RU-486 Abortion Pill Hasn’t Caught on in U.S.
Dr. George Kung believes RU-486, the French abortion pill approved for sale in the United States last September, is an important reproductive milestone. But the San Diego gynecologist, who performs surgical abortions, does not offer it.
He has little incentive to do so. Few women have asked him for the drug, which activists fought for years to bring to this country. A pill-induced, or medical, abortion can take several days and is less reliable than a surgical abortion, which is over in minutes, he said.
“It is a major development in political terms,” Kung said of the pill. “In practical terms, it is of small value.”
Economic and medical realities are weighing heavily on the introduction of the RU-486 abortion pill in the United States. High prices--the drug usually costs more than the surgery--and the reluctance of doctors and even many abortion clinics to offer it have slowed the women’s health revolution that many expected.
Private physicians have shunned the pill because it is a costly medication they must be trained to use. Some clinics are offering the drug, also known as mifepristone, but an informal survey suggests these veteran abortion providers haven’t fully accepted it either.
Of 53 clinics in California contacted by The Times, 43% said they do not use the drug. Among them was a Northern California clinic that talks women out of trying the drug; a receptionist described a medical abortion as a “Third World method” used when surgery isn’t available.
To abortion activists who guided the drug through a regulatory thicket and funded a company to market it, mifepristone held great promise. The Feminist Majority Foundation, the Population Control Council and other supporters had expected the drug to expand abortion beyond clinics--where women can face harassment--to doctor’s offices. Abortion would become more available and private.
Because no special equipment is required to administer the drug, any doctor, in theory, can offer it. Eleanor Smeal, a Feminist Majority co-founder, predicted that once the Food and Drug Administration approved mifepristone, “the number of abortion providers will double overnight.” A signed editorial in the New England Journal of Medicine hailed mifepristone as a “dramatic advance” because it would allow women to avoid the “emotional nightmare” of harassment at clinics.
“It is not turning out to be the social revolution many predicted,” said Ronald Fitzsimmons, executive director of the National Coalition of Abortion Providers, which represents less than 10% of abortion providers. “It is happening slowly.”
It May Be Too Early to Gauge Demand
To be sure, some advocates for the abortion pill believe it is too early to write it off and that it will eventually gain wider acceptance. Mifepristone has been available in this country for only about six months, they say, and it is unrealistic to expect physicians--who tend to be conservative with new treatments--to embrace it immediately.
The company that markets the drug in the United States will not disclose sales data and no information is available on what portion of abortions it accounts for. Annually, more than 1 million abortions are performed in the U.S.
In places where mifepristone is available, demand from women has been mixed. Some clinics report strong interest, said Fitzsimmons, while others report none.
Clinics typically charge $75 to $100 more for a pill-induced abortion than for surgical abortion, putting the method beyond the reach of some women, especially in states where Medicaid does not cover abortion, experts noted. And a medical abortion can be a prolonged ordeal, involving cramping and bleeding for up to two weeks.
A pregnant woman receives one to three mifepristone tablets, which she takes with water before leaving her doctor’s office. The pills block the action of progesterone, causing the embryo to detach from the uterine lining. Two days later, usually at home, the woman takes a second drug, misoprostol, an ulcer medication that can cause uterine cramping. She vaginally inserts up to four tablets, which cause the uterus to contract and expel the embryo, usually within a day.
Two weeks later, the woman returns to her doctor for a physical exam to make sure the abortion is complete. If it is not (the pills have a 5% failure rate) she must undergo a surgical abortion, usually a vacuum aspiration by machine.
The FDA has approved the method for up to the seventh week of pregnancy.
Obstacles Stand in Way of Physician Acceptance
To doctors who do not perform surgical abortions, mifepristone presents obstacles that activists didn’t fully anticipate as the drug made its way through the government approval process:
* Legal restrictions. UC Davis sociologist Carole Joffe said private doctors have been discouraged by state laws that entangle abortion in red tape. Some states have 24-hour waiting periods or require minors to obtain parental consent, she said. Doctors may need to examine fetal tissue. Michigan ended what amounted to a ban on chemical abortion last month, after abortion advocates sued.
* Business burdens. Dr. Richard G. Roberts, president of the American Academy of Family Physicians, said a typical family doctor can expect one to two cases a year, too few for a physician to become comfortable with mifepristone. Add to that the cost of abortion drugs that might expire before being used and the paperwork and training required. Most doctors will refer women to clinics, he said.
To doctors who already do surgical abortions, mifepristone has other drawbacks. Medical abortions can take place outside a doctor’s office at any hour. This means physicians must be on call to answer questions and handle emergencies should a women bleed heavily or react badly to the drug. Doctors also must follow up with patients to make sure the drug worked.
Mifepristone “involves too many appointments and too much counseling,” said a San Diego gynecologist who does surgical abortions but does not offer the pill. “It isn’t worth it.”
Kung, president of the gynecological society in San Diego, has sent the few women who have asked for mifepristone to Planned Parenthood, which operates 83 clinics nationwide, including three in San Diego, that offer the drug. “If a patient doesn’t keep her [post-abortion] appointment . . . if she cramps in the middle of the night, I don’t want to deal with that,” Kung said. “I don’t want to be responsible around the clock, seven days a week.”
Smeal of the Feminist Majority said she understands the reluctance of some abortion practitioners, who had been expected to lead acceptance of the drug. But she thinks they will offer mifepristone in time. “A surgical abortion is a two-minute procedure. They can do them easily and fast,” Smeal said. “There is a natural lag to try something new.”
But Diane Maracich, who manages the mifepristone program for Long Beach-based Family Planning Associates, the nation’s largest for-profit abortion chain, doesn’t expect much competition from private physicians.
“It is not that simple. It isn’t, ‘Take this pill and see you in a week.’ There is a lot of counseling involved,” she said.
Along with Planned Parenthood, which accounts for 20% of abortions nationally, Family Planning is one of the largest providers of mifepristone in California. To Family Planning, with an existing staff available to counsel and track patients, the abortion pill offers advantages.
A medical abortion is “slightly more profitable” than a surgical abortion, depending on how it’s done, said Family Planning President G. Michael Lyon. Though the FDA-approved procedure calls for three tablets administered up to the seventh week of pregnancy, Family Planning uses one pill given up to the ninth week. The chain charges $500 for a pill-induced abortion, $130 more than for a first trimester surgical abortion--in part to cover the second office visit and the $90 cost of a mifepristone tablet.
Family Planning said the lower dosage is equally effective; it claims only one “failure” in its first two months with the drug. And by offering mifepristone up to the ninth week of pregnancy, Family Planning obtains a competitive edge over Planned Parenthood, which stays within the seven-week guideline.
“You can catch a lot of women in those two [extra] weeks,” Maracich said.
Clinic Patients Are Not Choosing the Drug
Family Planning declined to say what percentage of women choose mifepristone; Planned Parenthood clinics in Southern California say acceptance is low.
At Planned Parenthood of Los Angeles, the percentage of women choosing mifepristone was “way less than 1%” in January and February, according to director Nancy Sasaki, who is mystified as to why the percentage is low. Half of the women who express interest in mifepristone do not go through with it, said nurse practitioner Mary Kelly, who runs the mifepristone program for Planned Parenthood in San Diego and Riverside counties.
Some women are more than seven weeks pregnant, and therefore ineligible for it. Others decide they do not want a prolonged ordeal, Kelly said. And since the abortion occurs outside a doctor’s office, it isn’t appropriate for teenagers who may not want their parents to know, she added. No more than 3% of women at clinics she supervises choose mifepristone.
Cost May Be a Factor for Some Women
Experts believe cost plays a role in which method women choose. The price of a medical abortion using a single tablet, the practice at many clinics, is $75 to $100 more than a surgical abortion, which typically costs from $325 to $350, according to the National Abortion Federation.
Most women who obtain an abortion are poor, according to research by the Alan Guttmacher Institute. Only 16 states, including California, use Medicaid funds to pay for medically necessary abortions. MediCal covers mifepristone. The remaining states pay for abortions in cases of life-endangerment, rape or incest.
“There is no question cost can make a difference, especially to a young woman,” said Dr. Felicia Stewart, a public health expert at the UC San Francisco Center for Reproductive Health. “If two options are safe and effective and one costs $75 more, which one are you going to choose?”
Danco Laboratories, the New York company that markets the drug, priced mifepristone to bring it “within range of a surgical abortion.” Danco charges providers $270 for the recommended, three-pill dose. That price, Danco spokeswoman Heather O’Neill said, makes mifepristone “a viable option in the marketplace” and allows Danco to recoup the cost of bringing the drug to market.
The same dosage costs the equivalent of $40 in France, where the drug was developed by a unit of Hoechst of Germany and has been available for 13 years. A medical abortion in France costs $130.
USC pharmaceutical economist Joel Hay said the price appears to include a risk premium to compensate Danco for entering a business in which abortion providers have been threatened and, in some cases, murdered. Abortion practitioners, for their part, said there are costs associated with a medical abortion that justify a premium over a surgical procedure.
A pill-induced abortion requires an additional office visit, they said. And if the drug fails to work, some clinics perform a surgical abortion at no added charge. “It is more profitable, yes,” said Family Planning’s Maracich of a pill-induced abortion. “But if you need a surgical abortion, it is not.”
There is anecdotal evidence that more women may choose mifepristone if it is priced more competitively with surgical abortion. At Planned Parenthood of New York City, which charges $375 for a first-trimester abortion regardless of method, about 12% of abortions from January through April used mifepristone.
But that Planned Parenthood affiliate also ran a highly visible advertising campaign for the drug in the city’s subway system from the beginning of January through mid-March, which Planned Parenthood believes stirred interest. Posters showed a pill held between a thumb and forefinger, and noted: “The choice is now in your hands.” The $50,000 campaign has been the biggest consumer push to date for the otherwise poorly promoted drug.
Danco, backed by such organizations as the David and Lucile Packard Foundation, said it lacks the resources to advertise mifepristone to consumers. It has promoted the drug in medical journals, where it hopes to reach doctors.
The National Abortion Federation plans an advertising campaign in the July issues of Self and People, with ads to follow in 11 magazines later in the year. The $2-million campaign, intended to spur awareness, should reach 70% of women from age 18 to 49, NAF said. The ad depicts a woman with a wistful expression and says, “You have the freedom to choose. Now you have another safe abortion choice.”
In February, it distributed postcards on 50 college campuses that simply showed a small white tablet next to the caption: “In the history of abortion in America, this is not a pill, it’s a milestone.” The cards prompted calls to the advocacy group’s hotline, where 35% of inquiries are about mifepristone.
Dr. Anne La Hue, director of the gynecology and obstetrics residency program at Los Angeles County Harbor-UCLA Medical Center and expert on reproductive issues, is perplexed as to why acceptance of mifepristone has been low locally. She believes the lack of advertising and promotion, while expected, has played a role. With so little being spent to advertise mifepristone, women aren’t likely to hear about the drug unless their doctors tell them about it, she said. But many physicians won’t stock it, she noted, until women start asking for it.
“The push has to come from doctors and women,” La Hue said. “It has to come from both.”
