Abortion Pill Means More, but Not Easier, Choices

On a frigid morning last January, Christine, a 34-year-old mother of two, sat in the doctor’s office, nervous but sure.

She sipped a glass of water and swallowed a pale yellow pill. Then she buttoned up her coat and drove home.

Two days later, she curled up in her living room and vaginally inserted four white pills. The cramps were less severe than she had expected. There was no pain. Snug on her sofa, watching “Law and Order,” it felt like any normal Friday night. Upstairs she could hear the kids romping with her husband in a bedtime pillow fight.

The bleeding began the next morning. Sighing with relief, Christine came out of the bathroom and told her husband that everything had gone as planned.

She had just had an abortion.

In the coming months, in the privacy of their homes and doctors’ offices, many more women throughout the country are expected to do the same. The French abortion pill mifepristone, which will be sold under the brand name Mifeprex, will become widely available to doctors in about a month.

The drug, which has been available in Europe for more than a decade, was recently granted FDA approval after a 12-year process that included clinical studies on 7,000 women at 15 sites throughout the country. One of those women was Christine. The Associated Press agreed not to use her real name in order to protect her privacy.

When Christine discovered she was pregnant for the third time, it was the second biggest shock of her life. The first was a year earlier when she screamed at her 3-year-old son and then wondered where all that rage had come from. Her second child was just a year old. She knew she couldn’t cope with another.

Before having children, Christine had worked as a medical secretary at a local hospital. She was familiar with mifepristone, also known as RU-486, which blocks the progesterone hormone essential to sustaining pregnancy. She knew the drug can be used only in early pregnancy and that if it fails, surgery is necessary.

Christine is a small, friendly woman with long reddish hair and soulful blue eyes. She has always supported abortion rights, has marched in pro-choice rallies, has watched in horror as upstate New York became a battleground in the abortion debate: a doctor in Buffalo killed by a sniper in 1999, another shot at in Rochester two years earlier, weekly protests by abortion foes outside the local Planned Parenthood clinic, occasional pickets outside the hospital where she made her appointment.

The last thing Christine expected was to become a key figure in the battle herself.

Her involvement began last December. After the shock of a positive home pregnancy test, the tears and recriminations, and an agonizing talk with her husband, Christine called Planned Parenthood. She was referred to Dr. Eric Schaff of the University of Rochester Medical Center, who headed the national mifepristone trials from his clinic at Highland Hospital.

Christine was a good candidate for the drug. An ultrasound showed that she was only seven and a half weeks pregnant. She was educated about the drug. She had no qualms about being part of a research study. Nor did she worry about signing extensive forms that explained possible side effects--days of heavy bleeding, painful cramps and the possibility that a surgical abortion would be necessary if there were complications.

Far more unnerving for Christine was the cloak-and-dagger secrecy that surrounded her appointment. Grilled over the phone about her identity and her condition, she was directed to an unmarked department in Highland Hospital, where she pressed a buzzer outside a locked door. Before it was opened, she was grilled about her identity again. Inside the tiny waiting room, security cameras monitored everything.

“I felt like I was in a bad spy movie,” Christine said.

But, she added emphatically, it was better than having to walk past placard-wielding protesters. It was better than hearing shouts of “baby killer.” And, she said, it was far better than “lying on a table in a little paper dress and have someone else do something to my body.”

Mifepristone begins to work immediately, blocking the action of progesterone, thinning the uterine lining so the embryo cannot grow. Physically, Christine didn’t feel any different after she swallowed the first pill, just the same nagging tiredness that had alerted her to her pregnancy in the first place. She went home clutching instructions about how to proceed, along with some Tylenol and codeine for pain.

She didn’t need painkillers. After two normal hectic days of motherhood, she inserted the second drug, misoprostol, which causes uterine contractions similar to a miscarriage. In Christine’s case, the cramps began almost immediately. They were not particularly painful. In fact, she was nervous about not feeling more.

“Mostly I was just emotionally keyed up and tense,” she said, “wondering if it would work.”

She practiced some breathing exercises and went to bed. The next morning, alone in her bathroom, she saw a small strip of tissue that looked like a piece of gauze: the gestational sac containing the embryo, which at this stage measures about one-fifth of an inch. Her abortion had been successful.

Christine was relieved. Like many women who have used mifepristone, she had been afraid of what she might see. She had been afraid of how she might feel. But she had no regrets about using the drug, and no complications.

“It’s an awful decision to have to make, and I still feel terrible about having to make it,” she said, sitting in her kitchen, her 2-year-old daughter on her lap. “But I felt lucky to have had the opportunity to do it this way.”

Not all women feel the same. Schaff and other doctors involved in the clinical trials expect about half of their patients to choose the surgical procedure even when they have the option of the drug.

“Women bring their own experiences, personality, psychological makeup to the choice,” said Dr. Carolyn Westhoff, an obstetrician-gynecologist at Columbia University, who has prescribed mifepristone to about 700 women as part of the clinical trials. She performed about 1,200 surgical abortions in the same three years. All patients were given a choice about which method to use.

“Some women opt for a longer, drawn-out experience with heavy cramps and bleeding, but done themselves,” Westhoff said. “Some prefer a surgical procedure that might seem more invasive but is over in an hour.”

Schaff, who performs about 1,000 abortions a year, sees the same mixed reaction among his patients. On one recent morning, a 19-year-old woman waited in his office for a surgical abortion. She had been offered mifepristone, but declined. She felt safer with a doctor present, she said. She was afraid she would panic if something went wrong at home. And she wanted it over as quickly as possible.

According to the New York-based Alan Guttmacher Institute, which tracks abortion statistics, more than 1 million women have abortions in the United States every year. One-third take place in the first seven weeks of pregnancy. Until recently, most were done surgically because there were few other methods.

Women’s options are changing regardless of the new drug. In the past, women have generally had to wait between seven and nine weeks before having an abortion--a period that was agonizing for some. Some doctors, including Schaff and Westhoff, now perform surgical abortions as early as five weeks. In recent years doctors have also used a cancer drug called methotrexate to cause abortion. The drug is administered intravenously; it is not as effective as mifepristone and tends to have more side effects and complications. It is used mainly for ectopic and other problem pregnancies.

How mifepristone will ultimately affect women’s choices, and change the national debate, is still unclear. A survey by the Henry J. Kaiser Family Foundation of 767 physicians found that a third of doctors who don’t now provide surgical abortions would consider prescribing the drug.

“I think some physicians who quit doing abortions, either out of fear or for philosophical or ethical reasons, are likely to rethink their decision,” said Dr. Thomas Purdon, president-elect of the American College of Obstetrics and Gynecology, which represents about 35,000 ob-gyns. “Mifepristone involves far less physical trauma and is done so much earlier, I think more ob-gyns will be comfortable with it.”

FDA regulations, and how they are interpreted, will also affect doctors’ decisions. The FDA requires that mifepristone be prescribed in the first 49 days of pregnancy, although some European countries allow its use up to nine weeks. In order to prescribe it, doctors must pinpoint the date of the pregnancy, rule out women with ectopic (or tubal) pregnancy, and be prepared to complete the abortion surgically in the event of complications. Also, women must sign a form agreeing to three doctor visits: two to take the pills, one to follow up.

In Rochester, Christine made her final visit to Schaff’s office about two weeks after her abortion. She was given an ultrasound to make sure the abortion had been successful. The cost of her abortion, which she paid for herself, was $400, similar to the cost of a surgical abortion.

Christine was luckier than some. About 1% of women who take mifepristone suffer serious bleeding and need surgery to complete the abortion. A handful need a transfusion.

But as with surgical abortions in early pregnancy, serious complications are very rare. There is just one documented case of a death related to mifepristone, a 31-year-old Frenchwoman who was a heavy smoker and mother of 11. Her death, in 1991, is used by abortion foes to question the drug’s safety. They also denounce the drug as “baby poison” and vow to target doctors who prescribe it with the same vigilance that they target clinics.

But there seems little doubt that, moral and ethical concerns notwithstanding, over the next few months the new drug will be welcomed by many women and doctors as the method of choice for early abortions.

“In the privacy of my own home, I felt like I was in control,” Christine said, testifying before a U.S. Senate committee in September. “I could choose the time and the place. And I liked the idea of working with my own body to expel the pregnancy, without the interference of surgical instruments or anesthesia.”

Still, Christine has regrets. “It was a terrible decision to have to make, and I wish it hadn’t happened,” she says, as her son and daughter tug at her in her kitchen. “Using mifepristone made the process easier, but it didn’t make the psychological decision any easier.”

Christine won’t have to make the same decision again. Her husband recently had a vasectomy.