Taken from the July/August 2014 issue of the Women's Health Activist Newsletter.

When a woman in Mexico suspects she might be pregnant when she doesn’t want to be, she can buy drugs at a pharmacy or an informal market that she can take at home to bring on her period.

In both cases, women used medications to cause an abortion. Both did it outside the formal medical system. And both did it safely, without any harmful health consequences. But the woman in Idaho did it in fear and uncertainty, without knowing what to expect and without confidence that the drugs she had taken were safe and would be effective. And she went to jail. Yet, it is the United States where abortion is generally considered to be legal, and Mexico where it is highly restricted, and even banned entirely in some Mexican states.

The illogic and contradictions in these contrasting experiences are driving an important new conversation among reproductive health, rights, and justice advocates in the United States about women’s self-use of medication abortion.

Medication Abortion or Using Pills to End a Pregnancy

Medication abortion is an abortion that is caused by taking a drug or combination of drugs to end a pregnancy. In the United States, the Food and Drug Administration (FDA) has approved the specific combination of mifepristone and misoprostol for medication abortion, and it is also approved for use in about 50 other countries around the world.

The World Health Organization’s (WHO) safe abortion guidelines state that misoprostol can be used alone to cause an abortion through 12 weeks after the first day of a woman’s last menstrual period. Though the WHO does not recommend use of misoprostol alone because of lower efficacy and greater side effects than when it is combined with mifepristone, the guidelines note that “in some settings its broader use has been reported to contribute to a decrease in complications from unsafe abortion,” and it “appears to be common where mifepristone is unavailable.”¹

With its drug regulation expertise and experience, the National Women’s Health Network (NWHN) played a leadership role in efforts to ensure that the FDA fairly evaluates the safety and efficacy of medications used for abortion. Since 2000, when the FDA granted approval to mifepristone, women in the U.S. have been able to get medication abortions at clinics and some doctors’ offices. (Misoprostol was already approved and has been available for other uses in the U.S. since the late 1980s.) Due to the politically embattled context of abortion in this country, however, the FDA approval of mifepristone included distribution restrictions, which extensive research and decades of safe use have demonstrated to be medically unnecessary. Yet, these restrictions remain in place, reducing U.S. women’s access to medication abortion.

Meanwhile, women living in countries (like Mexico) where abortion is highly restricted and drug distribution is less regulated have figured out that they can get pills that will end a pregnancy safely, and that they can take them at home without ever seeing a health care provider. As Francine Coeytaux of the Public Health Institute and Leila Hessini of Ipas reported recently in RH Reality Check, “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.”²  In most cases, the women are using misoprostol alone, without mifepristone, to cause an abortion.

Evidence and Information About Self-Use of Medications for Abortion

At a meeting the NWHN and these authors convened last fall, advocates and researchers discussed what we know about women’s self-use pills for abortion, what we don’t know, and what U.S. women might be able to do to meet their needs for safe abortion when and where clinical services are unavailable or inadequate.

Researchers at the meeting provided additional information on methods of self-induction of abortion broadly, and self-use of misoprostol specifically, including:

• Studies show that, when a woman takes misoprostol up to 9 weeks since the first day of her last menstrual period, it is 75-90 percent effective in ending the pregnancy completely within 2 weeks.³
• In the limited cases when medication abortion does not fully end a pregnancy, the follow-up treatment is usually the same used for miscarriage management, and is commonly available at medical facilities throughout the U.S., even in places where abortion care is not.
• Reasons women report having taken misoprostol on their own, or trying to end a pregnancy on their own through other means, include barriers to accessing clinic abortion -- such as parental notification laws or bans on insurance coverage of abortion -- and a belief that it would be more private and natural and less disruptive to their work and family obligations than a clinic abortion.⁴

Prior to the meeting, the Public Health Institute conducted a preliminary scan to determine what information about using pills to end a pregnancy is available on the Internet. The scan explored what a woman using common search terms in English and Spanish would find.

Searching for “abortion” does not necessarily lead to information about women using pills on their own to end a pregnancy. Searches using the key words “abortion pill” or “DIY abortion” lead to some accurate resources, such as those provided by Women on Web, an international on-line service that helps women gain access to safe medication abortion in order to reduce the number of deaths due to unsafe abortions.

The scan also found that searches for “Cytotec” (misoprostol’s brand name) have increased over time, especially in Texas, Louisiana, Florida, New York, and Oregon. Women on Web has also reported a recent increase in email inquiries about misoprostol from the U.S., and that searches of its website from U.S. users have increased dramatically. Similarly, a survey conducted at 8 Texas abortion clinics found that 6.9 percent of women reported they had attempted to end their current pregnancy before seeking clinical abortion care, and there was a trend toward more self-induction in places closest to the U.S.-Mexico border.⁵

Advocates Raise Self-Help Model Parallels and Questions

Meeting participants delved into a number of parallels from other aspects of health care, including drawing on the self-help history of the women’s health movement. One example cited was the effort to ensure that pregnant women who want to give birth at home get the information and support they need to act on that choice. Supporting homebirth as an option, it was noted, does not mean getting all women to abandon hospital births and the technological support that they offer but makes it possible for a woman to choose the birth setting that offers the advantages most important to her.

Similarly, a woman might prefer to take a drug to end a pregnancy without seeing a health care provider, even if the drug is less effective than what she would get at a clinic. This preference might be driven by a wide range of factors that the woman prioritizes, including: having more privacy, avoiding clinic protestors, being in her own home, taking the pills at a time when she has childcare available and/or doesn’t have to miss work, being more affordable, and fostering a greater sense of personal control.

Some meeting participants were excited about developing projects to provide women with accurate information and reliable sources of drugs to increase awareness that misoprostol can be used alone to end a pregnancy safely, and support women who want to pursue this option. There was particular excitement about exploring these activities in places where legal and economic barriers make it hard for a woman to get abortion care. Others raised questions about whether promoting the use of misoprostol alone would institutionalize a system of second class, less effective medical care for poor and uninsured women.

With the understanding that U.S. women are already using misoprostol for abortion outside the formal medical system, however, there was solid agreement among meeting participants that:

[Reproductive health, rights, and justice advocates] must do more to ensure that women have positive, safe and supported abortion experiences, whatever path they take to get that care.  An authentic commitment to reproductive rights and autonomy demands that we recognize and respect a woman’s ability to identify the option that is best for her and that we work to ensure that women who decide to take abortion pills on their own are fully informed and able to act on that decision in the safest possible way.

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This article draws on “Abortion pills in US women’s hands: Bold action to meet women’s needs,” a meeting report prepared by the Public Health Institute, Ipas, and the National Women’s Health Network with assistance from the Reproductive Health Technologies Project.  The full report is available here.

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Amy Allina, MA, is a leader in women’s health advocacy who spent 15 years on NWHN staff as Program Director and Deputy Director. Throughout her career, Amy has used her expertise to further women’s rights including serving on the board for the Universal Health Care Network and consulting for organizations like Planned Parenthood and the International Family Planning Coalition.

Read more from Amy Allina.

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