SELF-MANAGED ABORTION – Self-managed abortion: a constellation of actors, a cacophony of laws?

by Lucia Berra Pizzarossa, Rishita Nandagiri

Sexual and Reproductive Health Matters, 2021 (25 March);29:1. (Open access)

Self-managed abortion (SMA) is not a new phenomenon but occurs across histories and social and legal contexts, utilising a range of methods. SMA is broadly understood as actions or activities undertaken by a pregnant individual to end a pregnancy outside of clinical settings, but there is considerable debate around how SMA is understood. These debates are underpinned by a range of approaches, politics and standpoints. Language use also varies (e.g. self-administered or self-care), reflecting the types of technologies or individuals involved….

The steady increase in the use of medical abortion (MA) drugs – misoprostol and mifepristone – has enabled safer self-management and self-use, centring autonomy, privacy and confidentiality, while also contributing to the reduction of abortion-related morbidity and mortality globally. MA has increasingly been included as an element of sexual and reproductive health interventions and is gaining greater consideration within notions of self-care. The advent of telehealth and the growing network of organisations supporting safe self-use has fundamentally altered the abortion landscape. This is also evident in the temporary shift from some governments during the Covid-19 pandemic, allowing abortion via telemedicine or “pills by post”. Medical societies and organisations have also called for a similar shift to provision via telemedicine. We understand “telemedicine” as the provision of remote clinical services through formal systems, while “telehealth” covers a broad range of health activities (e.g. health promotion activities) that are provided remotely through technology and other platforms. We acknowledge (and agree with) feminist groups’ disagreement around accompaniment models, information or safe abortion hotlines being classified as “telemedicine”, especially as their approaches directly challenge the medicalisation of abortion….

These shifts in the abortion landscape demonstrate how SMA – through the use of MA – challenges binary conceptualisations of abortion safety, unsettling heavily medicalised notions of what safe conditions are and who a provider is. By enabling and centring the needs and autonomies of abortion-seekers, SMA reclaims abortion autonomy as a feminist political demand. Yet rather than a solely individual act, pregnant persons’ SMA trajectories are shaped and influenced by a number of actors at different points along their journey. These actors, functioning locally and nationally, as well as transnationally, enable SMA access and provide different types of support….

Abortion laws, even in their “best” constructions, set burdensome requirements for access. Even new laws that bring about liberalisation of abortion still propose a model of criminalisation or medicalisation of SMA and as such create vulnerabilities and risks for those engaged in the practice….

Under most current laws, people that self-manage and those who provide them with information, support or accompaniment risk arrest, police harassment or bribery, prosecution and imprisonment. Indeed, laws such as the Uruguayan or South African laws that are considered ground-breaking, still criminalise those who self-manage their abortions. These laws are part of the majority of laws that require medical involvement (multiple medical professionals in these two cases) and specifically criminalise those that procure abortions outside of the process set up in the law, while simultaneously placing very burdensome barriers to access. Criminalising people who self-manage their abortions has no societal purpose nor any benefit for women’s health.