For Privacy's Sake, Taking Risks to End Pregnancy

The New York Times January 5, 2009

For Privacy’s Sake, Taking Risks to End Pregnancy
By JENNIFER 8. LEE and CARA BUCKLEY
Amalia Dominguez was 18 and desperate and knew exactly what to ask for at the small, family-run pharmacy in the heart of Washington Heights, the thriving Dominican enclave in northern Manhattan. “I need to bring down my period,” she recalled saying in Spanish, using a euphemism that the pharmacist understood instantly.

It was 12 years ago, but the memory remains vivid: She was handed a packet of pills. They were small and white, $30 for 12. Ms. Dominguez, two or three months pregnant, went to a friend’s apartment and swallowed the pills one by one, washing them down with malta, a molasseslike extract sold in nearly every bodega in the neighborhood.

The cramps began several hours later, doubling Ms. Dominguez over, building and building until, eight and a half hours later, she locked herself in the bathroom and passed a lifeless fetus, which she flushed.

The pills were misoprostol, a prescription drug that is approved by the Food and Drug Administration for reducing gastric ulcers and that researchers say is commonly, though illegally, used within the Dominican community to induce abortion. Two new studies by reproductive-health providers suggest that improper use of such drugs is one of myriad methods, including questionable homemade potions, frequently employed in attempts to end pregnancies by women from fervently anti-abortion cultures despite the widespread availability of safe, legal and inexpensive abortions in clinics and hospitals.

One study surveyed 1,200 women, mostly Latinas, in New York, Boston and San Francisco and is expected to be released in the spring; the other, by Planned Parenthood, involved a series of focus groups with 32 Dominican women in New York and Santo Domingo. Together, they found reports of women mixing malted beverages with aspirin, salt or nutmeg; throwing themselves down stairs or having people punch them in the stomach; and drinking teas of avocado leaf, pine wood, oak bark and mamon fruit peel.

Interviews with several community leaders and individual women in Washington Heights echoed the findings, and revealed even more unconventional methods like “juice de jeans,” a noxious brew made by boiling denim hems.

“Some women prefer to have a more private experience with their abortion, which is certainly understandable,” said Dr. Daniel Grossman, an obstetrician with Ibis Reproductive Health in San Francisco, which joined Gynuity Health Projects in New York in conducting the larger study. “The things they mention are, ‘It is easier.’ It was recommended to them by a friend or a family member.”

Dr. Carolyn Westhoff, an obstetrician at NewYork-Presbyterian/Columbia University Medical Center, said the trend fits into a larger context of Dominicans seeking home remedies rather than the care of doctors or hospitals, partly because of a lack of insurance but mostly because of a lack of trust in the health care system. “This is not just a culture of self-inducted abortion,” she said. “This is a culture of going to the pharmacy and getting the medicine you need.”

Physicians say that women can obtain the pills either through pharmacies that are willing to bend the rules and provide the medicine without a prescription or by having the drugs shipped from overseas.

It is impossible to know how many women in New York or nationwide try to end their pregnancies themselves, but in the vibrant, socially conservative Dominican neighborhoods of Upper Manhattan, the various methods are passed like ancient cultural secrets. In a study of 610 women at three New York clinics in largely Dominican neighborhoods conducted eight years ago, 5 percent said they had taken misoprostol themselves, and 37 percent said they knew it was an abortion-inducing drug. Doctors and community leaders say they have not seen any signs of the phenomenon disappearing, which they find worrisome because of concerns about the drug’s effectiveness and potential side effects.

Sold under the brand name Cytotec, misoprostol is approved to induce abortion when taken with mifepristone, or RU-486; doctors also sometimes use it to induce labor, though it is not approved for that use. A spokesman for Pfizer, which manufacturers Cytotec, declined to comment beyond saying that the company does not support the off-label use of its products and noting that the label includes “F.D.A.’s strongest warning against use in women who are pregnant.”

That warning, in capital letters, also notes that the drug “can cause abortion.”

But it does not always do so, not least because notions of how best to use it vary from inserting several pills into the vagina to letting them dissolve under the tongue. The side effects can be serious, and include rupture of the uterus, severe bleeding and shock.

“We do worry because we don’t know where women are getting the instructions from,” said Jessica Gonzalez-Rojas of the National Latina Institute for Reproductive Health, which was also a partner on the Ibis study. “We imagine that there is misinformation on how to take it, which is why it could be hit or miss.”

In 2007 in Massachusetts, an 18-year-old Dominican immigrant named Amber Abreu took misoprostol in her 25th week of pregnancy and gave birth to a 1-pound baby girl who died four days later; a judge sentenced her in June to probation and ordered her into therapy. In South Carolina in February, a Mexican migrant farm worker, Gabriela Flores, pleaded guilty to illegally performing an abortion and was sentenced to 90 days in jail for taking misoprostol while four months pregnant in 2004. A Virginia man, Daniel Riase, is serving a five-year prison sentence after pleading guilty in 2007 to slipping the pills into his pregnant girlfriend’s glass of milk.

Researchers studying the phenomenon cite several factors that lead Dominican and other immigrant women to experiment with abortifacients: mistrust of the health-care system, fear of surgery, worry about deportation, concern about clinic protesters, cost and shame.

“It turns an abortion into a natural process and makes it look like a miscarriage,” said Dr. Mark Rosing, an obstetrician at St. Barnabas Hospital in the Bronx who led the 2000 study, which was published in the Journal of the American Medical Women’s Association. “For people who don’t have access to abortion for social reasons, financial reasons or immigration reasons, it doesn’t seem like this horrible thing.”

Ms. Dominguez, for her part, said she had no insurance or money to pay for an abortion, and could not fathom getting one for fear her mother would find out. One of her friends had spent $1,200 on an abortion that left her with a uterine infection, and another friend endured the procedure without anesthesia, she said. In addition, Washington Heights is a tightknit community where abortion — as well as birth control — is shunned; if Ms. Dominguez were spotted entering a clinic, rumors could fly.

“There are scary moments, and you got to have a friend right next to you,” said Ms. Dominguez, now 30 and a mother of four. “It’s cheap but dangerous. Certain people are more delicate than others. But afterwards, I felt relief.”

A friend of Ms. Dominguez’s said her stepsister took the pills last year because she was in the country illegally, and worried that a doctor might turn her in. “She was just scared,” the woman said, speaking on the condition that her name not be published to protect the stepsister’s privacy. “She had no papers, no insurance, no nothing.”

The woman went to a free clinic afterward to make sure the pills had worked (they had). Health care workers and other community leaders say such visits are how they discovered widespread illicit use of the drug as well as homemade potions.

Dr. Rosing said he learned about Cytotec during his residency at NewYork-Presbyterian/Columbia hospital in Washington Heights, where he saw a lot of Dominican immigrants with incomplete abortions in the emergency room. They spoke of taking the “star pill,” a nickname for the hexagonal shape of one form of misoprostol. He suspected “that has to be the tip of the iceberg,” he said, “and it was.”

The pills allow pregnant women a degree of denial over what is taking place. Like Ms. Dominguez, many women in the neighborhood talk about the need to bring on — or “down” — their periods, not abortion. Afterward, they might tell doctors or relatives they had lost the baby.

The Planned Parenthood study concluded that women in both nations “seemed to see inducing the termination of pregnancy, or abortions, as a part of the reality of their lives,” in a community where, as one interview subject put it, “we are all doctors.” The report noted that in a culture steeped in machismo, birth control is generally seen as the woman’s responsibility.

“If I introduce the condom into a relationship, I’m basically saying I’ve had somebody else, and I’ve not been faithful to you,” said Haydee Morales, a vice president at Planned Parenthood of New York.

Debralee Santos, program director at Casa Duarte, a community arts organization in Washington Heights, said that while she had never had reason to distrust medical professionals, she understood the apprehensions that kept other women from seeking them out. “I get it, I really do,” she said.

“It’s a community that, even as it comes of age, always relies on itself first,” explained Ms. Santos, who was born in the United States to immigrant parents. “Women, in particular, continue to help each other in ways that speak to tradition and solidarity.”

Ms. Dominguez, who volunteers at Casa Duarte and is known as Flaca, Spanish for skinny, did not want her name or photograph published at first. But after some thought, she decided to allow it so more people would learn about the trap many pregnant Dominican women feel they are in.

“It’s a health risk,” she said. “There’s a lot of girls in situations like that, and they’re overwhelmed.”