Dr. Mitchell Creinin runs an abortion clinic in Pittsburgh and has become something of an expert on the abortion-inducing pill, mifepristone, which was approved for sale in the United States on Thursday. Dr. Creinin has provided the pill to women in research studies, and he has traveled the country giving seminars to doctors who are considering offering the drug to their patients. But, he said, while hundreds of doctors — family practitioners and obstetricians — have attended his seminars thinking that they could begin providing mifepristone to patients seeking abortions, their eagerness to prescribe the pill often diminished as they heard him talk.
Mifepristone has been hailed as a change in the politics of abortion, making a decision to end a pregnancy a private matter between a woman and her doctor. Supporters have predicted that the pill will lead to more doctors providing abortions.
Doctors, some hoped, would simply provide mifepristone pills in the same way as they might write a prescription for birth control pills. But the reality, in the immediate future, at least, could be different. In fact, acceptance of the pill and the character of the national debate on abortion may be decided in the fall election.
Dr. Creinin said he told doctors about the office visits a woman must make, the counseling a doctor must do, the backup medical services that must be provided and the state laws that must be followed. "When you go through everything, they just say, `Oh no. This is a lot more complicated than I thought. I have to think about it,' " Dr. Creinin said. "Most doctors who answer surveys saying they are interested in offering this, change their minds when you tell them what's involved."
One survey of gynecologists and family practice doctors, conducted by the Henry J. Kaiser Family Foundation, found that about a third said that they would at least consider prescribing mifepristone. But, said Tina Hoff, a spokeswoman for the foundation, doctors often had no idea of what it meant to offer the drug, and when they found out, many backed off. People have looked at the decision by the Food and Drug Administration to allow the pill as a pinnacle, Ms. Hoff said. "But in many ways it isn't the final answer."
Janet Benshoof, president of the Center for Reproductive Law and Policy, an advocacy organization that represents abortion providers, said, "In general, if you're opening medical abortions to a wider range of doctors, they have no idea that this is a dungeon of criminal law, and once you do an abortion, the laws may apply even if it's just giving women a pill."
There are numerous state laws that regulate doctors who provide abortions, and they often go into detail — the size of the hallways in medical offices, the registration of abortion providers, the disposal of the fetal tissue.
In some states, the laws speak of "abortions" without saying how they are performed. In others, the states specifically include pill-induced abortions along with surgical ones. Such laws, abortion providers and legal experts said, raise questions about the future of mifepristone.
"The only people who really know about the panoply of abortion laws are the clinics," Ms. Benshoof said.
Gloria Feldt, the president of the Planned Parenthood Federation of America, said that her group was looking at state laws and trying to educate doctors. "I think that by and large they will understand that there will be some issues," Ms. Feldt said. "But will they catch all of the nuances at this point? Probably not."
In Pennsylvania, where Dr. Creinin practices, abortion providers must register with the state and report all abortions, without providing patients' names. They must counsel women on alternatives 24 hours before providing an abortion. The state also requires that abortion providers have a written agreement with a hospital where they can transfer patients.
But state laws vary. Bonnie Scott Jones, a lawyer at the Center for Reproductive Law and Policy, said that in 31 states, parents must be notified before a minor has an abortion. The laws in 13 states require that women be counseled about abortion and then wait for a period of time before having one. Other states, like North and South Carolina and Alabama, require that doctors examine fetal remains. In North Dakota, the remains must be buried, incinerated or cremated.
Dr. Stuart Schnider, who runs abortion clinics in Raleigh and Charlotte, N.C., said that he had provided women with methotrexate, a drug developed for cancer patients that can induce an abortion. Doctors are allowed to prescribe drugs for other uses once the drugs are on the market. Dr. Schnider said he knew about the fetal remains law and worried about it. "We asked them to bring back whatever remains are passed," Dr. Schnider said. And did the women comply? "Of course not," he said.
Ms. Jones said that doctors in North Carolina who do not collect and examine fetal remains faced a risk of criminal prosecution. Several states require that abortion providers be licensed and that their facilities meet requirements that also apply to surgical suites — even if they are doing pill-induced abortions.
Dr. Schnider explained that all abortion providers in North Carolina must register and their facilities must be open to state inspections. He provided a booklet of state requirements for facilities, including specifications that hallways must be at least 60 inches wide, that hot water be between 100 and 116 degrees and that life-support equipment and an ultrasound machine be available.
"The State of North Carolina says you cannot give a woman an abortion unless you are in a registered facility," Dr. Schnider said. Dr. Diana Dell, a gynecologist at Duke University, said she had not been aware of the laws regulating abortions in her state, and she thought they would give many doctors pause.
Registering as an abortion provider and making sure the hallways are wide enough and that the air flow meets state requirements is very different from what many doctors might have expected, Dr. Dell said.
"This is going to be very difficult for folks," she said. "This isn't an analogous situation to writing a prescription. I think that there clearly is going to be case law written. But who wants to be the one to make case law?"
Even in states like New York, Connecticut, New Jersey and Montana, that do not have laws regulating such things as the air flow in offices of doctors who offer abortions, some doctors may shy away from the likely social controversy.
Dr. James H. Armstrong, an abortion provider in Kalispell, Mont., said that he could not even tell doctors at the local hospital about how to use mifepristone. "Every Monday we have a medical staff meeting," Dr. Armstrong said. "They send out invitations and ask for suggestions for topics and suggestions for speakers."
He suggested that he talk about mifepristone, noting that he had experience with the drug since he provided it to women as part of research studies.
"They sent me a letter saying this would cause too many problems with the medical staff," Dr. Armstrong said.
Dr. Warren Hern, director of the Boulder Abortion Clinic in Colorado, was not surprised. "Doctors as a group are incredibly timid when it comes to controversy and social issues," Dr. Hern said. "There are very few doctors who will accept the controversy that goes with medical abortions." And, he added, social controversy is almost guaranteed since it would be likely that people will soon know that a doctor is providing mifepristone. Some opponents of abortion said that if they learned that a local doctor was providing mifepristone, they would let people in their communities know.
"At the national level, I don't think there would be a campaign," said Dr. Richard Land, who is president of the Southern Baptist Convention's ethics and religious liberties convention. "But I have no doubt," Dr. Land said, "that there would be churches that felt that that was something people should know when making a decision about what doctors to see. I certainly would not want my wife and daughters going to a doctor who dispensed that pill."
Others were more adamant.
"We are going to be absolutely sure that people know which doctors are doing this," said the Rev. Frank Pavone, the director of Priests for Life, a Roman Catholic group with its headquarters in Staten Island.
"We'll find out in the same way that any individual will find out — we'll ask and we'll have people ask," Father Pavone said.
And, for those doctors who fear protests from his group, "you're right," he said. "We will protest and it will be very visible, very vocal, and absolutely unrelenting." In addition, he said, the group will be looking for malpractice cases to pursue if a woman takes mifepristone and remains pregnant — which occurs in about 1 percent of cases — and decides not to have a surgical abortion, and gives birth to a baby with birth defects.
But Dr. Armstrong said he understood why doctors who do not now do abortions might be put off.
"What's in it for an ob-gyn? That's the way they think."