A Simple One Word Answer

A report on the abortion rate in America just released by the Alan Guttmacher Institute straddled the good-news/bad-news divide. In the good-news column, the rate plummeted among teenagers, falling by almost 40 percent. But the bad news was that among the poorest women in the country, abortions were way up; although the rate has dropped overall,for women below the poverty line it has increased by 25 percent.

Many of those in the business of women's health said they were perplexed and concerned by that second result. And the researchers at the Alan Guttmacher Institute said it would take more work to explain the increase in abortions among the poor. But those working closely with actual patients said that one word goes a long way toward explaining both the good news and the bad.

Contraception. It's been the rallying cry of those who favor keeping abortion legal for years now. As the bitterest public-policy (and personal privacy) debate of the 20th century refused to resolve itself, those who believed in planned parenthood argued that easy access to birth control would make abortion less and less necessary. It seemed a simple argument behind which everyone could rally, but it never built consensus among warring parties, because some anti-abortion activists thought it diverted attention, and because others are as opposed to an IUD as they are to a termination.

But in the way they so often do, the people outside the eye of the storm quietly went about making sensible choices. Thus the rate of teenage pregnancy began dropping steadily throughout the 1990s. Another Guttmacher Institute study found something for everyone in the reasons why: three- quarters of the teenagers surveyed said they were using contraceptives, and a quarter said they were putting off sexual activity. While adults sometimes believed that they were spitting in the wind, the kids actually got the message: don't rush into sex, but if you are sexually active, take care of yourself.

Yet for poor women the use of contraception was simultaneously becoming more problematic. New welfare-reform regulations changed what was available through Medicaid. Those in low-paying jobs often found themselves uninsured or with health-insurance plans that didn't cover any or all contraceptive devices. A Planned Parenthood clinic in Denver reports running out of the year's loan money for abortions for women in need after only six months.

It's preposterous that a nation this prosperous would have business and government policies that result in emergency borrowing from friends for an abortion because regular shots of Depo-Provera were too dear to maintain. Every private health-care plan should be obliged to cover contraceptives (and shame on those that currently underwrite Viagra but not The Pill); every public program should make them available at discount rates or, when necessary, free. "It's a win-win situation in actuarial terms," says Dr. Paul Blumenthal, who runs a program in contraceptive research at Johns Hopkins. He points to a study that compared the cost of unintended pregnancies and sexually transmitted diseases to the cost of a variety of birth- control devices. The dollar amounts varied, but in every case there were marked savings in using contraception.

These are good times for the development of new methods, from an implant that may work for as many as three years to microbicides that will prevent STDs as well as pregnancy. But it's a bust in terms of initiatives from Washington, where abstinence-only plans have now received enthusiastic federal support but the Title X program devoted to providing family planning to poor women isn't adequately funded. The Bush administration even wants an FDA panel on women's health policy to include a doctor who doesn't approve of prescribing contraceptives to adult women, but will if they really insist. He also suggests reading Scripture to treat PMS.

Preventive medicine has come to be accepted as the ruling principle of good health care, and birth control is no more, or less, than one form of preventive medicine. The Guttmacher study shows that teenagers increasingly understand this, which may bode well for the future. For their part, policymakers need only look at a country like the Netherlands, which has long had legal abortion. It has, however, one of the lowest abortion rates on earth because widespread use of birth control is taken for granted.

This is one of those strange and seemingly relentless areas in this country in which the ghosts of Puritanism have a headlock on the spirit of progress. It's ridiculous to have to restate the simple fact that cheap, accessible and reliable methods of contraception drive down the rate of abortion, yet in terms of public policy there has always seemed to be a disconnect on the issue, perhaps because there was the sub rosa notion that this was a carnal rather than a medical issue. Surely there are still some who believe the sole purpose of sex is untrammeled procreation, but it would be a pitiful nation that would let those fringe zealots run things for the rest of us. The good news is that we do not have to figure out what needs to be done, but only to do it. Contraception. Enough said.

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