Analysis Abortion

In Our Own Hands: What U.S. Women Can Learn from Self-Use of Medication Abortion Worldwide

Francine Coeytaux & Leila Hessini

There is much we can learn from our sisters in the Global South who, rather than trying to gain access to services that all too often do not exist or fail to treat them well, are obtaining pills to induce abortion and taking them at home without seeing a health provider.

Correction: A version of this article incorrectly noted that “Misoprostol is typically sold in tablets of 200 mcg; four tablets are taken by mouth to initiate an early abortion, followed by four more 12 hours later if required.” In fact, Misoprostol is typically sold in tablets of 200 mcg; four tablets can be taken by mouth to initiate an early abortion, followed by four more pills every three hours for a maximum of three doses. We regret the error.

Every day in the United States, abortion is under attack. Even when the news is positive, as in the recent dismissal by the Supreme Court of an Oklahoma law effectively banning medication abortion, we are still faced with the immediate and long-term implications of anti-choice groups and legislators systematically eliminating the health services women need.

There is much, however, that we can learn from our sisters in the Global South who have become active agents in securing their own reproductive health and autonomy. Women living in countries where abortion is legally or socially restricted have come up with a creative way to meet their needs: Rather than trying to gain access to services that all too often do not exist or fail to treat them well, they are obtaining pills—primarily misoprostol, also known as Cytotec—from pharmacists or informal markets and taking them at home without ever seeing a health provider. Because misoprostol is safe and effective, the use of pills to end pregnancy without formal medical guidance has significantly increased access to safe abortion for many women, especially poor, rural, and young women who are chronically under-served. And it allows women to be in control of the process.

Women in the United States have also been taking matters into their own hands. Over the past several years, there have been reports of home use of misoprostol by immigrants from countries where such use is more common practice. And recent articles describing the severe restrictions being imposed on abortion services in Texas attest to the fact that women who can no longer access clinic-based services are going to Mexico to obtain misoprostol, where it is available in pharmacies without a prescription. Given the rapidly dwindling access to abortion providers in large swaths of the United States, this practice is likely to increase.

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But because the drug distribution system in the United States is well regulated, gaining access to the pills is more difficult than in countries in the Global South. And obtaining information about the correct use of misoprostol for abortion can also be challenging, particularly in states where abortion is stigmatized and providing information is outright illegal. There is a lot we can learn from the solid body of evidence and experience from across the globe to increase public knowledge about the correct and safe use of various abortion pills and to ensure women’s access to quality products even in extremely restrictive settings.

Misoprostol and Women’s Agency

Women have been having abortions since time immemorial. The criminalization of abortion, however, is a more recent phenomenon, dating back to the 19th century, and supported by patriarchal social norms linked to female domesticity and motherhood, and a desire to control female sexuality.

In this context, women’s self-care is nothing new. Women have been fighting systems designed to limit their rights and protect the status quo for centuries, and those women who are most likely to be ignored by health systems have advanced some of the most innovative strategies for meeting their own needs.

One key advance has been abortion with pills, also known as medication abortion. Misoprostol, a pill available over-the-counter in many countries, provides a safe, low-cost, and easy-to-use method to terminate early pregnancies. In fact, self-use of misoprostol for abortion began in the 1980s, when women in Brazil, living under very restrictive abortion laws, realized they could take advantage of the contraindications of an otherwise readily available drug. The label on Cytotec (the trade name for misoprostol), a drug sold over-the-counter in Brazil to treat gastric ulcers, included a warning that it might induce abortion in pregnant women. Recognizing that this could serve their needs when faced with an unwanted pregnancy, women in Brazil began to use it and passed on their knowledge through word-of mouth, woman-to-woman. Since then, word has spread widely across borders and continents, and we now have global evidence that misoprostol is being used by women in many countries where abortion is restricted, including the United States.

Since this discovery by women of the “other use” of misoprostol, much research has been done to prove the safety and efficacy of misoprostol for abortion. Misoprostol is very effective in the termination of early pregnancies—up to nine weeks—and has an efficacy rate of 85 percent. Numerous studies have shown that women can use this life-saving drug safely and effectively by themselves, provided they have accurate information about its use. Misoprostol is typically sold in tablets of 200 mcg; four tablets can be taken by mouth to initiate an early abortion, followed by four more pills every three hours for a maximum of three doses. (Gynuity Health Projects and Women on Waves have posted clear guidelines for how to use misoprostol on their websites.) When combined with another drug—mifepristone—the efficacy of complete abortion approaches 98 percent. But while mifepristone followed by misoprostol is now the “gold standard” in countries where medication abortion is available, its use is limited for self-care because mifepristone is only registered in countries where abortion is legal.

Sharing Accurate and Trusted Information

So what tools do women in the United States need to safely and successfully terminate an unintended pregnancy on their own? To begin, women need:

  • Accurate information about misoprostol—its efficacy, safety, and how its use can enable women to be active agents in securing their own reproductive health and autonomy.

  • Trusted networks of friends, family, health professionals, and others who can be relied on to provide accurate information.

  • Access to affordable supplies of quality misoprostol (and/or other safe abortion pills, such as mifepristone).

  • Access to back-up health care and support should they need or want it.

Imparting information about the correct use of misoprostol for abortion and how to obtain the pills can be challenging, particularly in places where abortion is stigmatized and/or outright illegal. Successful approaches that have been developed in other countries where abortion is restricted include:

  • Ensuring access to medication abortion information and drugs over the internet. Women on Web provides virtual counseling and mail delivery of medication abortion in countries where it is not accessible.

  • Demystifying and democratizing medication abortion by sharing information with women where they work, reside, and socialize. In Nepal, information is shared at women’s hair salons, factories where they live and work, and during soap operas aired over the radio.

  • Training community health workers to distribute medication abortion information and pills, thus reaching a wider range of women. In Kenya and Ethiopia, research has shown that community health workers are often a first and trusted access point for women.

  • Sharing women’s knowledge and expertise related to abortion. In the Philippines and Mexico, networks have been created to share women’s knowledge and provide support to others.

  • Creating hotlines to share information about multiple uses of misoprostol. Such hotlines—often used by young women who may prefer anonymity—have been set up in countries where abortion is restricted, like Chile, Ecuador, and Indonesia.

  • Using mHealth technologies to deliver information to women on medication abortion. In South Africa, Ipas is partnering with a technology-based solutions company to send free, informational SMS text messages to women who have chosen to have a medication abortion and want to receive support and follow-up information.

  • Establishing women-centered pharmacies where medication abortion is available and affordable. The Women’s Promotion Center in Tanzania set up its own pharmacy due to the lack of distribution sites in that country.

  • Educating journalists to document the harms of legal and social restrictions on abortion. In Nicaragua, a prize is awarded annually to journalists and social communication students for outstanding writing on the topic of abortion.

Adapting These Strategies for the United States

Many of these strategies could be adapted to assist women in the United States to take advantage of the benefits offered by misoprostol: its simplicity of use, its low cost, and, most important, the fact that women can take it themselves, without medical assistance. There are many opportunities for reproductive health and rights advocates to come together to ensure that women in the United States who use misoprostol (or other abortion pills) do so safely and effectively. Misoprostol has the potential to reduce the barriers to abortion care that we face in the United States today by facilitating women’s agency and autonomy.

The lessons from our sisters who have created networks of knowledge around misoprostol are there for us to learn from; the evidence on its efficacy is in. Are we ready to use these tools in the United States to give women what they need—to take matters into their own hands?

Commentary Law and Policy

An Incomplete Victory for Evidence-Based Abortion Care

Liz Borkowski & Amy Allina

On June 28, just a day after the Supreme Court ruling, Texas published a revised draft of the pamphlet that must, by state law, be given to all people seeking abortion services. But the brochure still includes misleading information, reminding us that anti-choice politicians are still interfering in patient-provider interactions.

Reproductive health advocates cheered in March when the U.S. Food and Drug Administration (FDA) approved a revised label for abortion drug Mifeprex (mifepristone). We cheered again when the U.S. Supreme Court struck down central provisions of Texas law HB 2, which would have closed most of the state’s abortion clinics. Both of these were victories not just for access to abortion care, but also for health-care policies based on current evidence. However, on June 28, just a day after the Supreme Court ruling, Texas published a revised draft of the pamphlet that state law requires physicians to provide to all women seeking abortion services, reminding us that anti-choice politicians are still finding ways to interfere in patient-provider interactions.

Laws and regulatory actions of this kind, which require the use of biased and incomplete information, prevent health-care professionals from providing women with care that meets basic medical and ethical standards.

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State requirements that are at odds with up-to-date scientific or medical research are nothing new. Several states have passed laws requiring abortion providers to follow the FDA-approved label for Mifeprex. Those laws are currently in force in North Dakota, Ohio, and Texas, and have been halted by courts in Arizona, Arkansas, and Oklahoma. Before March, this meant that providers in those states had to follow the original Mifeprex label, which was based on clinical trials conducted in the 1980s and 1990s, and which didn’t encompass variations in practice used for years to make medication abortions safer and more accessible. These included lowering the dose of mifepristone from 600 mg to 200 mg; offering medication abortions for pregnancies of up to 70 days, rather than only through 49 days; and allowing the woman to take the second drug in the procedure (misoprostol) at home rather than requiring her to return to a provider’s office to swallow a pill. (For more on current science about medication abortion, see our white paper.) The new label reflects those changes and makes it easier for providers everywhere to offer evidence-based care.

Normally, providers’ use of approved drugs evolves as the evidence does. This is important because experience and research can show that it’s safe and effective to use drugs in different doses or for different conditions than what the label specifies. Providers can adopt these variations without waiting for a new label to be approved by the FDA by prescribing a drug off-label. For instance, the asthma medication albuterol (found in inhalers) is often prescribed off-label for chronic obstructive pulmonary disease due to substantial evidence supporting this off-label use. Drug manufacturers may apply to FDA for an updated label (particularly when insurers won’t cover drugs for off-label conditions), but they don’t have to do so.

However, a new Mifeprex label was important because some states were requiring abortion providers to adhere to the outdated label—in essence, telling providers that their practice could not evolve based on evidence, and denying women access to the care that’s been demonstrated to be safe and effective.

Much like laws requiring medication abortion providers to adhere to an outdated label, so-called informed consent laws requiring that a woman receive certain information before getting an abortion essentially substitutes the judgment of legislators for the judgment of health-care providers. In states like Texas, where a majority of the legislators are committed to a political agenda blocking access to abortion, this all too frequently means replacing scientific evidence with intentionally distorted information. When the Rutgers University Informed Consent Project asked anatomists specializing in embryological and fetal development to evaluate statements in the previously available version of Texas’s required pamphlet, they determined that 34 percent of the statements were either scientifically incorrect or misleading. (Preliminary findings on the revised draft suggest the accuracy hasn’t improved, project head Cynthia Daniels told the Texas Tribune.) True informed consent is a necessary and ethically valuable part of any medical process, but these types of laws subvert the true intent of consent when they require providers to give inaccurate or incomplete information under the guise of improving transparency.

Also problematic is what the revised Texas pamphlet still doesn’t say. The section on abortion risks reports the extremely low risk of death from abortion complications, but doesn’t mention the 2012 study that found the risk of death associated with childbirth to be 14 times higher than that from legal abortion. The pamphlet tells readers that “some women have reported” negative emotions, including depression, grief, and anxiety after abortions. However, it remains silent about rigorous, peer-reviewed research that compared outcomes for women who sought and received abortions to those who sought and were denied them. Those studies found no differences between the two groups in anxiety, depression, or post-traumatic stress disorder, and documented positive emotions, such as relief and reduced unhappiness, in those who obtained abortions. (See the Turnaway Study for details on this research).

Especially disturbing examples of legislators requiring providers to give women misleading information are laws passed in Arizona and Arkansas based on poorly supported claims that medication abortions can be “reversed” if a women decides to do so before taking the second drug. Such laws require physicians to provide a woman seeking a medication abortion with information about the possibility of “reversing” the procedure by taking another hormone to counter the mifepristone, despite the absence of reputable evidence that such “reversal” can occur. Requiring providers to give information like this, which is not borne out by human studies, conflicts with the responsibility of clinicians to do no harm.

These laws, along with many others that interfere with abortion care, are enacted amid claims that they are designed to benefit women. The evidence, however, contradicts those claims. As U.S. Supreme Court Justice Stephen Breyer wrote in his majority opinion striking down the provisions of the Texas law, the requirements imposed by the state “vastly increase the obstacles confronting women seeking abortions in Texas without providing any benefit to women’s health capable of withstanding any meaningful scrutiny.” Noted Supreme Court analyst and New York Times reporter Linda Greenhouse wrote that in this decision “evidence-based medicine meets evidence-based law.”

The next step is for evidence-based medicine to meet with evidence-based legislating. It’s time for legislators to stop requiring health-care practices based on outdated or incomplete evidence, and instead focus on promoting health and high-quality health care for all.

Analysis Abortion

From Webbed Feet to Breast Cancer, Anti-Choice ‘Experts’ Renew False Claims

Ally Boguhn & Amy Littlefield

In a series of workshops over a three-day conference in Herndon, Virginia, self-proclaimed medical and scientific experts renewed their debunked efforts to promote the purported links between abortion and a host of negative outcomes, including breast cancer and mental health problems.

Less than two weeks after the Supreme Court rejected the anti-choice movement’s unscientific claims about how abortion restrictions make patients safer, the National Right to Life Convention hosted a slate of anti-choice “experts,” who promoted even more dubious claims that fly in the face of accepted medical science.

In a series of workshops over the three-day conference in Herndon, Virginia, self-proclaimed medical and scientific experts, including several whose false claims have been exposed by Rewire, renewed their efforts to promote the purported links between abortion and a host of negative outcomes, including breast cancer and mental health problems.

Some of those who spoke at the convention were stalwarts featured in the Rewire series “False Witnesses,” which exposed the anti-choice movement’s attempts to mislead lawmakers, courts, and the public about abortion care.

One frequent claim, that abortion increases the risk of breast cancer, has been refuted by the National Cancer Institute, the American Cancer Society, and the American Congress of Obstetricians and Gynecologists. But that hasn’t stopped “experts” like Dr. Angela Lanfranchi, a breast cancer surgeon and anti-choice activist, from giving court testimonies and traveling around the world spreading that brand of misinformation.

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During a Thursday session titled “The Abortion-Breast Cancer Link: The Biological Basis, The Studies, and the Fraud,” Lanfranchi, one of Rewire’s “False Witnesses,” pushed her debunked talking points.

Throughout the presentation, which was attended by Rewire, Lanfranchi argued that there is “widespread fraudulent behavior among scientists and medical organizations to obfuscate the link” between abortion and breast cancer.

In a statement, the irony of which may have been lost on many in the room, Lanfranchi told attendees that sometimes “scientists in the pursuit of truth can be frauds.” Lanfranchi went on to point to numerous studies and texts she claimed supported her theories and lamented that over time, textbooks that had previously suggested a link between abortion and breast cancer in the ’90s were later updated to exclude the claim.

Lanfranchi later pivoted to note her inclusion in Rewire’s “False Witnesses” project, which she deemed an “attack.” 

“We were one of 14 people that were on this site … as liars,” said Lanfranchi as she showed a slide of the webpage. “Now when people Google my name, instead of my practice coming up,” Rewire’s story appears.

Priscilla Coleman, another “False Witness” best known for erroneously claiming that abortion causes mental health problems and drug abuse, similarly bemoaned her inclusion in Rewire’s project during her brief participation in a Thursday session, “The Conspiracy of Silence: Roadblocks to Getting Abortion Facts to the Public.”

After claiming that there is ample evidence that abortion is associated with suicide and eating disorders, Coleman suggested that many media outlets were blocking the truth by not reporting on her findings. When it came to Rewire, Coleman wrote the outlet off as a part of the “extreme left,” telling the room that “if you look deeply into their analysis of each of our backgrounds, a lot of it is lies … it’s bogus information.”

An extensive review conducted by the American Psychological Association in 2008, however, found “no evidence sufficient to support” claims such as Coleman’s that “an observed association between abortion history and mental health was caused by the abortion.”

Rounding out the medical misinformation pushed in that session was Eve Sanchez Silver, the director and founder of the International Coalition of Color for Life. According to the biography listed on her organization’s website, Silver bills herself as a “bioethicist” who focuses on “the Abortion-Breast cancer link.”

Silver, who previously worked at the Susan G. Komen Foundation but left, she said, after finding out the organization gave money to Planned Parenthood, spent much of her presentation arguing that abortion increases the risk of breast cancer. She also detailed what she referred to as the “Pink Money Cycle,” a process in which, as she explained, money is given to Komen, which in turn donates to Planned Parenthood. As Silver told it, Planned Parenthood then gives people abortions, leading to more cases of breast cancer. 

The seemingly conspiracy-driven theory has popped up in several of Silver’s presentations over the years.

Though Komen does in fact provide some funding to Planned Parenthood through grants, a July 2015 press release from the the breast cancer organization explains that it does “not and never [has] funded abortion or reproductive services at Planned Parenthood or any grantee.” Instead, the money Planned Parenthood receives from Komen “pays for breast health outreach and breast screenings for low-income, uninsured or under-insured individuals.”

On Saturday, another subject of Rewire’s “False Witnesses” series, endocrinologist Joel Brind, doubled down on his claims about the link between abortion and breast cancer in a workshop titled “New American Export to Asia: The Cover-Up of the Abortion-Breast Cancer Link.” 

Brind described the Indian subcontinent as the ideal place to study the purported link between abortion and breast cancer. According to Brind, “The typical woman [there] has gotten married as a teenager, started having kids right away, breastfeeds all of them, has lots of them, never smokes, never drinks, what else is she going to get breast cancer from? Nothing.”

When it came to research from Asia that didn’t necessarily support his conclusions about abortion and breast cancerBrind chalked it up to an international cover-up effort, “spearheaded, obviously, by our own National Cancer Institute.”

Although five states require counseling for abortion patients that includes the supposed link between abortion and breast cancer, Brind told Rewire that the link has become “the kind of thing that legislators don’t want to touch” because they would be going “against what all of these medical authorities say.” 

Brind also dedicated a portion of his presentation to promoting the purported cancer-preventing benefits of glycine, which he sells in supplement form through his company, Natural Food Science LLC. 

“If I sprain my ankle it doesn’t swell up, the injury will just heal,” Brind claimed, citing the supposed effects of glycine on inflammation. 

In a Thursday session on “the rise of the DIY abortion”, panelist Randall O’Bannon questioned the U.S. Food and Drug Administration’s (FDA) March update to regulations on mifepristone, a drug also known as RU-486 that is used in medical abortions. Noting that the drug is “cheap,” O’Bannon appeared to fret that the new regulations might make abortion more accessible, going on to claim that there could be “a push to make [the drug] available over the counter.”

O’Bannon claimed there are “documented safety issues” associated with the drug, but the FDA says mifepristone is “safe and effective.” A 2011 post-market study by the agency of those who have used the drug since its approval found that more than 1.5 million women had used it to end a pregnancy in the U.S. Of those women, just roughly 2,200 experienced an “adverse event.” According to the Association of Reproductive Health Professionals, mifepristone “is safer than acetaminophen,” aspirin, and Viagra.

Speculating that misoprostol, another drug used in medication abortions, was less effective than medical experts say, O’Bannon later suggested that more embryos would “survive” abortions, leading to an “increased numbers of births with children with club feet, webbed toes, and fingers [and] full and partial facial paralysis.”

According to the World Health Organization, “Available data regarding a potential risk of fetal abnormality after an unsuccessful medical abortion are limited and inconclusive.”

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