ARIS, Oct. 4 —
Even before she got to the Broussais Hospital clinic here
last month, the 28-year-old woman knew that she wanted to
have a drug-induced abortion.
She hated the idea of a surgical procedure, of being
touched by metal tools, of being put under.
"The other seemed more natural," she said.
"It felt more private, too."
And it all went very smoothly, she said, sounding
hardy for a moment. But then she added in a quieter voice
that it still had not been easy. "The most difficult
part was the pain in your head," she said 10 days
later. "The decision to do it. Waiting for the drugs to
work. And afterward I was crying all over the place."
While the United States has approved the use of the
abortion pill RU-486, it has been in use in France for more
than a decade. Across the country, government clinics
routinely offer it as an alternative to surgery for women
looking for abortions within seven weeks of their last
menstrual cycle. Officials estimate that about 30 percent of
France's abortions are now drug induced.
But far from promoting abortion, as some anti-abortion
activists had predicted, the pill here seems to have had
little impact on the total number of abortions performed
annually. The numbers have stayed about the same since 1990,
despite a slow but steady increase in the use of RU-486,
also known as mifepristone.
Nor has the procedure diminished the emotional pain
that often accompanies an abortion. Many of those who work
in France's abortion clinics say the drug-induced abortion
can actually have more impact on a patient because the
abortion takes place over several days and because a patient
is awake and aware of the expulsion of the fetal tissue.
"The drugs are a way of de-medicalizing the
procedure, and this is good for women " said Christine
Der Andreassian, a nurse who has worked at Broussais since
1987, and has supervised thousands of abortions of both
types. "But that is not to say that it trivializes the
process. The pill is not magic. It does not negate the act
of ending a pregnancy. It doesn't make the act
disappear."
Ms. Der Andreassian has often recommended that younger
patients have surgical abortions because the procedure is
over quickly and, in contrast to the United States, the
patient is usually asleep. Lately, however, she has stopped
doing so, believing that there may be some benefit for them
to be more in touch.
"There is all that time between the first pills
and the second set," Ms. Der Andreassian said.
"She is alone for two days, and she waits. And she
thinks. And maybe, that is a good process."
In announcing that it had approved the marketing of
the abortion-inducing drug last week, the federal Food and
Drug Administration set relatively few restrictions on a
doctor's ability to prescribe the drug beyond requiring that
physicians determine the length of time that a woman has
been pregnant and that they make sure that women who receive
mifepristone have ready access to surgical abortions, should
they need them.
In the United States, a woman will be given written
instructions on the pill's use and its side effects, which
can include bleeding and cramping, headaches, vomiting or
diarrhea, and her doctor must sign a statement saying she
has read the instructions and will comply with them exactly.
The woman must also agree to have a surgical abortion if the
pills do not succeed.
In France, however, the procedure, which is virtually
paid for by the government, must be under the watchful eye
of the medical establishment. The abortion is a two-step
process. A woman first takes mifepristone tablets, which
blocks the action of progesterone, a hormone required to
maintain a pregnancy, and then 36 to 48 hours later takes a
second drug, misoprostol, which makes the uterus contract,
expelling the fetal tissue.
Both sets of the pill must be taken in front of a
doctor or a nurse in France, and after the second set of
pills is swallowed, the woman is required to wait three or
four hours at the doctor's office or in a health clinic
until the tissue is expelled. There is no such requirement
in the United States The regulation is designed to make sure
that a woman is not alone during those hours. As in the
United States, she must return for a checkup within two
weeks.
On a recent day at the Broussais clinic, where about
2,000 abortions are performed every year, 1,200 of them drug
induced, two women chatted easily as they waited, regularly
ducking into the hallway to have a cigarette. When a nurse
checked up on them, they signaled they were feeling fine.
One woman said she had taken painkillers home with her for
the first two days, but had so far not needed them.
The abortion pill was approved for use in France in
1988. Three years later, Britain followed and in 1992 so did
Sweden. More recently, the pill has won much wider approval.
In 1999, Austria, Belgium, Finland, Greece, Israel and Spain
approved its use. The dosage and the protocol for use varies
slightly from country to country. Some allow its use up to
nine weeks after a woman's last menstrual cycle.
Anne Weyman, the chief executive of the Family
Planning Association of the United Kingdom, said that at a
recent conference on the use of RU- 486 in Europe, it was
clear that availability varied widely from region to region,
even within countries like France and England where it had
been legal for years. Not all practitioners had embraced it,
especially doctors in private practice.
In France, too, a recent report to Parliament found
that nonsurgical abortions were offered far less in private
practices than in public clinics. The report said many
private practitioners believed surgical abortions more
convenient because they were quicker and required fewer
return visits.
"There tends to be a conservatism," Ms.
Weyman said. "If you have been doing it one way, you
aren't inclined to change."
Ms. Weyman said that surveys had shown that women
liked "medical" abortions because they found them
more natural and less frightening. However, some women
prefer surgical abortions because they want to have it over
quickly.
The abortion rate in many European countries tends to
be far lower than in the United States. In France, for
instance, about 10.5 out of every 1,000 girls under the age
of 20 had an abortion in 1995, according to the most recent
World Health Organization statistics available. By
comparison, the rate of abortion in Germany was 6.8, in
Italy 6.3, in Spain 4.5. Britain has a higher rate at 18.5.
Former Eastern bloc countries, where other forms of
birth control used to be very difficult to obtain, continue
to have far higher abortion rates, some more than 30 per
1,000.
In the United States, in 1996, the rate of abortion
among girls between the ages of 15 and 19 was 29.9 per 1,000
girls, according to the Centers for Disease Control and
Prevention. Family planning experts believe that greater sex
education and availability of contraceptive devices has
helped keep the number of abortions in Western Europe down.
France has had only one death attributed to the pill,
a 1991 case involving a woman, 31, who was a chain smoker
and had already had 11 children. After that, the government
restricted the pill's use for patients over 35 who were
heavy smokers.
France this year decided to make a morning-after
contraception pill called Norlevo available through
pharmacies without prescriptions, hoping it would reduce the
number of abortions, particularly among young girls. The
government tried this year to make such pills, which must be
taken within 72 hours after sex, available from school
nurses, too, but the way it issued its regulations was ruled
illegal. The government is trying again to have the schools
distribute the pills, but will this time bring the measure
before Parliament.
At the Broussais clinic, Ms. Der Andreassian said that
in the beginning it was only the richer, better- educated
women who wanted the medical abortions. Nowadays, she said,
the process is well accepted. The biggest deterrent to its
use is that France imposes a seven-day waiting period for an
abortion.
One 38-year-old woman waiting to be examined for the
pill said that she had had two surgical abortions before and
desperately wanted to avoid that process again. "I
really wanted something less invasive," she said.
"I really didn't want to go through going into an
operating room again. There was a kind of violence there.
This seems, maybe not easier, but more under my
control."
