Rather than using his position of power to help people cope with the raging COVID-19 pandemic, U.S. Senator Ted Cruz (R-Texas) has declared war on medication abortion. But he’s done so dishonestly, with claims likely to mislead and inflame. And he chose this approach because the truth would get him nowhere.
In a tweet posted on September 2, 2020, Cruz wrote the following:
Pregnancy is not a life-threatening illness, and the abortion pill does not cure or prevent any disease. Make no mistake, Mifeprex is a dangerous pill. That’s why 20 of my republican colleagues and I are urging @US_FDA to classify it as such.
There’s only one true fact in this tweet—that Cruz and some of his Republican colleagues in the U.S. Senate did submit a letter to the FDA requesting that the “abortion pill” be pulled from the market. But that’s where the truth ends and the lies begin.
“Pregnancy is not a life-threatening illness. . . .”
The evidence is clear: childbirth can be dangerous, is often unpredictable, and is sometimes fatal. As I explored in detail in an earlier column, the rates and patterns of maternal mortality in the United States are truly shocking.
“Maternal mortality” is the term used to describe the death of a woman during childbirth or within one year of giving birth in the absence of another known cause. Great attention has been paid to tracking the maternal mortality rate across the globe, and great efforts have been made to reduce the risk of maternal death. Globally, the maternal death rate decreased 44 percent between 1990 and 2015. In the United States, however, the rate has steadily increased over the last twenty years. According to the CDC, which has tracked maternal death using the Pregnancy Mortality Surveillance System since 1986, the rate has increased from 7.2 per 100,000 live births in 1987 to 18 per 100,000 live births in 2014. (Detailed current information can be found here.) While some of this increase might be due to increased reporting or changes in the way deaths are recorded, some of it is due to the fact that pregnancy and childbirth are getting riskier rather than safer in the United States.
While the overall rate is alarming, the uneven distribution of risk is even more alarming. For 2011-2014, 40 Black women died for every 100,000 who gave birth, compared with only 12.4 white women. The maternal mortality rate also varies considerably from state to state, with the highest rates in states like Louisiana, Georgia, and Indiana. Texas has a higher than average rate of maternal mortality. In 2018, 70 women died while pregnant or within 42 days of the end of pregnancy.
Even more dishearteningly, researchers have identified several ways to reduce the risk of maternal mortality, but many states have not implemented the recommended measures. The Texas legislature failed to pass several bills designed to reduce maternal mortality during its last term in 2019.
Nationwide, the current maternal mortality rate is 17.4 per 100,000 live births; that number is much higher (37.1 per 100,000) for Black women. But this includes only the women who die from pregnancy or childbirth. Maternal “morbidity”—the term used to describe the non-lethal adverse outcomes of pregnancy or childbirth—adds another dimension to our understanding of the dangers of pregnancy and childbirth. The ways in which pregnancy and childbirth can adversely affect a woman’s health are virtually unlimited, but researchers have found a general upward trend in severe maternal morbidity from 1998 to 2010. According to one study, over 60,000 women a year in the United States experience severe maternal morbidity. (Just read the comments to Cruz’s tweet to get a sampling of the scary and sometimes life-threatening experiences of women who have been pregnant and given birth.)
“Make no mistake, Mifeprex is a dangerous pill. . . .”
This is a rather startling lie. First, let’s understand what this pill does. Mifeprex is the brand-name for mifepristone, which blocks the hormone progesterone. This hormone is necessary for a pregnancy to continue. A “medication abortion” involves the administration of mifepristone (a pill), which stops the pregnancy from developing further, and then misoprostol, which induces a miscarriage. This method of abortion can be used only in the first ten weeks of gestation. All abortions after 10 weeks are “surgical,” which means they involve some method of physically removing the contents of the uterus.
The FDA first approved Mifeprex in 2000, with some modest changes to the authorization in 2016 and again in 2019. It is available only through health care providers; the patient takes the first pill in the office and the second later at home. It cannot be sold legally over the internet. Providers must be able to accurately date a pregnancy (i.e. determine how many weeks since the last menstrual period or since fertilization) and diagnose an ectopic pregnancy (a non-viable pregnancy where the embryo implants somewhere other than the uterus, most often in a fallopian tube rather than the uterus).
Like any drug, mifepristone has potential side effects, which are mostly minor. The medication abortion is expected to produce bleeding as the miscarriage occurs, but excessive bleeding may require medical intervention. It is also possible that the pill will not cause a complete miscarriage, requiring a follow-up procedure to terminate the pregnancy. But what about the Cruz’s claim that Mifeprex is “dangerous”? Hardly. The letter Cruz and his colleagues submitted to the FDA makes much of adverse event reports submitted to the FDA, but, not surprisingly, they take the information completely out of context.
The FDA has received adverse event reports in women who took mifepristone, including 24 deaths between 2000 and 2018. This was from a pool of 3.7 million women who have used the drug for a medical termination of pregnancy since it was first made available in 2000. Adverse event reports, however, do not prove causation; as with any drug, an adverse event report may indicate that taking a drug caused a particular patient’s adverse outcome but may also indicate two coincidental but unrelated events. Adverse event reports are simply a report of a temporal connection between a drug and an adverse event. (This is why, you might notice, when television advertisements recite the long litany of scary things that might happen to you if you take the drug, they always use phrasing like “In patients who have taken Drug X, Lymphoma has happened” rather than “Drug X has caused Lymphoma.” If you don’t know which commercials I’m referring to, then you don’t watch enough Law & Order re-runs at night.) Thus, one should always be careful in drawing inferences from adverse event reports without more information. This is clearly the case with mifepristone. In a report summarizing the adverse event data for the drug, the FDA included a footnote to the 24 reported fatalities to explain that the number included two homicides, a suspected homicide, a suicide, two ectopic pregnancies (which are fatal if untreated), and more than one case of an opioid overdose.
Adverse event reports are just one source of information, with some obvious limits as mentioned above. But even if the deaths were attributable to mifepristone (which obviously was not the case given the findings of homicide and suicide, among others), 24 reported deaths in eighteen years, from a population of 3.7 million patients who used the drug, is a vanishingly small number. To draw just one obvious comparison, the FDA received reports of 240 deaths after patients took Viagra in only the first 7.5 months of its availability, and 522 reported deaths after 13 months. And within ten years, the number of reported deaths increased to 2,200. This certainly does not mean that Viagra killed all of these men; but if one were going to ring alarm bells based on fatal adverse event reports to the FDA, one would be better off studying Viagra before mifepristone. And, as an educated consumer, I would be much less worried about ingesting mifepristone than Viagra.
Maybe Cruz has carefully examined abortion data in his own state and knows something we don’t? Nope. The data from Texas, a state that has taken a variety of measures to curtail access to abortion and which scores poorly on virtually every measure of women’s health, tells a story about abortion safety that is completely at odds with Cruz’s tall tale. The Texas Department of Health and Human Services collects reports from providers on every abortion that occurs in the state. All told, those reports show that abortion is an incredibly safe procedure.
In 2017, 52,081 abortions were performed in the State of Texas. According to the state’s own data, this resulted in zero patient deaths. The data also show that there were zero cases of infection or sepsis, zero cases of cervical laceration, and only a single instance of uterine perforation. Indeed, only 21 of 52,081 women (.04%) experienced a serious complication. This data is consistent with findings across the country. Texas also breaks out abortion data by procedure. There were 17,050 medication abortions performed in 2017; all but 75 occurred before the ninth week post-fertilization. None of those women died, and fewer than a dozen suffered any kind of notable complication.
The year 2017 wasn’t an outlier. Ted Cruz could spend his next maskless flight perusing the data for the last ten years, and he would find no additional evidence of danger from mifepristone (or surgical abortion). Of the 52,310 abortions performed on Texas women in 2016, none died, and fewer than 10 suffered complications that could possibly have come from a medication abortion. There were also zero deaths of abortion patients in 2015, 2014, 2013, 2012, 2011, 2010, and 2009. One woman is reported to have died from an abortion in 2008 in Texas, but there is no additional information about the circumstances. One death a decade puts abortion in Texas on par with a pedicure in terms of safety. And neither deaths nor complications have increased as the proportion of medication abortions has risen as a percentage of the total. (Nationwide, almost forty percent of abortions are now done with medication instead of a surgical procedure.)
The Implicit Claim: Childbirth is Safer than Medication Abortion
Cruz’s tweet juxtaposes two false claims in the hopes perhaps that readers will infer a third—that abortion is more dangerous than childbirth. The opposite, however, is true.
The risk of dying from childbirth is many times greater than the risk of dying from an abortion. In a comprehensive study of birth and abortion data, Elizabeth Raymond and David Grimes found that the risk of death from childbirth is fourteen times greater than that with abortion. Their study was based on data from the CDC’s Pregnancy Mortality Surveillance System from 1998-2005. Other studies support this conclusion. For example, one study of abortion complications found little evidence of risk:
We observed a 2.1% abortion-related complication rate after nearly 55,000 abortions diagnosed or treated at all sources of care. The majority were minor. Rates of transfers to an ED, hospital admissions, surgeries, and blood transfusions were low. The complication rate is much lower than that found during childbirth and comparable to that found in the literature even when ED visits are included and there is no loss to follow-up.
Maybe Ted Cruz is genuinely confused about the relative safety of abortion versus childbirth—if he got his information solely from the State of Texas’s official “informed consent” pamphlet on abortion, he would be confused indeed. In a Woman’s Right to Know, the state provides women with rampant misinformation in order to dissuade them from following through with an abortion.
The WRTK pamphlet begins with a dubious claim about fetal pain, and then transitions into a misleading description of risks. The pamphlet states, without citation, that “[t]he further along you are in your pregnancy, the greater the chance of serious complications that can cause you to be infertile and the greater the risk of dying from the abortion procedure.” It also lists “Death” first, as if to suggest that this is a likely complication. It quotes only one data point from CDC data, showing a .00073 percent rate of death from legal abortion (which also includes deaths after abortion where the abortion did not cause the death), without providing any context for how very low that rate is. Nor does it quote its own data, which, as discussed above, would indicate the risk of death is very close to zero. The pamphlet continues with a variety of misleading claims about the ostensible risk to future fertility, higher rates of breast cancer, and the risk of depression or anxiety; none of these claims are supported by the scientific evidence.
Whatever Cruz’s sources of information, his conclusions are simply incorrect.
Why the Lies?
I don’t pretend to be in the mind of Ted Cruz, but I assume that what prompted the letter to the FDA and his Twitter-lies was the July 2020 ruling of a federal judge, which orders the FDA to allow patients to receive medication abortion pills by mail during the COVID-19 emergency. The American College of Obstetricians and Gynecologists (ACOG) and other organizations filed a lawsuit to prevent the FDA from enforcing its restrictions on the pills used for medication abortion. As noted above, the pills are given to patients directly by healthcare providers and are not stocked in retail pharmacies. This means that a patient, who might take both pills unsupervised at home, must first travel to a healthcare provider’s office. The combination of COVID-19 risks and the inaccessibility of many abortion providers means that women are forced to expose themselves to unnecessary risk of contracting the virus. The FDA had waived similar restrictions for other medicines due to COVID-19, but not for mifepristone. The court agreed, in ACOG v. FDA, that the FDA’s restrictions posed an undue burden on women who are seeking an abortion and ordered that women be permitted to receive medication abortion pills through telemedicine or over the phone (and the shipment of the pills through the mail). The order lasts as long as the federal Department of Health and Human Services deems COVID-19 a public health emergency.
In the letter to the FDA, Cruz and his colleagues accuse ACOG and other advocates for women’s health of using COVID-19 “as a ruse” to bypass the FDA’s restrictions on mifepristone. This is rich coming from members of a party that sought unsuccessfully to ban abortion completely (and unconstitutionally) because of COVID-19, without any justification at all. They demand that Mifeprex be taken off the market because it is “deadly” and an “imminent hazard to public health.” There is simply no support for these claims nor the demand they made of the FDA.
The reality is this: the GOP’s strong position against abortion is an unpopular one. Support for Roe v. Wade has been rising steadily, with 73% of Americans saying they support it in recent polls. A poll in 2019 found that 60% of respondents believe abortion should be legal in all or most cases—a record high—and only 36% believe it should be illegal in all or most cases—a record low. Support is broad regardless of gender, religious affiliation, and race. Support is stronger among Democrats and Independents, but about half of Republicans support Roe as well—support runs 47/52 even among Trump supporters. Many people who believe women should have a right to terminate a pregnancy identify as “pro-life.” They simply do not believe that their views are binding on others. Moreover, support for abortion rights is strongest for first-trimester abortions—the only time when medication can be used rather than a surgical procedure.
Politicians are entitled to take unpopular positions—and to use lawful means to change the laws they don’t like. But we all deserve better than a senator who lies to cover up his unpopular positions.