In recent years, medical science has devised new options for very earlytermination of unwanted pregnancy, measures that did not exist when Roe v. Wadewas decided in 1973. In addition to widening the range of choices for women,these advances--most notably the "morning after" contraceptive and the abortionpill mifepristone (RU-486)--are likely to alter the imagery and the politics ofabortion dramatically. Where the so-called pro-life movement has capitalized on atiny number of late procedures involving fetuses with the features of babies, thenew technology makes plain that most abortions involve microscopic embryos. Thisshifts the moral as well as the medical terrain for most people, as the country'srecent debate over embryonic-stem-cell research makes clear. Unless the radicalright succeeds in overturning Roe v. Wade, these new scientific developments bodewell for the pro-choice movement in this country.
Nevertheless, the abortion debate often seems, as Robin Toner put itin The New York Times, frozen in time. This is true despite the fact thathow, 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 aboutabortion 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 supportcomprehensive sex education, family planning, and the individual right toterminate a pregnancy safely, these new scientific and medical developments needto enter public discourse and shape it.
First, there is the matter of "emergency contraception," more commonly knownas the morning-after pill, which works up to 72 hours after unprotected sex bypreventing fertilization or by interrupting the implantation of a fertilized ovumin the uterine wall so that a pregnancy never occurs. The regimen is well knownand widely used in western Europe, where a dedicated product is now availablewithout prescription. The French distribute it in high schools.
For years, physicians in the United States have routinely broken uppackages of standard birth-control pills and administered consecutive doubledoses of them to women who report unprotected intercourse and fear unwantedconception. The procedure, which produces moderate nausea but no other sideeffects, is prevalent on many college campuses. Yet pill manufacturershere--perhaps fearing protests by anti-abortion zealots or cannibalization of themarket for standard oral contraceptives--year after year declined to market adedicated product, and the Food and Drug Administration only recently approvedone, after nearly a decade of effort by reproductive-rights groups.
The FDA is now considering a petition to bring emergency contraception overthe counter, but for the time being it needs to be made widely available throughprimary-care doctors working with local pharmacists. Estimates suggest thatemergency contraception alone could prevent half of all unintendedpregnancies--still about three million a year in the United States, half of whichresult in surgical abortion.
The emergency-contraception method is especially warranted as a backup tocondoms, which as a result of successful education and social marketing are nowwidely used in this country to protect against sexually transmitted disease.Condoms also work as barrier contraceptives, of course, and according to the AlanGuttmacher Institute, better use of contraception accounts for aboutthree-quarters of the recent 21 percent decline in adolescent pregnancy ratesbetween 1990 and 1997. The problem is that condoms have a high failure rate andrequire a backup--or a "Plan B," as the marketers are calling their new dedicatedproduct.
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 suspectthat they are pregnant. Relatively few Americans, including public officials,realize that when Roe first became the law of the land, a woman could not evenconfirm a pregnancy until she was seven weeks or more into gestation. To terminateit, she had to wait a least several more weeks, until her cervix softened, sothat a doctor could insert the metal surgical instrument then necessary toperform a standard dilation and curettage of the uterus.
Today, by contrast, an inexpensive urine test that can confirm pregnancy in itsearliest stages by registering hormonal changes is available for home use. Therecent 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 UnitedStates permit use of this oral medication up to the seventh week ofpregnancy--though in some parts of Europe and Asia, hundreds of thousands ofwomen are using it effectively up to the ninth week without adverse consequences.The simple regimen actually requires a combination of two pills taken insequence: mifepristone, which blocks the production of hormones needed to sustainpregnancy, followed by misoprostol, which induces moderate uterine contractionsand produces the equivalence of a heavy menstrual period that lasts up to fivedays.
The crucial distinction between mifepristone and emergency contraceptives isthat the former eliminates a fertilized ovum whereas the latter prevents the ovumfrom being fertilized. In other respects, mifepristone's effects do not differmuch from what many women experience every month from menarche (their firstmenstrual period) to menopause (their last)--when they eliminate unfertilizedeggs along with the contents of the uterine lining, without much fuss over theloss. The bleeding is heavier--the cramps more intense--but the process is notsubstantially different. Indeed, recent research confirms that about half of allconceptions spontaneously abort very early--generally before the woman evenrealizes she was pregnant--and pass away naturally, experienced as late and heavymenstruation.
A Comprehensive Approach
One can see the promise of these new approaches in a small andfriendly community-based family health center that operates out of a storefrontnear downtown Brooklyn, New York. Here, at the New Options Training Center, as itis being called, a revolution is brewing in how family planning andearly-abortion care are provided. Pioneered by a team of committed youngphysicians and nurse practitioners, the facility is among the firstfamily-medicine centers in the United States to integrate reproductive healthcare, including early-abortion services, into general medicine. This allows eachpatient to experience a continuum of care--from family-planning visits tomorning-after prescriptions or early abortion, if needed--as part of her ordinarymedical visit. Gone is the stigma that has been associated with the terminationof unwanted pregnancy since abortion was legalized more than a quarter of acentury ago, and for the many years before, when it was clandestine and illegalyet widely available.
Affiliated with the Long Island College Hospital, one of Brooklyn's mostvenerable institutions, the family health center sits less than a mile from themakeshift clinic in a Brownsville tenement where Margaret Sanger made history in1916 by defying the law to provide contraceptives to women, many of whom wereimmigrants. Sanger went to jail for 30 days, but subsequent appeal of herconviction established a medical exception to the New York State lawsprohibiting birth control and granted doctors (though not nurses, as Sanger hadhoped) the right to prescribe contraceptives for health reasons only.
The birth-control movement in America nonetheless remained a target of legalrepression and political controversy. It developed under these difficultcircumstances only through the slow but steady growth of independent,not-for-profit clinics affiliated with the Planned Parenthood movement, inisolation from mainstream medicine. Lost was Sanger's vision of a comprehensiveprogram of preventive public health, with clinics in every urban neighborhood andtraveling caravans of medical personnel in rural areas providing a full range ofservices. Only after 50 years of sustained advocacy and litigation--followingGriswold v. Connecticut, the historic 1965 decision in which the U.S. SupremeCourt struck down state laws banning birth control used by married couples--didPresident Lyndon Johnson finally incorporate family planning into America's stillfledgling public-health and social-welfare programs.
When abortion was legalized in 1973, however, the earlier patternwas replicated. Federal funding was denied, and today only 15 states provideMedicaid coverage of abortion. Abortion services quickly moved out of hospitalsinto freestanding clinics that in some cases are administered by PlannedParenthood but mostly run privately and for profit. In the increasingly hostileclimate that has since surrounded the practice in this country, providers havebecome true heroes, braving harassment and violence, and even risking death. Notsurprisingly, their numbers have decreased dramatically, down 14 percent inrecent years to a mere few thousand nationwide. Ninety-five percent of thecountry'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 ofthe horrors of illegal abortion, the problem has become particularly acute.Abortion training is not routinely provided as part of medical residencytraining, even for obstetricians and gynecologists [see "Making Choice Real" onpage A29]. And while committed medical students around the country--more and moreof them women--have begun to demand the reversal of this practice, wisdom mayprevail in moving back to the future, so to speak, by reclaiming MargaretSanger's vision of comprehensive neighborhood health centers.
Realizing a Promise
If the radical right has its way, however, clinics such as these willbe suppressed. The intense politics of abortion have already resulted in thedissemination of much misinformation about the abortion pill among providers andpatients--not to mention politicians. The first challenge for innovative serviceslike the New Options facility in Brooklyn is to overcome these distortions witheducation and training akin to what has worked in the past with new methods ofcontraception. A second challenge is to untangle the thicket of legal provisionsand administrative codes that govern abortion at the state and local levels andmake it a more intensely regulated procedure than, say, brain surgery.
New Options is providing family practitioners with a working model ofcomprehensive reproductive health care, including how early abortion can beintegrated into their practices. This includes hands-on training in emergencycontraception, medical abortion, and early-gestational ultrasound as well asinformation on the many administrative issues involved in implementing earlyabortion services--such as complex consent forms, proper medical-waste disposal,malpractice requirements, unusual billing protocols for third-party payers andMedicaid, and, sadly, enhanced security measures. Lawyers, meanwhile, areresearching how to revise state laws to permit nurse practitioners to dispensethe month-after pill with appropriate physician backup. Despite many obstacles,the pilot project in Brooklyn has attracted some 20 patients a week since itopened early this year, and it is now ready to train medical residents from eightfamily-medicine programs that together produce 60 new doctors each year. Successhas been so rapid that the Continuum Health Partners, of which Long IslandCollege Hospital is a member, is ready to sponsor a second site.
Approximately half of those who terminate early pregnancies at New Optionschoose mifepristone. The others are opting for a simple mechanical procedure thatevacuates the uterine contents without trauma and provides an alternative to thepill or a backup on the rare occasions when it fails. This process, manual vacuumaspiration of the uterus, uses an inexpensive handheld device called a cannulathat creates a gentle suction strong enough to dislodge a tiny embryo. Itreplaces the earlier technology of a large and expensive electric suction machineand is a variation on menstrual-extraction techniques used long ago. But the newtechnology makes the procedure safer, cheaper, and more accessible than earliermethods--one that can be easily administered in comprehensive primary-health-caresettings or in the doctors' offices. This too, however, requires training.
Pilot projects using such methods are now also under way in existing abortionclinics, in Planned Parenthood facilities where abortion has not been provided inthe past, and in other primary settings. In New York, these include thematernity-and-infant-care centers run by organizations such as New York'sCommunity Healthcare Network and Metropolitan Health and Research Association.Elsewhere in the country, progress is slower, with only a dozen or soresidency-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 familymedicine, and 393 in internal medicine. Providing midlevel service would alsorequire training of nurses and skilled midwives, but to achieve meaningful scalemuch broader investment will be required.
When the FDA finally approved mifepristone late last year in the waning daysof the Clinton administration, an unrealistic euphoria set in about thetransforming possibilities of the new drug. Few beyond the community of existingproviders acknowledged the many obstacles that must be overcome before the newmethod can be integrated into mainstream reproductive care. Still, the potentialis there, as early successes now demonstrate.
Surgical abortions in the United States already take placeconsiderably earlier than in the past: More than half are performed within eightweeks of conception, and nearly 90 percent occur within 12 weeks. A growing bodyof evidence points to an increasing eagerness by patients and clinicians to pushthe process even earlier and to integrate it back into standard medical practice.The timing is right in view of growing national trends toward providing primarypreventive care in neighborhood facilities affiliated with managed-care plans andhospitals, like the New Options center in Brooklyn.
George W. Bush notwithstanding, the political environment is also ripe forthis development. Despite deliberate efforts by both major candidates in lastyear's presidential election to duck the issue, abortion rights registered asurprising third place as a concern in at least two major exit polls--just behindthe much belabored campaign subjects of Social Security and education, and aheadof taxes. Independent women abandoned the Bush candidacy in droves despite hiseffort to appear compassionate in his conservatism, and the gender gap turnedinto a chasm, with a record 22-point divide in how men and women voted.
Since his inauguration, the situation has further deteriorated for Bushpolitically, with criticism of his policy restricting research on stem cellsharvested from very early embryos having now become the defining issue of the firstyear of his presidency. As the country engages in an unprecedented nationalconversation about early microbiology and gestational development, it is only amatter of time before voters more fully comprehend the implications and meaningsof the distinctions between stages of embryonic and fetal development. The resultis likely to be increasing levels of support for early and safe abortion.
Margaret Sanger and George W. Bush span a turbulent century, but the gulfbetween them may not be as wide as it seems. Bush's maternal grandmother, afterall, was a supporter of Planned Parenthood of Connecticut, and his father as aRepublican member of Congress from Texas in the 1960s joined in bipartisansupport for those first federal family-planning programs. This President Bush andhis political advisers may never see the wisdom of affirmatively endorsing earlyoptions to end unwanted pregnancies and integrating them into the continuum ofsafe, affordable, and accessible reproductive health care for American women. Butironically, his presidency may engender the public schooling in basic biologythat makes it happen.