When RU-486, the French abortion pill, was approved by the Food and Drug Administration last September, rural North Dakota seemed like just the kind of place where the drug might radically change the availability of the procedure. The pill induces a miscarriage if it is taken in the first seven weeks of pregnancy and can be administered by family practitioners or gynecologists. “The hope was that physicians could provide this in an office setting, and it would broaden access to abortion in rural areas,” says a New Jersey abortion provider, who participated in the RU-486 clinical trials.
Instead, the same political forces and anti-abortion groups that stalled the FDA approval process are now interfering with the drug’s distribution. In addition, the medical reality of administering RU-486 (known as mifepristone in the United States and marketed under the name Mifeprex) has discouraged many doctors from offering it to patients. Nearly nine months after coming to market, Mifeprex is still not available at all in some states. In those where the drug is prescribed, it is usually offered only at clinics that already provide surgical abortions. A recent survey of 30 Eastern colleges conducted by the anti-abortion American Life League revealed that only one college health center, Yale’s, is offering the drug to students.
TANGLED HISTORY
Abortion-rights advocates fought for FDA approval for RU-486 legalization for more than a decade, believing the drug could spare women long journeys to clinics and confrontations with anti-abortion activists who gather outside them. The process was fraught with political and bureaucratic obstacles. Clinical trials in the United States finally began in 1994. Two years later, The FDA deemed the drug “safe and effective,” but it couldn’t grant final approval until a manufacturer was named. It took another four years to locate a company willing to produce the controversial drug.
Almost immediately, anti-abortion groups launched national campaigns to dissuade private practitioners from giving the drug to patients. “Abortion is abortion, it doesn’t matter if its chemical or surgical,” says Jeremy Bowen, executive director of Believers Against Child Killing, an Oregon-based group. “We’ll picket their offices. This pill is a human pesticide, and we’ll treat it as such.”
Life Dynamics, another anti-abortion group has sent mailings to more than 100,0000 physicians, informing them that any doctor who provides Mifeprex to patients will be “identified, labeled, exposed, stigmatized, ostracized and in every way treated exactly the same” as those performing surgical abortions. The organization has set up a Web site called RU486registry.com, where it posts the names of doctors who offer Mifeprex.
Some doctors are getting the message. “The doctors here are terrified of the right-to-lifers, who are very active,” says Jane Bovard, who runs the Red River Women’s Clinic in Fargo. " I can’t see any doctor in this state providing this in their offices."
The Bush administration has begun its own effort to prevent widespread use of Mifeprex. During his Senate confirmation hearings, Secretary of Health and Human Services Tommy Thompson promised an FDA review of mifepristone, citing “safety concerns.” In late March, the Bush administration informed state Medicaid offices that government health plans would only pay for Mifeprex coverage under rare circumstances such as rape or incest.
NO EASY FIX
But political concerns are not the only reasons doctors have been slow to embrace mifepristone. The drug is time-consuming to administer. “It’s not like you walk into a clinic and the doctor says ‘hey, here’s your pill,’” say Ron Fitzsimmons, executive director of the National Coalition of Abortion Providers. Mifeprex generally requires two to four visits to a doctor, whereas a surgical abortion often takes less than 15 minutes. “In some ways, ’the abortion pill’ is an unfortunate name because it tends to oversimplify,” says Fitzsimmons.
On the first visit, provided the state does not have mandatory waiting-period laws, the doctor gives the woman Mifeprex in a pill form. The pill blocks progesterone, a hormone that prepares the lining of the uterus for a fertilized egg. Two days later, the patient must take a second drug, called misoprostal, which immediately causes the uterus to contract and expel the fetal tissue. In most cases that process takes less than four hours, but it causes heavy bleeding and cramping. For many women, the pain is comparable to a bad period, but bleeding and spotting can last between nine and 16 days. Two weeks after taking the drug combination, the patient must return to the doctor for an ultrasound to make sure the abortion actually occurred. The pill is ineffective in about 5 percent of women, which means they have to follow it with a surgical abortion.
Beyond the time commitment and repeat visits associated with offering Mifeprex, doctors face still more considerations. “You’ve got so many tangential issues when it comes to abortion,” say Fitzsimmons. “You’ve got to think about counseling for your patients, malpractice issues, security for your staff and equipment. Some doctors have to buy an ultrasound machine. You can’t just stop on a dime and start offering this.”
Despite the inconveniences, many doctors say the drug has benefits for women who view surgical abortions as invasive and view the pill as a more “natural” procedure. “My patients are incredibly happy with this method,” says Dr. Linda Prine, a New York City family practitioner who is one of the few doctors in the nation openly offering the drug from her private office. “It’s an option that allows women to feel more control over what’s happening. If you can take medication and be in charge of the situation yourself, many women feel better about that.” Prine, who also performs surgical abortions one day a week at a clinic, lectures regularly at medical teaching conferences about mifepristone, to encourage young doctors to offer the pill when they go into practice.
Danco Laboratories, which distributes the pill, says orders for Mifeprex and calls from curious physicians have been slowly increasing since they began shipping the pill in November. Many doctors say despite the slow start, it’s still too early in the drug’s legal life to assess how widely it will catch on. Demand could drive increased distribution as more women begin requesting the pill from their physicians, and doctors become more familiar with the method.
“It’s a sea change, not a revolution,” says Fitzsimmons. “These folks are human, it will take time.” He adds that doctors’ initial hesitance to embrace mifepristone is not entirely a disappointment for the abortion-rights community. “People should want their physicians to be cautious and not jump into it without knowing what it’s about. You don’t want some sleaze who doesn’t care about women offering mifepristone on the street corner.”
In the meantime, women seeking to end their pregnancies in rural North Dakota will continue their journeys to the Red River Women’s Clinic in Fargo for surgical procedures. The clinic hopes to begin offering Mifeprex some time in the fall.
