The Best Cure

How should Louisiana prevent unwanted pregnancies -- make it easier to obtain emergency contraception or exclusively teach abstinence?


Christie lay in bed, thinking that it was just their luck to have a condom break on a holiday.

It was a brand she and her fiance used all the time without problem, she says. But as soon as it happened on this past Thanksgiving, she knew what she would be doing the next day. "I thought, 'I'll be going to Planned Parenthood.'"

She planned to ask for emergency contraception pills (ECPs), which can prevent pregnancy after sex. ECPs contain the same hormones used in birth control pills, and can be prescribed for women whose birth control has failed, who have had unprotected sex, or who have been sexually assaulted. Studies show that ECPs taken within 72 hours after sex reduce the chance of pregnancy by 75 percent. The Alan Guttmacher Institute estimates that increased used of ECPs could reduce unintended pregnancies and abortions by half.

Yet the pills are little known and rarely used. According to a recent Kaiser Family Foundation survey, nearly 75 percent of American women between the ages of 18 and 44 haven't even heard of emergency contraception. Only 2 percent of women in that age bracket have ever used them.

Others confuse emergency contraception -- which works before pregnancy to halt ovulation, fertilization and implantation -- with the more controversial RU-486, the so-called abortion pill, which is used only after a women is confirmed pregnant. Some critics of ECPs argue that they free women to be promiscuous and irresponsible and then just pop a few pills afterward.

Emergency contraception has actually been around for decades -- the first documented use was in the mid-1960s in the Netherlands, where it was given to a 13-year-old rape victim. Since the 1970s, many gynecologists have routinely broken apart packs of birth-control pills and given women double doses of pills within 72 hours of unprotected sex. In 1997, FDA Commissioner David Kessler announced that "the best-kept contraceptive secret is no longer a secret" and confirmed that double doses of birth-control pills can prevent pregnancy.

Christie -- not her real name -- had first heard about ECPs when she was a teenager growing up in Europe. She had even used the pills once before, 10 years ago. She was living in Los Angeles and seeing a gynecologist who she says "liked to stay up-to-date," and so had prescribed them for her.

Currently, only California and Washington allow a woman to get emergency contraception directly from a pharmacist without a doctor's prescription. So Christie found herself, on the Friday after Thanksgiving, searching around for a doctor and a prescription. She tried Planned Parenthood -- where she usually goes -- but they were closed. She tried every family planning number in the Yellow Pages. No luck. So she called Charity Hospital's emergency room, where a woman answered and told Christie (in error) that Charity did not prescribe emergency contraception.

Finally, Christie remembered the name of a private doctor who she had seen once. She left a message with his answering service and he called her back -- obviously miffed, she says, "as if I'd been a bad girl and it is so tiresome to deal with people like you." He prescribed it anyway, she says.

Christie's story is actually pretty typical, says Julie Redman, president and CEO of Planned Parenthood of New Orleans and the Mississippi Delta. The need for emergency contraception, she says, is greatest during the evening, on weekends and during holidays -- times when most doctor's offices are closed. And since the pills are more effective the earlier they're used, timing is crucial.

Planned Parenthood waiting rooms are generally packed after a weekend. "It's amazing," Redman notes, "how many people are there at 8 a.m. Monday morning." And they get even more packed after a holiday, she says. Last year, during the two weeks surrounding Mardi Gras, Planned Parenthood doctors in New Orleans and Baton Rouge prescribed emergency contraception to 61 women.

Redman and her colleagues at Planned Parenthood are currently hoping to convince all area emergency rooms to stock ECPs for victims of sexual assault. A number of emergency rooms across don't stock them at all, primarily for religious reasons, she says. Planned Parenthood is currently conducting surveys on emergency-room practices and will release its findings later this year.

Some emergency-department personnel object to dispensing ECPs for anything other than sexual assault. One local doctor asks why Christie, who hadn't been assaulted, would want to burden the emergency department with her problems: "When she has intercourse and she's not careful, she expects to run in here and have us give her medication? That's what she wants?"

But Deborah Ratterree, clinical nurse specialist for Charity Hospital's emergency services, says that she wouldn't discourage women from showing up at Charity. She has, she says, seen women receive ECPs for various reasons ranging from birth-control failure to carelessness, although individual doctors can -- for religious and other reasons -- decide not to prescribe ECPs or any other drug.

Redman says that it may be tough to give ECPs priority in an emergency room when the staff is dealing with patients suffering from gunshot wounds and heart attacks. Which is part of the reason why, she says, both the American Medical Association and the American College of Obstetricians and Gynecologists have endorsed the idea of over-the-counter ECPs.

During the upcoming legislative sessions, a number of states will be introducing legislation to allow over-the-counter sales of emergency contraception. Louisiana is not one of them.

"I graduated, class of '66, from a high school in north Louisiana. There was not a single person at Ferriday High School with VD. There were only two out-of-wedlock births, and both girls married the guy," says Dan Richey, the state coordinator of the Governor's Program on Abstinence.

His point is that parents should stop obsessing only about pregnancy, because now, he claims, "for every one teenager who gets pregnant, 10 get a disease." The only way to avoid this, he says, is abstinence until marriage.

The Louisiana program on abstinence is one of the many state programs funded by the big federal welfare-reform bill, formally known as the 1996 Personal Responsibility and Work Opportunity Reconciliation Act. Richey says that Republicans knew that Clinton was going to sign the welfare-reform act and so they attached a bill creating an abstinence-only education program and authorizing its funding of $250 million over the course of five years.

Richey was brought on board to head up this program by Governor Mike Foster, who he describes as an old friend. His appointment was criticized by a number of people, he recalls, because he came from a religious, not a health background. "I am a faith-based guy," asserts Richey, a former state senator whose resume also includes a stint as a news director at a Christian TV station, "but there's a component of faith in every civilized institution and every law, for that matter."

One hallmark of abstinence programs funded by the 1996 act is they exclusively teach abstinence-only until marriage. According to the federal guidelines, programs can't include anything about birth control. Nationwide, schools have cut the other parts of their sex-ed curricula to accommodate this new program; one school even physically removed chapters about birth control and safe-sex out of its textbooks in order to be in compliance. One study indicated that, by the end of 1999, abstinence was the only "sex-ed" topic covered at more than one-third of all U.S. public schools. The following year, the White House Office of National AIDS policy expressed "grave concern" about the funding offered "to adopt abstinence-only approaches."

But Richey says that new research questioning condoms' effectiveness makes it clear to him that abstinence is the only truly healthy option. "When you talk to teenagers and tell them that there is such a thing as protected sex," he says, "they actually believe you."

Abstinence has to be taught in schools, he explains, because parents aren't teaching it at home. "You can't imagine," he says, "how many young girls say, 'When I went off to college, my mom put me on birth control.' Thanks mom -- your daughter just had a radical hysterectomy because of HPV (human papilloma virus). And yet here they are, handing out condoms and thinking that they're being responsible."

Ministers aren't preaching about abstinence either: "Look, sin's out, remember? The message resonating from the pulpit is, 'I don't know -- what do you think?' There's no message about abstinence or responsibility."

And doctors and nurses are no better, he says. "The message that some people from the health community are putting out about disease is, 'Get 'em now; get 'em later. We have a cream; we've got a shot; we've got a pill; we can solve everything.' And one of them always says, 'The only way to prevent this is abstinence, but we know that you're not going to be abstinent, you're going to be like a barnyard animal.'"

If a kid takes a pledge to be abstinent, where's the line that he or she can't cross? "Genital contact," Richey replies, cautioning that he's "not going to get into body parts or anything." Oral sex? Forbidden, even though it's more common now, he says, "because we had an absolute derelict as president for eight years, presenting anything but abstinence." Self-touching? "We don't promote masturbation," he replies firmly. "That's all I'm going to say about that."

The Governor's Program is mostly about common sense, he says. "You give teenagers a lot of sex, you'll get sex. You give teenagers a lot of abstinence, you'll get abstinence. That's a no-brainer."

If Dan Richey and the governor sit on one side, with Julie Redman and her supporters on the other, Jessica Pollak seems to sit right in the middle. Pollak is the Family Planning Program Manager for the state of Louisiana, working within the Office of Public Health. As she makes decisions, she must balance her knowledge of public health against the politics of this state.

She also has to consider federal politics. Because the state receives federal Title X funding for family planning, it has to follow the federal government's lead and offer all FDA-approved contraceptive options within their programs. As a result, Pollak is now, according to federal regulations, working to expand use of emergency contraception in Louisiana. "But you can't get an appointment with our clinics within two weeks, much less 72 hours," she says. So she's looking at possible contracts with existing entities, like perhaps the women's clinic at Charity.

Pollak is ready to rattle off research and study data pertaining to nearly any topic. In the state of Louisiana, 52.5 percent of live births -- that excludes those who have abortions -- are unintended pregnancies. If emergency contraception was made available on a wider basis, she says, it might be able to make an impact on those "high unintendeds."

Pollak was recently disappointed when her department didn't receive any of the Temporary Assistance for Needy Families (TANF) funding that came to Louisiana this year. With TANF funding, she says, family planning could have 300 sites instead of its current 94. A mere glance across the border and around the United States shows what is possible -- Texas family planning gets $14 million out of their state's TANF and Social Services block grant funding. At least nine other states fund family-planning clinical services with TANF money.

There is good news, however, about lower teen pregnancy rates -- Pollak credits both increased contraceptive use and increased abstinence. She also notes an increase, from 8 to 20 percent, in the number of patients on the Depo Provera shot, which is more effective than the pill because there are no daily pill-taking errors.

Funding is so tight, however, that such news must be tempered by the knowledge that only a certain number of people can be reached with the available resources. Within the state, there are 314,000 women of child-bearing age whose income qualifies them for publicly funded family planning to prevent pregnancy. Appointments at the state's family-planning clinics are so sought-after that there's a four-month waiting period at some of them.

"We could double our sites," says Pollak, "and still have women knocking on our doors."

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