Brownsville, Texas
 
Diana, a slight, 30-year-old office manager wearing a smart blouse and pencil skirt, has a tired note in her voice. In the privacy of her office, she has spent the afternoon discussing an event in her life that she previously never recounted to anyone. She is talking about her abortion. Or maybe her miscarriage. She’s glad she never has to know which.

A single mother of two boys, Diana was unemployed and in the hospital when she began to suspect she was pregnant. It was December 2006, and she had missed her period for two months. Her doctor conducted a urine test, which came back negative, but when Diana still hadn’t gotten her period in January, she started to panic. She knew it wasn’t the right time for another baby. She wasn’t working and had been suffering severe symptoms of brittle diabetes, a rare form of diabetes that requires frequent hospital visits and brings bouts of depression. She felt unstable and wasn’t able to afford her medications. "I thought, If I am pregnant, I want to take something to not be pregnant," she says.

For most women in the United States, this would mean a trip to a doctor or abortion clinic. But where Diana lives, in Brownsville, Texas, just north of the border, Mexican pharmacies are only a few miles away. Items said to be abortifacients—including pills, teas and shots—are well-known to be cheap and accessible just across the bridge. Misoprostol, a pill that makes up half of the two-drug combination prescribed for medical abortions in the United States, is easy to purchase over the counter in Mexico because of its effectiveness in treating ulcers. When used alone and taken correctly, it will produce a miscarriage between 80 and 85 percent of the time.

Meanwhile, the closest abortion clinic, in Harlingen, is some thirty miles away. That might not sound like much, but without a car it is difficult to make the trip discreetly. This was one of several reasons Diana didn’t want to go to the clinic. It was also prohibitively expensive: potentially more than $900, because she was already a few months into her pregnancy. Also, she was scared that the doctor wouldn’t want to operate because of her diabetes. Finally, Diana had been there once before to escort a friend. The whole time she’d felt like she was being judged by the strangers around her; she imagined their eyes on her as she sat waiting.

Widespread opposition to abortion in the Rio Grande Valley may not be obvious at first: it is not discussed in polite conversation. But spend a little time here and the bumper stickers that cry out from cars, the messages that dot billboards on the expressway and the rhetoric inside many churches resoundingly confirm an antiabortion message. There are accessible clinics, and the procedure is legal. But within many women’s homes, their communities, their churches and their minds, a trip to the abortion clinic amounts to a damnable transgression. In fact, abortion is so stigmatized, many women don’t even realize it is legal. Terri Lievanos, who worked for years as an education coordinator for Planned Parenthood of Brownsville, says that this is true even among women born in the United States: "They come in here and say, ‘Wait a second, abortion is legal?’ They’ve only heard it discussed in a negative way."

For Diana, who was born in Mexico and raised in a deeply Catholic household, the prospect of being seen at a clinic was more emotionally taxing than the risk of taking a mystery drug and enduring the consequences at home by herself. A friend told her that he knew where to buy an abortion pill—most likely Misoprostol, although Diana says she doesn’t know its name or what he paid—and drove across the border to pick it up for her. Diana took the drugs, two pills over two days, with no medical guidance. Nothing happened for nearly two weeks. Then she began to bleed. The intense bleeding lasted four days, and she had severe cramps. On the fourth day she began to have painful contractions. A small sac dropped into her toilet. "It wasn’t moving, so I flushed it. I didn’t know what to do. I was scared that if I looked at it, I’d be traumatized for life." Diana called her mother and her sister the next day and told them she’d had a miscarriage. She didn’t mention the pills. They urged her to go to the hospital. "The doctor looked at me, and I was fine," Diana says. "I told them it was a miscarriage. I didn’t tell [them] about the pills."

She doesn’t tell people she had an abortion, she says, because she never went to a clinic. "When people ask me if I had a miscarriage, I’ll tell them yes," Diana says. "I didn’t actually go get the abortion. I don’t know if it’s the pill that actually caused the abortion." As far as Diana is concerned, it’s possible the miscarriage was caused by the drugs. It’s also possible that it wasn’t.

Diana is one of many women along the US-Mexico border who appear to be seeking out drugs like Misoprostol as an alternative to an abortion clinic. Whether this represents a broader trend is difficult to say, given the lack of data and the underground nature of self-induced abortions. But it is hardly a new phenomenon. Even before abortion politics roiled the debate over healthcare reform and the 2009 murder of Dr. George Tiller, many women in the Rio Grande Valley were looking to have abortions in private, in order to escape the scrutiny of their neighbors and the fear of being attacked publicly. It is far easier to be able to say "miscarriage" in a city like Brownsville than it is to admit to an abortion. To protect herself, Diana asked that only her first name be used in this article.

Dr. Lester Minto works at the abortion clinic in Harlingen, a nondescript, out-of-the-way building. He says that some clients first find out about the facility when they are taken there by church groups to protest. "I wear a bulletproof vest to work," Minto says. "If the patient sees me that way, how does the patient feel?"

Minto estimates that some 20 percent of his patients have tried Misoprostol before coming to him. "That tells me there are many more who are using it who don’t need to come to me." Finances are a major factor. "It’s something you can try for a small amount of money," he says. In Texas, abortion care is not covered by Medicaid except in cases of rape, incest and life endangerment—and even in those cases the costs are reimbursed less than half the time. This means that a woman like Diana, without private insurance, could pay anywhere from $450 to more than $900, compared with $87 to $167 for a bottle of Misoprostol in a Mexican pharmacy. "But deeper than that," he adds, echoing Diana’s sentiments, "I am the abortionist. They come to me for an abortion. If I don’t touch them, maybe it wasn’t really an abortion."

At Whole Woman’s Health, an abortion clinic in nearby McAllen, executive director Andrea Ferrigno tries to provide an antidote to the antichoice billboards and fake cemetery erected by antiabortion activists just beyond the clinic’s property. She papers the walls with inspirational quotes, displays stacks of pamphlets about courageous women in history and plays movies on a TV up front to help clients relax. But she knows that even with these measures, some women will still be undone by social pressure. "Women are intimidated; they’re stressed," says Ferrigno. "We need to be protected, but we also want to be visible. I want women to walk out of here with their heads held high." This is an uphill battle. "What we’re dealing with now is thirty-five years of women being very publicly shamed by antichoice protesters," says Gloria Feldt, former president of Planned Parenthood. "Underground abortion is one of the consequences."

Diana moved to Brownsville at 4, but her parents maintained strong ties to their home country. They never discussed sex with her. "It was implied that you wouldn’t have sex until marriage," she says. "It was still a taboo subject." Jackie Christensen, a Brownsville teacher who taught high school health classes for more than two decades, says this is typical. "I would always start the class by asking if the students had ever talked with their parents about sex," she says. "I’d be lucky if one or two raised their hands." It wasn’t until Planned Parenthood came to Diana’s high school to give a presentation about sex and contraception that Diana became informed on the subject. These days, Planned Parenthood is no longer permitted to make such presentations in the district, and contraception is prohibited in the classroom. Christensen says she tried to fill in the gaps for her students but that many health teachers felt too uncomfortable. "A lot of health teachers didn’t want to teach that topic," she says. "They wouldn’t go into detail." Stories of underground abortions were so common that she took to warning against them during health class. "I’d tell my students, ‘If you do things your own way, there could be damage to the uterus,’" she says.

The familiar history of botched abortions has made Misoprostol increasingly popular among women seeking out a less dangerous private alternative to abortion, particularly in places where abortion is illegal. The Planned Parenthood in Brownsville reports visits by women who have used syringes, taken cocktails of prescription drugs, douched with battery acid and beaten themselves in the abdomen to attempt abortion. "These pills are beginning to revolutionize abortion around the world, especially in poor countries," New York Times columnist Nicholas Kristof wrote this summer, noting that the drug would be difficult to ban because of its other uses, which include stopping postpartum hemorrhages. Rebecca Gomperts, founder of the organization Women on Waves, which provides reproductive health services around the world, agrees. "It creates autonomy," she says. "The fact that [women] can just take a medication is huge, because they don’t have to depend on someone else doing something to their bodies."

Gomperts believes that using Misoprostol can actually be preferable to going to a clinic, particularly if a woman has access to information on how to use it correctly, knows how long she has been pregnant and can get medical help if something goes wrong. Still, there are significant risks: if used incorrectly, Misoprostol can cause the uterus to rupture and bring about internal bleeding. "In one of the most extreme cases, the girl took over a hundred pills," Dr. Minto, of the Harlingen clinic, says. "It’s amazing that she survived." Diana, too, was lucky. She now knows that taking the pills that far into her pregnancy was dangerous. She could have caused her child to have birth defects, had the drug not worked and had she carried to term. Or the pills could have caused her to hemorrhage or prevented her from having children in the future. That, she says, scares her.

A number of recent studies looking at self-induced abortions in the United States suggest that women across the country continue to seek out alternatives to clinics that are embattled, increasingly costly and geographically inaccessible. Dr. Dan Grossman, of Ibis Reproductive Health, whose research on the topic has focused on various US cities as well as the Rio Grande Valley, says the group of women attempting self-induced abortion is fairly diverse. An ongoing study by the Guttmacher Institute corroborates this: 79 percent of women who tried self-induced abortion were from the United States, and that number was spread across twenty states.

"I think our findings suggest that there are still significant barriers to abortion care in the United States," Grossman says. "Those include the high cost of abortion care—and in most states Medicaid cannot be used to cover abortion care." Low-income women feel these barriers more acutely. Three-fourths of women who have an abortion say that, like Diana, they cannot afford a child, according to the Guttmacher Institute. Forty-two percent of women having abortions are below the federal poverty line.

Brownsville, located in one of the poorest counties in the country, illustrates this economic divide. Driving through one of the new subdivisions, you could easily assume the city is middle-class. The adobe and brick homes look alike, with tall palm trees punctuating the wide lawns. Lakes where ibises, anhingas and ducks dive for food provide a scenic backdrop for the city’s wealthier families. But Brownsville’s poor neighborhoods resemble those across the snaking Rio Grande and the eighteen-foot border fence along its northern bank. Houses here are cobbled together from cheap wood and scrap metal, dogs run wild and the smell of sewage wafts through the streets. There is no medical school or law school for hundreds of miles, and while many soldiers in the military come from this area, there’s no veterans’ hospital either. As in many poor areas in the United States, health services are often acquired at the emergency room, with little preventive medicine being sought. Here, women don’t often have a consistent relationship with a physician they trust. Instead, care is delivered at times of emergency. In such an environment, a mission like Ferrigno’s at Whole Woman’s Health remains incredibly challenging. Without better healthcare education, affordable coverage and information for women about their reproductive rights, risky, self-induced abortions will continue. A drug like Misoprostol may be proving to be a safer alternative, but it is no substitute for reproductive care that happens out in the open, with the expertise of a medical professional.

For her part, Diana understands this. Now that time has passed, she has reflected on her experience. She knows she took a risk and admits she would have had regrets had things turned out differently. But when asked what she would tell another woman who is seeking an abortion and weighing her options, Diana takes a moment to reply. "Logically, you should go to a clinic," she says. "If you have the money, you should. It’s safer. But the whole thing of being in a clinic like that is, it traumatizes people too. Really, the more private thing and the more convenient thing to do would be to just take the pill."