The Norplant Debate

The Paquin School is a simple brick box of a building in a working-class Baltimore neighborhood. It doesn't look like the setting for a social experiment, but it is. Paquin's 300 students are all pregnant teens or new mothers; last month they became the first students in America to be offered the implantable contraceptive Norplant at school. For these girls, many of whom have babies at 13 or 14, Norplant's promise-no pregnancies for five years-could mean a second chance. "Our dream is to prevent them from getting pregnant again until they're at least 21," says Gracie Dawkins, a Paquin counselor.

But Melvin Tuggle, a black Baltimore minister, thinks making Norplant available at Paquin is genocide. "One third of us are in jail and another third is killing us and now they're taking away the babies," he says. "If the community, the churches and our white brothers don't stand up for us, there won't be any of us left." This week Tuggle and other black leaders say they'll use a Baltimore city council hearing to protest plans to expand Norplant to schools throughout the city. "We won't let a 12-year-old have a drink," he says, "and in the Baltimore school system, a 12-year-old needs a letter from her parents to go to the zoo. She needs permission to get aspirin but she needs nothing to get norplant."

Or get pregnant. Consuelo Laws's mother didn't like her boyfriend, so she insisted that Consuelo's little brother go with her everywhere. He wasn't much of a contraceptive device. Consuelo was 13 when the doctor told her she was pregnant, "and with that," she says, "my teenage years were over." Now 19 and the mother of two, Consuelo thinks girls should get Norplant as soon as they start menstruating. "My mother thought she could protect me," Consuelo says. When her mother asked how it happened, Consuelo told her: "My little brother would ... play with my boyfriend's brothers and sisters, while we went in another room." A Paquin senior, Consuelo has had Norplant for a year. "Without it I'd probably have more children," she says. "I want to complete my education."

When it was approved by the Food and Drug Administration in 1990, Norplant was heralded as the first innovation in birth control since the pill and the IUD in the 1960s. It's turned out to be as controversial as it is revolutionary. Norplant is being touted as a cure not only for teen pregnancy, but also for welfare dependency, child abuse and drug-addicted mothers.

It's a heavy burden for a half dozen little sticks to carry. The Norplant system, as it is called, consists of six matchstick-size capsules surgically implanted in the arm that slowly release a low dosage of levonorgestrel, the same synthetic hormone used in several versions of the birth-control pill. Norplant is as good as the pill in preventing pregnancy, and its long-lasting effectiveness-up to five years-makes it especially attractive to younger women who want to delay childbearing. It's teenager-proof; girls don't have to worry about remembering to take the pill or use a diaphragm. Its only serious medical drawback: couples still need to use latex condoms to prevent the spread of sexually transmitted diseases, including AIDS. A recent survey of 21,276 women who received Norplant through Planned Parenthood found that the vast majority, 89 percent, were under 30, and 22 percent were 19 or younger. "We need long-term methods like this because failure rates are high" for younger women using other forms of contraception, says Laurie Schwab Zabin of the Johns Hopkins School of Hygiene and Public Health.

But even Norplant's most ardent supPorters are troubled by the way the contraceptive has become the focus of an emotional debate about the fertility of poor women and teenagers. The issues here stretch well beyond poverty to the power of the state to regulate-or coerce-the reproductive choices of women. Put simply, if the state is expected to pay to support the children of the poor, do taxpayers have a say in whether the children will be conceived?

"There are all sorts of reasons why policies that might achieve a good goal-like the reduction of welfare costs and fewer poor babies-give too much authority to the government," says Arthur Caplan, a bioethicist at the University of Minnesota. "I'm not saying the goal is bad, but the means to get there will come at a terrible price, a scary price." Caplan thinks Norplant could be just the beginning of a whole range of efforts to cut public costs through control of reproduction. "I can see us mandating the genetic testing of embryos and fetuses," he says. "If we're willing to put Norplant into a 16-year-old today to contain costs, then why couldn't there be a government official saying you can't be a parent because you're likely to create a kid whose needs will cost society too much?"

To some lawmakers, Norplant is more than a contraceptive; it's a panacea. Last month, in his state-of-the-state speech, Maryland Gov. Donald Schaefer suggested requiring mothers on welfare to get Norplant or get off the dole. "The simple truth is, we've run out of money," he says. "We may be forced to make mothers take care of themselves." He's not alone. In the past two years, according to The Alan Guttmacher Institute, legislators in 13 states have proposed nearly two dozen bills that aim to use Norplant as an instrument of social policy. In Tennessee, officials wanted to pay women on welfare $500 to get Norplant and $50 a year for each year they kept it. The bill was approved by the state House with amendments offering a $500 incentive to men on Medicaid who got vasectomies. The measure foundered in the Tennessee Senate, but the sponsor, state Rep. Steve McDaniel, plans to reintroduce it in the next two weeks. Legislators in other states have proposed requiring Norplant for mothers convicted of felony drug abuse and mothers who have given birth to drug-addicted infants.

Politicians say they've turned to Norplant out of desperation. Last year Walter Graham, a state senator in Mississippi, proposed that his state require the contraceptive for women with at least four children who wanted any kind of government support. His legislation didn't pass, he says, because it got combined with another bill. But a new session has just begun and Graham thinks it will eventually be approved. "The taxpayer is willing to support one child, maybe even two children," he says. "But there's a point where if people want to continue to receive assistance, they will have to have an implant ... Everyone supports the idea of helping the person who cannot. They just don't support the concept of helping the person who will not."

Norplant isn't just a social issue; it's also an economic one. Because the contraceptive is so expensive-$365 plus $200 or more to have it implanted and then an additional $100 or so to have it taken out-many women can't afford to pay for it out of their own pockets. Medicaid, the health insurance for people on welfare, covers Norplant in all 50 states. That means that only two groups of American women can generally afford Norplant: rich women and very poor women. In the Planned Parenthood survey, 69 percent of women who received Norplant at the organization's clinics had the cost covered by Medicaid. There are no studies of overall Norplant use, but Dr. Michael Policar, Planned Parenthood's vice president of medical affairs, estimates that roughly half of the 500,000 women in this country who use Norplant are covered by Medicaid.

The U.S. distributor of Norplant, Wyeth-Ayerst Laboratories, set the price in this country when it obtained FDA approval at the end of 1990. In 13 other countries where Norplant is used, the cost is much less, as low as $23. All contraceptives are more expensive in the United States than in other countries where medicine is often supported by government and international aid. But Wyeth-Ayerst says its price is fair because it has had to pay the cost of training 26,000 medical practitioners to implant Norplant, at a cost of $1,000 each. There's also the potential cost of litigation-a concern for anyone in the contraceptive business after lawsuits by IUD users.

Given these numbers, Norplant is increasingly viewed as a contraceptive for women on public assistance. That has helped to revive a long-dormant debate over who should control the fertility of poor women. If taxpayers are paying for their health care and paying for the support of their children through welfare, isn't the government entitled to set limits? In the first half of this century, compulsory sterilization was legal in the majority or states. Dr. Allan Rosenfeild, dean of Columbia University's School of Public Health, estimates that between 1907 and 1945, as many as 45,000 Americans-most poor or mentally incompetent-were compelled to be sterilized. Since then, more progressive social policies-combined with the introduction of the pill and the IUD-presented a host of voluntary contraceptive choices. In 1974, the federal government issued guidelines for federally funded sterilizations that mandated counseling, informed consent and a ban on the procedure for minors. Those guidelines became law four years later. Now, sterilization by choice-normally tubal ligation-is the second most popular form of birth control for American couples, after the pill.

Before the introduction of Norplant, most available forms of reversible birth control were by nature voluntary. There's no way to make a woman swallow a pill every day or to force a man to use a condom during intercourse. But Norplant is different. Once inserted it remains in a woman's arm until a medical practitioner takes it out. "Because it's the closest thing to sterilization, folks have seized on this and tried to impose it on the women who have the least power in our society," says Julia Scott of the National Black Women's Health Project. "They see it as social control for those women who they believe are responsible for all of our social issues."

That certainly wasn't the intent of Norplant's developers, the Population Council, a nonprofit group based in New York that sponsors contraceptive research. Doctors supported by the council began work on an implantable contraceptive in 1966. After years of clinical trials involving 40,000 women in 43 countries around the world, Finland became the first country to approve Norplant in 1983. A Finnish pharmaceutical company, Leiras Oy, is the only manufacturer of Norplant. Over the next decade, Norplant was approved in 23 countries, including Indonesia, Thailand and Colombia.

The United States is the only country where coercion has emerged as a serious issue. Just after Norplant was approved by the FDA, an editorial writer for The Philadelphia Inquirer suggested linking Norplant use to welfare payments. Within a week, after protests inside and outside the newsroom, the paper published an apology. A few months later, a California judge tried to make Norplant a condition of probation for a mother of five convicted of child abuse. The woman appealed, but the case was dismissed last year when she violated another condition of her probation and was sent to jail. In Texas, a judge also ordered a convicted child-abuser to use Norplant. She didn't appeal, but developed medical problems and eventually had a tubal ligation instead.

While policymakers debate coercive use of Norplant, the contraceptive has gained popularity with women. Rosetta Stitt, the principal of the Paquin School in Baltimore, says many students chose Norplant even before it became available at her school. Some Paquin students see Norplant as a way to break a cycle of early motherhood. "The girls we have in our school today have seen two decades of what their aunts and mothers went through because they were teenage mothers, all the things they couldn't do because they had a baby," says Stitt. "They do not want to go through that, too."

Monica Irving, a 15-year-old ninth grader with a 3-month-old son, asked for Norplant right after her baby was born. She lives at home with her mother, Michele, 33. Monica's grandmother looks after the baby while Monica is at school. "I always thought I would get married and then have a child," Monica says. "I never thought of it happening when I was this young. If somebody had talked to me about Norplant before, I would have used it." Michele Irving supports her daughter's choice. "It broke my heart when Monica got pregnant," she says, "but I tried not to let her know that. Some mothers throw their daughters out when this happens. But I didn't. I have tried to back her up. But I am very happy she's on Norplant now."

Most studies have shown that women who use Norplant like it better than their previous contraceptives-mostly because it's much more reliable and effortless once it's implanted. The Planned Parenthood survey of women who received Norplant at the organization's clinics in the last two years showed a very high degree of satisfaction. Only 3.5 percent of women asked to have it removed, a much lower rate than the 10 to 25 percent in earlier Norplant studies. The women who complained generally cited the most common side effects: irregular bleeding, headaches, mood changes and weight gain.

But another study, of Norplant users in Texas, indicated that Norplant's growing popularity could have some negative consequences. Nearly half of former condom users said they wouldn't use condoms now that they have Norplant, putting them at risk for sexually transmitted diseases, especially HIV, the virus that causes AIDS. "If I had my druthers with kids, I would put them in a head-to-toe condom until they were 21," says Columbia's Rosenfield. "The best of both worlds would be if they would use Norplant and a condom, but I know it's hard to get them to use one."

Norplant's supporters say both the coercion issue and the risk of STDs without condoms point to the need for increasing sex education and adequate counseling for women-especially teenagers-who are considering Norplant. "This is one of the most critical issues in the adolescent population," says Dr. David Kessler, the commissioner of the FDA. "I think the risk of people using Norplant and not a condom is very real."

Some of Norplant's critics worry that for teenagers, the implant is a license for promiscuity. "If a girl has Norplant in her arm, the boy is going to say he can screw her because she's protected, she's not going to have a baby," says Tuggle. But Norplant researchers disagree. Dr. Philip Darney, a professor of obstetrics and gynecology at the University of California, San Francisco, participated in the clinical trials of Norplant. He's now studying teens and Norplant. "Some of the girls we have on Norplant are no longer sexually active," he says. "Twenty-five percent of them say they have no current partner-and they would have quit using birth-control pills. They keep the Norplant because they want to be protected if they do find a partner ... In that sense, Norplant makes it easier for them to be sexually responsible." In truth, these are all just tentative conclusions; hard facts remain elusive. One area ripe for study: a comparison of the sexual activity of girls who start on Norplant while still virgins with those who come to it later.

"We're still going to be saying: abstain, abstain, abstain," says Gracie Dawkins, the Paquin guidance counselor. "But if you're not going to abstain, Norplant is an option." For their part, the students say they need better sex education in the earlier grades, too. "My mom had talked to me about my period, but it was all Greek to me," says 21-year-old Kimberly Lucas, the mother of an 8-year-old and a 2-year-old. "I remember her giving me a book with body parts in it, but I didn't realize what the big deal was." Kimberly learned about sex from her boyfriend. "When you're in middle school, and you run into a boy who's 19 and cute, he can teach you about sex in a few minutes. You don't want him to be the one who teaches your kid about sex, but if you don't, he will."

After listening to these sad truths all day, Rosetta Stitt, Paquin's principal, gets angry when she hears people criticize Norplant-or any other method of birth control that can help get young mothers' lives back on track. "Morality is one thing, reality is another," she says. "We have to deal with reality here every day." The reality is that there's no silver bullet to stop teen pregnancy. But Norplant can be an effective weapon in an arsenal that includes sex education, better health care and the possibility of a future worth waiting for.

After giving the patient a local anesthetic, the nurse makes a 2-millimeter incision on the underside of the upper arm. The nurse then puts the tip of a metal tube through the incision, beneath the skin.

She then loads the first Norplant cylinder into the tube, pushing it with the tube's plunger until it is in place. She inserts the next five Norplants through the tube, arraying them in an arc.

The nurse removes the tube and presses together the edges of the incision, closing it with a bandage and wrapping the patient's arm in gauze to prevent infection. The procedure has taken about 10 minutes.