Exposing the Dangers of Predatory Abortion Studies

MDPI Redefines Predatory Publishing

Sometimes, I read a medical article and think, “Wow, what a waste of time and resources.” Usually, this is because the hypothesis is bizarre, the study design is tragic, or the bias is so massive it’s unbelievable. But this week, the New York Times brought to light two “What the Fuck” articles (in a great piece written by Patrick Adams). The big WTF here is both articles describe the methodology to forensically identify medications used for abortion, meaning they are blueprints for tests to identify people who might be of interest to law enforcement because they took either mifepristone or misoprostol. Both studies are from researchers in Poland, and the New York Times reported, “The studies were conducted as part of a state-funded research project started in 2022.”

Nice.

The studies (they are really case reports) were both published in late 2022 in the journal Molecules, which is published by MDPI (Multidisciplinary Digital Publishing Institute), which publishes open-access scientific journals, meaning researchers pay to get their work published. Open access is not, by definition, problematic. Still, if you make money by publishing, it creates a bias to accept more articles, and many pay-to-publish publishers are considered predatory. 

A predatory publisher is a pay-to-publish journal/publisher that exploits the need for researchers to get published to further their careers or, in the case of anti-vaxxers, racists, or forced birthers, it’s pay-to-play to further other agendas. These journals have little to no editorial oversight, and papers often get a rubber stamp. It’s possible these journals may also publish some good papers, but many dismal and even harmful papers get through. Sometimes, there are good reviewers or editors who reject a piece based on the low quality of science, only to find it later accepted by someone with more authority. Predatory publishers corrupt science because they allow the publication of scientifically invalid “research,” which then enters the scientific sphere, passing as a legitimate and well-reviewed paper. Unless the person reading that paper knows the source may be predatory, then the findings are often taken as accurate when that may not be the case. 

The first article, Forensic Toxicological Aspects of Misoprostol Use in Pharmacological Abortions

This details the testing to identify misoprostol acid, a metabolite of misoprostol, which is the drug that can be taken by mouth or used vaginally in combination with mifepristone or by itself (it is slightly less effective by itself) to complete a medical abortion. This medication is also used by people to complete a miscarriage.

The authors support the value of their work in what is possibly one of the worst introductions I’ve ever read:

Deaths due to an unsafe abortion remain close to 13% of all maternal deaths. Considering the above-mentioned data, the worldwide problem of unsafe abortion seems to be really important.

Yes, the worldwide problem of unsafe abortion does seem to be really important. And

As the number of illegal abortions increases, counterfeit abortifacients are becoming more widely available on the black market. Considering that the concentration of active ingredients can vary dramatically between different fake abortion-inducing drug specimens, their illegal distribution can pose a significant public health problem. 

Yes, women are at risk of taking counterfeit drugs. However, developing a test to see if someone took the REAL drug after the fact doesn’t help that problem. This is the first clue that this article didn’t receive appropriate editorial review. If one wanted to reduce the use of counterfeit drugs to reduce maternal deaths, then a test strip to see if what one was ingesting was actually misoprostol would be an idea. Or tests to detect harmful products, such as pennyroyal. 

The authors are quite clear that they are only paying lip service to abortion safety, and the real reason for this paper is to incriminate women or people who give them abortion medications because the introduction also states:

Misoprostol (one of the active ingredients of abortion pills) is used to induce an abortion during an unwanted pregnancy, which is a crime according to the law in some countries. This aspect is particularly important in forensic toxicology, since in some countries misoprostol is not approved.

The paper evaluated maternal blood from one person who had a self-induced medical abortion at 21 weeks. There is no mention of how the blood was obtained and if the person knew it would be tested in this way. Given this was in a country where abortion is illegal, I think the authors had a duty to disclose this fact. In addition, the authors used the discredited lung flotation test to try to determine if the fetus was born alive or was stillborn, something else that should have been flagged by the editors. The Los Angeles Times recently called the lung flotation test “an unreliable 400-year-old test.” 

The paper also evaluated fetal tissue from that abortion as well as fetal tissue from another abortion. This is how the second specimen was, ahem, obtained:

On the sidewalk next to the garbage container a male human fetus was revealed (3-4 months of pregnancy), covered with clothes. There was no cardiac or respiratory activity, but there were several recognizable signs of death, such as rigor mortis. Three days after the corpse was found, an autopsy was performed during which the placenta was secured for toxicological examinations.

They didn’t find a corpse, they found a fetus that, by their own report, weighed 34 g (about an ounce) and was 12.3 cm in length. That length is about 13-14 weeks, but there is no explanation of how they reached the unscientific gestational age of 3-4 months (we use weeks, not months, in scientific papers); this should also have been flagged by an editor. I'm unsure if one needs to look for “signs of death” for a 13 or 14-week fetus that is not inside a uterus. I mean, I just can’t even. And rigor mortis? According to the CDC, even full-term infants often don’t have detectable rigor mortis because they don’t have enough muscle mass. How exactly a 34 g fetus could have rigor mortis is not explained, another stunning editorial oversight.  

The fetal description makes it sound like they are trying to convince their readership that they found an almost fully grown baby in the trash when what they found was a tiny fetus far from viability. They also have no idea if that was an abortion or a miscarriage. The imprecision and inaccuracy here are something and would lead an informed reader to wonder, how legitimate is the actual work?

As misoprostol is cleared quickly from the body, the article looked for the metabolite, misoprostol acid, which is also rapidly cleared from the body. The maternal blood test was negative, but they identified misoprostol acid in fetal tissue. 

No words from the authors on how identifying misoprostol acid in fetal tissue will reduce MATERNAL deaths from clandestine abortions. However, they conclude, "The advantage of the research presented in this article is the possibility of confirming the use of abortifacients by the mother to self-induce termination of a pregnancy.”

Nice one, Molecules, nice one.

Paper 2, Determination of Mifepristone (RU-486) and Its Metabolites in Maternal Blood Sample after Pharmacological Abortion

This paper looks at identifying mifepristone in the blood, also from a woman who was 21 weeks pregnant, and I’m not entirely sure if this is the same person from the other paper or not. Super awesome that the authors of the paper wrote that her apartment was searched and didn’t tell us how that happened. Were the police involved or concerned family? I think an ethical editor would have demanded to know more or why this was even relevant.

Mifepristone is also cleared quite quickly from the blood. The half-life, the time it takes for the body to remove half the drug, is 25-30 hours. If we use 30 hours for the half-life, that means by about 6 days, only 3% of the drug is still in the system. The woman’s blood was tested at 24 hours, and the researchers found mifepristone (and several metabolites). The levels were higher in the blood than in fetal tissues, leading to the conclusion:

It suggests that to prove an illegal abortion with the use of mifepristone, maternal blood is significantly better biological material than fetal blood, because of the higher concentrations of this substance. 

I’ll just remind everyone that this isn’t a conclusion in the journal “Red State District Attorney Weekly,” this is in a medical journal, or at least a publication masquerading as one.   

These are Blueprints for Prosecution, not Medically Helpful Tests.

A study should add value to the medical literature, to patients, or preferably both. Studies can also add value to forensic evaluations. Tests to determine if someone has taken a medication can be of value, for example, to know if someone is getting enough medication for epilepsy or to check acetaminophen levels in the case of poisoning. However, there is no medical scenario where it is important to know if someone ingested misoprostol or mifepristone. These tests aren’t here to help people having miscarriages or abortions, they’re here to help with prosecuting those people. The authors seem pretty clear about that. These papers can only make abortion less safe, and this can only lead to more deaths. 

I’ve detailed some of my issues with the two papers. Still, admittedly, I am not a biochemist or expert in laboratory medicine, so I can’t speak to the quality of the tests themselves. 

It’s a big issue for me that consent for the testing is not mentioned in either paper, especially as the fetal tissue was provided by law enforcement. Ethically, we are supposed to get consent, even for case reports. In fact, I’d argue especially for case reports, as often there is more identifiable information. This is what a different medical publisher, Elsevier, says about consent and case reports:

Due to its nature of being a detailed description of an individual patient’s clinical presentation and therapy, a case report almost always contains information that could be traced back to the individual in question. Thus, a written, informed consent from the patient is a key requirement for the publication. Keep in mind that your patient is your partner in completing a case report, therefore make sure to discuss the report proactively with them including being explicit about any potential images that you are going to use, especially if they show or could identify the patient.

Concerns About MDPI In General

Reasons to question MDPI include their fast turnover times (from submission to publication) and the creation of journals with names that sound like other scientifically respected journals. For example, there is a legitimate journal Cell and an MDPI journal called Cells. Many have documented these issues, and the Wikipedia page for MDPI is a wild ride.

MDPI was on “Beall’s List of Potential Predatory Journals and Publishers,” an influential list notifying academics about predatory publishers. Jeffrey Beall, an academic librarian, had to close down his list (there is still an archived version if you google it), and there are reports online that pressure from MDPI may have played a role. In Beall’s own words:

In January 2012, I launched a new blog titled Scholarly Open Access that listed predatory publishers and journals and offered critical commentary on scholarly open-access publishing. In January 2017, facing intense pressure from my employer, the University of Colorado Denver, and fearing for my job, I shut down the blog and removed all its content from the blog platform.

Several scientific bodies have raised concerns about MDPI, and the number of special issues that they publish has raised concerns. Read about that here. 

Predatory Reports lists all MDPI journals as predatory. You can find that list here and excellent explanations of why MDPI is predatory here, here, and also here. 

Here’s a good summary of just some issues with a variety of MDPI journals

• In 2016, an MDPI journal published a terrible article linking internet pornography with erectile dysfunction. Among the many failings of the article was the fact that one of the authors ran an anti-porn ministry. No really.

• In 2018, the editorial board of the MDPI journal Nutrients resigned because of pressure to accept low-quality papers. Read about that here. 

• The MDPI journal Psych has published work from scientific racists. Look, if you publish people who have also published in a journal run by Nazis, what does that say about you? 

• The MDPI journal Molecules (the journal in question here) has a history of publishing some bizarre articles. 

• The MDPI journal Vaccines published an anti-vaccine article that was denounced as being “scientifically invalid,” and five of the journal’s editors resigned in protest. Eventually, the article was retracted. They also recently published another ridiculous anti-COVID-19 vaccine article this year, and to make it extra special, one of the authors, a doctor from Canada, lost his medical license in 2015.

• If you start searching online for issues researchers have had related to MDPI, you stumble across lots of posts on social media, like this one on Reddit. Albeit these are anecdotes, but there are a lot of them out there.

I could go on and on and on and dunk on MDPI all day, but at some point, this piece has to end. 

It’s No Wonder Blueprints for Prosecuting People for Having Abortions appeared in an MDPI Journal. 

These articles are about finding new ways to punish people who have abortions; that’s it. They have no value to the scientific community, and the lack of detail about informed consent from the two women whose medical histories are disclosed is ethically concerning to me. 

Apparently, women in Poland haven’t suffered enough because of the country’s draconian abortion laws, so MDPI needed to give the patriarchy there a helping hand. At least six women in Poland have died since the law was enacted because waiting until Death himself comes to unhook your intravenous before you can be deemed sick enough for a life-saving abortion is, surprise, a bad idea. And while women aren’t supposed to be prosecuted for having an abortion, they have been interrogated and threatened by the police. The idea that people could have their blood or fetal tissue tested for mifepristone or misoprostol only increases the risks to those who have abortions and those who help. Creating fewer avenues to take medications safely creates more desperation and a greater tolerance for risk. It’s abhorrent. 

What Now?

There are no tests yet in the United States to detect misoprostol acid or mifepristone, so don’t panic. If you use either of these medications and you are concerned about the legality in your state, say nothing. And take the misoprostol by mouth so no pill residue could be found in your vagina. Obviously, if some awful person decides to repeat the methodology here, we’ll have to cross that bridge, so it’s something we need to be watchful about. However, given that this work is in a predatory journal, the results may well be questionable. 

If you are a researcher or medical professional, don’t cite or use MDPI journals in your work, and don’t submit your work there for publication. 

I think Obstetrics and Gynecology, the journal associated with ACOG, should not accept MDPI journals as references for articles submitted for publication. I think I am going to write a letter about that.

I thought about writing a letter to the editors of Molecules, but I don’t want anything I write to appear in their dumpster fire. 

If you are someone who isn’t in the medical profession but likes to read articles to inform yourself, ignore those from MDPI. While some of their articles are likely fine, it’s clear many papers have issues. Remember, the more they publish, the more they make. Unless you are an expert in the field, it’s hard for you to know if you’re reading a legitimate paper or a piece of trash. Also, do you want to support the publisher of these papers?

Publishing blueprints for law enforcement that can only further restrict access to safe abortion redefines what it means to be a predatory publisher. These two publications could literally get people arrested or even killed. 

I guess MDPI isn’t content with preying on academics who need publications, so they’re now venturing out into the real world. 

References

Wise J. Covid-19: Vaccines journal retracts controversial paper after editorial board members quit BMJ 2021; 374 :n1726 doi:10.1136/bmj.n1726

Beall J. What I learned from predatory publishers. Biochem Med (Zagreb). 2017 Jun 15;27(2):273-278. doi: 10.11613/BM.2017.029. PMID: 28694718; PMCID: PMC5493177.