The day the U.S. Supreme Court overturned Roe v. Wade in 2022, the medical board that certifies OB-GYNs in America released a statement calling legal pregnancy termination and knowledge of abortion procedures “essential to reproductive health care.”

But a small number of influential anti-abortion doctors have spent the last two years trying to change the reproductive health care standards in state and federal health policy, in a way that is potentially dangerous, doctors representing major medical institutions say.

The question of when abortion is essential health care that states can’t ban is central to several ongoing lawsuits, including Moyle v. United States, a case about whether emergency rooms receiving federal funding have to treat pregnant patients with stabilizing care if it might result in the end of the pregnancy. The U.S. Supreme Court recently kicked the case back to the appellate court, a move that newly allows doctors in Idaho to perform emergency abortions. But the issues remain unresolved, with doctors in Idaho (as in other states) still seeking clarity about whether what they’ve long considered necessary care is legal.

Now as the case returns to the U.S. 9th Circuit of Appeals, researchers behind retracted studies claiming abortion drugs are dangerous are out with new policy recommendations that say when pregnancy termination is necessary, doctors should opt for procedures considered by the wider reproductive health community to carry bigger health risks, such as cesarean sections, rather than less invasive abortion procedures.

“[M]any physicians argue that it is almost never necessary to end the life of a child directly and intentionally by an abortion procedure,” public health researcher James Studnicki and OB-GYN Dr. Ingrid Skop, of the Charlotte Lozier Institute, wrote in a paper published this summer in Medical Research Archives, a journal of the European Society of Medicine. “[W]hen a pregnancy endangering the life of the mother requires termination, a direct ‘dismemberment’ dilation and evacuation (D&E) abortion may be unnecessary, as delivery can usually be performed with a standard obstetric intervention such as labor induction or cesarean section (if indicated).”

Experts told States Newsroom that Charlotte Lozier’s claims contradict national standards of care. And they come at a time when states with strict abortion bans like Texas and Louisiana are seeing a rise in surgical incisions like C-sections and hysterotomies to end pregnancies, even though they carry higher risk, delay future pregnancies, and can affect fertility.

“The end goal of doing a medical intervention to end a pregnancy and save a patient’s life is the same as when we do an abortion. They are just calling for more complicated, sometimes invasive procedures to get to that same end goal,” said Atlanta-based OB-GYN and complex family planning specialist Dr. Nisha Verma. “I think this is really dangerous — it creates confusion. It prevents the public from understanding that abortion is a necessary life-saving procedure.”

The Charlotte Lozier Institute has for more than a decade worked to build the anti-abortion movement’s credibility, by providing research and data to defend anti-abortion laws in the legislature and in the courts. Their claims frequently contradict major American medical institutions on abortion science and safety, and their research methods have faced academic scrutiny — while continuing to wield influence.

Between 2019 and 2022, Studnicki and Skop co-authored three papers in the journal “Health Services Research and Managerial Epidemiology,” two of which were used by anti-abortion plaintiffs and judges to argue for the restriction of abortion pills in a lawsuit against the U.S. Food and Drug Administration, which the Supreme Court rejected this term for lack of standing. But earlier this year, Sage Journals retracted these studies following a reader-prompted investigation, in part for methodological flaws and data misrepresentation. The Charlotte Lozier researchers have insisted the retractions were meritless and politically motivated.

Skop, an OB-GYN from San Antonio, Texas, and Charlotte Lozier’s director of medical affairs, now has even more influence, after her controversial appointment to Texas’s maternal mortality review committee. Skop has made unfounded claims, including that abortion bans will improve maternal mortality rates and that rape or incest victims as young as 9 can “safely give birth to a baby.” But experts say minors are at increased risk for serious complications like preeclampsia and likelier to give birth to low-birth-weight babies.

Last year the San Antonio-based OB-GYN served as a state expert witness when Kate Cox from Dallas asked a Texas judge to grant her an abortion for a nonviable pregnancy. Skop’s sworn affidavit alleged Cox was not at risk of death or “substantial impairment of a major bodily function,” though Cox’s doctor recommended an abortion to preserve her health and future fertility. Denied the abortion in her home state, Cox aborted in New Mexico, and is newly pregnant again.

As a fellow for the American College of Obstetricians and Gynecologists, which has more than 60,000 members, Verma said she has regularly testified before Congress alongside OB-GYNs with minority-held positions on reproductive health policy like Skop and Dr. Christina Francis, the CEO of the anti-abortion American Association of Pro-Life Obstetricians and Gynecologists, which comparatively has approximately 7,500 members.

“It can be really deceptive and confusing for the public who just hear different things coming from two OB-GYNs,” Verma said.

Studnicki and Skop argue that abortion is “not evidence-based” because many people do not seek abortions for physical health reasons, and because much of the existing abortion-safety and efficacy data does not involve randomized controls, i.e., comparing groups of people receiving abortion procedures with those delivering unwanted or nonviable pregnancies to term.

“Based upon the research standard of the Cochrane guidelines, our study shows the science required to consider abortion ‘evidence-based’, alone or in comparison to other interventions, does not exist,” said Studnicki in an written statement, referring to guidelines for systematic reviews, named after British medical researcher Archie Cochrane. “All of us who want the best for women should desire better quality data, including comparison of abortion to other pregnancy outcomes like childbirth, so we can best address the needs of women in heartbreaking circumstances.”

They do not mention the longitudinal Turnaway Study, produced at the University of California San Francisco, which found short- and long-term improved health and socioeconomic outcomes for women who received versus were denied wanted abortions. (Editor’s note: Reporter Sofia Resnick contributed proofreading and editing to UCSF professor Diana Greene Foster’s 2020 book about the study she led.) Anti-abortion activists have criticized that study, including in a published critique that was retracted following concerns about its peer review.

Studnicki and Skop did not agree to an interview but provided a fact sheet for their claims, which notes that OB-GYNs should adhere to guidelines set by ACOG when it comes to life-threatening situations, but also asserts that existing abortion bans do not preclude necessary care.

Claim: “Almost all induced abortions demonstrate no therapeutic intent or medical necessity.”

That abortion is not legitimate health care is a similar argument that a coalition of anti-abortion doctor groups including AAPLOG (of which Skop is a member) made in the abortion-pill case. It’s an argument Charlotte Lozier advanced in an amicus brief submitted to the Supreme Court in Moyle v. United States.

And it’s an argument featured in Project 2025, the Heritage Foundation’s blueprint for a potential future GOP presidency, which says that the federal Emergency Medical Treatment and Labor Act? should not be interpreted to cover abortions. Republican presidential nominee former President Donald Trump has attempted to distance himself from Project 2025’s proposed federal abortion restrictions, though they were authored by officials from his previous administration.

But decades of research have established the high safety record and medical benefits of termination.

“Data from the Centers for Disease Control and Prevention (CDC) clearly shows that pregnancy is a condition that can kill you,” said Dr. Sarah Horvath, an OB-GYN and complex family planning subspecialist and researcher at Penn State University’s Hershey Medical Center, in an email. “As a mother, I can tell you that the benefits of a wanted child often, but not always, outweigh the risks of pregnancy complications and death.”

According to the CDC, the U.S. has the highest maternal mortality rate in the developed world at 22.3 deaths per 100,000 live births as of 2022, with rates for Black women more than double, at 49.5 deaths per 100,000 live births. Research in the journal Obstetrics & Gynecology shows that by contrast the risks from an induced abortion are smaller than the continuing a pregnancy: In the first trimester (more than 90% of all abortions), the rate of maternal death is less than 1 per 100,000, and for abortions at 18 weeks gestation or higher, the risk of death is 6.7 per 100,000.

In the two years since the Dobbs decision overturned federal abortion protections, OB-GYNs in states with near or total abortion bans have reported denying critical care because of these new laws. Many have become politically active, trying to impress upon lawmakers and the public that pregnancy is highly variable and vague exceptions to prevent death are impossible to interpret medically, especially as complications are not always immediately deadly but could become so if not treated promptly.

Claim: When the ‘separation of a mother and her baby’ is necessary, C-sections and inductions should be prioritized over induced abortion to allow parents to ‘express appropriate grief.’?

Referring to a medically indicated abortion as the “separation of a mother and her baby,” which is not a medical term, Studnicki and Skop pose labor induction or cesarean section as the ethical choice.

“Beyond 22 weeks’ gestation, the baby will often survive separation from the mother if given active medical intervention, and even if too young or sick to survive, the family can show the child love and express appropriate grief with the assistance of supportive palliative care,” Studnicki and Skop write. “No study has compared the well-being of a woman and family who end their child’s life in these tragic circumstances to those who continue to allow their child to live until a natural death.”

Verma said depending on the situation and especially before 20 weeks, induction or a C-section could introduce unnecessary risks and delays of care. And the patient would have to wait longer to try to get pregnant again.

“I have a hard time even understanding this claim that a C-section is equally invasive and morbid to abortion procedure,” Verma said. “That’s a major abdominal surgery. We are making a large incision in the abdomen, making incisions in the tissue below the skin, pulling apart the muscles, going into the abdominal cavity, the peritoneal cavity, cutting open the uterus and removing a pregnancy. … If the patient wants to get pregnant again, after a D&E procedure, they can start trying a month later, whereas after a C-section, you have to wait months to be able to safely start trying again without as much risk of your uterus rupturing in the next pregnancy.”

Verma said that sometimes C-sections do make sense in these cases, and that many of her patients do opt for labor and delivery to hold their dead or dying child, but she doesn’t believe these options should be forced on patients.

Claim: Rape and incest victims — who are often adolescents and children – don’t need abortions.

“The emotionally provocative scenario of a young adolescent girl seeking to abort a pregnancy conceived in rape or incest is repeated in the media at a rate which is grotesquely disproportionate to the rarity of its occurrence,” Studnicki and Skop write. “The question of importance is whether an abortion in this circumstance improves the mental or physical health status of the victimized girl. Understandably, there have been no clinical trials addressing this question, so even an abortion in this tragic circumstance cannot be characterized as an evidence-based medical intervention.”

But there is evidence that children and teens face greater physical health risks from pregnancy and childbirth than adults. And Verma noted that the incidence of young children getting pregnant, often by rape or incest, is small but real.

“I have treated young kids in, like the 10-, 11-year-old range,” Verma said. “It’s not something that’s happening every day, but there are many reasons why people need abortions, and that is something that we see and it is terrible.”

Lauren Ralph, an epidemiologist and associate professor at UCSF who specializes in the impact of abortion policies on young people, told States Newsroom that initial research out of Texas is showing fewer young people able to access abortions. According to a national 2021-2022 patient survey, about 10% of abortion seekers were 19 and younger, and about 2% were 17 and younger. Ralph noted that many rape and incest cases among young people are likely underreported.

“The rarity of it, I don’t think diminishes its importance in conversations around the reasons why people seek abortion, for young people in particular, who are victims of sexual assault,” Ralph said. “We know that they’ve had their autonomy violated once, and then if you deny them access to a wanted abortion and force them to continue a pregnancy and give birth, that violates their autonomy yet again.”