Over the weekend I observed that conservatives have been notably silent about the flaky legal reasoning behind Judge Matthew Kacsmaryk's nationwide ban of the abortion pill mifepristone. Today, National Review's Michael New takes a different approach: instead of trying to defend Kacsmaryk's ruling on legal grounds, he claims that mifeprestone is, in fact, more dangerous than you think:
On April 1, the New York Times published a thorough analysis of the research on chemical-abortion drugs. They conclude that a vast majority of the academic studies show that chemical abortion drugs do not pose a significant health risk to women.
OK then! So what's the problem?
However, much of the research on the Times article is not relevant to current risks of chemical abortions obtained in the United States. That is because, on multiple occasions, the FDA has instituted policy changes that likely increased the health risks involved with the chemical-abortion-pill regimen.
....A November 2021 study by Charlotte Lozier Institute scholars appeared in the peer-reviewed journal Health Services Research and Managerial Epidemiology....They found that the rate of abortion-pill-related emergency-room visits increased over 500 percent from 2002 through 2015. The rate of emergency-room visits for surgical abortions also increased during the same time period, but by a much smaller margin.
That sounds like a lot. Let's go straight to the data:
I assume that New's use of 2002 was a typo since data goes back to 2001. During the period of the study, the number of ER visits for chemical abortions increased 532% while the number for surgical abortions increased 488%.
Is that a "much smaller" margin? You can be the judge of that.¹ However, the number of ER visits in 2015 stood at 35.5% for chemical abortions vs. 35.8% for surgical abortions.
This all comes from the Charlotte Lozier Institute, the research arm of Susan B. Anthony Pro-Life America, a group dedicated to electing anti-abortion candidates. Even so, I guess this is the best they could do on mifepristone. I'd say that its reputation as a dependable pharmaceutical is safe for now.
¹For what it's worth, the entire difference is due to a single ER visit in 2001. If, instead of one ER visit that year following a chemical abortion, there had been two, the increase in ER visits through 2015 would have been 266% compared to 488% for surgical abortions. This is a demonstration of the power of cherry picking increases from tiny starting numbers.
But why were visits to the ER increasing at all?
I would hazard a guess that there is way more use of chemical abortions now then there was before hand, so more people means more ER visits even if percentage of users visiting ER's doesn't change. The increase in surgical abortions leading to ER visits is a little more complicated. As more people use chemical abortions, fewer low risk cases use surgical procedures, so the percent of cases needed ER visits goes up as surgical abortions case load goes down. Now that should drastically affect total number of ER cases unless....anti-abortion laws delay needed care and create problems. Late term cases with fetal anomalies not consistent with life, but abortion is not allowed until the life of the mother is threatened--so wait for sepsis and then go to the emergency room.
I was wondering if use of the abortion pill in a doctor's office was being characterized as surgical abortion.
I'm going to go out on a limb and guess that there were more prescriptions without an in-house consult, because doctors understood the safety, but patients were still surprised by the heavy bleeding.
This is, essentially, a miscarriage, and so the discharge is much heavier than a normal period; more akin to what one experiences after birth, though of shorter duration.
Which brings up the notion that if this is too shocking and traumatic for women, then they should never be forced to actually give birth to a full-term baby, for that, my friends, is far more difficult, shocking, traumatic, and life threatening. There's a reason Wuthering Heights and Adam Bede had lacked mothers.
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I’m not a statistician, and reading the paper gave me a headache, but it seems a little tortured?
They claim that post-abortion ER visits are underreported, so they use pregnancy data to try and infer the number of actual ER visits were post-abortions?
And they wind up with fully one third of all abortions lead to emergency room visits? That does not seem plausible to me.
but as i said, not a statistician and headache from paper
Definitely a strange paper. Kevin’s data comes from Figure 7, which does claim that in 2015 35% of people who received a chemical or surgical abortion visited the ER within 30 days after the abortion. But Figure 9 seems to say that only 5% of chemical abortions and 2% of surgical abortions resulted in an “abortion-related” ER visit with 30 days.
As near as I can tell, the paper doesn’t address this huge gap between “total ER visits” and “abortion-related ER visits” within 30 days of an abortion. Nor does it attempt any causal explanation for why “total ER visits per abortion” would increase by a factor of 5 between 2002 and 2015.
It does have a lot of gobbledygook about “miscoded procedures.” I’d guess that means “the coding data didn’t show what we wanted so we invented data to support the conclusion our finders wanted.”
The paper is here: https://journals.sagepub.com/doi/full/10.1177/23333928211053965
OK, so explain to me this:
"Not surprisingly, the study found an extraordinarily low percentage (0.01%) of abortion-related visits among all ER visits to women age 15 to 49."
Which referenced a different paper here: https://pubmed.ncbi.nlm.nih.gov/29898742/
Did they really just entirely dismiss that paper's findings?
Oh, wait, that's all ER visits while the first statistic is ER post-abortion. Right?
Still, the second paper estimates 27,941 abortion-related ER visits (including illegal and self-induced), while the first paper claimed 121,283? But the 27941 is over the course of a year, while the 121,283 is over the course of 15 years?
Just asking questions..
I'm sorry I'm being tedious. But Pew Research tells me that there were ~630,000 abortions in the US in 2020.
So the first paper is making a longitudinal study of 423,000 "confirmed" abortions, and inferring that 1/3 of *those* resulted in ER visits. OK. I think I'm getting a handle on that.
So how were those cases selected? They came from "enrollee-level Medicaid Analytic eXtract files licensed through the Centers for Medicare and Medicaid Services (CMS) Chronic Condition Data Warehouse's Medicaid data".
Again, if somebody could clarify for me, would that be a skewed sample? Child-bearing age women in Medicare/Medicaid would be either low-income or have a chronic medical condition?
So many question marks in my posts.
I saw that in NRO Corner this morning. To my surprise, at least at that time, almost all the reader comments criticized the article, mostly on that same point, stating a scary 500% increase without mentioning the low base rate. But it would also seem to be an indication even regular reader of NRO are sympathetic to abortion rights and recognize Kacsmaryk's opinion as crap.
I never thought the GOPs would repeal Roe. It was so valuable as an issue. But it was a collective action problem. They didn't want to repeal Roe, but they all wanted to appear to want repeal. So no one could stand up an stop the process once the activists started the ball rolling.
Volokh Conspiracy, https://reason.com/volokh/2023/04/10/unikowsky-on-judge-kacsmaryks-mifepristone-decision/, quotes and links to a pretty thorough fisking of the decision by one Adam Unikowsky, a one-time Scalia clerk. He hits the usual points: lack of standing, expired statute of limitations, focus on dubious data to the exclusion of first class studies, but he does it in great legal detail. If the Circuit or the Supremes want to punt, they have technicalities aplenty.
I read dozens of medical papers a week. This one was very poorly written. I lost patience with it. However, in the conclusion they did have this paragraph.
"Consistent with CDC reports, we found the percentage of abortions performed by means of mifepristone and misoprostol increased from 4.4% of total abortions in 2002 to 34.1% in 2015. Similarly, ER visits following mifepristone abortion grew from 3.6% of all postabortion visits in 2002 to 33.9% of all postabortion visits in 2015. The trend toward increasing use of mifepristone abortion requires all concerned with health care utilization to carefully follow the ramifications of ER utilization."
So the number of ER visits grew proportionately to how frequently it was used. Now, ignore the charts and look at the raw data. The 630-639 code is abortion related. 634 is miscarriage. What you see if you look at the total number of abortions is that their has been a pretty proportionate increase in ER visits after an abortion for both surgical and medical abortions. You see an increase in total ER visits, also pretty proportionate. That would suggest to me that Medicaid pts increased their total usage of the ER, and since that was increased the number of visits to talk about abortion also increased. The miscarriage numbers I would mostly ignore since they are just speculating about wha they mean, they dont know.
Anyway, when someone does very confusing charts always go look at the original data. Of course what we really want to know is pt outcomes. We already knew pts visit the ER way too much and this was increasing. Were pts actually sicker or having more/worse complications is what we really want to know. There are other studies looking at those questions and the answer is no.
Steve
"Anyway, when someone does very confusing charts always go look at the original data."
Or skip it (the article) completely, specially when it is written by clearly biased researchers. Unless you are an expert in the field and know how to check the underlying data, there are too many ways in which you can be misled.
Thanks Obamacare.
People who needed to use an ER get to use an ER.
I don't have the time to research this properly. ER visits were being used in place of regular health care visits by people who could not afford insurance--which costs everyone a lot. Obamacare meant more office visits and less reliance on ER visits. It can also mean ER coverage, so needed visits to the ER and less waiting at home hoping this too shall pass.
Doesn't address abortion, but ER visits over time (relatively stable, but much fewer uninsured):
https://aspe.hhs.gov/sites/default/files/private/pdf/265086/ED-report-to-Congress.pdf
Medication Abortions, 2002: 4.4% of total abortions, 3.6% of abortion-related ER visits.
Medication Abortions, 2015: 34.1% of total abortions, 33.9% of abortion-related ER visits.
In both cases, medication abortions are underrepresented in ER visits, i.e. they have fewer complications that require ER attention.
How is that bad news for medication abortions?
In any event they always gloss over the fact that pregnancy is dangerous, at least in the US. In 2015, google says there were 32.9 deaths per 100.000 live births. That seems like a lot. By contrast, the homicide rate in San Francisco is around 6.9 per 100,000 residents. So having fun with statistics, getting pregnant is 4 times more deadly than walking around a liberal run criminal hell hole. I don't know how many non fatal pregnancies result in ER visits, but I'll wager it is more than those from using mifepristone.
I find the right-wing concern about the safety of this one particular drug to be very cute. Much like their concern for the safety of birds, but only in relation to windmills.
"Today, National Review's Michael New takes a different approach: instead of trying to defend Kacsmaryk's ruling on legal grounds, he claims that mifeprestone is, in fact, more dangerous than you think:"
This is clearly meant to distract from outrages such as Kacsmaryk's ruling or the Texas governor's pardoning of a murderer as covered in the previous post. Instead of getting distracted by the chaff we should be asking a bigger question: How did we end up here?
How much of this increase is simply people being scared by all the alarming media coverage of the topic?
Leading the reader to wonder what those tiny numbers were. I’d have thought Kevin would have included them as the coup de grace.
"For what it's worth, the entire difference is due to a single ER visit in 2001."
One. The tiny starting number was one.
I’ve only recently started hearing the term “chemical” abortion instead of medical abortion. I can only guess that it is an attempt by the right to come up with a more frightening term to describe the procedure.
Not surprised they would do this but surprised Kevin would go along and use the right’s preferred terminology himself.