20/07/2015 Comments Off on Accepting the global reality of “self-help” abortions
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 to 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 hangar 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 ‒ which in the past killed many women. No, very few of them have a major complication. However, if they have used misoprostol alone because mifepristone was not available, some of them 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 better 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 women 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, the complete abortion rate up to 9-10 weeks of pregnancy is around 96-98% ‒ 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, Asia and Eastern Europe. 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 ideal, and everyone involved in supporting the legitimacy of self-help abortions knows that well. For one thing, abortion is subject to criminal law everywhere, and 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 is a major issue, as there are many websites offering the pills that are not trustworthy. Such pills may not be of a high quality, or they may contain only small amounts of the medication. Some may even be fake. Moreover, if misoprostol pills do not remain vacuum sealed in a blister pack until soon before use, they may lose some of their effectiveness. Hence, the source and quality of the pills is crucial. Some safe abortion hotlines, knowing these problems, have helped pharmacies to stock the right pills. In at least one case, a group has even started their own pharmacy.
Nevertheless, even with these limitations, the numbers of deaths from complications of unsafe abortion have been falling rapidly in the past 10-15 years around the world ‒ not only because national laws have been changed for the better and in some cases some safe services have been set up, but also 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 until recently it has been ignored where the legal practice of abortion is the norm, e.g. in North America, Europe or Australia. This ignorance 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. Cases that have emerged to date have mainly been of women who are too late for a legal abortion, or who 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.
But what has happened is that a few of these women, who have used the pills on their own, have sought medical help after self-inducing, and that is how the trouble has started. Many reproductive 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 provide abortions, and like some of their brethren in Latin America and elsewhere, a few of them are reporting women to the police. In 2013, the International Campaign for Women’s Right to Safe Abortion reported cases in 26 countries globally and many more have been reported since.
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 has responded by bringing the criminal law down on the heads of those who have been “caught in the act”.
Officials have begun to notice 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 was reported when she took her daughter for a post-abortion check-up. She is currently awaiting trial.
A woman in a rural area of Pennsylvania, USA, was jailed for 9-18 months for purchasing pills for her daughter.
A young couple in Australia were 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 charges were dismissed.
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 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, it transpired that this charge was not permitted.
In the UK, in 2009 a woman who sought an abortion beyond the 24-week time limit, and was turned down for help by at least two clinics, successfully purchased medical abortion pills through the internet and terminated her pregnancy. Having sought post-abortion care, she was reported to the police, charged and in 2012 was 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.
In 2015, 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, the length of the sentence described as a warning to others. One can only hope this sentence will be reduced on appeal as well. In this case too, the charge was to do with the sale of a “noxious substance” under an 1861 law, the Offences against the Person Act, that is still on the statute books in the UK, 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 a newspaper article describing the case as saying: “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.”
Fearmongering that medical abortion pills are dangerous, and the “hook” of ‘using a noxious substance’ from the British 1861 Act to hang criminal charges on and sentence women to prison, wilfully ignores the fact that mifepristone and misoprostol are not noxious substances but are on the WHO Essential Medicines list. Medical abortion pills, with medical involvement and without it, are safe, and they are effective as soon as a woman misses her period, meaning abortion can take place much earlier than in the past.
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 that women are having abortions “outside the system”. In Ireland, the 2014 abortion law, which has allowed only a handful of legal 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’. This was meant, one can only assume, to warn women in thinly veiled terms not to purchase pills over the internet. It hasn’t worked. In the USA, 38 states require an abortion to be performed by a licensed physician, 21 require an abortion to be performed in a hospital after a specified point in the pregnancy, and 18 require the involvement of a second physician after a specified point.
Prosecution is very threatening for individual women, but at the same time, pursuing individual women like this is frankly absurd. Nothing is going to stop medical abortion pills from being manufactured, distributed, purchased and used widely on a global scale. It has been happening since at least 1988 in Brazil, even though it has long been banned, and the practice spread rapidly from there because it meets a huge unmet need among the one-in-three to one-in-five women on earth who need an abortion in their lifetimes, 42 million of them globally every year.
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 should women wait weeks or months and even 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 getting health systems to support women’s access to safe medical abortion without barriers, restrictions or delays. It means abolishing the criminal laws against abortion in every country.
It is time to let women buy medical abortion pills over the counter and have abortions as early as possible in the privacy of their own homes. It is time to fund nurse- and midwife-led safe abortion information hotlines and community-based services to ensure this happens in the safest possible way.
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 10-12 weeks of pregnancy. It must not be forgotten that not all women are organised or aware enough to have abortions very early, though the great majority can and do. In some cases, women 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 safe abortion at the woman’s request is available when they need them.
All the cases mentioned here were reported in the newsletter of the International Campaign for Women’s Right to Safe Abortion. To receive the newsletters, endorse and join the Campaign: www.safeabortionwomensright.org.
To sign the petition calling on the Northern Ireland government to drop the charges against the woman who bought medical abortion pills for her daughter: www.thepetitionsite.com/takeaction/716/597/066/
Posted 20-07-15. Revised 09-08-15 and 12-08-15.
 Cases in El Salvador and Mexico are frequent, and in Chile, for example, 73 convictions for abortion since 2005, all of poor women, were identified by the Public Defender in 2014. http://www.theclinic.cl/2014/06/12/como-opera-la-justicia-en-los-casos-de-aborto-la-historia-de-tres-condenadas-por-el-delito-de-las-mujeres-pobres/#commentsSection
 Abortion in the Criminal Law: exposing the role of health professionals, the police, the courts and imprisonment internationally. International Campaign for Women’s Right to Safe Abortion, October 2013.
 http://www.walb.com/story/29263746/official-5-month-old-fetus-lived-30-minutes-after-abortion-pill-delivery ; http://www.slate.com/blogs/the_slatest/2015/06/09/georgia_woman_charged_with_murder_for_taking_abortion_pill.html ; http://www.slate.com/blogs/the_slatest/2015/06/10/kenlissa_jones_case_murder_charge_against_woman_who_took_abortion_pill_dropped.html
All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!
11/07/2012 Comments Off on All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant!
Marge Berer, Editor, Reproductive Health Matters
I was among the first generation of women in the 1960s to experience the miracle of the pill just at the age when I was wanting to start having sex. All I had to do was take a pill every day, I was told, and hey presto, I didn’t have to worry about getting pregnant if I didn’t want to, and it worked! But oh, if only it had all turned out to be that easy! Like one in three women in the UK today, a country where contraceptive prevalence is almost as high as it can get, I needed an abortion several years later. Again, I was lucky, the 1967 Abortion Act meant I was able to get a legal abortion. The lesson is simple – while contraception continues to be a miracle, because it helps people not to have children if and when they don’t want to, it is not enough on its own and it never has been.
Family planning has been out of the news for a long time, and suddenly it’s back. Welcome!! Bring out the red carpet, and I mean it!! Women and men need contraception now as much as they have ever done, and young women and men who are beginning to explore their sexuality together need contraception and condoms more than anyone. But there has been a lot of water under the bridge since family planning was promoted as the cure-all for the world’s ills in the 1960s when the pill came out, and everyone needs to study that history anew so that the same mistakes, of which there have been many, and the same narrow vision, are not repeated.
My generation of women’s health activists, along with a whole generation of researchers, service providers and policymakers who brought their knowledge together at the International Conference on Population and Development in 1994, got the world to recognise that the need for the means to control fertility, which is as old as history itself, was part of a much broader set of needs related to reproduction and sexuality, and that these were inextricably connected. These include: being able to have sex without fear of negative outcomes, being able to have sex if and only if we want to and only with whom we want to, being able to have the children we want, being able to get pregnant at all, being able not only to survive pregnancy but also still be in good health, being able to have a safe abortion without fear of death or condemnation when an unwanted pregnancy occurs, being able to protect ourselves from sexually transmitted diseases, and being able to get treatment for all the many causes of reproductive and sexual ill-health, which start with menstruation and menstrual problems, and continue into old age with things like breast and prostate cancer and uterine prolapse.
There is indeed a huge unmet need in today’s world, but the unmet need for contraception is only a fraction of the unmet need for sexual and reproductive health, and for sexual and reproductive rights. The results we should be working for encompass every aspect of the issues I have just named, and those in turn must be seen in the even wider context of the right to health, social justice and an end to poverty and violence – which were the real point of the Millennium Development Goals – not the measurable targets.
I will be blogging about these issues in the light of the FP Summit over the next weeks – watch this space!
15/02/2011 Comments Off on Medical abortion in Britain and Ireland: let’s join the 21st century!
Medical abortion – popularly known as the abortion pill – has been in the news almost non-stop for several months now in both Britain and Ireland, though for very different reasons. That’s good news because more women are getting to hear about it. Although the method has been around since the late 1980s, most women didn’t start hearing about it until the last ten years or so. But as it’s become more known, so has controversy begun to brew around it. Why? Because the abortion pill potentially puts the control over abortion into women’s hands, and a lot of conservative men and women aren’t sure they like that.
Medical abortion, when used from the time a woman first misses her period until up to 9 weeks of pregnancy (dated from the first day of the last menstrual period), is more than 95% effective, and the earlier it is used, the closer to 100% effective it is. The method consists of two kinds of medication.
First, mifepristone (one 200mg pill) is taken by mouth, swallowed with some water. Then, misoprostol (four pills of 200mcg each) is used 24–48 hours later. These 4 pills can be inserted high up in the vagina, which a woman can do herself, or a nurse or doctor can do for her. Or, they can be taken buccally, that is, placed inside her mouth, two on the inside of each cheek, where they will slowly start to melt and should remain for up to 30 minutes, and then whatever is left should be swallowed with water. Within 4-5 hours later, the woman will (in almost all cases) have a miscarriage.
Spontaneous miscarriages almost always happen at home; women cope with them. There will be menstruation-like bleeding and fluids, but far heavier than a period, more with every week of pregnancy, often with clots. When the embryo is passed with the bleeding, the bleeding will slowly become lighter. It is likely to continue for several days, or somewhat longer, and then gradually stop. The woman will experience cramps and commonly nausea, and she should take ibuprofen for the pain when the cramping starts and more when needed.
For most women, at this early stage, this will terminate the pregnancy. This method is both safe and, yes, easy. Easy for women, and easy for the health service provider, who in almost all cases only has to give the woman information, give her a choice between this method and an early aspiration abortion, and then give her the pills (and insert them vaginally for her if the woman prefers that). With training, this person can be a family planning nurse, a regular nurse, a midwife, a GP, or if no one else is allowed, a gynaecologist. 
Three things may go wrong. First, nothing may happen and the woman will need to take a repeat dose of four more 200mcg misoprostol tablets, or opt for an aspiration abortion. Second, bleeding will start and the embryo will be expelled, but the abortion will be incomplete and treatment will be needed to complete it, again a repeat dose of four more 200mcg misoprostol tablets or aspiration. Third, very very rarely, bleeding will become very heavy and the woman will need immediate medical treatment to stop it.
Because these three things may happen, even though they will not happen for the great majority of women, access to medical treatment is very important. Moreover, access to assurance that everything is going OK is also important for women using this method for the first time. Waiting is involved and women can become nervous, and may want someone to talk to, so an abortion phone line can be an important part of providing this method in a way that meets women’s needs.
However, for the vast majority of women, early medical abortion consists of taking the tablets as prescribed, having a miscarriage, and it’s over.
So what’s going on?
In both the North and South of Ireland, where almost all abortion is illegal, women have been crossing the border and coming to Britain or other European cities for a safe, legal abortion. But that costs a lot of money and many women in Ireland can ill afford it. It may take them precious weeks or even a month or two to raise the cash and arrange the trip and the abortion. And meanwhile their pregnancy is advancing. And since the financial crisis started, more women are reporting difficulties in coming up with the money necessary to access abortion services, according to the Irish Family Planning Association (IFPA).
Women in Ireland have discovered medical abortion, because the women’s grapevine and the internet are more powerful these days than the 19th and 20th century Irish laws prohibiting abortion. Pills can be transported all sorts of ways, including through the post. And clearly that is now happening. The newspapers in Ireland picked up the story recently of a Chinese woman who brought medical abortion pills into Ireland and was selling them over the counter in her supermarket. Shock, horror! How could this be allowed to happen, and she has had to pay a €5,000 fine and €5,500 costs. I hope the pro-choice movement in Ireland is brave enough to come out publicly and support her.
But the fact is that in almost every country in the world across Latin America, Asia and many parts of Africa where abortion is still mostly illegal, medical abortion pills are available in pharmacies, drug shops, and street markets. This is far from an ideal situation, and no one who supports women’s right to a safe, legal abortion thinks it is fine as it is.
For a start, only misoprostol tends to be available on its own, and it is not nearly as effective (even with the optimum dose) as it is when taken in combination with mifepristone. Secondly, women and drug sellers may not know what the correct dosage and procedure to follow are. Thirdly, when things go wrong, women may or may not have access to medical back-up. However, medical abortion is reducing the number of deaths from unsafe abortion in many of these countries, because the method does not kill women in the same way as unsafe, invasive methods, such as putting a twig or a rubber hose up the vagina into the uterus, did.
The use of medical abortion pills in Ireland is also not ideal, though women in Ireland who know enough to have accessed the pills are also very likely to know where to ask for help if needed, and they will get that help. Everyone who is pro-choice would far prefer this situation to be regularised. However, that requires abortion to be made legal and medical abortion pills made available through national drug registration and health service provision. How likely is that, do you think, in the near future?
Well, it is possible after the recent European Court of Human Rights judgement (16 December 2010)– that Ireland’s strict law violated the right to life of a pregnant woman suffering from cancer – that Ireland will liberalise its abortion law, at least to allow abortion when the health and life of the woman are at risk. But the North? A more reactionary, anti-women set of male politicians in charge of the law would be hard to find.
It is ironic that women can cross the border and leave Ireland for an abortion in Britain, paying anything up to £2000 for the privilege, and do so legally (which it must be added Irish women fought for in the courts up to European level in the late 1980s/early 90s), yet medical abortion pills cannot cross the border into Ireland without the customs seizing them – do they not have anything better to do, like seizing seriously harmful drugs such as heroin? – and the anti-abortion movement making their usual hysterical remarks about the pills being “deadly” and so on and so forth, blah blah blah.
When will these guys get over it? As Agata Chelstowska from Poland says in an article I’m about to publish in RHM: “Is it possible that the purpose of the law is not to reduce the number of abortions, but to serve a purely political role, as a symbolic achievement of the Church and right-wing parties?” Yes, it is!! And the name of that achievement is control over women for its own sake. Unfortunately, women don’t accept that anymore, guys, and medical abortion pills are helping us to bypass all that medieval misogynistic control freakery.
Meanwhile, back in Britain…
Yesterday, in 21st century Britain, where abortion has been legal and available since 1967, you would have thought the “guys” involved had got over this issue and accepted that women need abortions, and always will, and that it is the job of the health service to make them available as early and as safely as possible, based on the best evidence-based practice.
We hear a lot about evidence-based practice today. It’s meant to be what everyone follows because it shows you what is best to do to achieve the ends you want and what can go wrong, so you can avoid it – in lawmaking, in economic policy, in health care. Ha ha. Are you watching the coalition government? Never heard of it. Or rather, mouth the words and then ignore the evidence and do something else.
Yesterday, a High Court judge ruled in a case brought by Bpas that the regulations related to the 1967 Abortion Act, which say that the treatment for abortion must be carried out in hospital premises, would have to be amended to allow women to use the second half of the medical abortion regimen (the misoprostol pills) at home.
The judge recommended (and many thanks to him for that, it was the best he could do), based on the substantial evidence provided by Bpas, that the government could amend the regulations, which were written at a time when all abortions were surgical procedures and carrying them out in hospital premises was intended to remove them from the backstreets to make them safe. We have long ago moved on from that, and the regulations need to move on too.
“Bpas is very pleased that the Hon Mr Supperstone J has ruled that Section 1(3A) of the Abortion Act as amended in 1990 enables the Secretary of State to react to “changes in medical science” as it gives him “the power to approve a wider range of place, including potentially the home, and the conditions on which such approval may be given relating to the particular medicine and the manner of its administration or use.” …
Since we brought our case to court, the Royal College of Obstetricians and Gynaecologists has produced new guidelines noting the weight of evidence in support of home-use of misoprostol for abortions up to nine weeks and the importance of giving women choice of method. This new, evidence-based guidance was supported by the Department of Health. Given Health Secretary Andrew Lansley’s commitment to evidence-based medicine, patient choice and the liberation of clinicians, we assume he will wish to employ the powers the ruling highlights rapidly so that doctors may provide women legally accessing early abortion with the best possible care.”
What will Andrew Lansley, the Tory Secretary of State for Health, who is planning to destroy the NHS, do? Hard to tell. He’s behind a radical blueprint to privatise and break up the NHS in England, which those who understand how the health service functions, from the medical professional associations to the editors of the BMJ and Lancet, are sure will cause chaos and destruction and cost £3 billion to implement. Does he also have the courage to amend this out-of-date regulation, to bring it in line with current practice in the USA, Sweden, Norway, France, Switzerland, and elsewhere? Probably not, because the anti-abortion fringe in his own party are likely to want to make mincemeat of him if he tries.
Ironically (and this is looking like the century of irony), in this same week the Roman Catholic Diocese of Phoenix, Arizona in the USA, castigated a Catholic hospital for allowing an abortion that saved a woman’s life.
Welcome to the 21st century.
 Why should we believe pain and suffering are good for women? Only misogynists and anti-abortionists think that.
 Bpas provide abortions for the NHS and for women not eligible for NHS abortions.
Chelstowska A. Stigmatisation of abortion and commercialisation of abortion services in Poland: turning sin into gold (working title). Reproductive Health Matters 2011;19(37). (In press)
Donnellan E. More find it harder to afford abortion services. The Irish Times. 29 June 2010.
Bpas disappointed its interpretation of Abortion Act is not deemed viable, but ruling shows Lansley now has power to ensure women receive best possible care. Bpas press release, 14 February 2011.
Hamilton S. Deadly abortion pills on sale in Ireland. Sunday Mirror (Ireland). 2 February 2011. [no link available]
Jacobson J. European Court finds Ireland’s abortion law violates rights of pregnant woman with cancer. RH RealityCheck. 16 December 2010. At:
Jordan A. Woman charged with selling illegal abortion tablets in supermarket. Medical Independent. 27 January 2011.