21 September 2022

RU486 or abortion pill: myths, misunderstandings and business

Chemical abortion is sold as more free and self-determined, but it is not the solution for everyone: it is longer and more painful than surgery, sometimes less safe, and mostly serves to save the health system money, as the essay by three American feminists explains. Women must be guaranteed the right to be informed and to make an informed choice between the two options: here is a bill to make hospitals work
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A few days ago we published "When abortion matters to men". In the afterword we mentioned the different methods of involuntary termination of pregnancy, including the abortion pill RU 486, also known as 'chemical abortion'.

Chemical abortion is spoken of as a step forward in self-determination. Younger women in particular can get confused between 'morning-after' contraception (which must be taken within 72 hours of risky intercourse) and the abortion pill, with which pregnancy can be terminated up to the 9th week.

It should be explained to the girls that RU486 does not make the pregnancy 'disappear', but just terminates it, and ends with the expulsion of the contents of the uterus. The process is considerably longer and more painful than surgical abortion (aspiration or Karman method): 3 days and more for the RU486, a few minutes under sedation and almost always day hospital admission for the Karman. The choice between the two methods must be conscious. The RU486 is not necessarily an 'easier' abortion, because it can involve a considerable physical and psychological effort that not everyone is able to cope with. That RU486 guarantees a 'freer' abortion is all to be proven.

The Ministry of Health authorised the administration of RU486 in consultation centres, but in most regions the practice has not yet taken place: neither in Marche, about which much has been said in recent days, nor in red Emilia. Caution that should not be stigmatised: it must be ensured that counselling centres, on which there has been considerable disinvestment in recent years, are really able to accompany the abortion process and to handle any complications quickly.

For further clarity, we point you to one of the fundamental books for understanding the chemical abortion debate: "RU 486: Misconceptions, Myths and Morals". (RU 486: Misconceptions, myths and morals).
Published by feminist publishing house Spinifex Press, was nominated for the Australian Human Rights Award when first published (1991), reprinted and updated over the years, until a new edition in 2013 (the full text can be found here).

The book is the result of the work of three scholars: Renate Klein, biologist and lecturer in Women's Studies at Deakin University, Janice G. Raymond, noted American feminist and Professor Emeritus of Women's Studies and Bioethics at the University of Massachusetts, and Lynette J. Dumble, surgeon and researcher at the Royal Melbourne Hospital and visiting professor of surgery at the University of Texas.

Here is the translation of the summary of "RU 486: Misconceptions, Myths and Morals', dto the publisher's website:

"This book has become a classic text for health activists and feminists interested in the complexities of how drugs are developed, marketed and sold to women around the world. In this book, the authors trace the unusual history of the French abortion pill RU 486 (mifepristone). They examine science and politics from its inception to its use on women.

- RU 486 is a miracle drug for abortion, a safe and effective alternative to conventional abortion procedures?
- Does it privatise and de-medicalise the abortion experience?
- Its availability is a 'victory' for women?
- RU 486 is safe for use in Third World countries World and in remote rural areas?
- Who benefits from chemical abortion and what influence does RU 486 have on existing abortion services?

The authors argue that the positive claims about RU 486 (mifepristone) are full of myths and misconceptions. RU 486 used alone is a failed abortifacient and requires the addition of a prostaglandin, a dangerous drug. But the success' rates of the RU 486/prostaglandin drug cocktail remain between 92 and 95 per cent, compared to 98-99 per cent for aspiration abortions. Aspiration abortion, which is best performed with a local anaesthetic, does not involve the use of harmful drugs and is completed in 30 minutes. On the contrary, abortions with RU 486/PG last for days, sometimes weeks.

Profuse bleeding, transfusions, vomiting, intense pain and infections are among the side effects unpredictable. Some women are death from sepsis and cardiovascular events. Abortion with RU 486/prostaglandin benefits the medical profession, pharmaceutical companies and government health economies.

Through careful research and analysis, the authors uncover the truth: chemical abortion is ill-conceived and unethical. They warn that low-tech abortion services are in danger because the mainstream hails RU 486 abortion as 'safe and effective', which it is not."

(original text here, translation by Maria Celeste)

In Italy a Karman method abortion costs an average of 1,200 euros, whereas a chemical abortion costs only 40 euros. That is why the national health system has every interest in promoting RU486. We say instead that a woman who wants to terminate a pregnancy must be guaranteed the possibility of choosing between the two methods. A choice that can only be made on condition that hospitals continue to take over surgical IVGs.

The high objection rates often make this option complicated. A difficulty that has persisted for years. Together with the non-objecting anaesthetist Mercedes Lanzilotta, Marina Terragni has produced a bill on the subject that was deposited in the House at the time. No party has considered it, least of all the 'champions' on the left: abortion is only talked about at election time, Normally, the subject remains forgotten.

We present it again: the data should obviously be updated, but the ihe proposal remains valid.

PROPOSAL ON LAW 194 AND CONSCIENTIOUS OBJECTION

Law 194 regulating the termination of pregnancy is an effective law, which has allowed an overall reduction of around 55 per cent in IVGs since the 1980s: 102,644 interventions in 2013, a decrease of 4.2 per cent compared to 2012, and a decrease of 56.3 per cent compared to 1982, the highest peak since the law came into force in 1978. The data are not definitive as some regions -Abruzzo, Campania, Apulia and Sicily- have not communicated their numbers, as required by law. About a third (34 per cent) of the terminations concern foreign nationals. Compared to other European countries, which have the highest abortion rate among women under 25, in Italy there is a high percentage of abortions among 30-39 year olds, probably due to economic difficulties and the lower rate of female employment.

Despite this, law 194 is today largely unenforced due to the very high percentages of conscientious objection by medical and paramedical staff (gynaecologists, anaesthetists, theatre staff): an average objection of 70 per cent, with peaks of up to 90 per cent in Campania, Lazio, and over 80 per cent in Molise, Sicily, Veneto and Apulia, and entire hospitals that do not guarantee the service (structure objection). Health Minister Beatrice Lorenzin's recent annual report on Law 194 does not contain absolute data on the objection of medical and paramedical personnel. As far as structure objection is concerned, however, it concerns as many as 36% of gynaecology and obstetrics wards.

The activities of the Consultatories have also been greatly reduced: their number is decreasing (e.g. in Lombardy, from 335 Consultatories in 1997 to around 200 at present) and their capacity for action is being weakened.

In 16 May 2014, a decree of the Lazio region reaffirmed the duties of the Consultatories, clarifying that all doctors, objectors and non-objectors, must guarantee the functions of:

1. prevention of unwanted pregnancies

2. certification of pregnancy status and possible willingness to terminate.

3. prescription contraceptives

4. prescription of RU486, the so-called abortion pill.

That is, the right of objection can only be exercised with regard to the technical act of terminating a pregnancy.

But after the Lazio Regional Administrative Court had approved the resolution, the Council of State, following an appeal by the Movimento per la Vita, partially suspended part of the decreated.

These attacks on law enforcement and counselling centres are in fact accompanied by the constant initiative of the Pro-Life Movement, in Italy and Europe, as well as the proliferation of cemeteries for the unborn, with burial ceremonies for abortion products. It should be remembered that the right to bury foetuses of any gestational age is already guaranteed by a presidential decree of 1990. There is therefore no need, other than ideological and propagandistic, to establish dedicated cemeteries.

Returning to the conscientious objection that prevents the application of the 194 in many areas of the country: we should also note a very high rate of objection among paramedical personnel, an issue neglected by Minister Lorernzin's report, a reality that, even in the presence of a sufficient number of non-objecting doctors, in fact makes it problematic to carry out interventions.

To this massive objection follows

1. a return to clandestine abortion

The Ministry of Health estimates between 12,000 and 15,000 clandestine abortions among Italian women, and around 5,000 cases of clandestine abortion among foreign citizens: This is an underestimation because the number of 'spontaneous abortions' in obstetrics is constantly increasing, and not only in the underworld of Chinatowns, see the recent case of the 17-year-old girl from Genoa who died after taking an anti-ulcer drug cast as an abortifacient and easily available online and on the black market in many urban areas. About 200 criminal proceedings for violation of law 194 are open in our courts. At least one third of 'spontaneous' abortions are allegedly attributable to 'do-it-yourself' abortions, incomplete abortions performed in outlawed clinics or caused with drugs found on the web or in complacent pharmacies

2. Abortion tourism: a phenomenon that particularly affects the Veneto with migration to Emilia Romagna where the law works better, Lazio with migration to Tuscany, and so on. The abortion rate per region recorded by the Ministry of Health is often distorted by internal migrations. For example: in Basilicata in 2012 there was an outflow of about 300 women to Puglia for Ivg (to evaluate the figure, take into account that Basilicata has a total population of 576,000 inhabitants)

3. increase in the abortion business:

For example, of the 3776 IVGs performed in Bari's ASL in 2011, 2606, or 70 per cent, were performed in contracted nursing homes, 1170 (30 per cent) in public hospitals. The DRG per IVG amounts to between 1,100 and 1,600 Euro. This means 3,000,0000 Euro in the private coffers (private where the objection is insignificant).

Is a right of objection legitimate for employees of public facilities who in fact refuse to apply a state law?

Conscientious objection is a right guaranteed by Article 9 of Law 194, which is a constitutional law. It is also guaranteed by the European Court of Human Rights, where it states that "member states are obliged to organise their health services in such a way as to ensure the effective exercise of freedom of conscience by health professionals".

However, if the right to object must be guaranteed, the Strasbourg Court states that this must not prevent patients from accessing services to which they are legally entitled (Court judgment of 26.5.2011). Europe therefore supports the need for the state to provide for objection as long as it does not hinder the provision of the service.

On 8.03.2014, the Council of Europe condemned Italy "because of the high number of conscientious objectors. Italy violates the rights of women who, under the conditions prescribed by the 194 of 1978, wish to terminate a pregnancy.

On 10 March 2015, the European Parliament approved by a large majority the so-called Tarabella resolution, which, among other things, states that women should "have control over their sexual and reproductive rights, notably through easy access to contraception and abortion".

How do you explain such a massive objection in our country?

1. career reasons: often the choice not to object results in the trainee setting himself against his Chair Director, and this ends up hindering his career path

2. excessive workloads, which are economically and professionally unrewarding, despite the fact that the Minister for Health claims that 'the number of non-objectors in hospital facilities is congruous with respect to the number of Ivg's performed', a fact belied by the daily experience of non-objectors and the high number of migrations for Ivg's, a practice that is widespread in regions such as Lazio, Molise, Basilicata, Veneto and Campania.

3. burnout syndrome: from being a non-objector you become an objector due to fatigue and the difficulties associated with a job that constantly confronts you with ethical questions. Burnout not dissimilar to the burnout that afflicts doctors and healthcare personnel in emergency rooms, pain and palliative care, intensive care, etc. Those who perform IVGs for years, without rotation due to the small number of non-objectors, are often tempted to throw in the towel

4. religious motivations

in this respect, two observations:

1. The creed of Jehovah's Witnesses prohibits blood transfusions. Consistently, no Jehovah's Witnesses choose specialisations such as Anaesthesiology or Haematology, the practice of which would pose constant ethical conflicts.

Similarly, those who choose gynaecology should be well aware that their duties also include those laid down by law 194 in all its parts: from prescribing contraceptives to prescribing Levonogestrel and RU 486, from surgical termination of an unwanted pregnancy to therapeutic abortion. Why choose this speciality if ethical reasons prevent one from accepting a large part of one's work, 'dumping' it on colleagues?

2. conscientious objectors normally perform both chorionic villus sampling and amniocentesis. Throughout Italy, it is possible to carry out both diagnostic procedures in public, private affiliated secular and denominational facilities (such as the San Raffaele in Milan). But amniocentesis and chorionic villus sampling are carried out for prenatal diagnosis, i.e. they allow us to analyse the number and shape of the foetus' chromosomes, to ascertain whether the foetus is affected by a chromosomal disease such as Trisomy 21 (Down syndrome), whether there is a risk of Thalassaemia or Cystic Fibrosis.

These diagnostic tests are the 'sine qua non' of therapeutic abortion.

Yet the operators are mostly objector doctors.

Procedures are also carried out in private denominational facilities where structure objection is practised. The problem is known but tolerated by the competent bodies.

POLICY PROPOSAL

The right to conscientious objection cannot be denied. It is therefore useless to venture down this road. This right is guaranteed by Article 3 of our Constitution, Article 9 of 194 and by Europe.

Not even staff mobility, proposed by several parties -some PD senators, Scelta Civica, M5S- can be the solution. There are very few non-objector doctors. Forcing them to move to several facilities would mean 'condemning' them to perform abortions exclusively, denying the rest of their professionalism.

Many Italian regions solve the problem by calling in 'token' non-objector doctors to guarantee the application of the law, and paying them handsomely: but money cannot be made on the skin of women, in an unacceptable mercenary logic.

The solution that propon is another:

Every obstetrics ward, and likewise the consultancies, must have 50 per cent non-objecting doctors, with a 24-hour presence of a team that guarantees the entire application of Law 194, from the prescription of the morning-after pill to therapeutic abortion, and thus allows the rotation of medical and paramedical staff.

A ruling by the TAR PUGLIA (14/09/2010, no. 3477, section II) states that "it is possible to prepare for the future announcements of vacant shifts for individual Consultatories and Hospitals that provide for a reserve of 50% posts for specialist doctors who have not given conscientious objection and at the same time a reserve of the remaining 50% posts for objector specialist doctors".

A fair, reasonable and practicable option that would not conflict with the principle of equality under Article 3 of the Constitution and would allow Law 194 to be fully implemented.

The Emilia Romagna Regional Administrative Court also clarifies an important aspect related to conscientious objection:

(Parma section, 13 December 1982, no. 289, in Foro amm. 1983, 735 ff). In fact, it is specified that 'the clause that conditions the employment of a sanitary worker on the non-submission of conscientious objection pursuant to Article 9 responds to the need to allow the performance of the public service for which the employee is hired, according to a perspective not extraneous to the intentions of the legislator of 1978'.


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