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.
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?