On July 11, The Journalist’s Resource and the Council for the Advancement of Science Writing’s CASW Connector hosted an online chat discussing how journalists can better cover hot-button topics, focusing on abortion as an example of a medical topic that has become increasingly political. The panelists shared lessons from their research and reporting, offered guidance for journalists covering abortion, and answered questions from the audience.

The event was moderated by Naseem Miller, senior health editor at The Journalist’s Resource, and the panelists were:

• Sarah McCammon, a national political correspondent at NPR who covers abortion policy among other divisive topics.
• Katie Woodruff, a public health social scientist in the Department of Obstetrics, Gynecology, and Reproductive Services at the University of California, San Francisco.

Below you’ll find a recording of the chat and links to resources curated by the panelists, as well as other links and tips provided during the session.

Sign up for CASW Connector’s and The Journalist’s Resource’s newsletters to receive updates about future online events.

Takeaways from Dr. Woodruff’s research:

• Research links:
  • Coverage of Abortion in Select U.S. Newspapers – PMC, Women’s Health Issues, 2019. 
  • Coverage of abortion in major U.S. newspapers, 2022-23, poster presentation for National Abortion Federation annual meeting, April 2024.
  • More details about Dr. Woodruff’s 2022-23 research from the University of California, San Francisco.
• Her 2019 paper found most news coverage treated abortion as a political buzzword without exploring the issue in-depth.
• Stories largely didn’t cover the experiences of people seeking abortion and omitted basic facts, such as that abortion is common and safe and that pregnancy carries a higher risk for women, especially people of color.
• Following the 2022 Supreme Court decision overturning Roe v. Wade, abortion coverage significantly increased. More stories covered the policy and health aspects of this issue in depth.
• Stories of people seeking abortion are more common in news stories in 2022-23 than pre-Dobbs, but news coverage tends to focus on atypical cases. Basic facts about abortion and pregnancy are still rarely included.
• News coverage also rarely focuses on medication abortion, even though this is now the most common method.
• We have an overwhelming body of evidence showing that abortion is safe, and that anti-abortion policies lead to harm. Journalists could do more to ensure these facts are clearly stated in stories.
• Be careful of language used to describe abortion policies; terms like “heartbeat ban” or referring to people seeking abortion as “mothers” can impact readers’ perceptions.

Finding sources, navigating interviews:

• Reproductive health clinics and providers can offer sources, including doctors and patients. Health care providers are good secondary sources if you aren’t able to talk to a patient.
• Abortion funds and advocacy groups can also connect journalists with sources. (Don’t call an abortion hotline; connect with organizers.) However, some of these organizations have been overwhelmed post-Dobbs and may not have the capacity to or be comfortable with sharing patient information. It is also worth taking note of whether any groups pay sources, as a few do this.
• Ethical consent is important during interviews. Make sure the source understands who you are and how their story will be used. Make it clear what it means to be on- or off-the-record, and let sources know they can choose not to answer a question if they’re uncomfortable with it.
• Vetting information from a source can include searching public databases and checking information between patients and providers.
• Expand your perception of who can be a source. Historians and other scholars may be able to offer historical context for news pieces.
• Providing sources with some level of anonymity, such as using a first name only, can help protect those at more risk from speaking out about their experience. Be clear about your outlet’s policy for anonymity during the interview.

McCammon’s other tips for covering hot-button topics:

• A framework to avoid bias: A journalist’s own experiences and perspectives are not nearly as important to a news story as the evidence. Consider your job to be informing the audience and shedding light on different aspects of an issue, not persuading anyone of a particular argument.
• Personal stories from sources can help your audience understand the impacts of policies on real people. These may be tough to find for some stories but are important to include when possible.
• Don’t assume you have all the answers, even if you’re experienced in covering an issue. Be curious and open-minded.
• Aim to be as accurate and specific as possible in language to reduce misinterpretation. For example, some outlets (like NPR) have moved to use “abortion rights supporter” and “abortion rights opponent” over “pro-choice” and “pro-life.”
• Ask rigorous questions of politicians and policy platforms and weigh their positions against scientific evidence and potential health impacts.

Articles & resources:

• Media briefing: Reproductive health and abortion, SciLine, July 11, 2024.
• Abortion pill mifepristone: An explainer and research roundup about its history, safety and future, The Journalist’s Resource, Naseem S. Miller, November 1, 2023.
• Covering abortion as a health care issue in all its complexity, politics aside, Association of Health Care Journalists, Tara Haelle, May 24, 2023.
• Covering abortion as a health care story, not just a political one, Association of Health Care Journalists, Jordan Gass-Pooré, June 12, 2024.
• NPR Public Editor: How abortion language evolves, NPR, Kelly McBride, April 4, 2024.
• Post-Roe: Journalistic “objectivity” meets the heated issue of abortion, Center for Journalism Ethics, Audrey Thibert, November 29, 2022.
• Editing Controversial Science, in Knight Science Journalism Science Editing Handbook, Laura Helmuth.
• Research highlights need for public health approach in news reporting of gun violence, The Journalist’s Resource, Naseem S. Miller, June 25, 2024.
• Trauma-informed journalism: What it is, why it’s important and tips for practicing it, The Journalist’s Resource, Naseem S. Miller, April 13, 2022.
• Covering scientific consensus: What to avoid and how to get it right, The Journalist’s Resource, Denise-Marie Ordway, November 23, 2021.

This tip sheet was published in collaboration with the CASW Connector, where it first appeared. It has been lightly edited for style.

The post Reporting on hot-button topics as a science writer: Lessons from abortion coverage appeared first on The Journalist's Resource.

This piece was updated on June 13, 2024 to reflect the recent Supreme Court decision about access to mifepristone, and to highlight new research on medication abortion. It was originally published in November 2023, shortly after the interviews with Ruvani Jayaweera and Carrie Baker took place.

On June 13, the Supreme Court justices in a unanimous decision preserved access to mifepristone, a medication that’s used for the safe termination of early pregnancy, writing that “federal courts are the wrong forum for addressing the plaintiffs’ concerns about FDA’s actions.”

The legal future of mifepristone had hung in the balance for several months.

In August 2023, the 5th U.S. Circuit Court of Appeals ruled that mifepristone should not be prescribed past the seventh week of pregnancy, prescribed via telemedicine, or shipped to patients through the mail. In September, the Justice Department asked the Supreme Court to consider a challenge to that ruling.

On Dec. 13, 2023, the Supreme Court justices announced that they would take up the case on the availability of mifepristone. The American College of Obstetricians and Gynecologists issued a statement on the same day urging the court to rule in favor of keeping the pill on the market and available to patients. The justices heard oral arguments on March 26, 2024 before issuing the June 13 ruling.

Meanwhile, abortion is on the ballot in four states this year so far. Measures have also been proposed in several other states, with initiatives that aim to ban, restrict, or expand abortion rights. (State laws that ban abortion apply to both abortion medications and surgical procedures.)

It’s important for journalists covering abortion to have a good understanding of medication abortion so that they can better inform their audiences. Below, we explain what medication abortion is, how individuals access it, and what research shows about its safety and effectiveness.

Medication abortion

Medication abortion is also known as abortion with pills or medical abortion. The Food and Drug Administration has approved medication abortion for up to 10 weeks of pregnancy and the World Health Organization authorizes its use for up to 12 weeks. It is endorsed by several organizations, including the American College of Obstetricians & Gynecologists and the American Medical Association. Medication abortion can also be used beyond 12 weeks of pregnancy, according to several organizations including the World Health Organization and the International Federation of Gynecology and Obstetrics.

Medication abortions accounted for 51% of all abortions in the U.S. in 2020, according to a 2022 CDC report. Use of medication abortion has been on the rise in recent years, increasing by 154% from 2011 to 2020, and by 22% from 2019 to 2020.

In many parts of the world, including the U.S., a two-medication protocol is used for medication abortion: mifepristone followed by misoprostol. Mifepristone blocks the hormone that is required for the continuation of pregnancy, and misoprostol causes the uterus to cramp and expel the pregnancy tissue.

The current approved regimen for medication abortion is 200 mg of mifepristone, followed by 800 mcg of misoprostol within 24 to 48 hours. Individuals are advised to follow up with a health care provider seven to 14 days after taking mifepristone, according to the FDA.

Studies have shown that both drugs are safe and effective. In consultation with medical experts, The New York Times has curated and reviewed a collection of 101 studies on medication abortion, all of which conclude that the pills are safe.

History of mifepristone

Mifepristone, or RU-486, is a drug that blocks progesterone, a hormone that’s needed for a pregnancy to continue.

Developed by the now-defunct French pharmaceutical firm Roussel-Uclaf, the pill was first approved in France and China in 1988. As of May this year, 96 countries have approved it for medication abortion, according to the Guttmacher Institute, a sexual and reproductive health research and policy organization that supports abortion rights.

The FDA approved mifepristone for medical termination of pregnancy in September 2000. Some 5.9 million women in the U.S. used mifepristone between September 2000 and December 2022, 32 of whom died, according to the FDA, which notes in its report that “the fatal cases are included regardless of causal attribution to mifepristone.” Causes of death included infection, homicide, ruptured ectopic pregnancy, drug overdose, and suicide.

Danco Laboratories manufactures Mifeprex, the brand name for mifepristone. In 2019, the FDA approved a generic version of the drug, which is manufactured by GenBioPro. The drug is also manufactured by other companies around the globe.

When the FDA first approved the pill in 2000, the recommended dosage of mifepristone was higher, 600 mg, compared with the current 200 mg. Studies over time showed the lower dose is effective.

Initially, the FDA also required three doctor office visits, on days one, three, and 14 after taking the pill. Prescribers had to be licensed physicians and the drug had to be dispensed in person at a medical facility. The pill was approved to be prescribed within 49 days of gestation, or seven weeks.

By 2016, after evaluating safety data, the FDA modified prescribing requirements, extending the prescription period to up to 70 days of pregnancy, or 10 weeks. It reduced the number of required office visits to one, between seven and 14 days of taking the pill, and the prescriber no longer had to be a physician. Still, mifepristone was not available at brick-and-mortar pharmacies for patients who had a prescription, nor was it available via telemedicine.

But the onset of the COVID-19 pandemic in 2020, which closed many practices and limited in-office doctor visits, changed that.

Mifepristone prescription after COVID-19 and overturn of Roe v. Wade

In December 2021, the FDA reviewed mifepristone’s long-standing safety data and decided to remove the in-person dispensing requirements, expanding access to telehealth visits in states where abortion isn’t banned. The pill can also be mailed to patients since providers no longer have to dispense the pills in person.

It also allowed brick-and-mortar pharmacies that obtain certification from manufacturers to dispense the drug to people in person or through mail with a prescription.

So far, 18 independent brick-and-mortar pharmacies are dispensing mifepristone, and larger drugstore chains may soon join their ranks.

It’s important to note that since approving mifepristone, the FDA has required prescribers to be certified — which means they have to register with the drugmaker. Pharmacies too need to be certified. Advocates say this requirement further limits who can distribute the drug.

In June 2022, the U.S. Supreme Court overturned Roe v. Wade, striking down the constitutional right to abortion and allowing individual states to decide on access to abortion. Since the decision, 14 states have banned abortion altogether. Those bans apply to both surgical and medication abortions.

Misoprostol and misoprostol-only abortions

The second pill used in the two-pill regimen for medication abortion is misoprostol. The pill is approved by the FDA to prevent stomach ulcers in people at high risk of developing them. It was first approved in 1988.

Even though the FDA hasn’t approved it for medication abortion, misoprostol is used off-label as part of the approved two-pill regimen for medication abortion.

Off-label use means health care providers prescribe a drug for diseases or conditions for which it’s not approved by regulatory bodies such as the FDA. They do so when they deem its use is medically appropriate for the patient.

It is also used worldwide for medication abortion, medical management of miscarriage, induction of labor, and treatment of postpartum bleeding. The drug causes the uterus to cramp and expel pregnancy tissue.

The pill can be used alone for medication abortion.

The World Health Organization has endorsed the use of misoprostol-only for ending a pregnancy in parts of the world where mifepristone is not available. Studies have shown the regimen is safe and effective, although it may have more side effects compared with the two-medication regimen.

A study published in JAMA Network Open in October 2023 finds that misoprostol alone is highly effective in self-managed medication abortions.

Abortion with misoprostol alone is rare in the U.S. but the a legal ban on mifepristone could have made it it the only option for some individuals, she says.

“What our study adds is that under the worst-case scenario in which mifepristone is removed, it doesn’t mean that there’s a ban on medication abortion,” says Ruvani Jayaweera, an epidemiologist and research scientist at Ibis Reproductive Health, a nonprofit organization that conducts social science research primarily on access to abortion and contraception around the world. “Our hope is that this study provides assurance to providers and people who are using misoprostol alone, whether it’s in a clinic-based setting or a telehealth setting or a self-managed setting, about the effectiveness of this method.”

Accessing abortion pills

Abortion pills are prescription medications in the U.S. Individuals in states where abortion is still legal can obtain them from licensed providers in person or via telehealth.

Abortion is currently banned in 14 states. Eleven states have laws limiting abortion between six and 22 weeks. Twelve of the 36 states where abortion is available have restrictions on prescribing medication abortion via telehealth, according to the Kaiser Family Foundation.

In response, activists have created networks of support to help individuals access abortion pills, explains Carrie N. Baker, a contributing editor to Ms. Magazine and professor at Smith College who studies and teaches courses on gender, law and public policy.

“The mainstream press is not adequately paying attention to what’s happening in the United States with regard to the underground network of abortion pill access,” says Baker, who has a forthcoming book on the history and politics of abortion pills in the United States.

These networks have also existed to help individuals around the world.

Europe-based Aid Access mails the medication abortion regimen — mifepristone and misoprostol — to all 50 states, regardless of abortion restrictions. There are other U.S.-based services, including Plan C, which provides people with available options to get abortion pills based on the state they live in.

In a November 2022 research letter published in JAMA, Aid Access reported that after the U.S. Supreme Court overturned Roe v. Wade, the average daily requests for telemedicine services for medication abortion increased from 82.6 to 231.7.

In the U.S., prescribing abortion medications via telehealth is nuanced based on state abortion laws.

For instance, U.S.-based virtual reproductive and sexual health clinic Hey Jane and online pharmacies like Honeybee can provide care and ship the pills to people in states where abortion is not banned. In all states, people may obtain medication abortion from alternative telemedicine services, online websites, or community networks, though the legal risk of each of these options may differ depending on the state. Services like ReproLegal Helpline help guide individuals on laws in their state, Jayaweera says.

Also, physicians in states that have passed shield laws can also prescribe medications via telemedicine to people in states where abortion is banned. So far, several states including Washington, Colorado, Massachusetts, Vermont, New York and California have passed telemedicine shield laws for health providers.

Abortion shield laws “seek to protect abortion providers, helpers, and seekers in states where abortion remains legal from legal attacks taken by antiabortion state actors,” according to a review article published in The New England Journal of Medicine in March 2023. Seven states so far have enacted a shield law since the overturn of Roe v. Wade.

But it’s important to know and note that those laws don’t protect individuals, Jayaweera says.

“One of the things to be especially sensitive to is with telemedicine or online models is that even if the risk is very much minimized for the provider, the legal risk falls on the individual in restricted states,” she says, underscoring the importance of educating individuals about those risks during counseling.

Self-managed abortion

Self-managed abortion is when individuals use medication abortion without medical supervision, ordering pills via telehealth, online pharmacies, mail or in-person.

Worldwide, most medication abortions are self-managed, Jayaweera says.

As a reminder, although the drugs are shown to be safe and effective, the individuals who use self-managed abortion may face legal risks, explain Drs. Daniel Grossman and Nisha Verma in a viewpoint published in JAMA in November 2022.

“Resources like the If/When/How legal helpline may be useful for patients and clinicians who are trying to understand their legal risks related to self-managed abortion. Patients requesting emotional support could be connected with resources that provide free confidential talk lines,” the authors write.

Worldwide, 22 countries ban abortion altogether, according to the Center for Reproductive Health, a global advocacy organization, and many others restrict it. This has given rise to safe abortion hotlines and “accompaniment groups” of people who have training in abortion counseling for individuals who are using medication abortion.

They also “provide a lot of empathetic counseling throughout the process and provide people with additional assurance and support and to help them understand if what they are experiencing is normal, or if they need to seek care,’” says Jayaweera.

She was part of a research team that found the outcomes of self-managed abortions were comparable to the ones performed under clinical supervision. The study, among others, contributed to the World Health Organization revising its guidelines last year to add self-managed abortion in early pregnancy to its abortion guidelines.

National organizations including the American Medical Association and the American College of Obstetricians and Gynecologists oppose the criminalization of self-managed abortion because it deters patients from seeking care when complications occur, write Dr. Lisa H. Harris and Daniel Grossman in a review article published in the New England Journal of Medicine in March 2020.

“Given the safety of the combination of mifepristone and misoprostol for self-managed abortion, the biggest danger to patients may be legal prosecution,” the study authors add. “Doctors and health care institutions must develop strategies that favor effective, compassionate clinical care over legal investigation of patients.”

A note on abortion ‘reversal’ pills

On Oct. 30, a judge in Kansas blocked a state law that requires health care providers to tell patients that medication abortion can be reversed, despite a lack of scientific evidence. A few days earlier, in Colorado, a federal judge ruled that a Catholic medical center can’t be stopped from offering medication abortion “reversal” treatment.

So-called abortion medication “reversal” treatment involves taking a dose of the hormone progesterone in an attempt to stop the effects of mifepristone, but it’s important for journalists to inform their audiences that “reversal” of medication abortion is not supported by science. (The Associated Press recommends using quotation marks in order to stress the lack of scientific evidence.) The American College of Obstetricians and Gynecologists has publicly stated that it does not support the treatment.

“Despite this, in states across the country, politicians are advancing legislation to require physicians to recite a script that a medication abortion can be ‘reversed’ with doses of progesterone, to cause confusion and perpetuate stigma, and to steer women to this unproven medical approach,” reads a statement on ACOG’s website. “Unfounded legislative mandates like this one represent dangerous political interference and compromise patient care and safety.”

Between 2012 and 2021, 14 states had enacted abortion “reversal” laws, according to a February article in the American Journal of Public Health.

“States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians’ agents to inform patients, instruct patients to contact a health care provider or visit abortion pill reversal resources for more information, and require reversal information be posted on state-managed Web sites,” the authors write. “Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking [a medication abortion].”

A 2020 randomized controlled study of medication abortion reversal, involving 40 patients, ended early because of safety concerns for 12 participants. Some of the women in the study received 400 mg of progesterone after taking mifepristone to “reverse” the abortion. Others were given a placebo after taking mifepristone. Three patients – one had taken progesterone and two had received placebo – had severe hemorrhage and required ambulance transport to the hospital, the authors write.

“We could not estimate the efficacy of progesterone for mifepristone antagonization due to safety concerns when mifepristone is administered without subsequent prostaglandin analogue treatment. Patients in early pregnancy who use only mifepristone may be at high risk of significant hemorrhage,” they write in the study.

A March 2023 systematic review of four studies finds, “based mostly on poor-quality data, it appears the ongoing pregnancy rate in individuals treated with progesterone after mifepristone is not significantly higher compared to that of individuals receiving mifepristone alone.”

A 2015 systematic review of 11 studies on medication abortion reversal during the first trimester of pregnancy finds “evidence is insufficient to determine whether treatment with progesterone after mifepristone results in a higher proportion of continuing pregnancies compared to expectant management.”

Research roundup

The following roundup of systematic reviews examines the safety and effectiveness of medication abortion. They are listed by publication date. The list is followed by additional research and reporting resources.

Effectiveness and Safety of Misoprostol-Only for First-Trimester Medication Abortion: An Updated Systematic Review and Meta-Analysis
Elizabeth G. Raymond, Mark A. Weaver, and Tara Shochet. Contraception, November 2023.

A review of 49 published studies, including a total of 16,354 patients, finds misoprostol-only is effective and safe for the termination of first-trimester pregnancy, especially when mifepristone is not available.

“Technically An Abortion”: Understanding Perceptions and Definitions of Abortion in the United States
Alicia J. VandeVusse, et al. Social Science & Medicine, October 2023.

The study is based on in-depth interviews of 64 cisgender women and 2009 participants in an online survey. Individuals were asked about their understanding of pregnancy outcomes including abortion and miscarriage. “The blurred boundaries between different types of pregnancies and their outcomes emphasize the differences in people’s notions of what constitutes an abortion,” the authors write. “It shapes how abortion stigma can arise across different pregnancy outcomes, as well as people’s own perceptions of the care they have sought, the legality of this care, and their experience in accessing it. Understanding how people construct boundaries around abortion allows for more effective healthcare messaging and advocacy, which is increasingly relevant as legal restrictions on abortion mount while telemedicine and medication abortion become more widely available to some.”

Requests for Self-managed Medication Abortion Provided Using Online Telemedicine in 30 US States Before and After the Dobbs v Jackson Women’s Health Organization Decision
Abigail R. A. Aiken, et al. JAMA, November 2022.

The authors analyze anonymized requests for abortion pills to Aid Access, a Europe-based abortion pill provider. They analyzed the requests before Roe v. Wade was overturned, after the decision was leaked, and after the decision was announced. They find that each of the 30 states from which requests came, regardless of abortion policy, showed a higher request rate after the leak and announcement compared to before. The largest increases were in states that enacted total bans on abortion.

Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries
Ian Ferguson and Heather Scott. Journal of Obstetrics and Gynaecology Canada. April 2020.

A review of 36 studies, including a total of 25,385 medical abortions, finds the combination of mifepristone and misoprostol is “highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.” Among a group of 17,381 women, 0.8% required hospitalization.

Telemedicine for Medical Abortion: A Systematic Review
M. Endler, et al. British Journal of Obstetrics and Gynaecology, March 2019.

A review of 13 studies, mostly based on self-reported data, finds the rates of complete abortion, hospitalization, and blood transfusion after abortion through 10 weeks of pregnancy were at similar levels to those reported after in-person abortion care in the published studies.

First-Trimester Medical Abortion with Mifepristone 200 mg and Misoprostol: A Systematic Review
Elizabeth G. Raymond, Caitlin Shannon, Mark Weaver, and Beverly Winikoff. Contraception, January 2013.

A review of 87 studies, including a total of 47,283 women, finds medical abortion in early pregnancy with 200 mg mifepristone followed by misoprostol is highly effective and safe.

Additional research

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening
Daniel Grossman, et al. JAMA Internal Medicine, May 2024.

Pharmacists’ Experiences Dispensing Misoprostol and Readiness to Dispense Mifepristone
Meron Ferketa, et al. Journal of the American Pharmacists Association, October 2023.

Medication Abortion Safety and Effectiveness With Misoprostol Alone
Ruvani Jayaweera, et al. JAMA Network Open, October 2023.

Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis
Andrea Henkel, et al. Obstetrics & Gynecology, October 2023.

Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022
Catherine S. Hwang, et al. Annals of Internal Medicine, October 2023.

Explaining the Fifth Circuit Court of Appeals Ruling on Mifepristone Access
Molly A. Meegan, JAMA, October 2023.

Effectiveness of Self-Managed Medication Abortion Between 9 and 16 Weeks of Gestation
Heidi Moseson, et al. Obstetrics & Gynecology, August 2023.

Comparison of Mifepristone Plus Misoprostol with Misoprostol Alone for First Trimester Medical Abortion: A Systematic Review and Meta-Analysis
Tariku Shimels, Melsew Getnet, Mensur Shafie, and Lemi Belay. Frontiers in Global Women’s Health, March 2023.

Experiences Seeking, Sourcing, and Using Abortion Pills at Home in the United States Through an Online Telemedicine Service
Melissa Madera, et al. Social Science & Medicine: Qualitative Research in Health. December 2022.

Abortion Surveillance — United States, 2020
Katherine Kortsmith, et al. Morbidity and Mortality Weekly Report, November 2022.

Mifepristone: A Safe Method of Medical Abortion and Self-Medical Abortion in the Post-Roe Era
Elizabeth O. Schmidt, Adi Katz, and Richard A. Stein. American Journal of Therapeutics, October 2022.

Effectiveness of Self-Managed Abortion During the COVID-19 Pandemic: Results From a Pooled Analysis of Two Prospective, Observational Cohort Studies in Nigeria
Ijeoma Egwuatu, et al. PLOS Global Public Health, October 2022.

Increasing Access to Abortion
American College of Obstetricians & Gynecologists, December 2020.

Abortion Pill “Reversal”: Where’s the Evidence
Advancing New Standards In Reproductive Health, July 2020.

A Qualitative Exploration of How the COVID-19 Pandemic Shaped Experiences of Self-Managed Medication Abortion with Accompaniment Group Support in Argentina, Indonesia, Nigeria, and Venezuela
Chiara Bercu, et al. Sexual and Reproductive Health Matters, June 2022.

Medical Abortion in the Late First Trimester: A Systematic Review
Nathalie Kapp, Elisabeth Eckersberger, Antonella Lavelanet, Maria Isabel Rodriguez. Contraception, February 2019.

Continuing Pregnancy After Mifepristone and “Reversal” of First-Trimester Medical Abortion: A Systematic Review
Daniel Grossman, et al. Contraception, September 2015.

Medical Compared With Surgical Abortion for Effective Pregnancy Termination in the First Trimester
Luu Doan Ireland, Mary Gatter, Angela Y. Chen. Obstetrics & Gynecology, July 2015.

Resources

What to Know About Fetal Viability — And Why Some Advocates Want It Out of Abortion Law
Mary Chris Jaklevic. Association of Health Care Journalists’ Covering Health blog, October 2023.

#WeCount: A series of reports by the Society of Family Planning aiming to capture the shifts in abortion volume by state and month following the Supreme Court decision to overturn Roe.

History and Politics of Medication Abortion in the United States and the Rise of Telemedicine and Self-Managed Abortion
Carrie N. Baker. Journal of Health Politics, Policy and Law, August 2023.

Mifepristone U.S. Post-Marketing Adverse Events Summary through 12/31/2022
Food and Drug Administration

Questions and Answers on Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation
Food and Drug Administration

Key Facts on Abortion in the United States
Usha Ranji, Karen Diep and Alina Salganicoff. Kaiser Family Foundation, August 2023.

The Availability and Use of Medication Abortion
Kaiser Family Foundation, June 2023.

A Review of Exceptions in State Abortions Bans: Implications for the Provision of Abortion Services
Kaiser Family Foundation, May 2023.

State Requirements for the Provision of Medication Abortion
Kaiser Family Foundation, April 2023.

Are Abortion Pills Safe? Here’s the Evidence.
Amy Schoenfeld Walker, Jonathan Corum, Malika Khurana, and Ashley Wu. The New York Times, April 2023.

Abortion Care Guideline
World Health Organization, March 2022.

Center for Reproductive Rights provides a global view of abortion.

Abortion Facility Database by Advancing New Standards in Reproductive Health, based at the University of California San Francisco, is a research program that informs the most pressing debates on abortion and reproductive health.

The post Abortion pill mifepristone: An explainer and research roundup about its history, safety and future appeared first on The Journalist's Resource.

For nearly four decades now, a federal law known as the Emergency Medical Treatment and Labor Act, or EMTALA, has given Americans the right to receive care at emergency departments, regardless of income or insurance status. The law applies to all kinds of emergencies, including pregnant people in labor, or those for whom an abortion may be medically necessary to preserve their health or save their life.

Since the U.S. Supreme Court struck down the constitutional right to abortion in June 2022, some experts have worried that EMTALA would clash with states that restrict or ban abortions. So far, two states — Texas and Idaho — have ongoing lawsuits with the federal government, claiming their state bans and restrictions on abortion take precedence over EMTALA. And on January 5, the Supreme Court said it would consider Idaho’s case, which centers on the relationship between EMTALA and the state’s abortion ban.

Legal experts worry that if the Supreme Court rules in favor of Idaho and allows states to shape their own laws for pregnancy emergencies without regard to EMTALA, then the states could apply the same logic to all other forms of emergency medical care that currently covered under the federal emergency law.

“So, states could start carving out HIV care, or mental health, or serious and chronic conditions that they deem too futile or not worth the time and energy of emergency department,” says Sara Rosenbaum, a professor emerita of health law and policy at George Washington University’s Milken Institute School of Public Health, who has written extensively about EMTALA.

Through memoranda and various efforts, federal health officials have emphasized that EMTALA takes priority over state laws.

Most recently, on January 22, the 51^st anniversary of Roe v. Wade, the Department of Health and Human Services and the Centers for Medicare & Medicaid Services introduced new resources for the public and health providers to learn about their rights to receive emergency medical care under EMTALA. The announcement was part of a wider effort by the White House to strengthen Americans’ access to contraception, medication abortion and emergency medical care.

The Department of Health & Human Services has issued other notices about the application of EMTALA, including a memorandum in September 2021 after a Texas abortion ban case, in July 2022 after the overturning of Roe and following an executive order by President Joe Biden, and in May 2023 following the investigation of two hospitals in Missouri and Kansas that violated EMTALA.

“If a physician believes that a pregnant patient presenting at an emergency department is experiencing an emergency medical condition as defined by EMTALA and that abortion is the stabilizing treatment necessary to resolve that condition, the physician must provide that treatment,” states a Biden administration memorandum in July 2022. “When a state law prohibits abortion and does not include an exception for the life of the pregnant person — or draws the exception more narrowly than EMTALA’s emergency medical condition definition — that state law is preempted,” by the federal law.

Abortion rights advocates have filed lawsuits over several states’ strict abortion bans, Axios reported in September. Rosenbaum said she’s preparing an amicus brief on behalf of the American Public Health Association and more than 100 law and policy scholars before the Supreme Court makes its decision on Idaho’s case.

EMTALA in brief

EMTALA was introduced in 1985 with bipartisan support in response to a spate of “patient dumping” cases, which refers to emergency departments refusing care to patients who are indigent and have no health insurance, including patients who were in labor. President Ronald Reagan signed it into law in 1986, when Roe v. Wade was still law of the land.

Under EMTALA, hospitals must examine and stabilize patients, regardless of insurance status, citizenship or other factors.

“It essentially is the closest thing we have in this country to a human rights statute,” says Rosenbaum.

The law applies to all hospitals with emergency departments that participate in Medicare (only about 1% of non-federal community hospitals don’t participate in Medicare, according to the American Hospital Association). The Department of Health and Human Services oversees and enforces EMTALA.

Physicians and hospitals can be fined up to $50,000 per incident of failing to comply with EMTALA and are at risk of exclusion from Medicare and Medicaid programs for repeated violations. Physicians’ malpractice insurance does not cover EMTALA violations.

While EMTALA is an important safety net for people without health insurance, it doesn’t guarantee free care, and patients may still be billed, as the authors of a 2018 study published in AIMS Public Health explain.

Emergency departments and pregnancies

EMTALA covers not only conditions that threaten life but also conditions that can impose severe and long-lasting health impacts. That includes pregnancy-related complications and emergencies that may require medically necessary and life-saving abortions, even though abortion is not specifically mentioned in the law.

The majority of people who have emergencies related to pregnancy go to an emergency department, according to a 2023 study published in the American Journal of Emergency Medicine. At least a third of pregnant women go to an emergency department at some point during their pregnancy, studies have shown and up to 15% suffer from a potentially life-threatening condition during the first trimester.­

A 2020 study of 2.8 million women in Ontario, Canada, who were pregnant between 2002 and 2017, finds that 40% visited an emergency department, mostly during the first trimester or soon after giving birth.

The most common conditions during the first trimester were threatened abortion (the technical term for vaginal bleeding at less than 20 weeks of gestation), hemorrhage (severe bleeding), and spontaneous abortion (miscarriage), according to the study.

Other emergency medical conditions involving pregnant patients may include but are not limited to ectopic pregnancy — which is when a fertilized egg grows outside of the uterus and can be a life-threatening emergency, complications of pregnancy loss, or high blood pressure conditions such as severe preeclampsia.

Dr. Glenn Goodwin, an emergency physician in Florida, says at every shift there’s a first-trimester pregnant patient who’s bleeding.

“I’d say probably 10% of our ER visits are somewhat OB-related, whether it’s a first-trimester bleed, or whether it’s abdominal pain in pregnancy,” Goodwin says. “How many of those cases are actually life-threatening? Very, very few.”

EMTALA and state abortion bans

Since the end of Roe in June 2022, 14 states have enacted a total ban on abortion, four states ban abortion after six or 12 weeks, and seven after 15 or 22 weeks. Abortion is legal, including beyond 22 weeks, in 25 states and the District of Columbia, according to the KFF, a nonpartisan health policy research organization.

What leads to confusion among health providers is the vague language of the law in states that have abortion bans.

For instance, many states with strict abortion bans have exceptions to “prevent the death” or “preserve the life” of the pregnant person, according to an analysis by KFF.

Arkansas, Idaho, Mississippi, Oklahoma and South Dakota have exceptions to save the life of the pregnant person, but do not have any exceptions for protecting their health.

Other states with abortion bans have exceptions that consider protecting the health of the pregnant person — not just their life — permitting abortion care when there’s a serious risk of substantial and irreversible impairment of a major bodily function. The Texas abortion ban says physicians must determine whether an abortion is necessary based on their “reasonable medical judgment.”

“These exceptions are not clear how much risk of death or how close to death a pregnant patient may need to be for the exception to apply, and the determination is not explicitly up to the physician treating the pregnant patient,” according to the KFF analysis.

A KFF 2023 National OBGYN survey, including 569 physicians, finds more than half of those who practiced in states that banned abortion were concerned about their legal risk when deciding on the necessity of abortions.

In an opinion piece published in the Annals of Internal Medicine in January 2023, Dr. Eli Y. Adashi and I. Glenn Cohen write, “physicians in restrictive states face extremely difficult choices between protecting pregnant persons and the threat of legal sanctions.”

Out of frustration with confusion in his own emergency department, Goodwin, the Florida emergency physician, set out to do a study in 2022 on state abortion laws and whether they conflicted with EMTALA.

He and his co-authors find that the overturning of Roe “does not prohibit termination of pregnancy in the setting of life-threatening conditions to the mother, including ectopic pregnancy, preeclampsia, and others,” but they recommend that “physicians be mindful of the rapidly-evolving laws in their particular state, and to also practice in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA). Patient safety must be prioritized.”

Goodwin completed his study before the Supreme Court said that it will consider whether EMTALA takes priority over Idaho’s restrictive abortion ban. The oral arguments are scheduled for April.

Before states like Florida passed a 15-week abortion ban except for saving the patient’s life, things were much clearer for emergency physicians like Goodwin.

“We never really considered any legal ramification at all,” Goodwin says. “The patient came in and all of our brains were just focused on the medical aspect of care. Since this law change, we have to consider some of the legal aspects of it.”

He gave the example of a patient who’s 15 weeks pregnant, has been bleeding for days and is miscarrying, but still has a fetus with a heartbeat.

“At that point, the conventional medical treatment will be to just give an abortive medication, because there’s really no chance of this fetus living and the mother is bleeding,” he says. “And you don’t want her to continue bleeding because that would be a risk.”

But Florida’s 15-week abortion ban makes the decision complicated. For Goodwin, whose hospital doesn’t have a labor and delivery unit, the solution would have been to transfer the patient to another hospital that has a labor and delivery unit, instead of proceeding with the standard treatment in his own emergency room.

Goodwin also worries that the ongoing legal battles will further reduce the number of medical students who will choose to specialize in Ob/Gyn.

“You have Ob/Gyn hopefuls saying they don’t want to train in states like Mississippi because they’re not going to learn how to do an abortion,” Goodwin says. “And however you feel about abortion, it is kind of a crucial aspect of Ob/Gyn training because there are times where you have to do it as a life-saving procedure.”

An April 2023 report by the Association of American Medical Colleges shows that the number of applicants for Ob/Gyn residencies dropped in all states in 2023, but had the steepest decline in states with abortion bans. In those states, applications dropped by 10.5% compared with the previous year.

To help journalists prepare to cover the upcoming Supreme Court hearing, we’ve gathered several research studies on EMTALA, including analyses of hospitals’ general compliance issues since the law was passed. The studies were published both before and after the overturning of Roe.

Research roundup

A National Analysis of ED Presentations for Early Pregnancy and Complications: Implications for Post-Roe America
Glenn Goodwin, et al. The American Journal of Emergency Medicine, August 2023.

The study: The study, published before the Supreme Court took up EMTALA, uses data from the National Hospital Ambulatory Medical Care Survey, from 2016 to 2020, to evaluate trends in pregnancy-related emergency department visits that could be impacted by restrictive abortion laws. The dataset included 4,556,778 pregnancy-related emergency department visits in the U.S. The authors also analyzed the state laws.

The findings: Nearly 80% of the visits in the study were for patients between 18 to 34 years old. This age group also made up 76% of visits for pregnancy complications, including ectopic pregnancies, and 80% of visits for miscarriage or threat of miscarriage in early pregnancy. This age group also accounted for all visits for complications following an induced abortion or a failed abortion.

A quarter of the patients were Black and 70% were white. By ethnicity, 27% of the patients were Hispanic.

Almost 71% of the visits were due to complications after an induced abortion occurred in patients who lived in the South. Such visits were also twice as likely to occur in non-metro areas.

Nearly 50% of the patients were covered by Medicaid, compared with about 25% with private insurance. About 10% had no insurance.

The takeaway: Pregnancy-related emergency department visits comprise a significant proportion of emergency care, the authors write. The overturning of Roe “does not prohibit termination of pregnancy in the setting of life-threatening conditions to the mother, including ectopic pregnancy, preeclampsia, and others, but the resultant uncertainty and ambiguity surrounding the constitutional change is leading to an over-compliance of the law, necessarily obstructing reproductive health care,” they write.

Penalties for Emergency Medical Treatment and Labor Act Violations Involving Obstetrical Emergencies
Sophie Terp, et al. The Western Journal of Emergency Medicine, March 2020.

The study: There’s no question that EMTALA applies to active labor, which is the only medical condition — labor — included in the title of the law, the authors write. They review descriptions of EMTALA violation settlements involving labor and other obstetric emergencies, listed on the Office of the Inspector General website between 2002 and 2018.

The findings: Of 232 EMTALA violation settlements, 17% (39) involved active labor and other obstetric emergencies. Settlements involving obstetric emergencies increased from 17% to 40% during the study period. Of those, 18% involved a pregnant minor. Most violations involved failure to screen and/or stabilize the pregnant patient.

Of the 39 cases, the Southeast had the most number of violations — 38%, including eight violations in Florida and five in North Carolina.

The takeaway: “Recent cases highlight the need for hospital administrators, emergency physicians, and obstetricians to evaluate and strengthen policies and procedures related to both screening exams and stabilizing care of patients with labor and OB emergencies, even if the hospital does not provide dedicated OB care,” the authors write.

Complying With the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and Solutions
Charleen Hsuan, et al. Journal of Healthcare Risk Management, November 2017.

The study: Despite the passage of EMTALA in 1986, hospitals continue to violate it, which includes refusing to examine or stabilize patients, or making inappropriate transfers to other hospitals. In the first decade after the law was passed, nearly one-third of U.S. hospitals were investigated for EMTALA violations. “And as of 2011, almost 30 years after the Act was passed, 40% of investigations still found violations,” they write.

The authors explore the reasons for not complying with EMTALA and suggest ways to improve compliance. Their analysis is based on 11 interviews with hospital officials, hospital associations and patient safety organizations that review clinical data on EMTALA violations in Georgia, Kentucky, North Carolina, South Carolina and Tennessee. The South had the highest number of EMTALA complaints at the time, compared with other U.S. regions.

The findings: There were five main reasons for non-compliance: financial incentives to avoid unprofitable patients; ignorance of EMTALA’s requirements; high burned of referral at hospitals that receive EMTALA transfer patients; reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations; and opposing priorities of hospitals and physicians.

The authors propose four ways to improve compliance with EMTALA: align federal and state payment policies with EMTALA; amend EMTALA to permit informal mediation sessions between hospitals to address borderline EMTALA violations; increase the hospital role in EMTALA training and spread information; and increase the role of hospital associations.

Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements
Nadia Zuabi, Larry D. Weiss, and Mark I. Langdorf. The Western Journal of Emergency Medicine, May 2016.

The study: The Office of Inspector General (OIG) of the Department of Health and Human Services enforces EMTALA. The study examines the scope, cost, frequency and common allegations leading to mandatory settlements against hospitals and physicians for patient dumping. The enforcement actions are listed on the OIG website, where you can find more recent cases.

The findings: Between 2002 and 2015, there were 192 settlements, with fines adding up to $6.4 million. The average fine against hospitals was $33,435 and against physicians was $25,625. 96% of the fines were against hospitals.

The most common settlements were for failing to screen the patient or stabilize them in emergency situations. There were 22 cases of inappropriate transfer to another hospital and another 22 cases for failing to transfer to a facility that could care for the patient. In 25 cases, hospitals failed to accept an appropriate transfer. In 30 cases hospitals turned away patients because their insurance or financial status. Thirteen cases involved a patient in active labor.

Examining EMTALA in the Era of the Patient Protection and Affordable Care Act
Ryan M. McKenna, et al. ASIM Public Health, October 2018.

The study: The authors examine the characteristics of hospitals that violated EMTALA between 2002 and 2015 — before and after the implementation of ACA in 2014 — using the OIG database and matching them with a national hospital database.

The findings: There were 191 EMTALA settlement agreements during the study period, although the analysis included 167 cases after excluding others due to lack of data. Settlements decreased from a high of 46 in 2002 to a low of six in 2015, a decline of 87%. The settlements were most common in hospitals in the South (48%) and urban areas (74%). The average settlement for hospitals was $31,734, adding up to $5,299,500 during the study period.

The takeaway: There was an overall downward trend in violations of EMTALA, even though the study can’t establish that the implementation of ACA caused the downward trend. The authors suggest the reduction in EMTALA violations could be due to two factors: “First, in shifting hospitals’ payer mix away from self-pay, the insurance expansion of the ACA reduces the risk of uncompensated care to systems,” they write. “Second, the ACA helped improve access to health care at facilities other than the ED.”

Additional reading

Will EMTALA Be There for People with Pregnancy-Related Emergencies?
Sara Rosenbaum, Alexander Somodevilla and Maria Casoni. The New England Journal of Medicine, September 2022.

The Enduring Role Of The Emergency Medical Treatment And Active Labor Act
Sara Rosenbaum. Health Affairs, December 2013.

Emergency Medical Treatment and Labor Act: Impact on Health Care, Nursing, Quality, and Safety
Theresa Ryan Schultz, Jacqueline Forbes, and Ashley Hafen Packard. Quality Management in Health Care, March 2024.

The post EMTALA and abortions: An explainer and research roundup appeared first on The Journalist's Resource.

Google searches for abortion medications reached an all-time high in the hours and days after the May 2 leak of a draft Supreme Court majority opinion in favor of overturning Roe v. Wade, and the searchers were more common in states with restrictive reproductive rights, according to a research letter published on June 29 in JAMA Internal Medicine. 

The surge in searches highlights the importance of providing women with information on where they can legally and safely obtain abortion medications, including telemedicine consultations with health care professionals, researchers note. 

“Elevated interest in abortion medications should alert physicians that many of their patients may pursue this option with or without them,” they write in “Internet Searches for Abortion Medications Following the Leaked Supreme Court of the United States Draft Ruling.” 

Using Google Trends, which analyzes the popularity of individual Google searches and provides relative search volumes with a value between 0 to 100, the researchers retrieved Google searches in the U.S. for abortion pill or abortion medications mifepristone (brand name, Mifeprex) and misoprostol (brand name Cytotec) from Jan. 1, 2004, when Google began collecting data, to May 8, 2022. 

They analyzed weekly national online search trends for the medications for the entire study period, finding that the weekly search volume reached its historic peak during the week of the Supreme Court draft leak, with 350,000 searches. The volume was 1.67 times higher than the prior week and twice as high as 2012, according to the researchers.

They also looked at hourly search volumes for the three days before and after the Supreme Court draft leak. The spike in searches for abortion medications were cumulatively 162% higher than they had projected for the 72 hours after the leak. The spike was immediate in the hour that Politico reported the leak, study co-author John W. Ayers wrote in an e-mail to The Journalist’s Resource.

Researchers also find a correlation between the volume of searches and women’s reproductive rights in states — such as public funding for abortion and access to abortion services providers.

For instance, Nebraska had the highest search volume for abortion medications in the three days following the leak, followed by Iowa and Missouri. The three states have received grades of F, C+ and D respectively, from the Institute for Women’s Policy Research, which assigns each state a letter grade based on the level of reproductive rights. Hawaii, which received an A- from the institute, had the lowest online search volume for the medications. 

The study was accepted for publication on May 31, before the Supreme Court officially overturned Roe v. Wade in a 5-4 decision on June 24, ending five decades of federal abortion rights and sending back to the states the authority to ban or allow abortions. 

The team has not analyzed the online search data after the official Supreme Court ruling on June 24, wrote Ayers, vice chief of innovation at U.C. San Diego Medicine, in the email to JR.

A search on Google Trends shows that the search volume for “abortion pill” on June 24 was more than twice as high as the peak on May 3.

Medication abortion, also known as medical abortion or abortion with pills, involves taking two different drugs, mifepristone and misoprostol, during the first 10 weeks of pregnancy, according to Kaiser Family Foundation, a nonprofit organization that conducts health and health policy research. Since the Food and Drug Administration approved the drugs in 2000, half of abortions at 8 weeks gestation or less have been medication abortions, according to KFF.

Mifepristone, sold under the brand name Mifeprex and also known as the abortion pill or RU-486, blocks progesterone, a hormone essential to the development of a pregnancy, and prevents an existing pregnancy from progressing. Misoprostol, marketed under the brand name Cytotec, is taken 24 to 48 hours after mifepristone and empties the uterus by causing cramping and bleeding, similar to an early miscarriage, according to KFF. 

The researchers note their study is limited in that it can’t confirm whether the searches were linked to an abortion attempt, but the authors provide some potential reasons for the online searches.

“Although mifepristone/mifeprex or misoprostol/cytotec require a prescription and their use is restricted in some states, internet searches may reflect people exploring the safety and effectiveness of these medicines, how to obtain them, or stockpiling in anticipation of curtailed access,” the authors write. “Some searchers may be seeking substitute and/or illicit abortion medications as alternatives.”

Shortly after the Supreme Court ruling on June 24, the demand for the emergency contraceptive medicines known as “Plan B” or “morning after pills,” which prevent pregnancy, surged to such an extent that several retailers and drugstore chains, including Amazon, Rite Aid and CVS, began limiting the number of pills consumers can buy on their website or in their stores, according to CNBC and the Associated Press.

The ruling also led to a surge of social media posts offering women abortion pills, prompting Facebook and Instagram to swiftly begin removing them, according to NPR. 

In 32 states, only physicians are allowed to prescribe abortion pills. In the rest of the states, rest advanced practice clinicians, including advanced practice registered nurses and physician assistants, can also prescribe them, according to Kaiser Family Foundation and the Guttmacher Institute, a sexual and reproductive health research organization.

Since January, at least 20 states have proposed bills to restrict or ban access to abortion pills, according to Pew Stateline. 

Additional resources:

• Medication Abortion. This is a comprehensive explainer by the Guttmacher Institute.
• Lay of the Land: Abortion Policies and Access in the United States. The interactive map by the Guttmacher Institute shows each state’s abortion policies, demographic information and statistics. 
• The Availability and Use of Medication Abortion. Provided by the Kaiser Family Foundation, this report provides an overview of medication abortion, insurance coverage and access by state. 
• Medication Abortion and Telemedicine: Innovations and Barriers During the COVID-19 Emergency. This report by the Kaiser Family Foundation provides an overview of barriers and opportunities in using telemedicine to prescribing abortion pills.
• Medication Abortion Up to 70 Days of Gestation. This practice bulletin by the American College of Obstetricians and Gynecologists provides evidence-based guidance on the provision of medication abortion up to 70 days (or 10 weeks) of gestation.
• Medication Abortion: Q&A with experts.  In May, SciLine, a free service for journalists and scientists based at the American Association for the Advancement of Science, asked experts about the fundamentals of medication abortion to help reporters cover the topic.

The post Google searches for abortion pills spiked after the May leak of SCOTUS draft opinion on Roe v. Wade appeared first on The Journalist's Resource.

This article was originally published in May 2019. We have updated it in the context of recent reporting revealing a draft Supreme Court opinion that would overturn Roe v. Wade and subsequent news coverage about the implications of Roe potentially being reversed.

• On May 2, 2022 Politico published a leaked draft Supreme Court majority opinion that would undo the Court’s decisions in Roe and Planned Parenthood v. Casey, which in 1992 upheld Roe. “We hold that Roe and Casey must be overruled,” Justice Samuel Alito wrote in the draft opinion in Dobbs v. Jackson Women’s Health Organization.
• On May 3, the Supreme Court confirmed that the draft copy Politico obtained is authentic, adding that “it does not represent a decision by the Court or the final position of any member on the issues in the case.”
• The disclosure of the draft opinion has intensified social and traditional media attention on research linking legalized abortion crime rates — and an awareness of the need to discuss this work with nuance.
• Our original coverage was of a 2019 working paper published by the National Bureau of Economic Research. That working paper has since been published in a peer-reviewed journal, and the update below reflects that.

Violent crime rates in the U.S. have fallen by nearly half since the early 1990s.

A 2020 paper in the American Law and Economics review, based on a working paper published in 2019, finds that legalized abortion following the Supreme Court’s landmark Roe v. Wade decision in 1973 accounts for a large share of the crime drop over the past three decades.

The authors, Stanford University economist John Donohue and University of Chicago economist Steve Levitt, take new data and run nearly the same model they used in their influential — and much discussed — 2001 analysis published in the Quarterly Journal of Economics, where they first suggested an association between abortion and crime.

“Legalized abortion is estimated to have reduced violent crime by 47% and property crime by 33% over this period, and thus can explain most of the observed crime decline,” Donohue and Levitt write.

The research has received renewed attention on social media since Politico on May 2 published a draft Supreme Court majority opinion that would overturn Roe.

The Roe decision effectively legalized abortion in the U.S., based on a 7-to-2 ruling that decided prohibiting abortion was unconstitutional because it infringed on a woman’s right to privacy. When referencing this research from Donohue and Levitt, it is important to note the reservations that some other economists offer below.

Donohue earlier this month stressed the need for nuance when CNN host Michael Smerconish earlier this month asked him, “More abortion. Less crime. That’s what your data suggests. True?”

Donohue responded: “That’s what the data suggest, but I would make the point that the critical factor is enabling women to choose the timing and selection of their family generation, and if they’re able to avoid unwanted pregnancies then all of the benefits that we saw that occurred because of abortion could be generated in that manner as well.”

In the same interview, Donohue pointed out, “I do think critics are always right to question a single study, but with the accumulation of data, and the greater capacity to evaluate over time, we now have a much more confident attitude that the original conclusions have been held up with an additional 20 years of data.” 

Replicating the original

In the 2001 paper, Donohue and Levitt found that legalized abortion appeared to account for up to half of the drop in rates of violent crime and property crime to that point. They also predicted crime would fall an additional 20% over the next two decades. Levitt featured the research in the 2005 bestseller Freakonomics. The recent research also looks at violent crime and property crime.

“The thing that’s most interesting about the [research] is we simply repeated the regression process we went through 20 years ago with more data and the results got even stronger,” Donohue said in a May 2019 interview with The Journalist’s Resource, referring to the statistical method researchers often use to study relationships among variables. “That was a pretty interesting and powerful affirmation of the original hypothesis which was initially proposed.”

The headline finding works on the idea that, as the authors write, “unwanted children are at an elevated risk for less favorable life outcomes on multiple dimensions, including criminal involvement, and the legalization of abortion appears to have dramatically reduced the number of unwanted births.”

In the recent research, Donohue and Levitt use an almost identical analysis model as they did in 2001 but add abortion and crime data covering 1997 to 2014. The original analysis covered 1985 to 1997.

“By imposing the restriction of using the same model we used for a paper published in 2001, no one could claim that we were fiddling with the model to generate a particular result,” Donohue said.

Changes in crime within states

The finding that abortion legalization accounts for a large share of the decline in crime rates over the past three decades comes from several analyses.

The authors examine crime in states that legalized abortion before Roe; crime in states with high and low abortion rates after Roe; differences in crime patterns in states among people born before and after Roe; and differences in arrest rates within states among people born before and after Roe.

In the analysis on differences in crime patterns within states, they find a 10% to 20% reduction in crime associated with abortion, after controlling for several variables: prisoners and police per 1,000 residents, state personal income per capita, welfare assistance, unemployment rates, poverty rates and beer shipments.

“There has been this literature that talks about how abuse of alcohol is related particularly to violent crime,” Donohue said. “So [beer shipments are] a crude measure of alcohol abuse but the best we could correlate fairly well.”

As with their 2001 paper, not all economists are convinced by Donohue and Levitt’s more recent findings.

“Modern econometrics is focused on looking at really sharp changes in the variable driving your analysis,” said Theodore Joyce, an economics professor at Baruch College whose research on abortion has been published in several academic journals, including the New England Journal of Medicine and The Journal of Political Economy. “In other words, you look for really sharp breaks [changes] because you can isolate what changed and if anything moves when this moves. When you have smooth changes going on, smooth changes in employment, crime, demographics — abortion is part of that smooth change as you move into ‘80s, ‘90s and 2000s — you can’t identify abortion from the other things going on at that time.”

During the 2000s, Joyce published several papers in NBER and elsewhere that were critical of Donohue and Levitt’s original findings.

“To run these long panel regressions in which you are picking up the sweep of humanity and say you controlled for poverty — it moves very slowly and it’s mixed in with all these other trends, and I don’t think they can sort it out,” he said.

Donohue and Levitt replied to several of Joyce’s criticisms in a 2004 paper in the Journal of Human Resources.

Changes in crime across states

Another portion of the 2019 NBER analysis compares crime patterns across states that had low and high rates of abortion post-Roe. The authors report no relationship between abortion and crime before 1985, because there were fewer criminals affected by abortion being legal. In their analysis, a 20-year-old arrested for a property crime in 1985 is part of a cohort not affected by legal abortion because he or she was born in 1965 — before Roe. But a person born in 1975 would be part of a cohort that was affected.

As Donohue and Levitt explain in their paper: “There should be little or no impact of abortion on crime prior to 1985, because effective abortion rates are extremely low in 1985, even in high-abortion states.”

From 1985 to 1997, the researchers show a pattern where crime fell more in states with high rates of arrestees affected by legalized abortion, compared with states with low rates. Again, other economists are not convinced that state-to-state comparisons are appropriate.

“There are a lot of reasons New York crime might decline relative to Utah crime,” said Christopher Foote, a senior economist at the Federal Reserve Bank of Boston, in May 2019. “You can try to control what’s going on with unemployment and beer sales but at the end of the day you’re never really sure whether a state like New York is better prepared to prosper in the new economy than perhaps Oklahoma is, so maybe there’s different types of people moving into New York rather than Oklahoma. There’s all sorts of other factors you can’t account for when you’re doing this state-to-state comparison.”

Foote and another economist, Christopher Goetz, identified several technical flaws in Donohue and Levitt’s original analysis in a 2008 comment published in the Quarterly Journal of Economics. They noted then that cross-state comparisons came with too much data noise, meaning those comparisons include variables that can’t be controlled for. More precise findings could be drawn from within-state comparisons, they argued.

“The best way to determine if abortion has a causal effect on crime is to compare two people who are in a similar environment today, but who had differing probabilities of being wanted at birth,” they wrote.

Donohue and Levitt responded to Foote in 2008 in the Quarterly Journal of Economics, acknowledging and correcting mistakes in their 2001 analysis while reiterating their finding that “abortion legalization reduces crime.” They acknowledge in the working paper that they added more within-state analysis because of Foote’s 2008 comment.

Questions about the validity of comparing data across states are, “certainly appropriate to think about,” Donohue said. “One thing that’s so interesting is we are able to look not only across states at current levels but also within states.”

An ongoing scholarly discussion

Donohue and Levitt have been forthcoming with their data and methods over the years. Authors who have written papers critical of their past work often thank them for sharing their data or for providing comments.

One NBER paper from 2008 allows for the possibility that legal abortion had an impact on crime, but questions the magnitude that Donohue and Levitt found. A 2008 paper in Criminal Justice Policy Review cautions against using events that happen on an individual level — such as a person having never been born into a situation that might have led them to want or need to commit crime — to draw broad conclusions, such as that abortion legalization accounts for a huge drop in national crime rates.

Other research has found links between abortion and crime reduction, but for different reasons than Donohue and Levitt articulate. A 2007 paper in The B.E. Journal of Economic Analysis and Policy looks at data from Canada and suggests that lower crime rates are not because of fewer “unwanted” births in a given year, but rather because fewer women were becoming teen moms.

Likewise, a 2015 study in Crime and Delinquency finds that, “if there is a statistically significant relationship between crime and abortion, it is due to varying concentrations of teenage abortions across states, not unwanted pregnancy.”

Still, Donohue and Levitt remain confident in their analyses: “It is rare for an economic theory to make predictions for 20 years into the future that are both bold and precise,” they conclude in the 2020 peer-reviewed version of the paper.

‘Not conceiving an unwanted baby’

Levitt, in a 2006 blog post, explained a subtle point that’s worth restating here. A critic had brought up that abortion rates among white women were declining and asked if Levitt would expect a rise in crime among white teenagers.

(Total abortion rates have declined substantially since the early 1980s.)

As Levitt explains in his blog post, the idea is that it is not access to abortion per se that leads to a decline in crime, but rather a decline in unwanted births. Here’s how he put it:

“It appears that the 1990s were a time when factors such as AIDS were leading people to, for instance, use condoms or abstain from sex altogether. Not conceiving an unwanted baby is equally effective in reducing unwantedness as having an abortion.”

The post Economic research resurfaces debate about the link between legalized abortion and crime reduction appeared first on The Journalist's Resource.

As we wind down the year, we’re counting down the most-read Journalist’s Resource posts of 2019 — articles and research roundups we published (or significantly updated and republished) in the past year.

After you revisit the year’s most popular posts, please think about the subjects you’d like us to cover in the future. You can reach out to us on Facebook, Twitter or via e-mail at Journalists_Resource@hks.harvard.edu. We’re looking forward to working with, informing and supporting you. We have a hunch 2020 is going to be a big news year.

Here are JR’s most-read posts of 2019:

#10. Should states ban religious exemptions for student vaccinations? Researchers weigh in

Denise-Marie Ordway highlighted three recent academic studies that suggest banning religious exemptions might not be the most effective way to improve childhood vaccination rates. In fact, the research indicates banning these exemptions could backfire.

#9. Raising the federal minimum wage to $15 an hour: What the research says

In the lead-up to the 2020 elections, the Journalist’s Resource team is combing through the Democratic presidential candidates’ platforms and reporting what the research says about their policy proposals. Clark Merrefield kicked off this series with this piece about the federal minimum wage.

#8. New economic research resurfaces debate about the link between legalized abortion and crime reduction

Merrefield highlighted new research by economists John Donohue and Steve Levitt, who find that legalized abortion following Roe v. Wade accounts for 45% of the decline in U.S. crime rates over the past three decades. (Some other economists are not convinced.)

#7. What Game of Thrones tells us about ourselves: A GoT research roundup

“Game of Thrones” isn’t just a cultural phenomenon — it’s an academic one too. Academics have analyzed GoT from many angles — race, history, politics, gender and power, and linguistics — to find out what a fictional show based on past events can tell us about our real present. Merrefield dug into recent GoT research.

#6. Black men 2.5 times more likely than white men to be killed by police, new research estimates

A black man in the U.S. has an estimated 1 in 1,000 chance of being killed by police during his lifetime, according to a study published in August by the Proceedings of the National Academy of Sciences. Merrefield explained the findings.

#5. Prince Harry in Afghanistan: Miguel Head shares the story of a historic media blackout

For 10 weeks in late 2007 and early 2008, hundreds of news organizations agreed to embargo a big story:  Prince Harry had been deployed to Helmand, Afghanistan, serving with the British Army. Miguel Head sat down with Carmen Nobel to share the inside story of how and why a cutthroat press kept a major secret about a beloved public figure.

#4: The health effects of screen time on children

Chloe Reichel’s research roundup looked at the effects of screen time on children’s health. The studies she included range from childhood to adolescence and focus on topics including sleep, developmental progress, depression and successful interventions to reduce screen time.

#3. What the research says about border walls

Border security remains a newsy topic. Ordway’s roundup of research focused on what border barriers are, why they have become popular, whether they actually help countries control their borders and how they affect the environment and local communities.

#2. Cutting through the clutter: What research says about tidying up

Early in 2019, thrift stores across the United States were inundated with donations in the wake of Netflix’s January 2019 release of “Tidying Up,” a series starring Marie Kondo, professional organizer. Is tidying really that beneficial to well-being? Reichel looked into the research on the benefits of decluttering.

#1. The four-day school week: Research behind the trend

To save money and help with teacher recruitment, a growing number of public schools across the United States are taking Fridays off. Ordway gathered research on the benefits and consequences of four-day school weeks.

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Crisis pregnancy centers (CPCs) are pro-life organizations that often offer women incorrect, incomplete or misleading information about their reproductive options.

In response, some localities have passed legislation requiring CPCs to make disclosures to their clients. California, for example, passed the Reproductive FACT Act in 2015. Under this law, CPCs must notify clients of public resources available to prevent or terminate pregnancies. It also mandates that CPCs inform their patients if they are not licensed as a medical facility.

Anti-choice advocates have taken issue with these requirements. The National Institute of Family and Life Advocates has sued California’s attorney general on behalf of CPCs. In November 2017, the U.S. Supreme Court decided it would hear the case.

Two law review articles provide context. While papers published in law journals often promote a particular interpretation of the law, these sources offer background on CPCs and relevant legal precedent. A 2016 article in the American Journal of Law & Medicine looks specifically at the First Amendment and reproductive freedom. An article published in 2017 in the Northwestern Journal of Law & Social Policy, “Have Crisis Pregnancy Centers Finally Met Their Match: California’s Reproductive FACT Act,” suggests the California law will be held constitutional and represents a first step to regulating CPCs.

The upcoming Supreme Court case, National Institute of Family and Life Advocates v. Becerra, No. 16-1140, will evaluate whether requiring CPCs to disclose information that counters their beliefs is a violation of First Amendment rights to free speech.

But what, exactly, do these centers believe, and what information do they promote?

A number of academics have explored this topic, scouring the websites of CPCs. A 2016 paper published in the Journal of Pediatric and Adolescent Gynecology found that nearly half of the 85 websites surveyed promoted abstinence-only sexual education. Over 60 percent of these websites provided negative facts about condoms, including minimizing their efficacy and suggesting they break often, and less than 10 percent encouraged the use of condoms to prevent sexually transmitted infections.

A larger examination of 254 CPC websites, published in Contraception in 2014, found that 80 percent provided at least one item of false or misleading information — most commonly, claiming links between abortion and mental health concerns.

A study published in 2017 in Women’s Health Issues focused on the websites of crisis pregnancy centers in Georgia. It reviewed all of the accessible websites of the CPCs in the state and found that more than half had “false or misleading statements regarding the need to make a decision about abortion or links between abortion and mental health problems or breast cancer.” Eighty-nine percent of sites did not indicate that their centers do not offer contraceptives or direct patients to resources where they might find them.

Researchers from the University of North Carolina who visited 19 CPCs in the state from March to June of 2011 found that nearly half “provide counseling on abortion and its risks,” and over half provided at least one piece of information that was misleading or false, ranging from the efficacy of condoms to links between abortion and infertility, breast cancer and mental health problems.

In fact, research on the associations between abortion and mental health indicates that women who are denied abortions might have a higher risk of adverse psychological outcomes in the short term compared with women who received abortions. A 2017 study in JAMA Psychiatry found that eight days after seeking an abortion, women who were denied one reported more anxiety symptoms, lower self esteem and similar levels of depression as women who received abortions. In the longer term — 4 to 5 years after the abortion — women who terminated pregnancies were not at a higher risk of post-traumatic stress disorder, depression, or anxiety than those denied abortions.

Though research from the 1990s suggested a link between abortion and increased risk of breast cancer, these studies have come under scrutiny. More recent research indicates that abortions do not cause an increased risk of breast cancer.

While CPCs tend to provide inaccurate information about abortion, a study published in 2016 in Contraception suggests that many who visit these centers in-person are not seeking pregnancy counseling. The researchers looked at the reasons why 273 first-time clients went to a secular pregnancy resource center in Indiana and found that only 6 percent discussed pregnancy options during their visit. Most said they went to the center for parenting-related support, including free diapers and baby clothes.

For those seeking information about pregnancy options, even disclosure requirements like California’s disputed Reproductive FACT Act have their limits. Research suggests that publicly funded family planning clinics do not always offer women the full range of reproductive health care options.

A study published in Perspectives on Sexual and Reproductive Health in 2016 looked at survey data from 567 publicly funded family planning facilities across the country and found that a smaller proportion made abortion referrals compared to adoption referrals (84 percent versus 97 percent). Moreover, they found issues relating to access — less than 3 percent of rural facilities had a first-trimester abortion provider located within 20 miles.

Limited access and barriers to abortion care have consequences. A study published in 2017 in Perspectives on Sexual and Reproductive Health found that most women who had to travel across state lines or over 100 miles within their state to receive an abortion reported “delays in care, negative mental health impacts and consider[ed] self-induction.”

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In January 2017, President Donald Trump reinstated and expanded a policy that forbids international organizations from using U.S. foreign aid to promote abortion or provide information about abortion as a form of family planning.

The policy, established by President Ronald Reagan in 1984, is commonly referred to as the Mexico City Policy because it was introduced to the International Conference on Population held in Mexico City that year. Critics often refer to it as the “global gag rule.”

Reagan’s policy tightened restrictions on funds distributed through the U.S. Agency for International Development (USAID). The Foreign Assistance Act of 1961 already prohibited non-governmental organizations from using federal money to pay for abortions or entice women to have them. Over the years, the Mexico City Policy has been reinstated and rescinded multiple times, depending on the party of the president who is in office.

Despite the controversy and amount of federal funding involved, there is limited published research on the impact of the Mexico City Policy. Journalist’s Resource has pulled together a few academic studies as well as other resources that we hope will be helpful to journalists covering this topic.

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“United States Aid Policy and Induced Abortion in Sub-Saharan Africa”
Bendavid, Eran; Avila, Patrick; Miller, Grant. Bulletin of the World Health Organization, 2011. doi: 10.2471/BLT.11.091660.

Summary: Three researchers from Stanford University look at how the reinstatement of the Mexico City Policy in 2001 affected the probability that a woman in sub-Saharan Africa would have an induced abortion. The study, which focuses on 20 countries, suggests the Mexico City Policy is associated with an increase in abortions. “Overall, the induced abortion rate increased significantly from 10.4 per 10,000 woman–years for the period from 1994 to 2001 to 14.5 per 10,000 woman–years for the period from 2001 to 2008 (P = 0.01). Although the trend changed gradually, the timing of the rise is consistent with the reinstatement of the Mexico City Policy in early 2001.”

“Contraceptive Supply and Fertility Outcomes: Evidence from Ghana”
Jones, Kelly M. Economic Development and Cultural Change, October 2015, Vol. 64. doi: 10.1086/682981.

Summary: The author examines how cuts in U.S. funding for contraceptives affect pregnancy, abortion and births in one nation in sub-Saharan Africa. The study indicates that a smaller supply of contraceptives resulted in a greater number of pregnancies. Among rural women, the use of abortion rose by 2.35 percentage points.

Other resources:

• A 2016 study published in The Lancet, “Abortion Incidence Between 1990 and 2014: Global, Regional, and Subregional Levels and Trends,” finds that abortion rates have fallen globally.
• The U.S. Agency for International Development (USAID) helps fund a range of international projects aimed at, among other things, improving global health and reducing poverty.
• This 1984 article in Population and Development Review explores the Mexico City Policy.
• President Donald Trump’s 2017 “Presidential Memorandum Regarding the Mexico City Policy.”
• The 2009 statement from President Barack Obama on rescinding the Mexico City Policy.
• The 2001 statement from President George W. Bush on restoring the policy.
• The 1993 statement of President Bill Clinton on rescinding it.

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The issue: Some academics, policy makers and advocates hypothesize that contraceptives and abortion are considered substitutes. The theory goes: In a society with widely available, inexpensive contraception, women will not have as many abortions. Conversely, if contraception such as birth control pills, IUDs and condoms are difficult to obtain, women will have more abortions. If such a relationship does exist, there could be major consequences for population policy and foreign aid programs targeting women’s health.

An academic study worth reading: “Population Policy: Abortion and Modern Contraception Are Substitutes,” published in Demography, July 2016.

Study summary: Grant Miller, director of the Stanford Center for International Development and an associate professor at the Stanford University School of Medicine, teamed up with Christine Valente, a lecturer in economics at the University of Bristol, to study whether women in Nepal use abortion and modern contraceptives interchangeably. For their research, they examined an unusual policy change adopted in Nepal in 2004. That year, abortion was legalized, but there was no significant change made to the supply of modern contraceptives.

To understand Nepalese women’s reproductive behavior, Miller and Valente studied data collected during four waves of the Nepalese Demographic and Health Surveys. The surveys were conducted in 1996 and 2001 – before the policy change – and then in 2006 and 2011 – after the change. The analysis involved a sample of 32,098 women.

Key findings of the study:

• Each new legal abortion provider in a woman’s district of residence was associated with a 2.6 percent decrease in the likelihood of using modern contraception.
• Each new legal abortion provider was associated with a 2.2 percent reduction in the odds of women undergoing sterilization. Centers have no effect on male sterilization, however.
• The decrease in contraception use was driven primarily by decreased usage of reversible birth control methods such as injections. To a smaller extent, there was a decrease in the use of condoms and birth control pills.
• The authors note that their estimates “provide evidence of true substitution between use of modern contraceptives and abortion.”

Helpful resources for reporters writing about this issue:

• The U.S. Centers for Disease Control and Prevention (CDC) tracks abortion and collects information about the characteristics of women who have obtained legal abortions since 1969.
• The CDC also tracks the number of women using contraceptives and the most commonly used contraceptives. It also offers reports on rates of unintended pregnancy.
• The Guttmacher Institute offers a variety of public reports and datasets related to reproductive health, including surveys of unmarried adults’ attitudes about contraception and surveys of abortion patients.
• The United Nations’ Population Division annually estimates and projects contraceptive prevalence among populations around the world.

Related research:

• A 2012 study from scholars at Washington University in St. Louis found a reduction in abortions and teen birth rates when women received free birth control as a part of the Contraceptive CHOICE Project.
• A 2015 study published in Health Affairs found that the federal Affordable Care Act reduced out-of-pocket costs for multiple types of birth control.
• A 2014 study by researchers from J.P. Morgan and Williams College found that early access to birth control can reduce the likelihood that a woman will live in poverty.

Keywords: birth control, family planning, fertility, abortion clinic, reproductive rights, pro-choice

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