This Report is in Pain
On November 1, 2021, when Iran’s Guardian Council approved the Youthful Population and Protection of the Family law, many predicted that this law could lead to an increase in the number of illegal abortions in the country. From the start, the absence of gynecologists, midwives, healthcare system experts, as well as the State Welfare Organization in the drafting and writing of this law was a source of controversy and criticism. Concern over the prolongation of the process of medical abortion of the fetus, missing the window of opportunity for this procedure, limiting screening tests, denial of insurance coverage for tests and screenings, as well as creating a police environment by requiring medical facilities to register and log women’s tests on special websites were among the most important criticisms. Of equal concern were pregnant women’s loss of trust in doctors and midwives, as well as their increasing apprehensions over the birth of children with developmental disorders or disabilities. All problems that can lead to an increase in the number of illegal abortions.
After imposing restrictions on carrying out additional fetal health tests in Iran, under the pretext of the Youth of the Population Law, news was published about the increase in the number of premature and premature births. The news that gynecologists were revealing, but there was no official comment for it due to restrictions. In this report, I tried to tell about the disaster that the population youth plan without scientific support can have for children as well as their mothers by being in the black market of drugs and also illegal abortion centers and talking to women who tried to end their pregnancies. .
Niloufar Hamedi: On November 1, 2021, when Iran’s Guardian Council approved the Youthful Population and Protection of the Family law, many predicted that this law could lead to an increase in the number of illegal abortions in the country. From the start, the absence of gynecologists, midwives, healthcare system experts, as well as the State Welfare Organization in the drafting and writing of this law was a source of controversy and criticism. Concern over the prolongation of the process of medical abortion of the fetus, missing the window of opportunity for this procedure, limiting screening tests, denial of insurance coverage for tests and screenings, as well as creating a police environment by requiring medical facilities to register and log women’s tests on special websites were among the most important criticisms. Of equal concern were pregnant women’s loss of trust in doctors and midwives, as well as their increasing apprehensions over the birth of children with developmental disorders or disabilities. All problems that can lead to an increase in the number of illegal abortions.
This report delves into this prediction and raises serious questions from delivery rooms to Nasser Khosrow Street, from gynecologists’ offices to underground curettage rooms, from hospitals to women’s own lived experiences.
Has the number of illegal abortions increased after the implementation of the Youthful Population and Protection of the Family law?
First location: Nasser Khosrow Street
“Guaranteed abortion with a sheet of pills.”
These days, Misoprostol is the primary and the most readily available medication and method for abortions, both as a legal medical procedure as well as an illegal practice. Misoprostol is prescribed to reduce the risk of stomach ulcers caused by taking non-steroidal inflammatory drugs such as aspirin, but that is not all it does. As a result, pharmacies will not only not provide this medication without a prescription, but they will not even tell you it’s cost. In fact, if you mention Misoprostol without a prescription in a pharmacy and you are not asked to leave, consider it a courtesy on the part of the pharmacist.
The fate of Misoprostol is closely tied to Tehran’s Naser Khosrow street. It doesn’t matter in which direction you decide to walk or what time of the year it is, Naser Khosrow is always the one of most crowded streets in the city. In the past two years and during the Covid pandemic, the crush of people has worsened. Although businesses are thriving, this congestion of crowds has been bad news for the healthcare system of the country.
On Naser Khosrow street, at the intersection of Souresrafil street, I easily find a Misoprostol dealer. A young man hardly 30 years old, explains that in this “line of work,” his expertise is in the abortion market. As though he were a prescribing doctor, he quickly presents his products and insists that I am as dear as to him as his sister and I can trust the quality of the medications he sells.
“The current market price isn’t stable, Sister, but I want to help you,” he says. “If you want the American Miso Cytotec, I can arrange it for 4,500,000 tumans. It’s the real deal and you won’t have to worry.”
He quickly takes out a folded box of the pill and proudly continues, “Look, read here. Mead pharmaceuticals also has this in America. The business belongs to Pfizer, the same company that made the Corona vaccine, which we couldn’t get in Iran.”
I interrupt him and explain that I am not a buyer, but I need some information for an academic research project. Concealing his disappointment, he quickly retorts, “I knew from the start by the look of you. Listen, I don’t have a problem talking to you, but write something for your university that keeps things quiet. Every time news leaks from here, they raid the street just to show they’re supposedly alert and aware. They harass us for two, three days, arrest of couple of miserable guys, and leave.” His phone starts to ring, he says he has to deliver a package of pills somewhere and he has to go. Of course, I he wanted to get rid of me.
Nearby, I hear a man call out, “Guaranteed abortion with a sheet of pills.” I walk over to him and before I say anything, like a professional salesman who reads his customer’s face, he says, “I have an Iranian pill, one sheet for a 1,400,000. I have the foreign one, too. The real American Pfizer for 4,000,000. Don’t bother going around the street, you won’t find anything cheaper than my prices.” He pauses, as if to let me process what he has said, then adds, “I also know a doctor who specializes in curettage abortions. The price is high, but it does the job with no pain or complications.”
Several other sellers on the street quote similar prices. There is a cheaper medication made in Iran, but the sellers claim that its effectiveness is unreliable. “I want to give you good stuff,” one of them says. “If you want the Iranian one, you can find it for 700,000 tumans, but who knows if it’ll work or not. And that’s only if you’re lucky and find a decent seller who gives you a decent product. Most of the cheap ones are fake or passed their use-by date.”
“You’re doing well in your business,” I tell him. “At least consider lowering the price.” He won’t be swayed. I explain to his colleague standing next to him that I’m doing some research and ask him why the prices have increased so much in recent months. “The abortion business has always been good, and now it’s even better,” he says. “Our sales have gone up 30%. The price has quadrupled, but actual sales have increased. I wasn’t in the line of selling Miso at all. I got into it when I saw how well it’s doing. … The highest demand for abortion pills is in Tehran, Karaj, and Qom.”
I buy a cup of tea from a stall and go on the internet where everything can be found, even abortion pills. I search different keywords and I cannot believe the countless number of sources I can contact. I send a WhatsApp message to the first number, and I receive an automatic reply: “The price of Misoprostol Cytotec tablets from the United States is 4,800,000 tumans for a sheet of 10. Shipping costs is the buyer’s responsibility. Should you wish to proceed, send a payment deposit receipt along with your address. Maximum delivery time: two business days.”
I was busy with the numbers when one of the nurses I know replied to a message I had sent to her. I was looking for Misoprostol sellers and she had told me that after the Corona virus pandemic and the deplorable circumstances many face, some medical staff and personnel have also turned to selling medications. Now she has sent me the telephone number for one of them, who is a seller, but not on Naser Khosrow street. Their business is fully organized, and the nurse is responsible for the delivery of medications.
I call the man and ask him about the Misoprostol market, and whether their sales have changed after the Youthful Population and Protection of the Family law or not.
“I don’t know about the law,” he says. “But I know that since last winter, sales have increased by 30%. Being responsible for sending out the medication, I have clearly noticed the upsurge. I receive more than 50 new contact numbers and addresses on a daily basis to send pills to. Perhaps it’s because the price is increasing, and people are worried and want to have the medicine for emergencies. Besides, this pill is easy to use, and everyone prefers to opt for it first. If it doesn’t work for them, then they seek out other solutions. Sale of abortion-inducing injections has also skyrocketed. But there are too many fake versions of it, so we don’t deal in them at all.”
I ask him about their sales in other cities. He explains that they have their own distribution lines. His team is only active in Tehran and its suburbs. “Of course, the markets in the two areas close to us, Qom and Karaj, always have the highest number of orders and we are responsible for supplying them, too.”
Second location: In the company of women
“The window of time for a legal abortion passed. My baby died one month after delivery.”
Nine months have passed since Bita aborted her fetus. She and her husband were not ready to become parents when they were suddenly faced with her pregnancy.
“Unfortunately, for me it was a two-step process. I found out I was pregnant when I was six weeks along. I went for an ultrasound to make sure that the fetus was not outside the womb. Then I wondered where I could find the pill. Fortunately, one of our family friends is a woman who works in the healthcare field, and with her help, I was able to get two sheets of Misoprostol for 400,000 tumans. According to the instructions, I used two sublingual pills and one vaginal suppository and waited for the bleeding to start about 30 minutes to an hour later. But nothing happened until late at night. The bleeding started, but the placenta did not leave my body. I went for another ultrasound. The sonographer told me that the gestational sac was still inside me. This might sound simple now, but I was terrified. I was confused, I was shaking and crying afraid that I might have to have a curettage procedure and surgery. But after asking others, I realized that I could repeat the process of taking the pills. With great anxiety, I took them again and this time, they worked easily.”
Bita knows she was lucky compared to many other women. “Although it was a difficult time,” she says, “I had my family by my side and my husband’s support. This is not the case for everyone. Sometime later, a very young woman was introduced to me who was not financially comfortable and needed to have an abortion without her family’s knowledge. Her child was not conceived out of wedlock, but she had just gotten married and had quickly become pregnant. She could not let her family know, and given that she had no money, she was terribly afraid and anxious. I still had some pills left over, and I gave them to her. The cultural problems in our society force women to endure these situations without having done anything outside of the law and Sharia. I wish instead of imposing rigid laws that force people into such circumstances, our government officials would focus on education and strengthening our social culture.”
The side effects of taking this drug were minor for Bita.
“I have read several places that this pill and the way it is used can cause serious complications, but I didn’t experience any. Perhaps because I was under the supervision of a kind person in the medical field. Still, after the abortion, my monthly menstruation has greatly decreased and the fat content in my belly has increased.”
Illegal abortions are often immediately associated with extramarital relationships, while many of those who are forced to illegally abort a fetus are not in such relationships. Many of them even desire to have children. For instance, Shamim, a young mother who was to give birth to her second child last winter.
“I was in the thirtieth week of pregnancy,” she explains. “But the result of the ultrasound was not good news for me and my husband. The doctor said that signs of physical defects were observed in the fetus. We did more follow-ups and consulted with other specialists. The result was certain. My child would be born with physical and mental disabilities. My husband and I talked a lot about the repercussions, and how it would affect our other child’s life. In the end, we decided to have an abortion. The problem was that we had lost the window of time for a legal abortion. As time went on, our situation got worse. The doctors now clearly said that my child had generalized swelling due to the accumulation of water in her body, which caused her brain to not function normally. Many even determined the possibility that she would be stillborn. But we had no choice. The legal way was not open to us, and we did not want to go down the clandestine road.”
“Finally, the day of delivery arrived, my daughter was born, and immediately taken to the neonatal intensive care unit. I didn’t even get to hold the baby that I carried inside my body for nine months. She was born on January 30, 2021, and on February 30, while I was in my psychiatrist’s office trying to cope with the trauma I had experienced during the pregnancy, my husband telephoned and told me he had received a call from the hospital. Our little girl had run out of strength to go on.”
It was around November 2021 that the defects of Shamim’s child were identified, and from that day on her family has suffered through serious crises. From financial costs of several hundred millions, to Shamim’s continued need to be under the supervision of a psychiatrist, and her son, who blames his parents for not having ever seen his sister.
“When we found out about the fetal development disorder, it was not even six months into my pregnancy. If I could have legally had an abortions at that time, everything would have been very different. Myself, my husband, and our families were under a lot of emotional stress. At a time when Corona was considered a serious threat to lives, we were constantly going to medical facilities. Financially, we incurred enormous costs. We have supplemental medical insurance, which helped us in some cases. Still, we spent millions of tumans. Just the cost of my child’s one-month-stay in the NICU amounted to 70 million tumans, and this does not include the cost of all the other medical services provided. In total, we spent more than 150 million tumans for that one month. This means that not only we, as ordinary citizens, were financially burdened, but the national health system also incurred costs for a baby who was mentally and physically severely disabled and was in this world for only a month.
Shamim and her family survived their crises being financially relatively comfortable. But families who have to struggle through such traumas with empty pockets have far greater difficulties.
Samaneh was in her 27th week of pregnancy when she found out that her fetus had brain and ribcage defects. She immediately went to one of the people who carry out abortion procedures away from the eyes of the law. Turning to a fraudulent person led Samane close to the brink of death.
“One of my friends, who had an abortion with pills, introduced me to a woman doctor. I had no choice, I didn’t want my husband to know. The sum of money she asked for was lower than what others were charging, and I was able to come up with it by borrowing from several friends. The woman tore my amniotic sac and said the baby would be miscarried in a few hours. I was terrified. I wasn’t feeling well and went to a hospital. I told the doctor and nurses what had happened. They chastised me about what I had done, but in the end they did the abortion themselves. The amniotic sac had ruptured, but the fetus was still in my body. Later, the doctor explained that if I hadn’t taken action and the fetus was not expelled, after one day infection would have spread and they would have had to remove my uterus. I could have even died from the severity of the infection.”
Third location: Dilation and curettage room
“The anesthesia worked for 20 minutes, and I was in awful pain for 45 minutes.”
Many women who do not get results from Misoprostol or do not have access to it, are forced to opt for D&C (dilation and curettage). A procedure that according to many is one of the most painful physical and psychological experiences for a woman.
“I found a doctor who said he performs abortions,” Neda tells me. “I went to see him, but he treated me very badly, as if I were guilty of something horrible. He didn’t help me at all. He just wrote the name of the medication that I already knew about on a piece of paper and told me to get it in any way I can, knowing that no pharmacy would sell it without a prescription. Even if I were to ask for the price, pharmacists would not tell me unless I showed them a prescription.”
“We were finally able to buy Misoprostol through an acquaintance who worked in a pharmacy. I remember he was so anxious that he told us not to go to there and instead sent the medication to us by courier. According to the instructions, I was to use the pill as a suppository, but the bleeding that resulted was not as much as it should have been. I decided to go for an ultrasound. My gynecologist was away, and this is where my worst difficulties began. Every clinic I contacted and explained that I had bleeding and needed to have an ultrasound refused do it and said that I must have a doctor’s prescription. I later realized that I shouldn’t have mentioned I was bleeding, because the doctors were all worried that after the sonography a family might claim that the abortion was the doctor’s fault, or a husband might blame the doctor for the miscarriage. In short, no doctor or facility agreed to do it.”
Neda finally found a midwife’s clinic.
“The clinic was in Qala Hassan Khan. I went there with my husband and my best friend. I had been told that the surgery is done under anesthesia that lasts for about 20 minutes. However, it is not clear how long it takes for the fetus to be aborted. I endured 45 minutes of that device inside me. I cannot begin to describe the excruciating pain I endured. I had no choice but to tolerate it, because if the procedure didn’t work, I would have to come back another day, and I couldn’t bear the thought of suffering all that pain again.”
Fourth location: Gynecologist clinic
“Low-income families are the main victims of screening restrictions.”
As explained earlier, denying insurance coverage for screening-related tests that check for fetal problems has been one of the main criticisms of the Youthful Population and Protection of the Family law. But where does this criticism come from?
A gynecologist, “N,” who preferred to remain anonymous explained that in order to assess the result of banning insurance coverage for screenings, the target population can be divided into two groups.
“The first group is the middle class to upper society women who go to capital cities of the provinces and to Tehran to undergo screenings under any condition and at any cost. Regardless of insurance coverage, they pay for the necessary blood tests and ultrasounds. The second group are women who are referred to educational centers such as the teaching hospitals of Shahid Beheshti university branches. These women are generally in financial distress and cannot afford the high costs of screening-related tests. For instance, an aminosynthesis, even with insurance coverage, will cost the patient more than 1 million tumans.”
The legal window of time for abortion in Iran is 18 weeks and six days. If a woman in her 20th week of pregnancy is tested and the results determine grave problems with the fetus, such as anomaly and malformation (a structural disorder of the fetus that can be incompatible with life, for instance, lung hypoplasia or Down syndrome) she cannot legally have an abortion. This is where the situation becomes more complicated. These government mandated preventions clearly target poor and vulnerable families.
Gynecologist “N” explains that this is how low-income families are deprived of the right to know about the health of their unborn child. “Among our patients, those who have financial security, each spend nearly 8 million tumans to perform a screening, regardless of whether the insurance will reimburse the cost or not. But the group that does not have this financial ability, encounter the sentence “screening is not covered by insurance” and are removed from the chain.
“The story does not end here,” the doctor continues. “The screening results and the timing are critical. If there is a problem with the fetus and the prescribed 18 weeks and 6 days has not passed, a letter will be sent to the medical examiner stating that the patient must undergo a legal abortion due to problems with the fetus, and all goes well.”
However, if this time has passed, the target groups again change.
“The first group are those who no longer seek to have an abortion because it is illegal and they have the financial means to care for a child born with special needs and health problems. The second group are those who are in the same economic category but are not willing to keep the fetus and seek an illegal yet safe abortion without the risk of physical harm to themselves. The third group are those who suffer the most. The low-income families that cannot afford to have and to care for a child with special needs, nor can they afford to pay for an illegal yet safe abortion. Some give birth to the child, and it is unclear what will await the baby and that family, others opt for a clandestine, underground abortion. In most cases, they turn to people who are not doctors, have no expertise, and conduct abortions in a non-medical and non-sterile manner, which put the patient’s health in grave risk, including infectious diseases, subsequent miscarriages, permanent infertility, uterine rupture, and even death.”
What awaits women who go for an abortion in a non-hospital setting?
“Women who go for an abortion regardless of the location and environment basically have two different options ahead of them. First, the surgical method (curettage) in which the risks of physical injury are higher. Another method is to take abortion pills they buy on black markets, such as Nasser Khosro street. Once they get hold of the pill, they likely think they have reached the end of the journey, but it is not so. Often times the pills have expired or are fake. Also, the medication must be taken under the supervision of a doctor. For example, if a woman has previously had a cesarean section, a small change in the dosage of the pill could cause her to suffer rupture of the uterus and internal bleeding, which can result in death.”
Final location: Hospital medicine dispensary
Misoprostol, a safeguarded medication in a hospital dispensary.
Amir is a pharmacist at a government hospital. His burden of responsibility has reached a point that he has requested to be transferred several times. He explains how sensitive an issue some drugs, including Misoprostol, have become at the hospital, and to what extent this sensitivity has multiplied in recent months.
“In order for you to understand how critically responsible we are in our work, I will tell you the process of dispensing Misoprostol. If you are to provide a 200 mg Misoprostol tablet to a patient, you must have a prescription from the resident professor and the gynecologist. This means that a fourth-year gynecology resident cannot prescribe such a medication by stamping a prescription. On the other hand, vetted and highly trustworthy staff are responsible for the drug dispensary section in the hospital. I am the main person in charge, the person who receives the medicine from me has an equally important duty. First, I enter the name, time, and number of pills in the logbook. I get a signature from the person to whom I have given the medicine, and the person guarantees to return the casing and packaging to me the medication has been used.”
Loss of a single pill can be equivalent to losing a job.
“Once, a casing was lost in an operating room. I remember they searched the entire operating room to find it. Even the surgeon was under a lot of pressure, because he knew if the casing was not found, he will be in serious trouble. It was eventually found, but that room was turned inside out for several hours searching for a small casing. The doctor knew that he would be fined, but the person who was responsible for delivering the pill and returning the casing to me could have easily been fired over the incident.”
