Photo credit: Stephen Cummings, flickr creative commons

The bill adds discussion of abortion as a cause of preterm birth to the health curriculum. Final House approval on the bill has been scheduled for Thursday, where it is expected to pass.

By Rose Hoban

After a contentious debate on the House floor, North Carolina lawmakers tentatively voted to require middle school teachers to instruct their students on the top five causes of preterm birth, and tell them that one of those causes is having had an abortion.

Senate bill 132 would put discussion of abortion into North Carolina classrooms for the first time, and make North Carolina the sixth state in the country to only mention abortion in sex education classes in the context of talking about potential negative consequences of the procedure.

Including abortion in the reproductive health and safety education curriculum has been hotly debated in committees as the science behind the proposal was picked apart, while lawmakers argued over the semantic difference between “risks” and “causes.”

“The reproduction part of the curriculum is around preventing teen pregnancy and sexually transmitted diseases and other diseases – such as heart diseases, cancer, diabetes and healthy activities – behaviors to benefit you,” said Vanessa Jeter, a spokeswoman for the Department of Public Instruction.

“We don’t really talk about abortion per se in the standards, so this would really open a new door.”

‘Go ask your mom’

Educators involved in working with teens regarding reproductive health said they were uncomfortable with adding language on abortion and preterm birth to the health-education curriculum.

“I think it would be very uncomfortable for many teachers to teach about abortion as a result of this bill,” said Donna Breitenstein, who runs the health education program at Appalachian State University and trains health educators from around the state.

“The Standard Course of Study in Healthful Living Education has not addressed the topic of abortion in the past,” she said, “and there’s not enough time in the school day to teach all the objectives.

Donna Bretienstein. Image courtesy Appalachian State University
Donna Bretienstein. Image courtesy Appalachian State University

“So when teachers select what they have to teach, they’re more likely to omit areas of teaching that are required if they perceive that it’ll be controversial in their communities.”

Breitenstein said local school boards have discretion over some of the topics in the curriculum mandated by the Healthy Youth Act. Some school districts have teachers stay away from hot-button issues, such as homosexuality and masturbation – and abortion.

“It doesn’t mean that students won’t ask questions. Different school systems have different policies about answering those questions, or referring students to parents or guidance counselors or school nurses,” Breitenstein said.

“Teachers are worried that once you start teaching sex education, people will show up with pitchforks,” said Elizabeth Finley, a spokeswoman for the Adolescent Pregnancy Prevention Campaign of North Carolina.

The current reproductive-education curriculum for middle schoolers teaches about the onset of puberty, resisting peer pressure, respecting their bodies, abstinence, contraception and other more prevention-oriented messages.

“Our position has always been that if you prevent pregnancy in the first place, you don’t need an abortion,” Finley said. “So there’s not really an in-depth discussion of what constitutes a healthy pregnancy, and now you’ll be inserting this random thing about how to avoid a preterm birth without any context.”

Under the bill, the Division of Public Health, working with the Department of Public Instruction, has 60 days to come up with materials to be used in middle school classrooms.

But Finley said even the best-created curriculum doesn’t mean that teachers will have in-depth conversations with students on “value-laden” information.

“Teachers will be standing in front of a classroom of curious seventh-graders, and the most likely thing is that teachers will get a very rigid lesson plan or a script that they’ll have to read,” she said.

“Some won’t stray from the prepared text. And the ones who’ve been well trained will say, ‘Some people think this, some people think that, go ask your mom,’ which is really how teachers are trained to address those things.”

Breitenstein said if lawmakers think this material will change behavior, they don’t really understand how teenagers think.

“How many 14-year-olds will say that if I have sex, and I might get pregnant, and then if I have an abortion, it might affect my ability to have a baby once I’m in my 20s and 30s?” she asked.

“They don’t think that far ahead to that many layers of consequences.”

Risk and cause

Arguments over the scientific evidence for saying an abortion can lead to subsequent preterm births hinged on a single Finnish study that  examined the medical records of more than 300,000 women over a decade, the vast majority of whom had had no abortions. For women without an abortion, about three in every 1,000 had a birth before 28 weeks.

About 4,000 women had had two abortions, and their risk of a very early birth rose to about six in 1,000. And for the 942 women who had had three or more abortions, their risk of preterm birth rose to 11 in 1,000 births.

SB 132 sopnsor Sen. Warren Daniel (R-Morganton)
SB 132 sopnsor Sen. Warren Daniel (R-Morganton)

Proponents of the bill said this study shows abortions cause later preterm births, even though the authors note, “Observational studies like ours, however large and well-controlled, will not prove causality.”

In a House health committee hearing Tuesday and on the floor Wednesday, legislators debated over the wording of the bill, which reads that the curriculum will teach “about the preventable causes of preterm birth in subsequent pregnancies including induced abortion, smoking, alcohol consumption, the use of illicit drugs, and inadequate prenatal care.”

The other risk factors for preterm birth listed in the bill have been extensively studied, with, in most cases, multiple studies supporting an assertion those behaviors add to the chances a woman will give birth prematurely.

“No single medical association recognizes that there’s a causal link between a legal abortion and preterm births,” said Rep. Jean Farmer-Butterfield (D-Wilson), noting that organizations as varied as the American Congress of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention and the World Health Organization do not support the contention that having an abortion can lead to a subsequent preterm birth.

During committee debate Tuesday, Farmer-Butterfield offered an amendment that would have changed all instances of the word “causes” in the bill to “risk factors.”

“I don’t think that we should get wrapped up in semantics of cause versus risk,” responded Sen. Warren Daniel (R-Morganton), the bill’s senate sponsor.

Daniel argued that the change would weaken the bill. “This is going to be in statutes, and once you get down in the classroom level, teachers may be using the word ‘risk’ because it’s a word that children understand.”

Rep. Jim Fulghum (R-Raleigh), a semi-retired neurosurgeon who supports the bill, said the two terms could be used interchangeably and the two definitions were “a distinction without a difference.”

“I would call it causation when you find evidence that an increasing incidence occurs associated with another factor, and that factor – when you eliminate that out as much as you can from other factors – that may be influencing the situation,” Fulghum explained.

Later, after the hearing, he said he didn’t see “any sense in making a fine point between the two.”

“We’re not using it in a scientific basis in the bill; we’re using it to say these are the lists of things that can cause you to have problems,” Fulghum said. “Those words are used interchangeably by physicians when talking to patients.”

But those who do scientific research disagree that the difference between the two words is merely semantic.

Russ Harris, a researcher at the UNC schools of medicine and public health, said the difference between risk factor and cause is “elementary,” something students learn in the first few weeks of classes.

“Let’s say that if there are some cohort studies where there is a statistical association between two things, that does not mean that’s causal,” Harris said. “Association is not causation. And that comes up time after time. They’re different things.

“If my students haven’t memorized that by about the third class, they fail the class, “Harris said.

Update June 27th: During the final House debate on Thursday afternoon, Rep. Paul Stam (R-Apex) proposed an amendment changing instances of the words “causes of” to “risks for” throughout the bill.  The measure passed 110-4.

Update July 2: Senators voted 32-12 Tuesday to concur with the House version of the bill, without debate. Now the bill makes its way to Gov. Pat McCrory for a signature.

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Rose Hoban is the founder and editor of NC Health News, as well as being the state government reporter. Hoban has been a registered nurse since 1992, but transitioned to journalism after earning degrees...