Advice Abortion

Much Ado About Nothing: Pro-Life Misconceptions About Contraception

Cristina Page

There's no evidence that any birth control method prevents a fertilized egg from attaching to the womb. Why isn't that a relief to pro-lifers?

One of the most amazing things about the stir caused by the recently leaked HHS proposal is how little, make that no, effort has been made to investigate whether the claim by the anti-abortion establishment about the mode of action of hormonal birth control is even true. A subsequent draft of the regulations without the redefinition of abortion has been released, but the underlying question — can contraception prevent implantation? — still stands.

Now, of course, for pro-choice people, this is a moot point. Even if hormonal birth control could prevent a fertilized egg from implanting in the womb, that’s not abortion because pregnancy doesn’t begin until implantation. To enter into this discussion is to first set aside the medical and legal definition of pregnancy and indulge the extremists. That’s why this discussion never really happens. But what would we find if we did indulge them?

According to the Code of Federal Regulations, The American College of Obstetricians and Gynecologists and the National Institutes of Health, pregnancy begins when a fertilized egg implants in the womb. Until it affixes to the woman’s womb a fertilized egg can not receive nutrients from the woman’s body, which is essential for it to grow. Implantation is also the only way in which a pregnancy can be determined, there is no test that can tell when an egg has been fertilized—there is no way of knowing whether or not this has happened.

Implantation is what sets in motion all the signs that pregnancy has begun. On this one point, science, medicine and the law agree: implantation is the moment at which pregnancy starts. The only dissenting group is the pro-life movement, which dismisses this definition. It, instead, would like pregnancy to start at the unknowable moment the sperm fertilizes an egg. Once sperm meets egg, any effort to prevent the egg from implanting in the womb is considered an abortion by the pro-life movement. This is one of the arguments they offer up as justification for the campaigns to keep women from using birth control. Their claim is that most birth control methods prevent fertilized eggs from implanting in the womb, which to them, though not to science, is an abortion. But even that is not true. There is no evidence that birth control methods actually do what pro-life groups claim.

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Prompted, in part, by the growing efforts of anti-abortion groups to define birth control as abortion, the American Journal of Obstetrics and Gynecology in 1999 reviewed the available research on “the mechanism of action” of the contraceptive methods that so dismay pro-lifers. The authors take up the pro-life concerns directly writing, “Recently, some special interest groups have claimed, without providing any scientific rationale, that some methods of contraception may have an abortifacient effect.”

After reviewing the available literature, the authors conclude that hormonal contraceptive methods (oral contraceptives, the patch, the ring, the shot) cause a number of changes in a woman’s body which prevent
pregnancy. Primarily, what they do is simply prevent ovulation. In other words, take the pill and in almost all instances a woman won’t release an egg. No egg, no chance of pregnancy. The secondary way these contraceptives function, the authors report, is by preventing fertilization. So, on the very slim chance that a woman using a hormonal method does produce an egg another mechanism of action kicks in. Hormonal contraceptives also thicken the mucus lining of women’s reproductive organs which hamper the ability of the sperm to even get to the egg. And if a rogue sperm reaches the egg, hormonal contraceptives prevent it from penetrating the egg. Specifically, they stop the shell encasing the egg from disintegrating so a sperm can’t actually do the deed of fertilization. This is what is known about how hormonal birth control works.

What gets pro-lifers so worked up is that they insist on believing that a fertilized egg can be stopped from implanting in the womb. First off, hormonal contraceptives stop fertilization. What if, through some extraordinary, unknown, and seemingly unknowable process, an egg got fertilized? The researchers
consider the question and report , “No direct evidence exists showing that implantation is prevented by progestin-only methods” and “The evidence does not support the theory that the usual mechanism of action of IUDs is destruction of fertilized ova in the uterus,” say the authors. After reviewing all the research available on the modes of action of all contraceptives in question the authors summarize their report by explaining that “Even though the precise mechanism of action of modern contraceptive is not yet fully known, scientific evidence suggests the main mechanisms of action for each method. Inhibition of ovulation and effects on the cervical mucus are the primary mechanisms of the contraceptive action of hormonal methods. Evidence indicates that the primary mechanism of action of IUDs is the prevention of fertilization.”

“All of these methods, directly or indirectly, have effects on the endometrium [the lining of the uterus] that might prevent implantation of a fertilized ovum,” the researchers acknowledge. But as they quickly point out, “So far, no scientific evidence has been published supporting this possibility.” There’s just no evidence that any birth control method prevents a fertilized egg from attaching to the womb, even though that’s the basis for the pro-life claims.

What’s most striking about all this, is that, really, it should be a relief to pro-lifers. Birth control doesn’t have any effect on the egg once fertilized. The primary and secondary ways in which these methods work should be completely acceptable by the pro-life movement. In fact, though, they’ve taken just the opposite stance. Their argument usually sounds like this: We can’t really know for sure that in some cases, however rare, a
fertilized egg isn’t kept from fulfilling its God decreed destiny of implanting in the womb. And the dutiful scientist, limited by the research facts, must acknowledge that though there is no evidence to suggest that such a thing happens, it’s impossible to rule it out. So there! Says the pro-lifer. It can’t be ruled out. You can’t prove a negative. It’s a little bit like deriding gravity as a hypothesis. Yes, the last ten times you dropped that spoon, it crashed down on the table. But what about the eleventh time? Or the eleven  hundredth? Or the eleven millionth? There is also know way of knowing how breast feeding works as a means of birth control, which it does in the exact way hormonal methods menitioned above do, or whether fertilized eggs to breast feeding women are prevented from implanting. Applying the same exact standard here, pro-lifers would even be against the birth control method God designed. They propagate “education” campaigns, with great vehemence and assuredness, about the “abortifacient” method of birth control—all this, because while there is no evidence to show these methods actually prevent implantation of a fertilized egg, there is also no evidence to show they do not. “Insufficient evidence exists on whether cellular or biological changes in the endometrium could actually prevent implantation,” say the authors. However, their point is that it doesn’t matter. “The possibility of fertilization during combined oral contraceptive use is very small. Hence, endometrial changes are unlikely to play an important role, if any, in the observed  contraceptive effectiveness of combined oral contraceptives.” Thus pro-life campaigns against birth control are based not on scientific evidence, but rather on wishful thinking. Indeed, on a slim hypothetical chance, the pro-life movement has successfully opposed legislation that would have provided millions of women access to effective birth control methods. If the science isn’t on your side, then, the pro-life side seems to believe, ignore it.

Even some pro-life physicians, sparked by the recurring actions by the pro-life movement as a whole against birth control, stepped in to offer their medical views on the concerns their fellow pro-lifers raise. In 1998, twenty-two pro-life Ob/Gyns published an analysis entitled “Birth Control Pills: Contraceptive or Abortifacients?” and four of these pro-life physicians followed up with a more detailed paper on hormonal
contraceptives in general. The physicians open their statement boldly warning, “Currently the claim that hormonal contraceptives [birth control pills, implants (norplant), injectables (depoprovera)] include an abortifacient mechanism of action is being widely disseminated in the pro-life community. This theory is emerging with the assumed status of “scientific fact,” and is causing significant confusion among both
lay and medical pro-life people. With this confusion in the ranks comes a significant weakening of both our credibility with the general public and our effectiveness against the tide of elective abortion.” The authors explain that any effects on the uterine lining that the pro-life movement uses to support the claim that fertilized eggs are being prevented from implanting would be insignificant and has no role in the ability for a fertilized egg to implant. Fertilized eggs are able to implant in much more hostile conditions than those resulting from the mode of action from the pill. They report “The presumption that implantation of a blastocyst is thwarted by “hostile endometrium” is contradicted by the “pill pregnancies” we as physicians see. Pill company literature estimates 3 to 5 pregnancies per l00 women per year for pill users. Many of these women take the “pill” an additional month or two before finding out they are pregnant. These pregnancies generally progress with no more difficulty than non-pill pregnancies. To our knowledge, there are no studies showing that the spontaneous abortion rate in these cases is any greater than in pregnancies with a “friendly endometrium.” The pro-life physicians conclude that there is no evidence to support that the contraceptive methods in question act in the ways that would be unacceptable to the pro-life individual who
believes life begins at fertilization. They state it as plainly as they can, “the ‘hormonal contraception is abortifacient’ theory is not established scientific fact. It is speculation, and the discussion presented here suggests it is error” and continue “if a family, weighing all the factors affecting their own circumstances, decides to use this modality, we are confident that they are not using an abortifacient.”

Yet, their campaigns against birth control continue today with more intensity than even before this  intervention from the most expert on the pro-life side. Of course, arguing over inconvenient biological truths is, in many ways, besides the point when it comes to pro-life disenchantment with birth control. Don’t be
misled. This fracas is not caused by a simple scientific misunderstanding. Otherwise, they’d rush to support birth control methods that don’t ’cause abortions,’ even in their implausible view. Like the diaphragm, condom, cervical cap, and spermicides. But the pro-life forces aren’t on record anywhere in favor of methods that keep sperm and egg apart. It appears impossible to find a single instance in which a pro-life group has anything good to say about any birth control method except natural family planning—a technique most notable for its high failure rate. Remember, even the lowly condom disturbs them.

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

News Health Systems

Complaint: Citing Catholic Rules, Doctor Turns Away Bleeding Woman With Dislodged IUD

Amy Littlefield

“It felt heartbreaking,” said Melanie Jones. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

Melanie Jones arrived for her doctor’s appointment bleeding and in pain. Jones, 28, who lives in the Chicago area, had slipped in her bathroom, and suspected the fall had dislodged her copper intrauterine device (IUD).

Her doctor confirmed the IUD was dislodged and had to be removed. But the doctor said she would be unable to remove the IUD, citing Catholic restrictions followed by Mercy Hospital and Medical Center and providers within its system.

“I think my first feeling was shock,” Jones told Rewire in an interview. “I thought that eventually they were going to recognize that my health was the top priority.”

The doctor left Jones to confer with colleagues, before returning to confirm that her “hands [were] tied,” according to two complaints filed by the ACLU of Illinois. Not only could she not help her, the doctor said, but no one in Jones’ health insurance network could remove the IUD, because all of them followed similar restrictions. Mercy, like many Catholic providers, follows directives issued by the U.S. Conference of Catholic Bishops that restrict access to an array of services, including abortion care, tubal ligations, and contraception.

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Some Catholic providers may get around the rules by purporting to prescribe hormonal contraception for acne or heavy periods, rather than for birth control, but in the case of copper IUDs, there is no such pretext available.

“She told Ms. Jones that that process [of switching networks] would take her a month, and that she should feel fortunate because sometimes switching networks takes up to six months or even a year,” the ACLU of Illinois wrote in a pair of complaints filed in late June.

Jones hadn’t even realized her health-care network was Catholic.

Mercy has about nine off-site locations in the Chicago area, including the Dearborn Station office Jones visited, said Eric Rhodes, senior vice president of administrative and professional services. It is part of Trinity Health, one of the largest Catholic health systems in the country.

The ACLU and ACLU of Michigan sued Trinity last year for its “repeated and systematic failure to provide women suffering pregnancy complications with appropriate emergency abortions as required by federal law.” The lawsuit was dismissed but the ACLU has asked for reconsideration.

In a written statement to Rewire, Mercy said, “Generally, our protocol in caring for a woman with a dislodged or troublesome IUD is to offer to remove it.”

Rhodes said Mercy was reviewing its education process on Catholic directives for physicians and residents.

“That act [of removing an IUD] in itself does not violate the directives,” Marty Folan, Mercy’s director of mission integration, told Rewire.

The number of acute care hospitals that are Catholic owned or affiliated has grown by 22 percent over the past 15 years, according to MergerWatch, with one in every six acute care hospital beds now in a Catholic owned or affiliated facility. Women in such hospitals have been turned away while miscarrying and denied tubal ligations.

“We think that people should be aware that they may face limitations on the kind of care they can receive when they go to the doctor based on religious restrictions,” said Lorie Chaiten, director of the women’s and reproductive rights project of the ACLU of Illinois, in a phone interview with Rewire. “It’s really important that the public understand that this is going on and it is going on in a widespread fashion so that people can take whatever steps they need to do to protect themselves.”

Jones left her doctor’s office, still in pain and bleeding. Her options were limited. She couldn’t afford a $1,000 trip to the emergency room, and an urgent care facility was out of the question since her Blue Cross Blue Shield of Illinois insurance policy would only cover treatment within her network—and she had just been told that her entire network followed Catholic restrictions.

Jones, on the advice of a friend, contacted the ACLU of Illinois. Attorneys there advised Jones to call her insurance company and demand they expedite her network change. After five hours of phone calls, Jones was able to see a doctor who removed her IUD, five days after her initial appointment and almost two weeks after she fell in the bathroom.

Before the IUD was removed, Jones suffered from cramps she compared to those she felt after the IUD was first placed, severe enough that she medicated herself to cope with the pain.

She experienced another feeling after being turned away: stigma.

“It felt heartbreaking,” Jones told Rewire. “It felt like they were telling me that I had done something wrong, that I had made a mistake and therefore they were not going to help me; that they stigmatized me, saying that I was doing something wrong, when I’m not doing anything wrong. I’m doing something that’s well within my legal rights.”

The ACLU of Illinois has filed two complaints in Jones’ case: one before the Illinois Department of Human Rights and another with the U.S. Department of Health and Human Services Office for Civil Rights under the anti-discrimination provision of the Affordable Care Act. Chaiten said it’s clear Jones was discriminated against because of her gender.

“We don’t know what Mercy’s policies are, but I would find it hard to believe that if there were a man who was suffering complications from a vasectomy and came to the emergency room, that they would turn him away,” Chaiten said. “This the equivalent of that, right, this is a woman who had an IUD, and because they couldn’t pretend the purpose of the IUD was something other than pregnancy prevention, they told her, ‘We can’t help you.’”


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