Canadian Medical Association Journal 1996; 155: 11-20
Wiebe's contribution is particularly admirable because of the adverse conditions under which she performed her research: first, she had no access to mifepristone (RU486), a well-studied and effective agent for medical abortion, and, second, she had limited access to ultrasonography.
Mifepristone is available in France, England, Sweden and China and is available for research purposes in the United States. In Canada, it is not even available for research owing to the politics of the pharmaceutical industry and government agencies. These two groups blame each other for the lack of availability; in fact, both fear the political backlash that may result from introducing an abortifacient drug. Because of this deadlock, medical abortion is not yet available to Canadian women, and it has become necessary to find alternative agents such as methotrexate. This is a good example of how a lack of political clear-sightedness affects women's health care by limiting their choices.
The limited access to ultrasonography is even more unacceptable. Ultrasonographic examination allows precise pregnancy dating, which is crucial in the context of drug- induced abortion, since the agents used lose their effectiveness after a certain stage of pregnancy. Studies have shown that dating pregnancies on clinical grounds leads to errors in 10% of cases.[1,2] Furthermore, ultrasonography is a very useful tool to monitor the efficacy of the abortifacient drugs involved.[3,4] Relying solely on testing for the beta human chorionic gonadotropin level can lead to potentially serious errors. Therefore, frequent ultrasonography-aided examinations are fundamental to the practice of medical abortion.
Pregnancy dating and assessment of gestational evolution by ultrasonography are simple procedures that require minimal training. Physicians performing medical abortion should have access to ultrasonographic equipment at the bedside of their patients to complement the physical examination. Scheduled appointments in a radiology department complicate the already intricate timetable necessary for medical abortion. They also increase the costs of the procedure considerably.
By restricting access to ultrasonography, provincial colleges and hospital boards deprive women and their family physicians of an essential tool for high-quality, up-to-date care. This is an unacceptable situation in a developed country on the eve of the 21st century.
Edith Guilbert, MD, MSc
Chef de service
Clinique de planification des naissances
du pavillon CHUL
Centre hospitalier universitaire
de Québec
Sainte-Foy, Que.
Francis R.M. Jacot, MD, CCFP
Chef de service
Clinique de planification des naissances
Centre universitaire de santé de l'Estrie
Sherbrooke, Que.
The complex process of medical abortion -- injection of methotrexate, vaginal application of a prostaglandin, prolonged bleeding, severe pain and a wait of up to 44 days to abort -- clearly demonstrates the extraordinary lengths to which women are driven to obtain an abortion. Nevertheless, is it wise to give a cancer drug to normally pregnant women? Do we really view normal pregnancy as a form of cancer, and, if so, does this not smack of misogyny?
It saddens me that medicine has become an agent of our society's destructive reshaping of women. The logical extension of drug-induced abortion is a drug combination that will selectively abort female fetuses, considered undesirable in some parts of the world. Although the short-term safety of medical abortions for women participating in carefully controlled trials is reassuring, the long-term safety must remain a major concern, especially since hundreds of thousands of women may be encouraged to undergo this complex procedure. The side effects for the unborn include limb defects, death and, paradoxically, the risk of being born alive; however, these side effects do not count.
I hope that, one day, medicine will return to a mission based on life-giving solutions to human problems, will relinquish its role in reshaping women and will work toward shaping a culture in which the biologic and intellectual gifts of women are valued. Wiebe's study is certainly a turning point on the road of women's health -- where this road will lead us is less certain.
James L. Reynolds, MD, MSc, CCFP
London, Ont.