Emergency Contraception and Faith in Truth
Women’s health, in regard to either pregnancy prevention or pregnancy maintenance, requires resources and referrals that will best educate women on how to actively promote and enhance their own health. Although striving towards such a goal seems expected, it has nevertheless been difficult for policy-makers and healthcare providers to grasp the differences between all-inclusive options for women, versus ideologically-driven mentalities. This is in large part due to the fact that women’s health is a field that is entrenched with personal bias against certain types of sexual behavior. At any rate, the use of contraceptives is still highly maintained in most modern areas of medicine, which is fortunate, as even the most careful use of birth control has some degree of risk of unplanned pregnancy. Such unintended pregnancies incur costly medical expenditures and additional hardship for the populations that government agencies serve. Furthermore, careful analysis of the preventative benefits of Emergency Contraceptive Pills (ECPs), as well as the agencies that supply this service, quickly reveals that the welfare of our community, and even our nation, would face serious economic and social turmoil if women did not have access to this service.
In the interest of explaining what Women’s Health education entails and why strong opposition to it often jeopardizes its fate, it is important to consider the debate surrounding emergency contraception. The medical purpose of emergency contraception will be elaborated on and I will analyze the importance of being aware of ECP availability, including timely and affordable access to ensure their efficacy.
Major ethical impasses have long contributed to the decline in positive progress toward achieving the goal of increasing access of emergency contraception, and recent political attention has been focused on Crisis Pregnancy Centers (CPC). Data on emergency contraception gathered through research by CPCs and Family Planning Clinics, and regarded by young women and the public as important resources for pregnancy counsel, are used for comparison purposes. It should be noted that a key element regarding this point is that if CPCs are an alternative resource to pregnancy consult, the decision to use this service, like Sloane (2007) charges should include “…the same informed choice one uses for the usual forms of medical care” (p. 570). Whether or not this issue speaks to policymakers, it does speak to the health and dignity of women who wish to avoid pregnancy. Just as important, it speaks to general humanity and people’s right to the truth in making informed decisions about their health. To remain fair and balanced, it is imperative this perspective harnesses current and relevant medical and legislative insights.
Emergency Contraception Pills
Emergency contraception pills (ECPs) are commonly utilized in family planning programs as a preventative measure for unwanted pregnancies. They are used when sex has been forced, a barrier method has failed, or when the sexual partners have failed to use contraception altogether. As with most contraception, problems arise when the safety and efficacy of the contraceptive mechanism are not entirely certain. The Food and Drug Administration (FDA) has proved the efficacy and safety of Plan B, used interchangeably with the ‘morning-after pill.’ Plan B contains Levonorgestrel, a progesterone hormone that works to prevent or delay ovulation. In general, once a woman begins treatment with oral Levonorgestrel, the viscosity of her cervical mucus increases, thereby reducing any opportunity for fertilization and implantation. The significance of this mechanism, however, can only be understood if the actions after coitus are illustrated.
Conception
As often as women and men are warned that it only takes a single unprotected sexual encounter to cause pregnancy, many find it surprising to learn that conception is an elaborate biological process fraught with physiological barriers. However, when those barriers are surpassed and fertilization occurs there are a limited number of alternatives available for those women who do not wish to proceed with a pregnancy. Levonorgestrel was created for just those women.
Sloane (2002) reports that “…between 250 and 400 million sperm …are deposited in the vaginal cavity” upon ejaculation; if this happens close to the ovulatory stage, these sperm encounter -“a very hostile environment” within the vaginal canal (p. 314). During this period, roughly the mid-point of the regular menstruation cycle, vaginal acidity is hazardous to sperm survival. At the same time, leucocytes become prevalent in the vaginal canal and target the ‘foreign invader’ sperm for destruction and elimination. Sperm, therefore, deplete their available energy stores in their race to rapidly transverse the vagina and enter the uterine cavity. Once safely within the more hospitable environment of the uterine cavity sperm have been observed to enter a state of rest, until they are signaled to respond to a released ovum. To date, the precise chemical communication that takes place between the sperm and egg, which facilitates the reactivation of sperm motility, remains unknown. However, the molecular events that occur in response to those communications are well-defined. Sloane has termed this subsequent process as capacitation. Those sperms that succeed in reaching the available ovum, however, are faced with a whole new set of physiological barriers. In order for the sperm to gain access to the egg it must penetrate the egg’s outer covering (the zona pellucida) and an inner layer of cells (the corona radiata). To accomplish this, the sperm secretes digestive enzymes that effectively create a tunnel to the egg’s cytoplasmic core wherein fertilization takes place.
This entire acrosomal reaction is reliant upon a few brief events that occur in the woman before ovulation. At the start of the menstrual cycle, estrogen levels are low. In order to maintain homeostasis, the body compensates for the hormonal imbalance by secreting the follicle-stimulating hormone, which is in turn responsible for the initiation of egg maturation. Of the many developing follicles, only one will be released from the ovary in preparation for fertilization (American Pregnancy Association, 2011). At this point estrogen levels are significantly increased, since this hormone is required for the signaling events that trigger complete maturation. In response, the hypothalamus and pituitary gland will then release LH, the luteinizing hormone. Interestingly, LH is one of the principal targets of the active ingredients found in emergency contraception pills (ECPs) used to prevent pregnancy.
Levonorgestrel
Although a few different ECPs are currently on the market, this paper will focus on the variation known as Plan B One-Step™ by Teva Women’s Health, Inc. This single dose pill is clinically defined as an off-white round tablet containing 1.5mg of levonorgestrel, the only active ingredient. The pill also contains the following inactive ingredients: colliodial silicone dioxide, corn starch, lactose monohydrate, magnesium stearate, potato starch, and talc (Plan B One-Step, 2009). Before we delve into the exact mechanism of levonorgestrel, we will discuss its intended use and clinical effectiveness.
Pharmacists note that Plan B One-Step should be taken within 72 hours after unprotected sexual intercourse to achieve the greatest efficacy. The medication is available over-the-counter without a prescription for women 17 and older throughout the United States. It is often difficult to determine what type of side effects will appear for each individual. The clinical trials were designed to examine several variables and the most common adverse side effects were reported as: “…heavier menstrual bleeding (30.9%), nausea (13.7%), lower abdominal pain (13.3%), fatigue (13.3%) and headache (10.3%)” (Plan B One-Step, 2009). The general consensus among health care professionals and consumers has been that Plan B’s side effects are relatively mild.
Once ingested, levonorgestrel interferes with a woman’s natural secretion of the LH hormone. If Plan B One-Step is taken prior to the LH surge, as mentioned earlier, follicular rupture is impeded (Downing & Sturpe, 2010). Specifically, levonorgestrel-mediated inhibition of the LH surge renders any viable sperm incapable of capacitation; thus, fertilization of the ovum is not achieved. The mechanisms, of course, vary considerably depending on how soon the woman begins treatment after the unprotected sexual encounter and at what stage she was at in her menstruation cycle when coitus occurred (Downing & Sturpe, 2010).
Of all the scientific studies that have been completed on emergency contraceptive pills (ECPs), the issue that has generated the most controversy is whether or not ECPs interrupt or damage physiological activity that takes place after fertilization. For this reason, the public became increasingly convinced that emergency contraception was a medical abortifaceint. This concern has caused not only ethical constraints, but also constraints that extend to the design of experiments and studies in human subjects, which focus on the consequences of ECP ingestion after fertilization has occurred. There is currently no direct evidence approving or disproving the theory that ECPs interrupt activity after fertilization. Thus additional insights must be provided from animal studies.
When animal studies were performed, predictably, levonorgestrel, the active ingredient in ECPs, had no effect on animal subjects at each measured interval, especially after implantation. Thus, the two researchers who conducted the study concluded that pregnancy could be sustained even after levonorgestrel ingestion.
Other researchers like Murphy (2011) emphasize the same point, which is that, “recent studies have not supported an effect of altered endometrial receptivity that interferes with implantation” (p. 907). In 2009, researchers conducting an in-vitro study tested endometrial expression under the influence of the drugs levonorgestrel and mifepristone. With the aid of a three-dimensional endometrial construct, they concluded that several epithethlial and stromal receptors, measured through timed endometrial biopsies, were not affected by the administration of levonorgestrel treatment. This was not the same for mifepristone although opponents of EC lead many to believe so.
Murphy also debunked recent claims of an increased risk of ectopic pregnancy, claiming, “…due to effects on thickening reproductive tract mucous and slowing down tubal motility…there are no data to date that support this concern” (p. 908). The researchers even cited research claiming that ECPs have protective benefits against ectopic pregnancies. Further clinical assessments showed no contradictions other than pregnancy. The overall effectiveness of ECPs has been reported to be high, albeit contingent on the amount of time that has passed between coitus and ingestion. In the absence of contraception therapy, the risk of pregnancy for a one-time sexual intercourse experience is currently 8%, but with ECPs, this risk decreases to 2%.
Finally, The American Medical Association, widely recognized as one of the largest organizations of physicians dedicated to the “betterment of public health,” approves the use of Emergency Contraception. As outlined in AMA policy H-75.985, “Access to Emergency Contraception”, physicians should actively commit to educating patients about emergency contraception as part of the standard contraceptive counseling for individuals of reproductive age.
Context of Care
The biological review of Plan B-One Step, even with the help of objective, scientific facts, should consider the controversial aspects regarding the administration of the pill. In the context of its use, it must be emphasized that its mechanism plays a complex role in terms of how pregnancy is identified and defined. Consequently, the scientific interpretation of pregnancy is interwoven with how the public understands prevention and healthcare. Herein lies the motivation for the striking divide between social movements.
Emergency contraception, supported by evidenced-based study, does not interrupt an established pregnancy. With this in mind, the claim that ECPs are abortifacients is not based on fact. According to the Office of Population Research at Princeton University, as well as the Association of Reproductive Health Professionals, citing the National Institutes of Health and the American College of Obstetricians and Gynecologists, “pregnancy begins when the fertilized egg implants in the lining of a woman’s uterus” (2011).
Sloane (2002) concurs by stating, “There is no evidence that oral contraceptives have any effect on an already-implanted ovum” (p. 470). Even with the wealth of evidence supporting this claim, the myth that ECPs are abortion pills continues to be ubiquitously and passionately maintained in public to this day. No greater example of this statement can be confirmed without looking at how CPCs are operated. CPCs currently operate with practices that seem to undermine the past 35 years of progress made in women’s health.
CPCs and Emergency Contraception
Over the past five years, many women, healthcare professionals, activists, and even lay persons, have brought attention to the fact that agencies that call themselves crisis pregnancy centers (CPCs) have not only been coercive and deceptive, but have also made women victims of harassment. Additionally, some women claim that CPCs have even threatened their right to informed consent and put their health at risk (Harrison and Kristin, 2006). During this five-year period, there have been an estimated 4,000 CPCs in the United States, some of which have been prominent across Canada (Harrison).
Recent criticism has been leveled at CPCs for falsely imitating the appearance of a medical clinic, for dressing staff to look like physicians and nurses, and even for using medical grade ultrasound equipment without requiring skilled ultrasound technicians for its operation (Harrison). Some of these clinics are even going to great extremes by recruiting medical professionals who object to family planning and abortion care. On the other hand, others argue that many of the medical professionals who staff CPCs or even just consult clients may feel compelled by their faith or conscience to help. By intentionally locating CPCs near actual family planning clinics, CPC staff has easy access to the clinic’s vulnerable, typically young, low-income women. Many CPCs have been shown to wage misleading advertising campaigns while refusing to divulge legal and safe all-options healthcare information to the women they manage to get inside their doors (National Abortion Federation, 2006).
Although there is much more to be said about the actions of CPCs, arguably what should be the primary concern is the ill-informed and limited counseling these agencies offer clients, specifically about Emergency Contraception.
Whether a woman is pregnant or not, the type of potential harm inflicted on those using CPCs is all the same. If a woman discovers she is pregnant, some CPCs have been said to withhold medical care, as limited as it, until adoption papers have been signed (National Abortion Federation, 2006). Even before pregnancy results are revealed, clients subject to in-person care versus phone counseling adamantly emphasize that ECPs are abortifacients and that condoms are an unreliable means of preventing STDs and pregnancy. While CPCs do not seem to require their staff to provide information approved by the American Medical Association, a more devastating revelation is in an analysis of the health cost incurred by women when they haven’t been counseled about emergency contraception.
Efficacy of Plan B-One Step
In November 2010, researchers set out to determine the effectiveness of oral Levonorgestrel and the risk of pregnancy after various 24-hour time intervals. Prior to this study, the effectiveness of oral Levonorgestrel for 72 hours of unprotected sexual intercourse was not fully understood. The World Health Organization, using random clinical trials, gave each woman Plan B-One Step 48, 72, and 120 hours after unprotected intercourse. Using logistical regression, the results proved that up until the fifth day, the efficacy was the same. On the fifth day, however, the risk of pregnancy is said to increase over five times than it normally would following earlier treatment. This study is significant in that protection, although minor, surpasses the original FDA recommendation stating that ECPs like Plan B offer protection only if taken within 72 hours after coitus.
Against CPCs
As much as CPCs should be criticized according to individual value, more often than not they have a reputation for delaying pregnancy results or sharing the results with great ambiguity (Institute for First Amendment Studies, Inc., 1998). At times, too, pregnancy tests may be unnecessary. Robert Pearson, an anti-choice activist, was the first person ever to create a CPC and published a manual that is still widely used today. The manual, “How to Start and Operate a Pro-life Outreach Pregnancy Service Center” as cited by the Institute for First Amendment Studies, Inc. (1998), explicitly states, “If the client asks how long it takes to do the test, tell her we offer the results in 30 minutes, you will have the results by that time. (You have not told her how long it takes you to run the test, but how long it will be before she has the results of the test.)”
Pearson’s suggestion, which clearly shows an intention to delay pregnancy results, perfectly illustrates how politicized pregnancy has become. Many people would agree that a positive pregnancy test can only happen after implantation has occurred, something of course that would make emergency contraception irrelevant. However, CPC staff may put the patient at unnecessary risk by failing to disclose that a pregnancy test is not accurate within 48 hours of sexual intercourse and by delaying that information or even by administering an unnecessary pregnancy test, the patient is put at additional risk by not seeking timely medical care.
The legislative disputes about making ECPs an over-the-counter medication, along with a blatant refusal to provide ECPs, through the protection of the “Conscience Clause” shows just how polarized ECPs have become, even in the short time since the FDA approved their marketing. It would seem reasonable to assume, of course, that pregnancy counseling would be an objective and unbiased practice. Considering all the scientific literature on how pregnancy occurs, the willingness by some parties to accept information not based on fact is bothersome. One might argue that some people are especially susceptible to misinformation shared by CPCs. As one Crisis Pregnancy Center operator noted, “About 65 percent of the center’s clients are women aged 19 to 25, the “most abortion vulnerable group of women in the United States” (Weeks, 2001). She goes on to state, “Girls ages 15 to 18 make up about 35 percent of the clientele.”
To complicate circumstances even more, many CPCs fail to disclose available treatments that require immediate application for success, such as ECPs. Pearson’s manual also asks CPC staff to, “Never counsel for contraception or refer to agencies making contraceptives available. “Fornication is still a sin no matter what the circumstances” (Institute for First Amendment Studies, Inc., 1998). While waiting for the unnecessary pregnancy results, it is clear a client endures anything but a full-range of reproductive health options.
All of this would seem appropriate to many, because as consumers it is their choice. However, if 65 percent of the women seeking services are the most vulnerable, this raises some moral questions. After all, a mistimed and unwanted pregnancy can be inherently traumatic and stressful for a woman.
At a time in history where Western medicine has advanced its reproductive technology and services, the idea that ECPs are ignored as a treatment option is inexcusable. Furthermore, as time elapses, especially when the efficacy of Plan B-One Step is greatest within a time frame of up to 120 hours after unprotected intercourse, the additional constraints imposed by CPCs puts women at an increased risk of unwanted pregnancy, which may lead to greater exasperation and stress.
In Defense of CPCs
As a person of faith, detaching oneself from religious teaching and challenge faith-based leaders may not be comfortable. Roman Catholic religious doctrine requires that faithful Catholics “…hold a consistent life ethic means to work to protect the dignity of life from conception through birth, through childhood, through the many challenges of adult life, and through infirmity and death” (Brice, 2006). This teaching is humane and well-respected by many. However, the sanctity of life should also be shown with mindfulness to scientific evidence.
Spiritual answers and scientific truth seen to include difficult hurdles that require meticulous investigation, which are often made more complex in the context of self-determination and authority. Do we place faith in modern medicine and its answers confirmed through years of clinical trials and robust studies? Or, does scientific law fail at the hands of the God’s people? Insofar as it requires discourse, scientific fact is also a type of faith guided by subjective belief and grounded by objective evaluation. As scientists quantify when pregnancy occurs, and how pharmacological intervention manipulates the physiological behavior of an embryo, one asks, “What are we to do?”
What are we to do with this information? Have we reached an impasse in which public policy cannot speak for the common good? To begin to answer these, one must know where good originates and what standards fulfill the needs for achieving the goals of the common good. Can what is good be measured by scientific data alone? Such questions reflect the challenges of implementing public policy in a pluralistic and partisan society.
The Most Reverend Charles J. Chaput, O.F.M. Cap, the Archbishop of Denver made a profound statement in response to Catholic healthcare. He states to Catholic professionals, that if they, “… cannot apply it [on reproductive principles of faith-based teaching] with an honest will – then you need to follow your conscience. The Church respects that.” He further states, citing Newman, “Obedience to conscience is the road to integrity. But conscience… has rights because it has duties… One of those duties is honesty.”
It is no accident that theologians and secularists approach the same situation with their hearts flowing in different directions. Whereas a family clinic focuses on pregnancy prevention and planning, CPCs steer towards abstinence and nurturing pregnancies, sometimes using subtle force, to ensure that a client goes to term. Despite the different intentions, it should be noted that any behavior that infringes on a person’s right to a moral conscience should be reevaluated.
Unwanted Pregnancy
Several consequences, including a greater risk of unwanted pregnancy, have been identified when a woman is forced to bring her pregnancy to full term, either through unconscious awareness of misinformation about ECPs perpetuated by CPCs, or a total lack of general knowledge about the availability of ECPs. In his research study, Bouchard (2005) found that among 118 adult couples, those facing an unwanted pregnancy faced higher risks of inadequate care, perinatal morbidity, and significant postnatal problems than those who had intended to become pregnant.
The incidence of depression created some uncertainty. Bouchard reports that unplanned pregnancies, predictably, reveal high levels of neuroticism, depression, and perceived stress (p. 629). However, whether the incidence of depression is ascribed to the discovery of an unplanned pregnancy or because depressed women generally have more unplanned pregnancies, is debatable. It is not known whether the couples received counseling from CPCs to help through the process, or if they were receiving care from a family planning clinic.
Should this data come as a surprise, further research on having an accurate understanding of sexual knowledge portrays a more optimistic approach to reproductive decision making, and consequently the health of women. Providing women with full reproductive options in a timely manner, especially information about safe and effective contraceptives, and allowing them to achieve an informed consent status can help them lead happier and healthier lives. This would not be possible with severe depression and stress. Critics, however, are quick to argue that the same may hold true depending on the outcome of CPC counseling.
Conclusion
It is increasingly becoming the consensus among policy-makers, healthcare professionals, and even consumers, that healthcare is a multi-faceted issue that goes beyond just treating the symptoms, but also looks at various dimensions of behavior. Therefore, it should come as no surprise that mandatory ECP counseling is quickly becoming the norm. To some reproductive health advocates, Crisis Pregnancy Centers (CPCs) may pose a threat in respect to providing full reproductive options for women; an achievement that many years of societal diligence has worked to create. In addition, although the services of CPCs are becoming more front and center, there is still little known about how beneficial they truly are to their clients. Given the fact that the target population of CPCs is often vulnerable young women who are at a particularly sensitive age, there is a crucial need for further investigation into these clinics and their supposed intentions to further promote the success of Plan B.
References
American Pregnancy Association. (2011, March). Understanding Ovulation. Retrieved April 15, 2011, from American Pregnancy Association: http://www.americanpregnancy.org/gettingpregnant/understandingovulation.html
Bouchard, G. (2005). Adult Couples Facing a Planned or an Unplanned Pregnancy: Two Realities. Journal of Family Issues , 619-637.
Brice, S. (2006). Third Sunday in Ordinary Time. Retrieved April 29, 2011, from St. Anne’s Wausau- Bulletin Letters: http://www.stanneswausau.org/Bulletin_Letters_2006/l012206.html
Carlson, S. (2007, May). The Politics of Emergency Contraception: How Broad Refusal Clauses Are Unwise and Against Medical Advice. Retrieved April 2, 2011, from Harvard Law- LEDA: http://leda.law.harvard.edu/leda/data/817/Carlson_07.html
Chaput, M. R. (2010). Health-care reform and the future of the Catholic health-care vocation. Houston: Archbishop of Denver.
Curricular Organizer for Reproductive Health Education. (2011). Emergency Contraception. Retrieved April 2, 2011, from CORE: http://core.arhp.org/search/searchResults.aspx?c=3
Downing, D., & Sturpe, D. A. (2010). Emergency Contraception. In L. M. Borgelt, M. B. O’connell, J. A. Smith, & K. A. Calis, Women’s Health Across the Lifespan: A Pharmacotherapeutic Approach (pp. 311-323). Bethesda: American Society of Health System Pharmacists.
Harrison, Kristin. (2006). Abortion Facts: Crisis Pregnancy Centers. Retrieved April 15, 2011, from National Abortion Federation: http://www.prochoice.org/about_abortion/facts/cpc.html
Hatcher, R., Trussel, J., & Nelson, A. L. (2008). Emergency Contraception. In R. Hatcher, J. Trussel, & A. L. Nelson, Contraceptive Technology (pp. 87-109). n.a.: Ardent Media.
Institute for First Amendment Studies, Inc. (1998, October). The deceptive practices of crisis pregnancy centers. Retrieved April 15, 2011, from Institute for First Amendment Studies, Inc.: http://www.publiceye.org/ifas/fw/9810/crisis.html
Murphy, P. A. (2011). Contraception and Reproductive Health. In T. L. King, & M. C. Brucker, Pharmacology for Women’s Health (pp. 907-908). Sudbury: Jones and Bartlett Publishers.
NARAL Pro-Choice America Foundation. (2011, January 1). The Difference Between Emergency Contraception and Medical Abortion. Retrieved April 2, 2011, from Naral Pro-Choice America: http://docs.google.com/viewer?a=v&q=cache:3OeJfeDv9LgJ:www.naral.org/media/fact-sheets/birth-control-ec-mifepristone.pdf+american+medical+association+emergency+contraception&hl=en&gl=us&pid=bl&srcid=ADGEESj7ARNQF78qFqsc9ZLkUdaeiXuuNn_WagMha4ZRxq5KSbSUqXMe
National Abortion Federation. (2006). Crisis Pregnancy Centers: An Affront to Choice. Washington D.C.: National Abortion Federation.
National Conference of State Legislators. (2010, August). Issues and Research: Emergency Contraception. Retrieved April 2, 2011, from NCSL: http://www.ncsl.org/default.aspx?tabid=14420
Piaggio, G., Kapp, N., & von Hertzen, H. (2011). Effect on pregnancy rates of the delay in the administration of levonorgestrel for emergency contraception: a combined analysis of four WHO trials. Retrieved April 25, 2011, from Science Direct: Contraception: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T5P-51WM25T-2&_user=10380671&_coverDate=01%2F07%2F2011&_rdoc=1&_fmt=high&_orig=&_origin=&_zone=rslt_list_item&_cdi=5008&_sort=d&_docanchor=&view=c&_ct=2&_acct=C000050221&_version=1&_urlVersion=0&_
Plan B One-Step. (2009, August). Higlights of Prescribing Information. Retrieved April 15, 2011, from Plan B One-Step: http://www.planbonestep.com/pdf/PlanBOneStepFullProductInformation.pdf
Sloane, E. (2002). Biology of Women. Albany: Thomson Learning.
Teva Women’s Health, Inc. (2010). Consumers: Plan B One-Step. Retrieved April 2, 2011, from Plan B One-Step: http://www.planbonestep.com/
The Henry J. Kaiser Family Foundation. (2005, November). Fact Sheet- Emergency Contraception. Retrieved April 2, 2011, from Women’s Health Policy Facts: http://www.kff.org/womenshealth/upload/3344-03.pdf
U.S. Department of Health and Human Services. (2010, August 26). Drugs: Plan B. Retrieved April 2, 2011, from U.S. Food and Drug Administration: http://www.fda.gov/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm109775.htm
