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Baltimore Plan To Offer Norplant Raises Ethical, Medical, Legal Questions

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A number of educators, church officials, and health organizations have voiced concern over the decision of public-health and school officials in Baltimore to begin offering Norplant, the surgically implanted contraceptive, in school-based health clinics next month.

Baltimore is the first school system in the nation to offer the long-term contraceptive to its students, in an effort to combat a skyrocketing teenage pregnancy rate, according to Planned Parenthood of America.

The controversial program, run by a consortium of public-health officials, hospitals, and a private foundation, has raised a number of ethical, medical, and legal questions.

"We present a mixed message in this program, that we really don't have the confidence in our young people, that they can't say no,'' said Ronald Valenti, the superintendent of schools for the Roman Catholic Archdiocese of Baltimore.

The Baltimore city school board, which was one of the first in the nation to approve the distribution of condoms in schools, has authorized that Norplant be offered alongside condoms, diaphragms, and birth-control pills in public school clinics.

The Lawrence Taquin School, a high school for girls who are pregnant or have had babies, will begin offering the contraceptive in January, school officials said. Six additional schools plan to stock the contraceptive sometime next spring.

"Because we have a high pregnancy rate, we are looking for any innovative, sound, medically proven ways to deal with this complex issue,'' said Nat Harrington, a district spokesman.

In Baltimore, 97 out of 1,000 girls between 15 and 17 years old gave birth in 1990, three times the statewide average, according to state and local health officals.

'Coercive Potential'

Norplant consists of six matchstick-sized capsules, surgically implanted in a woman's upper arm, that slowly release a dose of the contraceptive hormone levonorgestral to prevent ovulation over a five-year period, according to Wyeth-Ayerst Laboratories, the drug's manufacturer.

The device has been shown to be as effective as birth-control pills, yet a woman's fertility is restored within 24 hours after the capsules are removed, according to Audrey Ashby, a Wyeth-Ayerst spokeswoman.

The insertion takes less than 10 minutes and must be performed by a trained health-care worker, according to the firm.

Since it was approved by the Food and Drug Administration in 1990, more than 500,000 women have used Norplant. But the contraceptive is relatively expensive, costing as much as $700 for the capsules, counseling, and insertion procedure.

In Baltimore, the Abell Foundation, a philanthropy based there that funds education and social programs in the state, has made a grant of $400,000 to the public schools as part of its wider effort to provide opportunities for women in the economically "gray areas''--those who do not have medical insurance but are not eligible for Medicaid--to purchase the device at a reduced cost.

Medicaid covers the cost of the implant in all 50 states.

But whether this program is a social equalizer or an invasive instrument of public policy is a question many health experts and educators are grappling with.

Some note that these teenage women must be adequately informed of the side effects of the drug, which can include irregular menstrual bleeding, headaches, mood swings, weight gain, and acne, according to the Alan Guttmacher Institute, a nonprofit reproductive-research organization.

Others fear that officials might use the contraceptive in a manipulative manner.

"The coercive potential of these methods is enormous,'' said Ellen Moskowitz, a lawyer with The Hastings Center in Briarcliff Manor, N.Y., which is conducting a two-year study of ethical concerns about long-acting contraceptives in the United States. "It is a big step; you have to have real informed consent,'' she added.

Education Campaign Planned

Some family-planning experts believe these fears are exaggerated.

"Youngsters who make this choice understand their rights,'' said Jane Johnson, the vice president of Planned Parenthood of America. "The more methods women have the better,'' she added.

A concern that all parties share is that Norplant might lull teenage women into a false sense of security, making them less likely to practice safe sex and, therefore, more vulnerable to contracting sexually transmitted diseases, including AIDS.

But Planned Parenthood, which is a partner in the consortium, says it plans to link the distribution of Norplant with a vigorous education campaign about the necessity to use a condom for protection against these diseases.

"We have to remind teens that Norplant will not protect them against H.I.V.,'' Lisa Geeson, a spokeswoman for Planned Parenthood of Maryland, said of the virus that causes AIDS.

Racial Impact Assessed

Use of the device has also sparked controversy about the ethics of targeting a long-term contraceptive mainly at poor black teenagers.

Eighty-one percent of students in the Baltimore public schools are African-American, while 17 percent are white, according to school officials.

"Norplant is a simplistic solution to the complex question of teenage pregnancy, and it is aimed at controlling the reproduction of people with the least amount of power in this country,'' said Julia Scott, the director of public education and policy at the National Black Women's Health Project, who calls the program an exercise in "social engineering.''

"The potential for racially discriminatory use is enormous, given the rich history in this country of [violations of] informed consent,'' Ms. Scott said.

"When you start targeting women of color and poor women for Norplant, it raises questions of propriety,'' echoed Ms. Moskowitz.

But Rosetta Stith, the principal at the Lawrence Taquin School, said this is precisely the population that is requesting the device. Ms. Stith said 20 percent of her students, most of whom are poor and black, are seriously considering using Norplant. Nationally, 71 percent of Norplant users are under age 30, according to the manufacturer.

"Norplant is giving them an opportunity to finish high school and college, and allows them to have a life,'' Ms. Stith said.

The heated debate surrounding Norplant may be due in part to the fact that many people first became aware of the contraceptive in a coersive legal context. In a 1991 California case, Norplant was offered to a woman convicted of child abuse as an alternative to serving time in jail.

And in five states, lawmakers have proposed legislation that would require women receiving public assistance to use Norplant, according to the American Civil Liberties Union.

"The use of a birth-control method as a 'stick' would be anathema to anyone concerned with civil liberties,'' said Estelle H. Rogers, the public-policy director of the A.C.L.U.'s reproductive-freedom project.

"It is as shocking as sterilization was for male criminal offenders, a practice the Supreme Court ruled as unconstitutional years ago,'' Ms. Rogers said.

The American Medical Association this year condemned the practice of ordering the use of Norplant as part of a criminal sentence.

Although the device has been proved medically safe for older women, no tests have been done on the medical or psychological effects of Norplant on women under age 18, said Ms. Scott of the black women's health project.

"We don't know what kind of impact it will have on the growing bodies of young women,'' Ms. Scott said.

"I hate to think of poor teenagers being guinea pigs,'' she added.

Other health professionals counter that Norplant is well researched and has proved safe and effective for European women for two decades.

The Baltimore consortium, in addition to distributing Norplant, plans to advertise in health clinics and introduce discussions of the contraceptive in sex-education classes.

The consortium will provide teachers with training manuals to include discussions of Norplant in the school's family-life classes, attended by 95 percent of the city's public high school students.

Birth control must be dispensed as part of a comprehensive social policy and not isolated from other causes of teenage pregnancy, many educators say. Policymakers should instead be focusing on providing better education and housing, Ms. Moskowitz argued.

"Norplant is not a magic bullet--it is not the key to getting women out of poverty,'' she said.

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