The Rise of the DIY Abortion in Texas
Customers browse simple items—miracle-diet teas, Barbie dolls, or turquoise jeans stretched over curvy mannequins—but there are also shoppers scanning the market for goods that aren’t displayed in the stalls. Tables lined with bottles of medicine like Tylenol and NyQuil have double meanings to those in the know: The over-the-counter drugs on top provide cover for the prescription drugs smuggled over the border from nearby cities in Mexico. Those, the dealer keeps out of sight.
I’m here to look for a small, white, hexagonal pill called misoprostol. Also known as miso or Cytotec, the drug induces an abortion that appears like a miscarriage during the early stages of a woman’s pregnancy. For women living in Latin America and other countries that have traditionally outlawed abortion, miso has been a lifeline—it’s been called “a noble medication,” “world-shaking,” and “revolutionary.” But now, it’s not just an asset of the developing world.
As policies restricting access to abortion roll out in Texas and elsewhere, the use of miso is quickly becoming a part of this country’s story. It has already made its way into the black market here in Texas’s Rio Grande Valley, where abortion restrictions are tightening, and it is likely to continue its trajectory if anti-abortion legislation does not ease up and clinics continue to be closed.
.. Today, throughout Texas—from the Rio Grande Valley to El Paso—miso’s story is being drafted anew. And in this narrative, it is Latin America that has answers for the United States.
Misoprostol’s role as the world’s revolutionary abortion pill began by accident, and nobody knows for certain where it all began. Early scientific literature traces the drug’s abortion-inducing use to Brazil, but it’s possible that it was also being taken—but not documented—in the Caribbean at the same time.
.. Ironically, misoprostol was never developed to induce abortions: Instead, it was created and marketed as an ulcer medication called Cytotec.
.. In 1986, misoprostol was approved for sale in Brazilian pharmacies as an ulcer medication and was distributed over-the-counter. But its use as an abortion-inducing drug spread rapidly, and slipped below the radar at first. Like many drugs, misoprostol’s label had a simple warning: Do not take if pregnant.
.. But not everyone heeded the warning, including a number of Brazilian women who read the drug’s packaging and decided to try their luck. Or that’s how the story goes.
.. Some believe that certain Brazilian women made this discovery on their own; others say that a select few pharmacists who knew that Cytotec could induce abortions secretly spread the word.
.. That is, until they found the little white pill—that special drug that could, miraculously, “bring the period back.”
.. When women searched for the magic drug, they would shield their intentions with coded language: “I need to bring down my period,” they would say, or “bring it back.”
.. As miso became more popular, Latin American doctors from Peru to Brazil started noticing a trend: They were seeing, it seemed, a dramatic decrease in abortion-related complications. Fewer women were carted through hospital doors with gruesome infections from back-alley botched abortions, and ob-gyns saw a reduction in the grisly abortion complications that had so frequently plagued providers
.. Word of misoprostol spread at the grassroots level, working its way up from Brazil and snaking from one Latin American country to another.
.. In 1991, the company reported that misoprostol’s use as an abortion-inducing drug could reach up to 35 percent of its total usage.
.. Public pressure to regulate the drug in Brazil mounted, and in May 1991, the state of Rio de Janeiro restricted miso’s use to hospitals, while the state of Ceara imposed a total ban on its sales. On July 17, 1991, the Ministry of Health required that the purchase of miso had to be accompanied by a prescription from a physician, and made a deal with Biolab Laboratories to reduce the availability of the drug. In 1992, miso’s public availability in the State of Sao Paulo was restricted to authorize pharmacies registered with local government authorities. Today, it’s difficult—but not impossible—to get the drug in Brazil. Traffickers sell it on the black market and online, but it can be prohibitively expensive (according to a recent Al Jazeera article, one pill can cost up to $60), and when it is sold online, it’s often counterfeit.
.. But miso is still commonly used in Brazil, and it accounts for nearly half of the country’s one million annual abortions. As these numbers reveal, many of the women in Brazil and Latin America had welcomed miso in the absence of safer options. Now, more than three decades later, the secret has made its way to the United States.
.. A study conducted by the University of Texas predicted that the law would bar nearly 23,000 Texas women from getting abortions—or almost one in every three women who seeks an abortion.
.. Many of these women can be found in the Rio Grande Valley, where the admitting privileges provision forced both of the county’s abortion clinics to shut down. Now, the closest clinic for the region’s one-million-plus residents is 150 miles away. For many poor, uninsured South Texas women, that distance is beyond feasible. Few have access to a set of wheels for the long haul, and others lack the right paperwork to cross immigration checkpoints on highways that run through the state.
.. Meanwhile, the flea market is close to most people living in the Valley, and the massive Alamo pulga looks like just the kind of place to pick up miso. According to several of my local sources, the drug is sold here and it’s not difficult to get—you just need to know who to approach and what to ask for.
.. But the “silver standard” is readily available without a prescription. In Mexico, miso is sold over the counter as an ulcer medication (in the U.S., it’s only available with a prescription) creating the perfect conditions for black-market sales in the United States... “When I first found out how many women were asking for it, I couldn’t believe it,” he recalls. “The market had tons of people selling the pill, and I still got asked for it so many times. Almost every time I was here, someone asked me for it.”Lopez’s experience was common. There seemed to be a consensus among nearly everyone I interviewed—from health educators to Valley residents—that if abortion providers remain shut, women will continue to look for miso.
“If a woman wants to abort, she’s going to abort,” says Lucy Felix, a Valley-based promotora, or health educator, at the National Latina Institute for Reproductive Health.
.. “It’s in demand right now. It’s what our patients are doing and they’re going to continue taking it. … The fact of the matter is that women are going to get pills and are going to figure out ways to have an abortion.”
.. “They were so shocked when they found out we weren’t offering abortions anymore. I even have patients that call, and after we tell them that we can’t offer abortions anymore, they’ll just say, ‘That’s fine. I’m going to figure out a way to do this on my own.’ And imagine all the women who don’t call us at all, who are still taking [miso],” she sighs. “We have no idea how many are doing this. We just hope for the best.”
In Latin America, miso was a secretive lifeline for many women without means to have other options. Now that the same is happening in the United States, the phenomenon is even more underground here. The networks are just starting to develop and proper information about dosage is not widely available. Moreover, those in the know appear hesitant to distribute material—much of which is circulated around Latin America—about how to safely take the drug.
.. According to the World Health Organization, more than 21 million women annually have unsafe abortions worldwide, which account for nearly 13 percent of all maternal deaths. Miso is a much safer alternative. If taken in the correct quantities (four to 12 pills over the course of at least nine hours) in a women’s first trimester, the drug is 80 to 85 percent effective.But miso’s safety is also a function of the information that comes with it. In Texas’s Rio Grande Valley, according to Carreon and others, many women are using the drug improperly because they don’t have access to basic facts about the correct dosage. That ignorance can lead to problems... Instead of ingesting four of the 12 pills every three hours, as is recommended by the World Health Organization, she took two pills under her tongue, then four pills vaginally, then two more under her tongue, then four more vaginally. She began to bleed profusely, doubled over in pain. But because she was undocumented, she was afraid to seek medical help at a nearby hospital or clinic. Instead, she crossed the border to Mexico with her five children—all the while hemorrhaging—in search of medical assistance... Mexican pharmacists can’t provide information about the drug and abortion, since it’s only sold there as an ulcer medication, and many of the vendors selling miso at flea markets know very little about correct dosage... “So I’m curious about how many pills you would sell,” I start. “Because women are supposed to take 12 pills over nine hours if they’re in their first trimester. That’s what most doctors recommend.”I glance at Lopez and ask him if he knew this. His answer is a firm no.
When customers came to Lopez looking for the pills, he says he would sell the number they asked for—which often landed in the three or four range—and would charge around $13 per pill. Commonly, buyers didn’t know how many to purchase, so Lopez says he would defer to odd numbers and sell them three. Once, he sold a woman 20.
“I didn’t know what was right,” he says with a shrug.
.. “But if it isn’t sold in flea markets, more people are just going to end up going to Mexico.”
.. while pharmacists are aware that women are using it for other reasons, they can’t provide information about how to terminate a pregnancy with the pill. After all, abortion is restricted outside of Mexico City.
.. To avoid legal prosecution, hotline volunteers read information about misoprostol abortions that’s publicly available on the WHO (World Health Organization) website.
.. In the United States, laws related to self-abortion vary by state. In some states, women who induce their own abortions, as well as those who assist them, are subject to criminal liability, and in states like Massachusetts, South Carolina, and Idaho, criminal charges have been brought against women who used miso to end their own pregnancies. In 39 states, it is illegal for anyone other than a medical provider to perform an abortion. But there is no consistency among states when it comes to the penalties for women inducing abortion without a physician, or for those who help them get information about the medications necessary to self-induce.
.. Many of the abortion advocates and women’s health organizations I talked to were reluctant to even discuss the topic of phone hotlines, concerned that establishing such networks could have serious legal consequences. After all, self-induced abortion is illegal in dozens of states. One reproductive health expert told me that creating phone hotlines, or handing out flyers with information about miso from the WHO is out of the question.
“Giving general information” about where to get an abortion “is never a problem. Helping a woman who wants to end her own pregnancy is a crime,” she said firmly.
.. Francine Coeytaux, a public health specialist and founder of the Pacific Institute for Women’s Health, says that reproductive health advocates often have a tendency to self-censor because they’ve been playing on the defensive against the pro-life movement for so long, and perhaps are overly cautious.
“I don’t think we should assume that it’s illegal,” she said. “It’s sharing information and we’re not telling them what to do.”
.. “The only website we trust to help women gain access to a safe medical abortion is www.womenonweb.org and we cannot guarantee that any other website is trustworthy,” the organization writes.
.. “It’s incredibly liberating having misoprostol in my bathroom cabinet,” she says. “The idea of a pregnancy scare is … less scary, in a very real way. I wouldn’t need to even tell anyone except me, if I didn’t want to.”
.. Molly says that many of the women who contact her are already mothers who live hours away from the nearest clinic. Often, they don’t have anyone to watch their children while they go in for the procedure, especially if they have to return for more than one visit and can’t afford to take more days off of work.
A New Front in the War Over Reproductive Rights: ‘Abortion-Pill Reversal’
When the abortion pill became available in the United States in 2000, 12 years after it was approved in France, activists on both sides of the debate predicted that what was then called RU-486 would revolutionize the abortion landscape. One Planned Parenthood medical director told a journalist in the late 1990s that he expected medication abortions to make up 30 percent of all abortions within three or four years. Anti-abortion leaders, meanwhile, foresaw the procedure’s becoming effectively invisible, and therefore difficult to confront directly. George W. Bush, then the Republican nominee for president, said he feared the new protocol would ‘‘make abortions more and more common.’’
.. In 2014, the number of abortions in the United States dropped below one million for the first time since 1975.
.. A decade after RU-486’s arrival in the United States, fewer than 18 percent of abortions took place via medication
.. Even among women whose pregnancies were eligible for the abortion pill — at the time, eight weeks’ gestation or less — almost three-quarters underwent surgery instead.
.. As public discussion about abortions has focused on surgical abortions, the anti-abortion movement has notched victory after victory, chipping away at abortion access through a constellation of state laws that heavily regulate clinics, starve providers of funds and require women to undergo ‘‘counseling’’ or waiting periods before procuring the procedure. As a result, at least 162 abortion providers closed or stopped offering the service between 2011 and 2016
.. In the Midwest and the South, more than half of all women live in counties with no abortion provider at all.
.. But today, 17 years after RU-486 was approved, medication abortion is approaching its initial promise — or threat, depending on your point of view. American women now end their pregnancies with medication almost as often as they do with surgery
.. The experience of taking a few pills in private is on the cusp of becoming what we mean when we say ‘‘abortion.’’
.. This steady rise of medication abortion, or what the anti-abortion movement calls chemical abortion, presents the movement with a significant challenge, one that has turned out to be more complicated than the fear that abortion would become more common.
.. Medication abortions take place relatively early in pregnancy, and they are eliminating many of the images and narratives — the abortionist’s instruments, the impersonal clinic — that have historically served as persuasive scare tactics.
- .. What the anti-abortion movement has thought through carefully is how to tell stories about abortion’s impact. Early activists, who were mostly Catholics, were almost solely concerned with saving the life of the fetus.
- Feminists arguing for choice, in turn, made a convincing case for their own rights — and accused people opposed to abortion of not caring about women at all.
.. By the 1990s, emphasizing abortion’s supposed harms to women had become a full-fledged strategy, one that changed both the public face of the anti-abortion movement and its self-identity. Today many young anti-abortion activists frame their work as feminist
.. Promoting abortions as murder had always carried the uncomfortable implication that the women who procured them were killers. In the revised narrative, ‘‘the women are viewed as essentially victims,’’ Williams says. ‘‘The argument is always that they didn’t have the knowledge they really needed.’’
.. And ‘‘abortion pill reversal’’ implies exactly that — that a woman made an uninformed decision and has now thought better of it. The brainchild of a San Diego doctor named George Delgado, ‘‘reversal’’ is a medical protocol that floods a woman’s body with progesterone, the so-called pregnancy hormone, within hours after she has taken mifepristone, the drug that begins a medication abortion. ‘‘If you have something that’s poisoned a specific spot in your body and we know what the antidote is, then you just take the antidote,’’
.. For all the challenges that the abortion pill poses to the anti-abortion movement, it turns out to have at least one unexpected benefit: The hours between the two doses of medication represent an extra decision point to interrupt and redeem. ‘‘With a surgical abortion, once the instrument enters the uterus, then it’s over,’’ Delgado says. Medication abortion, by contrast, gives women ‘‘a second chance at choice.’’
.. Natural Procreative Technology, a Catholic-friendly approach to women’s reproductive health. Developed by an anti-abortion OB-GYN named Thomas Hilgers who was also inspired by ‘‘Humanae Vitae,’’ ‘‘NaProTechnology’’ eschews most forms of birth control and fertility treatments and relies instead on tracking widely used ‘‘biomarkers’’ like cervical mucus and body temperature.
.. he knew that mifepristone, the first drug in the abortion-pill protocol, works by blocking progesterone from the uterus. Couldn’t an extra dose of progesterone overcome the mifepristone? Within hours, he sketched out a plan to inject the woman with 200 milligrams of progesterone and to continue giving the progesterone until the end of the first trimester.
.. Delgado later found out that a doctor in North Carolina, Matthew Harrison, had received a similar call from a crisis pregnancy center in 2006 and independently made the same guess about progesterone counteracting the effects of the mifepristone. That fetus, too, survived, after the mother received progesterone injections through her 26th week of pregnancy.
.. They soon published a small case series in the journal Annals of Pharmacotherapy. The article, just four pages long, describes seven pregnancies treated with progesterone after mifepristone. Two of the abortions completed, but four of the fetuses survived.
.. Delgado’s hotline received just 28 calls in all of 2012. But the volume increased over the years: 200 calls in 2013, more than 400 in 2014 and more than 600 for each of the last two years
.. When a call comes into the hotline, the nurse’s job is to connect the caller as quickly as possible with a local doctor willing to administer the reversal protocol. The program has a network of about 350 doctors
.. If the caller doesn’t live within driving range of one of those providers, the hotline nurse immediately starts calling local doctors and hospitals to explain what reversal is, hoping to find a sympathetic provider. Catholic hospitals are usually a good place to start.
.. One fan gave Harrison a T-shirt that read ‘‘Reversed RU-486. Now reverse Roe vs Wade.’’
.. A vanishingly small percentage of women decide they want to reverse a medication abortion halfway through. In fact, regret is quite rare when it comes to abortions in general. A 2013 study found that although women experienced a wide range of often conflicting responses to the procedure, relief was the most common emotion one week after. A later study found that women who had abortions were also confident in their decisions beforehand — more confident than people who decide to get reconstructive knee surgery, for example.
.. ‘Most women are certain of their decision when they present for care,’’ says the study’s lead author, Lauren Ralph, an epidemiologist at the University of California, San Francisco. Their certainty is largely unchanged by waiting periods and mandated counseling, which suggests ‘‘women do not change their minds.’’
.. Ralph also found that women who do experience uncertainty are more likely to already believe a myth about abortion, such as that it causes breast cancer.
.. In Cynthia’s memory, it wasn’t the pressure from a priest, a doctor, her mother and her boyfriend that changed her mind. It was the ultrasound. ‘‘When I saw the heartbeat, I mean, truly everything changed,
.. Women who regret their abortions, and are willing to speak publicly about it, have long been valued spokeswomen for the anti-abortion message. But reversal offers a twist to those stories: a happy ending.
It also represents a concrete action that women can take to atone for their initial mistake.
.. While Delgado claims that flooding a woman’s body with progesterone saves the fetus, other doctors say that in many cases the fetus would have survived if the woman simply declined to take the second pill, misoprostol, after the initial dose of mifepristone.
.. The American Congress of Obstetricians and Gynecologists issued a strongly worded statement against reversal in 2015 that said the fetus would survive 30 to 50 percent of the time.
.. The question, in other words, is whether the progesterone protocol is effectively just a placebo. ‘‘There’s no evidence that any kind of treatment is better than doing nothing,’’
.. Delgado and Davenport are also preparing a larger case series for publication later this year, which they say will include about 350 women. Delgado says it shows that the most effective progesterone protocol results in an embryo survival rate between 60 and 70 percent.
.. Critics say that even if those numbers are valid, they aren’t what they seem. Many women who decide to take progesterone undergo an ultrasound first, to see if the pregnancy remains viable; those whose fetuses have died do not go forward with reversal, which means the initial pool of subjects is skewed toward women whose pregnancies had a good chance of continuing even without progesterone.
.. The protocol, however, has attracted almost no interest from the mainstream medical community, in part because the presumed audience is so small.
.. Since 2015, legislators in 10 states have introduced bills requiring doctors to inform women procuring the abortion pill that they can change their minds after taking the first dose. ‘‘These laws are essentially forcing physicians to tell their patients about a treatment that is unproven and essentially kind of encouraging them to participate in an unmonitored research experiment,’’
.. The anti-abortion movement has effectively promoted the idea that many women regret their abortions. Supreme Court Justice Anthony M. Kennedy, considered a wild card on abortion questions, waxed eloquent on the topic in his ruling in Gonzales v. Carhart, a 2007 case that upheld the ban on ‘‘partial-birth’’ abortion. ‘‘It seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained,’’ he wrote in the majority opinion. ‘‘The state has an interest in ensuring so grave a choice is well informed.’’ That assumption undergirds huge swaths of contemporary abortion law: waiting periods, mandatory ultrasounds and requirements that doctors give women more (sometimes dubious) information about the procedure and its effects. The idea seems to be that many women understand what an abortion is only after they have one.
.. Stories from individual women who struggle with remorse remain a powerful weapon in the anti-abortion arsenal, and the abortion rights movement has often stumbled in its attempts to respond.
.. Just raising the question of uncertainty and regret affects the abortion pill’s reputation. ‘‘You’re changing cultural norms about what people think about this kind of abortion,’’ she says. ‘‘You can do that regardless of what the research ultimately shows.’’