Thirty-five years after the Supreme Court's landmark Roe v. Wade decision, a pill that has largely faded from the rancorous public debate over abortion has slowly and quietly begun to transform the experience of ending a pregnancy in the United States.
The French abortion pill RU-486, on the market since 2000, has become an increasingly common alternative, making abortion less clinical and more private. At a time when the overall number of abortions has been steadily declining, RU-486-induced abortions have been rising by 22 percent a year and now account for 14 percent of the total -- and more than one in five early abortions performed by the ninth week of pregnancy.
The pill, often called "miffy" after its chemical name mifepristone and brand name Mifeprex, also has helped slow the decline in abortion providers, as more physicians who previously did not perform the procedure discreetly start to prescribe the pill.
"The impact and the promise is huge," said Beth Jordan, medical director of the Association of Reproductive Health Professionals. "It's going a long way towards normalizing abortion."
When the Food and Drug Administration approved mifepristone in 2000, some predicted it would revolutionize the abortion experience and debate by enabling women to get an abortion from any doctor, neutralizing one of opponents' most potent strategies -- picketing abortion clinics.
"The thinking initially was that this was going to change everything. There was a lot of hype. That didn't pan out," said Carole Joffe, a professor of sociology at the University of California at Davis. "But the impact has been happening gradually as it slowly and steadily is becoming integrated into the medical system."
'A much more private affair'
Judi Gilbert, 41, a nurse in Philadelphia, opted for mifepristone in 2005 when she had her second abortion. She had a 3-year-old son and was about to start a new job.
"It was something I could do at home and be with my husband," Gilbert said of taking the pill. "It was a decision we made together alone, and we were able to take care of it this way alone. It was just a much more private affair."
She added: "I wouldn't say it was easy -- it's never easy to terminate a pregnancy. But in the grand scheme of things, it was much more pleasant than a surgical procedure."
Gilbert is one of more than 840,000 U.S. women who have used mifepristone since it was approved, according to Danco Laboratories, which sells it.
The drug ends a pregnancy by blocking the hormone progesterone. Women take the pill in the doctor's office and then go home, where they take another drug, misoprostol, to trigger contractions, essentially causing a miscarriage. Women then return to the doctor within about two weeks to make sure the process worked.
The price of the procedure varies. Standard abortions typically cost about $400, and the pill can cost the same to about $100 more.
About 150,000 of the 1.2 million abortions in the United States in 2006 were done with medication, the Guttmacher Institute, a nonprofit reproductive-health research organization, estimated recently.
More than half of abortion providers now offer the option, a 70 percent increase from the first half of 2001, Guttmacher said.
"Mifepristone is clearly starting to become an important part of the abortion provision in the United States," said Lawrence Finer, who studies the drug at Guttmacher. "I think we'll continue to see increases."
He noted that in some European countries, more than 60 percent of abortions are performed with the drug.
Increase alarms abortion opponents
The increase is alarming to abortion opponents, who are expecting thousands to gather in the District today to protest Roe v. Wade on its 35th anniversary.
"This troubles me," said Randall K. O'Bannon of the National Right to Life Committee. "It obviously shows that the marketing efforts have been effective in getting doctors to introduce this into their practices."
O'Bannon questioned the drug's safety, citing a handful of reports of women who have died from severe complications from bacterial infections. "The idea that doctors are beginning to offer something that has a record of causing some serious problems is very troubling," he said. Supporters say that it remains unclear whether the complications were related to the drug and that overall the method has been shown to be extremely safe.
"The availability of mifepristone gives women another safe and effective way to terminate a pregnancy," said Vicki Saporta, president of the National Abortion Federation, which estimates that 83 percent of its 400 member clinics offer the drug.
The increase in mifepristone use has been fueled in part by more doctors and clinics that previously did not perform abortions now offering the drug. Guttmacher identified at least 119 and said those practices have slowed the decline in abortion services. The number of providers fell 2 percent from 1994 to 2005 -- a much slower decline than before the drug became available. Without mifepristone, the drop would have been 8 percent.
Ruth Lesnewski, a family physician in New York, did not perform abortions until mifepristone was approved.
"It allows abortion to happen in a more private, secure setting -- a doctor's office and a woman's home, rather than an easily targeted clinic," she said. "It's been a surprisingly smooth and rewarding experience for such a fraught area of life. My patients really tremendously appreciate being able to end an unwanted pregnancy privately and quickly."
Other doctors have begun to offer mifepristone in addition to surgical abortion.
"For some women, they like to have a more active role rather than just having something done to them," said Deborah Oyer, a family-practice doctor in Seattle. "For some, it feels in some ways more natural because it feels more like their body is doing it."
Walking a delicate line
Some doctors walk a delicate line. One doctor in Albuquerque, for example, said she does not use in the pill at one of her offices but does offer it along with standard abortions at a clinic where she works. At another clinic, she provides only the pill.
"My office is in a politically charged part of the community, so I try to be as diplomatic as possible," she said, speaking on the condition of anonymity. "But at my other office, we can do an abortion where no one has to know -- not even the support staff."
The proportion of abortions being done with the drug varies widely, with some providers saying mifepristone accounts for about 10 percent and others reporting it accounts for two-thirds.
"We see 10 to 12 patients a week who want it," said Mary Frank, who runs the Memphis Center for Reproductive Health. "I've noticed that the women who want this have really done their homework. They know exactly what the process is and really have made a very conscious decision about their choice."
Experiences vary widely
Women's experiences also vary widely.
"Some women say, 'It's the most horrible thing that ever happened and I'll never do it again,' and some women say, 'Heck, my period was worse than that,' " said Catherine McKegney, a family physician in St. Paul, Minn.
Mary, 25, an office administrator in Seattle, opted for mifepristone in December when she became pregnant and decided with her fiance that they were not ready to become parents.
"I liked the idea of being more in control," said Mary, who asked that her full name not be used. "I had some really, really bad cramps and had to take some Vicodin and ibuprofen to calm them down. But other than the cramps, it was pretty painless."
Victoria Reyes, 24, used mifepristone in 2006 when she became pregnant just before she was about to graduate from Ohio State University.
"It was one of the most difficult decisions I ever made in my life," she said. "My boyfriend and I got together and decided we were not in any position to financially afford a child. I chose it because it seemed like a more natural way."
But Reyes was surprised by how physically traumatic it turned out to be.
"It was one of the most painful experiences I've ever had," she said. "Not only were the cramps really bad, I was sweating and had a headache. I threw up at one point. It was pretty bad."
Reyes also had to take a second dose when an ultrasound showed she had not completed the abortion, requiring her to return to the clinic for a second time to confirm that the process was complete.
"I think I'm still glad I picked it," Reyes said. "I just wanted to be home and keep it private."