Yesterday, Ohioans voted fairly convincingly to keep abortion legal. The reason for most abortions in the United States is because of an unwanted pregnancy. The reason for most unwanted pregnancies is unintended conception. We keep wasting divisive emotional energy, political energy, and money on the end-result of unintended conception when we should be working together to fix the root causes of unintended conception. So, what can we do in Ohio (and in the rest of the country)?
Who gets abortions in the U.S.?
Abortion is common in the United States – nearly 1 out of every 4 (23.7%) American women will have an abortion before age 45. Data from the Guttmacher Institute shows that currently in the U.S., 46% of all pregnancies are unintended and of those, 34% end in abortion. The most recent data from the CDC shows that in 2020, there were 620,327 abortions in the United States. This is an underestimate of the true number because California, Maryland, and New Hampshire did not report abortion numbers to the CDC. The Guttmacher Institute includes data from all 50 states and thus its estimate of annual abortions is higher than the CDC’s. The Guttmacher Institute reported that in 2020, there were 930,160 abortions in the U.S. Every year. Overall, there were 198 abortions for every 1,000 live births – this works out to mean that 16.5% of all pregnancies end in abortion. Although the highest number of abortions occur in women in their 20’s, the highest rate of abortion occurs in adolescents. 1.5% of all women of childbearing age have an abortion. The majority of abortions (59%) are performed in women who already have children. In addition, 85% of abortions are performed in women who are unmarried and 49% are in women living below the poverty level.
Why do women get abortions?
A study in the journal BMC Women’s Health reported the most common reasons cited by women who underwent abortions in the United States. Most women (64%) reported more than one reason for undergoing abortion. The most common reasons were financial (40%), timing (36%), absence of a supportive partner (31%), and need to focus on their other children (29%). A study in the journal Contraception found that half of all women undergoing abortion were using some form of contraception during the month that they became pregnant with condoms being the most frequent method, followed by birth control pills.
So, how do we reduce the number of abortions without making them illegal?
In medicine, the key to curing a disease is to first determine the root cause of that disease and then treat the root cause, so that the disease never occurs in the first place. The same applies to hospital quality initiatives – you determine the root cause of a medical error and then correct that root cause so that the error can be prevented in the future. The problem with abortion in the U.S. is that we have focused most of our attention on the end result (abortions) instead of the root cause (unintended conception). Rather than contentiously facing off against each other over abortion, those who are in the “right to life” camp and those who are in the “right to choose” camp should unite on the common ground of reducing unintended conception. Here are some tactics that can reduce the number of unintended conceptions and thus reduce the number of abortions.
- Improve insurance coverage for effective contraception. The most effective methods of birth control are sterilization, hormone implants, and IUDs. These methods are required to be covered by federal law, however, there is a legal exemption for churches, religious-affiliated schools, and religious-affiliated universities who can opt out of health insurance coverage of contraception for their employees. The opt-out initiative was led by the Catholic Church that still decrees that the use of contraception is a sin. Although this decree is largely ignored by U.S. Catholic women (99% of who use some method of contraception), it may contribute to Catholic women having a higher rate of abortion than mainline Protestant women and nearly twice as high of a rate as evangelical Protestant women and women of other religions. Ideally, all health insurance should cover tubal ligation, IUDs, vasectomy, and hormone implants. If health insurance provided by religious organizations does not cover contraception, then women (and men) should have access to alternative health insurance plans.
- Improve over-the-counter contraception options. Condoms were cited as the most common method of contraception used by women undergoing abortion. Why were they used? – because they are immediately available to anyone over-the-counter. The problem with condoms is that they just don’t work very well – nearly 20% of women who rely on condoms are pregnant within a year. Fortunately, there is a new over-the-counter oral contraceptive pill (Opill) that will be available in early 2024. Hopefully, this will be followed by other over-the-counter oral contraceptives. The most effective contraceptive methods (sterilization, IUDs, and implants) are not amenable to over-the-counter sales since these methods require a procedure performed by a physician (or NP/PA).
- Improve sex education in middle schools and high schools. In the United States, by age 15, 21% of American girls have had sexual intercourse. By age 18, 65% of females have had sexual intercourse. Sex education requirements vary by state and only 39 states require schools to teach sex education. The CDC recommends 20 specific topics be covered in school sex education classes, however fewer than half of high schools and fewer than one-fifth of middle schools provide instruction on all 20 of these topics. The majority of teens reported that they had not had any sex education prior to their first sexual intercourse. In public schools, sex education curricula are usually set by elected school boards and recently, those school board elections have become heavily politicized, especially by ultra conservative groups. In many home-schooled and religious-affiliated schools, abstinence is the only contraceptive method that is taught (if anything is taught at all). But here is the thing: ABSTINENCE AS A PUBLIC POLICY JUST DOES NOT WORK. Parents, if you have 3 kids then statistically, 2 of them are going to have intercourse before they graduate from high school. You may not be very happy about it but that is reality. Clearly, our schools can do better.
- Fund organizations that provide sex education and contraception. Many abortion opponents advocate for defunding Planned Parenthood. This makes about as much sense to me as defunding the IRS in order to improve the federal deficit. Teenagers and adults in their 20’s need someplace to go to learn about contraception if they aren’t learning about it in their schools or in their homes. Furthermore, they need someplace to go if they don’t have health insurance, don’t have a regular healthcare provider, or don’t feel comfortable asking their doctor for contraception. If you really want to reduce the number of abortions in the U.S., then fund Planned Parenthood and similar organizations specifically to help prevent unwanted conception in the first place.
- Promote the use of “morning after” pills. These are levonorgestrel-based medications that can be taken up to 5 days after intercourse in order to prevent pregnancy. They range in price from about $12 (My Choice Emergency Contraception) to about $50 (Plan B One-Step). Most are available over-the-counter and you can even have them delivered to your door within 30 minutes using DoorDash. We need greater public awareness of these products and greater societal normalization of their use.
- Reduce fetal abnormalities. Although fetal abnormalities account for a minority of abortions, they are often sensationalized in the press. There are tangible measures that we as physicians can take to reduce fetal abnormalities and thus reduce the attendant abortions: ensure adequate folic acid supplementation, stop teratogenic medications (preferably before pregnancy), smoking cessation, and promotion of alcohol abstinence.
- Optimize the health of the mothers. A minority of abortions are performed because the mother’s life is in danger. Although these conditions are sometimes unanticipated and unavoidable, they are often preventable with good maternal care. Ensure that hypertension is treated. Screen and treat gestational diabetes. Provide regular prenatal office visits. Focus on achieving a healthy weight, a healthy diet, and a regular exercise regimen (preferably before pregnancy). Counsel women of childbearing potential who have chronic diseases about the risks of pregnancy and the timing of pregnancy in the anticipated course of their underlying disease. Support community educational programs for mothers-to-be.
So, where do we go after Ohio Issue 1?
For those who voted against Issue 1, don’t despair, there is still much that you can do to reduce the number of abortions in Ohio by reducing unintended pregnancies. For those who voted for Issue 1, your work is just starting since legalization of abortion means that you now need to focus your advocacy efforts on availability of contraception and sex education. Abortions should not be felonies but they should be fewer. Reducing unintended conception is the way to do it.
November 8, 2023