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Last June women throughout Quito, Ecuador looked up at the iconic statue of the Virgin Mary at El Panecillo, visible from every corner of the valley, to see a stark banner hanging from her skirts. It said: Safe Abortion followed by a cell phone number. The hotline was organized by local young activists, in collaboration with the Dutch organization Women on Waves, as a resource for women who sought a safe termination to an unwanted pregnancy in a country that outlawed the procedure. In the first two hours of its existence, the hotline received 79 calls.

As in much of the world where abortion is illegal, Ecuadorian women seeking abortions rely on the off-label use of misoprostol, available by prescription as an anti-ulcer medication. Women are occasionally able to obtain prescriptions from sympathetic doctors, but as the abortifacient qualities of the drug become increasingly well known, pharmacies are monitoring the frequency of misoprostol prescriptions. To keep their licenses, doctors must limit how many they issue for fear of drawing attention. Consequently more and more women have to rely on misoprostol bought on the black market, or through underground networks of misoprostol suppliers.

The underground network currently operating the Ecuadorian hotline answers approximately ten calls a day, a demand their inconsistent suppliers cannot satisfy. Instead, they direct the woman to Women on Web, a global online community at which women can access information, support and the pills themselves.

Women on Web operates under the premise that a woman will have an abortion if she needs to, by whatever means necessary, regardless of restrictive law. As a telemedicine service, they offer online consultations that determine if a pregnancy lies within certain safety parameters. If it does, a woman may receive misoprostol and mifepristone wherever she resides (provided she does not have access to a legal abortion), mailed in a discreet package, with comprehensive directions and a pregnancy test, often free of cost. She then may self-initiate the abortion in the privacy of her own home, without the need for permission, and if it is not forthcoming - without the assistance of a doctor.

This revelation of maternal autonomy in abortion practice poses an enormous threat to anti-abortion factions, and indeed a moments pause to even more liberal mindsets. Perhaps, though, it does not need to be feared as alarmingly radical. If one traces the history of abortion back to antiquity, the experience has historically been personal, quiet, informed (if not always aided) by midwifery knowledge - knowledge that became marginalized over time. But even as the powers-that-be condemned abortion as witchery, the secret heirlooms of womens knowledge were treasured and passed down over generations.

In that light, misoprostol is the latest in an evolution of potions, situated somewhere after Silphium, rue, and Queens Annes lace. Medical progress has rendered the potions more reliable, and this one is validated not only by global use, but by inclusion in the World Health Organizations list of essential medicines.

The true gift of the abortion pill is its access made exponential when used in conjunction with telemedicine. The Women on Web website includes over 1200 testimonials of women from over 60 countries who have shared their abortion experience (this being just a fraction of the women who have used the service). Hundreds of them used the medication, and hundreds of them were only able to do so in isolation. Many cite the experience as a lonely one, a few describe it as empowering, but all of them are alive to describe it.

It is a service for women in emergency situations, where ideal medical conditions are prohibited by law, and where the alternative is back-alley violence or mismeasured dosages. Emergency conditions, of course, are closer to home than many realize. Medical Students for Choice cites the general graying of abortion providers younger medical students are not learning the procedure, and the number of providers is declining. In the entire state of Kentucky, for example, where abortion is technically legal, there are only two working abortion doctors, who work only two days a week. The entire eastern half of the state has no access to providers.

How could the marriage between telemedicine and abortion be made more sustainable not only to remote areas of illegality, but also to aid communities that fall through the cracks

Telemedicines rapid rise in other areas of medicine is shifting more autonomy to the individual: remote sensors monitoring vitals, blood pressure and weight check-ups via video conference. A website and a pill may never outperform the capable eyes and reassuring hands of a medical professional, but until the law and the environment around it enable these caregivers to access women who need them, Telemedicine is a tool for abortion providers with vast reach and wider potential to help women provide for themselves.

July 15, 2009