Abortion Pill’s Effect in U.S. Hard to Predict

WASHINGTON —  The Food and Drug Administration’s approval of the abortion pill RU-486 could make the procedure more accessible than ever to millions of women in communities with no abortion provider, supporters of the drug say.

At the same time, however, these advocates make a seemingly contradictory claim: Despite wider availability, RU-486 will not prompt any increase in the number of abortions.

Are they right? In truth, many health analysts said, it is hard to know.

In predicting what will happen in the United States as the drug comes into use, the most compelling clues come from Europe, where more than half a million women have used it in the last decade.

In France, where the drug was invented, women have had access to it since 1989. Abortions have not increased. In fact, they have fallen. Just before the pill was introduced, France reported 13.4 abortions per 1,000 women of reproductive age. That dropped to 12.4 abortions in 1995.

The same has been true in Britain, where the drug was introduced in 1991, and in Sweden, where it arrived in 1992. Although many women are using the drug, abortion rates are in decline.

“My guess is that abortions will not rise in the United States, based on the experience in France, where they appear to have gone down,” said Dr. Beverly Winikoff of the Population Council, a New York nonprofit group that was instrumental in bringing the drug to the United States.

But Winikoff and others also noted that there are big differences between the United States, where abortion is a volatile political issue, and most of Europe, where government plays a far larger role in delivering health care. “You can’t just paste the experience of Europe onto the United States,” said James Trussell, a Princeton University economist who focuses on reproductive health.

To begin with, abortion in France is a government-sanctioned service offered by the national health system, and it is widely available throughout the country, Trussell said. French women do not face the hurdle of having to search for a clinic. And abortion rights is not a highly charged political issue, so no women are scared away from clinics by the prospect of picketers.

“They just don’t have to worry much about access there,” Trussell said.

In the United States, by contrast, 86% of counties have no abortion provider. In fact, state regulations, protesters and other factors have reduced the number of providers to just over 2,000 in 1996, down from 2,900 in 1982.

This means that some U.S. women may want an abortion but may not be able to find a provider, Trussell said. If doctors widely adopt the pill and reverse the falloff in abortion providers, he said, then the United States could see a “modest” increase in abortion--one that would not have taken place under France’s uniform national health system.

The new abortion pill, known formally as mifepristone, is part of a two-drug regimen that ends a pregnancy by inducing a miscarriage. The FDA approved it Thursday for use through the first seven weeks of pregnancy, the same as in France. British doctors use it through week nine under a slightly different regimen; some U.S. doctors are expected to offer it through nine weeks as well.

Other factors suggest that more American women might adopt the drug than those in France.

More will be eligible to take it. In France, Winikoff said, women must be referred to an abortion center by their own gynecologist, and they must wait seven days between requesting an abortion and obtaining one. Many women run out of time to have the procedure before the eligibility window closes at the seventh week of pregnancy.

On the other hand, American women are culturally programmed to take a more active role in their health care and to seek out services they want, Winikoff said. Sum up the differences between France and the United States, she said, and it is anyone’s guess where drug-induced abortion will be more widely used.

In the United States, the most likely outcome will be that women have earlier abortions, not more of them, and that they will have to travel less to obtain them, said Jacqueline Darroch of the Alan Guttmacher Institute, a reproductive health research group in New York. For abortion rights supporters, that would be a welcome development.

“Earlier abortions are safer and more accepted by the American public,” Winikoff said.

At the National Right to Life Committee, an anti-abortion group, legislative director Douglas Johnson saw a downside to earlier abortions.

“There are likely to be some women who, because of the increased access, will have an abortion before they would encounter the information we provide to explore alternatives,” he said. “We have more than 4,000 crisis pregnancy centers, and there’s experience to show that women who find their way to them and are presented with a viable alternative will often opt for life for their baby.

“But there has to be some time for [a woman] to find out about this.”

Adding more complexity to the question is that abortion rates have been falling in the United States, as they have in Europe, from nearly 30 abortions per 1,000 women in 1980 to about 23 in 1995. The likely causes include wider use of contraceptives, new contraceptive options and fear of AIDS.

It is impossible to know whether these factors would have caused an even bigger drop in European abortion rates if mifepristone had not come into use. To some health analysts, the falling rates suggest that the number of abortions is influenced by a variety of factors, and that mifepristone will be a relatively minor one.

The question of the drug’s use on U.S. abortion rates has already become politically charged, and it could become an issue in the presidential campaign. Criticizing the FDA decision, George W. Bush, the Republican presidential nominee, said Thursday that he feared the pill “will make abortions more and more common, rather than more and more rare.”

Republicans in Congress said the FDA action violated President Clinton’s long-standing promise to make abortions rare. The pill “will result in more abortions,” said the National Right to Life Committee.

To Winikoff, the argument that mifepristone will cause more abortions is patronizing to women, who go through cramping, bleeding and occasionally worse side effects during drug-induced abortions.

“It demeans women to say that, because someone on the corner is saying, ‘Here are abortion pills,’ that a woman will just take them,” she said. “Women don’t approach abortion with that light perspective. It’s a very serious and heavy decision for most, if not all, people.”

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Effect in Europe

In countries where abortion rates are available, the introduction of RU-486 did not lead to an increase in abortions. Critics contend that in the United States, where abortion rates are already high, the pill will boost the number of women who choose to end their pregnancies.

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Abortion rates per Year pill Rate the year Rate in 1,000 women introduced it was introduced 1995 France 1989 13.4 12.4 Britain* 1991 15.2 144. Sweden 1992 20.0 18.3

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*England and Wales

Note: For comparison’s sake, U.S. rate in 1995 was 22.9Source: Alan Guttmacher Institute