1 May 2001 | BIOETHICS
A background paper to the New Zealand Catholic Bishops’ Conference Pastoral Statement “Giving life, giving love”
While birth continues to be known as the everyday miracle, pregnancy is often portrayed as something to be avoided at any cost. If a pregnancy is unplanned, many assume it must be unwanted and should not be allowed to survive long enough for the child to become a miracle.
Today there are countless women and men who will never know that, given support and encouragement and time, the child they feared would ruin their lives may well have become the joy of their lives.
There was a time when our children were our hope for the future. Last year the proportion of New Zealanders under 15 reached a record low while the proportion of those over 65 reached a record high.1 Today we are building more rest homes than schools and we watch in sadness as our bright young graduates head off to greener pastures overseas. In this climate, the fears about overpopulation that were taken so seriously during the 1970's and 1980's appear pathetically misguided.
When the oral contraceptive pill came onto the New Zealand market in the 1960's it triggered what came to be known as the sexual revolution. This revolution flourished because people believed that as long as they used modern contraceptives they could have sex without fear of becoming pregnant.
Two outcomes were that people became sexually active at younger and younger ages and women sought to delay the birth of their first child until they were about 30.2 They had been led to believe that provided they used modern methods of contraception they could be sexually active from their mid-teens until their thirties without fear of becoming pregnant.
As people relied increasingly on contraception and sex education to avoid pregnancy, abortion rates escalated. Between 1980 and 1999 abortion numbers in New Zealand rose from 5,945 to 15,501 3
People are generally unaware that more than 80% of abortions in this country are carried out on women aged between 20 and 45 years of age.4 A major study carried out in 1995 by the Population Studies Department at Waikato University showed that nearly all of the women surveyed aged 20-45 were using either contraception or sterilisation if they wanted to avoid a pregnancy.5
Most of the 15,501 women who had an abortion in New Zealand in 1999 were using contraception when they became pregnant.6 Contraceptive failure is a major factor influencing the extent to which women resort to abortion. They had been led to believe they could rely on contraception and found it failed them. These high failure rates are well documented by the Alan Guttmacher Institute, the research arm of the Planned Parenthood Federation of America.7
This challenge to the "safe sex philosophy" has given rise to new initiatives. Some women are now placing their hope on a pharmaceutical back-up to failed contraception. They have urged the Government to allow chemists to sell the morning-after pill over the counter without a doctor's prescription.8
In February 2001 it was announced that the Minister of Health, Annette King, had asked officials in her Ministry to investigate whether over the counter (OTC) sales of the morning-after pill should be permitted.9 Mrs King is to send this report to the Medicines Classifications Committee. This committee, after debate and written submissions, will then make a recommendation to Mrs King as to whether or not it considers that OTC sales should be permitted.
The morning-after pill has been in use for nearly thirty years. During the 1970's Professor Albert Yuzpe developed a regimen of two tablets containing a combination of oestrogen and progestogen.10 Women took these pills within 72 hours of unprotected intercourse. The Yuzpe regimen has been widely used and is often described as postcoital contraception or emergency contraception. Its drawbacks include a high failure rate and severe nausea and vomiting for many women. Further, there are circumstances where doctors are advised it should not be used. These contra-indications include pregnancy, crescendo angina, transient ischaemic attacks, liver disease, undiagnosed genital bleeding and a history of thromboembolism.
In 1996 on the basis of concerns over these dangers, the New Zealand Catholic Bishops Conference endorsed an open letter to the former Minister of Health, Jenny Shipley, urging her not to proceed with her plan to allow OTC sales of the morning-after pill.11 As it happened, Mrs. Shipley did not proceed.
Last year the Schering pharmaceutical company launched a new progestogen-only morning-after pill. Each pill contains 750mcg of levonorgestrel. Women take the first pill no later than 72 hours after unprotected intercourse and they take a second pill 12 hours later. Altogether it involves taking 1,500 mcg of this synthetic derivative of the hormone progesterone.12 It is equivalent to taking 50 mini-pills such as Microlut which contain 30 mcg of levonorgestrel.13
The trade name of this morning-after pill in New Zealand is Prostinor-2. In June 2000 the New Zealand governments drug agency, PHARMAC, announced it would be fully subsidised. Eight months later it announced that more than 3,000 women each month had used the drug since it had been subsidised.14
A World Health Organisation study had shown this new drug prevented 85% of expected pregnancies compared with 57% for a control group of women using the Yuzpe regime.15 It also showed a significant reduction in the extent to which women experienced nausea and vomiting. Further, the lack of an oestrogen component in the new product meant there would be fewer contra-indications.
Having said that, the UK Drug Information Pharmacists Group has published a list of the contra-indications for this new pill.16 It says the drug should not be given to pregnant women. If a period is overdue, or if the last period was irregular in some way, or pregnancy is suspected for any reason, a pregnancy test should be done before the treatment is given. Other contra-indications include severe hypertension, diabetes mellitus with neuropathy, retinopathy or vascular disease, ischaemic heart disease, stroke or a past history of breast cancer. The study points to a World Health Organisation statement that absolute contra-indications include unexplained vaginal bleeding, current breast cancer, pregnancy or hypersensitivity to progestogen-only contraception.
We ask what might happen if a woman, with one of these contra-indications goes to a pharmacy where she is not known and asks for this morning-after pill. While her family doctor would have her medical records and would know of any contra-indications, the pharmacist would not have this information. Will the pharmacist discuss these matters with the woman while she is standing in public on the other side of the counter?
Another of our concerns relates to ectopic pregnancies. Becoming pregnant while using the mini-pill increases the likelihood of ectopic pregnancy.17 Women using Postinor-2 are taking the equivalent of fifty such mini-pills. An ectopic pregnancy can be life threatening if the fallopian tube ruptures and causes internal bleeding.
There will also be women who do not realise they are pregnant when they take the pills. If a woman has had intercourse shortly before ovulation and conceives, then ten days later has unprotected intercourse and goes to the pharmacist asking for the morning-after pill, she would be using the drug in circumstances that the World Health Organisation says is an absolute contra-indication.
Three days after ovulation, the ovum is no longer capable of being fertilised so taking the morning-after pill at this stage of the menstrual cycle is an exercise in futility. It can however result in adverse health sequelae for women whose medical history cannot be properly evaluated over the counter by the pharmacist.
This call for OTC sales of the morning-after pill is being driven by the same ideology that lead to claims last year that women should continue using the third generation oral contraceptive, even though it was known that fifteen New Zealand women had died from complications caused by these pills.18 .. 19
The Barnard Health Service of Columbia University advises women to consider using the morning-after pill if they have had sex where the condom broke or slipped, where the diaphragm or cervical cap slipped out of place or where two consecutive birth control pills had been missed during her current menstrual cycle.20 In these cases it is not that contraception had not been used but rather that it may have failed.
Finally we want to refer to a matter which is also of great concern to our Conference, and that is the process by which the morning-after pill prevents pregnancy. It can prevent or delay ovulation thus preventing conception. If it fails to prevent ovulation and conception does occur, the drug affects the lining of the womb so that the embryo cannot implant on the uterine wall or remain implanted.21
There are some who claim that the morning-after pill is not abortifacient because pregnancy only starts when an embryo implants in the womb. That is playing with words. A leading textbook on embryology says: "Human development begins after the union of male and female gametes or germ cells during a process known as fertilisation (conception)." 22 The Oxford Concise Medical Dictionary defines conception as: "The start of pregnancy, when a male germ cell (sperm) fertilises a female germ cell (ovum) in the fallopian tube." 23
When we are dealing with the morning-after pill we are clearly dealing with chemically induced abortion.
The Church cannot remain silent on this issue, given the serious nature of what is being proposed. In presenting the facts set out in this letter we are not seeking to impose our views on others. Rather we want to place before those willing to listen the truth about how the morning-after pill works, and the impact it can have on the health and wellbeing of women. These matters should be a cause for concern well beyond the Catholic Church.