Online Access to Misoprostol for Self-Managed Abortion in Indonesia

Misoprostol, when used correctly, is a safe and effective method for inducing abortions, including those that are self-managed. In Indonesia, the drug is typically obtained through informal online vendors and it is not possible for prospective buyers to assess the type and quantity of drugs, nor the quality of information provided by a seller, until after a purchase is made. This fact sheet presents findings from a 2019 study conducted in Jakarta, Indonesia’s capital and largest city, on the experience of purchasing abortion drugs, primarily misoprostol, online. Data on information given by sellers and drugs received were collected by trained buyers seeking drugs from 132 online vendors.

Abortion access in Indonesia

• In Indonesia, abortion is legal only in cases of rape (up to six weeks’ gestation), in cases of severe fetal anomaly and in medical emergencies where the pregnancy poses a threat to the woman’s health and life.
• Many women in Indonesia seek abortion outside these legal parameters. In 2018, 1.7 million abortions took place in the six provinces of Java, Indonesia’s most populous island. This figure corresponds to a rate of 43 abortions per 1,000 women of reproductive age (15–49).
• Misoprostol, often sold in Indonesia under the brand name Cytotec or Gastrul, can safely induce an abortion 75–90% of the time. In Indonesia, misoprostol is registered solely to treat gastric ulcers and can only be purchased legally with a prescription.
• The ability to purchase misoprostol for self-managed abortion from drug stores and websites without a prescription has led to law enforcement efforts to shut down illegal sales. As a result, most sales have moved to a fluid online marketplace for abortion drugs.

Availability of abortion medications online

• Buying misoprostol online through an informal vendor can be a discreet and accessible way to obtain the medication. However, this option is not without risk; prices are inflated, and potential buyers have no means of verifying a seller’s legitimacy, trustworthiness or medical expertise.
• Online sellers typically advertise “packets” of drugs, rather than misoprostol alone. The advertised contents and prices for these packets often vary according to the gestational age provided by the buyer.

Outcomes of purchasing abortion drugs online

• The study’s buyers paid for 76 packets of abortion drugs but received only 64.
• The average cost of each drug packet was about 903,000 Indonesian rupiah (US$65). This amount is roughly equal to one month’s income at minimum wage in many rural and suburban districts in Indonesia.
• Of the packets that arrived, 73% contained misoprostol. Almost two-thirds (64%) of the packets containing misoprostol had the correct dose. The minimum amount of the drug recommended by the World Health Organization (WHO) to induce an abortion at six weeks’ gestation is 800 mcg.
• In the majority (87%) of packages that contained misoprostol, the medication arrived in proper packaging, i.e., a sealed aluminum blister pack with no signs of damage or tampering.
• The majority of packets (92%) contained at least three different types of pills (e.g., pain medication, herbal supplements and vitamins). Sixty-four percent of packets contained at least one type of pill that was not identifiable.

Instructions received from drug sellers

• The accuracy and completeness of information provided to buyers varied widely.
• Twenty-one percent of sellers did not provide information about any of the four expected physical effects of taking misoprostol (bleeding, cramping, nausea and diarrhea). Sixty-six percent mentioned 1­–3 of these effects, and only 13% mentioned all four.
• None of the sellers mentioned the possibility of postabortion complications or what steps to take in case of complications.
• According to WHO, misoprostol should be dissolved under the tongue or against the cheek, or inserted into the vagina. Among the sellers whose packages contained misoprostol, 72% provided accurate information on how to administer the medication.
• Out of all drugs received, only 21% contained at least the minimum dosage of misoprostol in the recommended packaging, along with instructions on optimal administration.

Recommendations

Buying from online vendors will likely continue to be a popular source for misoprostol in Indonesia—both because of the anonymity it affords in a setting where abortion is legally restricted and highly stigmatized, and because the COVID-19 pandemic has driven people to seek online alternatives for a variety of health services. However, the study findings point to a high degree of uncertainty in the reliability and quality of care from online abortion drug sellers.

• Women’s rights groups and health advocates should disseminate information widely on the correct usage of misoprostol for abortion to help ensure users’ safety.
• High-quality postabortion care should be made widely available to ensure that any complications resulting from incorrect misoprostol use are treated promptly and correctly.
• The Indonesian government family planning program should help to reduce the need for abortion by better enabling people to prevent unintended pregnancies. Unintended pregnancy can be reduced by a number of interventions, including ensuring availability of a range of contraceptive methods and appropriate counseling on their use, and by offering comprehensive sexuality education.
• Safe abortion care should be available to the full extent of the law.