OP-ED: How I Tested the New (to the U.S.) World of Abortion by Mail

Kayla King is a student, abortion rights activist, barista, and native Texan currently residing in central California.

It can be scary to be a sexually active young woman in Texas these days-- all of the restrictions on access to birth control and abortion can make securing trustworthy reproductive healthcare challenging. I went through my teenage years in Texas hoarding condoms and using as many forms of birth control at one time as safely possible (the pill, condoms, emergency contraception, a diaphragm even). I have been incredibly lucky to avoid pregnancy thus far, but my luck seems to be inversely proportional to my age. In our volatile political climate, I, like many others, worry about the future of abortion rights, especially in a state like Texas, where restrictions on access are politically motivated, often under the guise of "protecting women's' health". Texas is politically notorious for restricting access to women’s healthcare. In the last year, Texas has been in federal court three times with lawsuits regarding various unconstitutional anti-choice laws, including a fetal burial and cremation rule, attempting to kick Planned Parenthood off state Medicaid funding, and SB 8, a omnibus anti-choice bill introduced shortly after Trump’s inauguration.  Many other states continue to pass similar unconstitutional laws restricting access to clinical abortion in the era of this anti-choice administration.

Medication abortion has been legal in the United States since 2000, when the FDA first approved Mifeprex in combination with Misoprostol to induce abortion in a clinical setting. 24 years after the landmark case of Roe, the only method of legal abortion in the United States until this point was surgical. Since then, the popularity of abortion with pills has grown. Nearly half of people seeking to end a pregnancy within 10 weeks opt to have a medication abortion. When the FDA finally approved medication abortion, many of the restrictions on surgical abortion were also applied to abortion with pills. Medication abortion could be used to greatly expand abortion access, as more medical professionals could provide it than those able to provide surgical abortion, and many women are comfortable and feel safe taking it outside of a clinic. However, much of the same politically minded restrictions on surgical abortion were blanketed across medication abortion. Although the context of medication abortion is vastly different than a surgical abortion, restrictions that apply to surgical abortion were used to limit the transformative potential that medication abortion could have on our reproductive healthcare landscape. The ease, effectiveness, and safety of medication abortion has the potential to radically transform the way we view early abortion, given that it were more accessible. Regulators and legislators were unable or unwilling to expand the accessibility of early abortion.  So for example, a person seeking an early abortion in Texas will have to contend with a plethora of politically motivated (not evidence based or health minded) restrictions that can cost the individual hundreds of dollars in transportation, housing, and additional unnecessary appointments in which a doctor must follow a state-mandated script of falsehoods about the health risks of abortion. Under these regulations, many who seek medication abortion are also subject to invasive and unnecessary medical procedures (transvaginal ultrasound, anyone?). All of this hassle to take one pill under doctor supervision, and a few more at home. One facing these obstacles can’t help but wonder if there can be a safe and effective way to end an early pregnancy without these interferences of the state.

Just in case I should ever need it, I began looking at ways to access abortion pills outside of the traditional medical system. An Internet search quickly identified three international non-profits that offer medication abortion services-- Women on Web, Safe2Choose, and Women Help Women. Women on Web and more recently Safe2Choose and Women Help Women have been delivering medication abortion  for over 10 years to women living in countries where abortion is illegal. Literally, delivering abortion care! In more than one hundred countries around the globe, a person can go online to these sites, calculate their gestational age based on the date of their last regular menstrual period and order a combination of Mifepristone and Misoprostol, to be delivered to their door for use in the privacy of their own home. When taken within 10 weeks of a missed period, the pills are about 95-98% effective at ending a pregnancy. A recent study involving women in Ireland who had used this service found that it was comparable in safety and effectiveness to clinical care and that the women appreciated the convenience of this home-based care. But this convenient, safe, private, and more affordable option is not available to people in the United States. For several reasons, including the complexity of the legal status of abortion by state and the messy politics involved, these websites do not currently ship to the United States. Although  abortion is technically legal in the U.S.,, that does not mean it is accessible to many people.

While searching Google for organizations like Women Help Women and Safe2Choose, I stumbled across PlanCPills.org. Plan C is a U.S. based initiative raising awareness of the option of a safe, effective, and affordable abortion in one’s own home. Plan C is spreading the word about how  people right here in the United States are leveraging the World Wide Web to access medication abortion in their own homes. Immediately, I emailed Plan C and asked about how I could join in their mission to expand access to this transformative technology.

Plan C recently published a study with Gynuity Health Projects in the international journal Contraception about the feasibility of ordering Mifepristone and Misoprostol online for delivery to U.S. addresses. Check out the full article, or this "report card" about the sites tested, but here’s a quick recap— 20 out of 22 orders places were received, most within less than two weeks. Shockingly, 15/20 packages shipped actually shipped from within the U.S. The median cost for a full dosage of both Mifepristone and Misoprostol was $200 (The average cost of an in-clinic abortion is $500 using the same pills). Pills from each shipment underwent a chemical assay and were found to contain the labeled active ingredients to induce abortion, though the amount of ingredient was lower than expected in some brands of pills.

Seeing the success of the Plan C researchers, I decided to try it for myself. At this point, I had formally joined the Plan C team as an intern. Although they had already finished the formal research phase, I wanted to know what it would be like to order pills on my own. My main interest in this project was the interaction of user and seller, how one exactly could go about finding and ordering these pills online. I decided to use buygenericmed.com, which a colleague at Plan C recommended I try.  I went to my favorite café, and after logging onto their Wi-Fi and getting a seven-day free trial of a VPN (Virtual Private Network, to obfuscate my web traffic and protect my identity), and entered the website into my browser. The front page of the site listed birth control options. I clicked into this page and found a package of both Mifepristone and Misoprostol front and center. For $115, I could get a "MTP kit “ or “medical termination of pregnancy” kit, containing both drugs shipped to my door. For only $80, I could buy misoprostol alone. Misoprostol is less effective in inducing abortion when used alone-- ending about 85% of pregnancies, but the World Health Organization recommends it when mifepristone is unavailable. I chose to spring the extra $35 and selected the combination pack. 

I placed my order, entering only my name and shipping address. Immediately I received an confirmation email  letting me know that my order had been received. The next week, I completed a payment request from the seller on PayPal International for $115. The PayPal feature felt more secure than other payment methods I had heard of. According to the Plan C study, some sellers asked for a money transfer requiring bank account info, a money order, or a credit card number on their site.  As time passed, I was beginning to get nervous. Had I thrown $115 away? Was I really going to get these pills? Had I fallen for a scam designed to trap desperate people in their time of need? My anxious questions piled up with the junk in my mailbox, conspicuously lacking the package I was looking for. Glad I wasn’t pregnant and in need of the pills before the 10-week window closes, I dutifully checked my mailbox every day, anxiously waiting and badgering my mailman. Four weeks after placing my order, I got an email confirming that the package had cleared customs, and would soon be in my mailbox. The U.S. inspects less than 2% of packages coming across its borders, so the chances of it getting through customs were high, but it was  comforting to get confirmation.

One week later , an unassuming brown envelope presented itself in my mailbox. Shipped from New Delhi, taped on to it were customs forms and across the opening, strips of fluorescent green tape, a reassurance from U.S. Customs and Border Patrol. Upon opening this envelop, nestled amongst bubble wrap was a small manila envelope with a foil blister pack containing one Mifepristone and four Misoprostol pills, labeled as containing quantities of the active ingredient to induce abortion. Although the shipping time for this website was much longer than the average for the study, I was in no hurry for this experiment.  This was quite a thrill! It had actually worked. I was in awe of this new reality; I had ordered abortion pills online and had them delivered to my door. And although my pills took a bit longer to ship, the top ranked site on Plan C’s “report card” shipped the pills in 4 days for only $80. I suddenly had a greater understanding of Plan C’s tagline, “convenience, confidentiality, control”. More than a great alliteration, Plan C’s mission has the potential to change the way early abortion is understood and exercised in the U.S.

Although the process of ordering pills online was relatively simple for me, I know from reading the news that not everyone who orders pills online is so fortunate and privileged. At least 18 people have been prosecuted for ordering or taking abortion pills on their own. According a recent report from the Self Induced Abortion (SIA) Legal Team, prosecutors abuse a patchwork of outdated and ambiguous laws to punish women who end their own pregnancies. These prosecutors have denigrated fetal harm laws, originally designed to protect pregnant people, as well as misapplied criminal abortion laws, many left over from the era before Roe. Seven states-- Arizona, Delaware, Idaho, Nevada, New York, Oklahoma, and South Carolina-- have laws against self-induced abortion. The SIA Legal Team recommends that these states repeal these laws, as they do not prevent people from seeking to end their own pregnancies, and only serve to create distrust of the medical system and invites law enforcement into healthcare settings, creating circumstances that may prevent people from seeking care when they need it.  When I set out to order my pills, I was aware of these issues yet relatively unconcerned because I ordered the pills as an experiment and with the intent to have them just in case; I did not need them to end an existing pregnancy. I also happen to live in California right now, where I am not as fearful of legal backlash and know that the SIA Legal Team is available for people who might need legal assistance.

 

Although these legal obstacles deserve careful consideration, the future that Plan C imagines is a revolution in reproductive health technology. In time, early abortion in the United States could be a simple as picking up pills at the grocery store, or ordering them on Amazon. Women are eager to embrace new reproductive health technologies, and women around the globe have long accepted the concept of mail order abortion. Plan C offers us an image of a country that allows women to be trusted with their own reproductive health decisions.

The pills have been sitting on my bathroom shelf for the last month, nestled between vitamins and ibuprofen.  This is a great spot for them. They are there just in case I should ever need them. Having these pills at my disposal is an act of power, reclaiming my rights, refusing to let my health and my life be left to the whims of whatever politicians are in office today or tomorrow. A friend of mine heard this story and ordered some pills of her own, and they now sit  on her bathroom shelf, just in case. Plan C’s work and research opens up a possibility of radical self health care that has previously been unavailable to Americans. The research about Women on Web's international service has corroborated that for most people, this alternative option is safe, effective, and even preferred. The feeling of reclaimed autonomy over my body, a feeling I had never fully felt under the oppressive Texas political climate, is here to stay. People deserve access to this technology, to have full control over their own bodies and destinies. We don’t have to be at the mercy of whoever is in office, the mercy of our credit card limit, the mercy of our insurance companies policies on abortion coverage, the mercy of our parents thoughts on abortion, the mercy of the distance from our homes to a clinic. We can take back our power, our bodies, and our rights.  The fact that women all over the world have this access, and that it has been restricted and even concealed from us here in the U.S. is a shame. It is time for us to trust ourselves, to trust women, and to embrace this technology.
 

BUST Magazine: Cut The Bullshit: How Online Pharmacies Can Help People Have Safe And Private Abortions

Plan C's own op-ed was featured in BUST Magazine. 

Barriers to abortion care are common; 90% of US counties have no abortion provider, creating vast “abortion deserts.” Annika, a 28-year-old from Colorado, noted that "it’s 50 minutes to an hour to the nearest clinic, and I don’t have any way of getting there myself. There’s no public transport that goes there, and a taxi or Uber would just be too much on top of the cost of the procedure.” The cost of the procedure was also a barrier for Vonda, a 35-year-old with 3 children who lives in Texas. For her, it was a question of paying the rent or paying for an abortion. 

These experiences of ordinary women who were trying to access a legal health service are included in a study released earlier this month in Perspectives on Sexual and Reproductive Health. The study looked at the motivations and experiences of people seeking medication abortion online in the United States. The findings document—in the words of women themselves—what we already know, that depending on where you live and how much money you have, an abortion can be hard to come by. But the study also revealed a possible solution to the abortion access problem, one that was seen as both convenient and desirable by women—making abortion pills available through online pharmacies. 

Read the full article here.

The Atlantic: Illegal Abortion Will Mean Abortion By Mail What to expect when you’re expecting your abortifacient pill delivery

by Olga Khazan

With the prospect of a more conservative Supreme Court on the horizon, some progressive women have begun to fear what will happen if Roe v. Wade, the case that legalized abortion, is overturned. Some of these prophecies have centered on a popular meme in the pro-choice community: The coat hanger.

During a recent rally, New York gubernatorial candidate Cynthia Nixon held up a wire coat hanger as a warning that we should not return to the previous generation’s means of obtaining illicit abortions. And Representative Lois Frankel, a Democrat from Florida, banged a coat hanger on the table at a briefing while discussing the latest Supreme Court nominee, Brett Kavanaugh.

And this isn’t counting the many happy hours in progressive cities that have become peppered with gallows-humor cracks about coat hangers and back alleys.

But medical technology has progressed significantly since Roe was decided in 1973, and we—realistically, fortunately—won’t see a return to women using coat hangers or other implements to self-abort. Instead, it’s more likely that more and more women will turn to shady online pharmacies to buy abortion pills through the mail—a practice that is already occurring with surprising frequency and effectiveness around the world.

Read the full article here.

The Philly Inquirer: Abortion pills are safe and effective. Why can't U.S. women buy them online?

From Philly.com:

The researchers behind a project called Plan C take a pragmatic view, arguing that women are already going it alone. To help them, the researchers ordered abortion pills without prescriptions from 18 online websites — the kind the FDA considers rogues. The results were published as a study that became Plan C’s online “report card,” which rates the websites based on product quality, price, and shipping time.

Although two orders were never received and some mifepristone doses were skimpy, the researchers concluded “self-sourcing pills from the internet is a rational option.”

“We don’t advocate that women do this,” said public health specialist Elisa Wells, co-director of Plan C. “We know women are already doing this, so we believe they should have access to good information.”

Read the full article here.

WBUR: Self-Induced Abortions Shouldn't Be A Crime, Mass. Medical Society Says

Self-Induced Abortions Shouldn't Be A Crime, Mass. Medical Society Says

May 7, 2018

by Chelsea Conaboy and Carey Goldberg

At its latest meeting, the Massachusetts Medical Society took a new stand: Women who attempt to end a pregnancy on their own should not be considered criminals.

Self-induced abortion is explicitly banned in seven states, and more have laws on the books that could be used to prosecute women for self-induction, according to a recent report.

The 25,000-member medical society passed a resolution saying it would advocate against “any legislative efforts or laws in Massachusetts or federally to criminalize self-induced abortion.”

It also encouraged its delegates to the national American Medical Association to propose a similar measure there.

“Criminalizing this will actually drive women away from care,” says Dr. Rebekah Rollston of the Cambridge Health Alliance, who helped spearhead the resolution. “Where women really need to access medical care, they may fear that they’ll be reported to legal authorities.”

The resolution did not come in reaction to a pending bill or petition. Rather, Rollston says, it emulates a recent policy passed by the American College of Obstetricians and Gynecologists.

And it responds to a political and legal climate in which efforts to limit or ban abortion are multiplying. As access diminishes, self-induced abortions are making a comeback, she says.

Read the full article by clicking below. 

http://www.wbur.org/commonhealth/2018/05/07/mass-medical-society-self-induced-abortion

Stanford Social Innovation Review: Reproductive Health Care by Mail

Reproductive Health Care by Mail

It is time to give US women the convenience, confidentiality, and autonomy of birth control and abortion pills that women elsewhere enjoy.

From the article:

For more than 10 years, women around the world have been able to self-diagnose their pregnancies and order highly effective and safe early-abortion pills online or obtain them from a local pharmacy, often without a prescription. Services such as Women on WebWomen Help Women, and, more recently, safe2choose offer online consultations and express delivery of abortion pills directly to women in their homes, all without a physical exam. These sites also offer information and support to women about what to expect during the abortion process. Not surprisingly, research has found that women value the convenience and privacy of online services. Research has also demonstrated that the safety and effectiveness of this model are comparable to those of services delivered through clinics.

Unfortunately, none of the services that supply pills in other countries will ship them to the United States, despite receiving nearly 10,000 requests per month from women here. These pills are the same ones given to women who choose a medication abortion at Planned Parenthood and other abortion clinics. But because abortion is so highly politicized in the United States, access to these pills has been severely restricted since the day that mifepristone (RU-486, also known as the French abortion pill) was approved by the US Food and Drug Administration in 2000. Unlike the vast majority of medications, which clinicians prescribe and patients pick up at a pharmacy, mifepristone can only be shipped to doctors who have specially registered with the manufacturer.

Chicago Tribune: Women can already receive abortion pills by mail in 4 states, what's next?

by Nara Schoenberg

Hailed in the 1990s as “the pill that changes everything,” the abortion pill mifepristone (also known as RU-486 and Mifeprex) got off to a slow start after Food and Drug Administration approval in 2000.

But now, the pill is at a crossroads, with 31 percent of American abortion patients choosing pill-induced abortion over surgery, and bold new initiatives dangling the prospect of dramatically increased access. The Gynuity study is allowing women in Maine, Hawaii, Washington and Oregon to confer with a doctor from home via video chat, and then get the pills delivered to their homes by mail. In California, women may soon be offered an even more streamlined medication-by-mail option. In Hawaii, the American Civil Liberties Union recently filed a lawsuit that could open the door to ordinary doctors nationwide prescribing the pill, and women picking it up at their local pharmacies.

“I feel optimistic,” said Francine Coeytaux, co-director of Plan C , an abortion-rights project that hopes to offer pills by mail in California soon via a demonstration study, and then expand to other states as well. Plan C offers a website with information about pill-based abortion and anticipates that established international telemedicine-abortion initiatives, such as Women on Web, will find a way to ship pills to women in the U.S.

“It’s not about what we’re doing. It’s a fact. It’s happening. It has so much potential, and there are so many ways in which it’s beginning to happen, that nobody’s going to be able to stop this,” Coeytaux said.

 

Read the full article on the Chicago Tribune website here. 

 

Cycles+Sex Podcast // Politics in our Privates

On November 4, Plan C cofounder Francine Coeytaux spoke on a panel about reproductive rights and politics at the Cycles+Sex conference in Los Angeles.

Participants:

Lauren Bille, founder Cycles+Sex

Jennifer Weiss-Wolf, founder, Period Equity

Francine Coeytaux, cofounder, Plan C

Assembly Member Cristina García

Ruth Dawson, ACLU
 

The panel was captured as a podcast. You can listen and read more here.

"Mystery Shopper" Report Card now live

CLICK HERE to view our "Mystery Shopper" Report Card: The results of our study with Gynuity Health Projects.


Photos of Abortion Pills Obtained Online

All of the pills pictured here contained real active ingredients as determined by chemical assay. Two brands (Pregout and Pregnot) contained considerably less misoprostol than indicated on the label, which may make them less effective.

  MIFEGEST KIT   Manufactured by Zydus Healthcare (Fortiza)  Contains: 1 mifepristone tablet (200 mg), 4 misoprostol tablets (200 mcg)  Quality: Acceptable

MIFEGEST KIT

Manufactured by Zydus Healthcare (Fortiza)

Contains: 1 mifepristone tablet (200 mg), 4 misoprostol tablets (200 mcg)

Quality: Acceptable

  PREGOUT KIT    Manufactured by Akums Drug and Pharmaceuticals  Contains: 1 mifepristone tablet (200 mg), 4 misoprostol tablets (200 mcg)  Quality: the mifepristone pills contained acceptable levels of active ingredient; the misoprostol pills contained low levels of active ingredient.  Note: each blister bubble on the package was pricked with a pin, which could account for the low level of misoprostol content (it degrades when exposed to air)

PREGOUT KIT 

Manufactured by Akums Drug and Pharmaceuticals

Contains: 1 mifepristone tablet (200 mg), 4 misoprostol tablets (200 mcg)

Quality: the mifepristone pills contained acceptable levels of active ingredient; the misoprostol pills contained low levels of active ingredient.

Note: each blister bubble on the package was pricked with a pin, which could account for the low level of misoprostol content (it degrades when exposed to air)

  PREGNOT KIT   Manufactured by Akums Drug and Pharmaceuticals  Contains: 1 mifepristone tablet (200 mg), 4 misoprostol tablets (200 mcg)  Quality: the mifepristone pills contained acceptable levels of active ingredient; the misoprostol pills contained low levels of active ingredient.  Note: each blister bubble on the package was pricked with a pin, which could account for the low level of misoprostol content (it degrades when exposed to air)      Compiled by Plan C , November 27, 2017

PREGNOT KIT

Manufactured by Akums Drug and Pharmaceuticals

Contains: 1 mifepristone tablet (200 mg), 4 misoprostol tablets (200 mcg)

Quality: the mifepristone pills contained acceptable levels of active ingredient; the misoprostol pills contained low levels of active ingredient.

Note: each blister bubble on the package was pricked with a pin, which could account for the low level of misoprostol content (it degrades when exposed to air)

 

Compiled by Plan C , November 27, 2017