Is One of These Things Not Just Like the Other?

Why Abortion Can’t Be Separated from Contraception

beverly-peaWe have come to a pretty pass: advocates of family planning, who have long believed they could shelter their cause from unending fundamentalist attacks on reproductive health services if only they could only distance themselves from the subject of abortion, have received a rude shock. Family planning advocates who are opponents of mixing abortion with their contraception have suddenly awakened to the fact that the return tactic is merely to tar all contraception with the allegation that it, too, might be equivalent to abortion. In other words, making “abortion” into an unequivocally stigmatized word (and action) has drawn attempts to attach “abortion” to whatever aspect of reproductive care challengers wish to discredit.

How could we have been so confused in the first place? It has never been behaviorally, biologically or pragmatically sensible to try to promote contraception by segregating abortion. First, it may be helpful to review the history of how abortion was banished from the world of family planning and the misconstructions on which this tactic has been based.

Early data on reproductive health and maternal mortality showed that limiting fertility to wanted children produced a great health benefit—both to women and to their families, including the children they did choose to bear. The safety of methods of fertility control and the public health impact of use of these methods was a subject of much research in the 1960s and ’70s. One of the intellectual heroes of that movement, Dr. Christopher Tietze of the Population Council, concluded that the safest strategy for a woman seeking to limit her childbearing would be to use a barrier method, with abortion as a backup in the case of failure. This integrated, strategic view of how a woman could achieve her fertility goals over her fertile years unfortunately became a minority vision when the family planning field changed to the more technocratic aim of optimizing the effectiveness of individual contraceptive methods.

The emphasis on individual methods also led to the kinds of policy compromises that have turned out to be costly in the long run. The official report of the UN International Conference on Population and Development in 1994 instructed that “in no case should abortion be promoted as a method of family planning.” Over time, the sentence morphed from emphasis on avoiding the “promotion” of abortion to the nonsensical but often used phrase: “Abortion is not a method of family planning.” The latter formulation effectively requires that everyone, including advocates for public health and women’s rights, subscribe to a fantasy—that women seek abortion for something other than to limit fertility.

The proposition that contraception and abortion are mutually exclusive contradicts women’s experiences by positing that women avoid all unwanted births either by preventing pregnancies or by terminating them. This false dichotomy sets up women who have abortions to be victims of friendly fire, abandoned by the very policies and people promising to help only with contraception. After all, contraceptives are not really available everywhere in the world, some have rather daunting price tags and none is 100 percent effective: even sterilization has a failure rate. And a woman who is dedicated to limiting her fertility may feel profoundly deceived if she cannot get a reliable method or if her method fails. In such a circumstance, she may well decide to terminate her pregnancy as part of an overall strategy to limit births.

Indeed, we know that abortion rates do not necessarily decline immediately when contraceptive services are introduced. This situation occurs in part because the widespread adoption of contraception requires that many women begin to believe they can and should be able to control the number of children they have. At the same time, the availability of contraceptive methods and contraceptive services may not keep pace with demand—and many women may find themselves wanting to limit their fertility but not have access to affordable, effective contraceptive methods. In such cases, abortion is more frequently practiced.

It has never been behaviorally, biologically or pragmatically sensible to try to promote contraception by segregating abortion.

Yet, the language of family planning has specifically created an aura of exceptionalism around the practice of abortion. Many documents refer to “recourse to abortion” or “need for abortion” as though abortion were not a common practice, when in actuality, there are an estimated 44 million abortions every year according to the latest figures in the Lancet.  Women are portrayed as needing abortions only in exceptional circumstances (e.g., rape, incest or urgent medical problems). Abortion in other circumstances is basically viewed as a moral failure.

As we have often been cautioned about abortion stereotypes generally, there is not one type of woman that has abortions and another that has babies: these are the same women who manage their lives in different ways at different moments, sometimes desiring a pregnancy and sometimes trying to avoid pregnancy and childbirth. Abortion has a relationship to all these goals: to avoid an unwanted birth, but also sometimes to deal with a very wanted birth when the trajectory of pregnancy has gone awry, for example, either endangering the woman’s health or resulting in a fetus with terrible, sometimes lethal, physical problems. 

In order to avoid the stigma associated with abortion—a stigma reinforced when advocates for contraception turn their backs on the intimate relationship between abortion and family planning—there has been a seemingly endless quest for bright line definitions of what is and is not an abortion. In order to be sure something is not abortion, we need specific indicators of what is an abortion, raising questions therefore of when “life” or “human life” or “a baby” is present. This perspective arises from a desire for clarity, such as one might find with legal definitions.

However, for biological phenomena, the task is much more difficult. Fertilization, implantation, embryogenesis, fetal growth, labor and delivery are part of a continuous, incremental biological whole where one process gradually leads into another. None of these processes takes place in an instant of time, and all are spread over hours, days, weeks or months. For each, there is a before, an after as well as a “during,” which may create difficulty in deciding when one stage ends and another begins. Indeed, the concept of “viability” is also subject to this tug of war between precision and functional understanding. The US Supreme Court weighed in on this subject in the Colautti v. Franklin case, which was decided after Roe v. Wade, and suggests that the common understanding of viability as something achieved after a certain number of weeks of pregnancy is flawed. The court decided:

“Viability is reached when, in the judgment of the attending physician … there is reasonable likelihood of the fetus’ sustained survival outside the womb…. Because this point may differ with each pregnancy, neither the legislature nor the courts may proclaim one of the elements entering into the ascertainment of viability—be it weeks of gestation or fetal weight or any other single factor—as the determinant….”

Many of the processes in question when debating whether something is or is not abortion are both incremental and unobservable, so applying any definition to a particular situation may be impossible.

Of late, the Supreme Court has taken another tack when confronted with biological uncertainty. In the Hobby Lobby case, corporation owners were exempted from covering certain contraceptive methods, such as IUDs and emergency contraception, in employee health plans, simply on the basis of a sincerely held belief that those methods were abortifacients. This perspective confounds Daniel Patrick Moynihan’s maxim that while you can have your own beliefs, you cannot have your own facts. By defining abortion as whatever each person decides it is—and ignoring the best current science—the decision essentially allows opponents to tag any reproductive health service with the stigma of abortion. The result is that contraceptives are becoming abortifacients in a way that leaves family planning advocates wringing their hands in dismay. There is irony here as well, since the fertility lowering effect of breastfeeding may function in ways similar to what is now considered “abortion” by opponents of IUDs and emergency contraception. Are we now going to withhold funds from breastfeeding equipment and counseling on the grounds that we would be supporting abortions?

There are other ill effects of this metastasis of abortion stigma. We are mortgaging future contraceptive development as well, since segregating contraception from abortion has become a requirement for contraceptive advocacy without controversy—a dampening effect that extends to the technology, funding and marketing of contraception. In this vision, contraceptive development is consigned to find additional ways to keep sperm and egg from meeting: anything else might be accused of being abortion. By acceding to this reality, we may very well be giving up the opportunity to create products that could exactly match what women say they want: something very effective, very safe, inexpensive and reversible, with minimal requirements to use.

If we cannot get the conversation and the politics right, we may compromise advances in technology; restrict women’s choices for planning their families; increase the stigma attached to all reproductive health options; fail to meet women where they are; and, generally, hinder the achievement of reproductive health and rights for large parts of the world, including the United States.

After all the noise we have heard in the political arena, professional forums and public spaces from those trying to impose an illogical and hurtful division between contraception and abortion, it would be easy to think that few in positions of power understand women’s lives. But it’s interesting that a US Secretary of State, Hillary Clinton, got it right: “You cannot have maternal health without reproductive health, and reproductive health includes contraception and family planning and access to legal, safe abortions.”

Beverly Winikoff, MD MPH is currently president of Gynuity Health Projects and a professor of clinical population and family health at the Mailman School of Public Health, Columbia University. Her work has focused on issues of reproductive choice, contraception, abortion and women’s health. Dr. Winikoff graduated from Harvard University magna cum laude, earned her MD degree from New York University and her MPH degree from the Harvard School of Public Health.

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