Complexities of Abortion, Reproductive Rights, and Motherhood
“No woman wants an abortion as she wants an ice cream cone or a Porsche. She wants an abortion as an animal caught in a trap wants to gnaw off its own leg.”1 I don’t write this from the perspective of pro-life or pro-choice, but rather in an attempt to dive deeply into a complex issue. I write this to illustrate a vital point that abortion is a downstream issue due to failures upstream in our culture. Tammy Bruce in a speech at Columbia University on April 6, 2005 stated frankly, “With every kind of birth control available in the world, abortion is not something to be proud of. If you need an abortion, you’ve failed.” Or rather, the system has failed. When we address only the issue of abortion, we ignore the reality that this is a painful last resort for many women because prior to the pregnancy, they did not have a choice or, rather, their reproductive rights have been denied since the beginning of our fallen patriarchal world. As we analyze the issue of abortion, then, I invite you, reader, to step back from your preconceived notions of abortion and to begin seeing the broader issues surrounding it, namely: lack of reliable, obtainable birth control, lack of prenatal care, and lack of postnatal care.
Blinded By Rage
Before we begin diving into this heavy issue, I want to give you the background story that inspired further exploration into abortion. Growing up, I was decidedly pro-life. I couldn’t imagine why a woman would kill a life inside of her—it was definitely not her body as it was separate DNA and would eventually become another human being—done, right? End of issue? That’s what I wanted anyway: I didn’t want to reconsider something I was so vehemently against. Yet, it wasn’t until medical school that I was forced to reconsider the issue. I had let the issue go a long time ago, and as I sat in a mental health class for our Interprofessional Experience Course, I didn’t blink twice as I looked down at an email sent out by the Medical Students for Choice campaigning against a law that would prevent women from aborting a fetus with Down Syndrome. I was apathetic: I felt I could not convince a person who was pro-life or pro-choice one way or another, and though I considered myself pro-life, I had lost my fire regarding the subject. Yet, a fiery email was sent in response to all four medical classes. It was sent by a Catholic student who was obviously vehemently pro-life and deeply upset by this issue. His email likened the petition to allow women to abort a fetus with Down Syndrome to the Holocaust, and it was deeply cynical and sarcastic. The leader of the Medical Students for Choice sat next to me and was deeply troubled by the email. I found a certain empathy rising up within me for this leader who seemed to be wanting to do the right thing but who differed so immensely from my own views regarding the subject. I also found myself angry towards the email sender, and I felt his attacks toward her were inappropriate and exponentially unprofessional. It agitated the Medical Students for Choice, many of whom I was friends with (though we never actually discussed the issue of abortion). It was a curious position that I found myself in: I was empathizing with a group I had traditionally (at least in high school and college) considered my enemies, the ones that were mistaken and blinded by a political agenda. As I sat there feeling rage towards a fellow pro-life advocate, I suddenly felt the opposite: perhaps, we were the ones blinded?2
Later, though, I found that I still retained my views that fetuses were life and should be considered sacred just as any other life on this planet, but I had empathy towards the pro-choice side of the argument. These seemingly conflicting feelings could only be reconciled by exploration. Why did this group (individuals I considered intelligent and who obviously cared for humanity) so adamantly advocate for the death of fellow humans? I was a leader of the Christian Medical Association at the time, and I met with a fellow leader regarding the issue. The Catholic Medical Association, a new group on the scene, had definitely taken a stance on the matter: they were marching at the Pro-life walk and advocated for Natural Family Planning in accordance with typical Catholic beliefs. I couldn’t align myself with them: Natural Family Planning seemed impractical to me in light of the erratic cycles many women had as well as the lack of stability present in many homes. Additionally, I was not about to follow the actions of our sister association simply because we both agreed that fetuses were deserving of life.
I spoke with this fellow leader of the Christian Medical Association, and she agreed that in order to show we cared about women and children as well as to bring Christians into a positive light among the student body, we must have a voice amongst the tension. Traditionally, the Christian Medical Association had stood as a pro-life group in contrast to the Medical Students for Choice. The groups had, in years past, held a debate regarding abortion, but I felt that wasn’t the route to take in this case. Did we really need more tension between those who are pro-life and those who are pro-choice? No, we needed reconciliation and understanding. What did I want in light of the tension? I wanted to show that the two opposing viewpoints had more in common than previously thought. I wanted to show that this issue of abortion was downstream of greater issues: namely, women’s reproductive rights and children’s right to happy, healthy lives. This was eventually done through a lunch talk held with the Medical Students for Choice that had two women speaking about birth control, prenatal care, and sex education. The speakers included a Christian physician who was pro-life working with an underserved population of women and a nurse practitioner, who was pro-choice, working with Planned Parenthood. Therefore, I began to discover that abortion was not simply about killing another human life but rather, it was about the difficulties women face in avoiding pregnancy in a world that often did not welcome children. As we dive into this heady issue, I firstly want to discuss the various forms of birth control and how their limitations, their side effects, and misconceptions about them demonstrate the need for further education and the gap in reproductive rights still present.
The Issue of Birth Control
We cannot ignore the issue of birth control if we are to talk about abortion. What drives abortions today is namely unplanned pregnancies. We can make many arguments regarding abstinence as a full-proof method of birth control, but in an increasingly sexualized world where women are consistently seen as sexual objects and men are increasingly seen as sexual objects, we cannot only promote abstinence. Even in the context of marriage, unplanned pregnancies occur and couples find themselves ill-equipped to take on (another) child due to financial and/or time constraints: could we tell these couples that they must abstain from sex? Is Natural Family Planning the only acceptable option even if the woman has an ailment such as Polycystic Ovarian Syndrome or another condition causing erratic cycles? Birth control has always been a subject shrouded in immense misunderstanding due to many mishaps from years past: from the numerous issues with the Danken Shield to the blood clots caused by the combined oral contraceptives. In light of the issue of abortion, I want to explore the accessibility of birth control as well as to go through the popular birth control options such as oral combined contraceptives, IUD’s, condoms, and Natural Family Planning as well as the mechanism of action in order to clear up misconceptions associated with them.
Obstacles to Birth Control
Although birth control access has come quite a long way over the recent years, there still exists gaps in obtaining it. In order to prevent unplanned pregnancies and abortions (legal or otherwise), these gaps must be filled. According to The American College of Obstetricians and Gynecologists, the major barrier to obtaining birth control is “…Lack of knowledge, misperceptions, and exaggerated concerns about the safety of contraceptive methods…”2 Another significant obstacle to obtaining oral birth control are state measures that inhibit women from accessing birth control on the basis that these methods are inherently abortifacient, preventing a fertilized egg from implanting in the uterus. The ACOG states, “Measures that define life as beginning at fertilization and, thereby, conferring the legal status of ‘personhood’ on fertilized eggs also pose a significant risk to contraceptive access. Supporters of ‘personhood’ measures argue erroneously that most methods of contraception act as abortifacients because they may prevent a fertilized egg from implanting; if these ‘personhood’ measures were to be implemented, contraception opponents may assert that hormonal contraceptive methods and IUD’s are illegal.”2 We see, therefore, that there are misconceptions regarding the mechanism of action of birth control and that many forms of birth control, which once had somewhat mysterious mechanisms of action (such as the copper IUD), are only recently coming to light.
Finally, we get to a barrier well recognized in healthcare: money. The ACOG states, “High out-of-pocket costs, deductibles, and copayments for contraception also limit contraceptive access even for those with private insurance… However, even when contraception is covered, women pay approximately 60% of the cost out of pocket compared with the typical out-of-pocket cost of only 33% for noncontraceptive drugs.”2 This, reader, only perpetuates abortion as women, particularly those with job instability, cannot reliably and consistently obtain birth control. And even if it were obtainable, the misconceptions surrounding birth control make women and lawmakers wary of obtaining or providing them, respectively. Now, dear reader, I recognize you may be against hormonal birth control or IUD’s for various reasons, but we must consider the society we live in. If abstinence were the only option for many women in a world where sexualization of women is rampant and women often times attribute their worth in light of a man’s sexual attraction to herself, it would be a strenuous undertaking. “Perhaps,” many women ask themselves, “if only he would have sex with me, if I just give him that, he will love me and I will be worthwhile.” These thought patterns, that I myself know well and have produced and reproduced in my own mind, can hardly be blamed on the individual. When we look at ads on television and women in magazines, we see women in skimpy bikinis and used to sexualize ordinary objects (like a burger) in order to sell a product. Additionally, in women’s magazines we see promises of losing 10 pounds in 10 days or getting rid of that pesky cellulite or how to perform sexual acts that will please a man. Also, the pornography industry perpetuates this view of women and sex: women are being used to please a man sexually. Both women and men eat this message up, and pornography, in general, is widely accepted as a means for a sexual outlet. I could go on and on about what is wrong with sex in this culture, but the bottom line remains that to tell a generation that is already told constantly how great sex is and that a woman’s worth is in her sexual appeal to remain solely abstinent without further explanation of what sex is, the meaning behind it, and the consequences of it (physically, emotionally, and relationally) will only serve to make them crave it more. Don’t get me wrong, reader, we cannot stop fighting for the de-objectification of women and their worth beyond appearances, but I fear, the damage is already done and we must prevent further damage.
Combined Oral Birth Control
For the first birth control option, let us discuss the famous (or perhaps infamous?) pill. Combined oral contraceptives are pills that contain both female hormones, estrogen and progesterone. These work essentially by inhibiting the release of luteinizing hormone which relies on a particular balance between estrogen and progesterone, and this is inhibited by the hormones released by oral contraceptives. Without an LH release mid-cycle, there is no ovulation and, therefore, no fertilization.3 With the constant stream of estrogen and progesterone, these pills have both benefits and risks. In teenagers, they can reduce acne, and for women with PCOS, they can reduce hirsutism and acne and restore normal cycles.4 The contraindications for combined oral contraceptives are numerous: being in the first month of breastfeeding, being older than 35 and smoking, having uncontrolled high blood pressure, history of deep vein thrombosis or pulmonary embolism, history of stroke or heart disease, history of breast cancer, migraines with aura, diabetes-related complications, liver disease, unexplained uterine bleeding, and being immobilized for a long period of time.4 Many of these contraindications are due to the presence of estrogen in the pill. Despite being a young, generally healthy woman who does not smoke and has a regular menstrual cycle, I cannot take combined oral contraceptives due to numerous family members experiencing blood clots and a known family history of thrombophilia. Despite the medical limitations, there are also other obstacles with combined oral contraceptives that make them less effective. For example, you must take the pill at the same time each day to reach 99% effectiveness.4 For women with unreliable schedules, this may be a significant obstacle.
Finally, we cannot forget about side effects. The most common side effects of combined oral contraceptives are headache, nausea, bloating, and breast tenderness as well as breakthrough bleeding. Overall cancer risk, it must be emphasized, is not increased with birth control use.5 Yet, thankfully, there are other birth control options available including the IUD, the ever-popular condom, and Natural Family Planning, and each of these will be touched upon in a (hopefully) objective light.
Intrauterine devices have historically had a bad reputation. In 1968, the Dalkon shield first made its debut on the market, promising women an alternative to the then-side effect ridden birth control pills. Yet, this first IUD proved to be the death of six women due to infection or perforation.6 Now we have two IUD’s on the market namely Paragard (Copper IUD) and variants of the levonorgestrel IUD or IUD that only releases progesterone and not estrogen (e.g. Mirena, Skyla, Kyreena, and so on and so forth). Previously, it was thought that both of these IUD’s, particularly the levonorgestrel-releasing one, are abortifacient, meaning they prevent pregnancy primarily by preventing the fertilized egg from attaching to the uterine wall. This thought is not unwarranted: progesterone can be thought as a natural antagonist to estrogen. Where estrogen builds up the lining of the uterus and prepares it for pregnancy, progesterone wants to keep the lining of the uterus thin and incapable of implantation. Yet, there is more to the story behind the mechanism of action of IUD’s.
A meta-analysis published in 2007 sheds light on the origin of the misconception that IUD’s primarily prevent implantation: “To our knowledge, the first study on the mechanism of action of an IUD conducted in an animal model was reported in the early 60s. It showed unequivocally that, in rats fitted with a silk thread in the lumen of the uterine horn, the reproductive processes proceeded normally until the embryos reached the uterine milieu where they disintegrated and no implantation took place. This report engraved in everybody’s mind and textbooks that IUD’s acted only by preventing implantation. Further studies in animal models showed that the mode of action of an IUD in a given species cannot be anticipated from what it does in other species.”7 All this means is that IUD’s have a complicated mode of action and to infer the mechanism of action from a single study of silk string in rats to simulate an IUD is erroneous. We must look at human women’s biology and the IUD in question. Remember, reader, that this original study was in the early 60’s prior to the Dalkon Shield’s introduction in 1968. IUD’s have come a long way since the Dalkon Shield’s deadly side effects.
As I further present this article, I first want to jump to the mechanism of action of the copper IUD or Paragard. Ortiz and Croxatto state, “Copper ions released from an IUD enhance and reach concentrations in the luminal fluids of the genital tract that are toxic for spermatozoa.”8 This copper IUD, then, primarily acts as a spermaticide, and if any sperm were to reach an egg (an unlikely and unusual event), then it would result in the termination of an embryo. In contrast, the progesterone-only IUD thickens the cervical mucus, mimicking pregnancy or the luteal phase of the menstrual cycle and rendering the sperm immotile as the mucus is too thick to swim through.8 Ortiz and Croxatto explored many ways to determine if fertilization took place in both women without IUD’s and those with IUD’s, and rather than painstakingly going through each of these modes of determining fertilization, I want to focus on the most striking. The authors found studies in which the eggs of women post-coitum (or after sex) were analyzed to determine if they showed signs of developing into an embryo or they had no signs of doing so. They also found eggs that were “uncertain” and could be fertilized.8 The findings were thus: “Nine of the 14 eggs recovered from IUD users showed no signs of development (or becoming embryos), while the other 5 were classified in the category of ‘uncertain.’”8 However, it must be emphasized that the appearance of normal fertilized eggs that were definitely destined to be embryos were not found among the IUD users.8 The primary mechanism appears to be via inhibition of fertilization rather than inhibition of implantation (which would be abortifacient), though it remains unclear whether these “uncertain” eggs would have developed into embryos that would have not implanted (albeit, this appears to be a small risk). May you decide, therefore, reader, which is worse: an unintentional possibility or an intentional certainty? For some groups of people, this would be worth the risk as to have an unplanned pregnancy would result in an abortion (the intentional certainty), and therefore, morally, it is preferable for them to have access to IUD’s to prevent a very intentional medical abortion. For others, this is an intolerable risk and to have an unplanned pregnancy brings no risk of an intentional abortion; rather, it would result in a serendipitous welcoming of the unborn child (the intentional certainty in this case). They would prefer other alternatives such as condoms or natural family planning as contraceptive methods.
Condoms and Natural Family Planning
I wanted to touch a bit on two of the cheapest and most easily accessible ways to prevent pregnancy. Condoms are popular because they are easily attainable (you can get them like free candy at Planned Parenthood or other clinics), and they are really the only form of male birth control outside of exogenous steroid use or vasectomies (which are typically permanent but can be reversed). Yet, despite its popularity, there are still failures to be seen with condoms. According to NBC news, breakage, slippage, and leakage of condoms are among the most common failures that result in an increased rate of unintended pregnancies with condom use.Additionally, NBC reports that numerous errors in using condoms contribute to the high failure rate of this birth control method (15%). These basic errors include: late application, early removal, unrolling a condom before putting it on, no space at the tip, failing to remove air, inside-out condoms, failing to unroll all the way, exposure to sharp objects, not checking for damage, no lubrication, wrong lubrication (oil-based lubricants can degrade the latex), incorrect withdrawal, condom reuse, and incorrect storage.9 Therefore, with such high rates of errors in condom use, it demonstrates a serious lack of sexual education, where formal birth control education is virtually absent in many teenagers’ lives before their first sexual experience: “Overall, in 2011-2013, 43% of adolescent females and 57% of adolescent males did not receive information about birth control before they had sex for the first time. Despite these declines in formal education, there was no increase in the proportion of teens who discussed these sex education topics with their parents.”9 Yet, will teaching kids about birth control lead to more sex? It is doubtful as it seems, as stated above, that approximately half of those teenagers having sex did not receive birth control information. If adolescents do not receive proper sex education from either the school system or their parents, where do they get their information from? Likely, the internet, sadly, which is riddled with misinformation, sex propaganda, and often, pornography.
Lastly, but certainly not least, I wanted to touch on Natural Family Planning, which uses the woman’s menstrual cycle to predict when ovulation will occur and then avoid sex during those days when pregnancy is most likely to happen (or, if allowed in certain circles, the couple will simply use a condom during her fertile period). The benefits of this method are that it is widely accepted in religious circles (Catholic couples have been particular advocates for this method), it is cheap, and it can easily and quickly be reversed. Also, abortifacient claims are certainly unwarranted with this method. The disadvantages are that it is strenuous to undertake as ovulation can be difficult to predict. It is not like menses when there is very obviously blood, but rather, there are far subtler signs such as a change in cervical mucus and an increase in basal body temperature.10 Checking cervical mucus and basal body temperature (which must be done prior to getting up out of bed in the morning) can be difficult for some women, particularly those who have erratic schedules. Even if a woman does everything right, this method still may fail due to erratic menstruation or changes in schedule: “Illness, travel, and alcohol or drug-use can affect your temperature and make it difficult to establish an accurate reading. Lack of sleep can also affect temperature reading, so it is important to get at least 3 consecutive hours of sleep before taking your basal body temperature.” Finally, it should be noted that this method encourages abstinence when a woman most wants to have sex which could lead to higher failure rates by “stretching the rules” just a tad bit on certain occasions (and speaking from a female perspective, this is generally not fair).
I went on this long rant about birth control for two reasons. The first is that I wanted to educate you on the various forms of birth control available and to clear up misconceptions regarding them. The second is to illustrate the disproportionate burden that is placed on women in terms of reproduction and that limiting women’s reproductive rights will only increase abortions (legal or otherwise). Currently, it is mostly men making laws regarding abortion and birth control access, but it is women taking on much of the burden. Three of the four methods I mentioned put the responsibility on the woman, and yet, we still can observe serious barriers to accessing reliable contraceptives. Sure, the Natural Family Planning method with condom usage must incorporate both sexes, but ultimately it is up to the woman to track her ovulation correctly, and if anything unusual happens to her (sickness, travel, what have you), it may cause erroneous predictions. Plus this method requires extensive practice and knowledge on the subject. This is significant in that it speaks to the general lack of reproductive rights available to women (particularly those with little to no education on birth control), and it demonstrates that if we want to avoid unplanned pregnancies and abortions (legal or illegal), we must develop better, safer, and more predictable birth control for both sexes. If lawmakers would like to continue making laws regarding birth control and abortion, they should first educate themselves on the nuances and mechanisms of these methods. As a person who still considers herself pro-life but also one who advocates for reproductive rights for women, I am in full support of furthering efforts to create more tolerable forms of birth control. In later blog posts, I hope to expand upon the current issues with prenatal care and postnatal care that contribute to women’s decisions to have an abortion.
Frederica Mathewes-Green Policy Review Summer, 1991. ↩
“Access to Contraception”, Committee on Health Care for Underserved Women. The American College of Obstetricians and Gynecologists. Number 615. January 2015. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Access-to-Contraception ↩ ↩2 ↩3 ↩4
“Combination birth control pills”, Mayo Clinic, Nov. 15, 2017. https://www.mayoclinic.org/tests-procedures/combination-birth-control-pills/about/pac-20385282 ↩
Martin KA, Douglas PS, Baribieri RL, and Crowley WF. “Risks and side effects associated with estrogen-progestin contraceptives.” UpToDate. 4 April 2018. Accessed: 19 June 2018. Available at: https://www.uptodate.com/contents/risks-and-side-effects-associated-with-estrogen-progestin-contraceptives?search=combined%20oral%20contraceptives&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H28 ↩
“Intrauterine device”, Case Western Reserve University, 2010. Accessed: 19 June 2018. Available at: https://case.edu/affil/skuyhistcontraception/online-2012/IUDs.html ↩
Ortiz, ME and Croxatto HB. “Copper-T intrauterine device and levonorgestrel intrauterine system: biological bases of their mechanism of action.” Contraception 75 (2007) S16-S30. ↩
Stokes T. “Condom use 101: Basic errors are so common, study finds.” Health News. NBC. 26 Feb 2012. Accessed: 20 June 2018. Available at: https://www.nbcnews.com/healthmain/condom-use-101-basic-errors-are-so-common-study-finds-207925 ↩ ↩2 ↩3 ↩4 ↩5
“What’s the State of Sex Education In the U.S.?” Planned Parenthood. 2018. Accessed: 20 June 2018. Available at: https://www.plannedparenthood.org/learn/for-educators/whats-state-sex-education-us ↩ ↩2
“Fertility Awareness: Natural Family Planning (NFP)” American Pregnancy Association. 2018. Accessed: 20 June 2018. Available at: http://americanpregnancy.org/preventing-pregnancy/natural-family-planning/ ↩