Embedded: The Network

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I'm Rand Abdir Fattah.

And I'm Ramteen Arab Louis.

Three years ago, when the Supreme Court overturned Roe v.

Wade, abortion opponents celebrated.

But many abortion rights supporters feared that American women were now in danger.

They thought without access to legal abortions, women would resort to unsafe methods.

Yet, a sprawling set of people have been expanding abortion access in unconventional ways since the 1980s.

They'd been prepared for this moment.

A network of activists and midwives, grandmothers, and friends.

Today on the show, we bring you episode one of the network, a three-part series from NPR's embedded podcast, and Futuro Media.

Hosts Victoria Estrada and Marta Martinez go inside the global movement that's helped millions of women have abortions at home.

The story begins decades ago when Brazilian women found a way to have safe abortions without a doctor and how their method is shaping the future of abortion in the U.S.

today.

Here's Marta.

The day after the fall of Roe, 13 states immediately banned or severely limited abortion.

Eventually, nearly half of all states did.

And within a month of the ruling, dozens of clinics stopped performing abortions, forcing many Americans to travel hundreds of miles to get one.

Other laws targeted abortion providers.

Are you scared?

I am scared, and I think a lot of us are, because there's nowhere else in medicine that is policed and regulated and now criminalized to such a degree.

You don't care if people die!

But not all abortion rights supporters felt this way.

Everybody was so calm in the network.

The network.

It's what we're calling the diffuse set of people who are expanding abortion access in an unconventional way.

They were not panicking.

Everybody was like, we've been doing this work.

We're going to continue doing this work.

nothing is changing, who cares?

I'm actually energized.

This network, it's hard to even describe because it's not formal or centralized.

There's no CEO, no headquarters.

Some people work together, but plenty don't know each other.

They're midwives and nurses, grandmothers and friends.

This network crosses borders and reaches people throughout the world, from South Africa to Myanmar to Mexico and all over the United States.

What unites the network is how they are expanding abortion access by helping women have safe abortions on their own without a doctor involved.

Their method grew out of a very small thing.

It actually fits in the palm of your hand.

But despite being physically tiny, When it comes to reproductive health, doctors, researchers, and people working in this field say it's been monumental, extraordinarily important.

It's a lifesaver in so many ways.

It's the equivalent to the discovery of penicillin because it's a before and after.

But unlike penicillin, this discovery has not been universally embraced.

Instead, it's the latest target of abortion restrictions that continue to make the news.

The future of abortion access could be impacted by a new lawsuit just filed by the Attorney General of Texas.

A long-dormant federal law prohibits the mailing of any supplies used for abortions.

Possession could be punishable by up to five years in prison.

From NPR's Embedded and Futuro Media's Latino USA, this is the Network, a series about the DIY method that took safe abortions out of the clinic and the women who made it happen.

Episode 1, SaintOTEC.

We'll be right back.

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I'm Victoria Estrada and I'm Marta Martinez.

We're both producers at the public radio show Latino USA.

We've been covering reproductive rights in the Americas for years now.

And when we started to see more and more challenges to abortion access in the U.S., we immediately thought about Latin America, because historically, Latin America has had strict abortion bans.

Not so different from what we're seeing now in parts of the U.S.

But as research from around the world shows, bans don't stop people from getting abortions.

They just lead them to take more risks to end their pregnancies.

That's where the phrase bacalley abortion comes from, and where we get the image of a woman using a coat hanger, self-managing her abortion.

But nearly 40 years ago in Latin America, women developed an abortion method that was medically safe and effective.

No doctor needed.

And this new type of self-managed abortion transformed how abortions happen across the world today.

It all started in Brazil, where this method was born in the late 1980s.

Victoria and I took a trip there last year, in 2024, and one of the people we interviewed was Jacqueline Pitankhi.

Hi, Jacqueline.

Jacqueline is a longtime feminist advocate.

How was your day?

And she lived through Brazil's military dictatorship, which lasted for more than two decades.

When the dictatorship fell in 1985, she fought to get women's rights into Brazil's new constitution.

Because women at the time had so little say in their workplaces, marriages, or over their bodies.

So, here in front.

You have the Christ.

Oh, it's right here.

Right here.

From Jacqueline's balcony in Rio de Janeiro, we could see what's probably the most iconic image of Brazil: the statue of Christ the Redeemer.

So, you see it every day in the morning when you wake up?

Say hello.

Yeah, I say hello, Christ.

How are you?

Be good, be good, Jesus Christ.

Maybe you've seen it in a movie or photos.

It's this huge sculpture overlooking the whole city of Rio de Janeiro on top of this spectacular cliff.

It's interesting because I was actually talking about this with Victoria this morning that religion is very present in this city in a very visual way because you have the Christ up there in the mountain looking at you

from everywhere.

Yeah,

everywhere, everywhere.

It's this constant reminder of the influence Catholicism has had on Brazil for much of its history.

For the Catholic Church, contraception has always been a key issue.

Until the 80s, many Brazilian women didn't have great access to birth control.

Before then, in the poorest region of the country, women had on average almost six children.

We heard that some women just didn't know much about their own bodies.

For example, some women were afraid of using tampons because they thought they might get lost inside of their vaginas.

We also heard that some women thought that their vagina was connected to their mouth.

This lack of knowledge had serious consequences.

The significant

let's call punishment on women's bodies:

death or morbidity.

In the 1980s, Brazil's maternal mortality rate was higher than most of the rest of the world.

I lived through a time when women got sick and died,

died of infection, died of bleeding, young women, extremely young women.

This is Dr.

Rivaldo Albuquerque.

I am a gynecologist.

I am a practicing Catholic.

And I have been working with women's health since I was a medical student.

We visited Rivaldo in the coastal city of Recife in northeast Brazil.

It's the poorest region in the country.

When he started working in a public hospital in 1985, the state that Recife is in had the highest maternal mortality rate in all of Brazil.

Rivaldo saw it every day in the emergency room.

A lot of pregnant women coming into his ER with complications from a lack of prenatal care, like chronically high blood pressure, and also complications from abortion.

Abortion was and still is illegal in most cases in Brazil, and it was often seen as a sin.

But that doesn't mean women were not getting abortions.

Research from that time estimated there were between one and four million abortions happening in the country every year.

People who had the money could look for doctors who did abortions in clinics, in hospitals,

with every safety precaution using sterilized material.

In other words, people who had the money could go see a doctor who was willing to break the law for the right price.

Those were not the women who ended up in the emergency room where Rivaldo worked.

His patients had often gone to places that were less reputable and unsafe.

Others just tried to self-manage their abortion.

We heard about lots of ways: herbs, teas or drinks,

and session of foreign objects,

the rods of an umbrella,

needles,

and whatever medicines they could buy at the pharmacy.

You know, all those horror stories that you read about.

By the time women got to Rivaldo, they often had perforations in their uterus, hemorrhages, and serious infections.

Rivaldo told us about a specific case that has stayed with him.

It was a patient who was only a few years younger than he was at the time.

She was a 19-year-old woman who had already had two children.

She came in with a generalized infection.

It was a desperate condition,

And we didn't have any background information about this woman.

She wouldn't speak.

She was in no position to explain what had happened to her.

And the person who brought her in didn't want to talk either.

Rivaldo and the other doctors suspected she'd had an unsafe abortion.

And so they decided to do an exploratory operation.

So that we could evaluate the abdomen, what was happening with this infection.

And when we opened the abdominal cavity, we found the uterus that smelled, pardon the word, rotten.

Rivaldo still remembers it.

A terrible smell with several perforations.

It was a classic picture of an unsafe abortion.

Since it's an illegal procedure, this woman must have stayed home for a few days or didn't receive proper medication.

Who knows how long she waited to go to the hospital after signs that something was wrong.

And now there was nothing the doctors could do.

Why did this woman die?

I can tell you without hesitation because she was black and because she was blood.

Rivaldo told us he really felt for these women.

They are in a situation of suffering, of vulnerability.

Their health and their life are at risk.

I know these women.

Many are Christians, evangelical, Catholic, but they are going through a specific moment in their life.

They are in need.

But Rivaldo was an exception.

Many doctors did not treat these patients well.

Women who had tried to have an abortion were the last ones to be treated during our shift.

So these women, they would be in the emergency room all day long without food or anything to drink.

They spend the whole day fasting, waiting for their procedure on an empty stomach,

and they were being punished

because they were the last ones to be taken care of.

He remembers that some doctors wouldn't give the women enough anesthesia before their dilation and courage.

or DNC.

So, the women would feel the pain of their cervix being dilated and the walls of their uterus being scraped.

And the women cried out because of the pain

of their suffering.

Unfortunately, I heard medical staff say

when you did it, it was a lot of joy, a lot of pleasure.

And now you're crying.

You don't know what you did.

You killed the baby.

One doctor told researchers at the time that his hospital was doing two hysterectomies a week because of so many botched abortions.

Another doctor called working with these patients a, quote, revolting process because she was presenting us with a disgusting mess, unquote.

Some doctors went even further than insulting the women.

In some cases, they called the police.

And the police would come all the way to the hospital and handcuff the women.

They would chain them to the bed.

Women were arrested.

Rivaldo says his hospital never let this happen, but he knew it happened elsewhere.

That was the standard for these women.

So these are things that I will never forget.

At the end of his shift, Rivaldo would make notes about his patients, who lived, who died, how many births, how many c-sections,

how many surgeries, how many abortions, how many infected abortions.

And around the year 1987, he noticed a change.

A big change.

Severe cases of infections, severe cases of hemorrhage.

They disappeared.

Women were still coming into the ER, but they were showing up with new symptoms, much less serious ones.

Like an increasing body body temperature,

hyperthermia,

and it didn't make sense because you couldn't find an infectious condition.

Some women also had gastrointestinal symptoms.

We realized that there was something different, and this made us a little confused.

Around the same time, a researcher named Sara Costa was working for Brazil's School of Public Health in Rio de Janeiro, more than a thousand miles south from Recife, Recife.

And she noticed another big change.

We were seeing this incredible decline in fertility.

Suddenly, women were having fewer children.

But why?

It was strange, because there were no big policy changes to account for it.

The government wasn't providing

much information about how to control fertility.

And abortion was still illegal, so something just wasn't adding up.

Was it spontaneous use of oral contraception?

How were they getting it?

So in the early 90s, Sara began talking directly to the women.

And we conducted those interviews over a period of several months and analyzed the results.

She and her team interviewed more than 800 pregnant women in seven hospitals in Rio de Janeiro.

Many of those women had come into the hospital bleeding.

Hospitals in Rio and in other parts of the country had been seeing more cases like this in the past few years of women who seemed like they had attempted an abortion.

We thought we would actually discover a lot more complications, serious complications, but most of the women went into hospital with bleeding, had a curatage, and left.

Left?

They didn't get stuck in the hospital with infections or other complications.

It was a bit of a surprise.

In Recife, Rivaldo had noticed a similar pattern.

We had a downward curve in

a downward curve in abortion complications.

And then there was a moment when you almost didn't see any complications of abortion at all.

Fewer complications from abortion meant one thing.

Women stopped dying.

Or at least, far fewer were dying.

From 1986 to 1991, the time Sarah and Rivaldo were observing, the World Health Organization recorded a 21% drop in Brazil's maternal mortality rate.

It seemed like magic, or a better word,

a miracle.

The cause of what Rivaldo calls a miracle after the break.

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In 1973, the same year that Roe v.

Wade was decided in the United States, something else happened that transformed reproductive healthcare, but in a much more roundabout way.

An American pharmaceutical company called Searle developed a new drug to treat gastric ulcers, kind of like Tums or Peptobismol or Milk of Magnesia.

It was a small, white, hexagon-shaped bill with a tiny figure of a stomach etched on one side.

Not a belly, the actual organ.

It's actually the stomach that makes me remember this bill.

It's called Cytotech.

And even though it was created by an American pharmaceutical company, the Food and Drug Administration was slow to approve it.

Several years before being available in the US, Cytotech first made its way to Europe and then Brazil in 1986.

And here's where it's hard to know what is fact and what is part of the myth of cytotech.

Because in Brazil, this ulcer pill took on a new life.

For starters, we know that the original cytotech box came with a warning.

But because it's been 40 years, people remember that warning differently.

Jacqueline Pitangui, the sociologist who says hello to the Christ statue every morning in Rio de Janeiro, remembers that the warning was written out.

It's that little paper that comes with the medicine that says you should avoid to take it if you were pregnant because it could cause contractions.

Dr.

Rivaldo Albuquerque remembers the fine print more specifically.

There was a very clear paragraph that said that it should not be used in pregnant women

because it could cause uterine contractions and lead to miscarriage.

Tebora Diniz, a Brazilian anthropologist and law professor who grew up in the 80s, remembers the warning as an image on the box.

It was a profile of a pregnant woman, big belly and a warning crossing the belly and also a skull.

There was a skull?

There was a skull.

Wow.

I'm 100%

sure of that.

We haven't been able to confirm the skull, but we have seen the image of a pregnant woman in a circle with a slash through it.

When the pharma company developed Cytotech, it discovered that the drug had the significant side effect on women, a serious side effect.

It caused bleeding and contractions that could induce a miscarriage.

So for people who were pregnant and wanted to stay that way, it was a very dangerous pill to take.

But for people who were pregnant, and did not want to be, Cytotech's side effect wasn't a problem.

It was a solution.

A new new tool to self-manage an abortion.

But unlike the tees and crochet needles women had been using, CETATEC was overwhelmingly safe and effective.

And somebody, somewhere, somehow, figured that out.

I don't think we ever identified where it started.

No, it's impossible to know this.

Don't forget, we didn't have social media then.

There's no records.

It wasn't like there was a lot of incentive to take credit.

Whoever did this was likely breaking the law.

They wouldn't give their name.

I am Mary Smith.

And listen, you can use this to induce an abortion.

Some speculate that it was a pharmacist or a midwife.

We certainly knew that pharmacists were involved.

I went to the pharmacy and I bought this.

But even if we can't know the original source, we do know how the knowledge spread far and wide.

The women themselves.

Women said ha.

I have no question of saying that it was from women.

Brazilian women.

Women continued taking it because it was another woman from her family who shared with her.

It certainly wasn't advertised.

It was in the air.

I can tell you when something is in the air among women's talks.

I mean, it was in the air.

This is a woman we're calling by her initial, R, to protect her safety, because what she did was and still is illegal in Brazil.

A woman who went through the process would tell another,

hey, buy that, buy that.

The whispers about cytotech reached R in 1986, the same year it came on the market in Brazil, and she thought it sounded a lot better than the first abortion she had been through.

The type of dangerous abortion Rivaldo had seen time and time again in the emergency room in the early 80s.

The first time R needed an abortion, she was a minor, 13 or 14 years old, living in Recife.

She was dating someone a lot older than her, and R says even though she was in a relationship, she understood almost nothing about sex or her body because of how she grew up.

Oh, my mother raised us like potatoes in the ground.

R was one of 12 kids.

We didn't have the talk about what sex was.

I just knew that I was going to get kissed.

I didn't know that the thing was going to create a child.

So I didn't know that a partner shouldn't cross certain boundaries.

When R started feeling funny and her period stopped, she confided in her older sister.

She sat me down and said, Look, you are pregnant.

There's going to be a baby and we have to find a solution because dad is going to kick you out of the house or he's going to kill you.

Her sister didn't mean it as an exaggeration.

She thought her dad would literally kill R if he found out she was pregnant.

He nearly done just that a few years earlier to our sister.

He once took out his gun and tried to kill my sister,

the same sister who helped me because my sister lost her virginity.

So it was dangerous for R to stay pregnant, but it was also risky to get an abortion, both physically and legally.

R's sister took her to a midwife, and R remembers the midwife inserted a catheter into her cervix to induce an abortion.

When she returned to her parents' house, she had very heavy bleeding and then passed out.

I actually fell on the bathroom floor.

My sister picked me up, showered me, and told my mother, I'm going to take her because she's having her period.

It's very strong and she's weak.

She didn't tell my father.

Our sister took her to the hospital.

While she was there, doctors questioned her.

They wanted to know if she'd done anything to cause an abortion.

R kept denying she had, even when they threatened her with jail.

I said no, of course.

I had to deny it.

I was told to deny it.

It was a crime that involved a lot of people, right?

R was given a DNC to complete her abortion.

The doctors told her she'd nearly perforated her uterus and had been at risk of losing it.

R stayed in the hospital for several days to recover, in a maternity room with other women who'd attempted an abortion.

All of them had done something, and the one next to me

died.

Died?

I asked.

Why?

Yes, I had a courage, right?

Then I was fine.

but the one next to me

never came back.

A few years later, when R was 19 years old, she got pregnant a second time.

She says a guy she had seen just a couple of times forced himself on her.

R decided to have another abortion, but this time it was a very different experience because of sight attack.

It was for gastritis, so they sold it at the pharmacy like water.

You just go in and say, hey, give me a box of cytotech.

Anyone could buy it.

The pharmacist she bought it from told her to swallow two pills, wait a couple of hours, then take two more pills until she finished six pills.

He also gave her an instruction that was very common at the time.

Look, you are going to expel.

When you expel, when you're bleeding a lot, go to the hospital.

I went home and took the pills.

She says the pain was strong, but not like with the first abortion.

She was bleeding, but she didn't faint.

She didn't have her sister by her side, but she was able to get herself to the emergency room.

One thing was the same.

The doctors again questioned her, and again, R denied that she had done anything to cause an abortion.

And this time, Ar says she didn't have to stay in the hospital.

She had a DNC and left.

Her parents never found out about it.

Ar went on with her life.

She moved in with her sister, who supported her going to school.

I graduated as a social worker.

The two experiences were very difficult for R,

but one thing was clear.

The second time, I didn't have a lot of side effects.

I didn't have a lot of bleeding, so it was safer for me.

I felt more comfortable.

Still, she wishes she'd had more support.

Because R and women like her who took side attack to cause an abortion in those early years, they were experimenting on themselves.

It's not like the pills came with a slip of paper explaining how to have an abortion.

In fact, if you remember, the instructions said, don't take this pill if you're pregnant.

In 1993, researchers from a public university in the country published a study called Cytotech in Brazil.

At least it doesn't kill.

In it, most women reported taking between four and 16 pills, but some reported taking dozens.

It's likely that R didn't take the right dose to have a complete abortion.

But over time, Brazilian women again figured out something by themselves.

One of the interesting things that I noted in my research is that women got much better at using Cytotech.

This is Sarah Costa again, the researcher in Rio de Janeiro.

While she conducted the study in the early 90s, several years after Cytotech became available, she heard about how women were taking the pills.

Put them under your tongue or insert them in your vagina.

Eventually, they started getting better results.

At the beginning I would say that a lot of women needed curatage but it turned out once they got better at using it they were actually having complete abortions.

In other words they no longer needed a DNC.

How long was your data collection period?

I think it was about six to nine months.

Fast.

It's fast.

Yeah.

So, you know, we were able to observe change.

Of the women who went to a hospital after having an abortion, Sarah found that nearly 60% reported using cytotech to self-manage it.

She wrote that this represented, quote, only the tip of the iceberg, because many more women could have taken cytotech and not needed medical help.

According to her research, the median dose the women were taking was 800 micrograms, four pills.

which is the same dose the World Health Organization now recommends for pregnancies up to 12 weeks.

And how were they getting this information?

Sarah found that the overwhelming majority of women who use CytoTech, 84%,

had learned about it from friends, relatives, or colleagues.

It was the network starting to form.

Women loosely connected by whispers.

Just by sharing their experiences, what worked and what didn't work, they began to build knowledge.

Women know how to be scientists at home when science is not offering what they need.

This is Deborah Denise again, the Brazilian anthropologist and law professor who remembers the skull on the cytotech box.

So basically it's about observation, it's about taking experiments in our own bodies and it's about sharing with others.

She calls it domestic science.

And she saw the results of this domestic science for herself.

By the time she learned about cytotech, it was no big deal.

So I was at school in the 80s when I saw for the first time a classmate

with the pills telling us, I'm going to take them today.

Her classmate got the pills through a family member and they worked.

Can you believe that the day after she was in school?

I'm wondering why you think Cytotech became so popular so quickly.

Let me try five reasons.

One, it was discovered by women.

It was shared from woman to woman.

It proved to work and to be safe.

It was used for an essential need to women's lives.

And it was available at the community level.

And it was cheap.

Very cheap.

Pharmacists in Brazil told us they sold it for about five bucks in the early 90s, compared to $500 for an abortion abortion at a private clinic.

At the time, Cytotech sales exploded.

Researchers tracked that in the late 80s and early 90s, more than 50,000 boxes of the pill were being sold in Brazil every month.

Actually, there are more reasons women chose Cytotech.

In that same report from 1993, Cytotech in Brazil, At Least It Doesn't Kill, the researchers interviewed women who had used it.

In their testimonies, they described lots of reasons for liking it.

We had voice actors read some of their quotes aloud.

Since it wasn't a procedure requiring a doctor's expertise, it didn't exactly feel like an abortion to some of these women.

It's less traumatic, a lot less.

You know what the sensation is?

The sensation is that your period is late, and so you take medicine for it to come.

As a result, some women describe feeling less guilty, taking the pill.

If I had gone to a clinic, I would never have forgiven myself.

And women felt it put them, not their partners or doctors, in control.

Using cytotech is something that is yours.

Nobody has to know what you did or you didn't do.

No one invades your privacy.

Even the gynecologist I went to later didn't know that I had had an abortion.

Women who wanted abortions weren't the only ones who appreciated side attack.

Many doctors did too, because they didn't have to deal with so many gruesome cases or do such serious procedures, like having to remove a uterus.

One doctor in Sao Paulo told the researchers that he'd seen hysterectomies drop from two a week to one every six months.

When we asked Rivaldo, the OVGYN Recife, how he remembers feeling at the time, he used one word: alive.

Relief.

Alifo de

relief of mind and of conscience.

I was happy because I saw that what we couldn't do, which was to help women, the network was doing it.

And that's what I wanted.

I wanted women to be healthy.

So if I couldn't do it effectively, the network was doing it.

Rivaldo told us that feminists and health providers coined a nickname for cytotech.

They called it Santotech

Cytotech, Santotech, it has many names.

You might know it as misoprostol, aka miso, like the soup.

Or maesto.

There's no agreement on how to pronounce it.

Experts believe it's now the most commonly used abortion pill in the world.

And the World Health Organization says it's safe to self-manage with pills through 12 weeks of pregnancy.

Later in the series, we follow the network as it spreads this pill across Latin America.

I was like, what?

No way.

And into the US.

Oh, there's a whole group of you, and you're all like underground and secret squirrel and using different names.

It was just mind-blowing.

Up next, women create an entirely new support system around miso.

That challenges the medical establishment and the law.

Someone was going to do what we didn't dare to because we had a license and we were afraid of the law.

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You'll get early access to every embedded series and sponsor-free listening.

Go to plus.npr.org slash embedded to find out more.

The network from Embedded is a collaboration with Latino USA, a production of Futuro Media.

This episode was produced by Monica Morales-Garcia and Abby Wendell.

Reina Cohen edited the series.

Additional reporting by Abby Wendell.

Fact-checking by Cecile Davis-Vasquez, Nicolette Kahn, and Jovana Romano-Sanchez.

Robert Rodriguez mastered the episode.

Voiceovers by Mariana de la Varva, Julia Carnero, Marcelo Starubinas, and Susi Valerio.

Liana Simstrom is our supervising senior producer.

Katie Simon is our supervising senior editor.

Irene Naguchi is our executive producer.

And Colin Campbell is the senior vice president for podcasting at NPR.

The embedded team also includes Luis Treyes, Dan Germa, Adelina Lancianese, and Ariana Garib Lee.

From Latino USA, our executive producers are Marlon Bishop and Penile Ramirez.

And our production managers are Jessica Ellis and Nancy Tujillo.

Thanks to our managing editor of standards and practices, Tony Kevin.

and to Johannes Durgee and Micah Ratner for legal support.

And Tommy Evans, NPR's Managing Editor, Editorial Review.

Our visuals editor is Emily Bogle.

Original tile art by Luke Medina.

Special thanks to Alyssa Natwarney, Selena Simmons-Tuffin, Mariana de la Barba, Maria Mapta Bruno, Julia Carnero, Roberta Fortuna, Dina Ortega, Kelly Blanchard, Maureen Paul, Lourdes Rivera, Abigail Aiken, Giselle Carino, Dee Red Wine, and Jefferson Drazette.

And a big thanks to our Embedded Plus supporters.

Funding for this series provided in part by the Levi-Strauss Foundation, outfitting movements and leaders fighting for a more just and abundant world,

and the International Women's Media Foundation, as part of its Reproductive Health Rights and Justice in the Americas initiative.

I'm Marta Martinez.

I'm Victoria Estrada.

This is Embedded from NPR.

Thanks for listening.

Muchas gracias for escuchar.

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