Mail-Order Abortions

In August 2004, Gabriela Flores, a 22-year-old farmworker in Pelion, South Carolina, learned she was pregnant. Flores already had three children—one living with her and two back in her native Mexico—and told a friend that she did not want to have another baby. Less than two months later, according to police reports, she took five pills that her sister had sent from Mexico. Six hours later, she miscarried her five-month-old fetus in her bedroom.
The drug she took was misoprostol, also known by the brand name Cytotec, a prescription ulcer medication introduced in the 1980s that can cause pregnant women to miscarry. This unintended side effect has quietly transformed the pill into an increasingly popular abortifacient. Since 2000, misoprostol has been used with little fanfare in conjunction with the abortion pill Mifepristone, commonly referred to as RU-486. (Mifepristone blocks the hormones that sustain pregnancy; misoprostol triggers uterine contractions that expel the fetus.) But recently, Cytotec's growing use as an inexpensive, relatively easy-to-obtain DIY abortion pill has forced pro-choice groups to decide whether they want to publicize a pill that may be the last, best option for some women.

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According to some abortion rights advocates, self-administered abortions using Cytotec are on the rise, particularly among low-income immigrant women such as Flores. "Women in the U.S. coming from countries with much more restrictive abortion laws may not understand they can seek a safe, legal abortion here," says Traci Baird, senior program adviser at the international reproductive rights organization Ipas. "You don't call Planned Parenthood when your experience is you call an aunt or sister or neighbor." In many Latin American countries, women can buy Cytotec directly from a pharmacist. In the United States, women must obtain it through more circuitous routes—often via relatives abroad or sometimes at local bodegas. But at less than $2 a pill, that is much cheaper than getting the drug from a clinic, where it is only prescribed with RU-486—a cocktail that can cost up to $650. The RU-486/Cytotec combination causes an abortion 95 percent of the time. Taken alone, Cytotec is about 85 percent effective.

Though more than 10 years of research has overwhelmingly shown that Cytotec is a safe way to induce abortion when administered correctly during normal pregnancies, the Food and Drug Administration has never approved this particular use. In 2002, Cytotec was relabeled to emphasize that "patients must be advised of the abortifacient property and warned not to give the drug to others." The FDA has endorsed its use with RU-486 and recognizes its off-label use by obstetricians to induce contractions in routine deliveries, a practice that remains controversial due to the risk of serious hemorrhaging in the mother and harm to the baby.

Officially, Cytotec remains just an ulcer medication. Yet as Dr. Byron Cryer, spokesman for the American Gastroenterological Association, explains, "Cytotec in 2006 is very infrequently—almost never—prescribed to treat ulcers," largely due to side effects such as diarrhea. Cryer says that the drug fell out of favor in the mid-1990s when more effective ulcer treatments such as Prilosec and Prevacid became popular.

Even though Cytotec's fortunes as a gastrointestinal drug have waned and off-label applications drive its current sales, its manufacturer, Pfizer, demurs when asked about its use in abortions. The company is clearly aware of Cytotec's unapproved applications, but, says spokesman Paul Fitzhenry, "We are restricted to talking about the product's approved indications." However, Fitzhenry says that Pfizer no longer actively promotes Cytotec as an ulcer drug and claims that the company does not track its sales figures. "This product is an older product, and its sales are very small"—reportedly less than $180 million annually.

While Cytotec is hardly a household name, its availability as an underground abortion drug poses a dilemma for women's health organizations that don't want to draw attention to self-induced abortion, which is illegal in 39 states. Nor do they want to give pro-life groups another target. "All of us kind of recognize that keeping it a little below the radar may be the best in terms of advocacy right now," says Silvia Henriquez, director of the National Latina Institute for Reproductive Health. National pro-choice groups such as NARAL and Planned Parenthood do not acknowledge Cytotec outside of its connection with RU-486. "Planned Parenthood's position is that women should be under the care of a physician when they're undergoing medication abortion," says spokeswoman Elizabeth Toledo. The National Abortion Federation, a coalition of abortion providers, links to instructions on the safest way to use Cytotec on its website, but it also emphasizes that abortions should be performed under a doctor's care.

Despite the political risks, the Latina Institute does openly discuss Cytotec use. "We are going to publicize it to the extent that we think it's safe to do so, because our concern is not only liability," Henriquez says, referring to the tension between maintaining the drug's low profile and advising women of its potential risks, which can include severe bleeding and toxic shock syndrome. "We can't not provide people with information because of the possibility there may be sanctions down the road." Sharon Stancliff, medical director of the Harm Reduction Coalition, which promotes the safe use of legal and illegal drugs, says that one benefit of educating women about Cytotec will be to encourage some to seek out medically supervised abortions instead. But, she points out, "politics and tact sometimes get in the way of being able to give everyone the information they need."

Despite the efforts to downplay Cytotec's use as an alternative abortion pill, the number of self-induced abortions involving it may be increasing in the United States. There is no definitive research on its use, but a recent study in the Journal of the American Medical Women's Association found that more than a third of Latina immigrants in New York City were familiar with the drug, and Baird says that anecdotally its use appears to be growing. And, occasionally, the law is catching up with the women who take it to end their pregnancies. After Gabriela Flores miscarried, a neighbor told the local sheriff that she had heard Flores had "given birth" and had disposed of the "infant." Flores spent four months in jail while the state weighed charging her with murder. She was ultimately charged with unlawful abortion, which carries the possibility of a $1,000 fine and two years in prison. Her case is pending.

Despite the legal and health risks, Cytotec will likely remain an attractive choice for many women—so long as it stays out of the spotlight. "The more restricted abortion access becomes, the more people will turn to the safest self-help methods," says Henriquez. "For many women, this will be the only viable option."

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