Gut tmacher Policy Review Fall 2014 | Volume 17 | Number 4 GPR
Contraception Is Not Abortion: The Strategic Campaign of Antiabortion Groups to Persuade the Public Otherwise
By Joerg Dreweke
mong the many storylines coming out gument—that U.S. policy should in some circum- of the November 2014 midterm elec- stances recognize pregnancy as beginning at fer- tions are two centered on birth control. tilization—as a way to undermine access to birth AAmerican voters decisively rejected bal- control. That strategy reached a new high water lot measures in two states that sought to define mark when it featured centrally in Burwell v. human personhood—with all its attendant legal Hobby Lobby, the high-profile 2014 U.S. Supreme rights—as starting at fertilization.1 This “person- Court case that granted certain for-profit employ- hood” agenda seeks not just to ban abortion, but ers an exemption from the Affordable Care Act’s some common Food and Drug Administration (ACA’s) contraceptive coverage guarantee. During (FDA)–approved contraceptive methods as well, this debate, leading organizations dedicated to because personhood proponents assert that banning abortion unequivocally endorsed the these methods work by preventing implantation view—in legal briefs, press statements and of a fertilized egg. At the same time, conserva- elsewhere—that emergency contraceptives and tive candidates did well at the ballot box, in part, IUDs constitute abortion. by keeping mum about or obfuscating their positions that would undermine access to birth The contrast between these two policy debates control—for instance, by removing insurance highlights something critically important but coverage for contraceptive services. often overlooked about much of the antiabor- tion movement. Birth control is very much in The underlying lesson—that the “personhood” the movement’s crosshairs, and antiabortion movement’s perceived frontal assault on birth advocates are working to stigmatize contracep- control is a political nonstarter—has apparently tion by blurring the lines between contraception not been lost on prominent U.S. antiabortion and abortion. Yet, the movement is doing this in groups like Americans United for Life (AUL), a strategic and deceptive way. Rather than apply- Susan B. Anthony List (SBA List), the Heritage ing the claim that some contraceptive methods Foundation and the U.S. Conference of Catholic in effect cause abortion consistently to all aspects Bishops (USCCB). These mainstays of the U.S. of their advocacy, antiabortion groups ignore and antiabortion movement have sought to keep their often contradict their positions when it might hurt distance, at least publicly, from fights over per- them politically. Taking the antiabortion move- sonhood amendments, even as they work in myr- ment at face value by consistently treating iad ways to undermine access to contraception. some forms of contraception as abortifacients— including under federal and state law—would ex- Yet, these same mainstream antiabortion groups pose how radical their agenda truly is and would have not shied away from asserting in other con- have far-reaching implications for women who texts that certain methods of contraception are obtain contraceptive services and providers who actually methods of abortion. They have in effect offer them. selectively embraced the core “personhood” ar-
14 The Science to exploit. The antiabortion movement has a long The campaign to conflate contraception with history of strategically using outdated informa- abortion is based on the assertion that certain tion and outright junk science to restrict access methods of contraception actually end—rather to reproductive health care, from the supposed than prevent—pregnancy. That assertion, mental health impact of abortion to discredited however, contradicts what science says about assertions that abortion causes breast cancer. 3,4 how pregnancies are established and how con- traceptives work. These facts are laid out in The medical groups’ amicus brief illustrates this detail in an amicus brief submitted to the approach by highlighting the anticontraception Supreme Court in October 2013 by numerous movement’s reliance on outdated FDA product medical associations, led by Physicians for labels to implicate Plan B. While the label states Reproductive Health and the American College of that Plan B “may inhibit implantation (by alter- Obstetricians and Gynecologists. 2 A contracep- ing the endometrium),” the brief notes that this tive method, by definition, prevents pregnancy “label has not been updated since the product by interfering with ovulation, fertilization or was originally approved in 1999 and it does not implantation. Abortion ends an established preg- reflect the most current research.” Rather, “later nancy, after implantation. This scientific defini- studies have led to the conclusion that [Plan B] tion of pregnancy—which reflects the fact that does not cause changes to the endometrium most fertilized eggs naturally fail to implant in (uterine lining) that would hamper implantation.” the uterus—is also the legal definition, and has However, updating FDA-approved labels is a long been accepted by federal agencies (during time-consuming and expensive process for both administrations both supportive of and opposed the agency and the relevant drug company, so to abortion rights), and by U.S. and international it is not uncommon that such labels do not keep medical associations. pace with the underlying science. 5
The amicus brief describes the most up-to-date More so, the FDA labeling for some popular evidence about how hormonal and copper forms of birth control pills contains similar state- IUDs and the emergency contraceptives Plan B ments. For instance, while the labels for the and ella work, and documents that none have combined oral contraceptive pills Yaz and Yasmin been shown to disrupt an existing pregnancy— say that they work primarily by suppressing meaning that none can accurately be called an ovulation, they also state that “other possible abortifacient. Rather, both Plan B and ella work mechanisms may include…endometrial changes primarily by preventing ovulation; they can work that reduce the likelihood of implantation.” 6,7 for up to five days after sex, because sperm can However, mainstream antiabortion groups, in survive in a woman’s body for that long. Both contrast to the “personhood” movement, appear the hormonal and copper IUDs work primarily by to have long concluded that a frontal assault preventing sperm from reaching and fertilizing on the pill—the most popular reversible form an egg. Of all these methods, only the copper of contraception, with more than 10 million cur- IUD, when used as an emergency contraceptive, rent users8—would be a sure political loser. That appears capable of preventing implantation of a is why their attacks have focused on less com- fertilized egg. However, even then it would not be monly used methods, like IUDs and emergency considered an abortion under standard medical contraceptives. and legal definitions. Having It Both Ways The weight of the evidence clearly shows that Conflating contraception with abortion as a emergency contraceptives and IUDs are not abor- means to chip away at contraceptive access is not tifacients. And yet, the science, when marshaled a new approach, but the debate over the ACA’s in bad faith and combined with anticontracep- contraceptive coverage guarantee has given it tion activists’ redefining pregnancy as beginning a new prominence. That this guarantee, even with fertilization, provides them with ambiguity though it explicitly extends only to FDA-approved
Guttmacher Policy Review | Volume 17, Number 4 | Fall 2014 15 contraceptive methods, requires private insur- to objecting companies being forced to cover ance plans to cover abortion is gospel among “abortion-inducing drugs and devices.” 13 virtually every influential antiabortion group (see box). 9–17 AUL states that the policy is a “back Echoing the Hobby Lobby complaint, antiabortion door abortion mandate” 12 that requires employ- groups have zeroed in on emergency contracep- ers to cover “life-ending drugs that have been tives and IUDs as causing abortions. SBA List has deceptively labeled as contraception.” 18 SBA List routinely referred to emergency contraceptives also refers to the guarantee as an “Abortion Drug as “abortion drugs” and describes the copper Mandate,” 9 while the Heritage Foundation says IUD as causing “early abortion.” 11 The American it requires “coverage of abortion-inducing drugs Association of Pro-Life Obstetricians and and devices.” 16 Gynecologists (AAPLOG) says that Plan B can lead to “embryo death” by preventing implanta- Court briefs filed by various antiabortion groups tion and that “IUDs work by either killing the em- in support of Hobby Lobby’s refusal to cover bryo or by preventing the embryo from implant- certain contraceptives assert that the case is ing.” 15 And AUL asserts that IUDs and Plan B “can about the company’s right to refuse on religious kill an embryo by blocking its ability to implant in grounds to facilitate abortion. A brief signed by the uterus.” 12 SBA List says the ACA policy “directly intrudes on the choice not to participate in abortion.” 10 The Many of these groups also assert—contrary to brief from USCCB contains numerous references the best available evidence—that the emergency
CONTRACEPTION IN THE CROSSHAIRS Prominent organizations committed to banning abortion say that certain Food and Drug Administration–approved contraceptive methods constitute abortion.
Susan B. Anthony SBA List refers to the contraceptive coverage guarantee as an “Abortion Drug Mandate”9 and has argued 10 List that the policy “directly intrudes on the choice not to participate in abortion.” The group also asserts that “all emergency contraceptives can cause early abortions,”11 including the copper IUD, Plan B and ella.
“Some drugs classified as ‘contraceptives’ by the FDA, such as Intrauterine Devices (IUDs) and Plan B… Americans United can kill an embryo by blocking its ability to implant in the uterus.…ella can kill an embryo even after im- for Life plantation has occurred. Thus, if HHS decides to include ‘contraception’ as ‘preventive care,’ all insurance plans will be required to provide coverage of these abortion-inducing drugs.”12
The Supreme Court brief from USCCB contains numerous references to objecting companies being U.S. Conference of 13 Catholic Bishops forced to cover “abortion-inducing drugs and devices.” The group also asserts that methods “that are referred to as ‘contraceptive’ are, in reality, sometimes also abortifacient.”14
American Association of Pro-Life “Ella…works to kill embryos.…Plan B can also act at times to prevent the embryo from implanting in the lining of the uterus, resulting in embryo death. IUDs work by either killing the embryo or by preventing Obstetricians and the embryo from implanting.”15 Gynecologists
Heritage says the ACA coverage guarantee requires “coverage of abortion-inducing drugs and devices.”16 Heritage Foundation The group has also asserted that hormonal IUDs, copper IUDs, Plan B and ella are “abortion-inducing drugs that can terminate life.”17
Sources: references 9–17.
16 Fall 2014 | Volume 17, Number 4 | Guttmacher Policy Review contraceptive ella has a postimplantation effect. proach seems grounded in political expediency For instance, AUL claims that “ella can kill an and can only serve one purpose: to obscure these embryo even after implantation has occurred,” 12 groups’ full antiabortion and anticontraception a position that is echoed by USCCB and AAPLOG, agenda. among others. 19 Far-Reaching Implications Despite their forceful and sustained assertions Under current federal and state laws and regula- while debating the ACA’s contraceptive coverage tions, for the most part, it is clear that abortion guarantee that emergency contraceptives and and contraception are separate from each other. IUDs constitute abortion, groups like AUL, SBA And for their part, the influential antiabortion List and USCCB simply pretend in other contexts groups that have been conflating some contra- that they hold no such views. For instance, when ceptives with abortion have been mostly silent on discussing abortion incidence statistics, they ac- whether existing abortion laws should apply to cept without question the mainstream definition these contraceptives. of abortion as ending an established (that is, postimplantation) pregnancy. A good example One notable exception is from an October 2014 is a February 2014 article by USCCB’s Richard comment letter to the U.S. Department of Health Doerflinger discussing the decline in U.S. abor- and Human Services regarding implementation tion rates. Doerflinger consistently refers to IUDs of the ACA contraceptive coverage guarantee, and emergency contraception as “contracep- in which the USCCB asserts that specific fed- tives” or “contraception,” 20 never mentioning eral and state abortion restrictions concerning these methods’ supposed abortifacient qualities insurance coverage of abortion should apply to and accepting without question (and contrary to the emergency contraceptive ella.21 To argue, as the Bishops’ own position) the mainstream defi- the USCCB unequivocally does, that an FDA- nition of abortion as the termination of an estab- approved method of contraception should be lished pregnancy. treated as an abortifacient under federal and state abortion law is truly radical. It is also some- The same goes for these groups’ efforts to enact what surprising because the USCCB is one of antiabortion legislation. Despite their significant the few major antiabortion organizations that legislative and lobbying clout, they have not unequivocally opposes contraception outright made the case that emergency contraceptives (other than periodic abstinence within marriage), and IUDs should be treated as causing abortion obviating the need to hide behind making a for purposes such as legislating waiting periods, case that certain birth control methods are really onerous clinic facilities requirements, parental forms of abortion. consent requirements or mandates that only phy- sicians may provide the service. If a particular federal or state abortion restriction should apply to this method of contraception, This tactic is deceptive and disingenuous on mul- then there is no reason why the gamut of federal tiple levels: The claim that some contraceptives and state abortion restrictions should not apply cause abortion is based both on a nonscientific to it as well—or, for that matter, why all abortion definition of pregnancy and on outdated informa- policies should not apply to any method that tion including FDA labels that have not kept pace antiabortion groups consider to cause abortion. with newer research. At the same time, this defi- The USCCB seems well aware of the implications nition and outdated science are applied inconsis- of its views, expressing them only in obscure tently to some methods, but not others—most comment letters, but omitting them in more high- notably omitting various forms of birth control profile settings. pills. Lastly, these supposedly “abortion-inducing drugs and devices” are entirely exempted from There are hundreds of policies in effect that regu- the rest of these groups’ extensive antiabortion late and restrict access to abortion care across agenda. This wildly inconsistent and cynical ap- the United States, both at the federal and, espe-
Guttmacher Policy Review | Volume 17, Number 4 | Fall 2014 17 cially, the state level. Treating some contracep- and IUDs were “abortion-inducing drugs and tives as abortifacients and applying the full range devices,” it is unclear how these supposed abor- of existing abortion restrictions to them would tions should or could be counted and, for that have a dramatic impact. In many cases, the out- matter, how many “abortions” by this definition come would border on the ridiculous—demon- would actually be induced in the United States strating just how out of touch the campaign to each year. Two of the most extreme openly anti- define certain contraceptives as causing abortion contraception groups, the American Life League really is. and Pharmacists for Life, have asserted that the “real” number of U.S. abortions—including those Implications for Women supposedly caused by contraceptives—is four to If the myriad hardships and indignities to which five times higher than what is currently counted.23 U.S. women who obtain abortions are often sub- jected were applied to IUD and emergency con- Implications Going Forward traceptive users, the effect would border on the The anticontraception movement’s efforts in the bizarre. A woman seeking to purchase emergency past several years have focused on rolling back contraceptives in Mississippi, for example, would the ACA’s provision that most private health need to make an initial trip to the provider to first plans must cover contraceptive services, coun- undergo mandatory in-person counseling, as seling and methods without out-of-pocket costs. well as a mandatory ultrasound exam. She would This campaign scored a significant victory with then have to wait a minimum of 24 hours before the Supreme Court’s Hobby Lobby decision, an making the second trip to obtain the emergency outgrowth of dozens of court cases pursuing ex- contraceptives. If she were insured through emptions from the ACA guarantee for for-profit Medicaid, her insurance would be prohibited and nonprofit organizations that have religious or from covering the cost of the method. If she were moral objections to some or all contraceptives.24 a legal minor, she would need the consent of The movement also supports repealing the entire both parents. ACA and has aggressively pursued that agenda legislatively, electorally and through the courts. Defining some contraceptives as abortifacients could even put women who use these methods An emerging, although still fringe, frontier in the in legal jeopardy. For instance, women who self- campaign to curtail contraceptive access appears administer Plan B would potentially run afoul of to be the attempted restriction of public insur- state laws that prohibit self-inducing an abortion ance coverage (under Medicaid and other federal or practicing medicine without a license. or state programs) and other public funding for some contraceptive methods by claiming they Implications for Providers cause abortion. Attacks on funding for contracep- Pharmacists, clinicians and others who sell tion, such as funding for the Title X national fam- emergency contraceptives, insert IUDs or other- ily planning program, are by no means new, but wise make available birth control methods that they have typically taken an indirect approach— antiabortion groups consider to cause abortion for example, by complaining that providing pub- would be affected in numerous ways. The most lic funding to family planning centers “frees up” far-reaching impact would stem from the targeted centers’ private funding to be used for abortion regulation of abortion providers (TRAP). If these care. In 2014, however, Colorado gubernatorial policies applied, a physician in Missouri inserting candidate Bob Beauprez (R) stated his opposition an IUD would be required to do so in an ambula- to any public funding for IUDs on the grounds tory surgical center and would also need hospital that the “IUD is an abortifacient.”25 And in Kansas, admitting privileges. a county rejected a $6,000 grant for contracep- tives from the state health department after one Numerous other abortion laws would come into commissioner “likened intrauterine devices to play as well, including reporting requirements in murder.” 26 effect in 46 states.22 If emergency contraceptives
18 Fall 2014 | Volume 17, Number 4 | Guttmacher Policy Review The Real Agenda tion, then their obvious intent is to eventually The assertion that women who use emergency ban these methods. They are not neutral on the contraceptives and IUDs (or even birth control issue of contraception, despite their protestations pills and other hormonal methods) are in effect to the contrary. Contraception is not abortion, obtaining abortions is radical and far-reaching. however. If those who believe and insist other- It is not supported by the science, nor by main- wise have the courage to own up to their beliefs stream medical groups. And it is completely out publicly and consistently, then the full breadth of of step with Americans’ attitudes toward contra- their anti–reproductive health and rights agenda ception and the actions of tens of millions of U.S. will be plain for all to see. www.guttmacher.org women and couples who use birth control to pre- This article was made possible by a grant from the vent pregnancy, not end it. Educational Foundation of America. The conclusions and opinions expressed in this article, however, are The influential organizations behind this anticon- those of the author and the Guttmacher Institute. traception agenda have compartmentalized the debate, which allows them to pick and choose REFERENCES when contraception should be viewed as abor- 1. Bassett L, Colorado and North Dakota voters reject fetal personhood measures, Huffington Post, Nov. 4. 2014, tion and when it should not. They are essentially
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