Publisher Health

RIO DE JANEIRO — 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 blister 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 by her first name out of fear of prosecution.

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 by the Food and Drug Administration.

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 by video or phone, as required by the F.D.A.

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.

While surgical abortion was the original target of Brazil’s abortion ban, the proscription 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 under one minute of asking to find someone willing to sell eight pills for $300, in a Rio neighborhood 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 any more,” 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 by 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 a 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.

Cytotec is misoprostol, one half of the World Health Organization’s recommended combination of hormones (the other is mifepristone) to carry out a medication abortion. Mifepristone 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 percent 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 hemorrhages from abortions they had tried to induce with the castor root or bleach or coat hangers, said Dr. Ana Teresa Derraik, an obstetrician-gynecologist 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 list 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 Ministry of Health for hospital use.

In 2006, the law prohibiting misoprostol distribution 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 Christian community, access became even more scarce.

International reproductive rights organizations such as Women on Web used to mail abortion pills to Brazil, and local feminist 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 counseling, 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 by the Ministry of Health this month include the assertion that “inducing abortion by telemedicine, using drugs from the special control list, can cause irreversible damage to the woman.”

Dr. Helena Paro, a gynecologist 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 W.H.O. considers the practice safe.

In response to questions from The Times, the ministry said the guidelines reflect that “misoprostol is authorized only in hospital establishments, that its use outside this environment is not allowed” by law and that use of misoprostol for abortion via telemedicine meant women would not have “timely access to health services that can manage the possible clinical or surgical complications resulting from the procedure.”

Dr. Derraik says she has seen an intensification of scrutiny for use of misoprostol in the hospitals where she offers abortion services to women who qualify as well as a simultaneous increase in the level of investigation of women who report miscarriages.

Other women have fallen into police traps. In 2012, a Rio sociologist decided she could not continue her pregnancy — she was already struggling to parent a 12-year-old with intense special needs. The sociologist (who asked to be identified by her first initial, A., because her family does not know about her abortion) went to her gynecologist.

“He said, ‘This medication exists, Cytotec, but I can’t give it to you: You’ll have to buy it from the black market’,” she recalled.

She found a website, ordered the drug and paid several months’ salary for it, but the package never arrived: She was tracking it online, and watched it stall when it entered the country.

She found a drug trafficking contact through a friend of a friend and bought a second batch, took the drug at home and ended the pregnancy with no complications — her only regret being that she had to be alone through a frightening process.

A year later, a letter arrived summoning her to the police. She thought it was about her car, which had been stolen the year before. But when she arrived, a male officer asked her, “Do you know what Cytotec is?”

She said she did. He asked if she had bought it. She could see he had her credit card information from the purchase on the paper in front of him, so she admitted she had.

He asked if she had carried out the abortion. She replied, “Of course not — the medication never arrived.”

It turned out that police were monitoring the website where she bought misoprostol, traced the package and said they would charge her with unlawful purchase of a controlled substance. After several years of hearings, she entered an alternative sentencing program and performed 60 hours of community service. She continues to have to report her whereabouts to police and cannot leave her state.

Women’s reliance on the black market for access to medication abortions means they may not follow best medical practice. When C., a 24-year-old teacher in Recife, bought misoprostol from a drug dealer last year, she searched Google to figure out how to take it. “Because it was illegal, there was no information about how to take it or what to take,” she said.

Her search found recommendations to insert the tablets in her vagina, as a doctor would if she were in a clinic, but cautioned that traces might be left behind and give her away if she wound up in hospital; instead, she dissolved them under her tongue, a method that also works but less quickly.

C., who asked to be identified only her middle initial out of fear of prosecution, bled for weeks after and wanted to ask her mother, a gynecologist, for advice. But her mother is an anti-abortion activist. Finally, C. said she thought she had miscarried, and her mother took her to see a colleague who performed a dilation-and-curettage under anesthetic.

“When I was having the curettage, I had to keep saying over and over to myself, ‘Don’t say anything, you can’t say anything’ — it was torture,” she said. “Even though I was totally sure that I wanted an abortion, I had no doubts, you still feel like you’ve done something wrong because you can’t talk about it.”

The restriction on misoprostol has complicated regular obstetric care, which uses on the drug for induction of labor, said Dr. Derraik. At the Rio public maternity hospital where she is medical director, a doctor must fill out a request in triplicate for the drug, have it signed by Dr. Derraik, take it to the pharmacy where the supervisor must also sign before taking it out of a locked cabinet, and then the physician must administer the drug with a witness, to ensure it is not diverted for black market sale.

“Not all of these steps are officially required,” Dr. Derraik said. “But hospitals do them because of the intense paranoia around the drug.”