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Salon.com (U.S.), August 26, 2009

Why hasn't RU-486 changed the game?

HIGHLIGHT: A new study by the Guttmacher Institute provides some clues

By Lynn Harris

A 1999 New York Times magazine cover story by Margaret Talbot called mifepristone (RU-486) "the little white bombshell," speculating that the pill used for first-trimester non-surgical abortion could blow the pro/con abortion debate to smithereens and leave entirely new terrain in its place. Mifepristone's promise to make abortion available as early as 5 weeks, shift a significant proportion of procedures from embattled clinics to private doctors' offices (sorry, protesters) and increase the overall number of abortion providers convinced Talbot -- and the feminists who fought for its approval by the FDA -- that medical abortion could "reconfigure the politics and perception of abortion in this country more definitively than any piece of legislation has in the quarter century since Roe v. Wade."

Ten years later, here we are. Dr. George Tiller is dead; Randall Terry, apparently, is still relevant. Has mifepristone changed anything at all?

Yes and no, according to new research by the Guttmacher Institute. Yes (as also described here earlier), RU-486 has -- at very least -- become an "integral" part of the abortion landscape. The number of mifepristone providers increased from 208 in 2000 to 902 in 2007; its availability may have contributed to a trend toward abortion at its earliest -- and, relatively speaking, least controversial -- opportunity. At very least, under some circumstances (though medical abortion is not for everyone), women's options have expanded.

But what mifepristone hasn't changed is possibly the most important aspect of legal abortion: access to the procedure in the first place. "Expectations that approval of mifepristone would result in a wider range of providers offering abortion have not yet been met, and mifepristone has not brought a major improvement in the geographic availability of abortion," reads the study. "Most mifepristone abortions were performed at or near facilities that also provided surgical abortion. Only five mifepristone-only providers of 10 or more abortions were located farther than 50 miles from any surgical provider of 400 or more abortions." In other words, it was largely those who already provided abortion who added mifepristone to their practice, not new doctors getting into the game.

"One-third of women live in a county without an abortion provider. We've had a missed opportunity here to facilitate access for these women," Lawrence Finer, Ph.D., director of domestic research for Guttmacher and a co-author of the study, told Broadsheet.

But why? Well, it's not like mifepristone "just didn't catch on." All that was a lot to ask of one little pill. For one thing, a doctor can't just add mifepristone to a practice like a chef adds in-season fruit to a menu; there are training and liability issues to consider -- not to mention lingering stigma and yes, fear. And mifepristone made its debut at a time when -- broadly speaking -- the anti-abortion movement had just begun to take some of its business from the sidewalks to state courts and legislatures, where specious and cruel laws could restrict abortion more effectively than signs and rosaries . That's another barrier to offering mifepristone, notes Finer: in many states, adding abortion services means complying with all manner of elaborate structural requirements (as in the case of Mississippi's clinic, singular). "And in a lot of those cases the focus of those regulations is to make it harder to do abortions [of any kind]," says Finer.

There was also speculation, way back when, that the possibility of ultra-early termination could help shift public perception. "Abortions in the earliest weeks of pregnancy are not only safer, cheaper and less emotionally wrenching for the women who undergo them, they are also more politically tenable," noted Talbot, who cannot be blamed for failing to foresee that in some influential circles -- talk about early -- contraception was on its way to becoming politically untenable.

So no, at least compared to predictions, mifepristone has not substantially changed the game. And for that, in large part, we can blame the very opponents we'd hoped to have stymied.

What can be done? Says Finer: "Well, this study is a quantitative assessment of what's going on. Maybe it's time for something qualitative: talk to the OBs, the family practice doctors, ask them whether they're interested in providing it and if not, why not -- and then based on those conversations we could have some insights on how to overcome that barrier."

So the headline here is not "Mifepristone: FAIL." Rather, this research should serve as a reminder that when it comes to abortion, there's "the debate," and there's the reality. The debate shifts here, and the terrain shifts there, but the bitter pill is this: despite certain victories -- and during theoretical, ill-informed, even specious wars of words -- so many women, right now, remain able to exercise their legal right to abortion only with unacceptable difficulty, or not at all.

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