Dr. Lester Minto raised four daughters in South Texas, just miles from the Mexican border, where most women are Hispanic and 3 out of 5 girls are pregnant before they reach adulthood.
"My wife died and I raised them on my own," said Minto, 64, who made sure his girls had access to birth control. "Not a single one of mine got pregnant."
For the last three decades, Minto, a family physician and advocate for women, has owned the Reproductive Services clinic in Harlingen, Texas, which performs about 1,500 to 2,000 abortions a year.
But now, with the stringent new anti-abortion law that just passed the Texas legislature, he worries that the women he serves, those from "deep" Texas and Mexico, will turn in greater numbers to do-it-yourself remedy for an unwanted pregnancy -- misoprostol, which goes under the name Cytotec.
The drug, used off-label in medical abortions, is smuggled in by relatives from Mexico to begin a miscarriage -- or what Hispanic women call, "bringing your period down," according to Minto.
"They get things started, then show up in the emergency room and avoid the negative image of having done an abortion," said Minto.
Hispanic women have the highest rate of unwanted pregnancies nationwide -- about 54 percent, according to Jessica Gonzalez-Rojas, executive director of the National Latina Institute for Reproductive Health. Many are uninsured and speak no English.
"With an increase of barriers mounting, what we are hearing is that a lot of women are turning to other folks they know who can smuggle [misoprostol] over the border or are finding it in flea markets," said Gonzalez-Rojas.
"It's the kind of thing -- people know where to get it and are very quiet. While it's not the most dangerous drug, there are a lot of questions about how to take it appropriately. We have tremendous concerns when women take their health into their own hands."
And it's not just women in Texas, according to Gonzalez-Rojas.
"There are lots of cases throughout the country of low-income women, even in New York City, using misoprostol or Cytotec," she said. "I think it's more about the stigma that exists around abortion and they get a lot of mixed messages and turn to underground methods."
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. It can be used to induce miscarriage, typically up to nine weeks, but can also be safely given in through the second semester.
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. In a worst-case scenario, if a woman has placenta previa, (when a baby's placenta partially or totally covers the mother's cervix) she can bleed to death if the drug is used alone.
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.
"If done properly and done in combination, they are safe," said Minto. But alone, misoprostol "doesn't work that well."
"It's kind of like a cheap cure for a radiator leak," he said. "Its efficacy rate is about 30 percent when used alone and improperly. But even though I don't approve of it, I can't criticize it. I would probably try the same if I were in a situation like these women."
Misoprostol is more readily available than mifepristone because it is prescribed to prevent gastric ulcers.
Hispanic 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 in overseas bodegas and pharmacies, according to Gonzalez-Rojas.
The Texas law, backed by Republican Gov. Rick Perry, is one of the strictest in the United States. It bans abortion after 20 weeks of pregnancy and hold clinics like Minto's to the same physical standards as hospital surgical centers.
Its supporters say that the strengthened regulations for the structures and doctors will protect women's health.
Rep. Jason Villalba, a Republican from Dallas, said the new law will not have a negative impact on low-income women, as critics have suggested.
"I am pro-life, but no one is denying Roe v. Wade is the law of the land," he said. "But if we are going to provide a procedure, then the state has the right to regulate how it's done to protect our women who receive this procedure.
"We want women to have the same kind of surgical care, for instance, if they have an appendix or tonsils removed," said Villalba.
One of the new regulations is that abortion providers are located within 30 miles of a hospital.
"If something goes awry," he said, "it's a serious procedure -- we want the doctor to be able to get to a hospital quickly and provide care."
Villalba wouldn't answer questions directly about the possibility of more women using these pills, but argued more broadly that clinics that can't comply with new regulations will "fall by the wayside." Villalba insisted women who choose abortion will still have access. He said opponents of the bill have exaggerated the numbers of clinics that will close.
"Here's the good news," Villalba said. "The clinics [that] remain after the dust is settled will have new standards to protect women."
But advocates like Gonzalez-Rojas say the new law is "an affront on women."
"What we know is that with the increase of barriers mounting, the limited clinics down there are likely going to close if they face all these regulations," she said. "Women get put in desperate situations. We don't know how the black market will turn out, so they might get something that isn't the right drug. We are fighting the laws to make sure women get access to care."
The bill was opposed by many doctors, including leaders of the American Congress of Obstetricians and Gynecologists and the Texas Medical Association.
About 1 in 3 American women will have an abortion by the time they reach 45, according to the Guttmacher Institute, which advocates for sexual and reproductive health and rights. In the first six months of 2013, states enacted 43 restrictions on access to abortion.
In Texas, the abortion rate has remained steady since 2005. The rate in 2008, the last year for which there are statistics, was lower than in the rest of the country: about 16.5 abortions per 1,000 women, aged 15 to 44. The national rate for that year was 19.6.
"You begin to discover the devil is in the details," said Minto, who said he will either have to close down his clinic or move his practice to Mexico.
With new regulations, the procedure for a medical abortion takes three days: A woman must get a sonogram and an explanation of the procedure. Twenty-four hours later, she gets the first pill -- RU 486 or mifepristone, a hormone blocker that makes the fetus unviable. After another 24 hours, the woman must return so the doctor can give her misoprostol, which causes the uterus to contract and expel the fetus.
Until the new law, as is the standard practice in other states, women take the second pill at home and then have a follow up visit with the doctor.
"It's added another doctor visit and, if you live 250 miles away or more, you have to stay in a hotel," he said.
Some women in Texas live as far as to 900 miles from an abortion clinic.
Minto said the safety record and his certification inspections over the last three decades have been "impeccable." He charges women less than $500 for a procedure -- either medical or surgical abortion.
"If you have a case of rape, it's tough," he said. "Where do you send innocent 12, 12, 13-year-old girls? What do they do? I thought about those girls in Cleveland who were held hostage. According to Texas law, if they get pregnant, after 20 weeks, forget it. We have just gone to Taliban Texas."
The next step will be a court challenge to the new law, but Minto is undaunted.
"My licensed abortion clinic has to close," said Minto, "But I'll never give up helping women. I am not a quitter."
- Medical Specialties & Services