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RU-486 will revolutionize D.C.’s abortion landscape—for some women, at certain times, if they can afford it.
Five women a day call up the Annandale Women and Family Center in suburban Alexandria searching for a miracle drug. And almost all of them ask the same question, the same way, says Director Penny Smith: “‘Do you have the abortion pill?’” She says it’s the most common inquiry she gets.
For now, the technical answer is no. Clinical trials of mifepristone—also known as the French abortion pill, RU-486—have not yet hit the D.C. area. Women in 20 countries have been using the drug for well over a decade, but Congress and various administrations have managed to block FDA approval here until recently. Within the next six months, though, the drug should finally hit the U.S. market.
And women are already clamoring at Smith’s gates. In response, her clinic and about 100 others nationwide currently have a substitute at the ready, an alternative drug called methotrexate. Technically a cancer treatment, the drug is used “off label” to induce an abortion, and works very much like RU-486. The whole process can take a few days longer than RU-486, but the ritual and price are generally comparable. For about a year, Smith’s center—one of several suburban clinics offering the method—has advertised nonsurgical (also called medical) abortion services in the local yellow pages.
It’s easy enough to understand why women’s imaginations are captured, when you consider the options: Let’s see, strap into stirrups and lie back for invasive surgery while good Christians stand outside with posters of dead babies—or swallow a few pills? And the forced miscarriages that follow the pills occur in the privacy of women’s own homes, rather than in cold, indifferent examining rooms. Local gynecologists who provide regular abortions say their patients are eager to try the nonsurgical option, and a Feminist Majority fact sheet predicts that RU-486 could one day replace 50 percent of traditional abortions.
But so far, the uberdrug’s performance hasn’t lived up to the hype. “I wouldn’t call it a revolution,” Smith says, dryly. “We’re really not doing too many medical abortions.” Although she expects to do more such abortions once RU-486 is approved, she says the numbers won’t be staggering.
By the time Smith is done explaining the procedure’s grisly details and $500 price tag, only about one woman every three months actually signs up for the nonsurgical option. “They have this misconception that you take a pill and you’re no longer pregnant,” says Smith, a registered nurse who has been running the clinic for 16 years. “Once women find out how time-intensive it is, and what all is involved, most opt to do the routine [traditional abortion].”
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Last July, a New York Times Magazine story heralded the dawn of a new abortion era in a story titled “The Little White Bombshell.” A big mouth opened wide on the cover for a tiny white pill. Inside, the story predicted that FDA approval of RU-486 will bring “enormous political consequences,” forever altering the abortion debate.
Once women can take a pill in their bathrooms to end their pregnancies, the thinking goes, abortion clinics will disappear. Doctors will be able to prescribe the pill in their offices, making them harder to track. And without obvious places to target their protests, anti-abortion groups will be stumped. Poof! There goes one of the most intractable social issues of our time. And here comes a new age when abortion is safer and easier for all. “This, it now seems fair to say, is the shape of abortion to come,” reads the article.
But Smith and other local providers know that the shape of abortion will be pretty hard to change. Even with the nonsurgical abortion option, Smith’s suburban clinic still works essentially the way it did before. Clinics located in the city—which performed 20,790 abortions in 1996, according to the Alan Guttmacher Institute—will be even less easy to transform, even after the arrival of RU-486.
For one thing, RU-486 and all other kinds of nonsurgical abortion will cost at least as much as regular abortions. That means anywhere from $400 to $700 to even more, depending on where you go. “You can have a clinic next door to your apartment complex, but if you don’t have the money to pay for an abortion, it’s the money that becomes a barrier,” says Susan Tew, spokesperson for the Alan Guttmacher Institute.
Paying for abortions is a more acute problem in D.C. than in many other places. Since 1995, Congress has banned the District from using any federal or even local tax money to help poor women cover the costs of abortion. And the city’s many women with government or military insurance are also out of luck when it comes to abortion coverage.
Poorer D.C. residents will also continue to struggle even to get to abortion services in the new abortion-pill era. RU-486 and methotrexate require up to three visits and much more counseling than old-fashioned abortion, because women must go through crucial parts of the procedure on their own. That means that patients who have trouble getting to clinics and taking time off from work will have even more trouble. “[Nonsurgical abortion] takes somebody who’s flexible, mobile, has transportation, and can come in at our convenience,” Smith says.
Perhaps the biggest downside of nonsurgical abortions is the small window of time women have to get them. A woman must take the pills within the first seven weeks following conception. In other words, she has to see her doctor no later than three weeks after her first missed period.
For many overwhelmed teenagers and poorer women coming to grips with unwanted pregnancies, finding money to pay for an abortion and seeking out services winds up taking a lot longer than that. More than half of the women who get abortions in the District would miss the seven-week cutoff point, according to 1996 data reported to the Centers for Disease Control and Prevention (CDC). Younger women and black women tend to seek out abortions later on in their pregnancies, according to the CDC report. And the D.C. Department of Health found that 72 percent of area abortion recipients in 1997 were black.
“There are still a lot of women who won’t be able to take RU-486,” says Stephanie Mueller, spokesperson for the D.C.-based National Abortion Federation, which will be training physicians across the country to administer the pill. “Obviously, we are really looking forward to the [FDA] approval, but we are more cautiously optimistic than some of the media reports.”
Never mind the cost of the pill or the city’s vulnerability to pro-life members of Congress. Hearing the actual details about what nonsurgical abortion entails should be enough to ramp down the pill’s hype.
Say you can afford a medical abortion, or you find a Planned Parenthood clinic that will help subsidize the cost. And let’s assume that you have your act together and get to the clinic in the first seven weeks after conception.
You still might change your mind when you get to the clinic and learn what you’re in for.
RU-486 is, in fact, a very normal-looking tablet. But the pill is only the first phase of a four-step ordeal. First, you get a talking to about what the nonsurgical abortion will entail. If you are a heavy drinker or have liver problems, you’ll probably be disqualified. You’ll also have bloodwork done and possibly a sonogram. Then come the pills: Once you take three of the mifepristone pills, they start to block your body’s progesterone—a hormone that preps the uterus for pregnancy. You remain under a doctor’s observation for a half-hour, and then you go home. Two days later, you come back to get a second drug—misoprostol. (In some cases, women take the misoprostol tablets with them after the first visit and then insert them vaginally on their own.)
Either way, within four hours, your body most likely expels the contents of your uterus—the uterine lining and gestational sac. Not to worry—the embryo is smaller than half of an aspirin tablet at this point, and it doesn’t look anything like a baby. But there are serious cramps, a good deal of blood, and, for many women, nausea and diarrhea. Bleeding may continue for several weeks.
Two weeks later, you return to the clinic to make sure the abortion has worked. If it’s not complete—as was the case in about 8 percent of recent U.S. trials—you will have to get a surgical abortion after all.
Despite the ordeal, most women who have gotten nonsurgical abortions say they are satisfied. Providers say that’s because they’ve been counseled and prepared for the process. Over the last several years, two test trials across the country have offered RU-486 to thousands of women. The Population Council ran studies at 17 sites around the country from 1995 to 1996 and reported that 96 percent of women would recommend the method to others.
None of these trials occurred in D.C., however. Planned Parenthood of Metropolitan Washington runs six centers in the District, four of which offer surgical abortion. But none of them have participated in the trials or offered the alternative methotrexate procedure. The closest RU-486 trial site is at Johns Hopkins Bayview Medical Center in Baltimore. Jatrice Martel Gaiter, president and CEO of the District’s Planned Parenthood, says she doesn’t know why methotrexate is not available here.
But Gaiter promises that D.C. Planned Parenthood clinics will offer RU-486 when it becomes available next year. And she says her staff is already thinking about ways to raise funds and educate the public about the procedure. “One of the things I’m concerned about is, is this only going to be an option for well-educated women who are reading analyses of the procedure?” she says. “Like most things, any change is going to be incremental.”
Ron Fitzsimmons, executive director of the National Coalition of Abortion Providers, in Alexandria, insists that traditional abortion—the kind that involves vacuums and suction—is not going anywhere anytime soon. “[RU-486] is not a simple pill. Abortion is not a simple matter,” he says. He believes that, because of all the hoops women must go through, many doctors are unlikely to offer RU-486 after it’s approved. It doesn’t promise to be very profitable, and there’s no guarantee anti-abortion extremists won’t discover and harass doctors who dispense it.
Fitzsimmons says he worries about the high expectations for RU-486, that they may lull people into a false sense of security—for example, why bother working to recruit doctors who do surgical abortions, if we allegedly won’t need them anymore? But he also points out that this is not the first time hyperbole has contorted the picture of abortion in America. “The reality,” he says, “is always different from the rhetoric in this field.” CP