When abortion pills were banned in Brazil, women turned to drug traffickers

Last November, Xaiana, a 23-year-old college student in northern Brazil, began exchanging text messages with a drug dealer in the south of the country. Following the dealer’s instructions, she transferred 1,500 reais ($285), her living expenses for several months. Then, she waited three agonizing weeks for the arrival in the mail of a bler pack of eight unmarked white pills.
When she took them, they had the effect she was hoping for: She underwent a medication abortion at home with her boyfriend, ending an eight-week pregnancy.
But Xaiana kept bleeding for weeks, an unusual but not rare complication. “It was like a murder scene every time I had a shower,” she said. She was afraid to get help because it is illegal for a woman in Brazil to use the drug, misoprostol, to trigger an abortion. If she went to a clinic, she feared, the staff might figure out she had induced the abortion and report her. The penalty for having an abortion in Brazil is up to three years in jail.
“It’s the loneliest feeling I’ve ever felt in my life,” she said, asking to be identified only her first name out of fear of prosecution.
Xaiana, who asked to be identified only her first name, in Recife, Brazil, on June 3, 2022. (Dado Galdieri/The New York Times)
After seven weeks, she went to a women’s clinic and admitted to having terminated a pregnancy. She was given a simple cauterization, and no one reported her.
Proponents of abortion rights in the United States have suggested that a post-Roe America would differ in a key way from the era before abortion was legalized nationally. Women seeking abortions today have the option of a medical termination, using hormone pills to trigger the body to expel the fetus in private, a practice approved the Food and Drug Adminration.
But the wave of state trigger laws that have begun to take effect after the Supreme Court’s ruling overturning Roe on Friday bar all abortion, including medication abortions. To get the pills legally, women will have to travel to states where it is allowed for a medical consultation, even if it is video or phone, as required the FDA.
The trajectory of access to abortion pills in Brazil may offer insight into how medication abortion can become out of reach and what can happen when it does.
The pharmacy of a university hospital in Rexife, Brazil, on June 2, 2022. (Dado Galdieri/The New York Times)
While surgical abortion was the original target of Brazil’s abortion ban, the prescription expanded after medication abortion became more common, leading to the situation today where drug traffickers control most access to the pills. Women who procure them have no guarantee of the safety or authenticity of what they are taking, and if they have complications, they fear seeking help.
Today, black market misoprostol, brought in from India, Mexico and Argentina, is sold for anywhere from about $200 to $400 for the eight tablets recommended for an abortion, compared with less than $15 for a 60-pill bottle in the United States. It took a New York Times reporter less than one minute of asking to find someone willing to sell eight pills for $300, in a Rio neighbourhood known for the sale of black market goods.
“You buy it from a dealer. You don’t know what it is. The whole process is made frightening. It’s secret. It’s not a medicine anymore,” said Maira Marques, who is the director of campaigns for an abortion access advocacy organization called Milhas pelas Vidas das Mulheres. “This is supposed to be the straightforward, less complicated way to have an abortion, but now, instead, it’s buying contraband.”
It has been illegal in Brazil to have an abortion since 1890, although exceptions were added in 1940 for women who were pregnant as a result of rape or incest and in cases where a woman’s life was endangered the pregnancy; more recently, access was added for women carrying a fetus with anencephaly (missing parts of its brain).
But starting in the late 1980s, word spread that an ulcer medication called Cytotec could “bring on a period.” In fact, it was Brazilian women’s experience with off-label use of the drug that led to research and eventual global adoption of medical abortion as a lower-cost, less invasive way to end pregnancies that could increase access, especially in developing countries.
Boxes of misoprostol are stored in a pharmacy cabinet at a university hospital in in Recife, Brazil, on June 2, 2022. (Dado Galdieri/The New York Times)
Cytotec is misoprostol, one-half of the World Health Organization’s recommended combination of hormones (the other is mifeprone) to carry out a medication abortion. Mifeprone has never been approved for use in Brazil, and women, unaware of the drug, do not seek it on the black market. Misoprostol is usually enough to induce a safe abortion; a study published in The Lancet found that 8% of women who used misoprostol to terminate a pregnancy experienced complications, including bleeding and abdominal pain requiring medical attention.
The drug was sold in pharmacies without a prescription until 1991, and then it was regulated to require prescription, although the prescription rules were lax.
The availability of the pills sharply reduced the number of women turning up in hospitals with the life-threatening infections or haemorrhages from abortions they had tried to induce with the castor root or bleach or coat hangers, said Dr. Ana Teresa Derraik, an obstetrician-gynaecolog in Rio. “It was a big relief for those of us who didn’t think women should be punished like this.”
But misoprostol was becoming a focus of attention for anti-abortion campaigners in Brazil and beyond. In 1998, Brazil’s health regulatory agency, ANVISA, included misoprostol on the l of controlled drugs, alongside opiates, which meant a prison sentence of up to 15 years for anyone caught importing or buying it. International pharmaceutical companies that made misoprostol were hit with boycotts and stopped producing it; a small domestic company took over manufacturing a generic version of the drug to sell only to the Minry of Health for hospital use.
In 2006, the law prohibiting misoprostol dribution was strengthened to ban selling or publishing information about the drug on the internet.
When Jair Bolsonaro was elected Brazil’s president in 2018, with the enthusiastic support of Brazil’s fast-growing evangelical Chrian community, access became even more scarce.
International reproductive rights organizations such as Women on Web used to mail abortion pills to Brazil, and local femin groups used to source them and supply them, along with instructions for safe use, said Juliana Reis, director of Milhas. Now they have almost entirely stopped.
“Because of the political climate, it’s much more difficult to get safe products and to get proper counselling, because the networks that used to do that are much more afraid,” said Sonia Corrêa, a researcher of reproductive health technologies in Rio.
New guidelines issued the Minry of Health this month include the assertion that “inducing abortion telemedicine, using drugs from the special control l, can cause irreversible damage to the woman.”
Dr. Helena Paro, a gynaecolog in the city of Uberlândia who introduced telemedicine consultations for legal abortion patients during the COVID pandemic, called the guideline “completely ideological and contrary to the scientific evidence.” The WHO considers the practice safe.