Hard to swallow

To millions of Latin American women denied legal abortion, pills originally designed to treat ulcers have become a controversial symbol of hope. Louise Rimmer investigates

When Viviane Borges Coutinho found out that she was four months pregnant last year, she knew exactly what to do. Still breastfeeding her 10-month-old son, with no job and no partner, she knew she didn't have the resources to raise another child. After making enquiries, she made the two-hour journey from her home to a street vendor in central Rio de Janeiro. There, she exchanged the money she had saved up for two tablets of the anti-ulcer drug Cytotec - Latin America's clandestine solution to the illegality of abortion.

Every woman in Brazil knows about Cytotec. How to swallow one, then insert the other. How it brings on sickness and diarrhoea, but eventually rids them of a pregnancy that for many impoverished women would be untenable. Coutinho was simply doing the same thing as thousands of other women.

But this time it went wrong. After suffering severe stomach cramps, she was persuaded by worried friends to go to hospital. Within minutes, an angry doctor detected the Cytotec and accused her of killing her child. Coutinho was left alone and in agony. Eventually she went to the bathroom, where she expelled the dead foetus. This time the medics accused her of homicide by attempting to flush the foetal remains down the lavatory. Haemorrhaging badly, Coutinho went into a state of shock. The next thing she knew, a policeman was handcuffing her to her bed. The nightmare, which would lead to two months in Rio's most notorious jail, had begun.

"I didn't see my boy for all that time. I couldn't believe it was happening," says Coutinho, who suffered further haemorrhages in prison but received no medical attention. Her trial is pending until evidence from the autopsy on the foetus is available. Meanwhile, human rights lawyers are trying to lower her crime from homicide to that of performing an illegal abortion.

Abortion is a taboo subject in the world's most populous Roman Catholic country. When a soap opera tackled it in a storyline earlier this year, people were outraged. Yet illegal abortion is widespread: between one million and four million are being carried out each year. The penalty for a woman who conducts an abortion on herself is between one and four years' imprisonment, with two to 10 years for a practitioner who performs a procedure. Although prosecution is rare, Advocaci, a human-rights group that is helping to defend Coutinho, says it may be on the increase. Last week, a woman was taken to prison straight from hospital in the state of Rio de Janeiro. The police were tipped off by an anonymous caller; she was arrested as she bled.

Botched home abortions are stretching the resources of the country's health system. According to Health Ministry figures, there were 242,000 cases of women seeking treatment for post-abortion complications in 2001. But it's Brazil's poorest women who suffer most as a result of the abortion legislation. "This law only punishes the poor," says Rosana dos Santos Alcantara, the chief executive of Advocaci. "The rich can afford to pay to go to a private clinic."

For many of these poor women, Cytotec is the safest and cheapest option. Distinctively star-shaped in tablet form, Cytotec is a synthetic analogue of prostaglandin E1, which has a stimulating effect on muscles such as the uterus, causing them to contract. Its primary use is for treatment of gastric and duodenal ulcers: the drug's label carries explicit warnings against its use during pregnancy.

Cytotec's use as an illegal abortifacient in Brazil spread in the Eighties, when it was approved for sale over the counter. The drug became notorious, and a wave of campaigns by right-to-life groups and state governors led to the Health Ministry imposing restrictions on its sale. Today, it is illegal outside hospitals, but the number of women arriving in hospital with post-abortion complications confirms that the drug is doing a roaring trade on the black market.

With surgical abortions at a private clinic costing about £300, it's easy to see why Cytotec, available at £20 for two tablets, is still a popular method for poor Brazilian women, who earn as little as £40 a month. Many of these women are Afro-Brazilians, who rank lowest in terms of wealth and social status. Abortion in Brazil is thus a racial as well as a class issue.

It is difficult to arrive at exact figures for Cytotec use in Brazil. "The women who come to us rarely admit to inducing the abortion themselves," says Dr Claudia Barquinha, the chief obstetrician at Rio de Janeiro's Fernandes Figueira Institute, a hospital specialising in foetal defects. "They deny it because they're afraid of punishment." Nevertheless, Dr Barquinha says that more than half the women she treats show symptoms of having taken the drug.

The consequences of using Cytotec without medical advice can be serious. "The main risk is haemorrhage," Dr Barquinha says. Misoprostol (the active ingredient of Cytotec) usually causes an incomplete abortion. "The patient may think she is having an abortion, but she has only partially aborted, or sometimes not at all. She may even continue the pregnancy with a deformed foetus." It is common for women to haemorrhage before undergoing premature labour, then having to wait for a formed foetus to be ejected.

But many of these women suffer the effects of Cytotec in silence, afraid to seek medical assistance for fear of retribution. "I thought I was dying," says Marcia, 29, who took Cytotec last year. "I had colic, vomiting, diarrhoea and dizziness for three days. I was only one month pregnant, and I didn't think it would be so bad. I wanted to go to hospital, but I couldn't. The doctors would ask questions."

Pfizer Brazil, which manufactures Cytotec, says that is concerned with the improper use of the drug. It has submitted a request to cancel Cytotec's registration in Brazil and says it will discontinue the product's marketing. The company believes that demand for the proper use of the drug can be met by another manufacturer that already supplies the hospital market with a similar drug based on misoprostol.

Despite the considerable problems of Cytotec misuse, Dr Barquinha admits that in some respects the drug may be less damaging than more primitive methods used by some women. "I have treated women who have tried to abort with celery sticks and papaya stems," she says. Knitting needles and other sharp objects are used. "The major complication in these cases is usually infection," Dr Barquinha says.

I spoke to women in the Complexo da Mare neighbourhood, one of Rio's poorest and most violent areas. There, old wives' tales such as drinking cinnamon tea are common. One teenage girl described drinking "newspaper tea" to provoke an abortion. "You get the dirtiest newspapers," she said, "boil them in a pan of water and drink it. Sometimes you just vomit, but sometimes you get lucky."

Such experiences contrast greatly with those of the women who can afford to pay. When Carme de Souza, a 29-year-old make-up artist, became pregnant two years ago, she knew that she wouldn't find a suitable clinic in Rio's Yellow Pages. Instead, word of mouth led her a clinic in the respectable area of Gloria. "Everybody knows where these clinics are," she says. "You phone up, ask for an appointment, then hand over the money. The later in pregnancy you are, the more you pay." But even wealthy women run the risk of damaging their health. "If anything goes wrong, they don't want to know," de Souza says. "The doctors are just as afraid of the law as you are." The next time de Souza found herself pregnant, she opted for Cytotec. "I chose it because it was cheaper."

Despite abortion being related to a whole range of issues, including class, race and religion, Mirian Goldenberg, an anthropologist at the Federal University of Rio de Janeiro, believes that there are other cultural issues playing a role. "There is huge pressure on Brazilian women to have children," she says. "A woman who opts not to is considered to be inhuman, incomplete or un-womanly. To be wholly woman is to be a mother, even without the right economic or psychological conditions." But Goldenberg concedes that ultimately even non-Catholics are influenced by the Church when it comes to the moral status of abortion. "This is why no political party would ever take office by being in favour of abortion," she says.

To pro-abortion lobbyists, religion is present at the very heart of Brazil's law-making powers. "There is a religious vision trying to influence public politics and to steer the progress of certain laws," says Almira Rodrigues, co-director of the Feminist Studies and Advisory Centre (CFEMEA) in Brasilia. Although some pro-abortion feminists had been optimistic when the leftist Luiz Inacio Lula da Silva came to power in January, they claim that the administration has strong ties with Catholic and evangelical forces. "The Lula government could make things even harder for us," says Rodrigues.

Although Lula's Workers' Party has no formal line on abortion, the party radicals are split between those in favour and those against. One such member is Angela Guadagnin, the federal deputy of Sao Paulo and president of the Commission of Social Security and Family in the Chamber of Deputies. Describing herself as "radically against abortion," Guadagnin is working on a string of anti-abortion proposals. One is for a day of celebration of the right to life, to take place each year on 25 March, a symbolic nine months before Christmas Day.

Other proposals include revising the laws that permit women to abort in the case of rape, supplementing the option of abortion with psychological and financial support. "If at the end of the pregnancy she doesn't want the baby because of the violent nature of the sexual act, she can then give this the child up for adoption. By taking away the life of the unborn child we are committing an even greater act of violence than the one committed against the mother," Guadagnin says. Linked to this is a proposal to force rape victims to watch videos of terminations before undergoing surgery. "It may be terrifying, but [women] need to see how the foetus fights against the action being taken against it. They should see how it is ripped to shreds inside the mother's belly," says Guadagnin, who believes that abortion is tantamount to child murder.

But some doctors and lawyers say that the abortion law in cases of rape needs reforming in the opposite direction, criticising it for not permitting many women impregnated by rape to use it. "We rarely authorise legal abortions in cases of rape," says Dr Barquinha, who feels that although women may be aware that abortion is legal in rape cases, there are cases where they cannot name the rapist. This is particularly so with incest. "How do you ask a judge for a legal abortion if you've been raped by your father or brother, and by seeking that abortion, you have to denounce him?" she asks. The human rights lawyer Rosana dos Santos Alcantara adds: "The woman's word should be enough."

Proposals for decriminalisation of abortion are being discussed alongside drafts for tighter anti-abortion measures. But it is clear that illegal abortions will continue to be performed with or without Cytotec, endangering the lives of the poorest women and straining the health system. Recently, there has been talk of installing a freephone hotline to report the illegal sale of Cytotec, which is easily smuggled into Brazil from neighbouring countries who permit the drug. But reality dictates that there will always be a downtown corner where a street vendor will sell this most desired and hated of jagged little pills.