Imagine that over the next 15 years we could reduce abortion by 90 percent simply by improving pregnancy prevention. Imagine, further, that during this same 15 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.
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 2,000, 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 10, 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 backup 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 offers 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) 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 nine 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, fights 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, technology access, 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 take mifepristone and misoprostol 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 and travel costs and other hardships 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 policymakers 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, 2.5 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, more than 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.
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