example, there is only one provider in South Dakota, and more than half of all Wyoming women who have abortions cross state lines for care. Women disadvantaged by lack of transportation or difficulties related to child care costs will find it difficult to make four separate visits for a first-trimester abortion. For example, this might require over 1500 miles of round-trip travel for many women in rural America. Use of this regimen would effectively deprive these women of this option, if one assumes that they could afford such care.
Medical science supports the need for two contacts with a health care provider for mifepristone abortion. The first would be for counseling, evaluation, and initiation of treatment. A second contact is important to confirm that the abortion has been completed and, if not, to perform a curettage. A second visit could be done at the initial facility or, if the travel distances were prohibitive, at a provider closer to home. A quantitative pregnancy test or a vaginal ultrasound examination can be used for this purpose. Women with a failed attempted abortion might be referred back to the initial provider.
Medical decisions about antiprogestins should be based on scientific evidence. Importation of abortion practices from dissimilar health care systems, without firm evidence of benefit, may be counterproductive. At the present time, a single visit to an abortion provider poses a hardship for many women in the United States. If mifepristone abortion is offered only in the European model, the service will be so cumbersome and expensive that many U.S. women will not have access to it. Rather than improving access to safe, legal abortion, this model would aggravate the existing disparity in access to service for disadvantaged women. To bring antiprogestins to our country and then to place them out of reach of women would be a cruel hoax.
I believe that randomized controlled trials could be done comparing the safety and acceptability of mifepristone abortions with varying numbers of visits. This would place clinical recommendations on a more firm scientific footing.
Third, we have heard discussed the appropriate dose of antiprogestins for the various indications. A common theme is the fact that we don't really know what the optimal dose is, and that is because we still lack sophisticated pharmacokinetic studies. As we have heard from several speakers, the dose-finding studies today have tended to use arbitrary doses with round multiples, such as 100, 200, 600 mg. They featured small sample sizes and, as we have heard from Dr. Nieman (see Appendix B3), have looked at relatively few outcome measures.
We need elegant pharmacokinetic studies correlating serum levels,