Getting Around the Back-Alley Abortion with Pills and Apps

Wherever abortion is illegal or highly restricted, women will risk mutilation, jail time, or death to terminate unwanted pregnancies.

Last year in Brazil, police discovered the charred, limbless body of Jandira dos Santos in the trunk of a car after a botched back-alley procedure, shocking the nation. A few months earlier in Ireland, a suicidal teenage rape victim went on a hunger strike after being denied a termination, repeatedly telling the hospital staff she "just wanted to die." And in January, El Salvador pardoned Carmen Guadalupe Vasquez after she served seven years in jail for miscarrying. To this day, 16 El Salvadorian women remain incarcerated for the same "crime."

Anti-abortion law's remarkable inefficacy in protecting life isn't only anecdotal. Statistics show banning abortion makes women more likely to suffer serious health consequences instead of reducing the frequency of abortions. Of the 42 million abortion procedures performed annually, Guttmatcher reports about half are done unsafely. The associated death toll is astonishing: A woman dies every eight minutes from unsafe abortion, according to the World Health Organization. For women who live in places where abortion is illegal but don't have the financial means to travel to another country, safe procedures are completely inaccessible.

"Women with money can have abortions, and women without money have babies or—and I'm not fucking kidding—they drink bleach," said Mara Clarke, the founder of the Abortion Support Network, an abortion fund that helps Irish women travel to England to safely terminate their pregnancies. "They drink floor cleaner. They take three packs of birth control pills with a bottle of gin. There was a mother of four who told us matter-of-factly, 'I'm trying to figure out how to crash my car to cause a miscarriage but not permanently injure myself or die.'"

Despite tens of thousands of women dying annually from illegal abortion—most of them from hemorrhaging, infection, or poisoning—much of the world remains vehemently opposed to loosening restrictions on the procedure. In Brazil, for example, about 80 percent of the population believes abortion should remain a crime. And so women with little hope of changing the system must risk circumventing it. A growing network of activists exists to help them, aiming to provide poor women with more options than either carrying an unwanted pregnancy to term or drinking floor cleaner.

Some of the activists who help women in this way use misoprostol. Of all the limited options available to women who want to terminate unwanted pregnancies outside of the legal system, it's by far the safest. Commonly prescribed to treat stomach ulcers, misoprostol is also used along with another drug, mifepristone, as medication abortion. When taken on its own, it's 75 to 90 percent effective at inducing a miscarriage. In several South American countries, they sell the drug over-the-counter under various generic names.

One popular brand called Cytotec rose to notoriety in Brazil in the late 1980s, after women learned of its off-label utility. By 1989, over half a million boxes of Cytotec were being sold per year in the country, an estimated 35 percent of which were used in terminating unwanted pregnancies. The growing trend stopped abruptly in July 1991 when the Brazilian government imposed harsh new restrictions on Cytotec sales. This decision had drastic effects: With Cytotec no longer readily available, abortion-related deaths tripled in Campinas alone. Now, over 20 years later, complications from unsafe abortion rank as the fourth leading cause of maternal death in Brazil, while Cytotec sales remain regulated.

Despite the Brazilian government's intervention, the story of Cytotec served as a blueprint for future subversive action to many activists, showing that women are fully ready, willing, and able to take matters into their own hands when given access to misoprostol. Of the people inspired by what happened in Brazil, Dutch activist Dr. Rebecca Gomperts is easily the most notorious-not that that designation bothers her very much. For years, she's been engaging in highly visible abortion activism, most famously commandeering an abortion ship that ferries women into international waters where they can legally take the pill.

In 2004, she began instructing women on how to obtain and use misoprostol over email. "But then I learned that, for a lot of women, it was really difficult to get the misoprostol," she said in a phone interview. "They started asking whether we could provide it or help them get it." She paused. "You know, the idea is that it's a pill. You should be able to mail it."

From that deceptively simple concept, in 2006, Women on Web was formed-not wholly without controversy. Dr. Gomperts said that some of her fellow activists were originally skeptical of the idea of an abortion-pill-by-mail service. "A lot of them said, 'You can't do that,' but there were also a lot of people who were supportive," she recalled. At the time, she knew that women were using misoprostol at home safely, but she felt she had to prove that the drug wasn't dangerous in order to successfully mainstream it. One-and-a-half years after Women on Web was founded, the organization published its first paper in the British Journal of Obstetricians and Gynaecology , concluding that "women seem capable of self-administering mifepristone and misoprostol at home without a doctor physically visiting them."

In the past nine years, Women on Web has grown exponentially, evolving into a complex network of doctors, legal experts, and volunteers. Twenty volunteers field over 8,000 requests a month in nine different languages, and according to Gomperts, the organization has sent mifepristone and misoprostol to women in 130 countries. Women on Web is constantly evolving, too: This summer they plan to test out a medical abortion delivery drone, and are in the process of launching an app.

Their success has inspired other, similar groups to launch. In September 2014, several former members of Women on Web formed Women Help Women, another abortion pill service open to women in over 100 countries worldwide. "We are called Women Help Women because women's hands can help get information and products to other women," representatives from the organization said in an emailed statement. "We simply cannot rely on governments, public health systems, medical personnel, individual services, or any other group alone to fight for women's rights. We all need to act."

Women on Web and Women Help Women both use the internet to help women gain control over their own reproductive agency, but other sites purporting to offer black market abortion pills often exploit women. "Women write us saying that they tried to buy misoprostol on the black market, and they had to pay $300, and then the pills were fake," Gomperts said. "It's awful. People are so mean." On the Women on Web website, there's an exhaustive list of websites that are known to scam women-many of which directly refer to misoprostol or abortion in their name. "Beware of these sites," a disclaimer warns. "They are a fraud, could harm your health, and will not end your pregnancy."

Complications have also arisen when a woman lacked the knowledge about the drug's proper dosage and/or method of administration. "Women on Web and Women Help Women are great, but there are issues as well," said the Abortion Support Network's Mara Clarke, whose organization only assists with travel and accommodations. "We had a woman who didn't have the correct instructions, so the pills didn't work, and in the time she was waiting to find out if she was still pregnant, the cost of the abortion went up [past what she could afford]. There have been cases where a woman who's 16 weeks pregnant thinks, Oh, well, if I take two sets… And things can happen, and because they're in countries where abortion is against the law, they're afraid to go seek aftercare." She fell into a brief, reflective silence and then added, "It is great, but it also shouldn't have to exist."

Gomperts hopes to address many of these issues with a new app, Safe Abortion with Pills. Although it's not completely finished yet-Women on Web are in the process of finalizing it, and the information will update automatically-it's currently available on Google Play. Safe Abortion with Pills functions as a comprehensive DIY abortion guide: "What you can do is select a country and a language, and then you get information on the law in the country," explained Gomperts. "You get information on which brands of misoprostol you can buy, about fakes and other organizations, and there's an animation about how to do a medical abortion with misoprostol." It's currently available in 15 languages, and it will eventually be free to download in the iTunes app store as well.

"One of the most important issues is that women know how to use medical abortion effectively," said Gomperts. "This app is a way to get the information out there."

Activists have realized it's insufficient to simply make misoprostol available-to make sure women are using it safely, they need to educate them as well. As Women Help Women put it in their emailed statement: "Arming women with knowledge about the safest and most effective way to use abortion pills and opening up access to genuine quality medication is simply the fair and right thing to do. The more groups and people are involved, the more we will be able to change."

Women Help Women partners with numerous abortion support organizations, ranging in size from grassroots feminist local groups to sprawling international networks. Most of these organizations operate as traditional abortion funds, which help women pay the various and often daunting costs associated with terminating an unwanted pregnancy, or activist groups that work in various legal channels by doing advocacy and raising awareness. A few assist women in accessing and using the abortion pill. One such group is the MARIA Fund, which three activists founded in 2009 after abortion was legalized in Mexico City. In the rest of the country it remains mostly illegal, and only thirteen of the country's 31 states allow the procedure if the mother's life is at risk.

"It was in response to the social injustice the law brought to Mexican women," MARIA Fund manager Oriana Lopez Uribe said in a phone interview. "This was a way to broaden the scope of the law, to help women from other states have access to the Mexico City law."

Like Dr. Gomperts before them, the founders of the MARIA Fund quickly realized that some women cannot possibly travel in order to obtain legal abortions, even when they're given financial assistance. Some women can't afford to take time off of work; some are incapable of finding childcare; some must conceal their pregnancies from abusive partners or from their parents. In Mexico, most pharmacies still sell misoprostol over the counter, so the women of the MARIA Fund decided to put clear, detailed instructionson their website, telling women how to safely locate and use the medication. ("Pharmacists are aware that oftentimes it is used to end pregnancies. As such, they obstruct sales by demanding unnecessary prescriptions. Some women have reported that it's simple for men to buy the medication for this reason," they advise.)

"We know the abortion pill exists. Everyone knows it," Lopez Uribe said, pointing to the numerous studies showing misoprostol's efficacy and safety. "It's better to have information that helps women use it the best way, not randomly."

Pro-life organizations and politicians often point to the grisly deaths women sometimes suffer as a result of illegal abortion as proof that the procedure inherently harms people, and they tend to argue illegalization is the only way to prevent women from dying during abortions. Activists vehemently disagree, noting that women have been terminating unwanted pregnancies for millennia and the procedure is only dangerous when performed in a setting of enforced ignorance.

"Women are going to have abortions," Lopez Uribe said. "They're not asking permission from anyone. Abortion happens when it's needed."

The Women on Web website encourages women to share their abortion stories, a practice Gomperts envisions as a way of combating the oppressive stigma around their reproductive choices. The site represents the stories as a series of circles on aworldmap, larger in areas where more women have shared their own accounts. The map illuminates both the ubiquity of the procedure and the way women will circumvent restrictive laws in any way they can: Circles cover much of South America-where most countries ban the procedure-and massive circles completely engulf Ireland.

478 Brazilian women have shared their story on the site. Writing under the pseudonym Maria Clara, one woman described why she chose to abort at home using Cytotec: "I know how daunting it is, but if you're certain that you cannot have a child, it's better to resort to [abortion] than to put a child in the world who is not wanted," she wrote. "Do not let anyone decide for you-not the government ban or religious standards. You have the right to decide what is best." Another, who went by Ray, chose a photo of Rosie the Riveter to accompany her account. "Every woman has the right to an abortion, no matter what her motives are," she said about taking Cytotec at home. "Abortion, whether legal or not, happens. It is a reality, and women will continue to do it."

And as long as women continue to go to extreme measures to terminate unwanted pregnancies, activists like Dr. Gomperts will be there to help. "Whatever method we have to use to respond to this need-the need to a safe abortion, to have access to healthcare-whether it's by information or with medicine or with a ship or a drone," she said, "we'll do it."