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.
0 TrackBacks
Listed below are links to blogs that reference this entry: How much has medical abortion changed things?.
TrackBack URL for this entry: http://www.feministing.com/cgi-bin/movabletype/mt-tb.fcgi/6748
Great post, as was Sara's.
In Sara's original post she points out that anti-choicers will probably shift (at least somewhat) to targeting individual women. I wonder if they might not also shift to targeting the manufacturers of RU-486, HMOs that cover it, and pharmaceutical companies that distriubte it, in much the same way as they now target Planned Parenthood (protests, harrasment of workers and legal injuctions), not to mention consumer boycotts.
Great post, as was Sara's.
In Sara's original post she points out that anti-choicers will probably shift (at least somewhat) to targeting individual women. I wonder if they might not also shift to targeting the manufacturers of RU-486, HMOs that cover it, and pharmaceutical companies that distriubte it, in much the same way as they now target Planned Parenthood (protests, harrasment of workers and legal injuctions), not to mention consumer boycotts.
"Medical abortion gives women the dignity of going through the process in the privacy and comfort of their own homes"
Um, pardon?
I've used misoprostol, and two words I would NOT use to describe the experience are 'dignity' and 'comfort'. You have to insert these dry little pills vaginally, and in my case, I got to do this in the restroom at work, because I just couldn't take any more time off.
Then there's the wait. In my case, it took multiple escalating doses of the drug, multiple ultrasounds, a couple of weeks, and it hurt like motherfuck. Generally, you're not going to wait serenely at home, surrounded by pillows and strawberries, for this stuff to work. Since one of the reasons to choose medical over surgical is the potentially reduced cost, I'm willing to bet that I'm not the only one who went through this while working.
I'm with you, Ann. I am very pro-choice and I certainly support the right to choose a medical abortion, but it does kind of chap my ass to see the process sugar coated.
As a patient advocate at an AB clinic, I can tell you that women usually do have a lot of misconceptions about medical abortions. Usually, they think that it's a much simpler, safer, and quicker experience than a surgical abortion. None of those assumptions are true. Also, you're right that women still have to hunt down a clinic and go to several appointments. Plus, rather than having a five-minute surgery and then going home, MAB patients must keep in contact with their AB provider over the phone to make sure nothing goes wrong with the MAB while the patient is at home. Then, she has to come back to the clinic after two weeks to make sure the MAG was successful. And if it wasn't, she has to have the surgical procedure anyway.
Obviously, I support a woman's choice to take RU-486 instead of having a surgical abortion; but from my experience, it seems like MABs are full of too much hassle and uncertainty.
Another perspective to consider is the health ramifications. I'd definitely choose surgical over medical abortion because I feel that it's the least disruptive to my body. The chemicals involved in the medical abortion don't appeal to me, and as a breastfeeding mom, I certainly wouldn't want to introduce medicines into my body if I were to terminate a pregnancy now.
I left my job at a clinic just as they were beginning to offer the medical option. All the literature I read really changed my mind about the pills. A surgery sounds more invasive at first but I think it would be easier on my body, all things condidered.
I'm ever leery of pills providing the answer, too. I think as a culture, we're always looking for the quick and easy answer, and we almost always want to believe it can be as easy as swallowing a pill.
Obviously, a number of measures are put in place to ensure women who will be adversely affected by the medication will look elsewhere (and hopefully know where to look and have somewhere to look) but I don't think it should be misconstrued as the better option in general, either. As Akeeyu above put it, I don't like to see it "sugar coated."
Thanks for this post. Lots to chew on.
Wonderful article. As with any other medical situation, there are options, and pros and cons to each option. No one solution is right for all patients, and anyone who thinks there is, is nuts.
In my case, I realized I was pregnant and that I couldn't have a baby at that time in my life too early for a surgical abortion and elected to proceed with a medical rather than wait and have the surgical at a later date, and based that decision on the excellent information and advice given by the wonderful counselors and physician at the clinic I was at.
Possibly because it was so early in the pregnancy, I had no complications and few side effects with the medical, and don't regret my choice. There was only really 1, maybe 2 days where I was really feeling ill and it was not the horrific experience I've read about other women having.
Had I been far enough along for a surgical, I'd have given it serious consideration.
Having both options is good, in my opinion... and just one more reason I'm determined to do my part to keep abortion safe, legal, and AVAILABLE.
I would just like to point out that misoprostol is only FDA approved for oral use, and that vaginal use is off-label.
What's the earliest you can have a surgical abortion?
chingoma, I believe the earliest you can have a surgical abortion is at five weeks gestation.
Great post, Ann. Like many seem to have here, I have given the matter some thought and would also opt for surgical if the need arose.
One huge benefit I see to the pills is that in the god awful hope it never happens possibility that abortion became illegal, they would be a life-saver. Literally. Since, as has been pointed out, there are several complications that can arise from medical abortion, it wouldn't make black market abortion "safe" -- especially since not everyone would find it through a feminist referral group and could instead get something else from an unscrupulous person. But it would make it about a million times safer.
Again, obviously, I hope that this never comes up here. But it is was Women on Waves does to help women in countries where abortion is illegal, and it's my understanding that many such countries have these kind of underground medical abortion referral services set up.
Kaethe, that was probably just a mistake. Many people think that a medical abortion consists of only misoprostol, but that's not the case. Misoprostol is given by the provider orally, and then the patient inserts another medication, Cytotec, vaginally at home.
The first drug used in a medical termination is mifepristone.
Cytotec is a brand name, but it's the same drug as Misoprostol, and whether or not it's off label, it does appear to be widely used vaginally.
What the heck, it's not even approved for use (oral or otherwise) in labor induction or terminations in the US, but it is approved in other countries. I'm sure political pressure in the US has nothing to do with that, right?
It's my understanding that misoprostol (or Cytotec, the brand name) -- the second set of drugs taken in a medical abortion -- is only approved in the U.S. as an ulcer treatment. But it's been surpassed by more advanced ulcer treatments, and so is almost never prescribed for to treat stomach ailments anymore.
It is, however, used in every medical abortion and in many later-term abortions as well. Doctors do use it off-label for this purpose, but using a drug off-label is really not a big deal. I had several physicians explain to me that lots of drugs are used in non-FDA approved ways, which can be completely safe if there's research backing up that particular use, etc. And there's ample research on the safe use of misoprostol in abortion.
As to whether misoprostol should be taken vaginally or orally, you're right, Kaethe, the FDA recommends it be taken orally. (Last time I checked, this only appeared, however, as part of the instructions for how mifepristone should be take. Quite funny, because as I just mentioned, misoprostol is not approved for use in abortions... In other words, the FDA approval commission realized that you can't take mifepristone without misoprostol, and yet did not take the step of approving misoprostol for this use.) There is some debate among abortion providers as to whether the vaginal or oral method is better. Some doctors feel oral is safer, as there's a slight risk of infection during insertion of the pills vaginally. Others believe that vaginal is better, as its easier on the stomach and patients have reported less painful cramps that way.
On a related note, it's important that misoprostol is approved for a non-abortion use -- that's what keeps it available and basically safe from anti-choice attacks. This is one major reason it would be *great* to get mifepristone FDA-approved for a non-abortion-related use.
As the lead author of the referenced Guttmacher study, I want to encourage Ann and others to give the study a close read and let us know your questions and criticisms! http://www.guttmacher.org/pubs/journals/4000608.pdf (You have been warned: It is not an easy read. Lots of numbers and quite dry.)
I also wanted to follow up on a few issues Ann brought up that are answered in the article. It is the case that most providers of early medical abortion (EMA) are abortion clinics that also offer surgical abortion. But in 2005 we counted a minimum of 119 providers that offered ONLY EMA. These facilities accounted for 7% of all providers in that year. Moreover, more than half of these providers (n=70) were clinics--not necessarily abortion clinics, but women's health clinics that also performed several hundred EMA abortions per year. The other 49 were physicians' offices.
While these developments are promising, our analysis does not allow us to assert that EMA/mifepristone is increasing access to abortion services. Most of these EMA-only providers are located in cities or in counties that also have surgical abortion providers. That doesn't mean they aren't increasing access, but the current analysis neither confirms nor disconfirms that they have increased it.
chingona, there are place that specialize in early terminations - even just two or three couple weeks in. though it's my understanding that if it's too early, some procedures are more difficult.
The first few years that medical abortion was approved by the FDA, the typical protocol used by many providers involved vaginal administration of the second medication, misoprostol. My understanding is that most providers now use buccal or oral administration.
Also, many "new providers" of medication abortion include clinic sites in existing systems. For example, a Planned Parenthood affiliate can have multiple clinic sites, and many have been implementing medication abortion at many more clinic sites, while they still offer surgical services at one or two sites. I'm not sure how that was covered in the Guttmacher article- since it may be the same providing physician responsible for all of the sites, they may count as one provider in that analysis (I'll take a closer look).
Overall, I think it is a really good option for a lot of women. It also informs the practices for managing spontaneous miscarriage, making it more likely that women who experience miscarriage have more options in managing their care.
Muslima Media Watch links to this article about medical abortion in Malaysia. Its an interesting mix of liberal and conservative policy. Surgical abortions are illegal without a health-related excuse, but women can purchase pills for a medical abortion at a clinic for less than $2.
Delurking after years of reading for this issue...
It seems that most people in the comments so far would prefer surgical so I just want to add my experience. I had a medical abortion a few years ago, and I think a surgical abortion would have been a lot harder for me psychologically. It was a very private thing (I didn't tell a single person in the world at the time) so I really liked the idea of being able to be alone at home while everything happened. It also made me feel like I was in control of the process, as opposed to a stranger being the one in charge of what was happening to me if I had been at a clinic. I liked that I was able to "do" it myself, rather than having someone else do something TO me to end the pregnancy. I did have a lot of nasty side effects (projectile vomiting, blinding headache, etc), but it was completely worth it to be able to be at home by myself. It made all the difference in the world to me and my experience was the best it could have been. I am so so so thankful that medical abortion was an option for me.
Obviously this is a perfect example of how any one thing is not always right for everybody. I can completely understand why surgical is a better option for other women. I just wanted to add my two cents because it seems like the value of the more natural/privacy/dignity argument for medical abortion has been very understated here. It can be a very big deal!
Rachel-- thanks for the link!
And Lori, I'm also glad that you had the option of medical abortion, and that it was the right choice for you. As I said above, I know that it *is* the best choice for some women, so I'm really glad the option is there.
I definitely agree. Based on my own experiences and the stories of others, I think a surgical abortion is safer and preferable in most cases, and we still need to make sure they are more available and less stigmatized.
Oops, I realize I made a mistake and confused the two medicine names--mifepristone and misoprostol. Sorry for any confusion I caused, but I'm glad other people dropped in an fixed my mistake.
I'm a little late to the discussion, and as things work out, was actually recovering from a medical abortion when this post went up. I went that route rather than surgery because, like Lori, I imagined it would be more psychologically easy. The whole being at home, having a more "natural" experience rationale, basically. Ultimately, it felt very empowering for me to be in control of the experience myself, in that I was the one who took the pills according to instruction. But physically, it was a lot harder than I was prepared for. Before I even took the second round of pills, I was wishing I had had the surgical procedure instead. (Wrote about the experience
here). Besides the complications I had, which are outside of the norm, it was hard that it lasted SO long.
Having never had an abortion before, the choice of taking some pills made the process a little less nervewracking to me at the onset, but in the event that I had to do so again, I would have a surgical abortion. I'm glad there's this option for women that seems more appealing beforehand, but I'd be curious to see how many actually have multiple medical abortions. I can't imagine having another medical one, unless that was my only option.