Emergency contraception and abortion: medical and ethical considerations

Morning after pill & Abortion

Emergency Contraception & Abortion

In the United States there are more than three million unplanned pregnancies per year (Raymond, Trussell, & Polis, 2007). The cause of these pregnancies varies greatly, generally resulting from improper use of contraception or even a complete lack of contraception. A lack of useful sexual education is a primary issue in the discussion of contraception, unplanned pregnancy, and abortion. Across the studies reviewed for this paper is a consistent lack of empirical readily available data regarding not only the uses and methods of use of emergency contraceptive regimens but also of information regarding how these treatments work and what they are actually made of. A lack of labeling from the FDA further impacts the relative availability of such information as well as the drug regimens themselves to the general public. Though the use of emergency contraceptives is becoming more common, the overall number of unwanted pregnancies is not decreasing significantly.

A meta-analysis of fourteen intervention studies which actively supplied participants with emergency contraception shows conclusively that access is not the problem (Raymond et al., 2007). Currently it is not known why access to such contraceptive methods has not significantly impacted the number of un planned pregnancies and consequent abortions. It is likely though that a number of co- occurring social phenomenon including misconceptions regarding the nature of the medication, social stigmatization through request of the medication, global fear of medical contraindications and complications, as well as the persistent yet false belief that emergency oral contraception constitutes early medical abortion. These social factors may work together affecting an individual's choice, even ability, to procure emergency contraception. This pervasive lack of knowledge and negative social stigma are the most effective methods of maintaining high abortion rates irrespective of the available less invasive and traumatic alternatives.

Emergency contraception is intended for use in the event that more common methods of contraception such as; condoms, diaphragms, or intrauterine devices fail. It is also intended for use when no contraceptive methods were employed at all. The two primary forms of emergency contraception available are the Postcoital Pill, or an intrauterine contraceptive device (IUD). Each method has a period of maximum effectiveness following unprotected sex, for the pill it is approximately 72 hours and for the I.U.D it is up to 5 days (Burton, & Savage, 1990). Though there are side effects associated with either method, generally they are not severe and the success rate of both methods in preventing unwanted or unplanned pregnancy is between 99% and 99.6% (Burton & Savage, 1990).

Though existing medical protocols discourage use of emergency contraceptive regimen after the 72-hour window, it is unlikely that the chemical effectiveness of the hormones become negated after that brief period of time (Glaiser, 1997). The risk though is that after that three day window, a pregnancy has been established which would render the emergency contraceptives ineffective. These protocols though are quite restrictive. There is no evidence that the emergency contraception would no longer work, yet individuals who are potentially at risk will choose not to take regimen based on those guidelines. It is possible that lifting or altering those clinical protocols would have an impact on the number of abortions simply by increasing the number of at risk women who take emergency contraception (Glaiser, 1997).

Side effects of emergency oral contraception include nausea, vomiting, between period spotting, or heavier than normal bleeding in the individual's next menstrual cycle. These side effects, though common are not experienced by all individuals who use emergency contraception methods. As research regarding more effective chemical compositions for these pills progresses, troubling symptoms like delayed menses (which can be extremely traumatic in the event of contraceptive failure) are becoming less common. Though it is not intended for regular use, or for use as a primary method of contraception, there are no known long-term side effects resulting from this method of pregnancy prevention.

The regularity of emergency contraceptive use is another fairly ambiguous area of data regarding these medication regimes. Though it is stressed that emergency contraception is not intended for regular use, the chemical composition of the pills are quite similar to that of oral contraceptives which are intended for daily use (Glaiser, 1997). This connotation of negative side effects or potential health risks with repeated use may discourage those at risk individuals from using oral emergency contraception, increasing their risk for an unplanned pregnancy as well as the likelihood of them seeking an abortion later.

One of the most significant issues faced by researchers undertaking a study of abortion rates is the extremely sensitive nature of the decision to undergo an abortion. The number of abortions yearly fluctuates significantly and varies greatly between populations (Glaiser, et al. 2004). It should be noted that not all abortions are the result of contraception failure or unprotected sex (without the intent of producing offspring). There are a number of legitimate medical reasons for undergoing an abortion even in instances when offspring was the desired outcome (Glasier, 1997). These instances though are included in the data regarding the number of abortions in a population. In such an event the relative knowledge or availability of emergency contraception would have been immaterial to the couple.

It was theorized, that if women were supplied with emergency contraception in advance, allowing them the opportunity not only to take the pill but also to take it earlier which improves its efficacy, there would be a decrease in the number of abortions evidenced in a population. This however has not been the case as observed in a number of unrelated studies conducted in over fifteen countries both developed and undeveloped. It has safely been concluded that simple access is not the primary factor affecting emergency contraception and unwanted pregnancy. Further, there is evidence that knowledge of emergency contraception is increasing greatly among the target population (sexually active females between the ages of 18 and 44).

Another confound to the successful study of emergency contraception is the scientific impossibility of running a controlled experiment. Though the pill is indicated for the prevention of pregnancy, the fertility of women who take it successfully is unproven (Glasier, 1997). It is also impossible to determine whether seminal fluid was actually introduced into the vaginal cavity. Finally, it would be unethical to attempt to have a control group and an experimental group. As such, the current data on efficacy as well as specific mode of action is inconclusive. Ultimately though emergency oral contraception is effective in preventing unwanted pregnancy, it is currently unknown precisely how effective the oral regimens are, or even how they work.

One of the most significant difficulties in assessing the impact of emergency contraception on abortion or unplanned pregnancy is the difficult in determining whether or not emergency contraception is necessary. It is possible that a significant number of unplanned pregnancies develop as a result of women simply not being aware that they were at risk (Lakha & Glasier, 2006). It has been reported in several studies that women were unaware of their pregnancy or even that they were at risk of pregnancy until their first missed menstrual cycle at which point emergency contraception would be ineffective (Lakha & Glasier, 2006). Unless a condom is literally in pieces it can be easy to miss small punctures or tears which might ultimately result in accidental pregnancy. There are also a great deal of misconceptions regarding an individual's ability to conceive. Popular myths include; a girl cannot get pregnant her first time, "pulling out" is an effective method of preventing pregnancy, if a girl is on top she cannot get pregnant, and many others. In instances where women believe misconceptions such as those above it would not occur to them to seek emergency contraception. Though such misconceptions are being combated regularly by educators and physicians, the dissemination of information is still not as wide spread as it needs to be in order to facilitate an accurate assessment of emergency contraception on the abortion rate of a given area.

The best testing strategy is keeping close account of participants ovulation cycle as well as their intercourse. Even though in instances when all of this data is faithfully and thoroughly recorded, the natural fluctuation in a woman's menstrual cycle which can vary by up to four days, makes it difficult to draw conclusive data. Though it should be noted that from the study where complete information was provided emergency contraception was approximately 74% effective which is far less than the 99% effectiveness most manufacturers advertise (Glaiser, 1997).

Emergency contraception is a genuine medical treatment which is poorly understood by the majority of individuals who are or should be using it. Though knowledge of its existence and availability is increasing, knowledge of what it is and what it actually does is not. This dissonance is likely responsible for the negative connotation this medical treatment has acquired. Ultimately the decision to acquire emergency contraception is as unique as the decision of how to handle an unplanned pregnancy. That decision though is generally influenced by which methods are socially acceptable within an individual's community, and which methods are most completely understood. It is important, then, for educators and physicians to not only inform women that the pill exists, but they must also explain how it works and why it should be used.

Emergency contraception in pill form is a dose of estrogen and/or progestin, generally taken in two doses twelve hours apart following intercourse. Currently the IUD method of emergency contraception has been largely replaced by pill regimens either a combination of estrogen and progestin or progestin only (Grimes, & Raymond 2002). Depending on the timing of administration the mode of action of these oral regimens differs. Taken before ovulation, emergency contraceptives prevent ovulation. There is also a possibility that the hormones affect the mucus of the cervix effectively trapping semen, or possibly even affecting the mode of transport of sperm to ovum (Grimes, & Raymond 2002). If the emergency contraceptive is taken after ovulation it is possible that the hormones result in an alteration of the biochemical makeup of the endometrium and the function of the corups lutem which inhibits fertilization. There is no evidence though of long-term alteration following treatment with oral emergency contraceptive (Trussell, et al., 1997).

One of the most significant and resilient controversies surrounding the use of emergency contraception is the fear that an oral contraceptive regimen is actually early medical abortion. It is this fear which accounts in large part for many individual's hesitation in use. This fear however is unfounded. Emergency Oral Contraceptive is ineffective once a pregnancy has been established (Grimes & Raymond, 2002). The "pill" as it is commonly called works only in the time between intercourse and establishment of a pregnancy which is a window of approximately one week. The preemptive biochemical alteration resulting from the oral hormone prevents conception from taking place, thus it is not actually interrupting or terminating a pregnancy simply preventing one from beginning. There are however, a number of religious and political groups who promote the idea that emergency contraception is chemical abortion. It is this stigma along with similar erroneous beliefs which prevent those individuals who need the medication from actively seeking it.

The direct correlation between misinformation regarding oral contraception and the number of abortions in an area is supported by the 1995 scare that certain birth control pills were responsible for doubling an individual's risk of developing potentially life threatening blood clots. In the aftermath of this scare which was later shown to be unfounded, the UK alone saw a 9% increase in the number of abortions (Harper & Ellerton, 1995). Such concerns have historically become widely circulated and have been fairly resistant to debunking because so little is known conclusively about the oral contraceptives mode of action as well as the potential long-term side effects of years of hormonal manipulation.

This misconception of how oral emergency contraceptives work as well as the lack of open discussion regarding regimens such as the popular "Morning After Pill" make it difficult for women to acquire the pills. These oral regimen are also not specifically labeled by the FDA for emergency contraception and as such their wide spread availability has been restricted (Harper & Ellerton 1995). These lingering ambiguities though are ultimately extremely detrimental in that oral emergency contraceptive is a viable and effective alternative to traditional medical abortion or child bearing.