Long-Awaited Abortion Pill Will Offer More Privacy--But No Less Controversy
Four years ago, Rory Hoag was a 22-year-old on a study-abroad program in Paris when she unexpectedly found that she was pregnant. She made the painful decision to end the pregnancy--and then faced a further anxiety. "The idea of having an invasive surgical procedure in the context of a medical system I didn't understand and with doctors I didn't know really scared me," she recalls. "And I didn't want the other students to know what I was going through." In France, though, there was an alternative: abortion by medication instead of surgery.
A gynecologist prescribed a drug called mifepristone, commonly known as RU-486. Two days after taking it, Hoag went to the hospital, where she was given another drug, misoprostol, to induce uterine contractions. After four hours of nausea and intense cramping, she went home. Hoag, who now runs a Planned Parenthood clinic in Gainesville, Fla., says she was relieved not to have to go in for surgery. "I was able to go to the doctor and keep the matter private."
Mifepristone has been available in France for 11 years and has gained regulatory approval in 13 other countries, but the passionate politics of abortion in the United States has kept it off the market here. That may be about to change: Final talks are underway between the Food and Drug Administration and the Danco Group, the company sponsoring mifepristone in the United States, to clear appro-val for the American market. Called Mifeprex, the drug could be available sometime this year.
No easy solution. For women who have made the decision to end a pregnancy, medical abortion can offer the comfort of being at home for much of the process. Women who have taken part in clinical trials of mifepristone in the United States say they appreciate the privacy. "I wanted to share this just with my partner," says one 36-year-old woman from Washington State who requested anonymity. And activists on both sides of the abortion debate agree that the pill may ultimately broaden access to abortion for American women. One Kaiser Family Foundation survey of over 750 physicians and nurses, most of whom are not abortion providers, found that over half said they were likely to incorporate mifepristone into their practice. "Lots of doctors are not surgical types," says Diana Dell, assistant professor of obstetrics/gynecology and psychiatry at Duke University Medical Center. "They are going to be more comfortable offering an early-stage, medical procedure."
Mifepristone won't make abortion as simple as popping a pill, however. A medical abortion resembles a miscarriage. The Washington woman took the misoprostol at home and spent the next few hours experiencing intense cramping and bleeding. "I didn't expect it would last so long," she says. The logistics aren't easy, either, involving at least three visits to the doctor as well as a few hours of bed rest. The method will be subject to the same legal restrictions as surgical abortion, and those who believe abortion is wrong think it is no less wrong when the means is medical rather than surgical.
For women who decide to seek an abortion, mifepristone has some clear advantages. Surgical abortions, in which the uterus is emptied by suction or other means, often cannot be done until several weeks after a woman learns she is pregnant. Mifepristone, by contrast, is more effective the earlier in pregnancy it is used.
The drug works by blocking the action of the naturally occurring hormone progesterone, which is crucial in the earliest stages of pregnancy, helping to build the lining of the uterus to support the fertilized egg. When it is blocked, the lining breaks down, and bleeding often begins. Misoprostol, which is an approved ulcer medicine, is given two days after the mifepristone. Misoprostol causes the uterus to contract and expel the fertilized egg. In women who have been pregnant for 49 days or less, the regimen works 92 percent of the time. When it fails or causes excessive bleeding, doctors perform a surgical abortion.
Learning curve. An estimated 500,000 women in Europe have taken mifepristone, as have thousands more in clinical trials in the United States. Its safety record is generally good, doctors say, although it should not be used in peo- ple taking corticosteroids, often given for asthma, or blood-thinning drugs.
Doctors say that patients should be counseled and monitored carefully, because the cramps and bleeding can be alarming. "If you do the counseling right, the phone doesn't ring," says Richard Hausknecht, associate clinical professor of obstetrics and gynecology at Mount Sinai School of Medicine, who has provided over 3,000 medical abortions during clinical trials of mifepristone and in an off-label use of a cancer drug called methotrexate. "But if you don't do the counseling right, you will not sleep."
Doctors need to learn how much bleeding and pain is acceptable, so that they don't intervene too early with a surgical abortion. "There is no question the learning curve is steep with this drug," says Hausknecht. As a result, says Caroline Westoff, medical director of family planning at Columbia University, doctors who do not perform abortions now may be slow to offer mifepristone. "This is not going to be like a new diet drug," she says.
Nor will medical abortion be any less expensive than an early-term surgical procedure, which typically runs between $350 and $500. Between a third and half of workers with health insurance are covered for abortion, according to a recent survey conducted by the Kaiser Family Foundation, and their plans are expected to cover mifepristone, too. Under federal law, Medicaid covers abortion only when the pregnancy results from rape or incest or endangers the life of the mother, although some states have expanded Medicaid coverage.
Other barriers facing women who seek an abortion will not disappear with the approval of the drug. Troy Newman, director of Operation Rescue West, an anti-abortion group in Los Angeles, says the organization plans to picket places where the drug is available. "We will treat medical abortion no differently than any other method," he says. "We will be picketing and protesting at any abortion clinic or provider, even if it is a pharmacy." And state laws mandating waiting periods or parental notification or consent for abortion will apply to the new drug as well. "This is not going to be a cosmic revolution," says Michael Burnhill, vice president of medical affairs for Planned Parenthood. "What it is, is an advance."
WHERE TO LEARN MORE Getting it. The National Abortion Federation hotline, 800-772-9100, will provide referrals to physicians and clinics offering mifepristone once approved.
Medical details. The Population Council Web site, www.popcouncil.org, describes mifepristone safety, use, and trials. Follow links through "Reproductive Health and Family Planning."
The morning after. The hotline at 888-NOT-2-LATE gives referrals to local health care providers willing to prescribe emergency contraception.
This story appears in the February 28, 2000 print edition of U.S. News & World Report.