Seeking abortion medications online: experiences from a mystery client study in Colombia

Abstract

Objectives

While Colombians gained broad legal access to abortion in 2022, people still lack knowledge about its availability and face variable quality of care at health facilities. This study sought to understand whether online sellers provide the instructions and medication dosages necessary for effective medication abortions.

Design

The study design involved mystery clients contacting sellers identified across websites and social media platforms (Facebook, Instagram, and TikTok) to purchase abortion pills. Unique sellers were contacted with two profiles (first and second trimester pregnancy gestational ages). Mystery clients documented information received on physical effects, complications and how to take the pills from the sellers in a predesigned survey in SurveyCTO.

Setting

The study was conducted in Colombia from July to September 2023. We documented and described sellers’ conversations with mystery clients and pills received. We identified 161 sellers across platforms, which resulted in 65 unique sellers after deduplication. We attempted to contact each unique seller twice.

Results

Almost all sellers screened for gestational age using last menstrual period. Bleeding (84.6%) and cramping (66.7%) were the physical effects most commonly mentioned to mystery clients, although pain was mentioned to second trimester clients more often than first (40.5% vs 22.0%). Less than 17% of sellers highlighted possible complications that could require medical attention. Almost 90% of purchases were received (88.9%). All contained manufacturer-branded misoprostol and 77.5% were undamaged aluminium blister packages. While 82.6% of first trimester clients were instructed to take an initial misoprostol dosage in line with Colombia’s Ministry of Health guidelines, all second trimester clients were told to take a dosage exceeding the recommended amount. Although most sellers provided appropriate information on administration routes for the pills, sellers also provided contradictory and unnecessary instructions.

Conclusion

Online sellers of abortion pills may persist even as legal abortion becomes more widely available in Colombia. While misoprostol was received from many of these sellers, they did not provide sufficient information about potential complications or accurate dosing instructions to second trimester clients. Accurate medication abortion information specific to Colombia should be made more accessible so that people can more easily navigate the new care landscape.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This is the first study in Colombia specifically and in Latin America to document the information, instructions, and medications that sellers are providing to clients purchasing abortion pills online.

• Although Colombia liberalised its abortion laws in 2022, making abortion up to 24 weeks gestational age available at health facilities, pregnant people continue to resort to online sellers operating outside of the country’s formal health system to self-manage their abortions.

• The mystery client study design provides data on simulated customer experiences from online sellers.

• The universe of online abortion pills sellers is constantly in flux and may have more duplicate sellers than identified, so conclusions are limited to the sellers identified with the search terms and social media platforms examined.

• Budget limits prevented purchasing pills from every seller contacted and from performing pharmaceutical testing on the medications received.

Introduction

Over the last two decades, Colombia has benefited from multiple law changes that have increased access to abortion. Medication and procedural (sometimes called surgical)¹ abortions are now legally available within the formal health system at no cost to patients, regardless of insurance coverage or immigration status. As of 2024, Colombia has the most progressive national legal framework for abortion in Latin America and the Caribbean.² Colombia’s current abortion policy environment contrasts starkly with that of the 1990s and early 2000s; liberalisation came about gradually after many years of advocacy and feminist mobilisation of non-governmental organisations, lawyers, healthcare providers and allies.³ Key among these advocates was La Mesa por la Vida y la Salud de las Mujeres (La Mesa) (The Committee for the Life and Health of Women (The Committee)), a feminist activist collective focused on women’s sexual and reproductive rights, especially the right to abortion, which in 2017 created the Causa Justa (Just Cause) movement (along with other organisations, including el Centro de Derechos Reproductivos (Center for Reproductive Rights), el Grupo Médico por el Derecho a Decidir (Global Doctors for Choice), Católicas por el Derecho a Decidir (Catholics for the Right to Decide) and Women’s Link, to seek freedom and reproductive autonomy for all women over their bodies and lives. Prior to 2006, Colombia had a complete ban on abortion without any exceptions. As a result of advocacy in the 16 intervening years, in February 2022, the Constitutional Court issued Ruling C-055, which fully decriminalised abortion up to 24 weeks (and also made it available at later gestational ages under three conditions established in the previous 2006 ruling: when the life or health of the pregnant person is in danger, when the fetus presents malformations incompatible with life, and when the pregnancy is the result of rape, incest or non-consensual insemination).⁴

Health system policy changes to align with shifting legality of abortion

Colombia’s Ministry of Health (MOH) adapted the national health policies and service delivery guidelines to comply with legal changes and operationalise abortion access for the population. These guidelines established abortion as an essential component of maternal healthcare.^{5 6} Misoprostol for medication abortion was approved by the Instituto Nacional de Vigilancia de Medicamentos y Alimentos (the National Institute of Medication and Food Surveillance) in 2006⁷ and as of mid-2024, the medication is currently available under the brand name Cytil in 7-pill and 12-pill packs. Mifepristone was approved 11 years later in 2017. Mifepristone can be prescribed with misoprostol by physicians in a facility or via telemedicine (in the first trimester of pregnancy for the latter).

The Colombia MOH guidelines detail recommended dosing for the use of mifepristone and misoprostol or misoprostol alone for medication abortion at different gestational ages of pregnancy.⁵ The combined mifepristone-misoprostol regimen is slightly more effective, but in settings where mifepristone is not available, using misoprostol-only is safe, effective and recommended.^{8 9} Serious complications and the need for additional interventions are rare with both regimens. For first trimester abortions using misoprostol-only (<12 weeks), the MOH guidelines are an initial dose (800 μg), followed by two to three repeated doses (a recent systematic review and other international guidelines recommend a minimum of three misoprostol doses to complete the abortion process).9,11 For 12–24 weeks gestational age, the guidelines are to use repeated doses of 400 μg misoprostol until the products of conception have been expelled. Colombia’s MOH guidelines also recommend that medication abortions beyond 12 weeks gestational age be performed under clinical supervision at a health facility until the process is complete.

Regardless of gestational age, accessing abortion care in Colombia often still involves some contact with a health facility; even for medication abortions, MOH regulations are that misoprostol should be provided with a medical prescription.¹² The sale of medicines without a medical prescription and without the corresponding sanitary registration (as in the case of Cytotec brand of misoprostol in Colombia) can lead to administrative sanctions, fines and even imprisonment.¹³ Partly in response to the COVID-19 pandemic, some non-profits began introducing the option of accessing medication abortion through telemedicine.¹⁴ Guidelines for provision of quality clinical abortion care from the World Health Organization (WHO) underscore that people seeking abortion at any point in pregnancy should be screened for gestational age as well as any contraindications for the use of mifepristone or misoprostol and be provided information about what to expect during the abortion process, including when to seek follow-up care for rare, but possible complications.¹⁵ As most pregnant people can accurately determine their eligibility for self-managed medication abortion,¹⁶ administer the medications, and assess the success of the abortion, WHO endorses self-managed abortion models of care in the first trimester (<12 weeks).¹⁷ Completion rates have been 88%–94% in recent studies of first trimester self-managed misoprostol-only regimens.18,20 Studies of self-managed second trimester medication abortions have found effectiveness rates of 74%–93%.21,24 People self-managing their abortions may also be supported by accompaniment groups, which are often activist organisations made up of trained members, which provide evidence-based counselling and support before, during and after the abortion process.²⁵

Barriers to obtaining abortion care in line with health policy guidelines

Although the Colombia MOH issued policy guidelines to guide the provision of abortion care (Resolution 051 of 2023) in response to legal changes, gaps remain in equitable and universal implementation in service delivery. Before the 2022 court ruling, advocates and researchers in Colombia documented the numerous barriers that pregnant people faced trying to obtain abortion care. Healthcare facilities failed to provide abortion services due to lack of knowledge of the legal framework, and legal and civil society systems lacked the necessary support to protect and facilitate people’s receipt of care.26,28 Religious beliefs and abortion stigma deterred some pregnant people from seeking out abortion services altogether and these beliefs and attitudes also prompted providers to refuse abortion requests.^{26 28} For rural and indigenous communities, Venezuelan migrants and other vulnerable groups with precarious socioeconomic and immigration statuses, challenges to obtaining care were compounded.²⁹ Even after the 2022 ruling, similar barriers to care have persisted, including lack of knowledge and restrictive interpretations of the legal framework, discriminatory or unjust treatment by healthcare providers, delays in care, privacy violations, lack of availability of abortion medications and difficulties obtaining abortion using health insurance.³⁰ Decriminalising abortion in and of itself has not been enough to guarantee care access in Colombia; rather, it is still necessary to verify that service providers are integrating the new regulations into the care pathway for patients, as well as to widely disseminate information to the public about the new regulations and the ways in which they can access abortion services through the health system. Continued training and knowledge updates for health personnel can also reinforce following the protocols established by the MOH.

Again, even after the liberalisation of abortion laws, the quality of care in Colombia is variable. Research participants in Colombia have highlighted that healthcare providers can lack empathy, timeliness and confidentiality, leading people to seek abortion care from other sources.2731,33 In response to disparate and discriminatory experiences, feminist networks of trained activists and volunteers organised across Latin America, including Colombia, to support abortion seekers throughout their pregnancy termination processes.³⁴ They provide instructions on how to obtain and/or safely take the drugs in addition to step-by-step emotional and practical support by phone or online in accordance with international guidelines; some of them also provide medication abortion pills (mifepristone and misoprostol or misoprostol alone), sometimes free of charge or for a small donation.³⁵ Beyond these feminist networks, other individuals sell medication abortion pills through channels outside of the formal health system or guidelines. Obtaining medication abortion pills from these sellers is one of the most common ways of terminating a pregnancy outside of the healthcare system, even though sales of registered drugs without a prescription can lead to legal repercussions for the sellers. Previous studies in Mexico have documented the sale of misoprostol over-the-counter at pharmacies (ostensibly for gastric ulcer and not abortion)^{36 37} and two studies conducted in Colombia before the 2022 law change found that misoprostol could also be accessed without a prescription from a variety of sources, including small-chain and independent drug stores, street vendors and online sellers.^{38 39} One-third of qualitative study participants who had acquired misoprostol from these channels had purchased it online.³⁹ Although the sample was small, those who used online vendors received more detailed instructions and information about what to expect during the abortion compared with those who had purchased the drug elsewhere.³⁹ These preliminary data suggested that online sellers may be an important source of medication abortion in Colombia. The practice of buying medication abortion pills online that emerged under previous restrictions may persist even in the face of broad decriminalisation given lack of knowledge of the legal framework or varying quality of experiences at health facilities.³³

Because barriers to legal abortion care persist in Colombia and medication abortion pills continue to be available for purchase outside of the formal healthcare system, the objective of this study was to assess if individuals purchasing medication abortion pills from online sellers in Colombia receive the information, instructions and medication dosages according to Colombia’s MOH guidelines for terminating pregnancies at various gestational ages. To make this assessment, we also sought to gather information about the landscape of online sellers of medication abortion pills in Colombia and to document the medications received from these sources.

Materials and methods

This study was a collaboration between Fundación Oriéntame, a private, non-profit organisation in Colombia focused on promoting and protecting sexual and reproductive health, and the Guttmacher Institute, a research and policy organisation focused on advancing sexual and reproductive health and rights worldwide. The methodology for this study consisted of four stages: (1) determination of keywords related to purchasing abortion medications online in Colombia using Google Trends; (2) identification of the universe of sellers from multiple online platforms (websites, Facebook, Instagram, and TikTok) using keyword searches and documentation of website and profile content; (3) deduplication of universe of sellers who had more than one website or profile and (4) collecting information on mystery clients’ contacts with sellers, including purchase and receipt of pills. More detail on each of these stages is described below. A variation of this methodology was implemented previously by the Guttmacher Institute in Indonesia.⁴⁰

Identification of keywords using Google Trends

We first used Google Trends to determine keywords being used by individuals seeking abortion pills online. To follow the potential logic of a person who does not know much about medication abortion, we began the search using general keywords such as pastillas abortivas (abortion pills) and progressed to more specific ones, using keywords that showed up as “related queries” on Google Trends. The keywords were identified on 4 July 2023. We then added complementary keywords to the search such as precio (price) and comprar (buy) as well as the names of the largest cities in Colombia: “Bogotá”, “Medellín” and “Cali”, with the goal of identifying sellers trying to reach purchasers in specific cities. We also used another set of keywords that included misspellings that sellers may strategically adopt to prevent their ads from being removed from the platforms. We filtered by location, time range and search type, but did not filter by category. In this way, we used “Colombia” as our location, “12 months” to “last day” as the time range and “web search” as our search type. We did several searches with the same keywords and different time ranges to see how the “related queries” varied and confirmed that more recent searches were often about price, while searches that went up to 12 months had additional topics including instructions and physical effects (see online supplemental table S1 for specific keywords used in the searches). It may be the case that the most recent searches were people seeking to buy pills for medication abortion. However, by including a longer time frame in our search, we captured a broader range of relevant keywords, including those related to symptoms and complications of the pills.

Identification of the universe of sellers and documentation of website/profile content

To identify the universe of sellers, we used the identified keywords to search on four different platforms: Google’s search engine (for websites), Facebook, Instagram and TikTok. (Some popular marketplaces in the country such as Mercado Libre and OLX were considered, but we did not obtain any relevant findings using the keywords). To identify the websites, we used a Google Chrome browser in Incognito mode, searched within Google using the keywords, and checked all the results found on the first 10 pages of each search, starting with the highest-ranking results (the most relevant according to the Google algorithm). We excluded news and academic articles and pharmacy websites selling misoprostol with a prescription. No Facebook, Instagram and TikTok profile websites shown in Google search results were captured in this stage—those platforms were searched separately. International sellers were included if they sold to people in Colombia.

To conduct searches on Facebook, Instagram and TikTok, the data collectors serving as mystery clients created accounts on each platform, logged into those accounts using a Chrome Incognito window and searched each platform. For searches on Facebook, we used its Marketplace feature. On Instagram, we used the Map search, in addition to the regular search function, which we also used on TikTok. For search results offering mifepristone and/or misoprostol pills, we identified the profile of each post included in the list of results, taking care to include them only once, no matter how many different posts had the same profile. For these three social networks, all the search results returned for each of the keywords were reviewed.

Searches used all identified keywords on every platform and were conducted between July and August 2023. A website or profile was included if: (a) it stated or suggested selling mifepristone and/or misoprostol and (b) its landing page was not otherwise listed in search results (eg, a subpage of a website that was already captured). Each website and social media profile was given an anonymised seller ID consisting of an abbreviation of the platform on which their page was found and a number. For each website/profile identified, a fieldworker recorded the information listed about medication abortion (including products offered, number of pills for sale and price, and information on contraindications, physical effects and complications described) using a predesigned survey in SurveyCTO.

Deduplication of universe of sellers

We identified duplicates by comparing the contact information provided on websites or social media profiles/messages, usually a WhatsApp number. Just over a third (38%) of sellers had more than one site or profile. A little over half of the duplicates were within the same platform (56%), while the remaining 44% were across platforms (eg, website(s) plus social media profile(s)). It was common for sellers to have duplicate websites with different specific names of cities, as well as multiple WhatsApp numbers posted on the same website/profile. For websites which contained the same WhatsApp number, the first website identified chronologically by date of search was retained. For websites and social media pages found to have duplicate WhatsApp numbers, the page with the most detail was retained, usually a website. After deduplication, we identified 65 unique sellers (figure 1).

Figure 1. Flow chart of online medication abortion seller universe in Colombia, mystery client (MC) contacts and successful purchases. *Attempted to contact each seller twice (once with each gestational age profile).

Mystery client contacts with sellers, including purchase and receipt of pills

The fourth stage of the research comprised four steps: (i) contacting each seller twice using two different mystery client profiles with different gestational ages; (ii) recording the details of each contact attempt and conversation including instructions offered; (iii) purchasing the medication offered and (iv) documenting the medications received by mail. Each step is described in more detail below.

Three individuals who identified as cisgender women were trained as mystery clients who would pose as pregnant people attempting to purchase pills online for medication abortion. Using the contact information from the deduplicated list of sellers, the mystery clients reached out to the sellers on study tablets using SIM cards purchased specifically for this study. Mystery clients were able to use two SIM cards simultaneously, maintaining a conversation with five sellers per SIM card. Conversations with sellers lasted 2–3 days on average, and mystery clients changed SIM cards after conversations with five sellers were complete. If a duplicate seller was undetected, the rotation of phone numbers was intended to prevent a seller from becoming suspicious of receiving similar inquiries from the same phone number. Mystery clients did not obtain verbal or written consent from the online sellers to participate in the study, as that would have alerted the online sellers to the study, potentially changing their behaviours or responses, and introduced bias to the findings from the conversations. All research team members, including the people trained as mystery clients, signed a confidentiality agreement not to disclose any research information outside of the study team.

Once the seller responded to the mystery client’s initial message, the mystery client engaged in a conversation based on the content of a predesigned survey in SurveyCTO. This survey included questions about how to use the medications and what to expect during the abortion; the mystery clients could ask for clarification from the sellers about the information the sellers provided. All contact took place over text message; mystery clients never spoke with the sellers via audio. Mystery clients documented any information requested or received from the sellers regarding pregnancy confirmation and gestational age, the types of pills offered and their prices, instructions on how to use the pills, including initial dosage amounts, repeat doses and administration route(s), information about expected physical effects, possible complications and any other instructions the seller provided about what to expect or do during the process of taking the pills. Between them, the three mystery clients were instructed to contact each seller using two separate profiles: once with a profile of a person with a pregnancy at 8 weeks gestational age and once with a profile of a person with a pregnancy at 16 weeks gestational age. Mystery client profiles included that they were 24 years of age, single, studying at university, experiencing their first pregnancy, and did not have any medical issues or contraindications (though this information was only provided to sellers if asked). Four sellers were mistakenly contacted twice with the same gestational age profile, so we retained the first contact with these sellers. Additionally, as fieldwork progressed, mystery clients did not always update the date of their last menstrual period (LMP) to align with the specified gestational age they were meant to be presenting in their profile. In about half of the 41 conversations in which the mystery clients used the first trimester profile and attempted a purchase, they provided a gestational age between 10 and 12 weeks, while use of the second trimester profile was more consistent. Therefore, for accuracy in the analysis, we report the gestational age categories as 8–12 weeks and 16–17 weeks.

The survey was not meant to be filled out in any specific order by the mystery clients, as we could not predict the order in which sellers would discuss survey items. For example, some sellers told the mystery clients they would only send instructions on how to use the pills once a purchase was completed or the pills were received. In these cases, the mystery clients went back and filled in the information after purchase or receipt. Sellers wrote out instructions about expected physical effects or complications in messages to mystery clients and provided links to third-party websites and videos as well. Images, videos, and website links with information about the abortion process from third-party sources (most of which were in Spanish) were generally counted as information provided to the client. The exceptions were cases where the seller explicitly said that nothing would occur (eg, the woman would experience no physical effects or complications as a result of taking the pills) but also sent information from third-party sources. For these, we considered the seller as not providing information. Mystery clients were instructed not to continue conversations with sellers after purchase or delivery of the pills, except when sellers said they would send instructions only after selling or shipping the pills. Some sellers offered accompaniment services which, as noted above, are generally characterised by provision of medications, information and support before, during and after the abortion process, especially by trained feminist activists guided by a focus on women’s own decision-making power and autonomy. We instructed mystery clients not to accept any offer of accompaniment because they did not intend to actually use the pills or go through the abortion process.

Mystery clients took screenshots of the full conversation with each seller on the study tablets assigned to them and saved the complete exchanges on a secure shared drive. Once the fieldwork phase was complete, Oriéntame’s technical team restored the tablets to their factory settings, deleting any saved files. Mystery clients were trained to go through with making a purchase of the pills if the seller offered up to a ceiling of Colombian peso (COP) $100 000 (US$24.53) for four pills, COP$120 000 (US$29.44) for six pills, COP$150 000 (US$36.79) for eight pills and COP$200 000 (US$49.06) for 12 pills. (Conversions to US$ used the median exchange rate for the fieldwork period of 23 July to 6 September 2023 of 4076.68.⁴¹) These prices were the average prices for the specified number of pills from a pretest conducted in July 2023. Partway through the study, we raised the maximum accepted price for each of the pill amounts by COP$15 000 (US$3.68) after determining that the prices specified by social media sellers were higher than the prices specified by website sellers. We also made exceptions to surpass the budget limit in three cases: when one seller offered a treatment of 14 misoprostol pills and when two sellers offered packages with pills other than misoprostol, including mifepristone, painkillers or antibiotics. Mystery clients were instructed to negotiate the price only once, when the price of the medications offered by the seller was higher than our prespecified budget limit. The pills were paid for using five different bank accounts in Colombia. Using this payment strategy avoided possible detection by sellers if using one single bank account or popular cash transfer application like Nequi or Daviplata, which display identifiable information like bank account numbers and names.

To protect the mystery clients and avoid arousing suspicion if additional duplicate sellers existed and were contacted, the study team provided 10 different physical addresses in two different cities (Bogotá and Medellín) at which to receive pills. When a purchase was made, all sellers but one informed mystery clients when the package had been shipped and the expected time of arrival. A tracking number was given by the seller only in cases when the package was shipped from a different city via certified mail. When packages were delivered to one of the study addresses, they were forwarded to the first author (DA) who retrieved and opened each package. He then recorded the contents of each package and any additional instructions for use that were sent in a preprogrammed SurveyCTO form. Specifically, he recorded what pill brand was received (if visible), how many pills arrived and the condition of the packaging (eg, if a blister package was punctured or opened). Abortion pills acquired in this study were disposed of in accordance with Fundación Oriéntame’s guidelines for this process, that follow Colombia’s hazardous waste management policy for disposal of unused medications.⁴²

Analysis

First, responses to the three surveys (the listing survey describing the seller’s website/social media profile, the mystery client survey with the details of the seller contact attempt and the package survey documenting the content of packages received) were merged using the prespecified anonymised seller ID. Most of the instructions the sellers provided on physical effects, complications and how to take the pills were recorded as free text in the mystery client survey due to the diversity of information provided. This free text was translated from Spanish to English and then quantitatively coded into descriptive categories. We present descriptive statistics on the conversations by gestational age profile, including the frequency that sellers screened for pregnancy confirmation, gestational age, and contraindications, and mentioned physical effects and possible complications. We then report if pills were received, their condition and what information sellers gave to mystery clients on dosages and administration routes, by gestational age. Finally, we summarise how often sellers provided instructions to clients on other aspects of using the pills: pain medication, using the bathroom, eating and drinking specific foods, and physical activity. All analyses were conducted using Stata V.18 (College Station, Texas, USA).

Results

Universe of online sellers and responses to initial contacts

Of the original 161 online sellers identified, we intended to contact each of the 65 unduplicated, unique sellers twice, for a total of 130 contact attempts (figure 1). The majority of these sellers were from websites or Facebook profiles. Ultimately, mystery clients made 122 initial contacts with sellers (61 with the 8–12 weeks gestational age profile; 61 with the 16–17 weeks gestational age profile). Mystery clients were unable to engage in conversation when the site/profile was no longer live, the seller was identified as a duplicate prior to initial contact, the contact information was not valid, the seller did not respond to the initial message, or the site provided information only and did not sell pills (n=35). Nine conversations were cut short before discussing a purchase. For clients with the 8–12 weeks profile, one seller asked to meet in person and two stopped responding. For clients with the 16–17 weeks profile, one seller asked to meet in person, one stopped responding, and four told the mystery clients that they were too far along in their pregnancies to provide them with pills (all four of these sellers reported 12 weeks as their maximum).

Seller rapport with mystery clients

For the mystery clients who were able to initiate contact with sellers (n=87), the conversations generally had an informal tone. Sellers often used slang and emojis in their messages and about one-third of sellers referred to the mystery clients with pet names such as nena (babe), linda (beauty), reina (queen) and amor (love), which are commonly used in casual conversations, but not appropriate in customer service, sales or medical encounters. About one-quarter of sellers offered “accompaniment” via WhatsApp throughout the abortion process (which was not accepted by the mystery clients), and this was slightly more common in conversations where mystery clients used the 16–17 weeks profile than the 8–12 weeks profile (25.6% vs 20.5%; not shown). Twelve sellers (13.8%) sent screenshots of conversations with other customers, which contained information about the physical effects those customers experienced, in addition to descriptions of the success that those customers had in terminating their pregnancies using the sellers’ pill products. Seven of these 12 sellers shared personal or identifying information of previous customers through the images, including names, profile pictures, phone numbers, banking account numbers, and addresses.

Screening and information provided about physical effects and complications

In the contact attempts where the mystery client initiated a conversation with the seller (n=87), communication most commonly commenced with sellers attempting to screen the mystery clients for pregnancy confirmation and gestational age (table 1). Few sellers asked if the mystery client had taken a pregnancy test (11.5%); rather, most attempted to screen for gestational age, either asking for the date of the last menstrual period (92.0%) or how many weeks pregnant the clients were (57.5%). Almost a quarter of sellers (24.1%) spontaneously mentioned that having an ectopic pregnancy was a contraindication for using medication abortion pills and a smaller proportion flagged an allergy to misoprostol or other medications (14.9%) as another reason not to take them. Five sellers incorrectly mentioned conditions such as anaemia as contraindications for use, while none mentioned conditions such as haemorrhagic disorder (not shown).

Table 1. Seller screening for medication abortion eligibility (n=87).

	%	N
Seller asked if mystery client had taken a pregnancy test	11.5	10
Seller tried to screen for gestational age*	95.4	83
Asked mystery client for date of last menstrual period	92.0	80
Asked mystery client how many weeks pregnant she was	57.5	50
Other†	10.8	9
Seller asked if mystery client was using an intrauterine device	3.4	3
Seller spontaneously mentioned other contraindications:
Ectopic pregnancy	24.1	21
Allergy to misoprostol or other medications	14.9	13
Taking other medications during treatment	10.3	9

^*Mystery clients could select multiple response options.

^†Other responses included asking how late the mystery client’s period was (n=4), the date of last unprotected sexual intercourse (n=3), ultrasound (n=3), and a quantitative pregnancy test (n=2).

Sellers with whom the conversation progressed to the point of the mystery client attempting to make a purchase (n=78; with an overlap of 30 sellers from whom a purchase attempt was made with both profiles) mentioned a range of physical effects the mystery client should expect when using medication abortion pills. Bleeding and menstrual-like cramping were most frequently mentioned for both the 8–12 weeks and 16–17 weeks profiles (table 2). One-quarter of sellers specified that both strong cramps and bleeding that is heavier than menstruation (possibly with clots of blood) were normal and expected physical effects of the abortion process, while another 15.4% described symptoms as being similar to those of a normal period (not shown). Other physical effects, including vomiting, nausea and mild fever, were mentioned by less than half of sellers. In general, all physical effects were mentioned more frequently for the 8–12 weeks profile, except for passing products of conception and pain, which were both mentioned in 40.5% of 16–17 weeks conversations vs 36.6% and 22.0% of 8–12 weeks conversations, respectively. About 8% of sellers did not give any information on any physical effects. Overall, <20% of sellers mentioned any complication of medication abortion for which the mystery clients should seek medical attention. Sellers mentioned ways to determine the abortion was complete during 85.4% of attempted purchase conversations with the 8–12 weeks profile, compared with 73.0% of conversations with the 16–17 weeks profile (not shown). The most common methods sellers suggested for determining a complete abortion were ultrasound (69.9%), expulsion of the products of conception (24.6%) and taking a pregnancy test (14.5%).

Table 2. Frequency of physical effects and complications mentioned by sellers, by gestational age profile.

	Total (n=78)	8–12 weeks profile (n=41)	16–17 weeks profile (n=37)
Seller mentioned any physical effect*	92.3	95.1	89.2
Bleeding†	84.6	92.7	75.7
Menstrual-like cramping†	66.7	75.6	56.8
Clots of blood	50.0	53.7	45.9
Vomiting†	39.7	41.5	37.8
Diarrhoea†	39.7	46.3	32.4
Mild fever†	38.5	39.0	37.8
Passing products of conception	38.5	36.6	40.5
Nausea†	35.9	36.6	35.1
Abdominal cramping	34.6	41.5	27.0
Shivering†	33.3	39.0	27.0
Pain†	30.8	22.0	40.5
Dizziness	17.9	19.5	16.2
Headache	12.8	14.6	10.8
Something else‡	6.4	9.8	2.7
Seller mentioned any complication requiring medical attention*	16.7	19.5	13.5
Heavy or prolonged bleeding†	9.0	9.8	8.1
Severe pain that is not relieved by analgesic†	7.7	9.8	5.4
High fever†	6.4	9.8	2.7
Foul smelling discharge	5.1	7.3	2.7
Continued pregnancy symptoms	5.1	4.9	5.4
Allergic reaction (hives, rash, difficulty breathing)	2.6	2.4	2.7
Something else§	3.8	2.4	5.4

^*Mystery clients could select multiple response options.

^†Mentioned in World Health OrganizationWHO, Cclinical practice handbook for quality abortion care, 2023.15

^‡Other physical effects included discharge, dilation, belly feels hard to the touch, inflammation, fatigue.

^§Other complications included intense dizziness or fainting, blood has strong smell, abnormal bleeding (no additional specification).

Pills purchased and condition of pills received

Mystery clients made 45 purchases: 27 with the 8–12 weeks gestational age profile and 18 with the 16–17 weeks gestational age profile. These purchases were from 35 unique sellers; two purchases were made from from 10 sellers. The median prices paid, including any shipping or delivery costs, were COP$150 000 (US$36.79) (8–12 weeks profiles) and COP$200 000 (US$49.06) (16–17 weeks profiles) (not shown). Price negotiations that mystery clients attempted resulted in one of three outcomes: (1) the seller refused to reduce their price and the conversation ended; (2) the seller agreed to reduce their price for the same number of pills that they originally offered; or (3) the seller reduced both the price and the number of pills that they were willing to offer. Among packages purchased, mystery clients were able to obtain discounts between COP$5000 and COP$30 000 (not shown). The most common reason for not completing a purchase was that the price the seller offered was higher than the budget limit the study team had at the time of the conversation (n=28). In four instances (two for each profile), mystery clients did not purchase pills because the seller told them that the number of pills that they could afford would not work compared with what the seller had offered them for their gestational age (6 and 8 pills for the 8–12 weeks profiles and 12 and 14 pills for the 16–17 weeks profiles, respectively).

Ultimately, we received 40 packages containing pills (88.9% of total purchases): 23 packages with the 8–12 weeks profile (equivalent to 37.7% of initial contacts with this profile) and 17 packages with the 16–17 weeks profile (27.9% of initial contacts). One additional seller sent a package, but it contained a pair of shorts and a T-shirt instead of pills (a possible mix-up). Four other packages for which payment for medication abortion pills was sent were never received. When the mystery clients followed up with the four sellers about the status of the missing deliveries, they either did not respond or attributed the delays to shipping mistakes or issues with the package carriers. None of these sellers sent a second package of pills. Nine of the packages were delivered on the same day that the medication was ordered and overall, three-quarters of packages received were delivered within 2 days of initiating contact (not shown).

Of the 40 packages of medication received, all contained Cytotec brand 200 μg misoprostol pills in aluminium blister packs labelled with Pfizer manufacturing information and sanitary registry approval from Ecuador and Peru (Cytotec is not registered in Colombia). Misoprostol pills in all the blister packs were stamped with the 1461 pharmaceutical code for Cytotec. In addition to Cytotec, two of the 40 sellers also sent painkillers, antibiotics and unspecified pills that we believed to be mifepristone, since both of those sellers had offered mifepristone to the mystery client as part of the treatment. While over 77% of all packages included misoprostol in a blister pack with no signs of damage, this was much more common for the 16–17 weeks purchases (94.1%) than the 8–12 weeks purchases (65.2%) (table 3). The other blisters had the foil around one pill carefully cut (the sellers sometimes sent pictures of the pills to the mystery clients) or in two cases, the sellers sent an undamaged blister along with additional pills wrapped in a paper napkin. Expiration dates were visible on 60% of the blisters (n=24) and all visible dates were in the future (2024, 2025 or 2026). Blister packs appeared to have been cut to send the specific number of pills that the clients and sellers agreed on, with some expiration dates removed as a result.

Table 3. Packaging condition, number of misoprostol pills and instructions given for use for received packages, by gestational age profile.

	Total (n=40)		8–12 weeks profile (n=23)*		16–17 weeks profile (n=17)
	%	N	%	N	%	N
Misoprostol packaging
Received misoprostol in an aluminium blister pack with no signs of tampering/damage	77.5	31	65.2	15	94.1	16
Received misoprostol in an aluminium blister pack with manufacturing information and expiration date visible	60.0	24	43.5	10	82.4	14
Number of misoprostol pills received
6 pills	5.0	2	4.3	1	5.9	1
8 pills	45.0	18	69.6	16	11.8	2
12 pills	47.5	19	26.1	6	76.5	13
14 pills	2.5	1	0.0	0	5.9	1
Initial dosage amounts instructed to take
Instructions were above MOH-recommended amount for gestational age	50.0	20	13.0	3	100.0	17
Instructions were at MOH-recommended amount for gestational age	47.5	19	82.6	19	0.0	0
Instructions were below MOH-recommended amount for gestational age	2.5	1	4.3	1	0.0	0
Seller directed mystery client to take repeat doses	92.5	37	91.3	21	94.1	16
Recommended dosing
4+4 (8 total pills)	35.0	14	60.9	14	0.0	0
4+4+4 (12 total pills)	40.0	16	21.7	5	64.7	11
6 pills at once	5.0	2	4.4	1	5.9	1
6+6 (12 total pills)	10.0	4	4.4	1	17.7	3
8 pills at once	2.5	1	4.4	1	0.0	0
3+3+2 (8 total pills)	2.5	1	4.4	1	0.0	0
5+3 (8 total pills)	2.5	1	0.0	0	5.9	1
4+4+4+2 (14 total pills)	2.5	1	0.0	0	5.9	1
Administration routes instructed by seller
Only MOH-recommended administration route(s) (vaginal, sublingual, buccal)	80.0	32	82.6	19	76.5	13
Combination of MOH-recommended and non-recommended (oral) administration routes	20.0	8	17.4	4	23.5	4
Seller provided contradictory information	35.0	14	30.4	7	41.2	7
Received manufacturer-labelled, undamaged packaged pills and instructions to take at least the minimum recommended initial dose of misoprostol using recommended administration routes	55.0	22	43.5	10	70.6	12

^*Two mystery clients provided a gestational age of 12 weeks.

MOH, Ministry of Health

Instructions for use provided to those who received pills

The number of misoprostol pills most frequently received for the 8–12 weeks profiles was eight (69.6%), compared with 12 pills (76.5%) for the 16–17 weeks profiles (table 3). Over 80% of the 23 sellers interacting with mystery clients using the 8–12 weeks profile instructed them to take an initial dose of misoprostol that was in line with the Colombia MOH guidelines for first trimester medication abortion (800 μg or four pills). Thirteen per cent gave instructions for more than that amount and only one seller gave instructions below the recommended amount. All 17 sellers that sold to mystery clients using the 16–17 weeks profile instructed them to take an initial dose that was above the MOH-recommended amount of 400 μg (two pills) for second trimester medication abortion. All but three sellers from whom packages were received directed the mystery clients to take repeated doses of misoprostol (92.5%; n=37). The most common instruction was two doses of four pills for the 8–12 weeks profiles and three doses of four pills for the 16–17 weeks profiles.

The majority of sellers (80.0%) advised the mystery clients to use MOH-recommended routes of administration of the pills (vaginal, sublingual and/or buccal).⁵ However, sellers more often mentioned non-recommended routes of administration (oral) for the 16–17 weeks profiles (23.5% compared with 17.4% for the 8–12 weeks profiles). About a third of sellers from whom packages were received provided contradictory information about the instructions for use or the maximum gestational ages at which medication abortion pills could be taken. Ultimately, just over half of the 40 packages that were purchased and received included manufacturer-labelled, non-damaged packaging, along with instructions to take at least the minimum recommended initial dose using recommended administration route(s).

In their instructions to mystery clients about the abortion process, many sellers also included recommendations that were not necessary for the abortion to be successful and although not always harmful, could result in additional and unnecessary pain and physical distress for the person having an abortion. For example, while over half of sellers told the mystery clients to take pain medications during their abortions, 12.5% explicitly told them not to take pain medications, stating that taking pain medications could impact the efficacy of the abortion pills (figure 2). Over half of sellers also gave instructions for the clients not to use the bathroom or eat or drink for varying numbers of hours during the abortion process (which can often last several days).¹⁰ Sellers also told clients specific foods to eat or drink (eg, light soups, orange juice, rue tea) or to specifically avoid (eg, citrus, dairy, alcohol). Fifteen per cent of sellers told clients to take antibiotics during the abortion (not shown), even though antibiotics are not routinely recommended for medication abortions.¹⁰

Figure 2. Additional instructions for abortion process given by sellers for mystery clients (MC) who received packages (n=40).

Discussion

This study is the first study in Colombia specifically and Latin America overall to examine medication abortion information provided by online sellers to clients and successful receipt by clients of medication abortion pills purchased online. Even though recent legal changes and MOH guidelines have outlined the processes for accessing abortion at health facilities, this study confirmed that medication abortion pills are still available for purchase from online sellers. This implies that sellers are meeting a demand that persists in Colombia. While people may choose to purchase from these sellers because they are perceived as more convenient and private in comparison with health facilities, their practices are not regulated by MOH guidelines. For mystery clients who were able to make purchases in this study, the majority of packages did arrive containing both the minimum necessary initial dose and often repeat doses of misoprostol for use of medication abortion as outlined in the Colombia MOH guidelines. However, particularly for mystery clients who contacted sellers with a second trimester (16–17 weeks) profile, the initial dose they were instructed to take was higher than the recommended amount. In addition, the instructions provided by sellers lacked information on contraindications, expected physical effects, potential complications, and how to determine that the abortion was complete, which are all recommended components of quality abortion care.¹⁵

For the 8–12 weeks profile contacts that resulted in completed purchases and receipt of the packages, most sellers instructed mystery clients to take an initial dose for first trimester abortions that was in line with Colombia’s MOH guidelines for pregnancies up to 12 weeks (four pills or 800 μg), and additionally sold and sent enough pills for repeat doses of misoprostol. There was only one seller who directed the mystery client to take less than the recommended initial dose of misoprostol for their gestational age. This would be a concern for an actual person seeking abortion, as it puts the individual at risk of continuing pregnancy.⁹ Compared with a similar quality of care assessment of online medication abortion pill sellers in Indonesia⁴³ and sales at pharmacies without prescriptions in Mexico,^{36 37} online sellers in Colombia were much more likely to provide enough misoprostol, as well as provide instructions about the correct initial dosages. The large majority of 8–12 weeks purchases were of 8 or 12 pills of misoprostol, which is sufficient for repeat doses in line with Colombia’s MOH guidelines, but not all sellers advised on repeat doses. Additionally, just over one-fifth of sellers provided the number of pills and instructions in line with international guidelines that recommend three doses of 800 μg misoprostol for first trimester abortions. Based on this finding, it is likely that some real clients would need additional doses to complete their abortions, necessitating repeating the online purchasing process or seeking follow-up care at health facilities.

For the 16–17 weeks profiles, sellers overwhelmingly sold and provided instructions for the use of more pills (four pills or 800 μg) for the initial dose than the two pills or 400 μg recommended by Colombia’s MOH⁴ (along with repeated doses). While this higher initial dose is not generally harmful, it may make the abortion experience additionally uncomfortable by inducing more physical symptoms. In addition, advising clients that more pills are needed overall comes with additional expense. Unfortunately, sellers did not usually provide details in their instructions about when repeat doses might be required or how to assess completeness of the abortion without ultrasound; rather, they recommended taking multiple doses to almost every mystery client. More accurate instructions about how people managing their abortion process should assess their need for repeat doses of misoprostol should be provided (eg, if no bleeding occurred), in line with MOH guidelines to take repeat doses as needed until pregnancy expulsion.⁴

The most common reason the mystery clients were not able to attempt a purchase was that the quoted price from the sellers was too high based on our study’s budget limit. As of 2023, the minimum monthly wage in Colombia was COP$1.16 million (US$276.61)⁴⁴; however, 39.2% of the population lives below the national poverty line.⁴⁵ Obtaining abortion pills from online sellers is likely cost-prohibitive for many individuals who cannot afford a large, unexpected expense that is almost 20% of the monthly minimum wage. Interestingly, a few sellers did not sell because they said the number of pills the clients could afford would not result in a complete abortion, when in many of the cases, the number would have been sufficient. In addition, when mifepristone was infrequently advertised, it was generally cost-prohibitive to purchase. This may be a result of its restricted availability, which makes it very difficult for non-clinicians to obtain and sell. A small but noteworthy percentage of purchases made during this study were also never delivered (10.6%) (a similar rate to online misoprostol sales in Indonesia),⁴³ and real pregnant people may be unable to afford a second purchasing attempt. Abortion care is a mandatory health service in the public healthcare system and is available at no cost to those using health insurance or otherwise seeking care in public facilities. However, data from abortion patients served by Oriéntame in the year following the 2022 legal changes found that only 34% of abortion patients used their health insurance benefits to cover costs, 10% received subsidies from Oriéntame and 56% paid out of pocket.³⁰ Bureaucratic delays from health insurance plans to access abortion care or a desire to avoid having abortion mentioned in their medical records may lead some people to choose to pay out-of-pocket.³³ Online sellers often tried to present themselves in a more casual and friendly manner and not like health facility providers, which may be a reaction to women’s lack of trust in the healthcare system for abortion care.³³ However, people’s privacy is a particular concern as online sellers not infrequently shared screenshots of other customers’ personal and private information.

While sellers shared a variety of information and resources, the instructions they provided about how to take the misoprostol pills, contraindications, and possible physical effects and complications varied in accuracy and completeness. More than three-quarters of the sellers from whom pills were received directed mystery clients to use the misoprostol through recommended routes (vaginally, buccally and/or sublingually) and some also suggested lying down for short periods of time after inserting pills vaginally or taking analgesics to manage pain, in line with WHO guidelines for quality abortion care.¹⁵ However, few sellers mentioned possible contraindications or complications associated with medication abortion or what to do if clients experienced them. Avoiding the mention of complications, even if they are uncommon, might be a strategy sellers use to ensure a sale, or it may also be the case that sellers themselves do not have accurate information about the potential warning signs. Either way, the average person’s knowledge of warning signs that indicate a need to seek follow-up care are likely to still be low, especially for vulnerable populations, including younger and less educated people, as well as Venezuelan migrants who are more likely to be unfamiliar with Colombia’s abortion law and health system.⁴⁶ Other complicated and contradictory instructions about diet, physical activity and using the toilet given to over half of the mystery clients who received pills were not necessarily harmful but could make the abortion process more cumbersome and uncomfortable than needed (similar complicated and unnecessary instructions were also mentioned by online sellers in the previous Indonesia study).⁴³ While previous qualitative research in Colombia had implied that online sellers of abortion pills gave better instructions and information than other sources operating outside of the medical system or guidelines,³⁹ we found them lacking in some areas, especially compared with recommended guidelines for provision of quality abortion care.¹⁵

Based on the results from this study, sellers did not consistently provide clients with information on accurate dosage amounts (especially for second trimester abortions), the conditions under which repeat doses of misoprostol are needed, and what physical effects and complications to expect and how to manage them. International websites that provided abortion information did come up in our website search and some sellers referred clients to external international sources of reliable information such as Ipas Mexico and safe2choose. Nonetheless, these findings highlight the need for compiling updated, medically accurate information about what to expect when having a medication abortion into one centralised, easy-to-locate online source that is Colombia-specific and disseminating it widely so that Colombians seeking self-managed abortion have clarity about what to expect. Accompaniment groups may also have a role to play in connecting with people ordering abortion pills online and providing them additional information that online sellers lack.^{22 47} In Colombia, there are several hotlines and feminist groups that provide instructions and reliable information on how to perform a medication abortion, as well as accompaniment and emotional support during the process. A quarter of sellers offered “accompaniment”, although we were unable to assess the quality of this support. Additionally, it was not the goal of this project to search for patient-facing materials or assess the quality of information available or being used by Colombian abortion patients. Therefore, more research is needed to determine what sources people ordering pills online are relying on for understanding the abortion process.

Strengths and limitations

The mystery client design of this study allowed us to simulate real customer experiences of pregnant people seeking medication abortion pills. This research is distinct from other studies of the online market of abortion medications in the USA and Indonesia (more restrictive environments than currently exists in Colombia^{43 48}) and it provides insight into how online sellers behave in a country with greater legal access to abortion.

Despite its strengths, this study also had several limitations. The market of online abortion pill sellers is constantly in flux. As a result, this study is only able to present a snapshot in time and is not a comprehensive picture of every online seller. We used a variety of search terms informed by Google Trends data, but the research team determined the keywords for the search, rather than asking potential clients what terms they would use. Even though we performed deduplication, the study team suspected that there may have been additional duplicates based on some similar sources of information and bank accounts shared with clients. We are not able to determine whether sellers are working together, independently, or where they obtain the information they share, and we are not able to comment on the qualifications of the sellers or where or how they are getting the pills they are selling. While purchasing medication abortion pills without a prescription and self-managing an abortion is not mentioned in the penal code, it is neither permitted to sell registered drugs without a prescription, nor to sell medicines that are not formally registered, which is the case of the Cytotec brand in Colombia.¹³ Therefore, we cannot comment on the legal risk the sellers are willing to take on and how that informs their advertising or behaviour with clients.

While we initially instructed mystery clients to report gestational ages of either 8 or 16 weeks to sellers, during analysis we determined greater variation in dates of last menstrual period provided, especially for those intended 8-week profile conversations. Therefore, we classified the profiles according to ranges (8–12 and 16–17 weeks gestational age). This deviation in gestational ages could also have affected the number of pills that mystery clients were offered, but since Colombia’s MOH recommends 800 μg of misoprostol for misoprostol-only regimens for all pregnancies under 12 weeks gestational age and 400 μg for pregnancies between 12 and 24 weeks (with repeated doses as necessary),⁵ we were able to consistently evaluate the sellers’ dosing adequacy according to MOH guidelines within these two gestational age groupings for all but two interactions that provided an LMP equivalent to 12 weeks of pregnancy. While the MOH guidelines were updated in early 2023,⁵ previous versions of the guidelines had recommended the same misoprostol-only dose could be used up to 13 weeks of pregnancy.⁴⁹ Therefore, we may have slightly overstated the extent to which sellers provided the correct instructions for taking the pills between 8 and 12 weeks in line with the current guidelines.

Due to budgetary constraints, we were not able to purchase pills from all identified sellers. This may impact our conclusions if the more expensive sellers were likely to provide a different number of pills and different information as compared with the sellers from whom we bought. In addition, we did not test the pills received to verify their authenticity; rather, we based our assessments of the drugs on the package labelling with manufacturer information and the shape and pharmaceutical code stamped on the pills.

Conclusion

These results demonstrate that online sellers selling medication abortion without a prescription continue to operate as a source for medication abortion pills in Colombia. Now that Colombia has a new progressive legal framework for abortion access, additional research with people who have purchased abortion pills online could provide more information on barriers to access and how and why the online abortion pill market continues to be appealing for some women. Similarly, additional studies of people who opt for medication abortion through telemedicine could provide further insight into the motivations for avoiding in-person care in this context. Continuing to assess barriers to expanding telemedicine for medication abortion through the formal health system could also highlight policy or operational recommendations for implementing those services more broadly. Finally, additional research on what information sources are available and used by people purchasing abortion pills online and through other informal sources outside of the medical system about how to use the pills, what to expect, and contraindications for use could shed light on what information individuals are referencing. People in Colombia should have access to complete and accurate information to ensure that they are well positioned to self-manage their abortions if they choose to do so.

The views expressed are those of the authors and do not necessarily reflect the positions and policies of the donors. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Data availability statement

Data are available on reasonable request.