Abortion Pill in Europe

The New York Times

http://www.nytimes.com/2000/10/05/world/05PILL.html

Europe Finds Abortion Pill Is No Magic Cure-All

October 5, 2000

By SUZANNE DALEY

PARIS, 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."