The phone buzzes insistently and I scramble to answer it. Nervously, the woman on the other end explains that she has six pills of misoprostol, and wants to know how to use them to induce an abortion. I explain that according to the World Health Organization (WHO) the recommended dose is 12 pills spread over nine hours, dissolved under the tongue. I explain the symptoms, and how to recognize problematic bleeding or infection. But I can’t say much more, or ask her any questions about her health, because helping a woman to get an abortion is illegal in Chile, and if we were caught openly discussing it, both of us could be arrested.
After I finish explaining, there’s a long pause. Finally, she asks if there’s a doctor she can call if there’s a problem. This is perhaps the biggest concern for women who have abortions in Chile: a misoprostol abortion is very safe, but if something does go wrong, women may hesitate to seek treatment because they face up to three years in prison if they’re reported to the police. I assure her that as long as a woman puts the pills under her tongue, she’s safe — in an emergency room, a misoprostol abortion looks exactly like a miscarriage.
As part of Chile’s only abortion hotline, most of my conversations with women are like this. I have to follow a lawyer-approved script that keeps us just on the right side of the law. While it’s impersonal, it’s the only way we can actually reach women without putting our callers and ourselves at risk.
Chile is estimated to have one of the highest abortion rates in all of Latin America, but it has one of the strictest anti-abortion laws in the world. Abortions are banned under all circumstances, including saving the woman’s life. Naturally, this has forced women to seek abortions outside of the law — with varying levels of safety.
That’s why the Chilean safe abortion hotline was launched in 2009. It’s run by a national network known as Lesbians and Feminists for the Right to Information. The hotline is open 365 days a year, for four hours a day, on a completely volunteer basis. Women call from all over Chile, and they are offered information on the correct dosage and administration of misoprostol, its contraindications and side effects, as well as information on abortion law and legal rights. Since its launch, it has received more than 10,000 calls, up to 15 a day.
There are five hotlines like ours in Latin America (Chile, Argentina, Ecuador, Peru and Venezuela), and others around the world. Some are independent, and others work closely with organizations such as Women on Waves, which uses tele-medicine to provide medical abortions to women in countries where it’s illegal.
Of the five Latin American hotlines, Chile’s faces the most constraints. We do have the right to share public information with the women who call us — but that’s about it. That means addressing women in the third person (“According to the WHO, a woman can….”), and not asking any questions. Cell phone minutes are expensive, and sometimes women run out of minutes before we finish explaining the procedure. If the line does go dead, we have no way of knowing if we’ll ever be in touch again. We also can’t provide any kind of counseling, and there’s not much we can do to address the social stigma of abortion. And as far as the pill itself is concerned, women are on their own.
Some women who call are already very informed about misoprostol, and looking for answers to very specific questions. Some are surprising: one woman called to ask if she could eat watermelon during the abortion (answer: yes!). Others have never even heard of misoprostol. Some have the full support of their partner, a family member, or a friend. But others call us in the midst of the abortion, because they are alone and are terrified that something will go wrong.
Some women are confident and matter-of-fact about their decision. Others call in tears, explaining that they can’t have a baby because they are already mothers, or are students, or have no support from their partner. Those are the calls that stick with us, because although we may believe that any reason not to have a baby is a legitimate reason, we can’t remove a lifetime of stigma and guilt in a five-minute phone call.
We can offer the information we do because it’s already available online from organizations such as the WHO, International Consortium for Medical Abortion, Ipas, and Women on Waves. Of course, for most women it’s not obvious where to find it, and there’s no guarantee they’ll understand the medical terms if they do. As an organization we have much more access to these resources. Some of us have been trained in misoprostol use by these international organizations. Some of us are health professionals. Some are involved in extensive activist networks, and have been able to share information and strategies with women around the world. These experiences allow us to take this public information, and present it in a way that’s accessible to as many Chilean women as possible.
Each of us has our own reasons for joining the hotline. Some of us have personal experiences with abortion — both good and bad. One hotline member saw her roommate hospitalized — and then jailed for two years — after an abortion with a TV antenna. Another woman watched her cousin be denied an abortion after discovering that the fetus had severe genetic defects, only to give birth and watch her child struggle to survive for more than a year before dying. Others are lifetime activists, who were frustrated with the lack of progress in decriminalizing abortion. But whatever our motivations for joining, once we do, few think of quitting. Answering the hotline is a radicalizing experience. It’s impossible not to listen, night after night, to the injustice that these women face, and not be moved to take action.
Misoprostol has indeed revolutionized the way women have abortions — especially illegal abortions. Throughout history, women have had their methods for inducing abortion, some safer than others. Likewise, throughout the world there have probably always been networks of women to help each other get abortions (the Jane Collective in Chicago in the early seventies is a famous example).
But for the first time, a safe method is available for women to use themselves, in the privacy of their own homes. Originally invented as an ulcer drug, today misoprostol is used around the world (including the United States) to provide first trimester abortions, along with the drug mifepristone (RU-486). Although the mifepristone-misoprostol combination is more effective, misoprostol alone is also recommended by WHO, as a safe alternative where mifepristone is not available. In Latin America, misoprostol use for self-abortion care was first documented in Brazil in 1986; today, in Chile it’s sold on the black market for about $250 for the full dose of 12 pills.
Unlike an illegal surgical abortion, a woman doesn’t have to put herself at the mercy of an illegal abortionist- who is likely someone she doesn’t know, may or may not be trained, will probably charge her exorbitant amounts of money for what is a relatively simple procedure, and may submit her to verbal or sexual abuse. The lack of training of many illegal abortion providers not only puts women’s health at risk, but also their security in an emergency room, a badly preformed surgical abortion is very easy to identify, which increases the chances of being sent to prison. And even in cases where the practitioner is well trained, the additional people that may be involved- the practitioner themself, assistants and contact persons — also may make it more likely to get caught.
But with misoprostol, the practitioner is often the woman herself. She doesn’t have to put her life in the hands of a total stranger. She can choose when, and where, to have the abortion, and she has much more control over who knows about it. A woman in an abusive relationship doesn’t have to tell her partner. A teenager doesn’t have to tell her parents. An emergency room doctor doesn’t need to know she used misoprostol, because the treatment for complications is identical to the treatment for miscarriage.
Perhaps most importantly, illegal misoprostol abortion is inherently safer than illegal surgical abortion, because there are fewer things that can go wrong. Since no foreign objects are introduced into the vagina, there is very little chance of infection, and therefore little chance of long-term consequences such as infertility. Problematic bleeding is uncommon. Uterine rupture (often incorrectly cited as a risk) is extremely rare, even in second trimester abortions when the uterine walls get thinner. Because no technical skills are needed, it is very easy to learn to do a misoprostol abortion; essentially, one must learn the timing of misoprostol administration, and what warning signs to look for.
For women who use misoprostol, information is key; it can be the difference between a safe abortion, and one that ends in an emergency room, or in jail. If they do have to go to a hospital, women who don’t know their rights may be pressured to confess by hospital staff. And there are plenty of myths about misoprostol use, some of which come from doctors themselves. Because there are no circumstances in which they can legally perform abortions, Chilean doctors only receive training on post-abortion care, not abortion itself, and will often prescribe the wrong dose. The problem is that misoprostol dosage is very counterintuitive — the further along the pregnancy is, the lower the dosage that is needed. So 12 pills may seem like a lot, both to women, and to doctors who are used to using smaller doses of the drug (for example, in induction of labor).
Many people don’t realize that in a legal medication abortion, the actual abortion takes places in the woman’s home. According to clinical guidelines published by the WHO, ICMA, and Ipas, the practitioner (who may be a doctor, nurse, midwife, or physician’s assistant) begins by confirming the length of the pregnancy and ruling out contraindications, of which there are few. Next, the women is told how to take the pills and how to recognize signs of hemorrhage and infection, and then sent home to take the pills at her convenience. She would need to return to the clinic in two weeks, and if the abortion was incomplete it can be taken care of at that point; unless there are signs of infection, an incomplete abortion is not a life threatening situation.
So in a country like Chile- where almost 90 percent of the population lives in urban areas, with easy access to hospitals and post-abortion care, women are able to mimic clinical procedures, and safely induce their own abortions. Chilean reproductive health specialists have publically stated that misoprostol use has greatly reduced the number of abortion complications they see in their practice, a phenomenon that has been documented in other countries as well.
Unfortunately, most press coverage of illegal misoprostol use is sensationalist and misinformed. The image of a woman taking pills in the privacy of her home is quite different from what most people imagine that illegal abortion is like. The image of a “back-alley” abortion is a powerful one for Americans and Chileans alike. Gruesome images, such as that of Geri Santoro, dead in her hotel room 1973, played an important role in the struggle to legalize abortion in the United States. But they don’t accurately represent the reality of illegal abortion today.
In today’s United States, we have women Jennie Linn McCormack, an Idaho woman who bought the abortion pill over the internet because she didn’t have the money to obtain a legal abortion in Salt Lake City, three hours from her home. She underestimated the length of her pregnancy, and was surprised by the size of the fetus. When she called a friend for help, the friend’s sister called the police. McCormack had no complications, and her case was later dismissed, but she still had to suffer abuses at the hands of the police, media attention, and ostracism by her neighbors.
Of course, McCormack’s case represents a huge failure on the part of the US healthcare system. Even though she lives in a country where abortion is a constitutional right, a safe abortion was no more accessible to her that it is to her Chilean counterparts. It’s unclear how often American women have to resort to inducing their own abortions. But in other countries, stories like hers are all too common.
Chile is one of 5 countries in the world with a total abortion ban; the others are El Salvador, Nicaragua, Malta, and the Vatican. There are no reliable statistics that tell us how many abortions there are in Chile each year, and even less information on the number of misoprostol abortions. Estimates range from 60,000 to 200,000 abortions per year, in a country of 17 million people.
So-called “therapeutic” abortion, permitted only if the woman’s life or health is in danger, was legal from 1939 to 1989. It was legalized in part to bring down the high maternal mortality rate. Its prohibition was one of dictator Augusto Pinochet’s last acts in office.
Pinochet’s 17 year reign ended not with a counter-coup, but rather a plebiscite. In exchange for a bloodless “transition to democracy,” the country maintained the dictatorship’s constitution and many of its legislators. Because of this and related social processes, there have been no changes to the abortion law since 1989. The most recent bill, which would restore the therapeutic abortion law, was proposed in March of this year, but Congress refused to even open discussion.
For many Chileans, abortion is a non-issue. It is rarely even mentioned in the press, and when it is, coverage is invariably anti-choice. As in most countries with restrictive laws, there is little political will among the legislators. That may be in part because most come from the upper class, and safe abortion has always been available to those who can pay for it. Some thought that the government of Michelle Bachelet — a female, socialist, physician who was president from 2006-2010 — would make more progress. But in fact, it was during her government that misoprostol was pulled from pharmacies (where it had been available with a prescription), leaving women to try their luck on the black market.
Another reason may have to do with Chile’s low maternal mortality rate. Abortion has long been established as an important cause of maternal mortality, and in many countries where some form of abortion is now legal, legislators were moved to lift the abortion ban because they wanted to protect women’s lives. But Chile has one of the lowest rates in Latin America- 26 per 100,000 live births, comparable to the US rate of 24 per 100,000. There are probably many reasons why maternal mortality has declined, but some of the most important factors are likely government subsidized birth control and post-abortion care, and access to safer illegal abortions using misoprostol. But increasingly safer abortions means there hasn’t public outcry to remove the ban.
In 22 years of democratic government, there has been zero progress towards decriminalizing abortion. Another 20 years could easily pass before any action is taken at the national level. Chile has shown itself incapable of protecting women’s reproductive rights. And if current trends are any indication, the United States is not much better. But meanwhile, women still need abortions. So we have no other choice than to organize ourselves, and empower women to have the safest, most positive abortion experience they can. Someday, women in the United States and Chile alike will have access to affordable, legal abortion offered by a trained practitioner. But until then? We’ll be here. Give us a call.