Redefining Abortion

Many of you know of the recent court case of Hobby Lobby vs. Sebelius, in which Hobby Lobby executives claim that their religious freedom trumps the medical needs of their employees. What many people don’t realize is that Hobby Lobby has said they’re not against all contraception; they are mainly protesting the mandate that includes Plan B and other emergency contraception. This is because they have followed the lead of the wider anti-choice movement and redefined abortion to include emergency contraception. Here is a helpful graphic to explain why emergency contraception is not, in fact, the same as abortion:

Helpful graphics are helpful

Helpful graphics are helpful

 

Let’s ignore for a moment the ridiculous notion that how I use my insurance is somehow an infringement on my boss’s religious freedoms and focus on their argument that emergency contraception is an abortion. After all, the entire reason they claim it’s against their religious beliefs is due to the fact that their particular religion forbids abortion. Therefore, if emergency contraception is the same thing as an abortion, then it would be against their beliefs to use it. If emergency contraception is not an abortion, and works similarly to how other contraception methods work, then it is not against their beliefs (or at least not against the ones pertaining to abortion, which is what their primary claim is).

Now, the reason they claim emergency contraception is abortion is because they believe that life begins at the fertilized egg and that any deliberate “killing” of a fertilized egg is an abortion. Let’s put aside for a moment the fact that the medical establishment has a much more stringent definition of abortion and run with their definition. How does emergency contraception work? Does it “kill” a fertilized egg? The answer is no.

There are two kinds of FDA approved emergency contraception: levonorgestrel and ulipristal acetate. The only known, proven, mechanism for how emergency contraception prevents pregnancy is that it delays ovulation. This means that there is no egg for the sperm to fertilize. However, there are a few other mechanisms that are suggested by the available evidence (that have not been fully studied to determine the veracity of the claim) such as  “interference with corpus luteum function; thickening of the cervical mucus resulting in trapping of sperm; alterations  in  the tubal transport of sperm, egg, or embryo; and direct inhibition of fertilization.”

How do we know that the mechanism is a delay in ovulation and not the destruction of a fertilized egg? The best line of evidence is the fact that emergency contraception’s effectiveness goes down after ovulation has occurred. If you take it before you’ve ovulated, it has a high rate of effectiveness. If you take it after you start ovulating, the effectiveness goes down for each day after ovulation started. This suggests that the primary mechanism is a delay in ovulation.

Of course, that leaves the question open as to what the other mechanism(s) could be. The high effectiveness rate of emergency contraception overall suggests that there is a separate mechanism. The anti-choice movement (and Hobby Lobby) wants us to believe that the other mechanism is the destruction of a fertilized egg by preventing implantation. The claim is that emergency contraception causes cervical mucus to thicken which prohibits the implantation of an egg. There have been studies that suggest this in the past, but the most recent studies designed specifically to test this hypothesis show no effect on the endometrium or other endometrial receptivity biomarkers. In other words, it doesn’t prevent implantation. So there is no conclusive evidence that emergency contraception prevents implantation of a fertilized egg. There is another problem here. If emergency contraception were preventing implantation, then we wouldn’t expect to see a drop in effectiveness after ovulation starts.

So, what is the other mechanism? At present, scientists aren’t sure. One promising study showed that taking levonorgestrel (Plan B) increased the concentration of glycodelin at the time of ovulation. Glycodelin is known to inhibit fertilization, so this is seen as a valid hypothesis for the secondary mechanism. Of course, more study is needed on this question.

You can go here to get a more in depth discussion of emergency contraception, how we know it works and how it works.

Now I want to get into the discussion of how the medical establishment defines abortion and pregnancy. The medical definition of an abortion is: Expulsion from the uterus of an embryo or fetus before viability (20 weeks’ gestation [18 weeks after fertilization] or fetal weight less than 500 g). A distinction made between abortion and premature birth is that premature infants are those born after the stage of viability but before 37 weeks’ gestation. Abortion may be either spontaneous (occurring from natural causes) or induced (artificially or therapeutically).

Now, we can get into the more philosophical definition which is the termination of a pregnancy, which doesn’t necessitate the death of the fetus if it occurs after viability. But the medical establishment typically defines the expulsion of a healthy fetus as premature birth – which seems to be more accurate anyways if you’re focusing on the effects of the pregnancy termination on the fetus.

So what is the medical definition of when pregnancy begins? Well, this gets a bit fuzzier when looking at what doctors have to say about it. The American Congress of Obstetricians and Gynecologists says pregnancy begins only after implantation is complete. This has been the medical establishment’s view for decades, and federal policy is built around this definition. However, there are individual ob/gyns who disagree and believe that pregnancy begins with egg fertilization. Recent surveys have shown that the belief in fertilization as the beginning of pregnancy is highly correlated with religiosity and the ob/gyn’s personal moral stance on abortions. This leads one to conclude that the impetus for claiming pregnancy begins earlier is wrapped up in religious and political stances that have little to nothing to do with the actual biological processes.

Now, the implications for this could be huge. Redefining when pregnancy begins, in the medical literature and in law, would have lasting effects on women, especially low income women. The Hyde Amendment for instance states that public funds will not be used to provide for abortions for low income women who need them, but public funds can be used to provide contraception, including those that act by preventing implantation (some inserted IUD devices *do* work this way). Redefining pregnancy, on a federal level, to start at fertilization would mean that this funding could be blocked.

The other implication obviously has to do with regulating abortions and further regulating women’s bodies while they’re pregnant. Since the anti-choice movement had little success in outright banning abortion, the movement has decided to instead slowly chip away at abortion access, while broadening the definition of a legal person, what constitutes abortion and when pregnancy begins. One of the strategies they use to restrict access is to make abortions illegal passed a certain week. Pregnancy is not detected at the time of fertilization, but later sometime around/after implantation has happened. This can be up to a week or two after the egg was fertilized. This means that a woman who needs an abortion and thinks she’s at only 18 weeks, might actually be at 20 weeks if the start of the pregnancy is measured from the time of fertilization. Should important medical decisions really be made at the whims of arbitrary cut-off dates based on dubious definitions of biological processes? If a pregnant person is beholden to the “person” growing inside her, when does that begin? Does it begin at fertilization? Does it begin at implantation? Does it begin at viability? Some states have already started arresting women for actions taken during pregnancy that may or may not have resulted in a stillbirth. If pregnancy is defined as beginning at fertilization, what will happen to women who use IUD’s? Will the expulsion of a fertilized egg carry the same legal weight as a still birth?

Even if the current case is decided that emergency contraception doesn’t cause abortion because it doesn’t prevent an implanted egg, it could still have drastic effects on women if the Supreme Court concedes to the new definition of when pregnancy begins. Do we really want courts defining medical terminology in such a way that it would effect legislation that already interferes in women’s health decisions? How far do we want the government to go in defining medical terminology based on partisan political and religious beliefs? Even if we win this battle, the war for women’s reproductive freedom could take a huge blow if the Supreme Court continues its habit of declaring illusory victories for the pro-choice side.

Don’t fall for Hobby Lobby’s gambit*. You don’t get to redefine medical terminology to fit your religious beliefs in order to deny more medical choices to women.

*I see this as a gambit for the anti-choice side. If they win the case, then they can successfully use “religious beliefs” to deny contraception to women. If they lose, they could still convince the courts to redefine when pregnancy begins. Sacrificing the ability to deny women medical care now through employer insurance for the possibility of denying women medical care in the future through strict legislation.


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