TWO YEARS ago a new drug promised to revolutionise abortion for British women. For the first time, women seeking early abortion had an alternative to surgery. Now, specialists are wondering what went wrong with the abortion pill.
Mifepristone (or RU486) has been used for nearly four years in France and women who want an early abortion are routinely offered the drug. More than half of them opt for it, welcoming the fact that it does not require a general anaesthetic nor involve instruments being put inside the body.
But only 5,000 abortions are expected to be carried out medically, rather than surgically, in Britain this year, although RU486 could be offered in 30,000 cases. Why has the uptake here been so low?
'One of the main problems has been that it really requires its own facilities,' says David Paintin, chairman of the Birth Control Trust. 'It works best as a dedicated service outside gynaecology clinics but hospitals rarely have facilities such as a separate sitting room and toilets, so most have tried to make do.'
Attempts at improvising meet with disappointment. At St James's Hospital, Leeds, attempts have been made to include medical abortions alongside other gynaecology procedures, with little success. 'It's very likely that other units trying to offer women a choice will run into the same problems,' warns David Bromham, senior lecturer in obstetrics and gynaecology.
The lack of separate facilities has meant that Mr Bromham's unit has had to slot medical abortions into the existing gynaecological clinic.
'The best way to make this drug available is very different from the normal working practices of an everyday 'gynae' unit. We do offer the treatment but the patient has to be admitted to a hospital bed as they would be for a surgical procedure,' he says. He can admit only two women per week for abortion using RU486.
But is sectioning off women who are having medical abortions absolutely necessary? 'Women who seek early abortion don't perceive themselves as being ill,' says Ann Furedi, the Birth Control Trust's assistant director. 'They want to be up and about, wearing their own clothes, watching television and able to talk to one another. That's difficult in a routine ward when you have women in for other investigations.' She believes one way of improving the situation is by integrating the service with family planning clinics.
One of the few successful NHS medical abortion services has done exactly that. Dr Muriel Broome is director of family planning services at the Royal Berkshire Hospital in Reading. 'We've found that a medical abortion service fits very well into a family planning clinic,' she says. Women come in to Dr Broome's clinic to be counselled, are given tablets and have the abortion separately from, but within reach of, the gynaecology department. Women can refer themselves directly to the clinic and demand has been high.
'Unfortunately, there's a limit to what we can do and sometimes we are slightly overwhelmed,' she admits. 'But we've shown that if you offer the service, it will be picked up.'
All abortions, surgical or medical, have to be carried out in units licensed by the Department of Health. Dr Broome is fortunate to work in a family planning clinic attached to a hospital licensed unit.
The use of RU486 itself is subject to tight controls to avoid a black market in the drug and any other improper or unsafe use. This, too, hinders medical abortion being widely available, according to the Birth Control Trust. They are urging Virginia Bottomley, Secretary of State for Health, to reconsider the regulations.
'We're pushing for any family planning doctor, including GPs, to be able to give the tablets after counselling,' says Mrs Furedi. 'Then the woman would have the actual procedure in a hospital unit.'
The trust believes that this is the best way to ease the current log jam that women so often face when seeking early abortion. 'It makes perfect sense by helping to free hospitals that haven't time to see women in the first place,' says Mrs Furedi.
Despite the problems of provision and use, medical abortion is popular with patients and doctors. In a survey last month by Marie Stopes Health Clinics, 92 per cent of women who had used the drug said they would recommend medical abortion. Nearly 70 per cent said they chose it because they wanted to avoid surgery.
Doctors are enthusiastic, too, despite the problems. Dr Kate Paterson, an associate specialist at the Obstetrics and Gynaecology Department at St Mary's Hospital in London, is trying to set up a medical abortion service there. The problems are huge, especially when fighting for a designated sitting area for the women.
'But I seriously think that it's safer because early surgical abortions do have problems. It's difficult to dilate the cervix. It's difficult to be sure you've terminated and a perforated uterus is more likely. All this can be removed with medical abortion.
'I'm committed to increasing choice. Once it's up and running it's going to be first choice,' she says.
Medical abortion: how RU486 works
A woman is given RU486 after pregnancy is confirmed in a centre registered for abortion.
She is observed for at least two hours in case of vomiting.
She returns 36-48 hours later for a small dose of a hormone, prostaglandin, to improve the efficacy of the drug and is observed for around six hours. Bleeding usually begins within two hours.
She returns for check-up eight to twelve days later to ensure abortion was complete.
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