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Abortionist
An Abortion Pill, but No Revolution, YetNovember 14, 2000
So it may come as no surprise to Dr. Prine's patients that she plans to provide the newly approved abortion pill mifepristone, or RU-486. But patients may not expect the reaction they will get if they call her office and say they want a pill-induced abortion. Wary about abortion opponents, Dr. Prine plans to set up a system that she learned from doctors who provided mifepristone in clinical trials. She explains how it will work: "If a patient calls and says, `I'm interested in getting a medical abortion,' the front desk staff says, `Call this number.' They give a beeper number for me. I call the patients back on a cell phone that blocks caller ID. Then I screen the patients," she said. While Dr. Prine's scheme may seem reminiscent of the contortions doctors went through decades ago before abortions were legal, what makes her unusual is not so much her plan as the fact that she will offer mifepristone at all. Although the abortion pill's distributor, Danco Laboratories, says it will begin shipping the drug later this month, many private doctors say they still have no plans to offer it to their patients. That would leave it to abortion clinics to provide the pill. But many doctors at abortion clinics say they will advise their patients to choose a surgical abortion instead because they think surgery is a better method. Their decision to offer mifepristone, some say, is dictated more by competitive reasons than by their conviction that it is the best way to end a pregnancy. Doctors say they know that the situation is paradoxical. For abortion rights supporters who have waited for years for mifepristone, the drug's great promise was that it could take early abortions out of clinics, where women can be harassed and doctors threatened, and bring them to private doctors' offices. There, no one but a woman and her doctor would know that she had decided to terminate her pregnancy. And as soon as the Food and Drug Administration announced its approval of mifepristone in September, abortion rights advocates reported great excitement. Danco Laboratories said it had received hundreds of requests for order forms for the drug. Groups like the National Abortion Federation and Planned Parenthood advertised their training sessions for doctors on how to use it. And abortion clinics and abortion rights advocates like Planned Parenthood say they have been swamped with calls from women asking about the pill. But Heather O'Neill, a Danco spokeswoman, said most of the orders seemed to be from Planned Parenthood or independent abortion clinics. That is also the affiliation of most of the doctors attending National Abortion Federation and Planned Parenthood workshops, said Stephanie Mueller, a spokeswoman for the federation. And many of the women calling seem to be confused about what the pill does, thinking that they can swallow it at any stage of pregnancy and that their pregnancy will magically disappear. In fact, a mifepristone abortion can be a lengthy ordeal, in contrast to a surgical abortion, which is over in minutes. The Food and Drug Administration said mifepristone could be used to induce abortions only through seven weeks of pregnancy, dated from the first day of a woman's last menstrual period. After swallowing three mifepristone pills, the woman must return to her doctor's office two days later to take another drug, misoprostol, that makes the uterus contract, expelling the fetal tissue. Then she must come back again two weeks later to be sure the abortion is complete. The drug combination causes bleeding and cramping that typically lasts 9 to 16 days, but it is about 95 percent effective in completely aborting a pregnancy. If the drugs fail, the woman must have a surgical abortion. While in theory, at least, any licensed doctor could offer mifepristone, many say now that they have no intention of doing so and others say they will try to avoid providing the drug. For example, a family practice doctor in Maine, who asked not to be identified, said he was so committed to providing abortions that he secretly worked nights at an abortion clinic in another town 40 miles away. He said he would offer mifepristone at that clinic. But if one of his regular patients asks for the drug, he does not plan to provide it. And, he said, his partner in his family practice as well as the other doctors in his town are not interested in providing it either. "The greater good that I do is the abortion work I do out of town," the doctor explained. "My first obligation is to those patients. If I were to offer mifepristone in my office, and risk picketing, that would compromise what I regard as my important abortion work elsewhere." Dr. Steven Tamarin, a New York doctor in family practice, also applauds the approval of mifepristone. A member of the board of directors of Physicians for Reproductive Choice and Health, an organization of about 2,000 doctors who promote abortion rights, Dr. Tamarin said he was not worried about abortion opponents. But he has another concern: the time it takes to provide a mifepristone abortion. The drug agency requires that the women be counseled about the pill before using it. "There's no extra payment for doing the counseling," Dr. Tamarin said. But there also is an abundance of abortion clinics in Manhattan where women should be able to get the pill, he said. "If a patient comes to me," he said, "and says, `Doctor, I'm really uncomfortable going anywhere else. I'm terrified. I trust you. Would you please provide the medical abortion?' I would certainly do it. But if there's 10 people around the corner who do it and I'm up to the gills in other things, then I might not go out of my way looking for more work." Doctors point to other obstacles as well. One is deciding how far along a pregnancy is, since mifepristone can be used only within the first seven weeks of pregnancy. Another involves making sure that the fetus is in the uterus and not in a fallopian tube. The way to check on an early pregnancy is with intravaginal ultrasound, a method widely available at abortion clinics, but not in most private doctors' offices. The Hope Medical Group for Women, an abortion clinic in Shreveport, La., spent $27,000 on a machine, said Robin Rothrock, the clinic's administrator. And even if a doctor bought one for mifepristone abortions, "you've got the issue of making sure they know what they are doing," she said. "Few of these doctors in every hamlet, village and town who are supposed to make medical abortions so widely available have ultrasound equipment or the expertise to use it," said Dr. William West, who runs an abortion clinic in Dallas. "They are not going to acquire such expensive equipment to enable them to do a few medical abortions that won't come close to paying for it," he added. The F.D.A. also requires that any doctor who provides mifepristone be able to provide a surgical abortion in case mifepristone fails or to have an agreement with another doctor or an abortion clinic that can provide a surgical abortion. Abortion clinics would be a logical choice for such backup agreements, doctors say. But clinic doctors say they have not heard from doctors who want their services. "We have not been called by anybody about surgical backup and we are the only clinic in the Pacific Northwest that's been using mifepristone since the first trials," said Dr. Deborah Oyer, medical director and owner of Aurora Medical Services in Seattle. "We have gotten lots of calls over the years about medical abortions. We have done seminars on medical abortions and we have had tons of phone calls from the lay public and potential patients. But I don't know of any doctors calling about surgical backup or about how to get started," Dr. Oyer said. "I'm a little surprised," she said. "But also at some level, I'm not. In studies that were done in the last several years, there were always a significant percent of doctors who say they would do medical abortions. But I was always a little suspicious. It's a lot easier to say you'll do it than to actually do it." In addition, Dr. Oyer said, many women do not want their doctor — or anyone in their town — to know they had an abortion. "I can't tell you how many women who come on their own say, `Oh, I can't tell my doctor,' " Dr. Oyer said. "And sometimes their doctor is someone who does abortions in their own office." Ms. Rothrock said she too had not received any calls from private doctors for backup services. Her clinic, she said, is one of only two that provide abortions in a 200-mile radius, and the other clinic has decided not only that it will not provide backups but that it will not even provide mifepristone. Its owner, Roneal Martin, said his doctors did not have time to be on call for the patients 24 hours a day. Even so, Ms. Rothrock said, she was not sure she would want to help private doctors whose mifepristone patients needed surgical abortions. "It comes down to taking over someone's complications," she said. "Does that mean I'm putting my doctor on call in the middle of the night. We might say, `Go to the emergency room.' " Dr. Warren Hern, director of the Boulder Abortion Clinic in Colorado, worries about that, too. "What's going to happen if the emergency room doctor takes care of the patient and perforates the uterus?" he asked. "Who's responsible?" Some say that the driving force that will bring mifepristone to private doctors' offices will be women who demand it. "This will not be physician driven; it will be patient driven," said Dr. Carole Joffe, a visiting professor of sociology at Bryn Mawr College, outside Philadelphia. And all agreed that women seemed interested in the drug. Vicki Saporta, executive director of the National Abortion Federation, said so many women were calling about mifepristone that the group had to double the capacity of its hot line. "We get over 3,000 calls a month, and it's increasing," she said. Gloria Feldt, president of the Planned Parenthood Federation of America, said her organization's clinics had been deluged with calls. "We're taking tens of thousands of calls here," she said. YEAH RIGHT!!! Doctors at abortion clinics also say they have been inundated with calls from women who are interested in mifepristone. But the problem, they say, is that most of these women are confused about what the drug does. "They think that no matter how far along you are in a pregnancy, you just swallow a pill and that's it," said Dr. West, the operator of the Dallas abortion clinic. "There's a very common misconception in the lay public, and even way too common among physicians, that this is a nice, easy way to get rid of a pregnancy," said Dr. William Ramos, who runs an abortion clinic in Las Vegas. Many abortion providers say they tell women that a pill-induced abortion is an option, but that surgery is faster and less painful and requires one visit to the clinic rather than three. "We're telling them straight up front that if any of us needed an abortion, we'd go for the surgical procedure," Dr. Ramos said. Dr. West said that he would offer mifepristone, but that he was not happy about it because he thought surgery was much better. "I'll be forced by market pressures to offer it," he said. Dr. Charles Livengood, a gynecologist at Duke University who provides abortions there, also said he preferred surgical abortions. "I think it's good to have mifepristone available," Dr. Livengood said. "But I do think that an abortion with mifepristone tends to be a prolonged and messy affair as opposed to a quick procedure that I do in the clinic." Nonetheless, he has been dutifully presenting it as a possibility to his patients, explaining carefully what taking the drug entails. "I've presented it to 10, maybe 12 women," Dr. Livengood said. "I haven't had any takers at this point."
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