As dependable as the summer sunshine, the abortion industry is always ready to present a new study as soon as a new abortion policy or method is introduced to defend. The most recent study is entitled “Effectiveness and safety of telehealth medication abortion in the USA,” authored by Ushma Upadhyay and a team from the University of California, San Francisco (UCSF). It was published in the journal Nature Medicine on 15 February 2024.
As might be expected, the study concluded that telehealth medication abortion is an effective, safe and comparable method of providing abortion care to patients.
A study conducted by researchers at the University of California, San Francisco (UCSF) examined the efficacy of abortion pills obtained via mail after an online, email, or text interview. The study involved a review of thousands of cases and found that 97.7% of these were effective, with less than one percent experiencing any serious complications.
Those versed in the pharmacological properties of these drugs and cognizant of their pharmacological actions recognize that the presented data is subject to a considerable degree of interpretation and manipulation. A more detailed examination of the data and the study’s unwarranted assumptions reveals that the process remains beset by numerous significant challenges for women.
One of the primary obstacles to the widespread adoption of home use is the issue of safety.
From its inception, it became evident that the abortion industry sought to establish chemical abortion – the use of pills such as mifepristone and misoprostol – as a procedure that could be conducted outside of the clinic, in the privacy of one’s own home. Nevertheless, a number of safety concerns were identified with the drugs, prompting the government to implement certain safeguards. In order to ensure the safety of the procedure, patients were required to undergo a series of screening procedures, including a physical examination, dating of the pregnancy, confirmation of the absence of an ectopic pregnancy, and the development of a contingency plan in the event of bleeding or other complications. As the pregnancy progressed, the efficacy of the pills diminished, concomitantly increasing the probability of adverse outcomes.
It is of the utmost importance that women are aware that mifepristone is ineffective in the treatment of ectopic pregnancy.
In response to industry demands, the Biden administration eliminated the requirement for in-person visits in 2021, paving the way for the distribution of abortion pills and telehealth abortions.
There is a continuing debate about the safety of such abortions, as evidenced by the case of the Alliance for Hippocratic Medicine v. the U.S. Food & Drug Administration, which is currently being considered by the Supreme Court. The Alliance contested the safety and legality of the government’s recent actions.
The rationale behind the timing of this study is as follows.
In accordance with the established schedule, the abortion industry has released a study purporting to demonstrate the safety and efficacy of abortion procedures conducted remotely. The study compares the safety and effectiveness of these procedures with those conducted in a medical setting, where the woman is personally screened and examined by a physician before being administered the pills and monitored by clinic staff.
Those who have observed this process over the past three decades or so are aware of the typical procedure. The researchers gain access to the medical records of the abortion pill provider, noting the number of patients, the scarcity of recorded complaints, and then pronouncing the new method or modification to be absolutely safe and effective.
However, those of us who have read these studies and studied them carefully are aware that a significant amount of information is omitted from the press release, which could potentially lead to a different interpretation of the findings.
The study analysis is missing more than 1,800 patients. The New York Times (2/15/24) reports that the number of patients involved was “more than 6,000.” Additionally, the claims that a high percentage of these abortions (97.7%) were “effective” are questionable.
However, the 97.7% figure does not apply to the original 6,974 patients whose records were sought, nor even to the 6,154 whose charts indicated that they had been sent the “medications.” The figure is applicable only to the 4,454 cases for which the outcome of the abortion was known.
It is possible that these pills were generally effective for women who responded to follow-up from the virtual clinic and whose outcomes were known. Nevertheless, this represented less than three-quarters of the original sample.
It is reasonable to question the wisdom of entrusting one’s affairs to a remote stranger.
The authors posit that their effectiveness figures are representative of the entire sample, or perhaps even more so. However, this assumption is not substantiated by the evidence presented.
It is difficult to comprehend why a woman who has received pills from an online clinic, which she has never met in person, and which is located hundreds or even thousands of miles from her home, would contact the clinic when she has a problem. It is unclear what other recourse they could offer her, other than directing her to the nearest emergency room, which she could easily and more quickly access independently.
The authors’ assertion that the pills were “successful” for 4,352 of the 6,154 patients who received them is based on the assumption that the remaining 1,802 patients did not experience any complications. However, there is no evidence to support this assumption. This would represent an “effectiveness” rate of just 71%, a considerable discrepancy from the advertised 97.7%. It is therefore possible that a significant number of abortions may have been unsuccessful or that other complications may have occurred.
In truth, the pills are likely to be effective for some individuals who do not recontact the virtual clinic. However, it is not possible to assume, as the authors of this study do, that the results were the same for those who followed up as for those who, for whatever reason, dealt with the consequences in some other way.
The rationale for the determination of effectiveness.
Before turning to the issue of safety, it is important to note that the effectiveness of abortion pills in ending pregnancy is open to question. The authors of the study did not rely on the examination of fetal remains or the results of a later physical examination. Instead, the authors state that the outcomes were “ascertained using a test or the patient’s history.”
Consequently, the individuals in question are not aware of the efficacy of the pills; rather, they are aware of the documented successful outcome. Those versed in the specifics of this type of abortion are aware that heavy bleeding and the expulsion of large clots are possible without the termination of the pregnancy. The child could survive, or the child could die and remain in the womb, which could lead to infection or other complications. It is therefore evident that without an actual test or physical examination, it is not possible to be certain.
The concept of ambivalence is a significant factor in the dissemination of misinformation regarding the APR.
A further point regarding the effectiveness of the intervention is worthy of consideration. As evidenced by the study, a significant number of women (120) who were sent the pills did not take them. Although these were not included in the final effectiveness analysis, they do indicate some ambivalence among patients regarding their wishes.
Among the patients who received and took at least the first pill, the authors report that two requested abortion pill reversal. This finding refutes the claims of abortion pill promoters that women never change their minds after initiating this process.
It is therefore pertinent to enquire as to the response of those engaged in the sale of these pills. Despite the existence of thousands of cases and published studies attesting to the high rates of abortion pill reversal (APR), Upadhyay and colleagues assert that patients were informed that evidence-based reversal treatment does not exist and were referred to urgent in-person care.
Rather than being administered progesterone with the intention of blocking the effects of mifepristone and potentially saving their babies, it appears that they were transported to their local emergency rooms and informed to await the outcome. Other studies have demonstrated that this approach is ineffective for reversing the effects of mifepristone and may be associated with adverse outcomes.
It is astonishing to hear the claims made about the safety of the abortion pill.
The claims of safety are at least as questionable as those of effectiveness, yet the data nevertheless provides insight.
It is not possible to make any definitive assertion regarding the safety of the 1,802 patients who received the pills but did not subsequently report back to the virtual clinic. As previously stated, there is a compelling rationale to suggest that women experiencing haemorrhage, infection, a ruptured ectopic pregnancy, or an ongoing pregnancy did not seek assistance from remote online contacts or faceless telephone operators from a virtual clinic situated on the other side of the country. Instead, they were more likely to seek the assistance they required from a local medical practitioner they knew or an emergency department in the vicinity that could effectively treat or address their problem.
If the aforementioned circumstances are indeed probable and logical, then the complications reported by Upadhyay may represent merely the most evidentiary aspect of a much broader phenomenon. At the very least, they may serve as a mere indication of the types of issues that other women may be facing.
The resolution of a multitude of safety concerns.
It is to be expected that those who defend the abortion pill and the abortion industry would claim that complications were exceedingly rare. Indeed, 99.7% of women reported no major abortion-related adverse events. Those who have followed the research into the abortion pill for some years will be aware that a significant proportion of the work is devoted to defining what constitutes a “major abortion-related adverse event”.
The information in question is not available in the online article, but can be found in a supplement. The supplement defines “serious adverse events” as those including “blood transfusion, abdominal surgery (including salpingectomy, laparotomy and laparoscopy to treat ectopic pregnancy), hospital admission requiring an overnight stay, or death.”
While these are undoubtedly serious outcomes, the fact that they occurred at all is significant. It is important to note what is not included in this definition. A woman may experience haemorrhage, with a profuse loss of blood, and be transported to the emergency room for treatment. She may receive uterotonics to halt the bleeding. However, if she is not transfused or admitted to hospital for an overnight stay, this does not constitute a major complication.
It would appear that the surgical procedure in question does not meet the criteria for inclusion.
It is currently unclear whether further surgical intervention would warrant a more serious classification. It is known that surgical procedures such as salpingectomy or laparotomy to remove the foetus in an ectopic pregnancy are performed. However, it is necessary to consider the potential for surgical intervention to halt the bleeding or to complete the abortion.
The data published in the study indicates that 63 women, representing 1.4% of the effectiveness sample, required a “procedure, aspiration or surgery” more frequently than would be expected in the 0.3% of the sample who experienced “major adverse events.” It is evident that the authors were able to identify a complication severe enough to require surgery without classifying it as a major complication.
This is the rationale behind the claims commonly seen in the popular media that “serious complications” occur in less than one percent of cases (e.g., Washington Post, 4/10/23). However, this figure is significantly lower than the actual number of patients who end up in the emergency room.
The frequency of visits to the emergency room
Indeed, even in this study, 81 patients, representing nearly 2% of the total sample (i.e., those for whom the researchers had information), visited the emergency room. Although this figure is not a significant concern for the researchers, when viewed in the context of the study, it is a cause for concern.
The rationale behind the promotion of telemedical abortion is that it allows women to circumvent the necessity of travelling to a clinic. The procedure can be initiated by ordering the necessary medication online, which is then delivered to the patient’s residence.
When one collects their medication in person from the clinic situated in close proximity, they have the option of contacting a member of staff should they encounter any issues. For instance, if bleeding occurs, a fever develops, pain becomes unbearable, or if any unusual symptoms arise, such as those associated with a chemical abortion, it is advisable to seek medical attention.
It is reasonable to expect that assistance will be available when it is required.
One particular issue that affects rural patients is…
This is not always the case for the client seeking a chemical abortion at the virtual clinic. The prescriber is not typically a known individual, a readily available surgeon, or even a resident of the same state.
Individuals who originate from suburban or rural communities, which collectively represent nearly one in ten (9.9%) of the study population, may be at a disadvantage in accessing the requisite medical assistance. This could result in a deterioration of their condition, even in the absence of a “major” complication as defined by Upadhyay and her team.
The implications for the broader U.S. population are significant.
In general, even if one were to accept the findings of the study at face value, there is a willful and callous blindness to the implications of the study. If we consider that 56% of abortions in the United States are now chemical (as indicated by the U.S. Centers for Disease Control’s 2021 Abortion Surveillance), and that there are somewhere between 900,000 and 1 million abortions a year, then even a seemingly small percentage can represent thousands of women.
A failure rate of 2.3% against a backdrop of 950,000 annual abortions, with 56% or 532,000 being chemical abortions (the number today is certainly higher) would indicate that more than 12,000 women may require some form of intervention to complete the abortion. Even if the potential outcomes of the remaining 26% of patients in Upadhyay’s study are disregarded, and the reported 1.8% of patients who visited the emergency room are accepted, the total number of patients still exceeds 9,500.
However, if there is a higher failure or complication rate for the women in the study who were unable to be tracked, these numbers could increase significantly.
Even researchers have expressed doubt about gestational dating.
The claims of safety and efficacy of telemedical abortion depend in part on the ability of virtual prescribers to determine gestational age and identify ectopic pregnancies without the use of ultrasound or a direct physical examination. If one is to accept the claims of these practitioners (and one ignores the fate of those patients who were lost to follow-up), it would appear that they have been unusually successful in this screening process.
The records examined by Upadhyay and her team from virtual clinics revealed no instances of women over the age of 70 days attempting to terminate their pregnancies, despite the advertising by Planned Parenthood and others for abortifacients at 11 weeks or more and the FDA’s adverse event reports indicating the widespread use of mifepristone on women with gestational ages exceeding the FDA-mandated 10 weeks LMP (after a woman’s last menstrual period). Four cases were identified where the gestational age was unknown.
This implies that women were somehow unusually knowledgeable and forthcoming about the timing of their pregnancy, or that prescribers were exceptionally adept at verbal screening of their patients. However, an alternative hypothesis is that some women were neither accurate nor honest in their assessments, and that the records merely reflected the gestational ages that they had reported, rather than the actual, accurate gestational ages.
Even the authors of the study expressed some reservations. Upadhyay and her team observed that there were no unexpected pregnancy durations beyond 70 days, which was unexpected given previous studies that had indicated that there should have been at least a few. However, they suggest that this may be due to underreporting by patients. The UCSF team postulated that women who may have underestimated their gestations may not have reported their errors to the clinic.
A number of ectopic pregnancies remain unaccounted for.
Ectopic pregnancy is estimated to occur in 1-2% of all pregnancies, where the embryo implants outside the womb. If left untreated, it can result in the rupture of the fallopian tube and may result in the death of both the mother and the child. Mifepristone is not an effective treatment for ectopic pregnancy.
Despite the apparent efficacy of prescribers in screening their patients for ectopic pregnancy, the study indicates that a few patients were not identified.
Given the percentages presented above, it can be reasonably assumed that there should have been some 60 to 120 ectopic pregnancies among the initial 6,034 patient records that were initially examined by the researchers. It appears that the virtual screeners were able to identify a significant number of these cases through verbal screening. Data indicates that 486 women were referred for ultrasounds for the purposes of confirming gestational age or intrauterine pregnancy.
Nevertheless, six patients were diagnosed with ectopic pregnancies, including at least one case that resulted in rupture. Once again, if appropriate medical assistance is available and the condition is treated, it is likely that the mother will survive. In the event that these complications arise at an inopportune time and in an area where qualified medical assistance is not readily available, the consequences could be catastrophic.
It can be reasonably assumed that if ectopic pregnancy affects 1-2% of mifepristone patients, as it does the rest of the population of reproductive-aged women, that this would potentially impact five to ten thousand women a year. Nevertheless, even these patients were subjected to the most rigorous verbal screening by text, email, or webcam, as reported here. However, this screening only affected 0.013 of those patients, which would still result in more than 700 patients a year in the U.S. being subjected to unnecessary risk.
Is the quality of care provided remotely comparable to that of in-person care?
One of the key arguments put forth by researchers is that this study provides evidence that telehealth abortion, or abortion managed by a virtual prescriber, is as safe as those managed directly by an in-person prescriber.
The claim is rendered virtually meaningless by the multitude of questionable assertions and assumptions upon which it is based. If both in-person and telehealth chemical abortions depend on studies where a sizeable number of patients are missing from safety and efficacy calculations—and excluding those patients who are the most likely to experience problems—then the results from both types of studies will be flawed.
The results of various studies appear to be relatively consistent with one another, indicating that the data they report is largely comparable. However, this is because each study is generally limited to those patients who are both most satisfied with their abortions and most likely to report back. The outcomes that truly reveal the safety and efficacy of these abortion drugs are those of patients for whom none of these studies have data.
The data from other Western countries demonstrate a markedly different profile of safety and efficacy.
This is why studies conducted in countries with national healthcare systems and different methods of data collection and recording yield disparate results. This is despite the use of the same drugs and the presence of similar (or superior) patient profiles.
Finland
In 2009, researchers from Finland discovered that 20% of women undergoing chemical abortions reported adverse events, such as excessive bleeding and incomplete abortions. This figure is nearly four times higher than the rate of adverse events reported for standard surgical abortions. In response to pressure from those defending chemical abortion, the authors conceded that some of the adverse events may not have been as serious as others. It is important to note that these events were still significant enough to prompt women to re-access the healthcare system with these concerns.
Britain
A study conducted in Britain, which recently implemented a similar programme, has revealed that the efficacy of the pills is lower and the complication rates are higher. While the government claimed extremely low adverse event rates (identifying just one single complication among 23,061 chemical abortion patients), a researcher who contacted the hospital system directly found that 5.9% of patients reported complications connected to an incomplete abortion with “retained products of conception.” Three percent of patients required surgery to deal with incomplete abortions, and 2.3% of patients were treated for haemorrhage in Britain’s National Trust hospitals (Percuity, 10/27/21).
The aforementioned figures are not as elevated as those observed in Finland. This discrepancy may be attributed to the United Kingdom’s higher population density, which facilitates patients’ access to emergency assistance. Nevertheless, these figures remain higher than those reported by Upadhyay and her team from California.
The introduction of this programme was accompanied by a notable increase in the number of calls to ambulances, as reported by British newspapers. The number of calls to emergency services increased significantly following the implementation of the “Pills by Post” programme, with an increase of over 50% in some areas and at least 25% in others (London Daily Express, 25/04/23).
Canada
A Canadian study published in the online edition of the Annals of Internal Medicine on 3 January 2023 found that patients picking up mifepristone prescriptions from pharmacies had even higher complication rates than those observed in the recently authorised protocol in the United States. Among the 39,856 patients in the study, emergency room visits were reported by 10.3% of patients, equating to at least one in every ten patients.
All of these foreign studies, conducted in modern Western medical settings, utilising the same pharmaceutical agents and employing the same basic protocol, have reported much lower efficacy and much higher complication rates. The only discernible distinction appears to be that they were conducted by private or more impartial state observers rather than those regularly published and cited in the United States by medical professionals involved in and dedicated to the promotion and performance of chemical abortion.
A detailed examination of other American studies reveals a higher incidence of complications.
Upon closer examination, even American studies reveal a much less positive safety profile. An earlier study of emergency room visits in 2015 by Upadhyay herself is often cited as proof that the rate of serious complications with mifepristone is “less than 1%”. Indeed, in the January 2015 issue of Obstetrics & Gynecology, Upadhyay published a study entitled “Incidence of emergency department visits and complications after abortion,” in which she found that the major complication rate was 0.23%, which is less than a quarter of one percent.
However, this is contingent upon the implementation of several questionable techniques designed to manipulate the data. Firstly, Upadhyay stipulates that only those complications that can be classified as “serious” or “major” should be included in the analysis. The article defines major complications as serious unexpected adverse events requiring hospital admission, surgery, or blood transfusion. “Minor complications were defined as all other expected adverse events.”
Although this appears to be a reasonable classification, it is important to consider the specific complications included in Upadhyay’s definition of “minor”. These include haemorrhage, infection, incomplete or “failed” abortion requiring “uterine aspiration” (i.e. surgical abortion). Even conditions such as uterine perforation were classified as minor.
Secondly, it is important to consider that when Upadhyay included both major and minor complications in the calculations, the complication rate for chemical abortions was 5.19%, which is considerably higher than the figure of less than one percent that is often advertised.
The designation of these complications as “minor” serves to diminish the significance of the fact that these incidents were sufficiently serious as to prompt so many of these patients to visit their local emergency rooms.
This was among a select group of individuals who, despite the assurances of those who were promoting and selling the pills, revealed their experience of undergoing a chemical abortion.
Summing Up
The distressing aspect of the abortion industry’s latest study on chemical abortion is that it is likely to be met with a similar level of media spin and reaction as that of the researchers themselves. This is despite the fact that the study fails to account for the hundreds or even thousands of women who are missing from the counts.
It seems unlikely that the news media will devote any coverage to the distressed women, in agony and in need of immediate assistance, who reject the faceless, ineffectual bureaucrats of the virtual clinic in favour of the more direct, personal, and accountable help of their own local doctor or emergency room.
It is unlikely that these women and their complications will be included in studies such as that conducted by Upadhyay. It is possible that these incidents may not be recorded in hospital reports if women follow the advice of many abortion pill prescribers and do not reveal their chemical abortions to emergency room staff. Nevertheless, the risks and injuries they face will be very real.
The reliance on reports from abortion pill suppliers and prescribers has resulted in the structuring of U.S. abortion industry studies in a manner that fails to capture this critical data. However, studies conducted in other countries are more comprehensive in their tracking of patients and reveal significantly lower safety and efficacy rates for mifepristone.
If American women wish to ascertain the veracity of the claims made regarding the safety and efficacy of mifepristone, and if the U.S. Food & Drug Administration is to make an accurate assessment of the risks associated with mifepristone, it is imperative that they cease to rely on data that has been sifted and spun by abortion pill promoters.
Daniel Miller is responsible for nearly all of National Right to Life News' political writing.
With the election of Donald Trump to the U.S. presidency, Daniel Miller developed a deep obsession with U.S. politics that has never let go of the political scientist. Whether it's the election of Joe Biden, the midterm elections in Congress, the abortion rights debate in the Supreme Court or the mudslinging in the primaries - Daniel Miller is happy to stay up late for you.
Daniel was born and raised in New York. After living in China, working for a news agency and another stint at a major news network, he now lives in Arizona with his two daughters.
