By Kath Gelber
RU486, the "abortion pill" manufactured by Roussel Uclaf, has again hit the headlines. It is to be trialled in both Sydney and Melbourne by the World Health Organisation (WHO), although Roussel has said it has no intention at this stage of seeking to register the drug in Australia.
The emotional headlines and high profile of anti-abortionists have obscured informed discussion about the reliability and safety of this method of abortion.
RU486 is currently registered in France, Britain and Sweden. In Britain a licence was granted for use of the drug in 1991.
In France, where the method was first developed, a licence was granted in 1989 amid controversial circumstances. Pressure from anti-abortionists had persuaded Roussel Uclaf to withdraw the drug after its initial launch. It was released back on to the market within a month, after the French health minister stated, "From the moment governmental approval for the drug was granted, RU486 became the moral property of women, not just the property of the drug company".
More than morals were involved, however — at the time the French government owned more than a third of Roussel Uclaf shares. Today in France approximately one quarter of abortions are carried out with RU486.
Opinion within drug industry circles is not unanimous on the marketing of RU486. The German agrochemical giant Hoechst AG is a majority shareholder in Roussel Uclaf and has had an ambivalent attitude to the pill from the start. In January 1989 it was reported that Hoechst allowed Roussel to develop the drug only because it never expected it to succeed.
Hoechst chief executive Wolfgang Hilger went on record saying that an abortion pill violated the company's credo to support life. The company faces pressure from the anti-abortion movement in Germany and the US, which then provided a quarter of its revenues.
The anti-abortion lobby's outright rejection of the drug has apparently had an impact on trials and availability of RU486 worldwide. The deputy managing director of Roussel Uclaf's Sydney office said the reason the company has no plans to seek to register RU486 in Australia is that at present this "would be going against the will of a significant section of the community".
But who is this "significant section" and how significant is it? The most recent Australian poll on the subject was in March 1991, conducted by Anderson McNair and commissioned by the NSW Abortion Rights Coalition. It found that 81% of those surveyed supported a woman's right to have an abortion, and only 12% opposed it.
A survey conducted in Queensland in 1991 showed 56% of Catholics support women's right to abortion. It is a small minority that is attempting to control the debate and restrict access.
The pro-choice movement has had a mixed reaction to RU486. Some have hailed it as the answer to restrictions on abortion access. Others have condemned it as a highly complex "chemical cocktail" which may present more problems and dangers than a surgical abortion, which is a 15-minute medical procedure when performed under a local anaesthetic and which is seven times safer than carrying a pregnancy to term. Still others have argued for measured support for investigation of this option as a possible expansion of choice for women seeking abortion — a critical appraisal which has the interests of women seeking abortion as its focus.
Speaking at a workshop in Washington, DC, in April 1993, Roussel Uclaf emphasised that optimal care must be guaranteed with regard to cases with complications, that the method should be strictly medicalised, and that no fewer than three visits to the doctor were necessary when undergoing treatment. The spokesperson warned that the pro-choice movement shouldn't leave these points out of the discussion.
Pro-choice activists who seek to investigate the possibilities of RU486, though, are unlikely to take the advice of multibillion-dollar drug companies that historically have had more interest in the profitability of drugs than in ensuring their safety or accessibility to those who need them.
The use of RU486 does present real problems and potential health risks. The procedure is relatively complex. In France, RU486 is administered at licensed clinics. The procedure is strictly supervised throughout and is available only to women up to seven weeks pregnant.
It involves a thorough medical check-up, ultrasound and a counselling session. Within three to four days of taking the RU486, prostaglandin is administered to cause the uterus to contract. A pain-killer is usually required at this point. Subsequent visits are necessary to ensure the contents of the uterus have been expelled and to check blood levels.
Some have only light pain and no side effects. About 15% of women abort using RU486 alone and do not require prostaglandin. About 4% require surgical abortion anyway because the contents of the uterus are not fully expelled.
In 1991 the first reported death associated with the procedure was reported. A French woman who was a heavy smoker and in her 13th pregnancy died after suffering a cardiac arrest. She had been treated with a synthetic version of the hormone prostaglandin used in association with RU486. The French Health Ministry admitted there was a direct link between the prostaglandin and subsequent heart failure.
Three other French women are known to have suffered non-fatal coronary attacks. Since that time Beaulieu, the doctor who developed RU486, has been developing newer versions of the prostaglandin, claimed to be less likely to cause circulation and coronary problems.
Critics of RU486 point out other health risks involved. These have been particularly well documented in Misconceptions, Myths and Morals by Renate Klein, Janice Raymond and Lynette Dumble (Spinifex Press 1991). The duration and amount of blood loss is cause for considerable concern. Duration of bleeding is on average two weeks and about 70 cc, equal to two average menstrual periods. This compares to blood loss after conventional suction curettage of 10-20 cc.
Many women are unable to use RU486. Women over 35 or under 18, epileptics, diabetics or women suffering from a heart, lung, kidney, liver, stomach or intestinal disorder, or who have taken steroid medication in the last 12 months are ineligible. Women assessed as "overweight" or "heavy smokers" are also ineligible, as are women who have used an IUD or hormonal contraceptive within three months prior to conception.
Significant pain may last for days, sometimes weeks. Other possible side effects include vomiting, nausea and diarrhoea.
Initial propaganda in favour of RU486 referred to its suitability as an alternative method of abortion because it was more private and less invasive than surgery. Critics point out that this is not necessarily the case, since the procedure involves a minimum of three visits to the doctor including pelvic examinations and ultrasound scans and the ingestion of a high level of hormones.
Pro-choice activists caution that to argue in favour of RU486 as "less invasive" than conventional methods buys into the propaganda of the anti-abortion movement. Surgical abortion does require the entry of instruments into the uterus, but in comparison to other surgical procedures the number and number of times instruments are used is very small. The tendency to think of surgical abortion as invasive is more likely to stem from the propagation of wild myths by the anti-abortion movement, and the feelings of vulnerability female patients have in a sexist health care system.
At the same time, to embrace RU486 uncritically may give legitimacy to anti-abortion forces by reinforcing myths about the danger, difficulty and undesirability of surgical abortion. It could also accelerate the trend of doctors not learning how to perform surgical abortions and thereby further restrict access.
In the end, the provision of safe and effective abortion for women on demand remains a crucial issue. More than 200,000 women still die every year from illegal abortions, predominantly in the Third World. Well over 50 million abortions are performed each year.
In the struggle to expand abortion rights for women, all new procedures require careful examination. It is important that decision-making is informed. RU486 has the potential to expand the choices available to women, not as an alternative to surgical abortion but as another option. RU486 is not a miracle, but it may give women another choice.