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,
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).
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
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
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
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.
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
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
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).
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.
SURGICAL ABORTION AT
LESS THAN 49 DAYS GESTATION
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,
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,
MEDICAL ABORTION AT
LESS THAT 49 DAYS GESTATION
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.
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).
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).
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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
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
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.
of two visiting Dutch abortion practitioners in France. See Alblas,
6 Mortality statistics
and the citations are drawn from Nisand 1999: 39.
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,
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 &
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