Abortion pills in U.S. women's hands: Bold action to meet women's needs Report on meeting held 12/4/13 in Washington, DC I. Background In many places around the world where access to abortion is restricted or prohibited, a woman can go to a pharmacy or drug outlet to obtain misoprostol (also known as Cytotec) to successfully end an unwanted pregnancy without talking to or seeing a healthcare provider. The drug distribution system in the United States is different than in many countries where this happens, and there is no direct parallel here to that experience. Still, some US women are using misoprostol (or mifepristone and misoprostol together) to end a pregnancy without formal medical guidance. Moreover, given the increased restrictions on abortion services that we are seeing in so many parts of the country, this practice is likely to increase. This raises complex legal, medical/clinical and political questions – some of which may not yet have clear answers. There is, however, a solid body of medical evidence and experience from across the globe that can inform the discussion. Convinced that it is time to share with women in the US the knowledge that global research and experience has produced regarding the self-use of pills to safely end an unwanted pregnancy, Francine Coeytaux (Public Health Institute), Leila Hessini (Ipas), Amy Allina (National Women's Health Network), and Kate Ryan (National Women's Health Network) organized a meeting to: 1) share what is known; 2) identify questions that need to be answered; 3) discover opportunities for advocates for women's health to work together; and 4) develop some actionable strategies to improve US women’s access to accurate information on abortion pills and reliable sources for the drug(s). The meeting was held on December 4, 2013 in Washington, DC in the offices of the Association of Reproductive Health Professionals. It brought together 29 advocates, researchers and community- based activists from 11 different states1 for a strategic conversation about how to ensure that women in the US have the information, resources, and support they need to use abortion pills safely. The funding for this one-day meeting was provided by an anonymous donor and the Mary Wolford Foundation through the Public Health Institute. II. Sharing Information on What Has Been Done to Date Historical background: The first part of the day was dedicated to sharing information about what has been done to date on the self-use of pills for abortion, both in the United States and internationally. 1 Participants came from: CA, DC, GA, MA, NC, NY, OK, TN, TX, WA and the Netherlands. Bold Actions to Meet Women’s Needs – December 2013 1 This experience was framed as one of women helping other women meet their own needs for safe abortion when and where clinical services are failing them. Francine Coeytaux shared the history of misoprostol use for self-induction, which started in the 1980s when women in Brazil discovered that misoprostol, a readily available drug, could help them end an unwanted pregnancy. As women began to use the drug on a large scale, spreading the information to others, they changed the public health landscape in Brazil, significantly reducing the rates of morbidity due to unsafe abortion. Since then, the medical community has confirmed this and other gynecological indications of misoprostol and scientifically documented that it can be used safely and effectively by women for abortion. Indeed, today it is misoprostol combined with mifepristone that is the regimen used in the US and abroad to provide medical abortions (i.e., abortions with pills in contrast to a surgical procedure). Lessons from other countries: Leila Hessini shared the lessons learned from other women in the global south, describing some of the strategies women who live in countries with restricted legal abortion access are using to challenge centralized healthcare systems and implement more woman-centered care. She stressed that how we think about the landscape of abortion access and safety has changed worldwide. The framing is no longer exclusively “Is abortion legal or illegal?” or that “legality equals safety,” but rather acknowledging that even in places where there are tight legal restrictions limiting or prohibiting provision of abortion in the formal medical system, some women are able to gain access to information, care, and drugs and to have safe abortions in their homes and communities. Questions that Ipas is exploring in its research internationally are also relevant for discussions in the US: What do women need to know in order to have a safe abortion experience? How do women want to obtain information about self-induction (friend, workplace, school, confidential hotline, self-help guidebook or website)? Who do women trust as credible sources of information? Leila also shared the findings of a recent program the Public Health Institute and Ipas implemented in Kenya and Tanzania.2 This initiative, which provided small grants to local organizations to share information about misoprostol with women in their underserved communities, produced two important lessons: 1) that the communities were hungry for information about misoprostol precisely because it empowered women to help themselves, and 2) a grassroots approach of community mobilization to get the information out was the best way to proceed. It was these lessons that inspired the meeting organizers to bring this strategic conversation to the US in the hopes that doing so would produce benefits for US women, particularly those who live in states where new restrictions on abortion are creating barriers to access that are impassable for many. Misoprostol Alone Working Group: Melanie Zurek (Provide) gave an overview of the work of the Misoprostol Alone Working Group, which was active from 2006 to 2010. Working group members included Provide (at that time Abortion Access Project), Ibis, Gynuity, National Latina Institute for Reproductive Health, and later, the Center for Reproductive Rights (CRR). In 2009 Provide commissioned CRR to review the laws of four states (IL, NY, SC, TX) that could expose women, providers, or advocates to criminal prosecution for self-induction. The Working Group also produced a set of talking points to counter unproductive media stories and stigmatization of immigrant communities. 2 Coeytaux, F., et al., Facilitating women's access to misoprostol through community-based advocacy in Kenya and Tanzania, International Journal of Gynecology & Obstetrics, in press (published online 1/21/14). Bold Actions to Meet Women’s Needs – December 2013 2 Melanie reported that the focus of the Working Group was on mitigating harm and assessing what steps the reproductive health, rights, and justice community might take to support women who choose self- induction in light of potential legal risks faced by women, providers, and advocates. The Working Group considered legal, public education, provider education, media, and research strategies. At times, this also included consideration of whether it was ethical to recommend the self-use of misoprostol as an abortion method, given the perception among some that it was substandard to the medical care a woman would receive in a clinic or substandard to mifepristone/misoprostol combined regimen; this tension was not resolved among Working Group members. While the Working Group agreed that the use of misoprostol by women was safe and effective, it did not identify a compelling need for direct action at that time and emphasized the continuation of existing work to secure equitable access to clinic-based care. In 2009, Gynuity and Reproductive Health Technologies Project (RHTP) sponsored a conference in New York City on misoprostol self-induction and produced a report entitled “The Best Defense Is a Good Offense: Misoprostol, Abortion, and the Law.” The report was distributed to the meeting participants and the document is available from RHTP (http://www.rhtp.org/abortion/misoprostol/default.asp). Texas Summit: Susan Yanow and Leila Hessini reported on a meeting they had recently participated in held in Austin, Texas in November 2013. Organized by Marlene Fried and Susan Yanow under CLPP (Civil Liberties and Public Policy Program at Hampshire College), the goal of the meeting was to identify strategies that could be used in Texas to counter the abortion regulations and legal restrictions that are resulting in a severe shortage of abortion services. Journalists have reported that some women in Texas and in other border states are using misoprostol and there have been some legal prosecutions of individual women seeking self-induction. Meeting participants re-examined some of the strategies and questions raised in the “The Best Defense Is a Good Offense: Misoprostol, Abortion, and the Law” report and brainstormed about what to call the self-induction process so as to be informative but not stigmatizing. Research on self-induction in the United States: Dan Grossman (Ibis Reproductive Health) provided an overview of studies undertaken on misoprostol self-use and self-induction methods more broadly: A survey in ob/gyn clinics in New York City (1999), in which 15% of respondents knew someone who had taken misoprostol; they considered it easier and less expensive than an in-clinic abortion. A prevalence study [based on Guttmacher’s 2008 abortion patient survey], which included a question on whether the respondent had ever self-induced (for this abortion or any previous one); 2.6% reported using some method to self-induce (1.2% identified misoprostol specifically). Foreign- born women were significantly more likely to have used misoprostol or another substance, but this outcome was not correlated with a particular race or ethnicity. A study conducted jointly by Ibis and Gynuity (2008-09) involved surveys of 1400 women in health clinics (not while seeking an abortion) in New York, San Francisco, and Boston about their knowledge of and experience with self-induction.