RU-486

Don't believe the hype. The 'morning after' drug does not offer women in need of abortions a safe, private alternative to visiting a clinic

by Margaret Doris

Somewhere tonight, somebody will forget to take a pill. A condom will break, a diaphragm will be left on the bathroom shelf. Last call will be followed by lost judgment. It will be many days before the consequences are clear.

But a month from now, women will be able to make a choice about ending a pregnancy that women cannot make today. Last week, the federal Food and Drug Administration (FDA) approved the sale in this country of the abortion pill, mifepristone -- or RU-486, as it has been known for many years. Danco Laboratories, the small, private company that holds the US distribution rights to mifepristone (or "Mifeprex," as they call it), says it plans to ship the first drug orders to abortion providers in four weeks. Across the country, many women and their health-care providers are eagerly looking to mifepristone as a way to de-surgicalize the abortion procedure.

And why not? After all, an abortion pill is something a woman can take in her own home, isn't it? She would not have to cross protest lines at an abortion clinic, or cede control of her body to medical practitioners.

"Some women will prefer having an option that's noninvasive, that they perceive as more `natural,' " says Pam Nourse, public-affairs director for Planned Parenthood of Massachusetts. But, she acknowledges, "noninvasive" does not mean an at-home, do-it-yourself procedure.

Indeed, if the drug is administered according to the manufacturer's recommendations and FDA guidelines, mifepristone abortions require a minimum of three medical visits, at least one more drug, and additional medical procedures such as a vaginal ultrasound. When a woman is judged to be an acceptable candidate for the procedure, she is given the mifepristone in the form of three pills, which she may be required to swallow in the presence of a doctor or nurse. Thirty-six to 48 hours later, the woman returns to the clinic to receive prostaglandin, which in this country will be in the form of misoprostol, a drug originally approved by the FDA to treat ulcers. This blocks production of progesterone, a hormone that is necessary to maintain pregnancy. It will cause the uterus to contract, expelling the fetal tissue.

A little less than two weeks later, the woman must return again, so a physician can determine whether the abortion is complete. If not, it must be finished surgically. Mifepristone can be used only very early in pregnancy -- no more than nine weeks, and preferably seven weeks or fewer, into gestation (it is usually administered within 49 days from the beginning of a woman's last menstrual period). Bleeding or spotting can be expected to last an average of nine to 16 days, but may persist for 30 days or longer. One percent of women will have bleeding so heavy they need a surgical procedure called curettage to stop it. Approximately five to 10 percent of women who use mifepristone will fail to abort, and will need to have their pregnancies surgically terminated. And because the majority of mifepristone abortions will be arranged through abortion clinics (at least at first), women will not be protected from protest-line harassment.

Any number of pre-existing physical conditions -- such as adrenal insufficiency, the presence of an IUD, or a recent history of steroid use -- may make a woman ineligible for the procedure. In addition, caution is urged in using mifepristone in women older than 35, or in those who smoke. A vaginal ultrasound may be done to confirm fetal age and to rule out ectopic pregnancy.

It's unclear how many providers will be willing, or able, to offer the drug. "A woman will be able to go to her own health-care provider," says Heather O'Neill, director of public affairs for Danco. "All ob/gyns [and] many family practitioners could provide this service." But O'Neill's optimism may be premature. State laws governing abortion providers vary widely and may result in compliance problems, especially for doctors who don't already offer surgical abortions.

"I think it will be a problem as new providers want to add it to their practices," says Vicki Saporta, executive director of the National Abortion Federation (NAF). "Especially when you're talking about fetal remains." The recovery and disposal of such remains are governed by many states' abortion laws. Since women taking mifepristone usually expel the fetal tissue at home, will they be required to bring the tissue back to the provider? What will happen if the provider, in attempt to obey the law, requests the tissue but a patient does not comply? Other state laws regarding physical-plant structure, accommodations, and emergency equipment may also limit a physician's ability to offer the abortion pill. The NAF has received a grant from Danco to train health professionals who are interested in prescribing the pill. However, anecdotal evidence suggests that a significant percentage of providers who express interest in prescribing the drug decide not to do so once they learn it is a multi-step procedure, and that they may have to make special efforts to fulfill state abortion regulations.

"We do hope that eventually mifepristone will offer women more power," says Stephanie Mueller, spokesperson for the NAF, which represents clinics and other abortion providers. "Obviously women will still be accessing clinics and will still be facing harassment. Certainly the promise of mifepristone is the promise of eventual privacy, but we believe it will be gradual."

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Margaret Doris is a freelance writer living in Newton.