Women in US turn to cheap abortion pills from India

By Bruce Einhorn & Dhwani Pandya

Angry over the US Supreme Court’s reversal of Roe v. Wade in June, Deborah Willoughby wanted to do more than attend a rally or make a donation. So she sat down at her computer and placed an order for a pack of abortion pills from India sold under the brand name Unwanted.

India has many online pharmacies offering to sell mifepristone and misoprostol, drugs commonly used to terminate pregnancies — no questions asked and no prescription required. Plan C, an American group that provides information on how to obtain at-home abortion medication, needed volunteers to test online suppliers’ delivery claims. Willoughby signed up and placed an order via Secureabortionpills.com, which describes itself as an online international pharmacy selling generic drugs.

She received instructions to describe the shipment as “family maintenance” or “medical treatment for family” when placing her order. The total price was $310, including a shipping charge of $151. Willoughby, who didn’t want her home state in the US disclosed, could have chosen less expensive options, but delivery would have taken longer. “You’re not on that website if you feel you have several weeks to wait,” she says. Two days later she received a nondescript package at her local post office. “You wouldn’t have known what it was,” she says. Inside was Unwanted, made by Mankind Pharma in New Delhi. Neither Mankind Pharma nor Secureabortionpills.com responded to Bloomberg News requests for comment.

India’s generic drugs industry, the world’s largest, has overseas sales of more than $24 billion, and in post-Roe America, its small mail-order businesses are helping people get around efforts to restrict abortions. After the US Supreme Court eliminated the constitutional right to abortion, Indian drop-shippers — companies that fulfill individual orders for medicines such as antidepressants, erectile dysfunction drugs and other medications — saw a surge in demand for abortion pills, according to several exporters who asked to remain anonymous because of the sensitivity of the matter.

With Republicans such as South Carolina Senator Lindsey Graham promising to enact additional restrictions on abortion access, the pills may be the next battleground in the fight over women’s reproductive rights. Twelve states have abortion bans in effect, according to the Guttmacher Institute, a researcher on reproductive health. Those restrictions don’t criminalise the use of abortion pills, but Texas bans them starting at seven weeks of pregnancy and imposes penalties of imprisonment and fines of as much as $10,000 for anyone prescribing the drugs via telehealth. Indiana bans pills starting at 10 weeks. And a South Dakota law that took effect on July 1 bans medical abortion by telemedicine.

Indian drop-shippers have gained visibility because of the efforts of Western reproductive rights groups offering advice on how to obtain mifepristone and misoprostol. Aid Access, launched by Dutch physician Rebecca Gomperts in 2018, offers online consultations for people dealing with unwanted pregnancies, who are then able to get pills from India. Plan C, the group for which Willoughby volunteered, has conducted tests to verify that Indian generics arriving via post are legitimate. “To police the border where packages come in would shut down global commerce,” says Plan C co-director and co-founder Elisa Wells. “It’s inevitable that there’s going to be access to these sites.”

For groups hoping to enhance abortion access, India is a logical choice because domestic demand and liberalised regulations have fostered the growth of manufacturers. Last year, India shortened the required training period for physicians prescribing the pills to three days from the previous 12, says Vinoj Manning, CEO of Ipas Development Foundation, a reproductive rights nongovernmental organisation in New Delhi. Because about 35 companies make mifepristone and misoprostol, one course of pills can cost only around Rs 500 ($6), he says: “Pricing is pretty cheap because there is competition.”

Many of India’s sellers are based in the central city of Nagpur, called India’s Orange City thanks to its many plantations of mandarin groves. Nagpur is about equidistant from Mumbai and Delhi and has a well-developed logistics network as well as inexpensive labour and rental costs. As in many Indian cities, Nagpur’s bustling streets are dotted with small stores where pharmacists prop up ladders to reach shelves jammed with cholesterol drugs made by Pfizer next to generic antibiotics made by local companies. Some Nagpur shops offer abortion pills on sites such as IndiaMart, an online marketplace, while other drop-shippers operate without brick-and-mortar storefronts. IndiaMart didn’t respond to a request for comment.

Sales of abortion pills to the US doubled after the Supreme Court’s decision to overturn Roe, says a Nagpur drop-shipper who asked to be identified only by the name Sandeep because of the sensitivity of the matter. Other sellers there saw a surge, too, according to another Nagpur exporter who asked only to be identified as Mohan. There are no local or national restrictions preventing companies from selling to overseas customers, so even if US states want to ban the pills, Indian companies won’t be under any obligation to change, Mohan says. “Once the order is placed from an individual on a trade portal, it’s legitimately binding for an Indian supplier to ship that order out.”Still, drop-shippers want to remain low-profile. “In most circumstances, it is illegal for individuals to import drugs into the US for personal use,” according to the FDA website, though the agency says it typically doesn’t object to personal imports of drugs that the FDA hasn’t approved under certain circumstances, such as when the drug isn’t considered risky and isn’t re-sold to others. In a statement on June 24, President Joe Biden instructed Health and Human Services Secretary Xavier Becerra “to identify all ways to ensure that mifepristone is as widely accessible as possible … including when prescribed through telehealth and sent by mail.”

Although Indian drop-shippers have become the go-to pill source for many international customers, the companies can’t do the same at home, says Jasmine George, founder of Hidden Pockets Collective, a reproductive health and rights non-profit in Bengaluru. “It’s a heavily regulated pill” for sales within the country, she says. “India has one of the most progressive laws when it comes to abortion, but you can’t mail a pill.”

To speed deliveries to buyers in the US who may need them urgently, Nagpur’s mail-order operations sometimes route them via Malaysia and the UAE, in an attempt to cut transit time and to capitalise on certain benefits given on bulk exports, says Navneet Verma, the Nagpur-based secretary of the India Pharmaceutical Dealers Association, who has his own business mailing medicines abroad but doesn’t offer abortion pills. “We’re exporting to places where regulations aren’t cumbersome and are friendly for re-exports,” he says.

There’s always a chance that people purchasing medicines online could receive fakes, but Plan C hasn’t found instances of fraud among the Indian pills it’s tested. “The products that we’re receiving are what they say they are,” Wells says, adding that India has a history of producing reliable no-brand drugs. “For a lot of medications we take, we just don’t realise they’re generics from India,” she says. Plan C refers consumers to about a half-dozen online pharmacies. Since the court overturned Roe, at least six more have asked Plan C to add them to its referral listing, Wells says. Even if anti-abortion politicians push harder to restrict access to abortion pills, tighter rules in the US aren’t likely to stop the cross-border trade, Verma says. The importing country can, he says, “check at entry point, confiscate it, destroy it, but they can’t stop us from exporting, as we are a sovereign nation.”