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Medical Versus Surgical Abortion: Social Determinants of 'Choice' 1
By Gail Pheterson

This paper was first published in French: Pheterson, G, 2001. 'Avortement pharmacologique ou chirurgical : les critères sociaux du 'choix''. Cahiers du Genre, no. 31. Paris: L'Harmattan, 221-247, and is reproduced here with kind permission of the journal.

The invention and authorization of a pharmacological method to induce early abortion has radically changed abortion care in a number of countries and provoked major controversy in others. Popularly named after one of its drug components, RU486 or mifepristone, this method has been heralded as 'a revolution in gynecologic medicine', 'of the same magnitude as the development of the hormonal contraceptive pill' 2. As of 1999, 250 thousand RU486 abortions had been performed in France, six million in China (currently about one million per year) and an increasing number in many other countries 3. Debates about so-called medical abortion typically compare it to the older surgical method, called vacuum aspiration or suction curettage. Both medical and surgical abortion are currently safe and effective when performed according to tested protocols by trained practitioners under adequate conditions. However, rarely are the two procedures offered under equally optimal conditions. A woman may have to decide between an immediate abortion with one method versus a delay for the other, between a method her practitioner favors and one he or she finds distasteful, or between one method in a nearby clinic and the other 200 km away. Those asymmetric choices may then be interpreted as inherent advantages of one or the other method rather than as idiosyncratic or institutionalized implementation of services according to medical conventions, legal codes, research objectives, restricted material resources, sociocultural styles of care and/or ideological notions about (pregnant) women's Nature or Responsibility.

This paper examines such determinants of method comparisons from the perspective of women. Beginning with clinical policy (who is eligible for each method) and moving to procedural protocols (such as anesthesia regimen), attention will focus on women's satisfaction with the two methods, the way the alternatives are presented, service accessibility, the sexual division of labor among practitioners, and cultural differences in method preferences. Lastly, a few discursive examples of provider attitudes toward women and women's attitudes toward abortion will serve to demonstrate the possible influence of gender ideology on scientific and experiential reports.

The focus here is specifically early first trimester abortion because the new drug protocol, hereafter referred to also as the mifepristone-misoprostol protocol, is authorized only for procedures under 49 days gestation. Given that most women who wish to terminate a pregnancy prefer to do so as quickly as possible and given that early abortions are safe and easy, procedures performed within the first weeks of gestation are of particular interest. In addition, rapid termination of pregnancy helps sidestep some of the social shaming, religious judgment and criminal sanctioning that currently limit or preclude abortion access to women worldwide (Banwell & Paxman 1993). Technical descriptions of each procedure are elaborated elsewhere 4 and briefly outlined here in Boxes A and B.

Early Abortion Eligibility

Medical abortion before seven weeks' gestation is often compared with surgical abortion between eight and 12 weeks' gestation. Women who go for an early abortion may have to choose between starting a drug protocol immediately or waiting up to three weeks for an aspiration. The deciding factor for them may then be immediacy versus delay rather than medical versus surgical; in fact, the pharmacological procedure may ultimately take more time to complete (from three to 15 days) than the waiting period for a suction curettage. The actual aspiration takes only a few minutes and, even allowing for the total process of intake interview, counseling, the intervention itself and a brief recovery period, a women is likely to complete the suction protocol in less than a few hours.

Delays for vacuum aspirations are common in many countries for a number of medical, legal and administrative reasons. Medically, the main reason for delaying aspirations in the past were (1) difficulty in verifying early pregnancy (and wish to avoid unnecessary surgery) and (2) greater difficulty in assuring evacuation of the complete gestational sac before eight weeks gestation than thereafter. However, pregnancy can now be verified as soon as women suspect conception and early vacuum aspiration with careful tissue inspection has been shown to be at least (Paul, 2001), if not more (Edwards & Creinin, 1997; Hakim-Elahi et al., 1990), effective and safe as a mifepristone?misoprostol abortion when sound surgical technique is used. Sound technique includes accurate dating, gentle dilation, meticulous evacuation with immediate examination of the uterine aspirate, and diligent follow-up (Edwards & Creinin, 1997; Edwards & Carson, 1997). Curiously, resistance to early vacuum aspiration remains strong in certain countries with otherwise advanced technology, such as England, France, Norway and Switzerland. Indeed, if practitioners do not inspect the tissue aspirate, as is commonly the case in France 5, early aspirations may be less effective than in settings with optimal conditions.

The major legal barrier to early aspiration is the imposed period of reflection required by law in a number of places between the first request at a doctor's office for an abortion and the procedure. Since surgical abortion is safe and legal at later gestational age than is medical abortion, it has become routine, again in France, to waive the delay for reflection for a woman who chooses the drug procedure but not for a woman who chooses a vacuum aspiration (Guyot-Brennetot, 2000). In addition, a lack of funding and staffing for abortion facilities together with a dearth of trained practitioners can lead to time-consuming searches for an abortion provider and waiting lists that may likewise give priority to women choosing medical abortion given its authorization only for very early pregnancies. Optimal choice would thus require congruence between abortion provision and demand, the exercise of correct protocols for early vacuum aspirations, an elimination of the imposed waiting period and practitioner flexibility. Drug-induced abortion is not an earlier abortion method from a scientific point of view, but it may become an earlier option by way of institutional policy or provider preference. An editorial by French researcher EE Baulieu illustrates how the 'position' of a physician can determine or simply erase a woman's options:

My position as physician and inventor of RU486, is not to encourage abortion, but rather to prefer contraception. When contraception fails....the least negative solution is contra?gestation or emergency contraception. When it's too late for that, the least negative solution is interruption of pregnancy with RU486 (between the 2nd and 7th week). And when ? unfortunately ? the limit for that is passed, the least negative solution is instrumental (usually aspiration). (Le Monde, Vendredi 1 décembre 2000: 16), (my translation, my emphasis).

In other words, for Baulieu, now that we have RU486, there is no decision between two early abortion methods. For him, RU486 is clearly the best ? or rather, 'least negative' ? method of terminating an early pregnancy, apparently because it most closely resembles the action of chemical pregnancy antagonists along the chain from contraceptive pills to contra? gestation pills to contra?progesterone pills. For Baulieu, as for many others, aspiration is really a last - 'unfortunate', as he says ? resort. He clearly favors pharmacological over instrumental means of pregnancy termination, irrespective of the equal or superior performance of the later.

Anesthesia Regimen And Pain

Medical abortion is often compared with surgical abortion under various regimes of anesthesia ranging from general anesthesia to IV sedation to local anesthesia to no anesthesia at all. Women are most likely to cite 'freedom from pain' as their reason for choosing medical abortion when anesthesia is insufficient or absent during surgical procedures, such as in China and Vietnam (Ngoc et al., 1999). They are more likely to cite 'avoidance of surgery' as a positive feature of medical abortion when their alternative is aspiration under general anesthetic, such as in Cuba and India (Winikoff et al., 1997). However, when aspirations are performed with adequate local anesthesia women report significantly less pain with surgical than with medical abortion, a factor they then cite for preferring aspirations (ibid). In other words, when women prefer medical abortion to surgical abortion, one reason is the (unnecessary) pain of inadequate sedation or a wish to avoid (unnecessary) general anesthesia.

In France, where researchers pioneered medical abortion, 75 per cent of vacuum aspirations are performed under general anesthesia (Nisand, 1999). Also, most procedures performed with local anesthesia are conducted in hospital operating rooms, a setting some women find intimidating and anxiety-producing (Neuchild, 2000:14). Mortality rates for first trimester vacuum aspirations in France are 0.37 per 100,000 when performed with general anesthesia and 0.15 per 100,000 when performed with local anesthesia. A research report for the French Ministry concludes that, 'Given the improvement in abortion techniques and sanitary conditions, the method of anesthesia...now constitutes one of the principal remaining risks' (my translation) 6. Gynecologist Dr. Joëlle Brunerie (director of the abortion center at the Hospital Antoine Béclère) maintains that 'practitioners refuse to use local anesthesia because they have not learned either the technique or the practice' 7. Local anesthesia requires better relational skills and a more delicate technique than general anesthesia.

For women in France, the choice may then be between waiting for a vacuum aspiration with a general anesthesia or starting a drug protocol procedure right away. For women in the Netherlands, the choice is very different. Abortions are performed by vacuum aspiration with local anesthesia (xylocain, bupovacain or the like) in 95 per cent of cases; general anesthesia is used for women who are exceptionally anxious. One-half of all aspiration procedures are performed at less than five weeks' gestation. Although pharmacological abortion is authorized in the Netherlands, the procedure represents a small percentage of the total number of abortions. One study found that suction curettage done by skilled and experienced doctors scores better than medical abortion for pain, blood loss, nausea, diarrhea, failure rate and women's time consumption. Nonetheless, the researchers 'realise that the results of this study don't mean that there is no place for medical abortion in Holland. Some women prefer the disadvantages of that method out of fear for any surgical treatment' (Willems 1996: 131).

Satisfaction

In certain countries, women who undergo the drug protocol may be more likely than those who undergo an aspiration to find it either more or less satisfactory than expected, depending upon their individual experience (Winikoff et al., 1997). Individual experience refers especially to the length, pain, bleeding and effectiveness of the pharmacological process. In France, the 2.2 per cent of women who expel the conception after the first medication (mifepristone) or, more probable, the 61 per cent of women who expel it while at the clinic within four hours of the second medication (misoprostal) could be expected to find medical abortion more satisfying than expected. The remaining 36.8 per cent of women who must wait longer, often bleed more, experience more cramping and expel at home are more likely to find it less satisfactory than expected 8. In general, women seem to evaluate their abortion experience predominantly on the basis of the degree and duration of pain or duress. In one multicenter French survey of 488 women, a majority of women (62 per cent) given the choice between drug-induced and aspiration abortion by local or general anesthesia chose the drug method (Bachelot et al., 1992). After the medical procedure some women were less satisfied with the abortion than they had expected: 12 per cent were unsatisfied versus 3.6 per cent in the total aspiration group. Women in another study evaluated medical abortion less favorably if they had had a prior surgical abortion than if they had never experienced one (Creinin, 1997), likewise suggesting that women may underestimate the difficulty of medical abortion and overestimate the difficulty of surgical abortion.

Often the meaning of 'satisfaction' is not clear. In one study on 'Safety, Efficacy and Acceptability of Mifepristone-Misoprostol Medical Abortion in Vietnam', researchers conclude that:

Success rates for both methods (medical and surgical) were extremely high (96per cent for medical abortion and 99per cent for surgical abortion). Medical abortion patients reported many more side effects than women obtaining surgical procedures did (most commonly, cramping, prolonged bleeding and nausea), but none of these side effects represented a serious medical risk. Nearly all women, regardless of the method they chose, were satisfied with their abortion experience (Ngoc, 1999: 10)

What does it mean for women to be satisfied despite cramping, prolonged bleeding and nausea? Are they simply satisfied that the abortion eventually 'worked' so that they are no longer pregnant, or that it went better than they imagined the alternative surgical procedure 9, or are they satisfied with their own performance or that of their clinician or, understandably under some circumstances, are they relieved to have survived? Any safe termination of pregnancy may be experienced as a satisfying resolution.

Other investigations of women's comparative satisfaction with the two methods address both 'emotional appeal' and 'more personal and practical considerations'. On the side of emotional appeal, women in one study conducted in the United States were generally satisfied with the drugs and considered them more 'natural' and less intrusive or frightening than a surgical procedure. But another study of procedure selection found that 75 per cent of women nonetheless chose vacuum aspiration because they 'just wanted to get the abortion over with' as quickly as possible and because they preferred fewer appointments and the confidentiality of completing the abortion away from home. In another study, only 18 per cent said they would chose medical abortion; 40 per cent said they would not and 42 per cent were undecided 10. For those undecided, the way alternatives are presented may determine their choice.

Presentation Of Alternatives To Health Personnel And Clients

Given the newness of medical abortion and the complexity of the protocols, current literature on method comparisons tends to give little attention to early aspirations while elaborating at length the more complicated, perhaps more 'challenging', drug protocol. For example, one article on procedure selection devotes three and a half pages to medical abortion and a half page to surgical abortion. The apparent promotion of the more cumbersome drug protocol is surely an unintended effect of not having much new to say about early suction curettage which is quickly summarized by the authors as 'simple, quick, and associated with a low risk of complications or failure' ?( Ellertson & Westhoff, 1999: 67). Furthermore, the authors suggest that. 'Because preferences vary, clinics should organize abortion services in such a way that staff members provide the type of abortion they prefer and that best matches their temperament' (ibid: 65). And, indeed, provider temperament may determine abortion method, a criteria generally unbeknownst to women whose temperament may or may not match their practitioner's.

Certain articles that purport to compare the two methods seem to dismiss aspirations as nothing other than a back-up technique. Recent guides for abortion counselors likewise tend to favor medical abortion, as if it were special treatment reserved for women with 'good' qualifications (i.e. those free of contraindications). One Counseling Guide for Clinicians Offering Medical Abortion produced by Planned Parenthood of New York City, Inc. explains that 'Some women may be disappointed or angry if they are 'ruled out' or found to be ineligible for the procedure' (Planned Parenthood, 1996: 19). Counselors are instructed to tell women that ineligibility 'doesn't mean anything bad about you or your health'. And, indeed, the 25 pages of instructions to counselors on how to judge (the eligibility of women), teach (the difference between normal and abnormal pains) and instruct (the necessary precautions in case of complication or failure) may foster a sense of pride in those accepted for the complex procedure and a sense of failure if their lack of qualifications obliges them to 'settle' for 'the simple, quick, low-risk' vacuum aspiration.

Service Accessibility And The Sexual Division Of Labor Among Practitioners

Medical abortion has been put forth as a more accessible method than surgical abortion, and it may become so. At present, protocols for mifepristone-misoprostol abortions are authorized only under tight medical surveillance. In France, mifepristone falls under the same medical codes as narcotic drugs (Aubény & Bureau-Roger, 1997). Beyond drug access, mifepristone protocols require a far more intense system of services than the brief one-step vacuum aspiration 11. Nonetheless, there is evidence in the United States, where 86 per cent of counties have no abortion provider (Forrest & Henshaw, 1993), that more physicians might be willing to offer medical abortion than vacuum aspiration and that a larger range of physicians as well as physician assistants, midwives or nurse practitioners might be authorized to guide the process. However, medical abortion authority Dr. Mitchell Creinin has reported that 'Most doctors who answer surveys saying they are interested in offering this 'procedure' change their minds when you tell them what's involved', referring to multiple office visits, counseling, ultrasound capability, backup facilities and state abortion laws (Kolata, 2000). Those who do offer the pharmacological method generally delegate counseling and monitoring to nurses and social workers. The gender implications of that division of labor may be significant given that doctors are more likely to be men than are nurses and social workers. The workload does not necessarily, however, change the locus of control. Physicians currently retain control of medical abortion even if their role is limited to prescribing the drugs. Dr. Richard Hausknecht, a prominent researcher-physician, encouraged Obstetrics and Gynecology residents to provide medical abortion by explaining: 'With medical abortion, you're in charge and you get the money, but your nursing staff does the work' 12. Of course, many physicians who provide abortion are themselves women, and women physicians have been found to have more favorable attitudes toward voluntary terminations of pregnancy than do their male colleagues and to be more likely to provide abortions (Weisman et al., 1986). Research has not yet been conducted to determine if gender differences exist in attitudes toward medical versus surgical methods.

Cultural Context

Abortion care generally, and abortion method in particular, are evaluated according to safety, effectiveness, accessibility and satisfaction of the women concerned as well as of their service providers. Close study of research conducted in diverse countries suggests, however, that the same indicators may be read differently in different cultural contexts even given comparable legal and technological environments. As a comparative case study, here is a glimpse at contrasting attitudes toward medical versus surgical abortion in the Netherlands, France, and the United States, each with liberal abortion laws, exemplary technological knowledge and a distinctive influence on abortion practice worldwide. Whereas the influence of the United States rests with its economic and political power, France is renowned for scientific drug innovation and the Netherlands for its effective programs of reproductive and sexual health education.

Reports from the Netherlands show a singular lack of excitement about medical abortion; rather there appears to be a consensus of satisfaction with the existing early suction curettage. Given that about 50 per cent of abortions in the Netherlands are currently performed at less than 5 weeks gestation (Willems, 1996), a high proportion of women seeking an abortion would be eligible for the new drug protocol. But vacuum aspirations continue to be the method of choice, despite government authorization of the pharmacological approach. Meanwhile the French, who pioneered medical abortion, have integrated the pharmacological procedure to the point where most eligible women are likely to follow that protocol in certain clinics and about 20 per cent of those seeking abortion nationwide, most notably in the public sector where two-thirds of all abortions are performed 13. Neither Dutch nor French feminists have focused abortion activism on the method used. Dutch feminists see abortion as a right basically won in theory (that is, ideologically), in law (one of the most liberal in Europe) and in practice (easily accessible as early as the unwanted pregnancy is verified and up to viability of the fetus). Certain French feminists continue to struggle against the access barriers of one week required waiting period for 'reflection', waiting lists due to insufficient facilities and providers, and the refusal of many hospitals to perform abortions despite legal obligations; in 2000, after much controversy, they won an extension of abortion rights from 12 to 14 weeks LMP, elimination of the three-month residency requirement for migrant women, and the right of minors to obtain an abortion without parental consent. Revealingly, those critical issues rarely touch questions of method alternatives, or lack thereof.

Dutch physicians are highly critical of French physicians' promotion of medication in reproductive health care, be it for an anti-progesterone/prostaglandin induced abortion or for hormonal replacement therapy during menopause. Since the Dutch consider suction curettage a 'fast, good and reliable' method, they are wary of prescribing what they consider unnecessary and uncomfortable, if not unsafe, drugs for women, be they burdened by an unwanted pregnancy or by normal signs of menopausal development (Alblas, 1996). In contrast, many French physicians consider the drug protocol superior to vacuum aspiration because, they say, it avoids surgical intervention, 'gives women more responsibility for their abortions', more closely mimics a 'natural process' and requires less of physicians' time or hands-on participation in what for many is a distasteful procedure.

The French distinguish themselves from what they call Dutch pragmatism, be it in relation to state attitudes toward (illicit) drugs, state attitudes toward prostitution or state attitudes toward abortion, all of which are more permissive in the Netherlands than in France. The Dutch medical and judicial establishment expresses little concern, for example, about individual marijuana use, cultivation or sale (considering 'concern' an unwarranted state expense and intrusion in individual lives); on the other hand, the Dutch pride themselves on state control of 'unnecessary' prescription of medication (and reimbursement only of generic products when available) and pride themselves on active state promotion of preventive health care (including safe conditions for abortion and safe conditions for prostitution) and of 'natural' methods (such as home deliveries that represent one-third of all births in the Netherlands, Notzon. 1987). In France, the equation is quite the opposite: tight controls of unauthorized drug and sex commerce (such as prohibitions of marijuana and prostitution) fit side by side with an expansion of authorized drugs and medical surveillance, notably in relation to female reproductive health (contraceptives, abortion, delivery, menopause). Regardless of historically persistent divergences between the two countries, Dutch physicians applaud the French innovation of drugs such as RU486 as an additional safe abortifacient and, especially, as a possible treatment for various diseases. And French physicians validate the Netherlands for having achieved wide contraceptive use and highly accessible abortion care along with one of the lowest abortion rates in the world 14.

Despite the Dutch-French divergence, both of those contexts share a European version of socialized medicine. The United States presents a radically different portrait with significant implications for abortion method evaluations: (1) Unlike the Netherlands and France, there is no commitment to universal health care in the US. (2) More than in the Netherlands and France, American US physicians are impelled to function defensively due to frequent lawsuits for malpractice and, in the case of pregnancy termination, due to the persistent threat of anti-abortion violence. (3) The US health care system, like other sectors of the society, is heavily shaped by market forces and economic incentives, true also in Europe but not nearly to the same extent. And that climate puts abortion method at the center of current political debates about reproductive rights: In the United States, the issue is abortion access, and if a new method will allow women to exercise their legal rights to reproductive choice then, understandably, they want it. When reproductive rights activists in the United States claim rights to medical abortion, they are not as engaged in evaluating the technical advantages and disadvantages of each approach as in trying to appropriate and enhance available resources.

Ideology

Practitioners and activists are well aware that even when abortion is legal and formally accessible, those who provide and consume services often face severe ideological judgment. Those judgments are so engrained that even providers who fight to guarantee safe abortion at personal or professional risk may reproduce condescending judgments of women who choose to terminate a pregnancy. Moreover, women who chose to abort may themselves internalize sexist ideology, as in assuming that they, as women, would be traumatized by instrumental action and soothed by biological processes. So, they might prefer an unpredictable waiting process (medical abortion) to a voluntary act (vacuum aspiration) since the process, painful as it may be, 'mimics Nature'. A few examples illustrate:

Provider's Attitudes Toward Women

Consider this description of 'Patient Eligibility' for medical abortion written by two distinguished physician researchers, one from the US and the other from France, both surely committed to increasing women's options for early abortion:

Although medical contraindications to abortion with mifepristone or methotrexate are few, social or psychological contraindications are more common. Women are not optimal candidates for medical abortion if they do not wish to participate in their abortion or take responsibility for their care, are anxious to have the abortion over quickly, cannot return for follow-up visits, or cannot understand the instructions because of language or comprehension barriers. Because of the risk of teratogenicity in an ongoing pregnancy, women must also be willing to have a surgical abortion should the medical method fail. Other nonmedical considerations include access to a telephone in case of an emergency and distance from emergency medical treatment (i.e., suction curettage for hemorrhage). (Creinin & Aubény, 1999: 97).

What is the message here about women ineligible for medical abortion? The facts of the description are solid: Women do need to take more time for a medical abortion, including self-monitoring, possibly repeated clinic visits, study of instructions, prepared access to emergency facilities in case of excessive bleeding and eventual aspiration should the method fail. As with any medical procedure, they would probably have a good reason to accept the additional risk and bother of such constraint when a more efficient alternative is available. But the guidelines are not framed in that way. The medical disadvantages of the method and linguistic limitations of information materials are framed as personal failings on the part of women who are profiled as passive, irresponsible, anxious, impatient, unavailable and illiterate. They may be one or more of the above, but they may also decide against 'medical' abortion from a position of personal agency, responsibility and informed reflection. The formulation, along the same line as the New York Counseling Guide described earlier, assumes engagement of the method to be a sign of strength, and refusal or 'psychological ineligibility' to be a sign of personal or female (?) weakness.

Another French practitioner, Director of a large abortion clinic, explained that:

The difference between a surgical and a medical abortion is the difference between experiencing and submitting (un avortement médical est vécu; un avortement chirugical est subi). With a medical abortion, the woman usually experiences contractions, bleeding, waiting, and finally the sight of the expulsion. She participates, whereas with a surgical abortion it's over in two minutes and she has done nothing but submit to the physician - it's me who does it. At our clinic, most eligible women under the 49 day limit without contraindications - except adolescents, they can't handle it - get a medical abortion. It fosters responsibility. (Interview with Dr. Jacques Mention, Amiens, 2 March, 1999).

Women's Attitudes Toward Abortion

For women, themselves who say they (would) prefer medical abortion, the advantages they cite are its 'non?surgical', 'non?intrusive', 'less traumatic', 'more private' and 'more natural' quality. What exactly do those terms mean? Women may share culturally pervasive ideas about demonic surgeons and magic pills, but those ideas may have little material base. Are even simple surgical procedures necessarily more traumatic or more intrusive than drug protocols? Anything from the removal of a wart to a heart transplant is surgery. Anything from aspirin to chemotherapy is a drug. Surely, removal of a wart could produce infection just as an aspirin could provoke gastric or prevent heart problems. Either instruments or chemicals can be intrusive with deleterious and traumatic results. What is trauma? Is childbirth 'traumatic'? Should it be? Is a caesarian section ? a surgical delivery ? more or less traumatic than a vaginal or 'natural' delivery? And is it more private at home or at a public clinic? Might some women define privacy - and security - by professional care and anonymity at a public clinic and others by solitude or support at home? The answer to each question is necessarily: 'That depends...'. Depending upon context, the same event can be a positive or negative experience. Cultural meanings - and gender prescriptions - might transform a painful vaginal delivery into a beautiful experience or a nightmare; they might transform an abortion into an experience of shame or a proud act of self-determination.

In relation to abortion methods, Dutch physician Marijke Alblas insists that 'the way the medical personnel explain the different options has a great influence on the choice the woman makes...the fear of the so-called 'surgical' method is so great that many women think it far easier to take some pills, they even find it a more natural procedure' (Alblas, 1996: 152). If, indeed, it is more 'natural', we could ask whether that constitutes a method advantage? RU486 plus misoprostol may, like rotten oysters, provoke a chain reaction of 'natural' contractions. What's positive is not the menstruation?like or miscarriage-like cramps, but the ability of the drug protocol to achieve a desired goal. We chose the drugs because we chose to terminate a pregnancy. We are in the realm of human volition, not biological reflex. As writes Béatrice Fougeyrolles, French general practitioner and abortion provider: '…abortion, beyond the right we demanded and won, is an act of insubordination to the natural order' (my translation: Fougeyrolles, 1999: 87).

Conclusion

The assumption that women are less responsible for their behavior and more subservient to medical authority when handled with surgical instruments than when prescribed chemical drugs, or visa versa, ignores the context and conditions of health care. Neither drugs nor instruments assure, in themselves, control or freedom from intrusion or satisfaction or Nature's ways. Both drug-induced and instrumental abortion methods can be positive tools for women's reproductive autonomy, and both can be patronizing, punitive tools of reproductive surveillance. The challenge of appropriating abortion technology on women's behalf goes beyond the chemistry or mechanics of terminating pregnancy to the politics of gender in diverse societies.

THE TECHNIQUES

SURGICAL ABORTION AT LESS THAN 49 DAYS GESTATION

The typical early surgical abortion, technically called suction curettage or vacuum aspiration, entails evacuation of the uterine cavity either manually with a cannula seated in a handheld syringe or electrically with a cannular attached to a suction machine. Some practitioners prefer the manual method to the machine because it may avoid the shredding of uterine contents with an electric vacuum pump and is inexpensive, easy to assemble, quiet and easy to use. The entire process takes a few minutes. There are no contraindications to performing a vacuum aspiration. Discomfort or pain depends upon the anesthesia regime, practitioner technique and the ambiance of the setting. After evacuation, the operating surgeon should examine the extracted embryonic tissue (under a fluorescent-magnifying lens, if necessary) to insure complete removal of the gestational sac, a practice diligently followed in some countries/clinics and rarely in others. If a sac is not identified on tissue examination, blood is taken immediately for a serum B-human chorionic gonadotropin (B-hCG) assay and the assay is repeated in several days to verify the expected drop normally occurring after termination of pregnancy. If the level does not drop, either the extraction was incomplete or an ectopic pregnancy exists. As a protocol variation, some practitioners routinely use misoprostol (brand name 'Cytotec') as a cervical opener prior to vacuum aspiration. After the procedure, all women are given a seven-day postoperative course of antibiotics to prevent infection. The protocol includes a follow-up visit three weeks later to confirm a negative urine HCG pregnancy test (Edwards & Creinin, 1997).

Results indicate complete abortions for 99.2 per cent of early procedures, including those at less than 6 weeks gestation. Safety for vacuum aspirations performed by trained practitioners under good conditions is reported as 'impressive' with a record of 99 per cent uncomplicated procedures. The remaining percent have minor complications such as slight blood loss or nausea with about .08 per cent requiring hospitalization for fever or other irregularity; no patients are reported to have excessive bleeding, uterine perforation or cervical laceration (the main serious risks under unsafe, often illegal, conditions) (ibid). As for discomfort, under local anesthesia most women feel pain during the suction itself, in another 20per cent it lasts for an extra 5 minutes. In one study the pain was described as 'severe' by 10 per cent of the women (who were given analgesics), as 'moderate' by 50 per cent and as 'hardly any pain' by 40 per cent (Willems, 1996). Mortality rates for first trimester vacuum aspirations in France are 0.37 per 100,000 when performed with general anesthesia and 0.15 per 100,000 when performed with local anesthesia (Nisand, 1999), less than the mortality rate for a penicillin injection, 1.1 per 100,000, or for childbirth, 6.6 per 100,000 (Gold, 1990).

 

MEDICAL ABORTION AT LESS THAT 49 DAYS GESTATION

Chemically induced abortion involves two drugs administered at an interval of two to seven days which together act to induce expulsion of the pregnancy. The first drug, mifepristone (RU486), is an anti-progesterone steroid that blocks the activity of progesterone, one of the hormones necessary for pregnancy; it induces shedding of the uterine lining including the embryonic tissue. Mifepristone is expensive and tightly controlled due to its primary use as an abortifacient. (In some places, such as the United States, where RU486 was authorized in 2000 after a decade of heated debate, or Canada, where RU486 has to this date 2001 still not been authorized, methotrexate is used in the place of mifepristone despite the disadvantages of a more lengthy process, a 10per cent failure rate and possible drug toxicity (UNDP et al, 1997). The second drug is a prostaglandin, which causes contractions that expel the embryo. The most usual prostaglandin now used is misoprostol/Cytotec (the same drug used to dilate the cervix before vacuum aspiration), a common drug on the market in 72 countries for the prevention and treatment of gastroduodenal ulcers; it is easy to stock, requires no refrigeration and is very inexpensive.

Despite variations in mifepristone/misoprostol protocols, a number of steps are common to all: There must be a preliminary visit to assess eligibility and to explain the possible duration of the process and the likely range of discomforts, uncertainties and precautions, including vacuum aspiration in case of failure. Medical contraindications include hemorrhagic disorder, use of anti-coagulants, chronic adrenal failure, allergy to mifepristone or misoprostol and lack of access to emergency care. Usually administration of the first medication, mifepristone, occurs either at the first visit or, in countries with a required delay for 'reflection', such as France, at the second visit. The woman then waits about two days before taking the prostaglandin (at home under some protocols and during a second/third clinic visit under required medical surveillance under others). A small percentage of women, two to five per cent, will expel the pregnancy after the mifepristone (thus no reason for additional medication), and a large percentage will expel within four hours of taking the misoprostol (60 per cent or considerably more, according to certain clinical trials, depending upon variations such as a second dose of misoprostol or vaginal application). In 10 to 15 days, everyone who has not yet had a confirmed expulsion must return to the clinic for verification of expulsion by ultra-sound scan or HCG assay. Most data affirm that 95 per cent of women will have a complete abortion by this time. The remaining 5 per cent can either return home to wait an additional 10 to 15 days or, surely if the pregnancy has continued to evolve, have an immediate suction aspiration (Creinin & Aubény, 1999).

The major discomforts with mifepristone-misoprostol are pelvic pain, bleeding (often abundant), nausea, vomiting and diarrhea. The major serious risk is hemorrhage (although rare at less than 49 days gestation) and fetal damage if a continuing pregnancy is brought to term due to the possible teratogenicity potential of misoprostol, thus the importance of emergency facilities and follow-up care (ibid).

References

Alblas M, 1996. 'Is the abortion pill an advantage for women? And do we want to fight for the introduction of the abortion pill into the Netherlands?' In: Ketting E & Smit J (eds.). Proceedings. Abortion Matters. International Conference on Reducing the Need and Improving the Quality of Abortion Services. 25th Anniversary of Stimezo Nederland, Utrecht: Stimezo, 151-153.

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1 This paper was first published in French: Pheterson, G, 2001. 'Avortement pharmacologique ou chirurgical : les critères sociaux du 'choix''. Cahiers du Genre, no. 31. Paris: L'Harmattan, 221-247. The author is grateful to Yamila Azize Vargas, director of the Proyecto de Transformación Curricular en Salud Sexual y Reproductiva at the University of Puerto Rico in Cayey, for inspiring this investigation, and for sharing ideas, documentation and a vital link to the training of abortion providers. Many thanks also to Stanley Henshaw, researcher of the Alan Guttmacher Institute in New York, and to the following physicians for their expert feedback and encouragement: Marijke Alblas (Netherlands), Joëlle Brunerie (France), Maureen Paul and Alexander Pheterson (both USA).

2 The first quote comes from a research article by Winikoff et al (1997: 78), the second from a press release by Sir Malcolm Macnaughton, former President of the Royal College of Obstetricians and Gynaecologists, United Kingdom 1996 (Childbirth by Choice Trust, 2001).

3 France was the first to authorize mifepristone in 1988 followed by China and Britain in 1991, Sweden in 1992, and Austria, Belgium, Denmark, Finland, Germany, Israel, the Netherlands, Spain, Switzerland and Russia all in 1999. In the United States the FDA approved mifeprisone (trade name Mifeprex) specifically for termination of early pregnancy on September 28, 2000, after a decade of intense controversy. See Creinin & Aubény 1999; Christin-Maitre 2000.

4 For an excellent overview of clinical comparisons between methods, see Paul et al., 1999. For a fuller integration of technical issues in the present analysis, see Pheterson, 2001.

5 Observation of two visiting Dutch abortion practitioners in France. See Alblas, 1996.

6 Mortality statistics and the citations are drawn from Nisand 1999: 39.

7 Assemblée Nationale, 2000: 37. In a personal communication, Dr. Brunerie asserted that 'C'est honteux d'utiliser une anesthésie générale pour ce geste aussi anodin'.

8 These statistics on the time of expulsion were reported in Aubeny, 1996.

9 This explanation was offered by Tang et al., 1993.

10 All research in this paragraph is cited in Kaufman, 1997.

11 See Two National (US) Surveys on 'Views of Americans and Health Care Providers on Medical Abortion. What they know, what they think, what they want'. Henry J. Kaiser Family Foundation, Menlo Park, California, September 1998.

12 Dr. Richard Hausknecht, Mt. Sinai School of Medicine, medical director of Planned Parenthood New York, speaking at the School of Medicine, Grand Rounds, University of Puerto Rico, Medical Science Campus, December 11, 1998.

13 For example, the University Hospital Abortion Center of Amiens reports 50 per cent medical abortions, representing 90 per cent of all procedures under 49 days gestation; most of the other 10 per cent are contraindicated (Guyot-Brennetot, 2000). The national average is a good deal lower due to differences between individual practitioner preferences and between the percentage of medical abortions in the public (23 per cent) and private (13-16 per cent) sectors (Le Corre & Thomson, 2000)

14 Note that low abortion rate is not always an indication of accessibility and quality care; in Puerto Rico, for example, the low rate is a function of inaccessibility and promotion of sterilization as a means of 'preventing abortion'. See Azize-Vargas & Avilés 1997.

 
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