Aug. 16, 2010 -- Kelly, a part-time hairdresser from Atlanta, took five little white pills at 7 a.m. and will take five more before her 6-week-old fetus is completely aborted.
"I am going through this as we speak," said Kelly, who did not want her last name used. "What I read about it was really scary. I didn't sleep at all last night, I was so anxious."
At first, the cramping pain and bleeding was "like a bad period" -- but later "it got worse" and even the painkiller hydrocodone didn't help. But Kelly could deal with the emotional event in the privacy of her own home and at about half the cost of a surgical abortion..
Kelly induced a miscarriage with misoprostol, sold under the brand name Cytotec, an FDA-approved drug for treating stomach ulcers. But it also has an off-label use that is a both a blessing and a curse.
Safe and effective, the drug is used globally to prevent women from post-partum hemorrhaging and is widely prescribed in combination with RU-486 in the United States to induce miscarriage.
But for some low-income women, misoprostol has become a do-it-yourself abortion tool.
That wasn't the case with Kelly. An ultrasound revealed her fetus had no heartbeat and she would eventually miscarry. But like many women, she elected a medical rather than a surgical procedure because it was cheaper and carried a lower out-of-pocket cost -- about $20 for the prescription.
Kelly is under the care of a doctor, but many women, particularly immigrants, are uninsured or don't have access to health care, and end up in emergency rooms or without professional care when things go wrong.
In 2007, a Massachusetts teenager took misoprostol in an attempt to induce a miscarriage at 25 weeks and the 1-pound baby was delivered prematurely and died. Amber Abreu, who was 18, faced murder charges that were later dismissed.
Health experts say illicit use of the drug underscores the barriers that many women face when trying to access reproductive care, particularly immigrants and women of color.
They worry that the amendment in the passage of the new health care law to ban the use of federal funds in Medicaid and insurance exchanges for abortion could further marginalize women's access to reproductive care.
"What the amendment does is if you are poor, you cannot get an abortion," said Jessica Gonzalez-Rojas , deputy director of the National Latina Institute for Reproductive Health (NLIRH). "Wealthy women can pay out of pocket and have access to clinics and services."
Under current law, abortion funding is prohibited through a patchwork of policies, most of which must be annually reapproved in appropriations bills. Now, Congress will consider the "No Taxpayer Funding for Abortion Act," which proponents say will provide a consistent government-wide prohibition on abortion funding.
The bill would also codify the so-called conscience clause known as Hyde-Weldon, offering protections for medical workers who refuse to participate in abortions. Only an act of Congress could reverse the law if it passes.
Kelly understands the prohibitive cost of abortion, but supports restrictions on federal funding.
"A woman can choose to do what she wants, but it's up to her to pay for it," she said. "It's not up to insurance or Obama care. It's not the government's responsibility. I stand 100 percent for choice, but not with my tax dollars."
Although the numbers are declining, 1.2 million abortions were performed in the United States in 2005, the last year statistics are available, making it a one of the most common procedures undergone by women. An estimated 40 percent of all women will have an induced abortion in their lifetime, according to the Guttmacher Institute.
The median cost for a first-trimester abortion is $430 and for a second trimester procedure, $1260, according to a study published in the February issue of the journal, Contraception.
As a group, women aged 24 to 34 are more likely to be uninsured and to have an abortion. Their out-of-pocket medical expenses can be as much as 10 percent of their annual income. Women pay more out of pocket than men and the gender disparity will worsen as health care reform further restricts access, according to researchers.
"We just want a fairer playing field," said Gonzalez-Roja. "We want women to [seek an abortion] in a clinic that is safe, accessible, affordable and culturally competent."
The use of misoprostol is often seen in the Hispanic community, where a self-induced abortion is known as, "bringing your period down."
Women call them "star pills" for their hexagonal shape and they are commonly used in Latin America where abortion is illegal, turning a shameful procedure into something that looks like a miscarriage.
American immigrants can obtain them for about $2 a pill from relatives overseas or in bodegas and pharmacies.
Finding the exact numbers of women who use the drug is "a challenge," according to Gonzalez-Roja. "The issue is very stigmatizing and is spoken in quiet and secrecy and we don't hear from women when it happens."
Misoprostol: 'New Solution to Old Problem'
In a recently completed survey by Ibis Reproductive Health and Gynuity Health Projects of about 1,500 women in New York, Boston, San Francisco and along the Texas-Mexico border, about 4 percent of ever-pregnant women admitted using the drug or some other method to self-induce an abortion.
"Forever, women have used things to end an unwanted pregnancy, and misoprostol is a new solution to an old problem," said Dr. Daniel Grossman, a San Francisco obstetrician gynecologist and a researcher with Ibis Reproductive Health.
"They are using a lot of different kinds of methods, including throwing themselves down the stairs and being punched in the stomach," he said. "In Michigan a young woman told her boyfriend to beat her with a toy bat to try to induce an abortion."
Grossman said use of misoprostol is not common, and though women do face economic barriers, they also have misinformation about abortion procedures and services, often relying on friends and family for advice, rather than health professionals.
"The important issue here is to look at why women do this," said Grossman. "It really comes down to barriers women face accessing abortion care. Restrictions we put on abortion access, like parental consent and denying public funding, end up forcing some women to kind of take matters into their own hands."
Misoprostol, a prostaglandin inhibitor, is usually used as part of a two-part FDA-approved medical abortion with mifepristone or RU486.
Alone, it is routinely used off-label for obstetrical and gynecological procedures such as cervical ripening, labor induction and mid-trimester terminations. Sometimes, as in Kelly's case, it is used to induce a miscarriage in an early pregnancy, typically up to nine weeks, but can be used through the second trimester.
In the U.S., only 1 in 8 women elects a medical abortion.
In combination, the two drugs are 95 to 97 percent effective; taken alone, misoprostol is only 80 to 85 percent effective, and is suspected of causing birth defects if it fails.
After care is critical to ensure the pregnancy tissue is expelled to prevent infection. Doctors also recommend that women live within two hours of a hospital.
Stacie E. Geller, director of the National Center of Excellence in Women's Health, at University of Illinois, said misoprostol is a "wonder drug" that has cut childbirth deaths by 50 percent in countries like India.
Birth Control, Abortions Are Unaffordable for Uninsured
"Women all over the world have been getting their hands on misoprostol and have been using it for years," she said.
When used for abortion, it is only slightly less effective, but there needs to be adequate medical follow-up, even used in combination with RU486.
"Having a medical or surgical abortion has fewer risks and lower mortality rates than a pregnancy, so we have to put that in perspective," said Geller.
Women turn to do-it-yourself methods for multiple reasons -- distrust of doctors, cultural shame and even lack of transportation to health clinics -- but the underlying factor is cost in a population that is largely uninsured.
About 38 percent of all Hispanics are uninsured -- 57 percent in the reproductive age, according to NLIRH. Even those who have insurance say out-of-pocket costs for birth control are prohibitive.
Jersey Garcia, a Dominican-American from Miami, has two children, and even though she and her husband have a combined income of $75,000, they struggle to pay for birth control.
"I had a baby three months ago and it was a planned pregnancy," said Garcia, 34, "Now, I don't want to get pregnant and I am trying to get insurance to pay for my birth control and I can't afford it."
She can't take birth control pills, which carry a co-pay of $40 a month, and wants to get an IUD (intrauterine device), which will cost $800 out of pocket. Now, she spends $20 a month on condoms, which are not reimbursed.
"To some people that might not seem like a lot, but when you have to pay the mortgage, food, day care, transportation and insurance, it is," she said. "We can't add another expense to the monthly budget."
"We are trying to live the American dream and be responsible and pay our bills and to plan our pregnancies and take care of our families," said Garcia.
Without access to birth control, abortions will be inevitable, according to Garcia, who advocates full-time for Latinas.
Even she had a close family member who ended up in an emergency room, hemorrhaging after taking misoprostol with a friend. "She nearly lost her life," said Garcia.
Gonzalez-Roja said the issue transcends the politics of abortion.
"There is a perception that Latinas are not pro choice, and many women we work with have different feelings about abortion, but we all agree about access," said Jessica Gonzales-Roja. "It shouldn't be restricted. We have all seen friends die in underground abortions. We know the reality of what happens when abortions are not legal."