New Options, New Politics

In recent years, medical science has devised new options for very early
termination of unwanted pregnancy, measures that did not exist when Roe v. Wade
was decided in 1973. In addition to widening the range of choices for women,
these advances--most notably the "morning after" contraceptive and the abortion
pill mifepristone (RU-486)--are likely to alter the imagery and the politics of
abortion dramatically. Where the so-called pro-life movement has capitalized on a
tiny number of late procedures involving fetuses with the features of babies, the
new technology makes plain that most abortions involve microscopic embryos. This
shifts the moral as well as the medical terrain for most people, as the country's
recent debate over embryonic-stem-cell research makes clear. Unless the radical
right succeeds in overturning Roe v. Wade, these new scientific developments bode
well for the pro-choice movement in this country.

Nevertheless, the abortion debate often seems, as Robin Toner put it
in The New York Times, frozen in time. This is true despite the fact that
how, when, and where an unwanted pregnancy is terminated today involves medical,
moral, and practical considerations that didn't exist when Roe v. Wade was
decided more than a quarter of a century ago. Indeed, nearly everything about
abortion has changed since then except for the way we think and talk about it.
With public-opinion polls showing that a clear majority of Americans support
comprehensive sex education, family planning, and the individual right to
terminate a pregnancy safely, these new scientific and medical developments need
to enter public discourse and shape it.

First, there is the matter of "emergency contraception," more commonly known
as the morning-after pill, which works up to 72 hours after unprotected sex by
preventing fertilization or by interrupting the implantation of a fertilized ovum
in the uterine wall so that a pregnancy never occurs. The regimen is well known
and widely used in western Europe, where a dedicated product is now available
without prescription. The French distribute it in high schools.

For years, physicians in the United States have routinely broken up
packages of standard birth-control pills and administered consecutive double
doses of them to women who report unprotected intercourse and fear unwanted
conception. The procedure, which produces moderate nausea but no other side
effects, is prevalent on many college campuses. Yet pill manufacturers
here--perhaps fearing protests by anti-abortion zealots or cannibalization of the
market for standard oral contraceptives--year after year declined to market a
dedicated product, and the Food and Drug Administration only recently approved
one, after nearly a decade of effort by reproductive-rights groups.

The FDA is now considering a petition to bring emergency contraception over
the counter, but for the time being it needs to be made widely available through
primary-care doctors working with local pharmacists. Estimates suggest that
emergency contraception alone could prevent half of all unintended
pregnancies--still about three million a year in the United States, half of which
result in surgical abortion.

The emergency-contraception method is especially warranted as a backup to
condoms, which as a result of successful education and social marketing are now
widely used in this country to protect against sexually transmitted disease.
Condoms also work as barrier contraceptives, of course, and according to the Alan
Guttmacher Institute, better use of contraception accounts for about
three-quarters of the recent 21 percent decline in adolescent pregnancy rates
between 1990 and 1997. The problem is that condoms have a high failure rate and
require a backup--or a "Plan B," as the marketers are calling their new dedicated
product.

As Americans come to understand and access the new "morning after"
opportunities, they also need to be made aware of the new "month after" options,
since it is after missing their menstrual period that most women first suspect
that they are pregnant. Relatively few Americans, including public officials,
realize that when Roe first became the law of the land, a woman could not even
confirm a pregnancy until she was seven weeks or more into gestation. To terminate
it, she had to wait a least several more weeks, until her cervix softened, so
that a doctor could insert the metal surgical instrument then necessary to
perform a standard dilation and curettage of the uterus.

Today, by contrast, an inexpensive urine test that can confirm pregnancy in its
earliest stages by registering hormonal changes is available for home use. The
recent approval of mifepristone (long known as RU-486) means that the pregnancy,
if unwanted, can be ended as soon as it is detected. Regulations in the United
States permit use of this oral medication up to the seventh week of
pregnancy--though in some parts of Europe and Asia, hundreds of thousands of
women are using it effectively up to the ninth week without adverse consequences.
The simple regimen actually requires a combination of two pills taken in
sequence: mifepristone, which blocks the production of hormones needed to sustain
pregnancy, followed by misoprostol, which induces moderate uterine contractions
and produces the equivalence of a heavy menstrual period that lasts up to five
days.

The crucial distinction between mifepristone and emergency contraceptives is
that the former eliminates a fertilized ovum whereas the latter prevents the ovum
from being fertilized. In other respects, mifepristone's effects do not differ
much from what many women experience every month from menarche (their first
menstrual period) to menopause (their last)--when they eliminate unfertilized
eggs along with the contents of the uterine lining, without much fuss over the
loss. The bleeding is heavier--the cramps more intense--but the process is not
substantially different. Indeed, recent research confirms that about half of all
conceptions spontaneously abort very early--generally before the woman even
realizes she was pregnant--and pass away naturally, experienced as late and heavy
menstruation.

A Comprehensive Approach

One can see the promise of these new approaches in a small and
friendly community-based family health center that operates out of a storefront
near downtown Brooklyn, New York. Here, at the New Options Training Center, as it
is being called, a revolution is brewing in how family planning and
early-abortion care are provided. Pioneered by a team of committed young
physicians and nurse practitioners, the facility is among the first
family-medicine centers in the United States to integrate reproductive health
care, including early-abortion services, into general medicine. This allows each
patient to experience a continuum of care--from family-planning visits to
morning-after prescriptions or early abortion, if needed--as part of her ordinary
medical visit. Gone is the stigma that has been associated with the termination
of unwanted pregnancy since abortion was legalized more than a quarter of a
century ago, and for the many years before, when it was clandestine and illegal
yet widely available.

Affiliated with the Long Island College Hospital, one of Brooklyn's most
venerable institutions, the family health center sits less than a mile from the
makeshift clinic in a Brownsville tenement where Margaret Sanger made history in
1916 by defying the law to provide contraceptives to women, many of whom were
immigrants. Sanger went to jail for 30 days, but subsequent appeal of her
conviction established a medical exception to the New York State laws
prohibiting birth control and granted doctors (though not nurses, as Sanger had
hoped) the right to prescribe contraceptives for health reasons only.

The birth-control movement in America nonetheless remained a target of legal
repression and political controversy. It developed under these difficult
circumstances only through the slow but steady growth of independent,
not-for-profit clinics affiliated with the Planned Parenthood movement, in
isolation from mainstream medicine. Lost was Sanger's vision of a comprehensive
program of preventive public health, with clinics in every urban neighborhood and
traveling caravans of medical personnel in rural areas providing a full range of
services. Only after 50 years of sustained advocacy and litigation--following
Griswold v. Connecticut, the historic 1965 decision in which the U.S. Supreme
Court struck down state laws banning birth control used by married couples--did
President Lyndon Johnson finally incorporate family planning into America's still
fledgling public-health and social-welfare programs.

When abortion was legalized in 1973, however, the earlier pattern
was replicated. Federal funding was denied, and today only 15 states provide
Medicaid coverage of abortion. Abortion services quickly moved out of hospitals
into freestanding clinics that in some cases are administered by Planned
Parenthood but mostly run privately and for profit. In the increasingly hostile
climate that has since surrounded the practice in this country, providers have
become true heroes, braving harassment and violence, and even risking death. Not
surprisingly, their numbers have decreased dramatically, down 14 percent in
recent years to a mere few thousand nationwide. Ninety-five percent of the
country's rural counties today have no abortion services and, statistically,
seven states have fewer than one provider per 100,000 women.

With the graying of a generation of doctors motivated by memories of
the horrors of illegal abortion, the problem has become particularly acute.
Abortion training is not routinely provided as part of medical residency
training, even for obstetricians and gynecologists [see "Making Choice Real" on
page A29]. And while committed medical students around the country--more and more
of them women--have begun to demand the reversal of this practice, wisdom may
prevail in moving back to the future, so to speak, by reclaiming Margaret
Sanger's vision of comprehensive neighborhood health centers.

Realizing a Promise

If the radical right has its way, however, clinics such as these will
be suppressed. The intense politics of abortion have already resulted in the
dissemination of much misinformation about the abortion pill among providers and
patients--not to mention politicians. The first challenge for innovative services
like the New Options facility in Brooklyn is to overcome these distortions with
education and training akin to what has worked in the past with new methods of
contraception. A second challenge is to untangle the thicket of legal provisions
and administrative codes that govern abortion at the state and local levels and
make it a more intensely regulated procedure than, say, brain surgery.

New Options is providing family practitioners with a working model of
comprehensive reproductive health care, including how early abortion can be
integrated into their practices. This includes hands-on training in emergency
contraception, medical abortion, and early-gestational ultrasound as well as
information on the many administrative issues involved in implementing early
abortion services--such as complex consent forms, proper medical-waste disposal,
malpractice requirements, unusual billing protocols for third-party payers and
Medicaid, and, sadly, enhanced security measures. Lawyers, meanwhile, are
researching how to revise state laws to permit nurse practitioners to dispense
the month-after pill with appropriate physician backup. Despite many obstacles,
the pilot project in Brooklyn has attracted some 20 patients a week since it
opened early this year, and it is now ready to train medical residents from eight
family-medicine programs that together produce 60 new doctors each year. Success
has been so rapid that the Continuum Health Partners, of which Long Island
College Hospital is a member, is ready to sponsor a second site.

Approximately half of those who terminate early pregnancies at New Options
choose mifepristone. The others are opting for a simple mechanical procedure that
evacuates the uterine contents without trauma and provides an alternative to the
pill or a backup on the rare occasions when it fails. This process, manual vacuum
aspiration of the uterus, uses an inexpensive handheld device called a cannula
that creates a gentle suction strong enough to dislodge a tiny embryo. It
replaces the earlier technology of a large and expensive electric suction machine
and is a variation on menstrual-extraction techniques used long ago. But the new
technology makes the procedure safer, cheaper, and more accessible than earlier
methods--one that can be easily administered in comprehensive primary-health-care
settings or in the doctors' offices. This too, however, requires training.

Pilot projects using such methods are now also under way in existing abortion
clinics, in Planned Parenthood facilities where abortion has not been provided in
the past, and in other primary settings. In New York, these include the
maternity-and-infant-care centers run by organizations such as New York's
Community Healthcare Network and Metropolitan Health and Research Association.
Elsewhere in the country, progress is slower, with only a dozen or so
residency-training programs having expressed willingness to undertake programs.
The potential, however, is enormous, with 121 medical schools nationwide,
supervising 253 residency programs in obstetrics gynecology, 487 in family
medicine, and 393 in internal medicine. Providing midlevel service would also
require training of nurses and skilled midwives, but to achieve meaningful scale
much broader investment will be required.

When the FDA finally approved mifepristone late last year in the waning days
of the Clinton administration, an unrealistic euphoria set in about the
transforming possibilities of the new drug. Few beyond the community of existing
providers acknowledged the many obstacles that must be overcome before the new
method can be integrated into mainstream reproductive care. Still, the potential
is there, as early successes now demonstrate.

Surgical abortions in the United States already take place
considerably earlier than in the past: More than half are performed within eight
weeks of conception, and nearly 90 percent occur within 12 weeks. A growing body
of evidence points to an increasing eagerness by patients and clinicians to push
the process even earlier and to integrate it back into standard medical practice.
The timing is right in view of growing national trends toward providing primary
preventive care in neighborhood facilities affiliated with managed-care plans and
hospitals, like the New Options center in Brooklyn.

George W. Bush notwithstanding, the political environment is also ripe for
this development. Despite deliberate efforts by both major candidates in last
year's presidential election to duck the issue, abortion rights registered a
surprising third place as a concern in at least two major exit polls--just behind
the much belabored campaign subjects of Social Security and education, and ahead
of taxes. Independent women abandoned the Bush candidacy in droves despite his
effort to appear compassionate in his conservatism, and the gender gap turned
into a chasm, with a record 22-point divide in how men and women voted.

Since his inauguration, the situation has further deteriorated for Bush
politically, with criticism of his policy restricting research on stem cells
harvested from very early embryos having now become the defining issue of the first
year of his presidency. As the country engages in an unprecedented national
conversation about early microbiology and gestational development, it is only a
matter of time before voters more fully comprehend the implications and meanings
of the distinctions between stages of embryonic and fetal development. The result
is likely to be increasing levels of support for early and safe abortion.

Margaret Sanger and George W. Bush span a turbulent century, but the gulf
between them may not be as wide as it seems. Bush's maternal grandmother, after
all, was a supporter of Planned Parenthood of Connecticut, and his father as a
Republican member of Congress from Texas in the 1960s joined in bipartisan
support for those first federal family-planning programs. This President Bush and
his political advisers may never see the wisdom of affirmatively endorsing early
options to end unwanted pregnancies and integrating them into the continuum of
safe, affordable, and accessible reproductive health care for American women. But
ironically, his presidency may engender the public schooling in basic biology
that makes it happen.

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