When the abortion pill was banned in Brazil, women turned to drug dealers

Last November, Xaiana, a 23-year-old university student from northern Brazil, began exchanging text messages with a drug dealer in the south of the country. Following her instructions, she made a transfer of R$1,500 to him, which would cover his daily expenses for several months. And then she waited three agonizing weeks for a blister pack of eight unmarked white pills to arrive in the mail.

When she took the pills, they had the effect she had hoped for: Xaiana had a medical abortion at home, with her boyfriend at her side, ending an eight-week pregnancy.

But she continued to bleed for weeks — an uncommon but not uncommon complication of abortion pills.

“Each time I got in the shower, it felt like a murder scene,” said she, who was afraid to seek help because the use of the drug she used, misoprostol, to induce an abortion is illegal in Brazil.

Xaiana feared that if she went to a clinic, the doctors might discover that she had induced the abortion and report her to the police. The penalty for those who practice abortion in Brazil is up to three years in prison.

“I’ve never felt so alone in my life,” she commented, asking to be identified only by her first name, for fear of being sued.

After seven weeks she went to a women’s clinic and admitted that she had terminated a pregnancy. They did a simple cauterization, and no one reported it.

Abortion rights advocates in the United States suggest that the country, following the repeal of the court ruling Roe v. Wade, will differ at one crucial point from the era before national legalization of abortion. Women seeking to terminate a pregnancy today have the option of medical abortion, using hormonal pills to induce the body to expel the fetus at home. It is a practice approved by the Food and Drug Administration.

But the wave of state laws that began to take effect after the Supreme Court’s decision last Friday, overturning Roe v. Wade, prohibits abortions of all kinds, including medical abortions. To get the pills legally, women will have to travel to states where abortion is legal to see a doctor, even if it’s by video or phone, as required by the FDA.

The trajectory of abortion pills in Brazil can offer insight into how abortifacient drugs can become out of reach and what happens when they do.

The original target of abortion bans in Brazil was surgical, but the ban was expanded after medication became more common, leading to a current situation where drug dealers control almost all access to pills. Women who come to them are not guaranteed the safety or authenticity of what they are taking. And if they experience complications, they are afraid to seek medical help.

Today, misoprostol purchased from India, Mexico and Argentina is sold on the black market for between R$1,000 and R$2,000 for the four pills recommended for an abortion. Meanwhile, a bottle of 60 pills costs less than R$80 in the United States.

It took a New York Times reporter less than a minute to find someone willing to sell her eight pills for R$1,500 in a neighborhood in Rio de Janeiro known for selling items on the black market.

“You buy a drug from a drug dealer. You don’t know what it is. The whole process becomes something frightening, confidential. It is no longer a drug”, commented Maira Marques, campaign director of the organization Miles for Women’s Lives, which promotes access to safe and legal abortion.

“This was supposed to be a simple, less complicated way to get an abortion, but now it’s turned to buying a contraband product instead.”

Abortion has been illegal in Brazil since the 1890s, although exceptions were made in the 1940s for pregnant women as a result of rape or incest, or when the pregnancy puts the woman’s life at risk. More recently, abortion has also been authorized for women whose fetus has anencephaly (when parts of the brain are missing).

But from the late 1980s, word got around that an ulcer drug, Cytotec, could “trigger menstruation.”

Indeed, it was the experience of Brazilian women using the drug for unauthorized purposes that led to research and the eventual global adoption of medical abortion as a less invasive and cheaper way to terminate a pregnancy, something that could increase women’s access. abortion, especially in developing countries.

Cytotec is misoprostol, which forms one half of the hormone combination recommended by the World Health Organization to promote medical abortion (the other half is mifepristone).

Mifepristone has never been approved for use in Brazil, and, unaware of the drug, women do not seek it on the black market.

Misoprostol is usually sufficient to induce a safe abortion; a study published in The Lancet found that 8% of women who use misoprostol to terminate a pregnancy experience complications, including bleeding and abdominal pain that require medical attention.

Misoprostol was sold in pharmacies without a prescription until 1991. After that, it was required, although the regulation of its issuance was not strict.

According to the gynecologist and obstetrician from Rio de Janeiro, Ana Teresa Derraik, the availability of the pills led to a sharp drop in the number of women who showed up in hospitals at risk of dying from infections or hemorrhages resulting from abortions that they had tried to induce with castor beans, bleach or hangers. . “It was a huge relief for those of us who didn’t think women should be punished this way.”

But misoprostol was attracting the attention of anti-abortion activists in Brazil and around the world. In 1998, Anvisa included the drug in the list of controlled drugs, alongside opiates, which implies that anyone caught importing or buying the product can be punished with up to 15 years in prison. International pharmaceutical companies that produce misoprostol were boycotted and stopped producing the drug. A small Brazilian company took over the manufacture of a generic version for exclusive sale to the Ministry of Health, for hospital use.

In 2006, the law that prohibited the distribution of misoprostol was strengthened, also banning the sale or publication of information about the drug on the internet.

In 2018, when Jair Bolsonaro was elected president, with the enthusiastic support of the Brazilian evangelical community, access to misoprostol became even more difficult.

International organizations that defend reproductive rights, such as Women on Web, previously mailed abortion pills to Brazil, and Brazilian feminist groups purchased and supplied them, with instructions for their safe use, said Juliana Reis, director of Milhas. Now that has practically stopped.

“Due to the political climate, it is much more difficult to get safe products and receive adequate care, because the networks that did this in the past are much more afraid,” said Sonia Corrêa, a researcher in reproductive health technologies in Rio de Janeiro.

New guidelines released by the Ministry of Health this month include the statement that “inducing abortion by telemedicine, using special control drugs, can cause irreversible harm to the woman.”

Dr. Helena Paro, a gynecologist from Uberlândia who during the Covid pandemic introduced telemedicine consultations for patients who would have legal abortions, described the guideline as “completely ideological and contrary to scientific evidence”. The WHO considers the practice safe.

In response to questions from the NYT, the Ministry of Health said the guidelines reflect the fact that “misoprostol is a medication for hospital use only, its use outside that setting is not permitted by law” and that the use of misoprostol for abortion via telemedicine would mean that women “would not have ready access to health services that could deal with the possible clinical or surgical complications arising from the procedure”.

Derraik said she has seen an intensification of enforcement of misoprostol use in hospitals where she provides abortion services to women who meet the legal conditions for termination of pregnancy and that she has observed a simultaneous increase in the level of investigation of women who report having had an abortion. spontaneous.

^{Translation by Clara Allain}