This article was originally published in October 2016. In light of the recent abortion laws passed in Georgia and Alabama, we're reposting it.
When RAfound out she was pregnant, she had two options: Have a baby she did not want or risk her life and face prison.
RA, who was born and raised in Dubai, lives with her husband and two children in Egypt, where abortion is illegal, except to save a woman's life. Women who voluntarily induce abortions face criminal charges and up to three years in prison.
"I already had a girl and a boy, so the best of both worlds," says RA. "It's not easy raising kids in Egypt — financially, culturally and psychologically — and I didn't want another baby."
RA found doctors who could help, but they either advised against abortion, insisted on surgery or were illegal "under the staircase" doctors — notorious for abusing their power over women.
Instead, she scoured the internet for alternatives and found articles discussing the use of methotrexate, normally used to abort pregnancies that occur outside of the womb, a complication known as an ectopic pregnancy.
RA's pregnancy was healthy, but out of desperation, she took the methotrexate.
"It was a huge risk, but I felt so helpless, like I couldn't even control my own body," she says. "I cried for days. I hated the situation I was in."
The methotrexate failed. RA went back to the internet in search of help. Eventually, she came across Women on Web, an online-only abortion service that conducts free web-based medical consultations and mails eligible women pills for medical abortions. It saved her life.
Since it was founded by Dutch physician Rebecca Gomperts in 2005, more than 200,000 women from 140 countries have completed Women on Web's online consultation, and approximately 50,000 women have performed medical abortions at home. Women on Web's helpdesk answers 10,000 emails daily in 17 languages, and the website attracts almost one million unique monthly visitors.
But before Women on Web became a safe harbor, it was a rogue vessel on the open ocean.
Abortion On The High Seas
Shortly after graduating from medical school in 1994, Rebecca Gomperts set sail with the Rainbow Warrior, Greenpeace's "purpose-built campaigning ship," as the ship's doctor. As the Rainbow Warrior sailed around South America campaigning, Gomperts witnessed the way women without access to reproductive health services suffered, and that among those women it was the poor, young and marginalized who suffered the most.
"Lack of access to abortion is all about economic and social justice," says Gomperts. "Women that have enough money and the proper information will always be able to access an abortion, but all women deserve information about their health."
The World Health Organization estimates that, worldwide, 19 to 20 million unsafe abortions are performed each year, "done by individuals without the requisite skills, or in environments below minimum medical standards, or both," according to a 2006 report. Of those abortions, 97 percent occur in developing countries, where according to research from Brigham and Women's Hospital, a woman dies every eight minutes from an unsafe abortion.
Gomperts's experience on the Rainbow Warrior sparked a radical idea: What if you built a ship that sailed to countries where abortion is illegal and provided safe medical abortions in international waters, where Dutch laws reigned on-board? Women on Waves was the answer.
In 2001, the Aurora, outfitted with a mobile abortion clinic and staffed by doctors and nurses trained in abortion care, set sail for Ireland. A lack of licenses kept them from performing any procedures in their maiden voyage. But over the next decade, Women on Waves sailed to Poland, Portugal, Spain and Morocco, facing steep resistance but attracting international attention along the way.
The "abortion boat" was more than a maritime women's health clinic — it became a symbol of resistance and defiance, a piratical "fuck you" to governments that claimed power over women's bodies and autonomy.
The ship not only provided desperate women with a service, but also triggered worldwide debates about abortion and helped catalyze meaningful change in the nations it visited. Most notably, Spain and Portugal have both liberalized their abortion laws in the years since.
While it made a dramatic statement, ferrying women back-and-forth to a boat anchored 12 nautical miles offshore was not a sustainable strategy. Only a handful of women were able to access direct abortion care aboard the ship. Some countries, like Portugal and Morocco, prevented Women on Waves from even entering their waters. Women on Waves provided support to as many women as it could in these countries through phone hotlines, but millions of women remained.
"After the ship campaigns, we got emails from women all around the world asking when we would be in their country because they needed an abortion," says Gomperts. "The ship turned out to be better as an advocacy campaign for raising awareness about medication abortion, and we decided if it's only a pill, it should be possible to mail it."
Gomperts wanted to make Women on Waves more accessible, but couldn't quite figure out how. Then, on New Year's Eve in 2003 it hit her: Why not bring Women on Waves online? Women on Web was born.
She received funding from Hivos, a Dutch humanitarian organization, to conduct initial research and get the infrastructure and website off the ground. Gomperts then found lawyers to help conduct legal research about abortion and pharmacy laws around the world, hired a team to build the website, scouted potential partners to provide the medication and worked with doctors to create a consultation process that was safe.
The Doctor Will See You Now… Sort Of
Women seeking medical abortions with Women on Web start with an online consultation of around 25 questions, based on the protocol from the World Health Organization. It includes the same standard roster of questions that women are asked when seeking abortion care in a clinic: Determining the state of her pregnancy, the motivations behind seeking an abortion, her location and her medical history.
The risk of an online consultation is that patients could massage the truth. A woman who is 12 weeks pregnant could say she is eight, or a woman could fail to disclose that she has severe anemia, and Women on Web's doctors would have no way of knowing these disclosures were false. However, Vicki Saporta, President and CEO of the National Abortion Federation, says this is not a serious concern.
"Women who want to know this is going to be safe and effective are inclined to tell the truth to a healthcare provider," says Saporta. "It is not in their best interest to provide medical misinformation, but there also are not many contraindications with this medication. It's very, very safe and the percentage of complications is very low."
Following the consultation, women are asked to pay a donation of $101, but they can still access the service even if they cannot afford the full amount (or anything at all). Part of Women on Web's policy is that no woman will be denied care. Around 75 percent of the women who use Women on Web pay the full $101, which, according to Gomperts, offsets the costs for the women who can't.
Women on Web runs entirely on donations, both from women who access the service themselves and from people who support their mission.
"We call the donation system a 'chain of solidarity,'" said Hazal Atay, a coordinator at Women on Web. "In many countries where there are available services, it is not covered by the insurance or just not affordable. We help women in places where they face economic hurdles, as well as legal restrictions."
Once a woman has completed the consultation and made the donation, her information is passed on to one of Women on Web's doctors, who writes a prescription for the medical abortion pills: Misoprostol and Mifepristone. The prescription is sent to Women on Web's partner in India, a company called NN Agencies, which buys the pills from Indian manufacturers and dispatches them where they need to go.
"I was scared because I could be prosecuted if anyone found out, but it was a lot smoother and quicker than I expected," says RA. "I answered the questionnaire, sent my donation, and my address. Then I received emails about what I should expect when I take the pills. I completely aborted at five-and-a-half weeks."
No Clinic Necessary
Medical abortion emerged as a method for first trimester pregnancy termination with the availability of prostaglandins in the early 1970s and anti-progesterones in the 1980s. A stockpile of research has found that the "combined method" — meaning a combined regimen of Mifepristone and Misoprostol — is a safe and effective procedure for an abortion up to 63 days.
Less than 1 in every 100,000 women who have a medical abortion die, meaning it's safer than a colonoscopy and death is less likely than getting hit by lightning. Taken together and correctly, these drugs are more than 95 percent effective. They are included on the WHO's list of essential medicines.
For the medication to work — whether using the combined method, Misoprostol alone or Mifepristone alone (the latter two methods work, but are less effective) — following the regimen is key. Women on Web has women take a sequence of seven pills, but they send nine, including two extra Misoprostol tablets, just to be safe.
The protocol for taking medical abortion pills is not quite as simple as swallowing a couple of Advil. There are specific steps to follow — Mifepristone is swallowed, Misoprostol dissolves under the tongue — and sequence matters. The pill packets come with instructions, but they may not be in the woman's native tongue, which is why upon prescribing the pills, Women on Web sends the recipient an email with detailed instructions, in her own language, for how to take them. The organization is able to send these instructions and answer questions in 17 different languages.
"A preponderance of evidence is very clear that these drugs are incredibly safe and effective if women know how and when to take them," said Dr. Caitlin Gerdts, a reproductive epidemiologist who studies abortion at Ibis Reproductive Health. "Nothing that a clinician is doing when they hand a woman a pill is any different than what she does when she takes it herself. Women, with the right information, can safely use these medications on their own with a very low risk of complications."
Dr. Daniel Grossman, a professor at the University of California's Bixby Center for Global Reproductive Health, led a study which found that the use of telemedicine for early medical abortion is as safe and effective as going into a clinic. Telemedicine, says Grossman, is an accepted medical practice for many types of care, and abortion is no different.
"We showed the model [of medical abortion via telemedicine] was safe and effective — with similar results to the same service provided with an in-person visit with a physician," Grossman says. "We also found that women really liked the service, and some measures of satisfaction were significantly higher among telemedicine patients compared to those with an in-person visit."
Abortion is shrouded in so much fear, misinformation, regulation and stigma that the notion of filling out an online questionnaire and then taking pills at home can seem almost too easy, reckless even. However, expert after expert insisted that the risks are minimal and the service essential.
"Women on Web were pioneers in providing medical abortion care over the web," says Saporta. "It is one of the reliable sources of information and medication, where women are not only assured of getting the correct medications, but can also get their questions answered and learn the effective regimens to take. In many countries, it is much riskier to carry the pregnancy to term."
Help, In Over A Dozen Languages
Searching on the internet for information about abortion and abortion pills can yield a litany of lies, judgement and fear-mongering. It can also direct women towards disreputable online services that exploit their vulnerability and desperation in order to sell pills that are placebos at best and something harmful at worst.
"There is so much bad information and scams on the internet and I think a lot of women feel very uncertain," says Gomperts.
Aside from wanting to empower women with as many facts as possible, Gomperts says Women on Web's information-heavy site and helpdesk service is intended to emphasize its legitimacy and trustworthiness.
"Our main work really is the helpdesk," she says. "To have someone who is there with women and supports them morally and mentally is extremely important."
The helpdesk serves as a knowledgeable guide through what can be a taxing, frightening process. Many of the hundreds of thousands of helpdesk emails that Women on Web receives contain questions that are already answered on the site. The barrage represents women reaching out through the anonymous tangle of the internet for reassurance that everything will be okay.
"Women always ask about instructions, even though we send clear instructions about what to do," says Atay. "They want to have a general understanding of what will happen to them. Most of the time, even in countries where abortion accessible, the process can still lead to isolation. It's still taboo to talk about and women feel the need to reach out to someone."
Atay said many women who communicate with the helpdesk are grappling with their own views on abortion. Part of working on the helpdesk is empathizing with each woman, helping them process what may be a churning knot of emotions, and providing support that respects their beliefs and cultural context.
"I often see women saying, 'Normally I am against abortion, but I need it now,'" she says. "They auto-censure themselves because of the public pressure, yet at the same time, they are determined to terminate their unwanted pregnancies and don't care about restrictions they face."
Women on Web's helpdesk staff is comprised of around 20 people, a mix of full-time employees, supervising doctors and volunteers who pledge to anonymously answer every of the 10,000 monthly emails within 24 hours. Every helpdesk staffer goes through an extensive training program that can take up to a month or longer to complete. Part of the training focuses on delivering information in supportive, positive manner.
"Having people help you without judging you — I wasn't used to that," says RA. "At the very least, I expected emails advising me against it. With Women on Web, I felt it was my decision, my right. Those feelings were indescribable. I felt relieved and empowered."
Leticia Zenevich has worked for Women on Web for two years on the helpdesk and more recently, as a campaign officer. She is originally from Brazil, and when she was 18 and pregnant in a country where abortion is a criminal act, she turned to Women on Web. Now, nearly 10 years later, she has completed law school and moved to Amsterdam. Zenevich speaks five languages — Portuguese, English, Spanish, French and Italian — and mans the helpdesk in all five.
"The levels of engagement from women vary deeply — some don't want to share their stories, but others need to, and we leave it open to them to establish the level of dialogue and intimacy," Zenevich says. "I think it works better as anonymous. Many women tell us we are their only friends, and it's heartbreaking because they don't even know our names."
Even through the veil of anonymity, certain cases are more difficult than others, and women's stories, if not their identities, stick with the people on the other side.
"Rape cases and cases with pregnant girls, also many times involving rape, are especially hard," Zenevich says. "Now we are in touch with a 14-year-old from Argentina who is pregnant. She's very nervous and alone and cannot trust anyone in her safety net. We're the only ones she can talk about her pregnancy with. As much as we want to reach her, the screen that allows us to exist and work globally also works as a barrier: there's only so much we can do and reach from behind it."
By Sea, Air Or Land
Sending the pills through the mail is something of a last resort. Before writing a prescription, or if a woman is does not meet the eligibility requirements, Women on Web explores other options. For example, some women in Ireland may be able to travel to England for the procedure. A recent study from the UK government found that 3,451 women from Ireland travelled to England and Wales for an abortion last year.
In many countries, Misoprostol, which is often sold under the brand name Cytotec, is available in pharmacies and is used to prevent and treat gastric ulcers. Gomperts said that in countries where Misoprostol is readily available, like Colombia and Morocco, Women on Web directs women to purchase the pills locally, while still providing guidance and support via the helpdesk.
"We have a whole database of what is available around the world," Gomperts says. "But there are a lot of women who can only access medicines through our service."
Another obstacle that Women on Web faces is customs. In countries like Ireland, the Philippines and Brazil the packages are frequently intercepted. Gomperts says that if Women on Web cannot guarantee the package will arrive, promising the pills would be an abuse of women's trust.
"In some countries, we can't navigate the legal system," Gomperts says. "For us, it's really important, if want to be sustainable, to work in a way that is legal, and if customs stops packages, there is not much we can do."
In those instances, Women on Web asks patients to provide mailing addresses outside of their country. For many women, especially those Women on Web hopes to reach, traveling to another country isn't a feasible option. But if she can travel, they will provide guidance — a woman in Brazil could be guided to Uruguay, or an Irish woman to England. And there are tips in the "I Had An Abortion" section of the website, where women share their personal stories, for retrieving the package.
Ships that delicately skirt the boundaries of legal and illegal; illicit packages that traverse the world to slip through customs unnoticed; an international network of anonymous support; underground distribution chains; even surreptitious drone delivery — collectively, the work of Women on Waves and Web reads like the stuff of spy movies.
But the protagonists of these stories are not international men of mystery or secret agents holding the fate of humanity in their hands. They are women fettered by governments that deny them the right to determine their own fates, who turn to the internet for hope, for choice, for salvation.
And somewhere, on the other end of a computer screen, is a coalition of doctors, nurses, polyglots, activists and volunteers, ready and able to help.
"Women on Web is still discriminatory against women who don't have access to the internet or are illiterate," says Gomperts. "This is why we will never stop fighting for legalizing abortion, because in the end, that is what will really make the difference for all women, not just women that are lucky enough to find an online service."
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