Pill Doesn’t Alter Abortion Ethics, RU-486 Creator Says

LE KREMLIN-BICETRE, France —  For Charlotte, a 28-year-old single Frenchwoman who works for an Internet company, the RU-486 abortion pill was no miracle drug. Two weeks after taking it, she still hurts and still bleeds.

But the hardest part for the gentle, sensitive Parisian was being the central actor in the abortion itself. There was no anesthesia, no wake-up-and-it’s-over relief. She wasn’t even in a clinic at the critical time.

Instead, it happened as she sat on the toilet in her boyfriend’s apartment, alone.

“I was worried about having to participate, about seeing things, about the blood,” the young woman says, speaking on condition that her last name not be used. In retrospect, though, she has decided that she made the right choice.

“An abortion by surgery would have been harder,” Charlotte says. “It’s a violation of the body. What a horror.”

One of the most controversial pharmaceutical achievements of modern times, the French-invented RU-486 pill will soon be available in the United States. Last month, the Food and Drug Administration authorized its sale and use, subject to certain conditions.

Abortion foes in the United States see the approval of the yellowish-white tablet, which will be sold under the brand name Mifeprex, as a further trivialization of the taking of life. “RU-486 kills innocent human beings,” Judie Brown, president of the American Life League, has protested. “It’s chemical warfare aimed at the littlest babies.”

The pill, which has been on the market for 12 years in France, selling for the equivalent of $12.80 apiece, has even become an issue in the U.S. presidential campaign. Texas Gov. George W. Bush, the Republican candidate, has called the FDA’s decision to permit it “a mistake,” arguing that it will favor abortions instead of discouraging them. His Democratic rival, Vice President Al Gore, in contrast, heartily endorsed the FDA’s action as widening “the right of women to choose.”

For its creator, prominent French endocrinologist Etienne-Emile Baulieu, the pill doesn’t make resolving the difficult moral issues surrounding abortion any easier--it just makes the process less invasive for the pregnant woman.

“It’s something that is scientifically and medically good for women, but it doesn’t alter the ethics of abortion,” says the 73-year-old specialist on human hormones, interviewed at his hospital laboratory in this southern Paris suburb. “It’s a different technique, that’s all.”

Few medical products, however, have aroused greater hopes and fears. In societies where abortion is taboo, such as Saudi Arabia, some women or their families have been prepared to pay virtually any price to obtain Baulieu’s pill, which is distributed and used in France under strict supervision.

Each year, American women also contact family planning clinics in this country by the hundreds, hoping to persuade medical personnel to ignore government regulations that allow abortions only for women who have lived in France for three months.

“The abortion pill is a great stride forward,” says Christine Der Andreassian, nurse counselor at Broussais Hospital in Paris, where 15,000 women have undergone abortions with RU-486 in the last 12 years. “What happens when a woman goes into an operating room and experiences a vacuum [surgical] abortion? Her legs are held open; it’s very intrusive. The whole process disturbs women very much.”

In his jumbled office, where paintings and collages compete for space with dense medical texts on methods of contraception, Baulieu waves a letter on White House stationery that he has just received. Signed by First Lady Hillary Rodham Clinton, it calls the FDA’s authorization of RU-486 “an important development in women’s health.”

In 1980, the French scientist invented the synthetic steroid--mifepristone--that became the basis of the abortion pill, which works by stopping development of pregnancy and causing the fertilized egg to detach from the wall of the uterus. Eight years later, the product was authorized here for commercial use. (The “RU” in its name stood for Roussel Uclaf, the French drug maker for which Baulieu worked as a consultant.)

France’s health minister at the time praised it as “the moral property of women.” Opponents of abortion, who succeeded in having sales suspended in France for a time, predicted that the pill would make having an abortion no more of a bother than swallowing an aspirin for a headache.

The statistics clearly show the fears of abortion foes were unjustified. The most recent figures from the French government’s General Directorate of Health, for 1990-98, show only an overall 6% increase in abortions, to 214,000 in 1998.

In the period from 1990 to 1995, the number of abortions in France actually declined slightly.

“There is no relationship between availability of the pill and the number of abortions in France,” says Marie Chirouze, spokeswoman for the government health agency.

“I think it is insulting to suggest, as Mr. Bush did, that the availability of this pill will encourage abortions,” Baulieu objects.

According to government figures, RU-486 is being used in 20% of all abortions in France. That may seem like a modest percentage, but there are reasons. First among them is that beyond the fifth week of pregnancy, only surgical abortions are permitted in this country.

Why such a strict limit? Der Andreassian explains that if use of RU-486 were allowed later in pregnancy, it would make the difference for a woman between potentially witnessing what is called the “expulsion” of an amorphous, whitish inch-long egg sac, and perhaps seeing a fetus with tiny but discernible arms and legs.

Strict procedures laid down for use of the abortion drug in France also have nothing in common with the simple popping of a pill to banish a headache. For the woman who decides to take RU-486, French law mandates a process requiring four visits to the doctor or hospital, spread over a period of about two weeks. (See box.)

A second drug, prostaglandine, is taken 36 to 48 hours after a woman has swallowed three RU-486 pills in the presence of a doctor. The additional drug is designed to induce contractions of the uterus. The woman is then asked to remain at the clinic under medical supervision, and if expulsion doesn’t take place within three hours, a second dose of prostaglandine is administered. She then waits an hour more.

In 82% of cases, according to a study, expulsion of the fertilized egg takes place between the time a woman takes the abortion pills and after the prostaglandine takes effect. At Broussais, two rooms are set aside, one light and airy, the other quiet and dark, where patients can wait, accompanied if they choose by their boyfriends or husbands.

But some women will leave the hospital or clinic without having expelled the egg. For almost all of them, the critical moment will come when they are somewhere else, perhaps alone.

Charlotte was taken by her boyfriend to his small studio apartment on the Right Bank in Paris. To try to get some sleep, she lay down but soon felt things stirring inside her. Bleeding heavily, she got up and went to the toilet.

“I felt fragile, morally and physically,” Charlotte says. “Even that word ‘expulsion’--I really don’t like it. It’s too clinical.”

Soon after it was over, her boyfriend returned home bearing two presents, a sweater and a bracelet. She looked at herself in the mirror and cried a lot.

This happened on a Friday. The next Monday, she was back at work.

“I had a slight stomachache but I was OK,” Charlotte says. Since then, she’s been coming to terms with her feelings. “Being pregnant makes you a different person,” she says.

In 1% of the instances when RU- 486 is used, the pills fail to work, and a surgical abortion is required.

Using synthetic hormones to terminate pregnancy isn’t for everybody--they aren’t recommended for heavy smokers more than 40 years old, or for women with kidney problems, severe asthma or emotional or psychological problems.

There also are possible side effects, including heavy vaginal bleeding, abdominal pain, diarrhea and nausea. According to French medical authorities, in 1989, a 35-year-old mother of 13 died when her uterus ruptured after taking RU-486, but an investigation found that the abortion pill was not at fault.

For Der Andreassian, one of the merits of RU-486 is that a woman is conscious of what is happening, unlike surgical abortion, which may take place under general anesthesia.

“When she has had a chemical abortion, a patient knows what she has been through,” the veteran nurse says. She says she believes that will make the woman more careful in the future about using contraceptives.

Charlotte agrees. She stopped taking birth control pills, she says, for two reasons--her gynecologist told her she might go blind if she continued to smoke and use the pill, and she had a vague but definite desire to see if she could become pregnant. When she did, she and her boyfriend, who have known each other for three months, decided they didn’t want to have a child, or not yet, anyway.

For Baulieu, use of the pill in the United States will be a form of consecration after years of combat and controversy. Originally, Roussel Uclaf announced it wouldn’t sell the drug in the American market, for fear of inciting a consumer boycott. U.S. distribution rights eventually ended up with a nonprofit family planning group, the Population Council, and a New York-based company, Danco Laboratories LLC, was formed specifically to market it.

“C’est formidable, formidable!” Baulieu says when asked how the FDA decision makes him feel. “For almost 20 years, we have known that this product works, and that it is not dangerous.” He places blame for the delay squarely on men in power. “Men don’t understand women,” the French scientist says, “and they underestimate their problems.”

At Broussais, Der Andreassian is happy that American women now have the same choice as their French sisters. “Women want to abort with drugs--it’s more human,” she says. “They don’t want to be dependent on doctors and nurses at a time like that.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

How the French Use the RU-486 Abortion Pill

A woman who decides to abort in France using the RU-486 pill embarks on a process that is supposed to last a little more than two weeks and requires four visits to her doctor or a hospital or clinic. The woman also must sign a consent form certifying that she understands the procedure and is aware of the risks. The abortion costs $166, all of which except $33 is reimbursed by the state-run health system.

Day 1--The woman seeks an abortion, and a physician agrees. By French law, there is a mandatory delay of one week to allow the woman to reflect.

Day 8--The woman swallows three RU-486 pills in the presence of her doctor or qualified medical personnel at a clinic or hospital. The synthetic steroid stops pregnancy and detaches the embryo from the wall of the uterus.

Day 10--The woman returns to the clinic or hospital and receives a dose of another drug, prostaglandine, which causes the uterus to contract. In the majority of cases, the egg will be expelled between the time the woman takes the pill and the end of the several hours she will be kept at the clinic or hospital after being given prostaglandine.

Day 15-16--The woman returns for a checkup to be certain that expulsion of the egg is complete.

*

Source: Broussais Hospital, Paris