The National Academies of Science (NAS) Report on Abortion Safety:
An Agenda-Driven Breech of Science Relied on in June Medical Services, LLC v. Russo
Bioethics in Law & Culture Winter 2021 vol. 4 issue 1
Priscilla Coleman, Ph.D.
Professor, Bowling Green State University
In June Medical Services, LLC v. Russo, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, the American Academy of Pediatrics, and the American Academy of Nurse-Midwives in conjunction with other U.S. professional organizations submitted an amicus brief. The authors of the brief made the inarguable assertion that laws regulating abortion must be evidence-based. However, they relied heavily on a flawed report titled, "Safety and Quality of Abortion Care in the United States," published by the National Academies of Sciences, Engineering, and Medicine in March of 2018 to back their claims of abortion safety in objection to Louisiana’s hospital admitting privileges requirement. The purpose of this article is to offer a close examination of the pro-choice bias that permeated the NAS document, resulting in a highly misleading and faulty characterization of the science on the safety of abortion. The following analysis has implications for interpretation of the Supreme Court decision as well as other court cases and documents produced by various professional organizations that use the NAS report to inform practitioners, legislators, and the public regarding issues of abortion safety.
I. Background on the NAS and Allegations of Bias
The NAS is a private, non-profit society comprised of scholars founded 157 years ago during the Civil War. President Lincoln signed the bill to incorporate the NAS, with service to the nation identified as the primary purpose. Throughout the years, the NAS has provided scientific and technological information from members elected by their peers for distinguished achievement in their respective fields.
In March of 2018, the NAS Committee report on the quality and safety of abortion was released, and within months the over 200-page document had quickly made its way into the reports of experts hired to assist with challenges of various state-level restrictions on abortion services throughout the U.S. As indicated on page S-12 of the report, "The committee concludes that legal abortions are safe and effective. Safety and quality are optimized when the abortion is performed as early in pregnancy as possible. Quality requires that care be respectful of individual patient preferences, needs, and values, so that patient values guide all clinical decisions. The committee did not identify gaps in research that raise concerns about these conclusions…”
A careful examination of the report reveals large segments of the peer-reviewed literature are ignored, notably studies revealing heightened physical and mental health risks associated with abortion. Further, the NAS Committee generally failed to provide clear information regarding the standards employed to select and evaluate individual studies in formulating general conclusions.
The NAS’ own guidebook to best practices titled “On Being a Scientist,” admonishes that “even the appearance of a financial conflict of interest can seriously harm a researcher’s reputation as well as public perceptions of science.” Ethical handling of potential conflicts of interest as explicated in the NAS guidebook is as follows: “In some cases, the conflict cannot be allowed, and other ways must be found to carry out the research. Other financial conflicts of interest are managed through a formal review process in which potential conflicts are identified, disclosed, and discussed.” More generally, in the online overview of the guidebook, the societal implications of scientific integrity are described, “The scientific research enterprise is built on a foundation of trust. Scientists trust that the results reported by others are valid. Society trusts that research results reflect an honest attempt by scientists to describe the world accurately and without bias. But this trust will endure only if the scientific community devotes itself to exemplifying and transmitting the values associated with ethical scientific conduct.” Despite articulating the dangers inherent to science when conflicts of interest are present, the work of the NAS has raised questions of conflict of interest for decades, largely due to continued recruitment of scientists with financial interests in the field studied by committees on which they serve.
The Center for Science in the Public Interest (CSPI) conducted one of the most comprehensive analyses of conflict of interest within the NAS. CSPI is a consumer advocacy organization launched nearly 50 years ago to conduct innovative research and advocacy programs in health and nutrition and provide consumers with current scientific information about health and well-being. CSPI represents the citizens’ interests before regulatory, judicial, and legislative bodies on food, alcohol, health, environmental, and other issues to ensure science and technology are applied to the public good and encourage scientists to engage in public-interest activities.
The CSPI published a document in 2006 titled, “Are the National Academies Fair and Balanced?” The conclusions of the CSPI report revealed significant problems with the NAS process for formulating committees, “Unfortunately, we found serious deficiencies in the NAS’s committee-selection process that could jeopardize the quality of future NAS reports. The NAS has allowed numerous scientists (and others) with blatant conflicts of interest to sit on committees. Compounding that problem, those conflicts of interest usually are not disclosed to the public.”
Three years ago, similar allegations were raised against the National Academies of Science, Engineering, and Medicine (NASEM) in the highly respected journal, PLOS ONE by Krimsky and Schwab (2017). In the abstract of their article, these researchers reported, "This study examines whether there were any financial conflicts of interest (COIs) among the twenty invited committee members who wrote the 2016 report on genetically engineered (G.E.) crops. Our results showed that six-panel members had one or more reportable financial COIs, none of which were disclosed in the report. We also report on institutional COIs held by the NASEM related to the report."
Toward the end of the article, they state, "It is notable that the committee members we identified as having financial COIs comprised all of the committee's expertise on key topics, including plant biotechnology, molecular biology, plant breeding, weed science, and food science. Presumably, committee members were asked to author the sections of the report relevant to their expertise, meaning entire chapters may have been written by committee members with financial COIs” and “Just as the NASEM did not disclose any financial COIs among its committee members, it also did not disclose institutional COIs. At the time the NASEM was developing its 2016 G.E. crop report, it was receiving money from agricultural biotechnology companies that have a financial interest in the study. The organization's annual financial reports do not give exact figures but note that three leading agricultural biotechnology companies (Monsanto, Dupont and Dow) have given up to $5 million dollars each to the NASEM.” The authors point out that their analysis “showed that the omitted disclosures may not have met the standards established by The Academies’ own guidelines or by contemporary standards of financial COI disclosure.”
Close examination of the 2018 NAS report titled “The Safety and Quality of Abortion Care in the United States” reveals blatant conflicts of interest in the tradition described above. Contracts between the NAS and several foundations with strong commitments to reproductive rights supported the undertaking, and most of the committee members and reviewers of the document have ideological and/or financial ties to the abortion industry.
Moreover, the impetus for a review of evidence on the safety of abortion did not originate with the NAS. Instead, as explained in the report, funding sources initiated the review “In 2016, six private foundations came together to ask the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine to conduct a comprehensive review of the state of the science on the safety and quality of legal abortion services in the United States. The sponsors—The David and Lucile Packard Foundation, The Grove Foundation, The JPB Foundation, The Susan Thompson Buffett Foundation, Tara Health Foundation, and William and Flora Hewlett Foundation—asked that the review focus on the eight research questions listed in Box S-1. The Committee on Reproductive Health Services: Assessing the Safety and Quality of Abortion Care in the U.S. was appointed in December 2016 to conduct the study and prepare this report.” Each of the funding agencies, which together formed the driving force behind the NAS Committee report, have provided significant financial support to abortion providers and/or donated large sums of money to pro-abortion/population control initiatives.
For example, the Susan Thompson Buffett Foundation (STBF) is the largest financial supporter of pro-abortion activities and population control. In fact, STBF is described by Callahan (2017) as the largest non-governmental funder of reproductive health and family planning, including extensive investments in abortion and contraceptives worldwide. The Media Research Center (2017) estimated that STBF gave over $1.2 billion to organizations that advocate for pro-abortion policy, perform abortions, or assisted with the development of medication abortion. The Center further reported that as of 2012, STBF had provided nearly $300 million to Planned Parenthood clinics and its national headquarters, Planned Parenthood Federation of America.
Examination of tax records by the Center for Medical Progress revealed that the STBF was by far the largest donor to Planned Parenthood in America, contributing $230,915,706 to Planned Parenthood between 2010 and 2013. In an article for Inside Philanthropy, titled "Long Distance Funders: The Money Behind the Endless Abortion Battles," Marek noted that "The foundation named after Warren Buffett's late wife and bankrolled by Buffet family wealth is the most important player by far in the abortion space. STBF has given tens of millions of dollars to the Planned Parenthood Federation of America and state affiliates since 2010. The foundation gave over $35 million in 2014 alone." Marek further explained that STBF is the single largest funder of the National Abortion Federation, the professional association of abortion providers. In 2014, it gave the group $23 million to support its national telephone hotline. STBF has supported an array of other pro-choice groups that engaged in policy fights over abortion restrictions, including NARAL and the National Women’s Law Center.
According to an article by Martin (2016), Warren Buffett donated at least $88 million from 2001 to 2014 to the University of California-San Francisco, a medical research institution with a strong reproductive health infrastructure. Martin (2016) interviewed Tracy Weitz, former director of UCSF’s Advancing New Standards in Reproductive Health project (ANSIRH), who commented: “there’s been recognition in the philanthropic community that in order to make progress, either culturally or politically or in the service-delivery arena, there are research questions that we need to answer.” Martin notes: “The ANSIRH program was established in 2002 as part of UCSF’s Bixby Center for Global Reproductive Health and lists more than two dozen separate abortion-related initiatives on its website on everything from mandatory ultrasound-viewing laws to abortion in movies and T.V. to reproductive health access for women in the military. The funder and recipient have been closely intertwined; Weitz left UCSF to become the Buffett Foundation's director of U.S. programs in 2014."
Martin further commented that for several years now, foundation-backed researchers have churned out studies aimed at debunking common justifications for abortion restrictions, including "that clinics were teeming with incompetent and unscrupulous doctors; that injured, abandoned patients were flooding emergency rooms; that the psychological damage caused by grief and regret after abortions often persist for years and ruins women's lives." Not surprisingly, the primary focus of the review of literature on abortion and mental health in the NAS Report involves many studies published using the same data set, the UCSF Turnaway Study.
Examination of every funding organization that backed the NAS review on abortion safety is beyond the scope of this article; however, a second example, the David and Lucille Packard Foundation, is considered. On their website, the Population and Reproductive Health Program is described as "committed to promoting reproductive health and rights, with a focus on high-quality information and services." Examination of tax records by the Center for Medical Ethics revealed that the David and Lucile Packard Foundation gave 14.7 million to Planned Parenthood's "Population and Reproductive Health" between 2010 and 2013. In the article referenced above, Marek noted that the Packard Foundation gave over $7 million to Planned Parenthood since 2011, noting the Packard Foundation also backed the National Abortion Federation with donations of approximately $2.2 million in the past few years. Other recent recipients of Packard funds noted by Marek included NARAL ($400,000 in the past few years) and The Center for Reproductive Rights (over $2 million since 2011).
Several NAS Committee members have associations with organizations that have supported unrestricted access to abortion, such as the Kaiser Family Foundation and the Reproductive Health Program at the Bill & Melinda Gates Foundation. Notably, none of the Committee members appear to have a research program specifically related to abortion safety. Many of the reviewers of the NAS report are directly involved in the provision of abortion services or have connections to pro-choice organizations revealing significant conflicts of interest.
II. The NAS Committee Ignored a Vast Literature on Abortion and Mental Health
In the section of the NAS Committee report on the association between abortion and women’s mental health, the authors ignored the majority of published scientific studies, focusing nearly exclusively on the seriously flawed Turnaway Study (Biggs, 2016) and two literature reviews produced by professional organizations.
The Turnaway Study results suggested serious consequences to denying a wanted abortion relative to women's health and well-being. Described below are the most egregious methodological flaws of the study that render the results completely unreliable.
a) Only 37.5% of women invited to participate in the study actually participated. Across the study period, 42% dropped out, rendering the final sample consisting of a mere 22% of those eligible for inclusion. The women whose voices are not included were likely those who had the most serious post-abortion psychological complications (Söderberg, Andersson, Janzon, & Sjöberg, 1998).
b) The authors failed to reveal the specific consent to participate rates for each group. Second-trimester abortions have been established as potentially more traumatizing than first trimester procedures (Brewer, 1978; Coleman, Coyle, & Rue, 2010; Soderberg, Janzon, & Slosberg, 1998); therefore, it is likely that a significantly higher percentage of women in the first-trimester group, compared to those in the second-trimester group, consented to participate. If the rates were comparable, they should have been provided, as failure to report critical information increases suspicion that the second trimester "near limit' group was in no way representative.
c) In the Turnaway Study, women who secured abortions near the gestational limits combined women for whom the legal cut off ranged from 10 to 27 weeks, ignoring the fact that women's reasons for choosing abortion and their emotional responses to the procedure differ greatly at varying points of pregnancy. Therefore, women aborting at such widely disparate gestational ages should not be combined, particularly when the information is available in the data.
d) The Turnaway Study authors did not provide sampling information. Specifically, they did not explain how the sites located in various cities were selected, nor did they explain the overall type of sampling plan.
e) All primary outcome measures were simplistic, with two variables containing only six items. This is inexcusable given the many psychometrically sound multiple item surveys available in the professional literature. Further, there is no theoretical basis for the cut-score employed to determine clinically relevant cases of depression or anxiety.
f) The authors suggested that later abortions are healthier for women than childbirth, obscuring the well-documented risks of late gestational age abortions to women's physical well-being in addition to the elevated psychological risks. For example, using national data, Bartlett and colleagues (2004) reported that the relative risk of abortion-related mortality per 100,000 was 14.7 at 13 to 15 weeks of gestation, 29.5 at 16 to 20 weeks, and 76.6 at or after 21 weeks.
The NAS Committee briefly described previously published systematic reviews of the literature, citing the conclusions of the American Psychological Association (APA) Task Force on Mental Health and Abortion (TFMHA) and the U.K. National Collaborating Center for Mental Health (NCCMH). The APA Task Force and the NCCMH Committee concluded that rates of mental health problems for women with an unwanted pregnancy were the same for abortion and birth. However, a close examination of the protocols for selecting and analyzing individual studies utilized by researchers affiliated with these two professional organizations reveals substantial evidence of bias and inappropriate scientific methods.
The APA, which published their literature review in 2008, now has a history of over 50 years taking a political stance on abortion, advocating for it as a civil right since 1969. Therefore, basic precautions should have been followed to assure the Task Force's work was done in an objective, scientifically defensible manner. The Task Force had no call for nominations, and the final make-up of the Task Force was comprised of individuals who have been public advocates of the pro-choice view. Several additional problems with the conduct of the APA review are described below.
There was a claim that three literature reviews (Coleman et al., 2005; Coleman, 2006; Thorp, Hartmann & Shadigian, 2003) were incorporated into the APA report; however, the conclusions of these reviews are entirely ignored and no explanation is provided. For example, Thorp et al. (2003) concluded that induced abortion increased the risk for "mood disorders substantial enough to provoke attempts of self-harm"; this is not alluded to whatsoever in the APA Task Force report. The APA Task Force did cite the review by Bradshaw and Slade (2003); however, the choice of information to report was highly selective. For example, they noted: “The conclusions drawn from the recent longitudinal studies looking at long-term outcomes following abortion, as compared to childbirth, mirror those of earlier reviews (e.g., Adler et al., 1992; Wilmoth et al., 1992), with women who have abortions doing no worse psychologically than women who give birth to wanted or unwanted children.” The Task Force ignored a central statement from the abstract of the Bradshaw and Slade review pertaining to more immediate mental health implications of abortion: “up to around 30% of women are still experiencing emotional problem after a month.” Also ignored from the Bradshaw and Slade article is the following statement: “The proportion of women with high levels of anxiety in the month following abortion ranged from 19-27%, with 3-9% reporting high levels of depression. The better quality studies suggested that 8-32% of women were experiencing high levels of distress.”
The APA Task Force did not perform a meta-analysis; therefore, the strength of abortion-mental health associations across studies was not quantified in the 2008 report. In the report, the authors noted, “Given the state of the literature, a simple calculation of effect sizes or count of the number of studies that showed an effect in one direction versus another was considered inappropriate.” From the authors’ perspective, there were too few studies to quantify effects, yet a sweeping, definitive statement indicating an absence of ill effects was considered justified.
According to the APA report, the Task Force "evaluated all empirical studies published in English in peer-reviewed journals post-1989 that compared the mental health of women who had an induced abortion to the mental health of comparison groups of women (N=50) or that examined factors that predict mental health among women who have had an elective abortion in the United States (N=23)." Note the second type of study is restricted to the U.S., resulting in eliminating at least 40 studies. The introduction of this exception allowed the Task Force to ignore studies, such as a large Swedish study of 854 women one year after an abortion, incorporating a semi-structured interview methodology requiring 45-75 minutes to administer (Soderberg et al., 1998). Rates of negative experiences were considerably higher than in previously published studies relying on superficial assessments. Specifically, 50-60% of the women sampled experienced emotional distress of some form (e.g., mild depression, remorse or guilt feelings, a tendency to cry without cause, discomfort upon meeting children); 16.1% experienced serious emotional distress (needing help from a psychiatrist or psychologist or being unable to work because of depression); and 76.1% said that they would not consider abortion again, suggesting it was not a very positive experience.
The APA Task Force did not select studies based on methodological criteria but instead included all studies with empirical data related to induced abortion and at least one mental health measure published in peer-reviewed journals in English on U.S. and non-U.S. samples. Sample size, characteristics, and representativeness, type of design, and employment of control techniques should have been the minimum foundation for selecting studies to include in the review.
In the APA Task Force Report, there are shifting standards of evaluation based on congruence with a pro-choice agenda. There are numerous examples in the APA report of studies with results suggesting no negative association between abortion and mental health being reviewed less extensively and stringently than studies indicating adverse relations between abortion and mental health. Positive features of the studies suggesting abortion is a benign experience for most women were highlighted, while the positive features of the studies revealing negative outcomes were downplayed or ignored. All the studies showing adverse outcomes associated with abortion were published in peer-reviewed outlets, many in very prestigious journals with low acceptance rates. A few examples of this bias are detailed below.
a) The Medi-Cal studies (Coleman, Reardon, Rue, & Cougle, 2002; Reardon et al., 2003) are sharply criticized for insufficient controls; however, using a large socio-demographically homogeneous sample, many differences are likely distributed across the groups. Moreover, the study's strengths included using actual claims data (diagnostic codes assigned by trained professionals), which eliminated the problems of simplistic measurement, concealment, recruitment, and retention, which all are serious shortcomings of many post-abortion studies. The authors of the Medi-Cal studies also removed all cases with previous psychological claims and analyzed data using an extended time frame, with repeated measurements enabling more confidence in the causal question.
b) Fergusson and colleagues’ 2006 study had numerous positive methodological features, yet the APA denounced it as flawed. Among the strong aspects of this study were the following:
1) a longitudinal design, tracking women over several years,
2) comprehensive mental health assessments employing standardized diagnostic criteria of DSM III-R disorders,
3) considerably lower estimated abortion concealment rates than found in previously published studies, and
4) the sample represented between 80% and 83% of the original cohort of 630 females, and the study used extensive controls.
Variables that were statistically controlled in the primary analyses included maternal education, childhood sexual abuse, physical abuse, child neuroticism, self-esteem, grade point average, child smoking, history of depression, anxiety, suicidal ideation, living with parents, and living with a partner. Very little discussion in the APA report was devoted to this study's positive features, and the limitations, which were few compared to most abortion studies, were highlighted.
c) Sample attrition as a methodological weakness is downplayed in the APA report. The studies with the highest attrition rates, conducted by Majors and colleagues, provided little evidence of negative effects; these studies are embraced as high-quality investigations despite attrition rates as high as 60%. Common sense suggests that those most adversely affected are the least likely to want to think about the experience and respond to a questionnaire. Research indicates that women who decline to participate or neglect to provide follow-up data are more likely to be negatively impacted by an abortion than women who continue participating (Soderberg, Anderson, Janzon, & Sjoberg, 1998).
Cultural stigmatization as a primary variable related to whether or not negative post-abortion emotional outcomes are experienced is a theme that factored heavily into the APA report. However, very few studies support the claim that any ill effects of abortion are culturally constructed. In fact, many studies have shown that internalized beliefs regarding the humanity of the fetus, moral, religious, and ethical objections to abortion, and feelings of bereavement/loss often distinguish between those who suffer and those who do not (see Coleman et al., 2005 for a review).
Perhaps most egregious is that the final conclusion in the APA Task Force report did not follow from the literature reviewed. It inappropriately rested on one study by Gilchrist et al. (1995) published in the U.K. that has a number of ignored methodological flaws. The authors of the report concluded: “The best scientific evidence published indicates that among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single elective first-trimester abortion than if they deliver that pregnancy.” Reliance on one study to draw a definitive conclusion stands in direct contrast to the accepted scientific protocol described by Wilkinson and the Task Force on Statistical Inference affiliated with the APA Board of Scientific Affairs. Wilkinson and colleagues (1999) specifically stated in the American Psychologist, "Do not interpret a single study's results as having importance independent of the effects reported elsewhere in the relevant literature. The thinking presented in a single study may turn the movement of the literature. Still, the results in a single study are important primarily as one contribution to a mosaic of study effects." (p. 602)
The APA Task Force ignored several flaws of the Gilchrist study, described below.
a) Very few controls for confounding 3rd variables were employed, meaning the comparison groups may very well have differed systematically regarding income and relationship quality, including exposure to domestic violence, social support, and other potentially critical factors.
b) The authors reported retaining only 34.4% of the termination group and only 43.4% of the group that did not request a termination at the end of the study. The attrition rate was highly problematic, as were the differential rates of attrition across the comparison groups. Logically, those traumatized are less likely to continue in a study.
c) No standardized measures for mental health diagnoses were employed, and general practitioners, not psychiatrists, reported evaluation of patients' psychological state. The GPs were volunteers, and no attempt was made to control for selection bias.
d) The initial response rate was not provided, meaning it was impossible to know if the sample was representative of women in the U.K. or not.