The Underground Abortion Pill

Prescribed to treat stomach ulcers, Cytotec is inexpensive ($2 per pill), easy to handle (no refrigeration) and simple to take (no needles). The drug does, however, have a serious side effect: It can induce abortion.

That fact is widely known in Latin America, where abortions are illegal and where women have been taking Cytotec, against the law and pharmaceutical regulation, to end pregnancies for more than a decade. U.S. health experts report that Cytotec is being used as an abortion method in this country, too, mostly among low-income Latina immigrants. Because they often lack the resources to navigate the American medical system, such women can be discouraged from considering safer, doctor-supervised options.

Any abortion carries risk, but women who attempt the procedure by themselves with Cytotec are assuming considerable risks. They may not know the proper dose to use, how far along their pregnancy is, and that dangerous heavy bleeding can result. "Women who self-induce may not know when to get help," says Dr. Emily Godfrey, family medicine professor at University of Illinois at Chicago. "They frequently delay their medical care and can suffer serious consequences, including death."

But when used in the first trimester, Cytotec, often referred to by its chemical name misoprostol, is less risky than other underground abortion methods. The drug works by loosening the cervix and causing the uterus to contract. Women who have taken Cytotec “are not necessarily completing [the abortion] on their own, but they're initiating the process," explains Godfrey, who also serves as a board member of the Association of Reproductive Health Professionals. "They often show up to emergency rooms, are told they are having a spontaneous miscarriage and are offered a completion."

The FDA warns: Risks associated with misoprostol include severe vaginal bleeding, uterine rupture and patient death. If the fetus survives, birth defects are possible. There are also legal consequences: Thirty-nine states require that abortions be performed by a physician, according to the Guttmacher Institute. In 19 states, abortions must occur in a hospital beyond a certain point past conception, for example, 12 weeks in Massachusetts.

In January near Boston, a Cytotec abortion gone wrong recently made national news.

An 18-year-old Dominican immigrant in Lawrence, Mass., was arrested for "procuring miscarriage" with misoprostol. Two days after allegedly taking Cytotec pills when she was 25 weeks pregnant, Amber Abreu gave birth to a 1.25-pound baby who lived four days. Prosecutors contemplated, but decided against, charging her with murder; abortion is illegal in Massachusetts after 24 weeks. Still, Abreu faces up to seven years in prison.

Despite the case, Cytotec-induced abortions largely remain hidden from mainstream America. No data exist for how many occur, but a study of primarily Latina women in New York City found that 37 percent were familiar with such usage, and that 15 percent knew someone who had taken it. Reasons cited for choosing misoprostol included ease of use (63 percent) and low cost (16 percent). The report was published in 2000 by the Journal of the American Medical Women's Association (JAMWA).

In 1988, the Food and Drug Administration approved Cytotec as an ulcer treatment. Manufactured by Pfizer (originally by Searle), the pill protects the stomach lining and inhibits acid secretion. Pfizer's patent expired in 2000 and generic misoprostol is now manufactured here and abroad.

Because of its effect on the cervix and uterus, misoprostol has several gynecological applications: Softening the cervix for diagnostic procedures, stopping postpartum bleeding and inducing full-term labor. But because the FDA approved Cytotec only to treat and prevent ulcers, gynecological usage is "off label." The Cytotec label even warns pregnant or possibly pregnant women not to take it due to miscarriage risk.

But doctors who prescribe misoprostol off-label for gynecological purposes point to studies of its safety and effectiveness. “ ‘Off-label’ does not mean incorrect use or malpractice," explains Dr. Beverly Winikoff, a professor of family health at Columbia University. "It's standard medical practice in this country." The American College of Obstetricians and Gynecologists has endorsed misoprostol to induce labor, and a 2005 study in the New England Journal of Medicine found the drug can safely clear the uterus after a first-trimester miscarriage. No group in this country endorses misoprostol alone as an abortion drug; there is a legal and more effective alternative—RU-486.

When the FDA approved mifepristone, or RU-486, in 2000, the agency underscored Cytotec’s link to abortion. The label on RU-486 instructs patients—in the first trimester and under a doctor's care—to take Cytotec orally two days after ingesting RU-486 in order to help the uterus empty. According to the label, this drug combination is 92.1 percent effective.

Whether medical or surgical, abortions are illegal, with rare exception, in Central and South America. Misoprostol has become known in those countries as a private, effective and inexpensive option. "Women can readily get misoprostol” without a doctor’s prescription, says Godfrey. "I asked at different pharmacies in Nicaragua, and the cost was 60 or 70 cents a pill." In the United States, Cytotec is available by prescription only for about $1.75 per pill, less for generics.

Women in the United States procure Cytotec from friends (either in person or via mail) or the black market. Abreu reportedly received her pills from a visitor from the Dominican Republic. Because such abortions are illicit, studies on safety and effectiveness are less common than for the RU-486 regimen, but misoprostol-only procedures are considered less effective.

But medical data obscure the true story of these underground abortions, says Jessica Gonzalez-Rojas, director of policy and advocacy at the National Latina Institute for Reproductive Health (NLIRH). "The real issue," she says, "is that Latinas, women of color and immigrant women face tremendous barriers to reproductive health services." Language, culture and money can all be factors. A first-trimester abortion, including one induced with RU-486, usually costs from $400 to $600, a steep sum for someone with limited financial resources.

According to the NLIRH, 56 percent of low-income Latinas of reproductive age do not have health insurance. Women with insurance do not use misoprostol alone to induce abortion, because RU-486 is legal and more effective. They also have better access to birth control. But Cyotec-induced abortions are, as Winikoff puts it, “a tale of marginalization, stigmatization and desperation."

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