How a Group of Women Sails Past Countries' Restrictions on Reproductive Rights
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There are five deaths from drug-related reactions for every 100,000 prescriptions written for Viagra, according to the Journal of American Medicine. The drug has won near universal acceptance—social and medical—and 1 billion prescriptions have been written for it so far.
Conversely, just one out of every 100,000 medical abortions results in death. This means that inducing one’s own abortion with the use of drugs such as Misoprostol and Mifepristone is actually safer than inducing an erection with Viagra. And yet, women in the United States and around the world are not afforded this autonomy, and instead must combat global politics to gain some modicum of control over their bodies.
Try to imagine doctors standing over the shoulders of Viagra users. Such a scenario is unfathomable because it would mean a medical professional interfering with one of life’s most private activities, and a reasonably safe one at that. So why aren’t women spared this indignity?
Dutch doctor Rebecca Gomperts began Women on Waves (WoW), an Amsterdam-based non-profit, in 1999. The group travels by boat to countries where abortion is restricted or illegal and offers medical abortions to women on board the vessel. International law dictates that territorial waters only extend for 12 miles. Beyond that, a boat and everyone on it can operate under the laws of the vessel’s country of origin—in this case the Netherlands.
In the Netherlands, medical abortions using the drug Misoprostol, alongside the “abortion pill” Mifepristone, are legal. The combination is safe and 99% effective in inducing a reaction that is very similar to a naturally occurring miscarriage. In fact, Gomperts said, natural and chemically induced miscarriages are indistinguishable by medical examination. According to Dutch law, however, a doctor must obtain a special license to perform abortions past six and a half weeks, which means many physically eligible women cannot receive abortions on board.
Medical abortions are recommended for the first trimester of pregnancy, and can be safely administered by a woman nine weeks pregnant or less without the help of a doctor. Misoprostol is 90% effective when used alone to induce abortion and can be purchased over the counter in many countries besides the U.S. as a treatment for gastric ulcers. Given that 90% of abortions occur during the first 12 weeks of pregnancy, according to the World Health Organization, at-home medical abortions are viable as a primary method for terminating pregnancy. This is especially the case for women living in countries where abortion is illegal, unsafe, or otherwise inaccessible.
“A woman does not need a doctor to put a pill under her tongue, or to put four pills under her tongue,” Gomperts said. “Women have miscarriages by themselves in rural areas without a doctor all the time. People have no agency in any way when it concerns health issues, and it makes [doing your own abortion] sound like a fairy tale in the U.S.”
WoW cannot operate in the U.S. due to strict FDA regulations, but it’s no surprise that the U.S. WoW helpdesk consistently receives calls from desperate women. According to the Guttmacher Institute, in the first half of 2011, 162 new provisions were set in motion regarding reproductive rights in the U.S. Nearly half aim to limit abortion access. As it stands, American women can get medical abortions with Mifepristone and Misoprostol through Planned Parenthood. But legality does not equal accessibility.
For women living outside the 15 states where Medicaid covers abortion services, a medical abortion costs about $500, varying slightly state to state. A surgical abortion costs around $460 with general anesthesia and slightly less with a local anesthetic. Because Medicaid does not transfer from state to state this fee would apply to the majority of American women on Medicaid.
According to the Guttmacher Institute about 40 percent of poor women capable of bearing children receive Medicaid coverage. The majority of these women already have children or are pregnant, as most adults without children are not eligible for coverage. Given that the average monthly income for a family of three with Medicaid is $930, paying out of pocket for an abortion could mean spending nearly half of that monthly check. The drugs for abortion can also be purchased illegally on Internet pharmacies. Outside the U.S., access involves little more than a trip to the drugstore.
In many countries where abortion is illegal, women can still purchase Misoprostol from a pharmacy for as little as $1 in Pakistan, for instance, and $12 in Morocco. Gomperts said it might ultimately be easier for women in Africa to terminate their pregnancies than women in Missouri where abortion is technically legal. This is not to say that the struggle for reproductive rights is easier for women outside the U.S., but rather, that in countries with less regulation, side-stepping the law is simpler and safer in this case.
Julia Ellis-Kahana, a rising senior at Brown University, has been working as Gomperts’ assistant since October. Ellis-Kahana considers Gomperts her mentor and said working for her is like “working for superwoman.” As an American, Ellis-Kahana said she was deeply affected by the ease with which she was able to purchase Misoprostol in Morocco, where abortion is illegal.
“I was totally shocked by how easy it was to the extent that the next day I went to a different pharmacy and did it again,” Ellis-Kahana said. “After I got back to Amsterdam I saw an article that the last abortion clinic in Mississippi might close, and that made it more real for me. I had this realization that women in the state of Mississippi would have no access, while a week earlier I was able to walk into pharmacy and buy a medication that could be used to induce a safe abortion.”
With its ship campaigns to Ireland, Portugal, Poland, and, most recently, Spain in 2008, WoW intends to show women that they too can access Misoprostol as Ellis-Kahaha did, and use the drug at home. Announcing the ship’s approach must be done carefully and quietly; a phone number printed on the side of the vessel serves to announce its arrival and the group lets the press do the rest. The physical space of the yacht, Gomperts said, can only help so many women. Its purpose is as much to spread the word about medical abortions, as to be a site for abortion services.
“The ship has become a symbolic gesture because it’s visible and so unapologetic,” Gomperts said. “Offering abortion services without shame, where nothing is hidden, is powerful. People are always apologetic. They don’t talk about it. There’s a lot of self censorship even in countries where abortion is legal, and in some cases, abortions don’t happen because doctors don’t want to talk about them and are so afraid to be prosecuted.”
When Gomperts founded WoW in 1999 medical abortion had not yet been approved in the Netherlands, and she planned to provide surgical abortions on board. Before the group first set sail in 2001, however, medical abortion was approved, reshaping WoW’s procedure and, in some ways, its mission. Not only would WoW aim to provide medical abortions to women living in countries where it is illegal; it would also disseminate information to teach women how to perform at-home medical abortions themselves.
“The revolution of medical abortion and the empowerment it has given is huge, but when we first published information on how to do an abortion yourself in 2004 we were so scared,” Gomperts said. “There was a legal investigation, but we didn’t break any laws. The investigation concluded that if we used generic names we were free to give information.”
With a new focus on education, Gomperts founded Women on Web International, WoW’s sister organization, in 2006. The foundation is a referral service to put women without access to abortion in touch with doctors who can supply the necessary drugs. As political obstacles mount, circumventing the law is the only option for many women.
Just this past May, Turkish Prime Minister Tayyip Erdogan of the Justice and Development Party denounced abortion as murder. In July, Turkey banned Misoprostol, formerly quite accessible in pharmacies, and has moved to ban abortions past four weeks of pregnancy—a point at which most women may not even know they’re pregnant.
“You have this drug that really liberates, but the government response is to restrict access as they’ve done in Turkey,” Gomperts said. “In Nicaragua, where Misoprostol used to be very available, they banned it, and the same in Honduras, Brazil—that’s the backlash.”
Despite these setbacks, which effect massive populations of women, Gomperts sees strides being made elsewhere and said she measures success based on availability and education, rather than legality.
Just a few weeks ago, activists in Kenya set up a hotline (the eighth of its kind around the world) in Nairobi called "Aunty Jane," with the help of Women on Waves. Using a software service called Freedom Fone, a Zimbawean open-source initiative, the hotline describes how to have an abortion using Misoprostol, how to prevent postpartum hemorrhaging, and provides birth control and reproductive health information. Unsafe abortion rates in Kenya, among the world's highest, caused 35% of maternal deaths, according to WoW’s Web site. In its first two weeks the hotline received over 50 calls.
“It’s one of the best-kept secrets, so we have been training women’s organizations about how they can spread information and train other women on how to use misoprostol for safe abortions and births,” Gomperts said.
Misoprostal also treats and prevents postpartum hemorrhaging, which, according to WoW’s Web site one in 10 women will experience after giving birth, and one in 100 will die. For this reason the drug has been placed on the World Health Organization’s List of Essential Medicines. According to the Guttmacher Institute, abortions in Sub-Saharan Africa results in 460 deaths per 100,000 procedures. Now, thanks to WoW, a woman in Kenya in need of an abortion can simply dial a number to learn how to protect herself.
Gomperts believes it is only a matter of time before at-home medical abortion is recognized as a viable option. “It will be totally accepted, within a very short period that women can do abortion themselves, but the problem will be to make sure that the medicines continue to be available,” Gomperts said, perhaps hinting at the next great struggle to come.
Instructions for how to do a medical abortion or get a referral are available on Women on Waves’ Web site, in both regular and low-literacy versions. The instructions are also printed below.
Medical Abortion Procedure
1. The woman swallows one 200 milligram (mg) tablet of Mifepristone.
2.Twenty-four hours later, the woman lets 4 tablets of Misoprostol dissolve under her tongue. Each tablet contains 200 micrograms (mcg) of Misoprostol. The tablets are kept in place for 30 minutes until they are completely dissolved.
3. Four hours later, the woman puts 2 more 200-mcg Misoprostol tablets under her tongue and lets them dissolve as before.
All the doses must be taken as directed, even if bleeding has already started. Following this process for how to do an abortion with pills ensures that the abortion will complete correctly.