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Is primary care ready for medical abortion?

Some physicians oppose RU-486's availability, others shy away for a range of reasons and even the most eager face barriers to its use.

By Victoria Stagg Elliott, amednews staff. Nov. 17, 2003.

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Mifepristone, also known as medical abortion or RU-486, can be administered safely and effectively in a family practice setting, according to a study published in the Journal of the American Board of Family Practice.

Researchers in New York City analyzed the records of women who received abortions at four community health clinics. One of the 236 women followed did not successfully abort and had to have a surgical abortion. Two had suction procedures for unknown reasons, and eight were lost to follow-up. One didn't take the medication as directed.

Thus, the positive conclusion. "If this can be safe in our setting, it can be safe anywhere," said Linda Prine, MD, lead author and a faculty member at the Beth Israel Residency in Urban Family Practice.

But just because it's safe doesn't mean it's available. Three years after the Food and Drug Administration's September 2000 approval of RU-486, reports indicate that the resulting increases in abortion access that some activists hoped for have not occurred.

For now, mifepristone is used primarily as an option offered by abortion clinics rather than something every physician can or is even willing to provide, although more doctors might be pursuing it. Right after approval, Danco Laboratories LLC, the drug's manufacturer, received orders almost exclusively from large clinics. As of last year, about 17% of its orders were to private practice physicians.

"For those who provide abortions in their practice anyway, they're now increasingly including medical abortion," said Richard Hausknecht, MD, medical director at Danco and an associate professor of obstetrics and gynecology at Mt. Sinai School of Medicine in New York. "But some private practitioners are starting to provide medical abortions as well."

There are many reasons why physicians are slow to take up medical abortion in the family practice setting, including ethical considerations, their own religious beliefs and possible negative community reaction. Some physicians also don't regard it as safe and worry that they wouldn't have medical backup available if things don't go quite right.

This concern was amplified in September when a California woman died after taking mifepristone. The county coroner's office concluded that she died of sepsis due to inflammation linked to drug-induced abortion.

"Abortion is legal in the land, and we can debate that separately, but the issue ... is what's safe for women," said Gene Rudd, MD, an obstetrician-gynecologist and associate executive director of the Christian Medical Assn. "We're not convinced of the safety of the FDA-approved protocol."

But even for those who want to provide it, there are significant barriers.

For Cynthia Chuang, MD, a fellow in general internal medicine at Boston University, the reality of mifepristone is that it's an expensive medication that she would have to pay for and store in her office, with no guarantee that a patient would ever even want it. "I'm not sure ... how much I would actually be providing," she said.

Despite the barriers, proponents say there are advantages to providing medical abortion in primary care settings. Patients may be more comfortable, and follow-up can be easier. For instance, even if a patient misses a post-abortion appointment, eventually she will come in for something else.

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