abortion is the administration of a mifepristone tablet that gets swallowed, and this is typically dispensed by a clinician. And that is followed, usually the following day, by four misoprostol tablets that are self-administered at home by the patient. Then the passage of the products of conception occurs at home. One thing that is poorly understood by some people is that mifepristone is highly regulated like dangerous medications even though mifepristone itself is very, very safe. For mifepristone currently, the FDA requires that a provider register to be able to dispense this medication. It is not a medication that I as a physician can write a prescription for for a patient to pick up at a pharmacy. And I’m happy to say more about that in the Q&A. Currently, 28% of OB-GYNs not providing medication abortion would do so if they could just write a prescription for mifepristone.

Uterine aspiration is also available, and this can be done either with a manual or an electric vacuum aspirator. And in the first trimester, this typically takes less than five minutes to accomplish. It usually does not require anesthesia or an operating room in the first trimester and sometimes beyond that.

Once we’re getting past 14 weeks, you still have those two basic options of doing a surgery or a procedure or using medication. The surgical option that we talk about is a dilation and evacuation and a subset of that is an intact dilation and evacuation. And then the medical option usually still involves misoprostol plus/minus mifepristone or other medications to induce a labor. And this generally happens in a hospital, often not until approximately 16 weeks or later although it can happen at any gestation.

The decision-making by patients is very different, however. If somebody wants something that is discreet and has a very definitive time at which it’s going to occur, potentially wanting something in an outpatient setting and not hospitalization, then surgical might make more sense, also has a lower complication rate. Patients choosing medical management often want something that feels more natural to them, or they want an option to hold a baby after the delivery. Or if the fetal tissue is required to be more intact for pathologic or autopsy evaluation, they often will choose medical management. However, they also need to go into that knowing that a procedure may be required if that process isn’t successful or if there – or if it’s incomplete.

There are a lot of myths about abortion, and that’s why we’re here today. There are no long-term health risks from abortion. It is not associated with a future risk of infertility or ectopic pregnancy, spontaneous abortion, birth defects or preterm delivery. There also are not increased risks of mental health problems compared to carrying a pregnancy to term. And my colleague Diana’s going to say much more about that.

We are talking about language throughout this discussion here. And there’s a real difference between clinical language and then more biased language that we often hear used in political or policy or legal discussions about abortion. I’m sure all of you have heard the term late-term abortion. That doesn’t actually have a medical meaning. A late-term pregnancy is a pregnancy between 40 and 42 weeks. And so that really has no relevance when speaking about abortion. If talking about an abortion that is later in a pregnancy, we simply say abortion later in pregnancy. You may also have heard the term partial-birth abortion. That is not a medical term. There is no medical definition of that. What they are typically referring to is what we medically call an intact dilation and evacuation.

At the heart of one of the new Texas laws is this concept of a fetal heartbeat. And again, this is very challenging to message, but it is complicated. Medically speaking, a pregnancy is not considered to be a fetus until after seven weeks. And this law is applying prior to that point. So that’s one point. The other point is that when we hear the word heartbeat, we picture a fully formed heart. And what we’re really talking about is the electronic signal picked up by, really, a vestigial organ that is not yet a fully developed, four-chamber heart. That doesn’t happen until, typically, about nine or 10 weeks in a pregnancy. And what we are seeing and/or hearing is what an ultrasound machine translates into what people conceive of as a heartbeat. So we refer to that as electronic cardiac activity, not a fetal heartbeat. And then final, you may sometimes hear the term chemical abortion. That, again, has no medical meaning. And we talk about a medication abortion. As mentioned, there are a lot of legislative restrictions. And the reason why I’m also bringing that up in spite of my focus on the medical or the scientific part about this is that they often get the medicine and the science wrong in those legislative policies.

So Texas SB8 is a ban on abortion after roughly six weeks of gestation. And then Texas SB4 is a ban, then, on most access to medication abortion – so really restricting that down so that virtually no abortions can be obtained now in the state of Texas. These particular laws are new. But they’re part of a decades-old trend towards creating restrictions for abortion. Right now, 36 states require abortion to be performed by a physician. Oklahoma, in fact, is trying to require that only OB-GYN physicians can perform abortions in spite of the fact that many physicians and many other types of health care professionals are well-trained to perform abortion. Forty-three states ban abortion after a particular gestational age limit even though there is no gestational age noted in Roe v. Wade. And 18 states require clinicians to give patients false information about abortion actually requiring physicians to lie to their patients, which is against our medical ethics.

Some of those – some of the false information that we are asked to present in certain states is that there is a link between abortion and breast cancer or that there is a link between abortion and depression or anxiety or even suicidality. There are currently 25 states that mandate a waiting period between consent and provision of an abortion. And that can be between 24 and 72 hours. And then 36 states require parental involvement. And that can be notification and/or consent of minors. It’s important to focus on maternal mortality when we’re talking about abortion access because access to safe and legal abortion decreases maternal mortality. Right now, women in the United States are more likely to die from childbirth or pregnancy-related causes than women in other parts of the developed world. And that risk is higher for some populations. It is higher for Black women in this country and American Indian and Alaska Natives, as you can see in this graphic with the green bars, as compared to white women in the United States are listed here.

So the overall maternal mortality ratio right now in the United States is approximately 17 per 100,000. But we know that people who are disproportionately impacted by restrictions are also those who are facing higher rates of maternal mortality if they cannot access those abortions. I am showing this slide because it is an indication of how much knowledge people have about abortion. And often what people think about abortion is not the true picture. If you look in the medium blue part of the bar here and the light blue bar, those are indicating people who consider abortion to be about as safe or less safe than giving birth or getting the appendix removed or getting tonsils removed. And as you can see, the majority of people consider abortion to be pretty unsafe, actually.

But the reality is that the risk of mortality from abortion – and these are data presented in 2012. The risk of mortality from abortion is 0.7 per 100,000, as compared at the time to a risk of death from childbirth, which is nine per 100,000. And, you know, just to compare, again, to one of the procedures mentioned in the prior slide, the risk of dying from a tonsillectomy was three to six per 100,000. So abortion is actually significantly safer than carrying a child to term and many other minor procedures. Thank you.

[0:23:07]

RICK WEISS: Thank you, Dr. Prager. And we will move now to Dr. Diana Greene Foster.

[0:23:15]

DIANA GREENE FOSTER: Thanks so much for having me on this panel and for talking about some of the science that has recently been put forward to help us understand the consequences for people receiving or being denied an abortion. So I’m going to talk about The Turnaway Study, which I led, which describes the mental health, physical health and socioeconomic consequences for women who received an abortion compared to carrying an unwanted pregnancy to term. And note, this is super relevant. What people – because the imposition of restrictions may actually increase the number of people who cannot get their wanted abortions, this comparison tells us what we might expect of the consequences from further restrictions.

So we recruited people from 30 abortion facilities across the country where if you’re too far in pregnancy, for these sites, there’s no one within 150 miles who will do an abortion later. So this is, in fact, a study exactly of gestational limits, which is what the Dobbs case that’s coming up is also about. This – we had just under 1,000 women who sought abortions over a three-year period. A quarter of them were turned away. A quarter of them were in the first trimester, and a half of them were just under the limit and got their procedure. And we followed them for five years with semiannual phone interviews, and we’ve published over 50 papers in peer-reviewed science journals. And I’m going to highlight some of the most important ones.

My colleague Antonia Biggs, a psychologist, looked at many of the mental health outcomes because there was a concern that abortion harms women. And so it’s really important to know since something between a third and a fifth of American women will have an abortion. If abortion harms women, we definitely need to know. But if we restrict abortion on that basis, we also know – need to know if restricting access to abortion harms women. And what she found was that women who were denied abortions actually experienced more anxiety and lower self-esteem at the time of abortion denial than those who received their abortion. But the groups converged by six to 12 months, and we don’t see a difference after that point. And on the outcomes like depression, suicidal ideation, post-traumatic stress, life satisfaction, we actually don’t see a difference at any point between the two groups. And that’s not because those who receive an abortion and those who are denied are both doing badly. In fact, both groups improve over time. So let me just give you one graph to show you. This is one where there’s a difference. This is anxiety. You can see elevated anxiety among the people who are denied abortions. By one year, they’re the same as the people who receive it. And anxiety actually goes down over time. So there is no mental health harm from abortion and no long-term mental health harm from denial of abortion. But there are some very big differences alluded to by my – by Dr. Prager before me.

I’m looking at what the effect is on people’s physical health. And two epidemiologists, Lauren Ralph and Caitlin Gerdts, led these analyses. What we find is that women who were denied abortions and give birth are more likely to experience over the five years higher rates of gestational hypertension from that and subsequent pregnancies in both groups, higher likelihood of a couple of kinds of chronic pain and are more likely to report fair or poor health. We don’t find any differences in physical well-being between the people who have a first trimester and second trimester abortion. And the saddest finding of the whole study is that two women denied abortions actually died from childbirth-related causes because they were denied an abortion and carried the pregnancy to term. That’s an astronomical death rate. It’s much higher than Dr. Prager presented to you. And I think it’s a sign. It’s an indication that carrying a pregnancy to term is associated with a lot of risks. And when people aren’t – don’t feel ready to do it, this is a very big physical health risk that they didn’t necessarily sign up for. Just to show you some of the data, this is self-rated physical health showing higher poor or fair health among people denied abortions than people who receive them over time. This is in the Annals of Internal Medicine paper. Turning our attention to – one of the areas where the biggest differences is in socioeconomic status. I led some of these analyses, and an economist from Michigan led some others of these analyses.

And when you ask people, why do you want an abortion, the leading reason people give you is that they can’t afford to have a child. And what we find is large and significant economic differences in the well-being of women who are denied abortions facing more hardship than women who receive them. And there’s an increase in public assistance, but it’s not enough to offset a loss of employment income. And therefore, houses are more likely to fall below the federal poverty level. And it is not the case that, when a woman is denied an abortion, that somehow that the man involved in the pregnancy helps support the family. There is no difference in the chance that she’s actually still with him in a romantic relationship and that he’s supporting the child. And just one graphical presentation – this is the chance that the household is below the federal poverty level. And you can see before in the first data point that they are the same. And then over time, women who are denied abortions are more likely to be poor than people who receive their abortions. One more set of outcomes – another reason people often give for wanting to have an abortion is they want to take care of the children they already have. And we can see differences in children’s well-being based on whether their mom received or were denied an abortion.

The majority of people – as Dr. Stevenson said, the majority of people who have abortions are already – have already given birth. And what we find is that the children whose mothers received an abortion were less likely to live in poverty than the children of women who were denied abortions. We also see differences in the chance that the existing children achieve developmental milestones compared to the children whose mothers – those whose mothers were denied the abortion are less likely to achieve developmental milestones than the children of women who received an abortion. I have to read the paper to get the – get all the details. A few other differences in life outcomes – my colleague Dr. Upadhyay looked – showed that women who receive an abortion are more likely to set and achieve aspirational plans in the coming year. A doctoral student at University of Nebraska used the data to show that women who receive an abortion are more likely to set aspirational plans for the next five years. My colleague Dr. Ralph again showed no differences in graduation or dropping out between those who received or were denied abortions, but those who received abortions got higher-level degrees than women who were denied.

And then one more result – this is my colleague Dr. Roberts – looked at experience of violence from the man involved in the pregnancy. And I already said that there’s no difference in the chance if the woman is in a relationship with him, but there is ongoing contact for people who carry the pregnancy to term. And that ongoing contact with the man involved in the pregnancy explains Dr. Roberts’ finding that women who receive an abortion have – experience a dramatic drop-off in violence from the man involved in the pregnancy, and those who are denied and carry the pregnancy to term have – are level. There is no drop.

And we have lots of quotes from women that you can – I have one – all reporters want to find an example of a woman to profile. Well, we have full stories of people about their experiences told in their own words. But here’s one very astute woman about her experience. She was denied an abortion, and she said, it’s very, very difficult to find a job when you’re pregnant, to keep a job when you’re pregnant or find or maintain a job with a baby, especially if your partner doesn’t want to help. And she attributes domestic violence to him having control over whether – of her location and housing her. And she says, pregnancy is an incredibly scary thing if you cannot trust the person you’re with. So more – for more information about the study, we have an annotated bibliography which talks about all our findings and all our scientific papers. There’s a book that contains the story of the science and the findings. And also, 10 women profiled – who participated in the study. And please feel free to email me also if you have more questions that aren’t answered in the Q&A. Thank you so much.

[0:32:18]

RICK WEISS: Thank you, Diana. And to all three of you, it’s so interesting to see that on a topic that seems, to so many people, to be simply a matter of personal opinion that there are some data to look at. They don’t resolve these questions for us, but they can certainly inform the question going forward. And I’m so appreciative that you’ve been able to share these research data to help serve as a foundation as reporters dig into this topic.

We typically start these Q&A sessions with just one question from the moderator here while we start collecting your questions. And again, a reminder to hover over the Q&A icon at the bottom of your screen to submit those questions. And I want to ask each of you, for starters, if you can give one bit of feedback to the journalistic community that covers this topic, that’s been covering it for so long, either something about the coverage that you see that you appreciate and think helps the cause of accurate and evidence-based reporting on abortion or something you see that goes on in journalism on this topic that you wish were different or done better. And why don’t I start with you, Amanda, to get your take on that.

[0:33:32]

AMANDA STEVENSON: I think that coverage of abortion in the media has gotten a lot better in the last decade. I’m very grateful for the many journalists who have become more expert in this work. And so I think that – I’m grateful for the work that I’ve seen people putting in. And the improvement has been the result of lots of labor. So mostly I just want to say thank you for that.

[0:34:00]

RICK WEISS: Great. Thank you. Sarah?

[0:34:05]

SARAH PRAGER: Thank you. And I’ll echo what Amanda said, but also add that I think what often gets missed is how unbelievably safe abortion is and also that it is extremely brief. You know, people – I would say the vast majority of my patients also don’t understand that this is a sub-5-minute procedure that we’re mostly talking about and that it is really, really safe, particularly in comparison to continuing the pregnancy. And I think that that is often not mentioned at all or underemphasized in reporting. Thank you.

[0:34:45]

RICK WEISS: And Diana?

[0:34:46]

DIANA GREENE FOSTER: I’m glad Amanda could start by being so positive, so I can balance that out. Wow, there are so many articles that talk about abortion entirely as a political topic, like what party’s winning, what party’s losing, you know, what are the – let’s all debate the philosophy behind it and no data about who’s affected, why anybody would want to have an abortion. And so without the people who are actually involved, you can think that it’s easy to debate this and come to some conclusion if you’ve completely omitted from the story the people who are affected by these laws. So it isn’t an abstract debate. Yes, it has big effects on our politics. But to omit the people who are actually affected is a problem, and it’s what allows us to continue to have this fight without any data, without any, you know, shift of perspective, as if it’s just a political – not debate but fight, a political fight instead of something with real-life policy impact.

[0:35:55]

RICK WEISS: OK. So that’s a great way to get us started. And now I’m going to start looking at some questions from our attendees. And I have a question first here from Joyce Frieden at MedPage Today asking Dr. Stevenson, at least for starters – and I encourage all of you to chime in on any of these – but she says that, I would be interested in knowing more about religious affiliations of people getting abortions, something that you left a little teaser about in your presentation.

[0:36:24]

AMANDA STEVENSON: So again, these statistics come from the Guttmacher Institute’s abortion patient survey from 2014. In that year, 62% of people getting abortions were religiously affiliated. So most people getting abortions are religious. And the representation of people by religious affiliation was roughly reflective of the U.S. population except evangelical – Protestant evangelicals. They were underrepresented. But there were still plenty of Protestant evangelicals getting abortions in 2014.

[0:36:59]

RICK WEISS: I have a question here from Ciara McCarthy at the Fort Worth Star-Telegram. What’s the most reliable estimate or source for how many pregnant people died from unsafe abortions in the pre-Roe era? And given the increased accessibility of medication abortion, what’s the best context with which to present pre-Roe figures in 2021?

[0:37:25]

SARAH PRAGER: This is Sarah Prager. I can try to tackle that. There are no reliable data prior to Roe, so I don’t feel comfortable even positing a number for that. Abortion was so unbelievably stigmatized that the data collected just are not a reflection of reality. What I will say is that we have natural experiments in other countries where we can look at maternal mortality when abortion is legal, when abortion is illegal and then when abortion is legal again. And Romania provides us a really great example of that where, under Ceausescu, abortion was made illegal. And you saw an abrupt and significant rise in maternal mortality. And then it was again made legal, and you again saw an abrupt and significant decline in maternal mortality. So there are these unfortunate natural experiments that you see elsewhere that are not due to what can be traced to other policies.

The second part of your question about – what can we expect with medication abortion now being available? – I would say that access to – mifepristone and misoprostol or just misoprostol is certainly safer and more effective than many of the methods that people were using in pre-Roe days. And it’s still – we still need access to those medications in order to be able to obtain the benefit from them. And that can be obtained through legal or illegal means, so I think we’re going to come to a point where we’re having to differentiate between illegal and unsafe abortion. We historically have equated those two to be the same thing. And I think illegal use of mifepristone and misoprostol is not unsafe but certainly would be preferable to be provided in a manner that a patient would prefer, which, most of the time, is in a clinical setting and in a legal manner.

[0:39:46]

RICK WEISS: That’s a very interesting new distinction that you’re introducing – of possibly linking illegal with safe. So I think that’s interesting. Just while you’re on this topic, Dr. Prager, maybe you could unpack a little bit about what you mean when you say these medications are not available by conventional prescription. What does a physician actually have to do to provide this kind of abortion to a woman?

[0:40:12]

SARAH PRAGER: Thank you for asking for clarification. So currently, because this is not a prescribable medication, the – a provider like myself, I have to register with the company that manufactures mifepristone. They will send that medication to my clinic, and then I have to hand that medication to a patient in the clinic setting. This has been a huge – as I indicated in my brief presentation, this has been a huge barrier for a lot of providers to actually give – you know, provide medication abortion but also to patients who would prefer to just go to a pharmacy and pick up those medications.

We have seen some attenuation of that restriction during the time of COVID, particularly it was allowed and then not allowed and is now allowed again in some settings to mail the medications and to do consent through telehealth, like we do many other medical processes currently. And that, I imagine, is going to continue post-COVID in the states that allow it. So there are also – there is a lot happening through policy to try to remove the current restrictions on mifepristone. But those restrictions still exist.

[0:41:40]

RICK WEISS: Anything further on that from either of you before I move on? OK.

[0:41:45]

AMANDA STEVENSON: I’ll just highlight something Diana said here, which is that in her study, the rate at which people who were denied abortions and then went on to give birth died was – was it 1 1/4, Diana? Is that right? – very high. And this indicates that the ratio of the safety of abortion to the safety of staying pregnant or giving birth is potentially far more severe for people who are seeking abortions now. So it is important to note that these are all very conservative estimates of how much safer abortion is than having – like, staying pregnant.

[0:42:28]

RICK WEISS: OK – a question here from Tom Wright from WJTV 12 News in Jackson, Miss. Mississippi, as I said, many of us are aware, the attorney general heads to the U.S. Supreme Court December 1 to argue Dobbs v. Jackson Women’s Health Organization, the latter being the state’s only abortion provider. It’s a fairly direct challenge to Roe v. Wade. What would be the impact on smaller, poorer states, such as Mississippi, should the case lead to Roe’s overturning?

[0:42:59]

DIANA GREENE FOSTER: I can start with this, which is that many states are poised to ban abortion if Roe – if the Supreme Court doesn’t uphold Roe. And those states – in those states, somewhere between eight and 15 will end the right to abortion in their state if the court no longer says that abortion is federally protected. And all of the consequences that we found in The Turnaway Study of people who – the consequences for people who cannot access a legal abortion and carry the pregnancy to term will happen for those people. There will be economic consequences. There will be physical health consequences and life consequences, like not being able to have a child later under better circumstances. So it’s not going to produce the best results for children to ban abortion either.

And as, I think, Dr. Prager pointed out is that many people will get their abortion even if it’s not legal. Some of the decline that Amanda Stevenson showed in clinic-based abortions is ’cause people are ordering pills online or getting pills some other way. There are many organizations – and they’re not all illegal – that – where you can order pills that are the same pills you would get at a clinic. So we don’t really have a great handle on how much the decline in clinic-based abortions is because people are already trying to get around the, I think, restrictions that make it harder to get to clinics and are trying to do their own – provide their own abortions.

[0:44:41]

RICK WEISS: Interesting. Any other comments on that question, impact of this case? All right. Oh, go ahead. Sorry.

[0:44:48]

SARAH PRAGER: I have one comment, which is just to build on what Dr. Greene Foster was saying, which is that, again, we really need to keep in mind on – you know, what the actual impact of this is. This isn’t just a political decision if Roe is overturned in Mississippi or anywhere else. What we’re doing if we’re saying patients are denied access to abortion is we’re saying we require you to have a baby and all of the risks attendant in that and to carry that pregnancy to term or find some inaccessible way to access abortion. But we’re really saying we think that the – we are requiring continuation of pregnancy and parenthood is what those laws are saying. And I think we need to understand that that has a real-life medical implication, not just social implications and political implications.

[0:45:46]

RICK WEISS: OK.

[0:45:49]

DIANA GREENE FOSTER: And I think Dr. Stevenson has some estimates of the effect on maternal mortality. Let’s see if she wants to be put on the spot.

[0:45:57]

AMANDA STEVENSON: Yeah, I was just about to say that. Thank you, Diana. I did estimate how many additional people would die from pregnancy-related causes in the United States in the absence of abortion altogether. So if nobody was able to get their abortions, how much would the number of people dying go up? And it would go up by 21% overall. The increase would be concentrated, though, among Black people. So the number of people dying from pregnancy-related causes for Black would go up by a third. So we would see substantial increases in pregnancy-related death in the absence of abortion in this country. And these are the most conservative estimates I could generate. I mean, I, like, took everything down to the very bottom. So the actual increases would likely be greater. It’s important to note, however, that these increases in death assume that nobody gets their abortions. So no one’s self-managing. No one’s traveling to other places to get abortions. Everyone’s staying pregnant and then experiencing delivery and birth.

So – although I do include assumptions that some people will miscarry and so forth because that does happen. So this increase would occur if nobody could get their abortions. What this means is that if organizations are able to help people access abortion via helping them travel like abortion funds do or by helping them terminate pregnancies via self-management with medication abortion, then that would make the increase in pregnancy-related death less. So basically, there are ways to reduce the mortality consequences of abortion bans, and they basically look like helping people get around them.

[0:47:30]

RICK WEISS: And how does that percentage increase translate out to absolute numbers?

[0:47:35]

AMANDA STEVENSON: A hundred and forty additional deaths a year.

[0:47:40]

RICK WEISS: All right. Thank you for those data. And I have a question here from Nick Gerbis at KJZZ public radio in Phoenix. This is directed to you, Dr. Prager. Are there other medical procedures reporters can compare abortion to to give the public a better sense of the safety, length, etc. of abortions?

[0:48:04]

SARAH PRAGER: I mean, it’s one of if not the safest medical procedure out there. You saw my final graph that, you know, in comparison to dental procedures, it’s even safer than that or equivalently safe to, you know, certain dental procedures. There’s not much that is as safe as having an abortion, and pregnancy can be rife with complication if it’s continued.

[0:48:32]

RICK WEISS: And a reminder to Nick and others – the slides that you saw today will be posted on our website soon after this briefing if you want to review some of those data. Let’s see. A question here from Beth Wang from Inside Health Policy. What are some of the biggest obstacles to medication abortion access currently? I’m especially interested in FDA’s restrictions and whether you think that affects how states approach their restrictions on the pill. We’ve touched on that a bit.

[0:49:04]

SARAH PRAGER: Yeah. I mean, I think that the restriction that doesn’t allow prescription of mifepristone is the biggest restriction currently. There are a number of states that have – that’s an FDA restriction. There a number of states that have additional restrictions that don’t allow telemedicine when it comes to medication abortion, and they carve that out from every single other procedure or process in medicine. And that’s actually a really good example of how abortion care is exceptionalized and not in a good way across, you know, many parts of this country. There are some countries that allow over-the-counter access to mifepristone and misoprostol because they are inherently very safe medications with very, very, very few side effects. And so that, again, would be an FDA restriction. But, I mean, theoretically, mifepristone and misoprostol could be available over the counter and could be safely used by people seeking abortion.

[0:50:15]

RICK WEISS: Question here from Rosemary Westwood, who’s at WWNO Public Radio in New Orleans. Anti-abortion activists and politicians advancing anti-abortion laws often reference science to support their arguments. And there are organizations of anti-abortion physicians, for example. How do you respond to claims that science supports anti-abortion arguments like fetal pain or PTSD in people who have had abortions? And how do you respond to claims that science, especially the advancement of technology to support fetal survival, support the claim that abortions should be illegal?

[0:50:52]

DIANA GREENE FOSTER: I’m going to take a first stab. So there are no scientific data that say that abortion causes PTSD. So that – you can claim that – if you’re politically motivated and don’t care about the science, you can claim science says something or another. But that – it’s just not accurate. And likewise, people who are knowledgeable about fetal brain development dispute the concept of fetal pain happening before 24 weeks. So there isn’t science. It’s like a claim of science, but it’s not published, good science. And the idea that, you know – that viability line is moving – I think it’s kind of an abstract concept because nobody’s allowing a pregnant person to deliver a pregnancy. The viability is, like, a philosophical point. And so the specifics of whether one can deliver a child or not is moot because nobody is allowing women to do that. It means if – whatever line they set that indicates the line where abortion is no longer allowed – after that point, women are just forced to carry the pregnancy to term, to continue to be pregnant. So I think it’s just misleading to try and talk about, you know, where that line should be exactly and without looking at the science of what the consequences are when people are forced to continue to be pregnant and deliver a child.

[0:52:21]

RICK WEISS: All right.

[0:52:24]

SARAH PRAGER: I could just very briefly add to that and say that the risks of pregnancy are not the same for every person. And so the decision about what risks to accept in continuing a pregnancy are also not going to be the same from one person to another.

[0:52:37]

RICK WEISS: Interesting. Question here from Madeline Heim, a reporter at USA Today based in Wisconsin – I’m a health reporter and would like to write more about abortion from that perspective, from the health perspective, to balance coverage from our state’s political reporters. What stories do you think are most crucial right now that don’t center on the political debate?

[0:53:01]

DIANA GREENE FOSTER: I think it’s really important to interview physicians and nurses who are providing abortion and also people who are trying to make that decision and to understand why. And if you’re primarily interested in health, you certainly can find people who are terminating pregnancies for health-related reasons. And, yeah, and so I think it’s important to center those people in stories on this topic.

[0:53:31]

RICK WEISS: Anyone else on that – story ideas that are non-political?

[0:53:38]

AMANDA STEVENSON: The safety of abortion relative to staying pregnant or having a baby, even putting it in context with other procedures – it’s a compelling story, and it’s surprising to most readers.

[0:53:54]

RICK WEISS: Here’s a straightforward question from Julie James at Mississippi Today. Is Plan B considered a medical abortion?

[0:54:02]

SARAH PRAGER: Great question and one that my mom always gets confused about, too. No, Plan B is a contraceptive. And so Plan B is a medication that is designed to prevent ovulation and therefore to prevent a pregnancy from occurring. That is very different from trying to interrupt an existing pregnancy, which is what medication abortion does.

[0:54:25]

RICK WEISS: OK. And a question here that – maybe, Amanda, this is for you, as it has to do with how stats are maintained. But are termination – sorry. This is from Joyce Frieden at MedPage Today. Are termination procedures that are done after a fetus is no longer viable due to genetic malformation, for example, considered abortions and reflected in statistics?

[0:54:46]

AMANDA STEVENSON: Sarah actually will know better than I this, but yes.

[0:54:50]

RICK WEISS: They are considered abortions. That’s even if the fetus has died – interesting. OK.

[0:55:03]

SARAH PRAGER: They are often included in abortion statistics whether it is a fetus that continues to have, you know, cardiac activity but has lethal fetal anomalies. And also, technically, it would be considered an intrauterine fetal death, but the procedure that is done is still exactly the same if there is actual fetal death.

[0:55:32]

RICK WEISS: OK. We’re getting close to top of the hour. I want to squeeze in a couple last questions here. We might run a minute or two over. Damian McNamara, reporter at WebMD and Medscape, asking – if a woman has an illegal abortion in the future and experiences a complication, would physicians in an emergency department or other clinical setting who treat them face any liability? Not sure under what legal regime this question is presuming, but is there a way to get a handle on that question? Or is it unknown, perhaps?

[0:56:07]

SARAH PRAGER: I can try to address that. It’s complicated. There are states that currently criminalize pregnancy in such a way that women are being prosecuted for having a miscarriage because there are assumptions about attempting self-managed abortion. Whoops, I’m disappearing here. Can you still hear me?

[0:56:30]

RICK WEISS: Yes, we can.

[0:56:31]

SARAH PRAGER: OK, sorry. There are other states where it is the provider who is specifically tasked. But in an emergency, it is our duty as physicians to manage a patient, and this would be considered a complication that we are required to manage and probably not prosecutable. But it’s difficult to say. And it would probably vary state by state.

[0:56:59]

RICK WEISS: All right. A question here for anyone wondering which states require physicians to share false information, as was discussed earlier, with their patients. Is there a list somewhere? Or do they all have to require the same false information? Where can we learn more about that?

[0:57:19]

DIANA GREENE FOSTER: There was a journalist who went and did investigative reporting and actually looked at all the material that states are required. And is there a way that we could post the link to it? Because I’m unable to come up with it off the top of my head.

[0:57:35]

RICK WEISS: Sure. We will post that in the supplemental – with supplemental slides after the briefing if you can share that link with us. We’re just a couple minutes from the top of the hour now, so I really want to swing around to a wrap up here. And what we typically do at the end here is just to go around the horn once and ask each of you what kind of a take-home message you would like to really emphasize for the reporters on the line here who are going to be covering this topic going forward. And we will go through in quick order here. But if each of you could just hammer home some last point that you want to make sure reporters get. Dr. Stevenson, I’ll start with you.

[0:58:15]

AMANDA STEVENSON: Never use the CDC statistics. They are wrong. They know they’re wrong. Never.

[0:58:20]

(LAUGHTER)

[0:58:22]

RICK WEISS: OK. Dr. Prager, I’m going to jump right to you ’cause I know your battery’s getting low.

[0:58:28]

SARAH PRAGER: Thank you. It’s been said, but I’m going to hammer it home. This is not just a question of politics or policy. These are real people who are impacted by these decisions, and there are medical implications, up to and including death, for people who are not able to access abortion, which is very, very, very safe.

[0:58:49]

DIANA GREENE FOSTER: And I’ll add on to Dr. Prager, which is the consequences are not just medical. But when you look at the reasons that people give for wanting to have an abortion, people have a lot of reasons. And when we look at the reasons they give – economic, relationship, their responsibilities to their children, their desires for children later under better circumstances and achieving other life goals – all of the reasons people give for wanting to have an abortion are – those are – concerns are borne out in the experiences of people who are denied. So to me, what that says is that people, when they’re trying to make this decision about what to do with an unintended pregnancy, an unwanted pregnancy, they’re making decisions, careful decisions, and they understand the consequences. And so we can trust people’s decision-making. It’s the – very good science shows that outcomes are worse for people on many of the areas that they specifically identify as being important when they’re unable to get an abortion that they want.

[0:59:58]

RICK WEISS: I want to thank our three panelists today for being such clear – offering such clear explications of what the data say on this topic that, too often, the sort of objective, research-backed, evidential side of is ignored. So we know this is a complicated political policy and belief system topic. We just would like to encourage reporters to remember that there is some science behind this as well, and we hope you’ll include some of that science as you continue your coverage here so that news consumers can make evidence-based decisions in their lives, whether it’s about something personal in their lives or what kind of policies they choose to support. Really appreciate the basis upon which the three of our presenters have worked today. I appreciate all the reporters for logging in today. I want to encourage all of you to follow us on Twitter at @realsciline. You will also, reporters, see a very short three-question survey as you log out today. None of us like filling out these surveys, but all of us here really appreciate getting feedback from you so we can keep choosing topics and handling these briefings in ways that are most helpful to you. Thanks, all, for attending. We’ll see you at the next SciLine media briefing.