Can William Saletan Get A Clue?

Via Professor Lemieux I read The Road From Roe
Can technology break the abortion stalemate? by William Saletan. I shouldn't have bothered. But since I have, here are my comments.

The article deals with second-trimester (2nd) abortions, with a focus on late 2nd trimester procedures. Mr. Saletan finds these abortions particularly icky, therefore he argues for a gradual, voluntary exodus from at least half the time frame protected by Roe.

Before I go on, let me point out that nowhere in the article does Mr. Saletan offer even a shred of evidence for his repeated assertion that the public's increasing squeamishness (no evidence this trend even exists) about 2nd trimester abortions is fueling the looming political battle over abortion/Roe. For all we know this battle is driven by a crass power grab by politicians lusting for ever more intrusive interference in our private lives, or maybe even a push by the ruling class towards a theocracy.

Actually, the fact that the number of abortions performed after the 1st trimester, particularly during the late 2nd trimester, has been relatively constant for over three decades argues against Mr. Saletan's assertion. More on this in a bit.

Returning to the article, Mr. Saletan asserts that [the way] to end the assault on Roe is to make it irrelevant. And how does he propose we do that? Via the magic of medical technology--improved neonatal survivability, more foolproof contraception, more access to morning-after pills, earlier and fewer abortions. Now if only any of these had any significant impact on reducing the number of 2nd trimester abortions, we might be on to something. Since they don't, we're not.

Let's look at the improved neonatal survival rates claim first. From the article:

Roe established a right to abortion through the end of the second trimester. The latter part of that time frame has always been the most controversial. Improvements in neonatal care have made fetuses viable-capable of surviving delivery-earlier than was possible in 1973.

What is the evidence that late 2nd trimester abortions have always been the most controversial? And, more importantly, for whom? In any case, there are several problems with the implication that improved neonatal survival rates are relevant to our discussion.

First, an abortion is intended to terminate a pregnancy. The patient who needs or wants an abortion, needs or wants to terminate a pregnancy, not deliver an extremely low birth weight (possibly suffering from the sequelae of prematurity) fetus.

The only way it makes sense to bring the issue of neonatal survival rates into a discussion of reducing the number of abortions is if you're advocating forced surgery on female patients in order to deliver the pregnancy without their consent.

Second, the issue of improved survivability of a normal fetus is irrelevant for nonelective 2nd trim abortions. These are done for either maternal, or fetal indications (maternal illness, fetal death, etc.).

Third, since Mr. Saletan brought up the topic, here's a bit of background on the impact of improvements in neonatal care on the survival rate of extremely low birthweight (ELBW) newborns. As you read the studies, some [very] general guidelines: late second-trimester abortions roughly cover the 18-22 weeks interval; birthweight >500g ~ 24 weeks, and 750g ~ 26 weeks. You should also keep in mind that "trimester" is not an accurate framework when discussing survival rates of ELBW neonates. The combination of estimated gestational age (EGA), maturity, and birthweight is. [As is gender, with lower survivability for males.]

Perceptions of the potential for survival are inevitably confused by difficulties incurred by imprecisely known gestational age. Most survival data are based upon birthweight, which may vary appreciably between 24 and 26 weeks. For example, infants born between 24 and 26 weeks can vary in weight from 435 g to 1640 g. [Williams, p692]

From the U.S. (1995/6 vs.1991 and/or 1988):

[From January 1995 through December 1996] Eighty four percent of 4438 infants weighing 501 to 1500 g at birth survived until discharge to home or to a long-term care facility (compared with 80% in 1991 and 74% in 1988)....The incidence of chronic lung disease [CLD]...proven necrotizing enterocolitis [NEC]..., and severe intracranial hemorrhage [ICH]...remained unchanged between 1991 and 1996." and "[From January 1995 through December 1996] Mortality for 195 infants weighing 401 to 500 g was 89%, with nearly all survivors developing CLD.

and

Survival to discharge was 54% for infants 501 to 750 g at birth, 86% for those 751 to 1000 g, 94% for those 1001 to 1250 g, and 97% for those 1251 to 1500g.... Mortality in infants weighing 501 to 600 g was 71%; among survivors, 62% had CLD, 35% had severe ICH, and 15% had proven NEC.

From NY (1978-2003):

A review of 25,448 admissions was performed to evaluate the progress of neonatal intensive care at Weill Cornell Medical Center since 1978....Survival of the smallest infants (<600 g) remained poor, but overall survival of all infants improved over time. Length of stay for infants 1000 to 2000 g fell over time while that of other infants remained constant.

From Chicago (1991-2001):

Fewer infants in all ELBW [extremely low birth weight/<1000 g/~23-28 weeks] subgroups are dying, compared with a decade ago, and the improvement has been most prominent for BWs of 450 to 700 g, at which mortality was and remains to be greatest. 2) This progress seems to have slowed, or even stopped, by the end of the decade. 3) Although most NICU nonsurvivors still expire early, doomed infants are lingering longer.

From Canada (1983-1989 [earlier cohort] vs. 1991-1993 [recent cohort]):

The recent cohort (n = 333) of live birth infants, compared to the earlier cohort (n = 911 ) showed a trend toward an overall improved survival to discharge (72 vs. 65%, p = 0.06). Further analysis showed that improved survival was seen only in 26- to 28-week GA [gestational age] infants (86 vs. 76%, p = 0.01), but not in 23- to 25-week GA infants (44 vs. 44%, p = 0.9), even when adjusted for gender or twin births. In addition, the incidence of major impairment at 18 months (36% in both periods) remained high. Reanalysis of 24- to 25-week GA infants again showed no evidence of improved survival (53 vs. 50%) or improved outcome at 18 months (major handicap rate 32%; vs. 34%). Survival rates improved for 26- to 28-week GA infants, but the survival rate and incidence of major impairment had not improved for of 23- to 25-week GA infants.

Last, but not least, a study of neonatal outcome of infants born at 23 weeks EGA, from Brigham and Women's (1995-1999):

About one third of infants delivered at 23 weeks' gestation survived to be discharged from neonatal intensive care. More advanced gestational age was associated with increased likelihood of survival. No neonates survived free of substantial morbidity.

Moving on, we have this:

Meanwhile, sonograms and embryology have made people aware of how well-developed fetuses are while still legally vulnerable to abortion. We even do surgery on fetuses now, which makes aborting them seem that much more perverse.

A 2nd trimester fetus has no more ability to perform any basic life functions (breathing, waste disposal, etc.) than an incipient embryo. Which brings me to what I think is a key fantasy propagandized in abortion discussions. An abortion terminates a pregnancy, not a fetus. There's no free-floating unborn American child in utero.

In any case, we perform fetal surgery on pregnant female patients who do not need or wish to terminate their pregnancy. What seems extra, super duper perverse [what, you thought only Mr. Saletan gets to grade perversions?] is to deny pregnant patients with an abnormal fetus fetal surgery because some other pregnant women need to abort their pregnancies. Equally perverse would be to deny pregnant patients with an abnormal fetus 2nd trimester abortions because some totally unrelated pregnant patients need fetal surgery.

Next, we have:

But if medical technology has helped to expose this moral problem, it can also help us solve it.

What moral problem, and, more importantly, whose moral problem? And since I'm asking questions, in what *relevant* way has medical technology helped us expose this alleged problem?

And this gem of an unsupported claim:

Second-trimester abortions are becoming not just harder to stomach, but easier to avoid.

Who says 2nd trimester abortions are becoming harder to stomach, and, who exactly is having these stomach aches? More importantly, where is the evidence showing that 2nd trimester abortions are becoming easier to avoid?

According to the CDC's 2002 abortion surveillance data:

As in the past, approximately 88% of all abortions for which gestational age at the time of abortion was known and reported adequately (44 reporting areas) were obtained at <12 weeks' gestation....The proportions of abortions performed later in pregnancy (>13 weeks' gestation) have varied minimally since 1992.

Also, the percent of abortions performed at or >21wks, from 1973 to 2002, has been relatively constant at ~1% (0.8%-1.7%).

And the assertions keep on coming:

The same high-resolution ultrasound that makes you queasy about aborting a 12-week fetus has made it safer to perform abortions at four or five weeks instead of waiting, as women were once routinely told to do.

Thank goodness women everywhere have Mr. Saletan to tell them exactly how undergoing a termination makes them feel. I don't discuss my clinical experience on this blog, but I must say that during all of my many patient encounters I have never once had the presumptuousness to tell a patient how she feels. And what does the high-resolution U/S have to do with the safety of performing 1st trimester abortions?

In 1993, only 7 percent of abortion providers could end a pregnancy at four weeks or earlier; by 2001, 37 percent could do it.

This is just a flagrant misrepresentation. Here's what the original says:

Thirty-seven percent of facilities that offer abortion services provide either surgical or medical abortions at four weeks or less LMP (Figure 1), often for any pregnancy that can be confirmed by ultrasound or even a pregnancy test. This represents a sharp increase from the level of 7% reported in 1993 (not shown).

Moving on:

Better yet, technology is helping many women avoid unwanted pregnancies altogether. According to the Centers for Disease Control, "emergency contraception"--high-dose birth-control pills that you can take after sex to block ovulation, fertilization, or implantation--was almost unheard of a decade ago.

Emergency contraception (EC) has been in common use (off label) since the 1970s. Also, based on the available evidence, there is no indication that the EC pill works by preventing fertilization or implantation. It works by preventing ovulation. [Hmm, maybe I should check out the CDC site to correct them as well.]

More importantly, in a discussion of ways to eliminate 2nd trimester abortions, the only way the topic of EC is relevant is if it can be shown that a) the majority of 2nd trimester abortions are elective, and b) restricted access to the ECP is one of the main reasons women delay obtaining a 1st trimester abortion.

Along the same lines:

The most widely accepted moral solution, short of abstinence, is contraception that's taken before sex. Here, again, the news is basically good: Contraceptive use rose 11 percent from 1982 to 2002 (though progress was uneven), and during this period, the abortion rate dropped by about 30 percent.

A moral solution to a medical problem? Oh, yes, I have seen the light! That's definitely the way to go!

There's no evidence that abstinence is a solution to anything. [Please, we don't even know the typical-use failure rate for this method. Can you imagine any other contraceptive method where such a gap in knowledge would be overlooked?]

Just because Mr. Saletan believes that one way to eliminate 2nd trimester terminations is use of regular birth control, doesn't mean his belief has any basis in reality.

First, in the real world, a significant number of unintended pregnancies occur in women already using birth control:

Results of a 1994-1995 national survey of 9,985 abortion patients ...The proportion of abortion patients who had been using a contraceptive during the month they became pregnant increased from 51% in 1987 to 58%.

Second, just because birth control use rose while the overall abortion rate dropped doesn't mean that contraceptive use is a solution to doing away with 2nd trimester abortions. As I mentioned before, the rate of 2nd trimester abortions has been relatively constant over the years. And just like with EC use, birth control use would be relevant to the discussion only if a) the majority of 2nd trimester abortions were elective, and b) if not using birth control were one of the main reasons women delayed obtaining a 1st trimester abortion.

This is also problematic:

Birth control isn't just more common; it's more effective...

First, just because a birth control method is more effective in theory, doesn't mean it is so in practice:

More than one in five U.S. pregnancies ended in abortion, according to a national sample survey conducted by AGI during 2001--2002 among women having abortions. Inconsistent method use of the pill (75.9%) or condoms (49.3%) was the most common reason that women became pregnant and obtained abortions.

Second, methods like Implanon are great (although one must note that Implanon isn't yet FDA approved), but just because it's available and it's quite effective in no way means that using more common/effective contraception can reduce 2nd trimester abortion.

In the context of reducing abortions, the relevance of the availability/effectiveness of any particular birth control method is limited by the fact that not all women (possibly, not even a significant number) can and/or will use that particular method. A very good example of this problem is the intrauterine device (IUD). The IUD is widely available (worldwide), and is more effective at preventing pregnancy than sterilization. But just because it's a common and most effective method doesn't mean it will have an impact on abortion rates. It all depends on the patient population. Not only are there acceptance problems with this method in the U.S. (a possibly surmountable problem), but not everyone (not even a majority of women in certain groups) can use an IUD (an insurmountable problem). [For example, the ideal patient, as well as her partner, should be monogamous.]

Also, for the availability/effectiveness of birth control to be relevant to our discussion you'd still have to show that a) the majority of 2nd trimester abortions are elective, and b) birth control unavailability and lack of effectiveness are main impediments to women obtaining a 1st trimester abortion.

Finally, we come to the grand assertion:

Technology can't avert all our failings or tragedies. There will always be abortions. But when you look at the trends--more foolproof contraception, more access to morning-after pills, earlier and fewer abortions--you can begin to envision a gradual, voluntary exodus from at least half the time frame protected by Roe....Maybe that six-month window made more sense in 1973 than it does today. Maybe, if we spend the next 10 years helping women avoid second-trimester abortions, we won't have to spend the next 20 or 40 years defending them. Maybe the best way to end the assault on Roe is to make it irrelevant.

And maybe Mr. Saletan is clueless (and, quite possibly, malevolent). Before we all embark on this voluntary exodus from 2nd trimester abortions, we most definitely need a reality check.

Speaking of reality, I must say that I find this Technology can't avert all our failings or tragedies. There will always be abortions. particularly odious. The degree of impertinence exhibited by Mr. Saletan--telling patients with a fetal demise in utero, or an anencephalic fetus that their pregnancies are a failing or a tragedy--is mind-blowing.

Back to teaching mode. First, we must keep in mind that there are nonelective and elective terminations. Second we must look at the indications/reasons for 2nd trimester abortions and see if more foolproof contraception, more access to morning-after pills, earlier and fewer abortions are in any way relevant.

Let's start with nonelective 2nd trimester abortions. Some of the common indications for performing these procedures are: fetal demise; chromosomal or structural abnormalities; preterm premature rupture of membranes (PPROM); false-negative findings [of a fetal anomaly] in the 1st trimester. Better birth control, improved access to EC, and performing an earlier abortion have no impact on these indication. But by all means, let's all "help" women voluntarily relinquish access to medical care, ideally, with a smile on their faces and a thank you in their hearts!

Moving on, what are some of the risk factors that could be associated with presenting for an elective 2nd trimester abortion? From the CDC:

The gestational age at which an abortion is obtained can be influenced by multiple factors in addition to those for which surveillance data are available (age, race, and ethnicity). These additional factors include level of education, availability and accessibility of abortion services, timing of confirmation of pregnancy, timing of personal decision-making, timing of prenatal diagnosis, level of fear of discovery of pregnancy, and denial of pregnancy (34--36).

Also,

Delays in suspecting and testing for pregnancy cumulatively caused 58% of second-trimester patients to miss the opportunity to have a first-trimester abortion. Women presenting in the second trimester experienced more delaying factors (3.2 versus 2.0, P < .001), with logistical delays occurring more frequently for these women (63.3% versus 30.4%, P < .001). Factors associated with second-trimester abortion in logistic regression were prior second-trimester abortion, delay in obtaining state insurance, difficulty locating a provider, initial referral elsewhere, and uncertainty about last menstrual period. Factors associated with decreased likelihood of second-trimester abortion were presence of nausea or vomiting, prior abortion, and contraception use....However, accessible second-trimester abortion services will remain necessary for the women who present late due to delayed recognition of and testing for pregnancy.

Last, but not least, this study from Mississippi:

After enactment of the law [a woman seeking an abortion must first receive, in person, information about the fetus and alternatives to abortion. She must then wait at least 24 hours before having an abortion.], the proportion of second-trimester procedures increased by 53% (from 7.5% of abortions to 11.5%) among women whose closest provider is in-state, but it increased by only 8% (from 10.5% to 11.3%) among women whose closest provider is out-of-state....The proportion of abortions performed later in pregnancy will probably increase if more states impose mandatory delay laws with in-person counseling requirements.

Again we see that some of the main reasons for not obtaining a 1st trimester abortion--delayed recognition of and testing for pregnancy, mandatory delay laws--are not affected by more foolproof contraception, more access to morning-after pills, earlier and fewer abortions.

Finally, the cherry on top of the cake:

Five hundred years from now, people will look back on our surgical abortions the way we look back on the butchery of medieval barbers. Like the barbers, we're just trying to help people to the best of our ability. But our ability is growing. So should our wisdom, and our ambitions.

Wow, where does one even start? I realize this isn't a medical article, but if you're trying to be taken seriously and you wish to safeguard the pretense of basing your argument on facts, you simply cannot bring puerile, uninformed, personal speculation into the discussion [Barbers, really? Are we even sure of the historical accuracy of the butchery of medieval barbers? I mean, why not medieval dentists, or even executioners. But I digress.] Although, I must say, it's a pity Mr. Saletan didn't go on with his fantasy, so that we, too, could gain some insight into how The People of the Future(TM) will look back on various contemporary surgical procedures, like, say, operative deliveries.

That's it. I told you in the beginning, the article wasn't worth reading. Mr. Saletan tries quite hard to gain some measure of credibility by discussing medical matters (unfortunately, without much insight), but he keeps tripping on his puny "Me, Me, Me" agenda which rears its ugly head (perverse, barbaric, butchery) at almost every turn.

Bottom line: Mr. Saletan finds abortion icky, therefore female patients should voluntarily relinquish their right to adequate medical care/certain internal organs. What is it with all these people and their desperate attempts to pass off as knowledgeable and objective, not to mention Truly Concerned(TM)?