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Plan B: My politically incorrect take on the news

The views expressed are those of the author and are not necessarily those of Scientific American.

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Protest over Savita Halappanavar's death - separation of Church and State

Sometimes I feel like Alice in Wonderland, staring into distorting mirrors. The ongoing fight over Plan B has again precipitated this disquieting feeling. There is such a disconnect between some stated outcomes that are claimed as being desirable and actions that don’t support that. In this case, probably most people would agree that elective abortions are unfortunate and not a desirable outcome. But how different sides would approach this problem are at polar opposites.

For example, conservative folks on the political right are using draconian measures of banning abortions—even if the mother’s life is at risk—and attacking clinics and murdering health care workers, at the same time as euphemistically proclaiming themselves “pro-life.” Small government proponents want to insert themselves into every aspect of a woman’s life and health, including via intrusive, medically unnecessary vaginal ultrasounds, psychological duress, and insanely stupid debates about legitimate rape. In contrast, many of us who are more liberal, focus our efforts on reducing the need for abortion, aiming to achieve this goal by providing education and family planning services.

Also, on the one hand, we are asking physicians to practice more evidence-based medicine, at the same time as, in the area of women’s reproduction at least, politicians are tying their hands.

Memorial rally in Dublin for Savita Halappanavar and women's rights

This issue has resurfaced in recent weeks, first with the tragic and senseless death of Savita Halappanavar, a 31 year old Hindu woman who had the misfortune to have a miscarriage “treated” in an Irish hospital imposing barbaric and antiquated Catholic doctrines on her. As well described by Dr. Jen Gunter, physicians did not perform a medically necessary abortion on a non-viable fetus, instead choosing to let a woman die painfully and needlessly from overwhelming sepsis.

Last week, the The American College of Obstetricians and Gynecologists called for birth control pills to be sold over the counter, noting that the cost and difficulty of seeing a physician to obtain a prescription is a major barrier to use of contraception.

This week, Plan B is again making headlines, as the American Academy of Pediatrics (AAP) just recommended that pediatricians provide prescriptions for Plan B to teenagers to have on hand “just in case.” Don’t get me wrong—I think this is a great step forward for health care for teens. But it falls short of what is rational, evidence-based, and necessary practically.

The battle over men’s control of women’s bodies has been going on for years, though has certainly heated up with this election cycle. Before, we even saw access to science-based information being limited through censorship and distortion even in government sources (e.g., data regarding the efficacy of condoms in preventing HIV infections and STDs were removed from the CDC’s Web site). This helped neither the rates of abortions, the teen birthrate, nor STDs and HIV to go down. At the same time as HIV prevention programs and NIH funding has been cut, funding for abstinence-only programs rose from $20 million to $167 million, despite any lack of evidence of effectiveness. To reiterate, No federal money is spent on comprehensive sex education. Even worse, since 1982, “Over $1 billion in government funding has been granted to abstinence-only programs…[which] are expressly forbidden from discussing contraception…and often contain factually inaccurate and distorted information. Those who design and operate these programs are often inexperienced, religiously-motivated and frequently have close ties to the anti-abortion movement.”

So why are we tolerating this? (For more history related to the FDA and reproductive politics, see my previous post here.)

Note that several years ago, Susan F. Wood, former assistant FDA commissioner for women’s health and director of the Office of Women’s Health, resigned because of the politicization of the agency—specifically, having the approval of Plan B emergency contraception denied, despite scientific evidence of the pill’s safety and recommendations from the FDA’s own advisory committee. Yet the same battles are still taking place.

Plan B Perspective

The irrational decision to overrule the recommendation of numerous experts appears to be based on the idea that young girls would be buying the pill without parental consent, and that such girls could not do so safely. They ignore that kids can readily buy Tylenol, which has significant liver toxicity and is often a component of deadly drug overdoses. Plan B is far safer—and also unlikely to be used routinely because, at ~$50, it is relatively expensive. They ignore the dangers of pregnancy, which are far greater…or the dangers of a teen suffering from rape or abusive parents, who certainly doesn’t need the added trauma of an unwanted pregnancy.

Plan B has the same hormone found in birth control pills, progestin, but in a larger dose. It works primarily by preventing ovulation. It does not cause an abortion. Taken within 72 hours of unprotected sex, it reduces the risk of becoming pregnant to only about 1 to 2 percent—the sooner taken, the more efficacious.

Given the clearcut and overwhelming data, I was tremendously disappointed by last fall’s decision by Secretary of Health Kathleen Sebelius’ to deny the emergency contraceptive, Plan B, over-the-counter status for women under the age of 17. This was a particular disappointment to many because President Obama had promised that decisions at the FDA would be made based on science, rather than politics. Clearly, that wasn’t the case.

President Obama expressed his concern as a parent, that his daughters must not have access to such a medicine without adult guidance. That may be true in an ideal world, but it is neither practical, nor does it bear any resemblance to the realities of many teens’ lives. The US has a higher teen pregancy rate than any other developed western country, with five times the teen birthrate in France and 2 1/2 times the rate in Canada. “Only half of the nation’s teen moms ever earn a diploma; more than half go on welfare; and more than half of the families started by teens live in poverty,” according to “Sacrificing ‘Change We Can Believe In’ for Expediency?” According to a pediatrician author of the new AAP policy, teen pregnancy perpetuates a cycle of poverty and problems, as these babies perform more poorly in school and tend to have ongoing behavior problems.

Given the safety data, the lingering educational and economic harm and the huge personal toll of unexpected and unwanted pregnancies, I am disappointed that the AAP did not go further in their recommendation. It is unrealistic to expect teens to be able to get a prescription from their physicians for emergency contraceptives. Many teens do not have access to regular medical care. Instead, the AAP and ACOG should strongly back the FDA, who already recommended OTC status for the drug for teens. And we should all send a strong message to President Obama: decisions should be based on science, not politics. You have been re-elected. Stand up and don’t overrule the FDA and data on this public health and economic issue. Make emergency contraception available to all, regardless of age.

Updates 11/30/12:

See my comments in response to a reader for further information about the application of the Catholic religious directives during miscarriages.

Also, to encourage HHS Secretary Sebelius to take action, the Union of Concerned Scientists has a new petition up, Tell HHS Secretary Sebelius: Allow the FDA to Revisit its Plan B Decision.”

Credits & Links:

Molecules to Medicine banner © Michelle Banks

Savita protest images by infomatique (William Murphy)/Flickr

Small portions of this post appeared previously in Plan B: The Tradition of Politics at the FDA.

see also:
Plan B’s ad: “I chose a condom but it broke. Now I Have A Second Chance.”

and a superb cartoon capturing the debate, Matt Davies,’ “Which of these responsibilities is a 15 year old too young to be handed?”—a screaming baby or Plan B pill.

Judy Stone About the Author: Judy Stone, MD is an infectious disease specialist, experienced in conducting clinical research. She is the author of Conducting Clinical Research, the essential guide to the topic. She survived 25 years in solo practice in rural Cumberland, Maryland, and is now broadening her horizons. She particularly loves writing about ethical issues, and tilting at windmills in her advocacy for social justice. As part of her overall desire to save the world when she grows up, she has become especially interested in neglected tropical diseases. When not slaving over hot patients, she can be found playing with photography, friends’ dogs, or in her garden. Follow on Twitter @drjudystone or on her website. Follow on Twitter @drjudystone.

The views expressed are those of the author and are not necessarily those of Scientific American.

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  1. 1. voyager 5:18 pm 11/29/2012


    A former Catholic with a bunch of bones of contention with the Church, I nevertheless have to say something in its defense. The tragic case of the expectant mother who died in Ireland has been badly misreported in the media, and in your article, regarding its major point: Catholic doctrine.

    The truth is that Catholic teaching says the mother’s life predominates: in the Ireland case, there was NO Church impediment to saving her life at the cost of the child’s. It may have been a policy or an established practice in that benighted hospital, but it’s not Catholic doctrine.

    Link to this
  2. 2. choppam 7:58 pm 11/30/2012

    Thanks, Judy – this is an excellent article. I’ll be using it to bolster the human approach to sex and intimate relationships here in Sweden, too. There’s a far better tradition of openness and realism here than in the States, but it’s constantly under threat, and teaching and reach-out to youngsters has been deteriorating in recent years.

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  3. 3. Judy Stone in reply to Judy Stone 9:55 pm 11/30/2012

    Thank you for your comment, Voyager. Unfortunately, the mother’s life does not predominate.

    I believe you are referring to the Ethical and Religious Directives of the Catholic Church (ERDs) #47 “Operations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of the pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the child”.

    In 2010, a 27 year old mother of four was admitted to St. Joseph’s Hospital in Phoenix, pregnant and suffering from life-threatening pulmonary hypertension. After consultation with physicians and the hospital’s ethics committee, the 11-week pregnancy was terminated in order to save the mother’s life.

    Bishop Thomas Olmsted revoked the Catholic hospital’s status for having approved an abortion to save the mother’s life. The Bishop also excommunicated Sister Margaret McBride because of her actions regarding the woman’s care. He stated: “I am gravely concerned by the fact that an abortion was performed several months ago in a Catholic hospital in this Diocese. I am further concerned by the hospital’s statement that the termination of a human life was necessary to treat the mother’s underlying medical condition…An unborn child is not a disease. While medical professionals should certainly try to save a pregnant mother’s life, the means by which they do it can never be by directly killing her unborn child. The end does not justify the means…The direct killing of an unborn child is always immoral, no matter the circumstances, and it cannot be permitted in any institution that claims to be authentically Catholic…The mother’s life cannot be preferred over the child’s.”

    A 2008 study, “When There’s a Heartbeat: Miscarriage Management in Catholic-Owned Hospitals,” by Lori Freedman, et. al., notes “Our interviews with US obstetrician-gynecologists working in Catholic-owned hospitals revealed that they are also restricted in managing miscarriages. Catholic-owned hospital ethics committees denied approval of uterine evacuation while fetal heart tones were still present, forcing physicians to delay care or transport miscarrying patients to non-Catholic-owned facilities…Although Catholic doctrine officially deems abortion permissible to preserve the life of the woman, Catholic-owned hospital ethics committees differ in their interpretation of how much health risk constitutes a threat to a woman’s life and therefore how much risk must be present before they approve the intervention.

    And in a 2012, Stulberg et. al. noted that “Among obstetrician-gynecologists who practice in religiously affiliated institutions, 37% have had a conflict with their institution over religiously based policies.”

    Thus, there is considerable inconsistency in implementing Catholic doctrine, and a pregnant woman is risking her life in a Catholic hospital, where her wishes may well, in fact, be overruled by someone else’s religious beliefs.

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