With one of the nation’s highest teen-pregnancy rates, Baltimore and the state of Maryland have been leaders in sex-education and birth-control programs. The efforts have had some success. Since 1989, teenage pregnancies have steadily fallen; still, teenagers gave birth to nearly a quarter of the city’s babies last year. Baltimore provides contraceptive counseling at the school-based clinics and even dispenses birth-control pills and condoms. Only a handful of urban districts have such extensive programs-largely because of community opposition. Norplant puts Baltimore even farther out in front, but a spokesman for Mayor Kurt Schmoke said he hadn’t heard any criticism of the new plan. Since 1989, even the number of teen abortions has dropped.
Norplant will create new challenges for the city. The Norplant system consists of six capsules implanted in a woman’s upper arm by specially trained medical personnel, usually either a physician or a physician’s assistant. The capsules automatically release low doses of the hormone progestin, which prevents conception, for five years. During that time, Norplant is estimated to be 99 percent effective in preventing pregnancy. The cost is $500 to $750 per patient. In Baltimore, some of the cost may be covered by foundation grants; Medicaid also covers Norplant. At the end of five years, the capsules are removed. Physically, there are few known side effects; the most common is irregular bleeding.
But Norplant raises many complex public-health and ethical issues that worry experts in teen pregnancy. Girls who use Norplant are less likely to use condoms, says Rebecca Stone of Chicago’s Ounce of Prevention Fund, which operates three school-based clinics that do not provide Norplant. And condoms, combined with foam, are the best method for preventing the spread of sexually transmitted diseases and HIV, which causes AIDS. “It’s hard enough to get anyone, let alone teenagers, to use one contraceptive, never mind two,” says Stone.
Counseling is crucial as girls make choices about whether to be sexually active and which methods of birth control to use. “What I wonder about,” says Ellen Moskowitz of the Hastings Center, a bioethics think tank, “is how are we going to draw the line between education, directed counseling, legitimate inducements and illegitimate coercion.” The issue is especially sensitive if Norplant is provided only to inner-city minority teens. “That’s singling out a group that’s particularly vulnerable,” says Moskowitz.
But other researchers say Norplant is especially useful for teenagers, who may take birth-control pills erratically or fail to use condoms every time they have intercourse. “Norplant is going to be a huge boon,” says Laurie Schwab Zabin of the Johns Hopkins School of Hygiene and Public Health, who has studied teenage pregnancy in Baltimore. “We need long-term methods because failure rates are high” with other contraceptives, she says. Jane Johnson, vice president of Planned Parenthood, says her organization has inserted Norplant in 30,000 women. “It’s been very popular and well received,” she says. “There’s no reason why it shouldn’t be an acceptable method for adolescents.”
In Baltimore, officials say they’re going to provide extensive counseling, not just about Norplant but about all health issues related to sexual activity. Stith, the Paquin principal, says many students were interested in Norplant but had trouble getting it. “They had to be referred to a clinic; they had to take their paperwork to a certain place and make an appointment and remember to keep it. With all that, the incentive for some girls was gone.” The school-based clinic can provide all those services in one place, she says. With such a high pregnancy rate, “everyone knows something has to be done,” Stith says. “Hopefully we can find a way to overcome this.”
