How 'Period Pills' Could Solve the Abortion Debate

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Brigid Bergin: It's the Brian Lehrer Show on WNYC. Welcome back, everybody. I'm Brigid Bergin from the WNYC and Gothamist newsroom and host of WNYC's Sunday politics show The People’s Guide To Power. I'm filling in for Brian who's off today. The abortion debate is a major component of the ongoing culture wars raging in the United States. With the decision to overturn Roe V. Wade this past June, numerous Republican-led state legislatures are instituting severe anti-abortion laws many of which do not make exceptions for rape or incest. These laws don't align with popular opinion. In fact, polls show a much murkier picture of Americans' beliefs about abortion.

In May, a Gallup poll found only 13% of people in the country believe abortion should be illegal in all circumstances. However, this does not mean the majority supports all abortions. No questions asked. This same Gallup poll reported that only about a third of Americans believe abortion should be legal under any circumstances. How do we deal with the diversity of opinions surrounding abortion in the United States?

Is there a compromise that could satisfy the majority of Americans? Joining me now, we have Abby Wendle, a producer with NPR's Invisibilia podcast, and Cari Sietstra, Director of the Period Pills Project. Abby recently reported on what scientists are calling "period pills" and a story titled a little bit pregnant. Abby and Cari, welcome to WNYC.

Abby Wendle: Hi, thanks for having us.

Brigid Bergin: So great to have you. Abby, some say that there's no way to be a little bit pregnant. What does it mean to be a little bit pregnant?

Abby Wendle: I know. It's like that joke. I talked with this woman, Allison Kaufman, and I'll just share her story because I think it like really illustrates the idea. Is that okay?

Brigid Bergin: Yes, absolutely.

Abby Wendle: Okay. Because I think it is a really difficult idea to get your mind around. Allison, this was a couple of years ago. She and her husband started trying to have a baby and it took him a couple of months but eventually, she missed her period and she tested and it was positive and that day she was like, "This is excellent. I'm pregnant, I'm going to have a baby."

A couple of weeks later, she went for her first prenatal exam. When the ultrasound technician started doing the exam, they couldn't find a heartbeat. There was no fetal cardiac activity. Allison's doctor told her that what she was experiencing was something called a missed abortion which is a type of miscarriage where, essentially, your body thinks that it's pregnant and so it continues behaving as though it's pregnant but it's not a viable pregnancy.

Allison, of course, was devastated. A couple of weeks after that experience, she actually received a bill from her insurance company which confused her because she had insurance coverage that was supposed to pay for all prenatal care. She called up the insurance company to be like why are you not covering this exam? The woman on the other end of the line said that because you didn't have a positive first exam, we don't consider you pregnant. That's not our definition of pregnancy. Yes, it was like an insult to injury and it really threw Allison into this tailspin about what is pregnancy like, "I was not pregnant? Who gets to decide that?"

Brigid Bergin: In this story, I think and I hope I'm not jumping ahead on you too much but I think part of that story helps you set up this thought experiment that you ask listeners to participate in centering around a pregnancy test as being how we understand what determines whether or not we're pregnant. I want to play a little clip from your story of researcher, Suzanne Bell tinkering with this idea.

[start of audio playback]

Suzanne Bell: Like Schrodinger's cat and that philosophy of the cat in the box could be dead or alive at the same point but until you open up the box and confirm, both realities could be true. In the same way, you could be perhaps pregnant and not pregnant at the same time but if you don't test you don't know.

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Brigid Bergin: Abby, how is it possible to claim that you're not pregnant simply because you haven't completed a pregnancy test?

Abby Wendle: I think it raises the question of like how we define pregnancy. I think the pregnancy test, culturally, in America right now it's so ubiquitous and there's an entire industry that exists around expecting to have a baby in nine months that really breaks pregnancy down into this binary. You pee on a plastic stick and it's a plus sign, it's a negative sign which makes it seem like this binary.

When you talk to doctors, which I talked to quite a few for this story, they'll talk about the fact that even the medical definition of pregnancy which is when a fertilized egg implants itself in the lining of the uterus, that's not something that happens in a binary way. That's not like a momentary thing where you're not pregnant and then suddenly you are, that takes days to happen.

Pregnancy might be better thought of as like a process that can be quite precarious, that it's never certain you're going to have a baby at the end of it until you actually have a baby at the end of it. I think it really gets at this idea that the definition of pregnancy is, in part, cultural. In America, in the 1800s, we have had different ideas about what the definition of pregnancy was.

It was when a woman felt quickening when she felt a baby move or kick inside of her because we didn't have a pregnancy test. We didn't have an external diagnostic technology that allowed us to detect a hormone in your urine. I think the idea that like the definition of pregnancy is like a fixed certainty is not maybe the best way to think about it and it's certainly not the experience that a lot of people who have the capacity to be pregnant experience, including Allison.

Brigid Bergin: Continuing on this thread, why would someone consider opting out of a pregnancy test?

Abby Wendle: Because they don't want to be pregnant and because they want to think about a missed period being a different kind of clinical condition. Their definition of pregnancy might not be rooted in having some HCG in their urine. A lot of people that I talked with talked about how pregnancy isn't just a bodily reality, it's a state of mind. It's a desire to have a baby and be a parent.

Also, it's important for us to remember that there's all sorts of reasons that people do miss periods aside from just being pregnant. There's medical conditions that people have. Irregular periods are very common. I think to jump to the conclusion that a missed period is a pregnancy is maybe not the best way, it just doesn't take into considerations those other experiences that people have. When talking about period pills, it gets it fundamentally like how does that person want to define pregnancy in their own life?

Brigid Bergin: Let's talk about period pills, what they are and how they work.

Cari Sietstra: Sure.

Abby Wendle: Hi Cari.

[crosstalk]

Brigid Bergin: Jump in there, Cari.

Cari Sietstra: Sure. Thanks for having me. Period pills are essentially the same pills that we use for very early medication abortion. They are misoprostol either alone or with mifepristone and they cause the uterus to contract and expel its context. They bring on bleeding whether or not someone is pregnant if their period is delayed. I think one of the real benefits around period pills, as Abby has mentioned, is that it can really embrace someone's lived experience, especially of ambiguity around the beginnings of a possible pregnancy.

We know that people can have a urine pregnancy test and it shows a raised level of HCG if it's positive but we also know that doesn't necessarily mean that someone has an ongoing pregnancy. That could indicate they have applied at ovum. It could indicate that they did have an embryo that was beginning to implant, that has already stopped developing and will be shed within a day to three days and it could indicate that there's an embryo that's still developing, that will stop at some point in the next two or three weeks.

Of course it can also indicate that you are at the beginning of what will become a viable pregnancy that would end in a live birth without intervention. For a lot of folks who have a late period, there's what Suzanne Bell has termed productive ambiguity. This time period of not knowing and so period pills give folks the option which we have technologically, we've used these pills safely for over 30 years both internationally and in the US, to take action.

During that ambiguous period, should they want to, to ensure that they are not pregnant without ever needing to enter Western late 20th century scientific conceptions of a pregnancy binary which, by the way, is complicated, there are a number of binaries around pregnancy. Quite religious people see the fertilization of an egg as the binary. As Abby mentioned, in Western medicine, we've seen implantation as the binary, but it turns out that the more we know about very early embryonic development implantation itself is this multi-stage process.

Then, of course, for lay folks it's often this positive pregnancy test, but I think as anybody who's gone through IVF can tell you, the women often have this experience of getting a positive pregnancy test. Then bleeding within 24 to 72 hours which, in the IVF community, folks often refer to as a chemical pregnancy because it's so early, it hasn't been able to be confirmed by ultrasound. While we often again think about this binary, it's much more complicated both scientifically and in people's real lives at times and we can think about using that productively, if we want to.

Brigid Bergin: Cari, you are part of a national working group on period pills. Can you talk a little bit more about who's in the group and what exactly you're advocating for.

Cari Sietstra: Sure, I'm happy to. The national working group on period pills has 22 members at this point from 12 different advocacy and research organizations, all of which work in reproductive health and justice in some way. The group is really dedicated to pursuing more research in the United States around period pills because we have great peer-reviewed research from other countries, but we know that often medical folks in the US really prefer to have US-based research as well and then to pursue education and advocacy around period pills as an option for fertility control in the United States and to make period pills available.

I think one of the real successes that we've had at the Period Pills Project which is one of the member groups in the working groups, is that period pills are now available in six states and the District of Columbia via telehealth and so they are in fact a real option in parts of the United States today.

Brigid Bergin: That's so interesting. Abby, in your reporting, you use the phrase menstrual regulation. Can you describe what that is?

Abby Wendle: Menstrual regulation is like an ancient practice that has existed all over the world where people have done things to restore their menstruation when it's late and they don't want to be pregnant. Historically, people have used herbs, tinctures teas. Like I mentioned, in the 1800s, there was something called female monthly pills that I think there were even traveling salesmen who would go around to give to women and it's basically just the idea of restoring your menstruation to a normal cycle.

Brigid Bergin: Which is something that I think a lot of women sometimes struggle with. If you're just joining us, I'm Brigid Bergin from the WNYC and Gothamist Newsroom filling in for Brian today. We're speaking with NPR's Invisibilia producer, Abby Wendle and Cari Sietstra, Director of the Period Pills Project. Listeners, we want to hear from you, would you ever consider taking period pills or is there an instance in your past where you wish period pills were an option? Maybe menstrual regulation is a practice in your culture and you have some knowledge you'd like to share about it.

Doctors and abortion providers, would you feel comfortable with administering period pills and providing the option to opt out of a pregnancy test. Call in, we'd love to hear your answers and your questions for our guests at 212-433-WNYC, that's 212-433-9692 or you can tweet @BrianLehrer. Though listeners might not be familiar menstrual regulation as you were saying, Abby has a history in this country. I want to play another clip from your piece of Michelle Drew, a midwife you spoke with, her grandmother was also a midwife and used to treat "missed periods" before Roe V. Wade. Let's take a listen.

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Michelle Drew: Someone would come in and it would be around I'm late. My courses are late and her eliciting, well, when's the last time your courses came on? Was it last month? Was it the month before?

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Abby Wendle: Conversations would go on like this, sometimes a physical exam until Michelle's grandmother was satisfied. She knew just how many courses were late, but at no point during any of this would anyone ever mention pregnancy.

Brigid Bergin: Abby, I think we may have some listeners who are now wondering is this just a question of semantics. How is this different from abortion?

Abby Wendle: That was the response from my editor at first, to be honest, and also, my current husband, he's a biologist. I think Cari and Wendy both they encountered similar feedback from people in the Abortion Rights Movement and journalists and doctors when they first started talking about this idea. The period pill working group, they did a survey back in 2015 where they asked people who were at clinics in two different states if they would be interested in instead of taking a pregnancy test when they went to the clinic, if they could just get pills in order to bring their period back without confirming formally whether or not they were pregnant.

40% of all of those people said, yes, they would love to have the pills instead of taking a pregnancy test, and 70% of people who definitely did not want to be pregnant were interested in having the pills. While I think an outsider can look at it and raise the question of whether or not it's semantics, I think for a person who is in the position of needing healthcare for them it's very easy for their mind to expand and for this to answer a need that they feel like they have.

Brigid Bergin: It's so interesting. You've talked about how there are other parts of internationally where the use of these pills is relatively common. I'm wondering, are there countries that have abortion bans in place, but that allow for menstrual regulation?

[crosstalk]

Abby Wendle: Oh, go ahead, Cari. No, go ahead.

Cari Sietstra: There are two countries where menstrual regulation is legal today. One of which is Cuba, where abortion is also legal, but the other is Bangladesh and in Bangladesh abortion is illegal, but menstrual regulation is both available and publicly promoted as an important part of maternal health. There are reasons that are culturally specific in Bangladesh around some conceptions within Islamic tradition around when installment occurs that make menstrual regulation a particularly good fit in a more conservative Islamic culture.

We also know that these sorts of threshold liminal practices are quite common culturally in a number of countries including ones in South Asia and some in Southeast Asia, as well as Latin America and the Caribbean and South America. That often, culturally, at least, they're seen as maybe an easier first option than formally engaging in an abortion. Often we see people try to take action in all sorts of contexts when they think they may be pregnant and don't want to be starting with something that feels gray and potentially easier like a tincture or tea or pills and then moving to more intense interventions as needed if their periods doesn't come down.

Abby Wendle: Could I add on to that we [unintelligible 00:20:05] with an activist in Peru, where I believe abortion is illegal? She helped put people in touch with people who could get them medications. People came to her both for abortion medication, but also for, they weren't calling them period of pills, but for ways to regulate their menstruation. She said that it was really interesting because the people who came to her seeking menstrual regulation services were just like, much more relaxed and much calmer and that in Peru, at least talking about menstrual regulation is more open and more accepted, than being able to talk about, having an abortion.

Brigid Bergin: I want to go to one of our callers. Let's bring in one of our callers. Carmen in Brooklyn has a question, Carmen, Welcome to WNYC.

Caller: Hi. Thanks so much for taking my call, actually told the screener that I felt compelled to call in because I had a medical abortion last week. I'm someone that's always been very active in Planned Parenthood rights equal access to women's healthcare. I'm curious because this is actually the first time I've ever heard of the term like a period pill, I've heard of plan B, obviously heard the abortion pill. I'm just curious about how this is different and how this can be properly communicated to people so that they better understand that the period pill is not, in fact, abortion or is not, in fact, a contraceptive.

Cari Sietstra: That's a wonderful question, Carmen. I also just want to affirm your bravery and openness and talking about your abortion last week, and I hope you were feeling well. Plan B, which will prevent ovulation, is something that you can take before or during ovulation to try to prevent pregnancy. Period pills are the same pills we use for a medication abortion, so just like the pills you took last week for an abortion, this is either misoprostol alone or misoprostol with mifepristone taken before it to increase its speed and efficacy. To be really clear, period pills will cause an abortion if someone is pregnant.

Some of the advantages though of period pills is that they can be taken even earlier than most providers will provide medication abortions so they can be taken when someone is just three or four or five days late with their menses and that they will also bring down a period in most cases if someone is not pregnant. For those who would prefer to stay within that range of ambiguity, they offer an earlier and different choice than medication abortion would, which people might want for lots of reasons.

The question of educating folks, this is a big piece of what we struggle with in the working group, that this is a complicated gray space in a very emotional context, where folks have very strong opinions, where we know that there are folks who are opposed to abortion, who see even oral contraceptive pills as being a board efficient. Trying to be very clear about what these pills are and how they work is, I think, one of the most important pieces of work we have, so that people can be clear when they choose to take them what is happening in their bodies, and make sure that is what they want to choose.

Brigid Bergin: Carmen, thank you so much for calling, and please feel free to call us again. Cari, thank you so much for that explanation. I think that gets at a question that I want to ask both you and Abby to weigh in on, which is, this conversation is that much more-- The tension around it is that much higher because of everything that has happened this summer. I'm wondering, and let's start with you, Abby, how do period pills fit into the new reality of a post-rural America where abortions are available in some states but not others?

Abby Wendle: My impression and Cari, feel free to jump in to, is that we just have to wait and see. First, period pills have to catch on as an option that prescribers prescribe. Then we'll have to wait and see how it plays out in the courts. From the where's that we spoke with, in places, states where abortion is not an option anymore, probably period pills would also be struck down as something people could do. We spoke with other lawyers who said that if-- Well, actually, Cari put it really well in the piece that putting pills into people's hands in progressive states is a great way to put pills in people's hands, that can help increase access.

Brigid Bergin: Sure. Go ahead, Cari.

Cari Sietstra: I think Abby's right on all of those points. I would only add that there may be longer-term benefits, culturally, to embracing a more gray area at the beginning of possible pregnancy, that not only do period pills me that folks in progressive states can get these pills as often as once a month really without a positive pregnancy test. That's very empowering that's lots of pills in people's hands. It may also mean that there is a little bit more psychological space for everyone to take a step back from such a black-and-white argument.

To say, well, there, there's actually a very scientifically accurate way of looking at this that reflects many people's lived experiences that isn't black and white. I think in such a polarized environment, the long-term benefits of being able to embrace some ambiguity, and grayness may be really positive for folks in blue and red states.

Brigid Bergin: Cari, just to build a little bit on that, there are some folks who might hear this conversation who are pro-abortion and may feel like, period pills feed into abortion stigmas. Anything you would want to say in response to that?

Cari Sietstra: I think it is a valid concern. What I generally say in response is that you can trust that the folks who are trying to make period pills more accessible are firmly within the reproductive justice community, and we will never set this option and opposition to abortion as if one is good, and one is not. I think it is safe to say that given that anti-choice folks often disapprove of Plan B, emergency contraception, IUDs, and even oral contraceptive pills, they are not going to hold up this option as the good moral option as opposed to abortion.

I think as long as we are very mindful that this is another piece of a spectrum of choices that fills in for many folks, a time where currently we don't have options that empower us to make fertility decisions, right after our periods are late, and we're worried we might be pregnant, that there are certainly ways that we can embrace both period pills, and save legal accessible abortion and hold them together and not pit them against each other. That's certainly what we're trying to do.

Brigid Bergin: Cari, finally, the kind of political question at the heart of this, in some ways, would the expanded education around period pills, potentially, be a way to appeal to more moderates? What do you think about that?

Cari Sietstra: I think that there are folks on all parts of the political spectrum who might find this embrace of people's lived experience and productive ambiguity to be helpful, and that includes moderates. I think there are so many different reasons why people might find this option to be attractive that it could apply to people on all parts of the political spectrum. I've probably had over 200 conversations with women and non-binary folks who can get pregnant about this as an option. I have yet to encounter a person who doesn't say something to the extent of, wait, we could do this, we can take pills when we're late, and is safe.

They know this, like why can't we do that? While I think it may appeal to moderates, I don't think that it is limited to moderates or that that is the primary reason to try to make this really quite empowering option available to everyone who's at risk of becoming pregnant so that they can make earlier decisions in a demedicalized context that meet their needs.

Brigid Bergin: It's a really fascinating story. We're going to have to leave it there. Our guests have been Abby Wendle, producer of NPR's Invisibilia podcast, and Cari Sietstra, Director of the Period Pills Project. Thank you both so much for joining us.

Abby Wendle: Thanks.

Cari Sietstra: Thank you for having me.

 

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