Clinic-based abortion would be almost obsolete were it not for conservative policies and priorities.
Imagine that over the next fifteen years we could reduce abortion by 90 percent simply by improving pregnancy prevention. Imagine, further, that during this same fifteen years we could replace most remaining abortion care with early, at-home therapeutic miscarriages that felt and looked a lot like bad periods —the sucky kind with cramps and nausea and nasty clots but which millions of women endure on a monthly basis. Imagine that almost nobody needed clinic- or hospital-based abortion services unless something went wrong with fetal development or a woman’s health. Imagine that the doctors and nurses who now provide abortion care could turn most of their energy instead to pregnancy planning, prevention, and prenatal care.
These scenarios are entirely possible thanks to changes in medical technology and medical practice. In fact we likely would be well on our way to attaining both of these goals were it not for obstruction and opposition from religious conservatives who seek to maintain traditional gender roles by keeping sex and pregnancy tightly coupled.
Game Changing Technologies
Long-acting “set and forget” contraceptives radically improve a woman’s ability to manage her fertility, effectively flipping the fertility switch to off until she wants it on. Three of these top tier methods are now available to most insured American women at no cost under the Affordable Care Act.
- The progestin IUD (Mirena, Skyla, Liletta) first obtained cautious FDA approval in 2000, a decade after it became widely available in Europe. Originally restricted to women with children, it is now recommended by the American Academy of Pediatrics as a front line option for sexually active teens. It works as an internal barrier method, by thickening cervical mucus, and has the bonus health benefit of reducing menstrual cramps and bleeding by on average 90 percent by the end of the first year. The annual pregnancy rate is less than 1 in 800 (compared to 1 in 9 for the Pill), and it is effective for up to seven years but can be removed at any time with normal fertility afterward.
- The etonogestrel implant (Nexplanon), which works by shutting down ovulation, was approved for U.S. females in 2006. Safe for teens, it is the contraceptive of choice for many young women because of the simple insertion procedure, which resembles a shot in the upper arm. In continuous use in Indonesia since 1998, by 2003 the etonogestrel implant had become the contraceptive of choice for over 11 million women in 60 countries. It has an annual pregnancy rate of 1 in 2000, and lasts for three years.
- The hormone-free copper IUD (Paragard) obtained FDA approval in 1984. Copper ions act as an internal spermicide that makes it hard for sperm to swim, while the T-shaped device itself stimulates a “foreign body reaction” causing a woman’s immune system to attack sperm as invaders. It has a less than 1 in 500 annual pregnancy rate with normal rates of fertility and infertility after removal. It can be removed at any time but may be effective indefinitely. Approved for four years, then six, then eight, then ten, accumulated data now show that the copper IUD works for 14 years and counting.Couples relying on less effective methods like the Pill or condom now have back up options in the event of unprotected sex.
Two after-the-fact emergency contraceptives can sometimes block a woman’s body from releasing an egg, averting a pregnancy, while a copper IUD inserted after-the-fact offer both emergency contraception and long-term protection. Note that many regular birth control pills, when taken at higher doses, can work as emergency contraceptives as well.
- Levonorgestrel emergency contraception (Plan B, Next Choice, etc.), when taken within 72 hours of unprotected sex, can reduce pregnancy risk by more than 70 percent, but is not recommended for women with a body mass index over 30.
- Ulipristal acetate (Ella) can interrupt ovulation later in the cycle, up to five days after intercourse (the sooner the better), and reduces risk by 85 percent.
When pregnancy prevention fails—whether because of technology factors or human factors—induced at-home miscarriage offers a safe, private and low cost alternative to clinic abortion.
- Mifepristone (Mifeprex) and has been approved in France for a generation and is used around the world to induce early miscarriage. It was approved in the U.S. for this purpose in 2000. Mifepristone triggers the uterus to shed a fertilized egg, and when coupled with a second medication, Misoprostol, it is 97 percent effective in ending pregnancy up to 9 weeks after the beginning of the last menstrual cycle.
Best Medical Practices Prevent Pregnancy, Late Abortion
Technological innovations change the world only when people broadly transition from old technologies to new. So, it goes without saying that medical innovations like long acting IUDs and implants, emergency contraception and therapeutic miscarriage can improve lives only if they are widely available and used.
To reduce abortion by improving pregnancy prevention, most women who currently contracept inconsistently (or not at all) would need to make the transition to set-and-forget contraceptives that take forgetting, finances and other “human factors” out of the equation. I have written elsewhere about what that would take—a mix of public education, technology upgrades, and updates in medical practice. (See “What a Serious Anti-Abortion Movement Would Look Like” and “Teen Pregnancy: Going . . . Going . . . “)
For women who don’t have long acting contraception—or for those rare occasions when even the best prevention fails—a shift from clinic-based abortion procedures to less expensive, less invasive and earlier therapeutic miscarriage will also require awareness and updates in medical practice. Simple changes can make a big difference:
- By talking more honestly and openly about sex and contraception and abortion, parents and educators can help young people to both prevent and recognize pregnancy and to know their options for taking care of themselves. Honest, frank talk reduces the likelihood of denial, avoidance, and delays.
- Experience shows that nurse practitioners, certified nurse midwives, and physician assistants can safely provide early abortions of all types. Permitting them to do so reduces costs and helps to prevent delays that increase costs or leave surgical abortion as the only option.
- Allowing patients to self-induce miscarriage at home if desired can lower costs while increasing physical and psychological comfort and access to supportive friends or family.
- Telemedicine services can reduce medical costs and other hardships like childcare and travel for women in small towns and remote locations.
Conservative Opposition Promotes Unwanted Pregnancy and Clinic-based Abortion
Most people agree that preventing unwanted pregnancy is preferable to abortion. Why mitigate harm if you can prevent it? Most also agree that early abortion is preferable to later abortion, which is more emotionally complex. Wide access to long acting contraception and therapeutic miscarriage clearly would be a step forward. These changes would drive down medical costs while improving health and mental health for women and children. And because well-planned childbearing is so fundamental to economic opportunity, these improvements in reproductive healthcare would drive a host of follow-on benefits: fewer high-school dropouts, more college graduations, less family violence, fewer moms needing welfare and food stamps, and less multi-generational poverty—all with less strain on public budgets.
Ironically, “Pro-life” political theater makes both of these changes more difficult. In fact, conservative policy priorities read like a list of what one would do to protect a market for high cost clinic-based surgical abortion. Conservative leaders spread scary misinformation about contraceptives, as in the American Life League’s “Pill Kills” campaign or the Catholic Church’s insistence that IUDs cause infertility (they don’t) or work by inducing miscarriage. (They don’t.) Conservative religious leaders and policy makers obstruct lower prevention costs for poor and working women—for example, the Obamacare contraceptive mandate. They obstruct evidence-based sex ed and efforts to meet sexually active teens where they are at—via school-based clinics.
Religious conservatives also are doing all in their power to block a transition from clinic-based abortion procedures to early therapeutic miscarriage: by excluding advance practice nurses from abortion care, by requiring multiple unnecessary tests and exams, by requiring that mifepristone be administered in a clinic or surgery center rather than at home, and by blocking the transition to telemedicine for women in remote communities. Some states require adherence to an outdated medication regimen that forces woman to take a larger dose of medication than she needs, increasing cost and side effects.
Despite posturing to the contrary, the mountain of laws restricting therapeutic miscarriage have nothing to do with promoting health. Despite obstacles, two and a half million women have now safely used mifepristone to self-induce an early miscarriage. The quality of early abortion care (both medications and aspiration procedures) provided by advanced practice clinicians is comparable to that provided by doctors. Many women like the option of consulting with a care provider via video rather than in person, and research shows that this option is not only safe and effective but also reduces second trimester abortions.
Tragically, over 200 American women die each year from pregnancies they hadn’t intended, many leaving behind motherless children. These deaths are preventable. The conservative determination to keep women from having sex—and to keep them pregnant if they do—is costing lives, devastating families and burdening communities that are left to pick up the pieces.
It Gets Better
Today half of U.S. pregnancies are unintended, and almost half of those end in abortion. We can do better. A lot better. And in fact we are doing better. My mother relied on a diaphragm, had no access to legal abortion, and then raised six “accidents” who taxed her marriage and mental health to their limits. As a young woman I had access to the Pill and then an abortion when I needed one, and I was able to limit my childbearing and enjoy my work and parenting (and my husband). My daughters, who have state-of-the-art IUDs that protect against cancers and miserable monthlies, will probably never need abortion care. Thanks to advances in technology and medical practice they will be able to pursue their dreams and form the families of their choosing, bringing children into the world when they feel ready.
My daughter are privileged. They have the best pregnancy prevention money can buy and, should it fail, will get whatever medical care they choose. But chosen childbearing shouldn’t be a matter of privilege—it should be a basic human right. We have the technology to make that a reality, and to vastly improve lives in the process. The only question is whether we have the will.
Valerie Tarico is a psychologist and writer in Seattle, Washington. She is the author of Trusting Doubt: A Former Evangelical Looks at Old Beliefs in a New Light and Deas and Other Imaginings, and the founder of www.WisdomCommons.org. Her articles about religion, reproductive health, and the role of women in society have been featured at sites including AlterNet, Salon, the Huffington Post, Grist, and Jezebel. Subscribe at ValerieTarico.com.
Men’s reasons for limiting women’s availability to contraception and abortion are more economic than moral. Women who lack control of their ability to reproduce or not, represent less competition at the workplace. Men believe they can be more confident that their children are, “theirs” and thus worthy of inheritance if their wives lack reproductive control. Men’s biggest worry is that they be cuckolded. The horror. Okay, not entirely economical.
LikeLiked by 2 people
I was fascinated to hear recently of a professor’s comment that one reason religion and culture encouraged constant pregnancy was that if a man kept his wife pregnant then nobody else could impregnate her.
LikeLiked by 1 person
My father, a southern Baptist, gloated to me when I was a little girl that the pain I caused my mother when she gave birth to me pleasured and amused him. I soon realized that a lot of men in my family got sick pleasure out of the pain their wives and daughters had while giving birth.
It was like the southern Baptist men in my family used child birth to sexually torture their wives and daughters.
I believe pro lifers are sexually sadistic. And men see birth control as a way for women to escape them.
My sexually sadistic pro forced birther father did not have to be sick in misery for nine months, my mother did, my sexually sadistic father did not have to have unbearable genital pain for my to be born, my mother did.
LikeLiked by 3 people
Smashing article, Valerie. This is the way to go: turning it on the religious conservatives, showing their bald-face hypocrisy. But more, you also describe available options to unwanted pregnancy and abortion. I’m thinking, if only one woman who doesn’t know comes across this article and acts on this information… it’d be worth it, wouldn’t it?
LikeLiked by 1 person
Thanks, Sha’Tara – For some reason this article was a total dud at Salon, and so it is wonderful to be reminded by you that if it changed one life it is well worth the effort. Warmly, Valerie
I thought the article was excellent. This father sent it on to his daughter. Nuf said.
Things have certainly changed since I used contraception. What a fascinating read. I didn’t think the pill was a 1 in 9 risk though :( Years back, it was the most reliable method, and implants were just some new technology being tried out …
But being in control of our reproductive rights is absolutely core for women. Until we have that, we will never achieve equality, because as Garth points out, it is also linked to economic independence. And women need both.
LikeLiked by 4 people
I think the big problem with the pill is “user error.” I was meticulous about taking it, and I’m naturally a creature a habit, but even I had days when I forget (usually on the weekend when I liked to sleep in, so my routine was disrupted).
Besides that, there are medical conflicts, like the lower effectiveness when taking antibiotics. I think there’s a lot more awareness of that sort of thing now, but it’s pretty easy to imagine someone slipping through the cracks there.
I did, unfortunately, manage to get pregnant around a hormonal IUD, so I don’t really trust them for myself at this point. I like condoms, just because you use them when you need them, so they’re a lot easier to remember than the pill, but I can appreciate that they aren’t for everyone.
LikeLiked by 1 person
Actually, I can’t ever remember forgetting to take the pill. Nor did I take antibiotics so that wouldn’t have been an issue back then. But I so did not want to get pregnant. I carried C film with me as well, and even after my husband had a vasectomy I was still on the pill! although that was partly about period convenience. Can’t say I was a fan of condoms within a relationship.
“And women need both.” Indeed, indeed. It’s been a long and difficult uphill struggle and judging by most of the world, it’s far from over. But comment such as yours do make a difference – just another push in the right direction.
LikeLiked by 3 people
Thank you. Sometimes it feels as though we often repeat ourselves or that our words fall on deaf ears. But when blog posts do change opinions, and people share views, then little by little, we are making some progress. Not enough, but some. And in the face of radical right wingers it’s important that we do continue to fight for women’s equality worldwide, and not buy into the myth that women are equal. We aren’t.
LikeLiked by 3 people
As a teenage girl growing up in conservative Christianity, I believed that my body and vagina was born in debt, that I had to breed no matter how sick it made me, or how much it hurt me to pleasure a sexually sadistic misogynistic sky tyrant.
They want us to be reproductive slaves, it is not the men that have to do it.
Conservative pro lifers are rooting for the right to FORCE raped ten year old little girls to be FORCED to breed with rapist.
We should start calling it what it is, reproductive slavery!
LikeLiked by 3 people
Yes, if you excavate deep enough, the biblical view is that women’s bodies (our reproductive capacity specifically) belong to men and that bearing children is the only way to pay the debt we owe as a consequence of eve’s sin.
LikeLiked by 2 people
Guest and Valerie, yes – it’s about control. These anti-choice guys claim that they are in it to “save the innocent babies.” However, their utter lack of concern about the majority of embryos which spontaneously abort (“it’s ok as long as their death was unintentional”), versus their absolute insistence that every UNWANTED embryo is a precious human being that MUST be carried to term, shows their real motive is to subjugate and punish women.
LikeLiked by 1 person