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In South Texas, Women Cross the Border for Abortion Drug

Posted: Aug 12, 2012

Photo by Reynaldo Leal / The Texas Tribune

MCALLEN, Texas — In this Catholic stronghold, where abortion is deeply stigmatized, reproductive health providers relay stories of women going across the border to Mexican pharmacies to find a drug they can use at home in the hope of terminating unwanted pregnancies.

But the providers say that often the unregulated pharmacies are not giving proper instructions for the drug, misoprostol, which does not always give women the result they seek. The health providers worry that by relying on the drug, which is not prescribed on its own for abortions in the United States, women are ignoring important follow-up care.

In Texas, there is no way of knowing how many women have gone to Mexico to get misoprostol to try to self-induce an abortion. But reproductive health providers say they know that it happens.

“I’m sure it’s always occurred, but we’re noticing it more,” said Kristeena Banda, the director of Whole Woman’s Health in McAllen, one of two Rio Grande Valley abortion providers. “Sometimes, a few times a week, women come in to ask for a pregnancy test. They’ve taken the pills, but they’re still seeing symptoms of pregnancy.”

Misoprostol, which requires a prescription in the United States, is not available alone as an abortifacient in American pharmacies. Researchers say that the brand-name form of the medication, Cytotec, has been available over the counter in Mexican pharmacies since 1985. The drug maker Pfizer labels Cytotec as a treatment for gastric ulcers. Generic versions have followed.

The drug is available in many small, independent Mexican pharmacies, but the employees dispensing it often lack formal training. Because abortion is illegal outside of the country’s capital city, they are also wary of providing information on how misoprostol should be used for that purpose.

The World Health Organization has confirmed that using the drug alone as an abortion method can be highly effective — but only if patients take the correct dosage within the first nine weeks of gestation.

In the United States, misoprostol is used for abortions when paired with the drug mifepristone. Clinics offer this “medical abortion” as an alternative to surgery. The process includes taking mifepristone in-office to stop the pregnancy’s growth, followed by taking misoprostol at home to clear out the uterus. A follow-up appointment is necessary to confirm the pregnancy has ended. The method, which must be supplied by a physician, is considered more effective than using misoprostol by itself.

Abortion rights groups are concerned that a lack of awareness about access to abortions in a clinical setting — as well as financing that is available to the poor — could lead more women to go underground and risk their health.

The region is already grappling with serious financial challenges in women’s health. In 2011, lawmakers deeply cut financing for family planning for low-income women. And a new law that requires women seeking an abortion to receive a sonogram 24 hours ahead of an abortion — requiring at least two separate visits to the abortion clinic — may be prompting some to seek alternate abortion methods.

Without proper instructions, Ms. Banda said her clinic’s patients have told stories about how they ingested misoprostol in varying amounts — some would take an entire bottle within days— based on what friends or family had told them.

“They wanted the least invasive option, both medically and personally for them,” Ms. Banda said.

Ms. Banda said it is likely that her clinic is only seeing a fraction of the women who are using the drug. South Texas has a concentration of immigrants who were born in Latin American countries, where self-medication is a common practice and abortion is outlawed or culturally stigmatized.

Mexico City legalized abortion in 2007, but the historical lack of access throughout the country has given rise to misoprostol for its unlabeled use, especially in poor areas where pharmacy regulations are largely unenforced, according to a 2010 study in International Perspectives on Sexual and Reproductive Health.

Dan Grossman, an obstetrician-gynecologist who is vice president for research at Ibis Reproductive Health and an assistant professor at the University of California, San Francisco, stressed that misoprostol is a safe drug used to prevent bleeding during labor and to control uterine contractions.

“The biggest risk for these women [trying to self-abort] is that it’s not going to be effective and that she could potentially have a continuing pregnancy and doesn’t get a follow-up,” he said.

From a public health perspective, Dr. Grossman said it is “never ideal” when women go underground, because while obtaining misoprostol in Mexico is easy, getting accurate instructions on how to use it is a challenge.

In July, at one of the many pharmacies lining the main street in Progreso, a Mexican town across from Weslaco, Jose Alfredo Acosta was selling Cytotec for $153 per box. The rectangular package contained 28 pills, each measuring about 200 mcg. The insert did not include directions for self-induced abortion, but Mr. Acosta said he knew that was why many women purchase the medication.

“If I see that a girl is too young, I won’t sell it,” he said, citing stories he’d heard of girls hemorrhaging after using the pills. “I try my best to explain the consequences, but there’s only so much I can do.”

Like many Progreso pharmacy workers, Mr. Acosta did not hold a pharmacy degree or a license, but he is allowed under Mexican law to dispense Cytotec. Asked about the proper dosage, he reluctantly suggested that patients take one pill every two hours — 18 tablets in all.

According to the World Health Organization, the recommended dosage of misoprostol if used alone for an abortion should be four tablets (800 mcg) every three hours for a total of three doses or 12 tablets.

Gabriel Noguez, another unregulated pharmacy worker who works down the street from Mr. Acosta, said his shop sold Cytotec for $241.80 per box.

“It sells. That’s the problem,” he said. “But I won’t tell them how to take it. I just say, ‘You might have problems later.’”

Dr. Grossman said he is concerned the misoprostol issue is a symptom of the barriers women face to get a legal abortion in the United States, especially for those who are determined to end their pregnancies.

In a 2010 study he published in the journal Reproductive Health Matters, a 30-year-old Texas woman reported that she started taking misoprostol in her 13th week of pregnancy. She bled so badly that she had to be admitted to a hospital.

The woman said cost was the factor behind her decision to try misoprostol instead of visiting a clinic. But she had no regrets.

“If I was put in the exact situation all over again? I’d probably do it again.”

This story was made possible by a grant from Atlantic Philanthropies, and was produced as part of the Women Immigrants Fellowship Program, a project of New America Media. It was also published in The New York Times.

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