The Long Goodbye

THE SO-CALLED French abortion pill recently cleared the last hurdle to FDA approval, and should soon be available through doctors and reproductive health clinics. But after years of controversy surrounding its trip across the Atlantic, the arrival of RU 486 on the U.S. commercial market may be something of an anticlimax. From the way it's been vilified by anti-choice organizations, you might think ending a pregnancy with RU 486 was akin to riding out a hangover--so convenient it would become a routine substitute for contraception. In reality, the process is frequently more painful, traumatic, and drawn-out than a traditional surgical abortion.

Here's how it works: After receiving a combination of chemicals at a doctor's office or clinic, a woman goes home and waits to miscarry, which can take anywhere from four hours to several days. During that time, she experiences the same cramps and bleeding she would in any other miscarriage. Sometimes it's no more traumatic than a bad period. Sometimes she passes clots the size of lemons or oranges. The pain and bleeding lasts for hours or weeks, until the woman passes the embryo. Frequently she can see the tissue--alone or hidden in one of the aforementioned clots--in the toilet or shower.

In clinical trials in this country, "medical abortions" (as the pill/injection combos are called) are only administered through the seventh week of pregnancy. At that stage there's not much to see when the embryo, contained in a small blob called the amnion sac, is expelled. Some women describe seeing red-and-white globs, some say there's a cocktail shrimp-shaped squiggle. Nurses at Planned Parenthood in St. Paul say no one who's undergone a medical abortion as part of their small clinical trial has so far reported recognizing what they call "the pregnancy tissue." But women elsewhere have reported pervasive feelings of sadness upon seeing the embryo. Some describe being relieved that it bears no resemblance to the tiny plastic fetuses displayed by abortion clinic protesters.

France experimented with and ultimately decided against allowing medical abortions between the seventh and ninth weeks, at which point the tissue expelled begins to look like a tiny baby, with a recognizable head and limbs. Neither the medical professionals nor the patients could stand looking at the expelled embryos, according to Health magazine.

Some women don't expel the embryo and have to go back to the clinic for another dose of the contraction-inducing drug. If that doesn't work, she must undergo the surgical abortion she presumably sought to avoid in the first place.

Two different chemical combinations can bring on a medical abortion: Mifepristone, the pills popularly known as RU 486, block the hormone that sustains pregnancy, and methotrexate, an injectable ulcer- and cancer-fighting drug, works by stopping fetal cells from developing. A doctor administers either of these on a woman's first visit. Misoprostol is the next drug given--two days after RU 486 and five to seven after methotrexate--causing the uterine contractions that expel the no-longer-viable fetus.

Mifepristone has garnered the most media attention, and also appears to have more painful side effects than does methotrexate, currently being tested at a handful of clinics nationwide, including Planned Parenthood's St. Paul clinic. Nurses in charge there say two or three women a week participate in the clinic's medical abortion trial. So far, several have returned seeking to end the drawn-out process with a surgical abortion, but none have said they wouldn't do it again.

Holly, the nurse coordinating the local clinical trial, didn't want her last name used in this story because of the harassment she and other clinic workers face. She says one reason Planned Parenthood has had few problems is because the clinic screens candidates, turning away anyone who seems squeamish, can't tolerate pain, or can't get back to the facility quickly if something goes wrong or they choose to end the process. About 10-15 percent of women seeking abortions opt for the medical procedure over the surgical one, which is consistent with countries where RU 486 has long been legal.

"We have had a lot of patients come in with the notion that they'll get a shot and it'll all be over," she says. "We try to prevent [emotional trauma] by giving people adequate information about how the process can go for them." Still, say other providers who've worked with medical abortions, patients' expectations can be wildly unrealistic. "They tend to believe what they want to believe," notes one.

 
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