In her grandstanding telemedicine/abortion executive order yesterday, Governor Kristi Noem failed to provide a clear citation for her medically malpractive claim that treating ectopic pregnancies is more dangerous to women’s health than just waiting to see if their ectopic pregnancies burst their fallopian tubes. I had to dig through our part-time Governor’s footnotes to track down the source of that dangerous and incorrect claim. My analysis of all the sources cited in Noem’s feckless Executive Order 2021-12 shows that, still far from reading all the science, Noem is simply cribbing radical anti-abortion sources to justify bad policy for South Dakota.
In an executive order directing the South Dakota Department of Health to write rules concerning medical practice, Governor Noem’s first source, cited in three separate articles, is Tessa Longbons, a research associate at the Charlotte Lozier Institute, an extremist anti-abortion lobbying group that cherry-picks and obfuscates real research to undermine abortion rights and produces occasional original “research” plagued with bias and errors. Ms. Longbons holds no degree in medicine or research; she has a bachelor of arts in communications from Thomas Edison State University in New Jersey.
On lack of qualifications alone, Longbons should be ignored in any serious discussion of state rules for medical procedures. But Noem uses Longbons for talking points, not rigorous science. Longbons’s 2019 opinion column provides no evidence that allowing women to access abortion drugs via telemedicine was harmful to women or required increased regulation. Noem plagiarizes Longbons’s 2021 column for most of the text of her second Whereas clause, without providing quotation marks or a targeted in-text citation to make clear she is using Longbons’s words. Longbons’s third column, a joint effort with fellow Lozier propagandist Hannah Howard, is more secondary opinionating reciting Longbons’s other opinion pieces and Noem’s purported primary sources. Thus, while Noem provides legal background with the passage she plagiarizes from Longbons 2021, Noem doesn’t wring any scientific weight from her citation of these three propaganda pieces.
Noem plagiarizes both Longbons’s text and Longbons’s citation of a Lozier “fact sheet” in this sentence of her third Whereas clause: “The result is likely to be an increase in chemical abortions and resulting complications [iii]“. Longbons sentence is just slightly different: “The result is likely to be an increase in chemical abortions and chemical abortion complications. ” (Noem is at least sufficiently attentive to renumber her footnotes.) The Lozier “fact sheet” that Noem/Longbons cite refers to more secondary-source opinion pieces by the institute, another anti-abortion advocacy group, and only two primary sources, the Aultman and Niinimäki papers that Noem cites elsewhere in her order. Thus, like all three Longbons columns, the Lozier “fact sheet” fails to lend scientific weight to the argument Noem makes for her order.
Those two papers and a third are the only primary and seemingly scientific journal articles Noem offers to support her order:
- Maarit Niinimäki et al., “Immediate Complications After Medical Compared with Surgical Termination of Pregnancy,” Obstetrics and Gynecology, October 2009.
- H.K. Atrash, H.T. McKay, and C.J. Hogue, “Ectopic Pregnancy Concurrent with Induced Abortion: Incidence and Mortality,” American Journal of Obstetrics and Gynecology, March 1990.
- Kathi A. Aultman et al., “Deaths and Severe Adverse Events After the Use of Mifepristone as an Abortifacient from September 2000 to February 2019,” Issues in Law and Medicine, Spring 2021.
Noem cites Niinimäki to support her claim that “chemical abortion has a four times greater rate of complications than surgical abortion.” Indeed, Niinimäki’s study of 42,619 induced abortions in Finland from 2000 through 2006 finds that medical abortion produces more “adverse events” than surgical abortion and may not as reliably terminate the pregnancy, but the study indicated no increased risk of infection or death:
The overall incidence of adverse events was fourfold higher in the medical compared with surgical abortion cohort (20.0% compared with 5.6%, P<.001). Hemorrhage (15.6% compared with 2.1%, P<.001) and incomplete abortion (6.7% compared with 1.6%, P<.001) were more common after medical abortion. The rate of surgical (re)evacuation was 5.9% after medical abortion and 1.8% after surgical abortion (P<.001). Although rare, injuries requiring operative treatment or operative complications occurred more often with surgical termination of pregnancy (0.6% compared with 0.03%, P<.001). No differences were noted in the incidence of infections (1.7% compared with 1.7%, P=.85), thromboembolic disease, psychiatric morbidity, or death [Niinimäki et al., 2009].
“Both methods of abortion are generally safe,” conclude Niinimäki et al. Noem says she’s ordering the the Department of Health “to enhance reporting requirements for this procedure so that we know how often and how harsh the results are,” but the very article she cites in this order seems to answer that question.
I don’t see the citation that points to Noem’s Atrash footnote, but Atrash’s 1990 paper appears to be the source of her irresponsible claim (in her fifth Whereas clause) that “A woman is 30% more likely to die from an ectopic pregnancy while undergoing an abortion than if she had an ectopic pregnancy but had not sought an abortion.” Yet Atrash did not say that the women in his 1971–1985 cohort died “while undergoing an abortion.” Atrash said, “Most of the deaths of women with ectopic pregnancy who underwent induced abortion were attributable to the failure to diagnose the ectopic pregnancy before the woman left the facility where the abortion was performed.” It appears (and I don’t have the full paper, so I’m stepping out on logical limbs) that the increased death-to-case rate arose from doctors failing to check for the ectopic pregnancy and letting the women leave thinking their problems were solved but carrying the ticking time bomb of the ectopic pregnancy. Doctors address the increased death-to-case rate identified in Atrash not by refusing to administer abortion drugs but by checking for signs of ectopic pregnancy and following up after the procedure to make sure they didn’t miss anything. Much more recent research [Bennett et al., 2009] citing Atrash indicates doctors do just that: in its 2001–2005 cohort of 2,550 women, the Bennett study found that “Missed ectopic pregnancies were successfully treated in the inpatient setting without mortality….” The risk Noem misrepresents in her order is already handled better by medical professionals than by her false-alarmism and misinformed/misinforming government overreach.
Noem’s last source, Aultman 2021, supposedly supports Noem’s claim that “women can experience severe and life-threatening side-effects after taking the abortion pills, including heavy bleeding, intense pain, and even death.” But as we well know, women can also experience severe and life-threatening side-effects after becoming pregnant, including heavy bleeding, intense pain, and even death. Where’s our executive order dispatching the Department of Health to patrol the backroads looking for teens who need to be informed of those side effects before they jump in the backseat and risk pregnancy?
The Aultman paper counts up the adverse events from mifepristone reported to the FDA. For its part, the FDA has reviewed these adverse reports and found they do not warrant additional safety guidelines. Dissatisfied that the data did not compel the policy action they desire, Aultman et al. inflate their case by claiming that the FDA reporting system is inadequate. The primary author of the article is another Lozier Institute hack (though at least a retired doctor) who appears to promote the false idea of post-abortion syndrome. The publisher of the Aultman article, Issues in Law and Medicine, appears to be strongly biased toward arguing against abortion rights with occasional forays into anti-vaccination advocacy.
I do appreciate the Governor’s effort to cite her sources for Executive Order 2021-12. Don’t be fooled: footnotes don’t guarantee weightier or reliable conclusions any more than they guarantee the author didn’t plagiarize (quote marks and tighter cites, Kristi!). But Noem’s sources do help us check her work, identify her bias, and see how she’s misreading science.