Pill may not revolutionize abortions

Even if mifepristone, also known as RU-486, is approved, it seems most women will still have to go to abortion clinics.

By WES ALLISON

© St. Petersburg Times, published September 17, 2000

For 12 years, abortion-rights activists have lobbied for the day when a woman could get a pill from her family doctor and quietly end her pregnancy at home, forgoing the invasive surgery, the public abortion clinic, the jeering protesters gathered outside.

By month's end, the Food and Drug Administration appears likely to approve mifepristone, commonly known as the French abortion pill, or RU-486, for sale in the United States.

But for all the expectations, for all the talk about how a pill could make abortion more available, especially in rural areas, the drug's approval actually may have little effect on access to abortion in Florida.

Few obstetricians-gynecologists now perform abortions, in part because it remains a contentious and sometimes deadly issue. Most refer their patients to free-standing clinics, and one pill isn't likely to change that, doctors say.

That means most women seeking an abortion will continue to have to visit a clinic, even if they opt for the abortion pill, and abortion services may remain scant outside urban centers.

"I don't think having this pill available is going to make people who aren't already doing abortions start doing abortions," said Dr. Elliot Cazes, a Tampa OB-GYN. He considers himself an abortion rights advocate, but will not prescribe mifepristone.

"They're still going to need to go to the same places," he said. "You're still going to have the same physicians and the same clinics offering this who are offering the surgical procedures."

Physicians across the Tampa Bay area and elsewhere in Florida say they'll make sure patients know about the pill, but they challenge many of the commonly held assumptions that RU-486 will make an abortion less traumatic, more private and easier to get.

"I think it will be a very nice option for . . . those women who are going to be seeking termination, by being safer and earlier," said Dr. Beth Benson of OB-GYN Associates in St. Petersburg. "It's a little more private. It would be between a woman and her physician, and no one knows why a patient would be going into a gynecologist's office. She could be there for any number of reasons."

But Benson also has no plans to offer it.

"Nobody wants people picketing in front of their office, and most physicians don't want to be worried about their safety the way some of the abortion providers are," she said. "We've seen the violence."

Florida has a history of protests and attacks at clinics, and doctors say they don't need the hassle. Anti-abortion groups, meanwhile, say they will try to identify which doctors prescribe mifepristone, which they call "a human pesticide," then promote peaceful protests against them.

Dr. Elisabeth Tucker, an OB-GYN in Pensacola and member of the Florida Board of Medicine, can see from her office window the spot where Dr. David Gunn was shot dead outside his abortion clinic seven years ago. Another doctor and his escort were killed a year later down the street. In St. Petersburg, a Central Avenue clinic has been torched three times.

"In this area, frankly, you're just taking too much of a risk if you do that," Tucker said. "And word gets out. They find out very quickly."

Mifepristone has been used in France for a dozen years. It's widely available in Europe and Asia.

Republican President George Bush had blocked its consideration in the United States, then President Clinton, a Democrat, ordered the FDA to start clinical trials in 1992.

Studies here, as in Europe, have shown it's safe and 95 percent effective, although there can be complications.

But finding a company willing to brave the potential fallout of selling the drug in the United States has proven difficult, and its European manufacturer gave the patent to the Population Council, an international non-profit organization.

The FDA has set a deadline of Sept. 30 for approving mifepristone for use here, seeking more information, or denying it.

The FDA isn't talking, but opponents and advocates alike agree the agency seems ready to approve it, at least before the presidential election.

Republican candidate George W. Bush opposes the pill, while Democratic candidate Al Gore supports it. If the FDA were to delay a decision and Bush wins, the drug may never be approved, said Betty Cavendish, legal director of the National Abortion and Reproductive Rights Action League in Washington, D.C.

Medically, there's little doubt mifepristone is a breakthrough. It's slightly safer than surgery and less invasive.

It is more effective, with fewer side effects, than other drugs sometimes used to trigger miscarriages. It must be taken within the first eight weeks of pregnancy, while most surgical procedures aren't feasible until after that.

The American Medical Association, the American College of Obstetrics and Gynecology and the American Medical Women's Association have asked the FDA to approve it.

In U.S. trials, women overwhelmingly have said they prefer it to surgery, and would recommend it, according to the Population Council.

"Earlier is a very big deal to a lot of people," said Dr. Wendy Chavkin, a professor of OB-GYN and public health at Columbia University in New York and editor of the Journal of the American Medical Women's Association, which published a special issue on mifepristone this summer for practitioners.

But mifepristone also is not as simple as it's often made out to be. It is not like taking an aspirin, or a birth control pill.

First, the patient takes mifepristone, which blocks the production of progesterone, a hormone necessary to sustain pregnancy. Two days later, either at home or at a doctor's office, she takes a pill called misoprostol, which triggers contractions.

The tiny gestational sac is usually expelled in four to 10 hours, though it can take two days.

"It's not, "Take a pill and I'll see you around,' " said Dr. Ronald Chez, professor of OB-GYN at the University of South Florida and a member of the national medical advisory board of Planned Parenthood, which has lobbied for the pill's approval.

"The provider has to be knowledgeable about how you use it, and the patient has to follow the instructions."

The patient must be examined in two weeks to make sure it worked. If not, she must have a surgical abortion. This happens about 5 percent of the time.

Some 1.3-million women will have an abortion this year, most of them at unfamiliar clinics where they don't know the doctors and nurses, where they can be seen going in and coming out.

Advocates say mifepristone, when given by a woman's regular doctor, makes the best of a bad situation.

Nationally, abortion rights groups will be asking gynecologists to offer it. But they acknowledge its acceptance will depend largely upon the restrictions, if any, that the FDA puts on the drug's use.

According to the Population Council, the FDA has proposed requiring that those who prescribe mifepristone also do surgical abortions, and requiring patients to take the second pill in the doctor's office and wait there until the abortion is complete.

Many doctors don't have the space available for that. Others aren't prepared to do surgery if the pill fails.

"I don't feel comfortable doing them, and I don't want to," Cazes said. "As long as I know I'm sending my patients to a trustworthy place where I'm familiar with the physician and staff, that's what I'm going to do."

A recent survey by the Kaiser Family Foundation found that among OB-GYNs who don't perform abortions, 31 percent would be likely to offer mifepristone, provided the restrictions aren't too tough. But local gynecologists scoffed at that figure and said it's way too high. So did officials at abortion clinics that handle doctors' referrals.

"Here's the conversation around the dinner table: "Honey, I don't want you to get into that. We're fine. . . . We've got kids in school. I don't want them getting harassed,' " said Maggie Gifford, executive director and owner of Alternatives of Tampa, a free-standing clinic that is frequently the target of protesters.

"I know these doctors and I know their wives. If doctors are comfortable now, they're not going to want to get involved," she said. "They've got to have a real right-to-choose leaning. A real desire to help in that area."

Lynda Bell agrees. And Bell, president of Florida Right to Life, doesn't think most doctors have that strong desire.

"I know what the abortion advocates are saying, that this is going to be great, . . . that now abortion's going to be available to all women," Bell said.

"I have to wait and see what happens. If it's a community standard that there are no . . . abortion clinics, and it's been this way, I think it's going to be equally difficult to find someone who will be willing to prescribe a pill to kill an unborn child."

Florida Right to Life, which has 28 chapters, and National Right to Life have been lobbying against RU-486 since it was approved in France, and its opponents say the pill will make abortion too easy.

If the FDA approves it, the organization plans campaigns designed to emphasize to women the risks of mifepristone, and to warn doctors against offering it. Those who do may face protests, she said.

"As we heard of doctors who were prescribing RU-486 to their patients, we probably would encourage people not to go to that doctor, to let everybody know," Bell said.

"I think the majority of physicians, they don't want their patients harmed, and they don't want their practices harmed. They don't want this bad reputation (of), "That's the doctor that gives this abortion pill.' "

Barbara Zdravecky, president of Planned Parenthood of Central and Southwest Florida, said she thinks more doctors in this area will offer the pill than say so. They're just keeping quiet because they fear retribution.

"I think we have a lot of physicians in Florida who don't do a lot of abortions, but do some for their patients, and they're not going to admit to that," she said.

Online information

These Internet sites offer more information about the abortion pill.

www.RU486.org: The RU-486 Files, including U.S. and European news stories and links to other related sites and reference materials.

www.jamwa.org Journal of the American Medical Women's Association, including the full text of articles from June's special issue about the abortion pill.

www.nrlc.org: National Right to Life, an anti-abortion group, including background and explanations of RU-486 and how it works, plus links to other abortion-related sites and resources.

www.frtl.org: News, links and local affiliates from the group's Florida chapter.

www.naral.org: National Abortion and Reproductive Rights Action League, statistics and links.

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