Brazil – Inside Brazil’s Abortion Pill Black Market

In a country where one woman dies every two days from a botched abortion, the internet is sometimes the only option.

By Leonardo Coelho, a Brazilian journalist based in Rio de Janeiro.

JULY 8, 2022 – Under a run-of-the-mill news clip posted on YouTube in 2012 covering Brazil’s online black market of abortion pills, something strange has happened in the comments section. Even though the video is a decade old, the comments—now totaling more than 68,000—continue to pile up every day.

Nearly all the new comments appear to be from female users with phone numbers in their usernames. Although it’s not entirely clear who these users are, they seem to be promoting mysterious individuals with names like Alice and Maísa who can provide “Cyto.

”“I was caught in a very bad time. r had no financial or psychological stability, so I decided that I didn’t want to carry on with this pregnancy, and ALICE helped me  she was very good to me,” one wrote.

All of these comments are, in reality, advertising extralegal businesses that sell Cytotec, the trade name of misoprostol—an “essential medicine,” according to the World Health Organization, that can treat ulcers, induce labor, and safely terminate pregnancies. Misoprostol is one half of what’s commonly referred to as the abortion pill. (The other half, mifepristone, is not yet sold in Brazil, though misoprostol can still be used on its own with only slightly lower efficacy.)

For decades, misoprostol has been widely sold in Brazil—where abortion is criminalized—as an abortion pill, finding its way to consumers online and on the streets through basic but effective marketing strategies. Yet since it is illegal to buy and sell these pills, the market for them is unregulated, and Brazilians seeking misoprostol are forced to navigate serious legal and medical risks.

Since the U.S. Supreme Court overturned Roe v. Wade, ending the federal right to abortion, demand for abortion pills—including in states where the procedure is now banned—is already on the rise. In the United States, mailing these pills has been cited by the anti-abortion lobby as the next frontier in the fight to ban abortion completely. What’s been happening for decades in Brazil—another major Western democracy with serious abortion restrictions—may offer some clues as to what lies ahead for the United States.

In Brazil, nearly all abortions are illegal, but in practice, they’re widespread. They are only legal in three circumstances: rape, risk to the pregnant person’s life, and fetal anencephaly (a birth defect that affects the brain and skull). Sometimes, not even these parameters are respected in the legal process, as was seen in the recent case of an 11-year-old child who was forced by a judge to carry a pregnancy for weeks after she was raped. The penalty for undergoing an illegal abortion is up to three years in prison.

Yet according to Brazil’s National Abortion Survey from 2016, the most recent year the survey was conducted, nearly 1 in 5 women had undergone at least one abortion by the age of 40, and half of the 416,000 abortions in 2015 were performed using some type of medication, the most common being misoprostol. In a 2018 Brazilian Supreme Federal Court hearing, the Ministry of Health estimated that at least 1 million abortions take place each year, with one woman dying every two days from a botched abortion. 

It all started in the late 1980s, when Brazilian women became the first in the world to realize that misoprostol—which was sold in pharmacies to treat ulcers starting in 1986—could also be used to terminate pregnancies. The drug quickly soared in popularity. It didn’t require a prescription, and it was cheap and safe compared with other invasive abortion methods. The World Health Organization has now recommended misoprostol as a method of abortion for more than a decade. As word spread, the state caught on. In 1998, Brazil registered misoprostol as a controlled substance, and it could no longer circulate legally outside of authorized health facilities.

Brazil—similar to a number of other countries in the region, such as Bolivia, Ecuador, Peru, and Venezuela—now has a “vast black market for abortion pills … where different kinds of unofficial networks operate,” said Alejandra Marks, a doctoral student in anthropology at Tulane University who studies networks of abortion care in Latin America.

Despite Brazil’s strict laws, on the street, misoprostol pills are sold in informal commerce districts and fairs. It recently took a New York Times reporter less than one minute to find a seller on a Rio de Janeiro street.

It’s easy to find misoprostol on the internet too. Marks said Brazilians she has talked to for her research tend to start their search online, typing words like “how to do an abortion” or “Cytotec” into Google and Facebook and quickly finding their way.

Despite its availability, obtaining misoprostol through illegal channels comes with risks.

This is exactly what happened to Bruna, a 37-year-old Brazilian teacher who bought misoprostol online. Bruna, who asked not to use her surname, went straight to Google. “I was too afraid to go to an illegal clinic,” she told Foreign Policy. These clinics are relatively common, but stories like that of Jandyra Magdalena dos Santos Cruz—who was found mutilated, dismembered, and burned after allegedly dying during a botched abortion in a makeshift clinic in 2014—have created a climate of fear around them.

Across social media, ads for Cytotec like those in the YouTube video comments section are common. They are often disguised as content, profiles, and even locations on platforms such as Facebook, Instagram, Google Maps, Pinterest, Twitter, TikTok, and LinkedIn. Many of these profiles feature feminine imagery, with pastel-toned illustrations of women smiling. Others display neutral representations of medicine, including white coats and stethoscopes. Some of these ads evade potential content moderation by using leetspeak, when numbers and other characters replace letters. They also often accompany photos of items that appear to be for sale, such as phone cases or handbags.

The goal of the ads is to funnel potential buyers directly to instant messaging apps, such as WhatsApp, a pipeline that has worked for more than a decade. Although it’s hard to find clear data about the suppliers, reports indicate there is a wide spectrum of providers: from doctors to medical students to poor people serving as mules who transport the drug into Brazil from other Latin American countries.

Comments, reviews, and testimonies—even if they’re fake—are an important part of this process and work to sway potential buyers. Bruna attested to this, as she said she bought the pills from the seller who had the most credible testimonies in an online forum and who identified as a woman.

“I was surprised by the extent to which testimonies from other women—strangers on social media—influenced Brazilian women’s decisions for who to trust and where to buy Cytotec pills,” Marks said, adding that fear and stigma around abortion made her interviewees feel like they could trust strangers (whom they could conceal their identities from) more than their close friends and family.

Despite its availability, obtaining misoprostol through illegal channels comes with risks. It is much more expensive than its retail price (which ranges from 5 cents to $2 per pill in countries where it’s legally sold as an abortion pill), and a pack of pills needed for an abortion often sells for hundreds of dollars. There’s also no regulatory or quality control, and sellers can peddle counterfeit pills or store misoprostol incorrectly, thus making it less effective. (Bruna, for instance, said the first time she bought misoprostol, the pills did not work, and the supplier blocked her after she told him.) Even though complications from using misoprostol are relatively rare, there are occasionally side effects that warrant medical attention. According to the U.S. Food and Drug Administration, about 1 out of 100 women who take misoprostol and mifepristone experiences heavy bleeding that might require a surgical procedure.

Another major medical problem is the lack of necessary information. As Mariana Prandini Assis, a political science professor at the Federal University of Goiás, said: “There are many available studies that show that this is a safe procedure if the protocols are followed. Going into labor is much riskier than performing such type of abortion with proper information.” But many Brazilians do not have that information, and some are unaware, for instance, that taking misoprostol with certain preexisting conditions might put their life at risk.

Compounding these issues is the risk of legal charges. Trials concerning possession of misoprostol have spiked since 2010, according to a recent study in Reports in Public Health (CSP). In 62.5 percent of the cases surveyed, it’s the suppliers who were prosecuted. Suppliers who are caught with misoprostol pills can be charged with crimes against public health, which can result in 10 to 15 years in prison—a penalty higher than that for murder or drug trafficking.

People who undergo abortions sometimes face charges too. In the Brazilian state of São Paulo, at least 30 women were officially charged for self-induced abortions in 2017; most were reported by doctors or nurses they saw after complications from misoprostol. It’s not uncommon to see reports of pregnant Brazilians detained in hospitals after miscarriages that had follow-up care or who were questioned at their homes by authorities after buying misoprostol over the internet.

Not even the Brazilian internet has escaped government overreach. Two internal resolutions by the Brazilian Health Regulatory Agency in 2006 determined that any advertising of misoprostol-based medicines in all media, including online, should be suspended. This April, the Public Prosecutor’s Office gave notice to Facebook to stop the use of WhatsApp in the illegal commerce of medications that induce abortions. In practice, however, these actions have not had much of an impact on online ads.

There is also some genuine societal backlash to misoprostol use. Anti-abortion rights groups and individuals, fueled by a growing evangelical movement, have condemned the pill. Some have even used the tsunami of available content to infiltrate groups of Brazilians seeking the drug and then report users and suppliers to the authorities. As a result, the act of turning to the internet for misoprostol comes with a degree of risk in itself. Still, as Prandini Assis said, “this parallel market undoubtedly creates the possibility of choice in a highly restricted landscape.”

That choice, though, is highly limited. As Anahi Martinho, a 33-year-old journalist from São Paulo, told Foreign Policy, her options when she found herself pregnant many years ago were few and influenced by her doubts, disinformation, and societal taboos.

“I knew about misoprostol, but it was seen as an unsafe and dangerous method used mainly by poorer women,” she said. After saving $1,000 in cash, she had a manual aspiration procedure with an unaccredited doctor who is still well known and sought out by many middle-class women. That day, she said, she went home alone with her fears and malaise. That isolation is similar to the feeling Bruna described, as she sat in her bathroom by herself, her then-boyfriend refusing to accompany her, as she took the pills for a second time.

Regardless of age, class, and race, many Brazilians experience abortion, Marks said, as “an alienating and lonely act that, despite taking place inside the homes they shared with loved ones, was kept secret at all costs.”

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WUNRN

Inside Brazil’s Abortion Pill Black Market (foreignpolicy.com)