New study shows the more doctors know, the more reluctant they grow

Possible Impact of Chemical Abortifacients on "Abortion Access" May be Overstated

By Randall K. O'Bannon, Ph.D.

Promoters of RU 486 have long maintained that chemical abortifacients could "increase abortion access" by expanding the pool of abortionists. However, a recent study appearing in the January/ February 1999 edition of Family Planning Perspective, a noted pro-abortion journal, provides evidence that doctors not already performing abortions may be reluctant to use abortion- inducing drugs. Physicians' enthusiasm dampens once they begin to understand RU 486's complicated, time-consuming regimen, the need for additional patient counseling, heightened costs, and the requirement for additional equipment.

It has long been a standard part of pro-abortion rhetoric to lament that 85% of U.S. counties lack an identified abortion " provider." At the opening of the U.S. trials of RU486 in October 1994, Population Council President Margaret Catley-Carlson specifically argued that chemical abortions "will eventually in- crease women's access to abortion services."

Making explicit the connection between "abortion access" and the new chemical abortion methods, Steven Eisinger and Eric Schaff, " pioneers" in the drive for methotrexate (another chemical abortifacient) and RU 486 abortions, stated directly in March 31, 1996, letter to the editor of the Ob.Gyn.News:

Perhaps the greatest advantage of medical abortion is that it can take abortion out of the clinics and distribute it among many physician's offices, particularly in many areas of our country that currently do not have abortion services.

The basic idea, in the words of one reporter who has covered the abortion pill for a number of years, is to "make the procedure as accessible as the nearest doctor's office" (Florida Times-Union, 10/23/94).

There has been reason to be concerned. While the number of doctors and clinics performing abortion has declined in recent years, several surveys indicate that a sizable number of doctors not currently performing abortions said they would offer chemical abortions if and when RU 486 obtained final government approval.

A Kaiser Family Foundation survey published in the Wall Street Journal in September 1995 is representative. According to Kaiser, only one-third of obstetricians/ gynecologists and just 3% of family practice physicians in the U.S. were performing abortions as of 1995, yet a third of the ob-gyns not doing abortions and a full 28% of family practice physicians said they would be likely to prescribe RU 486 if it were available.

Add to this all the hype generated by women's magazines declaring RU 486 a "miracle pill" (Mademoiselle, November 1988) and treating it as a nearly magic anti-pregnancy pill ("imagine being pregnant, swallowing a pill and presto! not being pregnant any longer" Ms. magazine, April 1987) and one can easily see an increased demand for abortion and more doctors to do them.

In France, where RU 486 has been available since 1988, estimates are that between 20-33% of all abortions are chemical abortions. If these were to represent new abortions, i.e., abortions that otherwise would not have taken place, it could mean as many as 273,000 to 450,000 additional abortions a year in the United States, all but wiping out recent drops in abortion numbers.

Another more encouraging scenario
An alternative scenario emer-ges, ironically, from a recent article written by Carole Joffe for the January/February 1999 edition of Family Planning Perspective, a publication of the Alan Guttmacher Institute, Planned Parenthood's special research affiliate. While the chemical abortion methods are likely to be picked up by those doctors and clinics already heavily involved in the abortion industry, it is not clear that other doctors will be that anxious or willing to take on RU 486 or other abortifacients once they discover what is involved.

Joffe conducted interviews with 25 "long term providers of abortion," including physicians, "mid-level practitioners," and clinic counselors, many having extensive experience with RU 486 or methotrexate. Their reactions and observations, while often predictable, contain a few surprises.

Not surprisingly, the article reports that "virtually everyone" who did the chemical abortions found them "satisfactory." Abor- tionists using the chemical method had been concerned about " being called to the emergency room in the early morning because a patient was hemorrhaging" and worried that women would not return for their required follow up visits.

These situations, the article asserted, had not materialized. But other comments reveal factors that made these doctors, and might make doctors considering the method in the future, much less enthusiastic.

"Cumbersome and challenging"
One of the doctors interviewed for the article admitted to changing the protocol. She limited herself to patients six weeks pregnant or less, rather than seven, because she thought an earlier cut-off might help avoid middle of the night surgery to treat heavy bleeding. Explaining her decision, she said, "I wanted to be able to offer the patient an option which is satisfactory for everyone, but I didn't want it to cause me more trouble than it was worth."

Even those most firmly committed to offering the chemical method, Joffe writes, found adding the option, at least in the short run, "cumbersome and challenging." This is not surprising.

Despite widespread belief that RU 486 and the other chemical abortifacients are "safe and simple," chemical abortions are complicated and often risky affairs. Rather than a simple visit to the doctor for a single pill, chemical abortions are long, drawn-out, multi-drug, multiple-visit events that take weeks to complete.

At an RU 486 patient's first visit, after a medical exam to date her pregnancy and determine whether or not she has any physical conditions that could make the drugs dangerous or deadly for her, she is given the RU 486 pills, which she takes in the presence of the abortionist. Over the next 48 hours, the RU 486 works on her reproductive system to shut down the life-support system for the developing child, depriving him and her of needed food or fluids.

Returning for her second visit two days later, the woman receives a prostaglandin, usually misoprostol, to stimulate powerful uterine contractions to expel the emaciated corpse of her child. She remains in the doctor's office for four hours after taking the misoprostol, waiting for the contractions, bleeding, and abortion to begin. Severe pain, nausea, and diarrhea are typical side effects.

While some 50-70% of women abort during this second visit, many abort later - - at home, in the shower, on the bus, at work. Some never abort at all with the method, which is why women are instructed to come back for a third visit, two weeks from the first, at which the doctor determines whether or not the abortion has been completed. If it hasn't (the method failed anywhere from 8-23% of the time in U.S. trials, depending on the baby's age), then the doctor will direct her to have a surgical abortion.

The same sort of steps are involved with methotrexate, a powerful anti-cancer agent now being used by some abortionists to induce abortions. Though methotrexate is administered by injection, rather than pill, and tends to take longer to act, the "success" rate is roughly equivalent.

As difficult as this process is for the women, doctors here focused on the burden the method posed on their practice. Joffe noted their reaction in the following way:

This protocol caused considerable disruption in their offices and clinics, largely because of the demand for bathrooms to accommodate the nausea and diarrhea that resulted. Some providers concluded that medical abortions could not be smoothly integrated with other office or clinic activities or would have to be done on separate days.

The amount of counseling and screening required for the procedure was also raised as an issue. Several doctors reported that patients were "misinformed" about the procedure, necessitating counseling that could take "far longer," even twice as long, than the counseling done for surgical abortions. " Disadvant-ages" of the chemical method that Joffe indicates doctors felt patients should consider included the long period of bleeding that could extend up to six weeks and the unpredictability of the timing of the abortion.

Patient misinformation was not the only concern of the abortionists during the counseling process. According to Joffe, additional time was crucial in enabling a counselor to conduct a thorough screening of prospective patients. During that initial interview, the counselor had to determine 1) "whether the candidate is suitable for the method," 2) "whether she is responsible enough to return for the necessary visits," 3) " whether she is likely to report complications promptly," and 4) " whether she has an adequate support system (e.g., that can get her to a hospital emergency room if necessary)."

Even if a woman meets the formal criteria, if she "seems" unreliable, the article mentions, the counselor will find a way " to talk her out of it."

Not a "real" abortion?
Another reason why counseling may take longer and take on added import, the report reveals, is that women coming in for chemical abortions often seem misinformed, not only about what a chemical abortion involves, but also about what it is that is really taking place.

In counseling patients, Joffe notes that several doctors are discovering that "some women do not consider the procedure a 'real' abortion." Counselors report women calling clinics saying "I . . . don't believe in abortion. But I can't be pregnant. Can you give me that pill that will make me stop being pregnant?"

Joffe writes, "Abortion providers now have a methodology about which there is much patient disinformation, and which given that it seems to induce a miscarriagecan allow some women the illusion that an abortion has not taken place at all."

This presents doctors with what Joffe terms "professional and philosophical dilemmasand conceivably legal ones." Citing her own previous work and a Planned Parenthood counseling manual, Joffe writes, "The cardinal rule of abortion counseling is that a woman should not get an abortion unless it is her freely made and informed choice. This principle, was designed to remove the possibility of coercion, but it was thought to be self evident what an 'abortion' is."

Does this mean that, after years of claiming abortion was no more that the removal of a "clump of cells" or a "bit of tissue," that doctors and counselors will actually now go out of their way to make sure a woman knows that every abortion really does take the life of another human being? Joffe doesn't say, but she does observe that "Given the willingness of certain antiabortion organizations to recruit plaintiffs who will sue providers for allegedly misleading patients, providers of medical abortion must take special pains to ensure that patients fully understand what it involved."

Misinformed doctors

Patients are not the only ones the article reports as misinformed. Much of the enthusiasm doctors have displayed for chemical abortifacients in polls may also stem from similar misinformation.

The article relays the account of a phone call received by a professor of an East Coast university that was doing abortions with methotrexate, another chemical abortifacient similar to RU 486.

I got a phone call from an internist who runs a program with lots of internists and family practice doctors, and they wanted to start doing it. But when he heard what was involved, he said, "Well, we'll wait a while." He had believed it's a pill that you give and the patient goes home and has the abortion and that's it [but] when we started talking about ultrasounds and dating the pregnancies . . . and [what to do] if the patient doesn't come back [for the misoprostol], he said, "Well, maybe that's not what I thought."

Doctors too, apparently, have heard and believed much of the hype about the ease, safety, and effectiveness of the drugs and assumed that their involvement could be limited to the dispensing of pills.

Joffe speaks as if the situation for RU 486 might be different than it is for methotrexate, since RU 486 is "more predictable and takes less time to induce an abortion." While it is true that doctors may be more skittish about methotrexate because of its high toxicity and its longer action period (several weeks as opposed to several days), the problems mentioned above apply to either chemical method.

Because of the decreasing "effectiveness" of the drugs as the baby grows, doctors dispensing either drug have to date the pregnancies to determine whether the chemical method will work. Moreover, because of the bleeding provoked by both drugs, women must be carefully monitored to ensure they do not hemorrhage. In addition, because both methotrexate and RU 486 require the use of an additional drug to expel the dead baby, and because neither of the chemical methods is 100% "effective," women must return for additional visits.

Women who miss their second or third visits may mistakenly believe they have aborted when they experience bleeding. If the baby dies but is not expelled, there could be serious health consequences for the mother. If the baby survives, his or her development could be affected by the drugs.

More equipment and higher costs
It is not just that these methods require additional time and trouble, but that they may involve the purchase of expensive new medical equipment. While ultrasounds may not ultimately be a required part of the standard chemical abortion protocol, Joffe writes, "Most respondents emphatically felt it unthinkable to do medical abortions without ultrasound, both to adequately size the very early pregnancies involved and to ascertain that the abortion has been completed."

While ultrasounds are a standard feature of many, if not most ob- gyn practices, they are less common among the family practices and other general practices the promoters of chemical abortion are hoping to attract. Lacking the sonographic equipment or the skill to interpret sonograms, these physicians would have to purchase equipment, undergo training, hire additional personnel, or make arrangements to have these done elsewhere.

This, too, could reduce the pool of interested doctors. Joffe quotes one family practice doctor discussing how an ultrasound requirement could impact physicians' willingness to offer the chemical abortion option.

[Requiring ultrasounds] is going to . . . decrease access. You have to get an ultrasound in your office? That's $20,000... so now you're not going to do ultrasounds yourself, but require that everyone get one? Well, now it's going to cost your patients an extra $150 [and] the radiologists are going to say, "What's with all these early ultrasounds?"

While virtually all of those interviewed by Joffe were charging the same for chemical abortions as they did for first-trimester surgical abortions [it was a requirement of the trial], several of the respondents speculated with the ultrasounds and the additional office visits, chemical abortions "will inevitably be more costly than a surgical abortion."

All these factors could impact utilization of the chemical abortion methods. Higher equipment and personnel costs could affect the willingness of physicians to offer chemical abortions. Higher costs passed on to patients could inhibit demand for chemical abortions among abortion-minded women.

Social disfavor
In repeating their assertion that 85% of all counties in the U.S. have no identified "abortion provider," the promoters of abortion "access" typically fail to mention that one of the reasons this is so is that many of these communities don't want an abortion clinic in their town. In such communities, being an abortionist is not considered an honorable vocation. This, too, Joffe gives reason to believe, could also impact the spread of chemical abortions.

So far, the majority of those offering chemical abortions have been those doctors already doing surgical abortions. Because of this fact, these doctors have been those who had both the training and the equipment to handle incomplete abortions and other surgical complications.

The new pool of doctors that the promoters of chemical abortions hope to tap are not likely to have the same skill, experience, or equipment, meaning that they will require extensive training or will have to find others to provide surgical backup. This presents a new and different sort of problem.

While a family practice doctor wouldn't necessarily have to have an established abortionist to provide surgical backup for the 4- 5% of patients who fail to abort or face serious complications such as uncontrolled bleeding (which was much higher than 4-5% in the U.S. trials), he or she would have to make arrangements with someone to handle the occasional emergency, and this would involve a tacit admission of one's involvement in abortion.

Joffe puts the issue in the following way. While this backup physician could be anyone the family doctor has previously referred his patients suffering miscarriages,

... the larger politics of abortion would inevitably intrude into these relationships. Whether a provider of medical abortion would feel comfortable in getting backup surgical services from a colleague, or in asking that colleague to do his or her ultrasounds for medical abortion patients, or in sending a patient to the local hospital in an emergency situation all of these will depend heavily on that individual's sense of the larger climate surrounding abortion in that particular community.

Chemical abortion's potential "overstated"
In light of such factors, Joffe declares that chemical abortion's potential for "expanding access," at least for the immediate future, has perhaps been "overstated." Joffe believes that interest may pick up once the faster acting, more predictable RU 486 receives final government approval, but it is unclear how this would resolve any of the issues raised by her study.

Abortion is still the taking of a human life and will never, for many in the medical community, as well as the wider social sphere, be thought of as an honorable activity. Despite its image, these chemical abortions are much more than a trip to the doctor to get a pill. The time, training, equipment, and facilities required to minimize and manage the risks involved with these abortions will increase costs for women and discourage many doctors from offering them.

Chemical abortions are much more complex and cumbersome than many women or doctors have been led to believe, and a great deal of misinformation exists about what these abortions are and what they involve. Enthusiasm for these "new and improved" methods will likely die down as the facts become more widely known. The sooner the truth gets out, the better.

Randall K. O Bannon, Ph.D., is the National Right to Life Educational Trust Fund director of education and research.

NOTES:

1. That they hadn't may have been more a function of a small sample size (only a few abortionists/clinics represented) and simple probability. We do know that at least 59 out of the 2,121 women in the 1994-95 U.S. clinical trials bled so badly that they required "surgical intervention" and that 25 women in those same trials were hospitalized for their bleeding. A woman in Iowa who took the drugs (RU 486 and a prostaglandin) lost over half her blood volume and probably would have died had she not had emergency surgery.

2. Like RU 486, methotrexate shuts down the child's life support system and causes the child to starve or suffocate. Unlike RU 486, it may take weeks, rather than days, to do its work, and methotrexate carries unique additional risks because of its toxicity.

3. U.S. trials found the RU 486/misoprostol combination 92% " effective" when used before seven weeks, but only 77.5% "effective" for women between eight and nine weeks pregnant (measured from a woman's last menstrual period).

4. The cost will be even higher, Joffe notes, for those women who later undergo a surgical abortion to complete an incomplete chemical abortion or require hospitalization for excessive bleeding.