The Pill: Contraceptive or Abortifacient?

By Karen Swallow Prior

It's an important distinction, both linguistically and scientifically.

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It's time for some political, scientific, and moral clarity on the birth control pill. It's time to distinguish clearly—in terminology, thinking, and public policy—between contraception and abortion.

We can begin with terminology, which has become increasingly sloppy in news analysis and public discourse. "Birth control" includes any device or practice that prevents birth, including elective abortion. "Contraception," by definition (but not necessarily in common usage), prevents conception (not implantation of the fertilized egg in the uterine wall); and "conception" refers to the joining of the sperm and ovum (not implantation). It is unfortunate (if not downright Orwellian) that "contraception" is used so loosely, particularly within the context of public policy and national health care.

For example, let's look at news coverage of Hobby Lobby's opposition to one provision of Obamacare. A recent story describes the position of the arts-and-crafts chain's pro-life owners this way: "The company opposes providing some contraceptives to employees through its company health care plan on religious grounds, saying some contraceptive products, like the morning after pill, equate to abortion." But the company isn't saying that contraception equates to abortion; it is simply acknowledging the way the morning after pill is routinely described as acting, which can include preventing implantation after conception.

In addition to the linguistic clarity about contraception, clearer scientific understanding of how the pill works is needed. Many years ago, as a teenager, I decided to go "on the Pill," as they say. I remember clearly my physician's explanation of how the birth control pill worked: first, it was supposed to prevent ovulation; second, in case ovulation did occur, the pill's backup mechanism was designed to prevent the sperm from fertilizing the egg; finally, the backup to the backup was to render the uterine wall inhospitable to any accidental zygote that may have formed if the first two steps failed. At the time, I shrugged off the last part almost as easily as the first two, having not yet arrived at the strong pro-life convictions I hold today.

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But now I—along with about half of the nation—am pro-life, and the distinction between contraception and abortion is the difference between life and death. The labeling of birth control pills, in their various forms, for years has included information similar to that given to me by my doctor, information that has caused strongly pro-life people, as I am, to consider the birth control pill—and the morning after pill, which operates on the same principles—to be, potentially, an abortifacient and, therefore, to be rejected within a pro-life philosophy. My own relationship with the birth control pill is a picture with more strokes of gray than black and white. I didn't go off it immediately after adopting my anti-abortion view but did in time with increased knowledge and conviction about its potentially abortifacient elements. Many conversations with like-minded friends reveal similar inner conflicts and downright confusion.

So it is no small thing for scientists to be saying now that perhaps the birth control pill does not sometimes operate as an abortifacient. An article this summer in the New York Times examined this changing position of doctors on how the Pill works. The research cited by the Times

found that the federally approved labels and medical Web sites do not reflect what the science shows. Studies have not established that emergency contraceptive pills prevent fertilized eggs from implanting in the womb, leading scientists say. Rather, the pills delay ovulation, the release of eggs from ovaries that occurs before eggs are fertilized, and some pills also thicken cervical mucus so sperm have trouble swimming.

It turns out that the politically charged debate over morning-after pills and abortion, a divisive issue in this election year, is probably rooted in outdated or incorrect scientific guesses about how the pills work. Because they block creation of fertilized eggs, they would not meet abortion opponents' definition of abortion-inducing drugs.

Some pro-lifers, this one included, find it at least a little bit suspect that now, in the midst of controversy around this issue that directly threatens around this aspect of the Obama administration's attempts at national health care overhaul, scientists are suddenly backtracking on long held views about how the birth control pill works. Note in the passage quoted from the New York Times above the acknowledgement that the issue is a "divisive" one "in an election year." Later, the article acknowledges that the "controversy over emergency contraception is figuring in...debates over the Obama administration's health care law."

It may be nearly impossible to prove exactly how hormonal contraception works within the current state of science. Yet some evidence is clear and compelling that the long held understanding is correct, as one blogger explains:

We know from studies such as the 2007 "Changes in measured endometrial thickness predict in vitro fertilization success" that the thickness of a woman's endometrium—the lining of her uterus—determines the likelihood of the successful implantation of an embryo. If an embryo—a living human by all characteristics - does not implant, it is passed out of the uterus in what's popularly called a miscarriage, or a spontaneous abortion. (If you're interested, this study also showed that oral contraceptive use also altered the quality of the endometrium, the markers associated with "endometrial receptivity.")

We've known for quite a while that the use of oral contraceptives has the capacity to thin a woman's endometrium. The 1997 study "The effects of monophasic and triphasic oral contraceptives on ovarian function and endometrial thickness" found that "endometrial thickness in OC users was significantly smaller than in controls", that is, than in women who were not using oral contraceptives.

A 2001 study of one the most popular oral contraceptives on the market, Yasmin, found that ... oral contraceptives have the effect of thinning the endometrium.

Such evidence is compelling enough for many pro-lifers to err on the side of life.

However, the birth control pill's status as a potential abortifacient has not found universal agreement, even within the pro-life community. For example, a paper published more than a decade ago by the American Association of Pro-life Obstetricians and Gynecologists—whose authors describe themselves as "committed to honoring the sanctity of human life from conception"—concludes based on a thorough evaluation of the available literature that there is not "substantive evidence that hormone contraceptives include an abortifacient mechanism of action."

Further inconsistency among pro-lifers is seen in the fact that greater opposition exists among abortion opponents for the morning after pill than for the regular birth control pill, which in most cases is the same medication taken hours later and in varying dosage, but working in the same way—with, presumably, an increased risk of implantation rather than fertilization being interrupted. Presumably, but not evidentially. I have never understood pro-lifers' squeamishness at the morning after pill absent the same concern with the daily pill—except perhaps the latter hits a bit closer to home for so many.

Of course, empirical evidence is not the sole basis for moral decision-making. Take instances of rape, for example. Fr. Paul CB Schenck, Respect Life Director for the Catholic Diocese of Harrisburg and Liaison to the Catholic Medical Association in Central Pennsylvania, explains,

Plan B [the morning after pill] may be used in a morally licit way in case of rape. If a pregnancy test is negative, A Catholic practitioner may administer Plan B within 72 hours to inhibit ovulation, thus preventing pregnancy without risking abortion. All that is necessary is moral certitude, not empirical certitude, that there is no human life in danger. So it is not as rigid as some assume or represent. It is always about life present, or the deliberate and intentional act against life. In the case or rape, the intent of Plan B is not to stop life, but to stop the act of the rapist from reaching its ordered end: impregnation, which would be a form of success of the violent assault. Therefore, a Catholic health plan may include emergency use of Plan B in case of rape, provided it is accompanied by a pregnancy test.

Commentary within the Christian and the pro-life communities debating these issues has cropped up in recent months, including a provocative post at Patheos providing analysis suggesting the likelihood that fewer human zygotes are lost when the birth control pill is used than when it is not. While not scientifically provable (at this point), such a notion could have radical implications for the policies and practices of people with pro-life convictions. More and more, it seems, younger members of these groups in particular are re-examining and re-evaluating previous thinking. This questioning seems to be prompted by an array of interests including rejection of the seeming inconsistencies within the pro-life movement described above, greater awareness of global issues such as poverty and with that greater sense of responsibility of meeting those global needs in real and immediate ways; and general distrust of the old, modernist categories such as "pro-life/prochoice," "liberal/conservative," or "Republican/Democrat."

Yet exactly how the birth control pill, as well as the related morning after pill, functions is a matter of importance well beyond the issues that concern pro-life philosophy and practice. It is essential to bring clarity to a moral and medical issue shrouded in ambiguity and contradiction for reasons that affect all of us.

For one thing, whether or not certain forms of contraception—coverage of which is required under the Patient Protection and Affordable Care Act—is the crux of much (certainly not all) opposition to the legislation.

Further, contraception is a crucial area of common ground within the abortion debate. Any clarity that can be brought to the issue has at least the potential of enlarging areas of agreement between pro-life and pro-choice forces in efforts to reduce abortion rates. The status of the birth control pill as contraceptive or abortifacient has implications for foreign aid policy and reproductive health issues across the globe. Finally, it is crucial for women to have as much knowledge as possible about how medication works and affects their body's functioning.

It's a medical issue. It's a moral issue. It's a political issue. It's a women's issue. It's a human issue. Whatever ambiguities persist around the pill in its various forms, it's time to start facing them honestly.

This article available online at:

http://www.theatlantic.com/sexes/archive/2012/12/the-pill-contraceptive-or-abortifacient/266725/