Accepting the global reality of "self-help" abortions
by Marge Berer
Coordinator, International Campaign for Women's Right to Safe Abortion
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. Many may just wish to be reassured that the pregnancy is over and everything is OK. Unlike women who have used an unsafe method (drinking a poisonous substance, inserting a twig or other object 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. Treatment for incomplete abortion can also be done by a clinician (e.g. a trained nurse or midwife) using vacuum aspiration. Some women 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 with directions for use, 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 a number of countries 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 almost 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 sorts of 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 becoming 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. And although they are the tip of the iceberg, they have made the news because the woman was prosecuted.
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 published a report with cases in 26 countries globally and many more have come to light 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".
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 is currently awaiting trial. She had purchased pills for her daughter and was reported when she took her daughter for a post-abortion check-up.
A woman in a rural area of Pennsylvania, USA, was jailed for 9-18 months, also 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 were 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. She 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 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 following graph shows the impact that medical abortion made in Sweden after 1991 as regards how early most abortions began to take place (80% before 8 weeks of pregnancy by 2011):
Impact of medical abortion in Sweden by 2011 
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 (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.  These restrictions are completely out of date.
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 there, 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 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 primary care setting for women to have abortions when home is not a safe place, or 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 develop 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 have previously been reported in the Campaign newsletter.
Notes and references
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.
National Institute of Health and Welfare. Induced abortions in the Nordic countries, 2011.