D.I.Y.: Self-Managed Abortion
The advent of abortion pills as a health technology has deep personal and political consequences for how, when and where abortions happen. The “discovery” of abortion pills occurred in the 1980s in Brazil, when women noticed that the label for misoprostol, a drug registered to treat gastric ulcers, cautioned against its use by pregnant women because the drug caused uterine cramping. Use of misoprostol alone to end unwanted pregnancy spread quickly in Brazil and across Latin America outside the formal health system, as abortion is criminalized in most of the region. [efn_note]Hist. cienc. saude-Manguinhos. vol.23 no.1. Rio de Janeiro. Jan./Mar. 2016. http://dx.doi.org/10.1590/S0104-59702016000100003 “The Biomedicalisation of Illegal Abortion: The Double Life of Misoprostol in Brazil. A biomedicalização do aborto ilegal: a vida dupla do misoprostol no Brasil.[/efn_note]
The use of pills for abortion entered formal healthcare systems when the French pharmaceutical company Roussel-Uclaf developed mifepristone for use with a prostaglandin like misoprostol to end a pregnancy (with higher effectiveness than misoprostol alone, although the World Health Organization (WHO) recognizes both misoprostol alone and the combination mifepristone/misoprostol as highly safe and effective).[efn_note]Medical management of abortion World Health Organization 2018.[/efn_note] Mifepristone was first approved in France in 1988, but almost immediately, Roussel-Uclaf tried to take it off the market and abandon distribution because of social opposition and a threatened boycott.[efn_note]Roussel-Uclaf, Press Release, October 25, 1988.[/efn_note] The French government intervened and declared the pill the “moral property of women,” but the pharmaceutical company would not seek approval for mifepristone in any other country without government invitation where abortion was lawful.[efn_note]Alan Riding, “Abortion Politics Are Said to Hinder Use of French Pill.” New York Times July 29, 1990. [/efn_note] These restrictions slowed the global availability of mifepristone, which was approved in the US only in 2000. In most countries, national regulatory agencies adopted unwarranted prescription and dispensing controls for mifepristone, beyond any evidenced need, thereby putting the pills beyond the reach of many. [efn_note] W.R. Ewart and B. Winikoff, “Toward Safe and Effective Medical Abortion” (1998) 24 Science 520–521. [/efn_note]
Self-management of the process marks the radical return of abortion to the people: something one does to oneself, something one experiences as their own.
In the US and many other countries where abortion is provided in the health system, mifepristone is given in the clinic, and misoprostol, the pills that provoke uterine contraction and bleeding, are routinely taken at home. In other words, the process of using abortion pills inherently involves the user taking some control of the process. In countries where medical abortion is lawful and available in formal health systems, there are multiple efforts to give users further control in how they engage with and experience abortion within formal healthcare systems, including practice innovations such as telemedicine, reduced follow-up requirements and advanced provision. In the US, as abortion is increasingly restricted, these innovations include developing models of postabortion care to provide medical support for those choosing to access pills outside the formal healthcare system.
Worldwide, the majority of abortion pills are used outside formal systems, particularly where abortion is criminally restricted, but where misoprostol can be self-sourced in a pharmacy, online or through local markets. Even where abortion is lawful, people may not have access to abortion services or prefer to avoid interaction with formal healthcare systems. Some people use the drugs and experience the abortion on their own, whereas others engage the help and support of partners, friends and family members. Self-management of the process marks the radical return of abortion to the people: something one does to oneself, something one experiences as their own. The innovation of abortion pills invites people to think and act positively about their bodies, to use their bodies to protect their health and well–being and to act out their basic human right to decide whether and when to reproduce on their own terms and for themselves, outside formal healthcare systems and sometimes outside the law.
Direct-service activism in self-managed abortion seeks to transform both the patient experience and the social view of self-managed abortion from a last and dangerous resort of risk and vulnerability to an empowered act characterized by feminist care, solidarity with people and even humor.
Over the last decade, a global network of activist groups has emerged to support people in self-management and to make the world outside healthcare and legal systems a safer and more-humane place. Working through a diverse set of practices (e.g., safe abortion hotlines, in–person and online counseling and accompaniment services and community-based distribution of pills), direct-service activists in self-managed abortion have fundamentally changed the abortion black markets and back alleys of today.[efn_note] J.N. Erdman, Kinga Jelinska and Susan Yanow. “Understandings of Self-managed Abortion as Health Inequity, Harm Reduction and Social Change.” Reproductive Health Matters (2018) 26:54, pp. 13–19.[/efn_note] They provide people with confidential, reliable and accurate information on the safest and most-effective ways to buy and use abortion pills; counsel and support people before, during and after their abortions; and help people navigate and access services within formal systems, including follow-up care. There are now more than 20 abortion hotlines worldwide.[efn_note] https://womenhelp.org/en/page/regional-resources.[/efn_note] Many activists also help people access quality drugs by bringing medicines into local communities, checking the quality of drugs and driving down prices among other private sellers, and through internet-based services, delivering drugs by postal or courier services. Their direct-service activism not only supports individuals with unwanted pregnancies but also targets the structural conditions that create vulnerability and expose people to risk in self-managed abortion: the information deficits and unregulated drug markets, as well as the social isolation and stigma of abortion. These projects question and force the reimagination of the social norms around abortion through demystification, demedicalization and destigmatization of the practice of self-managed abortion.
Direct-service activism in self-managed abortion seeks to transform both the patient experience and the social view of self-managed abortion from a last and dangerous resort of risk and vulnerability to an empowered act characterized by feminist care, solidarity with people and even humor. Self-managed abortion is not seen as a problem to be solved, or a temporary solution due to a failed healthcare system. Rather, self-managed abortion activism embraces the practice without shame or judgment. It is inspired by a collective conscience of respect, trust and dignity: “I trust you to know and to make good decisions for you.”
Central to self-managed abortion activism is a respect for a person’s needs and choices as expressed and a refusal to subordinate these needs to the interests of any another, including medical and legal authority. There is a commitment to meet people where they are and to strengthen their capacities to manage their abortions safely and effectively on their own terms. Risks such as ectopic pregnancy, inaccurate assessment of gestational age or counter–indications are not ignored or neglected, but instead become normalized and even predictable features of abortion that people can manage should they occur. The rare chance of a complication is not seen as a barrier, but rather as information about the process that should be widely shared, with support for people to access healthcare systems for intervention if needed. When there is community uptake in the use of pills in informal settings, public-health evidence shows that self-managed abortion can be practiced safely, with a decrease in abortion-related death and disability.[efn_note]Singh S, Maddow-Zimet I. “Facility-based Treatment for Medical Complications Resulting from Unsafe Pregnancy Termination in the Developing World, 2012: A Review of Evidence from 26 Countries.” Obstet Gynaecol. 2016; 123:1489–1498.[/efn_note]
Activism around self-managed abortion is also grounded in the belief that abortion should be easy and convenient, subverting traditional power dynamics of abortion care in recognition that people have a fundamental right to make decisions about their own bodies and to act on these decisions. Gone is the gatekeeper provider role, the policing of the boundaries of the law and the communication of its norms and values through the rationing of abortion care. People help other people to terminate their pregnancies on the collective trust that abortion can be demedicalized.
Official WHO protocols are released into the public domain, with the knowledge that people can and will use them and even innovate around the protocols. Building on the word-of-mouth origins of safe misoprostol use, people today share experiences of self-management and rate the quality of drug sources through online forums. Ordinary people are empowered to create and share knowledge about the process. With people well informed, adequately resourced and openly supported, abortion is treated as a normal life event, perhaps an affirming one. Building up this affirmative social view of abortion is a powerful antidote to the stigmatizing views of abortion in criminal justice and health systems.
The practice of self-managed abortion forces an overdue change in the existing discourse about all abortion. By working in the shadows of unjust abortion laws and the harmful health systems they create, direct–service activists are a powerful voice for removing all abortion practice from criminal law. These activists seek not only to mitigate the harms of these systems, but also to give public testimony to the fact that abortion outside formal systems is often necessary to avoid the abuse and mistreatment within them. They reveal the harms of criminal laws that explicitly ban self-managed abortion and regulatory laws that censor, withhold or otherwise obstruct the provision of safer use information and overregulate abortion medicines, confining them behind the walls of high-level healthcare facilities and out of reach to those who need them. Their activism reveals the hypocrisy of abortion laws and regulations that claim to protect health and life by reaffirming the worth of all those who seek abortion as members of a community whose health and lives matter. As efforts to affirm these most basic public values of respect, trust and dignity, their actions are best described as collective acts of conscience.
Global feminist activism on self-managed abortion supports people in moments of immediate need, while highlighting and resisting the daily injustices of abortion laws. Most importantly, in a spirit of reproductive justice, it offers a vision for health systems in which every person has the right to a safe and dignified abortion informed by the values and needs most important to them, and access to the means of realizing that right. Self-managed abortion highlights the potential of abortion pills to increase access to abortion for millions of people and presents a bold framework for empowering communities and breaking through abortion stigma.