Medical Abortions and the Internet

by Clíodhna Ní Chéileachair

Early last summer, Facebook removed Women on Web’s page for ‘promoting drug use’. The Amsterdam-based organization connects women with doctors who prescribe the pills necessary for medical abortions and provides information on taking abortion pills, on contraception and on accessing abortion services in states where access to safe abortions is restricted or illegal. This followed an earlier interaction in which Facebook removed a photo of the organization’s founder, Rebecca Romperts, superimposed with instructions on the use of the pills. Facebook later apologized and reinstated the Facebook page, claiming that the removal was an error, and that the page served Facebook’s function of allowing individuals to organize and campaign for the issues that matter most to them.

Leaving aside the question of whether it was indeed an error, WoW have never existed without controversy. In February of last year, their sister organization Women on Waves made headlines when their boat was detained by the Guatemalan authorities while campaigning in Guatemalan waters. Women on Waves provides medical abortions to women once they are in international waters and thus operating under Dutch law, which allows abortions up to 21 weeks. Both organizations will provide access to abortion services up to 9 weeks, using a combination of medicines – misoprostol and mifepristone – which together induce abortion. The WHO estimates that the drug combination is used by 26 million women globally per year and is recommended as an abortifacient up to 9 weeks of pregnancy. Women on Waves are one of many organizations that aim to allow women to access abortion services that are either explicitly illegal, or practically unavailable in their home countries. There are risks associated with taking the drug combination, but these are minimal, and far riskier is the danger of leaving women with access to illegal abortions which is often the reality of full abortion bans. In Guatemala, 65,000 women have illegal abortions every year, with a third of that number admitted to hospitals from complications associated with the backstreet procedure. A medical abortion before 10 weeks is safer than childbirth, and as safe as a natural miscarriage. Both drugs have been on the WHO’s list of essential medicines since 2005. Studies show a high level of effectiveness in self-sourced and administered abortion pills, such as the service offered by Women On Web, and outcomes generally compare favorably with in-clinic administration. Underscoring the importance of safe access to the drug combination, use of the pills is often studied as a self-administration method alongside getting punched in the stomach, taking herbs or homeopathic medicines, deliberately taking a high dose of hormonal pills, alcohol and illegal drugs.

Notwithstanding this and the myriad of other uses each drug has in isolation of the other, some women cannot effectively avail of WoW’s services as customs in their home country will impound the medicines if detected, and if possible, arrest the woman in question. Even in countries where abortion is legal, ‘conscience clauses’ and ‘refusal clauses’ can limit access to abortion in a manner that may act as an effective bar to accessing a medical abortion with pills. The Guttmacher Institute calculates that there are 6 states in the US with so-called ‘refusal clauses’ on the state’s books which explicitly apply to pharmacists; another 6 have refusal clauses so broadly drafted that they may apply to pharmacists. More expansively, misoprostol is often prescribed off-label to complete miscarriages as an alternative to waiting the often lengthy periods over which a body will expel uterine lining itself. Refusal clauses do much more than protect the conscience of the medical professional: they can unconscionably limit a woman’s right to healthcare, expanding far beyond the provision of abortion services and into post-pregnancy medical care. Coupled with the geographical limitations on the average woman seeking misoprostol for either reason, conscience clauses act as a very real obstacle to the full realisation of medical care that is, on paper at least, legal.

The issue is even more complex in cases where the medical practitioner in question is expected to perform an abortion themselves as opposed to prescribing a drug that may bring about that result. High rates of conscientious objection can lead to effective abortion bans. In certain regions of Italy, for example, it is effectively impossible to access abortion services despite abortion care being legal; 70% of gynaecologists conscientiously object to providing abortion services, a number that rises above 80% in particularly conservative regions in the north of the country. National laws granting access to medication abortions have not been converted into local regulations, meaning that in many regions Italian women cannot actually access medication which is technically legal.

These examples are illustrative of how service-providers like Women on Web have become central to the actualisation of reproductive rights for women, globally, even as abortion laws liberalise on paper. Increasingly, these kinds of service gaps are filled by the self-administration of drugs provided by organizations like Women on Web; ordered anonymously to postal boxes by women who are, in many instances, risking criminal prosecution if caught.

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