ANSIRH blog

The periodic exhaustive survey of  abortion incidence and access to services in the United States by researchers at the Guttmacher Institute is extremely helpful to qualitative social scientists, such as myself, who study the abortion issue. The most recent version of the survey, drawing on 2008 data, received most attention for its conclusions that the long-term decline in abortion incidence has stalled, that the number of abortion providers has remained about the same (after previous sharp declines), and that the level of harassment at abortion-providing facilities has increased.

All the above are of interest, but for me the most intriguing findings from the 2008 data concerned early medication abortion, which mainly occurs through the use of mifepristone (also known as “RU-486” or “the abortion pill”) in combination with another drug, misoprostol. Since FDA approval in 2000 of mifepristone for use in the United States, I have been interested in tracking the spread of this method of abortion and, in particular, in noting whether medication abortion could improve access to abortion in a country in which 87% of all counties have no abortion provider.

To back up a bit and give some context, mifepristone was developed in France and approved for use in that country in 1988, and other European countries quickly followed suit. But in the United States, the drug became embroiled in abortion politics, and it was not until 12 years later, at the tail end of the presidency of Bill Clinton, that approval finally came.

Meanwhile, all through the 1990s abortion violence intensified, with blockades, vandalism and firebombings at clinics and stalking of abortion providers at their offices, homes and churches. The prochoice community’s worst fears came to pass with the first murder of an abortion doctor in 1993, followed by several more murders in 1994, and again in 1998.

In retrospect, I believe this horrific violence understandably contributed to unrealistic hopes on the part of the prochoice movement as to what mifepristone could achieve. Given that abortion via mifepristone did not require the same specialized training as performing “surgical” or “aspiration” abortion, advocates began to fantasize that the pool of abortion providers would dramatically increase with FDA approval. I recall seeing a posting on the website of one group that gushed, “the number of abortion providers could double overnight.”

Moreover, advocates predicted that mifepristone would not only bring new providers, but that the violence and harassment associated with abortion provision would diminish. This was because family practice physicians and other primary care clinicians (including nurse practitioners, physician assistants and nurse-midwives) were seen as the logical groups from which these new providers would come. As the argument then went, no one would know who in a family practice waiting room was there for an abortion, and who for a prenatal visit or a blood pressure check, and so on. The “antis” would simply not know which practices to target.

In the years immediately following FDA approval, I spent a fair amount of time trying to locate “new” abortion providers—that is, those who did not provide surgical abortion. I found some, whose experiences I discuss in my recent book, Dispatches from the Abortion Wars, but quite few. As I had expected, though the clinical aspects of medication abortion were quite simple, the social aspects were not. New providers also had to deal with protestors, as it became clear that one could not inform one’s patients of this new service without protestors finding out. Also, those primary care providers who only planned to offer a few abortions each month found that the costs of malpractice, the cumbersome procedure the FDA established for offering the drug, and the need to comply with various state regulations (such as parental notification or consent) made incorporating medical abortion into one’s practice appear just too burdensome.

But though it initially appeared that mifepristone was not changing anything in the always conflictual American abortion situation, I recall reading in 2002 an article by Stanley Henshaw and Rachel Jones, two Guttmacher researchers, on the experience of mifepristone in Europe. Their argument, in brief, was that it took a good ten years for mifepristone to become normalized within the health care systems of various European countries—all of which had far less conflict over the abortion issue than the United States. The authors ended their article by cautioning patience to U.S. abortion advocates, saying that it could take a “decade or longer for mifepristone to be fully recognized and integrated as a method of abortion.”

Though the recent Guttmacher findings draw on eight, not ten, years of experience, it appears that there has been a turning point of sorts with respect to mifepristone. Some 199,000 early medication abortions were performed in 2008 (94% of these using mifepristone, with the remainder using another drug, methotrexate). This figure represents a 24% increase over 2005. Overall, some 17% of all abortions performed in 2008 in non-hospital facilties were early medication abortions (and again, the vast majority of these used mifepristone).

But most intriguing of all to me in this latest Guttmacher data was that 164 facilities, some 9% of all identified abortion providers, offered only early medication abortion, and not surgical abortions. These facilities included both private doctors’ offices and nonspecialized clinics, such as Planned Parenthood clinics which did not have a full—i.e. surgical—abortion service. It is facilities such as these that offer the best hope to realize mifepristone’s promise to truly expand abortion access.