How much has medical abortion changed things?

Via Jill, I see an article — and a post by Sara Robinson at the Group News Blog — about how medical abortion (mifepristone, otherwise known as RU-486) is “shifting the front lines” of the abortion debate. I have to say I think this is a bit of an exaggeration. Yes, it gives women another abortion option. Yes, may be a reason for the slower rate at which we’re losing abortion providers. That is all great. But I’d argue that its impact on the abortion politics has been a bit more limited than Sara suggests.
Let me also say that, while again, I fully support every individual’s right to choose what method is best for her (and I DEFINITELY support the legality of mifepristone), I think there are a lot of misconceptions about medical abortion. I’d like to respond to a few of Sara’s points, below the fold:

First, it’s already putting more abortion providers back in service. For 20 years, the number of doctors and clinics offering abortion was in free fall: every year, it seemed, more of them succumbed to anti-choice harassment and pressure and closed their doors. Old doctors retired; young ones were discouraged from learning the procedure; clinic directors balked at the PR and security problems and the insurance premiums. But, according to the Guttmacher Institute, the rate of decline suddenly flattened from 8% to 2% in 2001, as doctors started adding RU-486 to their practices — and that rate has held steady ever since. We’re still losing abortion providers, but most of those losses are being offset by the growing number of doctors offering drug-induced medical abortion.

Agreed that it’s absolutely a good thing that we’re losing abortion providers at a slower rate. I haven’t picked apart the Guttmacher numbers, so I can’t say for sure, but experts have explained to me that it’s mostly former surgical abortion providers who started providing medical abortions again — not family practitioners or ob/gyns becoming new providers. The requirements for being a provider of medical abortion and a provider of surgical abortion are actually very, very similar. Insurance premiums still go up when doctors decide to start providing medical abortion. Also, those doctors still have to get proper training in how to perform a surgical abortion, in case the drugs don’t work. When I researched this issue awhile ago, for a story about how mifepristone has affected abortion politics, most people I talked to said the number of ob/gyns and other doctors who became providers of medical abortion (but not other methods) were very small. (Mostly for the insurance and training reasons named above, but also because of the stigma attached. Word gets around in small towns, even if you are only dispensing pills.)
I’d like to see data on the number of doctors who have started dispensing mifepristone only. I could be totally off-base on this. But it’s my impression that this is not a very large group — certainly not large enough to drastically alter the landscape on this issue. At least not yet.

Second, it’s changing the way women experience abortion. Medical abortion gives women the dignity of going through the process in the privacy and comfort of their own homes, rather than having to hunt down a clinic, get themselves there, and face down the hysterical, pleading mob massed around the clinic doors both before and after enduring a painful and invasive surgery.

While it’s true that women actually abort in the privacy of their own home, medical abortions usually require the same number of trips to the clinic (a consultation visit, a visit to take the mifepristone — terminating the pregnancy, which is usually passed at home after a second dose of drugs — and follow-up visits afterward). Women still have to hunt down a provider, and personally go to a clinic. It’s not like they can send a friend to pick up the pills for them and have the entire experience be home-based. Also, especially in rural areas, it’s highly unlikely that a woman’s regular ob/gyn or family doctor is a medical abortion provider (for reasons listed above), so in the vast majority of situations, a woman ends up going to a women’s health clinic, anyway. The major benefit associated with medical abortion, as far as I’m concerned, is that women do not necessarily have to show up at a clinic on the specific day of the week the clinic usually provides abortions — which is usually the day it’s surrounded by protesters. So they do get to circumvent many of the antichoice crazies. (Sara makes some great points to this effect.)
It’s also worth noting that medical abortion is time-consuming. After the second round of pills (usually misoprostol), it can take several days for the body to entirely expel the pregnancy. A surgical procedure, at that early stage in pregnancy, is over in about half an hour. Medical abortion is a drawn-out process. (Of course, every woman is different, and this can be a positive or negative depending on the woman. Some have told me they wanted their abortion to be a process, so they could reflect and think about their choice, and really experience it. Others have told me they regretted choosing medical, and wish they had undergone a quicker surgical procedure and not had to watch the contents of their uterus pass.) The time involvement might not make this an ideal method for women who can’t get off work, women with children to care for, etc. — something that’s not often discussed when we talk about medical abortion.

Third, unlike most drugs, RU-486 is dispensed directly by doctors — which also cuts out of the loop moralizing pharmacists who see women’s most essential life decisions as a sort of moral gym equipment on which to freely exercise their underdeveloped consciences, and score some extra Jesus Points in the process.

This can cut both ways. The fact that this drug must be dispensed directly by a doctor also has a limiting effect. Say you’re a small-town ob/gyn who is also a medical abortion provider (though this is not a primary part of your practice). You probably only dispense mifepristone a handful of times per year. And yet you have to keep these very expensive pills (a couple hundred dollars a pop) in stock. That’s a lot of up-front cost for a private practice that doesn’t specialize in abortions.

Fourth: As medical abortion becomes the norm, it would seem to leave that howling pitchfork-and-torch-bearing mob at the clinic door all dressed up for battle — with absolutely nowhere to go. Unfortunately (as we’ll see) that doesn’t necessarily mean that the battle will be over any time soon. But it does make staying with the current tactics a lot more complicated.

Agreed — see the end of my response to the second point. But I also feel compelled to note that I don’t necessarily want medical abortion to become the norm. I don’t think it’s always the best choice for every woman. While I absolutely respect the right of each individual to choose what’s best for herself, based on my research into mifepristone, if I had to make the decision right now, I’d probably opt for surgical. It’s cheaper, I’m under the care of a professional an entire time, and it’s (generally, anecdotally, of course) not as painful. I’d rather have the process over in half an hour rather than up to three days.
I do think medical abortion has the potential to dramatically alter the political and medical landscape, but I just haven’t seen it yet. And while I know this isn’t what Sara is advocating in her very eloquent post, I want to note that this doesn’t absolve us from the responsibility to work to normalize and destigmatize the experience of going to an abortion-providing clinic. Several hard-working and dedicated abortion providers told me they were initially very hurt by the rhetoric surrounding medical abortion — as if bypassing the clinic (and, by extension, their care) was the best possible thing for women. It’s not. Some women, myself included, would choose to have a surgical abortion, performed by a doctor, in the clinic setting. And that’s an option we have to continue to protect (and value!) as well.