Prevention, not abortion

LAST WEEK, when an advisory committee to the Food and Drug Administration recommended that the "morning-after pill" called Plan B be available without a prescription, I remembered a teenage girl whose abortion I helped perform as a medical student.

The 15-year-old patient, whom I'll call Lakeesha, had a depressingly common situation. Each year, about one in 10 American girls between the ages of 15 and 19 gets pregnant, since about a third of teens use no contraception.

At the clinic, Lakeesha answered my questions in a monotone. A withdrawn girl, she had been having sex for a year and generally relied on condoms. Her last period occurred 10 weeks before.

"Did you consider a morning-after pill when you found out the condom broke?" I asked. Lakeesha looked at me blankly. Like almost 85 percent of students who get abortions, Lakeesha hadn't heard of this method, which has been available in the United States for more than 25 years and is about 75 percent effective. The regimen is exceedingly simple: Within three days of unprotected intercourse, pills of Plan B are taken twice.

In 1996 the World Health Organization added the medication to its "essential drugs list," but few American pediatricians mention its existence to adolescents during checkups. Perhaps it's underutilized because it's often confused with abortion; however, the pill arguably doesn't terminate a pregnancy -- it prevents it. The pill prevents conception in the first place by either delaying ovulation or changing the uterine lining.

After an hour of preparation, the supervising physician and I scrubbed into the operating room, where Lakeesha lay sedated. We placed a clear plastic tube through Lakeesha's cervix and flipped a switch. With a sucking noise, the tube filled with reddish tissue extracted from Laskeesha's uterus. We moved the tube back and forth until the flow stopped. The pulpy extract collected in a strainer-like device, and we poured its contents onto a sterile dish. With forceps, I picked through the tissue, which looked like clots of blood. Then I saw it: a pale, short piece of debris as wide as a matchstick. At the tip, I recognized small protrusions that were, without any doubt, five small fingers. I've never forgotten the haunting sight. I -- who after medical school became a pediatrician -- had helped kill an unborn child.

I have many emotions about the day. But rather than launching into an antiabortion or prochoice polemic, it would be best to find a constructive lesson. To be sure, no reasonable person likes abortions. We should agree that anything that reduces the number of abortions is a good thing.

But simply making abortion illegal won't save lives. What Lakeesha underwent occurs legally 26 million times a year in the world and 20 million times a year illegally. Women who get abortions assume great risk if they do so where abortion is prohibited. From complications of illegal abortions, estimates the Guttmacher Institute, 78,000 women die preventable deaths every year. Making abortion illegal doesn't appear to stop a woman from getting one; it forces her to hire an amateur instead of a professional.

Making abortion less accessible also won't work. The United States has one of the highest abortion rates among developed countries. This is remarkable because 86 percent of the counties in America have no abortion providers. In 1991, the Supreme Court ruled in Rust v. Sullivan that providers who accept federal funds couldn't even mention abortion, and it upheld the so-called "gag rule." Although mifepristone, known as RU-486, was approved over a decade ago in France and caused no increase in abortion rates, political pressure prevented its approval in the United States for over a decade. We operate with the mistaken belief that making an abortion harder to get makes it less likely. It doesn't. For example, the percentages of American teens who abort are 33 percent, 200 percent, and 500 percent higher than their respective counterparts in Canada, France, and the Netherlands, where abortions are easier to obtain.

Ignoring teen sexual behavior doesn't help. Adolescents simply don't learn enough about contraception and don't use it. Today, one-third of schools have no sex education. Among those schools that do, a third teach abstinence only (which has never decreased sexual behaviors), with contraceptive information either prohibited or limited to describing lack of efficacy.

Barring a miraculous improvement in contraception utilization or a sudden epidemic of abstinence among teens, making Plan B available over the counter will reduce the number of abortions in America. The medication is safe, easily self-administered, and effective. Studies show it doesn't reduce the use of other methods of birth control and doesn't cause birth defects when it fails. And most important, it could stop an estimated 800,000 teens and older woman from making Lakeesha's choice every year.

Dr. Darshak Sanghavi is a clinical fellow at Harvard Medical School and author of "A Map of the Child: A Pediatrician's Tour of the Body."

Copyright 2003 The New York Times Company