Thursday, September 19, 2013

The Texas Underground Misoprostol Railroad

Photo: Women on Waves article "How to Do An Abortion With Pills"
Originally posted at Alternet

New Texas Anti-Abortion Law Could Create Spike in Underground Medicinal Abortion

Restricting access to abortion in Texas will probably increase illegal medicinal abortions, which few people know how to administer.

by Julie Sunday 

The Texas House of Representatives’ State Affairs Committee is a hard audience for a pro-choice speaker. Near the end of June, as they considered the draconian anti-abortion bill Wendy Davis’ filibuster would soon make infamous, Heather Busby tried to warn the assembled politicians that their actions wouldn’t stop women from trying to end their pregnancies.

She would know: Busby is the executive director of the state’s NARAL and one of the founders of the Lilith Fund, which provides financial assistance to Texas women seeking abortions. "I think we'll see an increase in the use of [illegally obtained] drugs,” Busby told the legislators, referring to an array of drugs that can be smuggled in from Mexico or purchased during a cross-border trip.

The drug best suited to these purposes is misoprostol, which is approved by the FDA as part of a two-drug medication abortion regimen, but can also be used to induce abortion on its own—if used correctly. (The second drug is called mifepristone.) Its illicit use is documented [3] among women in Texas. According to a recent Texas Tribune-New York Times article [4], a director of Whole Woman’s Health (a network of clinics in Texas) reported an increase in the number of women who took the drugs with no medical guidance. The Lilith Fund has also reported the use of pills illegally obtained, and ineffectively used.

The extent of the practice cannot truly be measured because when the drug works effectively the women don’t need further care in abortion clinics or emergency rooms. What is certain is that demand for the pills—most often used by women who cannot overcome the already existing barriers to abortion access in Texas—will surely increase with the passage of this summer’s legislative assault on abortion rights. The new bill, which Texas Governor Rick Perry signed today despite Davis’ headline-grabbing filibuster, will probably close all but five clinics in America’s second most populous state.

Texan women are already being driven to attempt hazardous cross-border pharmaceutical expeditions because Texas already sharply restricts women’s’ right to control their own reproduction. All physicians providing abortion must be registered with the Department of State Health Services, patients must receive “counseling,” and 24 hours before the abortion they must be given a state-produced pamphlet called A Woman’s Right to Know [5]. Last year legislators mandated ultrasounds 24 hours in advance, which must be performed by the same physician who will perform the abortion.

“Where abortion is permitted on broad legal grounds, it is generally safe, and where it is highly restricted, it is typically unsafe,” according to a joint report[6] from the World Health Organization and the Guttmacher Institute. In the U.S., illegal abortion recalls back-alley clinics and coathangers, which pro-choice protesters have repeatedly evoked as a symbol of what women will be forced to resort to if the law passes.

But many abortions today are induced with pharmaceuticals. The FDA-approved dosage for medication abortion includes mifepristone and misoprostol and is effective 95-98 percent of the time (as compared to 98 percent with surgical abortion). But the World Health Organization, if not the FDA, recommends misoprostol alone when mifepristone is not available. Its effectiveness [7], all on its own, is between 85-90 percent. The drug can’t be obtained at the local drug store, but it can be purchase online, or in border states, at pharmacies in Mexico where misoprostol (brand name Cytotec) is available over the counter as an ulcer medication.

When women obtain misoprostol illegally, they often just take the pills and hope for the best. But as with any medication, the details matter (for example, misoprostol is most effective within the first 12 weeks of gestation). Reputable instructions can be located online, through groups such as the National Abortion Federation, but the information is usually written for clinicians and is not accessible to those without an advanced degree.

The most reliable and accessible source of information about misoprostol and early abortion is Women on Waves [8], an activist organization that operates a ship-board abortion clinic headquartered in the Netherlands. The ship sails to international waters close to countries where abortion is illegal. The staff then provides pharmaceutical abortion to women onboard. Its website provides step-by-step instructions [9], adapted from the World Health Organization guidelines, on how to use misoprostol alone for abortion up to 12 weeks after pregnancy.

Women on Waves’ sister organization, Women on Web [10], provides medication abortion by mail to women in countries where abortion is illegal. “Medication abortion belongs in the hands of women; it is their moral property,” said Kinga Jelinska, a staff member of Women on Web/Waves. Women on Web has a physician on staff and its packages include both mifepristone and misoprostol.

The FDA-approved dosage for medication abortion includes two drugs, mifepristone and misoprostol: three 200mg mifepristone tablets on day one, and on day two if abortion has not already occurred, two 200 mcg tablets of misoprostol. Patients return 14 days after taking the medication to ensure that abortion has occurred. This administration is only approved for use up to nine weeks gestation. According to the University of California San Francisco Medical Center, the drugs, in combination, are 95-98 percent effective at causing abortion, compared to 98 percent with surgical abortion.

In places where mifepristone is not available the World Health Organization recommends [11] an alternative, misoprostol-only regimen that requires twelve 200 mcg misoprostol tablets: three doses of four tablets under the tongue for 30 minutes, three hours apart.

Like many prescription drugs, misoprostol is available from online pharmacies. A Google search for “Buy Misoprostol Online” returned more than 6 million results, including, which sells 200 mcg misoprostol, intended for animals, for $1.99 per pill., the Canadian online pharmacy often used by Americans to purchase generic drugs, sells a variety of types, including brand name Cytotec (60- 200 mcg pills for $45) and generic misoprostol (100- 200 mcg pills for $49 or 300- 200 mcg for $125).

The use of medication for illegal abortion is relatively new, but the concept isn’t a radical departure. For centuries women have worked together, often in secret, to help prevent pregnancy, and terminate it when necessary. The artist Heather Ault’s project 4000 Years for Choice [12] highlights methods that women have shared with each other, sometimes under penalty of law, to maintain control over their bodies. Today, women can provide instructions to each other on messages boards and sell drugs clandestinely through eBay or Etsy. If women can access the appropriate information online, they won’t have to rely on shady operators or unsafe personal measures.

In the era of the Internet and pharmaceuticals, the “back alley” doesn’t have to look like Kermit Gosnell’s Philadelphia clinic [13]. In Texas, research [14] has shown that women in desperate circumstances already look beyond clinics for ways to terminate unwanted pregnancies. Texas Republicans just made the state’s abortion laws even more restrictive, but women will not stop seeking abortions. Given the availability of misoprostol, women in Texas and other states may be facing a return to the days when abortions were performed by women, for women, in secret.