A guest post by Marge Berer Co-ordinator International Campaign for Women’s Right to Safe Abortion originally posted on the Berer Blog
Taking medical abortion pills at home to have an abortion, mostly before ten weeks of pregnancy, though not always, is happening in most countries across the world, and each year more than ever. It is happening both in countries where terminating most pregnancies is still a criminal offence and registered abortion services are not available, and also increasingly where legal abortion may be available but is very expensive, and/or fraught with barriers and burdensome requirements, and/or requires travelling a long distance for services, including having to cross a border.
The fact is that almost all abortion laws and policies, and most health services, are way behind the times in acknowledging that early abortion with mifepristone + misoprostol is both easy and safe ‒ so easy and so safe that women are sharing information with each other on how to do it, bypassing formal service delivery and doing-it-themselves. Moreover, other women ‒ and a growing number of health professionals ‒ are helping women to self-induce abortions, giving them simple instructions based on proven guidance on how to do it and advising them to have somewhere to turn if they are worried or need help.
The permutations of how this plays out in different settings are worth spelling out.
In countries where there are almost no legal abortions, women buy the pills from pharmacies, street drug sellers, and the internet. They may have been given good information from a health professional or someone else on how to use the pills, or not. But use them they do, and although there is no way to obtain accurate data on how many do so, nor the extent to which they have had complete abortions, the numbers are probably in the millions internationally, annually.
Many of these women make their way to hospitals or doctors after self-inducing their abortions. Unlike those who have used an unsafe method (drinking a poisonous substance, inserting a twig or coat hanger into their uterus, or throwing themselves down the stairs), they do not present with the well-known range of serious complications ‒ sepsis, haemorrhage, uterine rupture or other major organ damage ‒ as were the only option in the past and killed many women. No, very few of those who have used misoprostol alone ‒ because mifepristone was not available, which means the method is less effective ‒ have a major complication. However, they may have an incomplete abortion unless they know the formula for taking additional doses of misoprostol until they are sure the abortion is complete. Some get frightened in the process, since they are often doing this alone, and they seek help when what they needed most was reassurance.
In places like Poland and Ireland and Northern Ireland, for many decades now, women have been crossing their national borders in large numbers to obtain legal abortions. However, it is now becoming well known that medical abortion pills can be obtained via the internet from trustworthy suppliers ‒ e.g. Women Help Women and Women on Web ‒ who provide them with accurate information, based on WHO guidelines, send them the pills, and are there for advice afterwards if required. Hence, more and more women are obtaining information and the pills that way. And they are having their abortions at home ‒ safely. From these two internet providers both mifepristone and misoprostol are available, and with the combination of these two medications, which is much more effective, the complete abortion rate up to 9-10 weeks of pregnancy is around 98% ‒ or higher if used even earlier.
In the past 5-10 years, in order to help women find this information, safe abortion information hotlines have been set up in a growing number of countries where abortion is legally restricted. These have been started mainly by women’s rights activists, who maintain a free phone line that women can ring and get information on how to do an abortion safely. These hotlines are found in Latin America, sub-Saharan Africa, and Asia. They work with each other across countries and regions and with other groups doing women’s rights work. They use public meetings and statements, blogs, text messaging, social media and graffiti to publicise their existence. They often have manuals, leaflets, and videos that have been written for women in their own languages, often using visuals to make explanations clear. Because they supply information but not pills, they are not doing anything illegal.
This situation is not always rosy or ideal, and all of us involved in supporting the legitimacy of self-help abortions know that well. For one thing, everywhere abortion is subject to criminal law, prosecution is always a risk. For another, where abortion is legally restricted, the pills may only be obtainable on the black market, which makes it hard to find them and means they can be very expensive. In addition, it is important to be aware that the quality of pills sold on the internet by dubious sources is a major issue, as there are many, many websites offering the pills that are not trustworthy. Such pills may or may not be of a high quality, or they may contain only small amounts of the medications. Some may even be completely fake and totally ineffective. Moreover, if they are not vacuum sealed in blister packs they may lose their effectiveness in transit. Hence, the source of the pills is crucial. Some safe abortion hotlines, knowing this, have helped pharmacies to stock the right pills. In at least one case, a group has even started their own pharmacy.
Nevertheless, even though this situation is far from ideal, it is the best alternative in what is not the best of all possible worlds. The numbers of deaths from complications of unsafe abortion have been falling rapidly in the past ten years around the world ‒ not because the laws have been substantially changed and safe services set up across the global South, where more than 90% of the deaths have been occurring in the past 20 years, but because women have taken a safe abortion method into their own hands.
This reality is well-known in the global South, particularly in urban areas, but it has been ignored where the legal practice of abortion is the norm, e.g. in North America, Europe or Australia. This benign neglect is changing rapidly, however, because women in the global North are also starting to avail themselves of medical abortion pills via the internet and bypassing their health system and its costs and controls altogether. Cases that have emerged to date have mainly been of women who are too late for a legal abortion, or are poor and cannot afford a clinic, or who live in rural areas where services are scarce or non-existent, or who are migrants from countries where self-use of abortion pills is common. Unfortunately, these women sometimes seek medical help after self-inducing and that is how the trouble has started.
Many health professionals don’t like the idea of women taking the means of abortion into their own hands, even if they themselves are not willing to help women in the first place, and like some of their brethren in Central America and elsewhere, they are reporting women to the police. Even in India, where so many abortions remain unsafe because the government has failed to make services accessible in spite of a liberal law dating back to 1972, the widespread self-use of abortions pills is suddenly being vilified. In the USA, UK and Australia more than once already, the justice system is responding by bringing the full force of the criminal law down on the heads of those who have been “caught in the act”. They have finally noticed that self-help abortion is not just a “third world” issue.
In Ireland, about five years ago, a Chinese woman who owned a pharmacy was caught selling medical abortion pills she had brought in from China. Luckily for her, she was fined but not jailed.
In Northern Ireland this year, more than 200 people wrote a public letter stating they had purchased medical abortion pills through the internet ‒ in solidarity with a woman who had done so for her daughter, and who was caught and is awaiting trial. A woman in a rural area of Pennsylvania, USA, was also jailed 9-18 months for purchasing pills for her daughter, even though there were no abortion providers anywhere near where she was living.
A young couple in Australia were also caught after purchasing and using the pills and both were charged. However, their defence successfully argued that the pills are not a “noxious substance” but rather WHO-approved essential medicines, and the couple were let off. A woman in Idaho, USA, was similarly charged and using this same argument, also successfully argued that it was unconstitutional for her to be prosecuted. A recent case to come to light is a woman in Georgia, USA, who took misoprostol, purchased allegedly from Canada, and had a miscarriage in her car (she was some 22 weeks pregnant) and had to call for help. She was initially charged with murder, a charge that was withdrawn within 24 hours because under current Georgia law, this charge did not seem to be permitted.
In the UK, about three years ago a woman who sought an abortion beyond the 24-week time limit, and was turned down for help by three clinics, successfully purchased medical abortion pills through the internet and terminated her pregnancy. She was reported when she did not turn up to deliver the baby, was charged and sentenced to eight years in jail by an anti-abortion judge, a sentence that was later reduced on appeal to “only” three years. She was not charged with infanticide under a 1929 UK law, which would have carried a much longer sentence, only because the fetus was not found.
Also this year, a woman in a London ayurvedic shop was caught selling medical abortion pills when women who had purchased them went to hospital for treatment after using them. She was sentenced to 27 months in prison. One can only hope an appeal will reduce this sentence as well. In this case, the charge was again to do with the sale of a “noxious substance” under an 1861 law that is still on the statute books in the UK, as in Australia and probably many other former British colonies. A spokesperson for the Medicines and Healthcare Products Regulatory Agency, the agency that investigated the case with the police and brought the charges, was quoted in an article describing the case to say: “Selling mifepristone with no medical qualifications is illegal and can be extremely dangerous for patients. If you require medical advice, we recommend you visit your GP, as a healthcare professional is best placed to advise you.”
This “hook” of using the noxious substance line from the 1861 Act to hang criminal charges on and sentence women to prison, wilfully ignores the fact that mifepristone and misoprostol are not noxious substances. Medical abortion pills, used both legally and illegally, with medical involvement and without it, are reducing, not causing deaths and complications.
The real message from those who are prosecuting women is: Get back in line! You are not permitted to be in control here! The real offence in their eyes is having had an abortion “outside the system”.
In Ireland, the “new” abortion law, which has allowed a handful of abortions so far (the pathetic sum of 26 in 2014) also created a prison sentence of up to 14 years for having an abortion inside the country but outside the system, was meant I assume to warn women in thinly veiled terms not to purchase pills over the internet.
These prosecutions are both very threatening and at the same time frankly absurd. Nothing is going to stop medical abortion pills from being manufactured, distributed, purchased and used widely on a global scale. It is already happening. It has been happening since at least 1988 in Brazil, and the practice spread like wildfire from there because it is meeting a need among the one in three of the billions of women on earth who need an abortion in their lifetime.
Countries in both the global North and the global South need to recognise this and act rationally and reasonably in response ‒ in a way that is to women’s benefit, not to punish them.
The evidence exists for all to read that the use of medical abortion with mifepristone + misoprostol from the point soon after a woman first misses her period is both extremely safe and very effective. Why make women wait weeks or months because the health system is fraught with hurdles and delays that make women wait and then have to beg for permission?
Criminalising safe, self-help abortions and the people who make them possible is not the answer. What is the answer is bringing the reality of safe medical abortion into health systems and abolishing the criminal laws against abortion in every country. Contraceptive information helplines have been funded by governments for years. It is time to fund safe abortion information hotlines and let women buy medical abortion pills over the counter and have abortions as early as possible in the privacy of their own homes.
At the same time, health systems need to continue to ensure help is available when needed, and that there is a safe space for women to have abortions in a primary care setting when home is not a safe place, and when women are beyond 10 weeks and safety means being in a clinic. It must also not be forgotten that not all women are organised or aware enough to have abortions early, and others have medical conditions (including fetal conditions) that lead to the need for wanted pregnancies to be terminated, often well into the pregnancy. Instead of demonising women in any of these situations, health systems must ensure that first and second trimester abortions continue to be available for those who need them.
For details of the cases mentioned in this blog, see the newsletter of the International Campaign for Women’s Right to Safe Abortion, 20 July 2015. To receive the newsletters, join the Campaign.