De-Medicalizing Abortion

B. Jessie Hill
Pages 57-58 | Published online: 02 Aug 2022 Download citation
https://doi.org/10.1080/15265161.2022.2089289

As we stand on the precipice of a world without Roe v. Wade and its constitutional protection for the right to terminate a pregnancy, new arguments, approaches, and conceptual frames for understanding and vindicating reproductive autonomy are desperately needed. Professor Katie Watson’s article brings one such novel and useful perspective to the debate around access to abortion care. The health disparities framework, which is compatible with the reproductive justice framework, focuses on the uneven impact of abortion bans and restrictions on poor women, Black and Hispanic women, and other marginalized groups. Perhaps most importantly, when combined with the reproductive justice model, the disparities framework pushes reproductive health policy to take account of the historical and systemic racism that may lead Black and Hispanic people to approach reproductive health care differently from white people (Watson 2022, 15).

Yet, Professor Watson’s health-disparities framework for access to abortion care remains firmly grounded in the medical model of abortion rights. It highlights the role of medical professionals in addressing and alleviating disparities in access to care. It thus stands in contrast with a de-medicalized approach—exemplified by the current movement to expand access to self-managed abortion—that places abortion within a deeply rooted tradition of self-care, bodily autonomy, and emancipation.

The tension between medical and non-medical understandings of abortion and pregnancy date back to at least the 1800s. For example, the nineteenth-century campaign to criminalize abortion in the U.S. was born, in part, of physicians’ desire to claim jurisdiction over pregnancy as a medical matter, wresting control from midwives and others who were mostly women and not professionally trained (Mohr 1978). This tension was reflected in the twentieth-century dichotomy between the abortion law “reform” and “repeal” movements—the former retaining the role of hospitals and physicians as gatekeepers to abortion and the later emphasizing the woman’s right to make her own decisions about her body (Garrow 1994).

The medical model surely has much to recommend it. In fact, I have argued elsewhere that “pro-choice advocates should … emphasize the notion of abortion as a form of health care, as a means of protecting and advancing the abortion right” (Hill 2010). Framing abortion primarily as health care arguably makes it more universal, as access to health care is widely supported, and nearly everyone needs health care at some point in their life (Hill 2009). Viewing abortion as health care centers the patient, rather than the fetus, and places the procedure squarely within the realm of private decisions that individuals expect to make without undue interference from the state. And given that the medical profession as a whole carries tremendous political and social clout, physicians and other medical professionals have been, and will continue to be, valuable allies in the contemporary and future fight for abortion rights.

New Yorker

On the other hand, the de-medicalized model of abortion has gained new importance as well, as advocates contemplating a world without legal protections for abortion rights have begun to emphasize self-care options including self-managed abortion (SMA). This de-medicalized model does not reject the framing of abortion as health care, but instead treats it as a form of health care that can be self-administered and that need not always be mediated by a medical professional. The de-medicalized abortion right is thus grounded in “a right of individuals to act autonomously without a doctor acting as an intermediary” (Lindgren 2022, 206). This de-medicalized approach complements the reproductive justice model, as it is recognizes and accepts the skepticism of some groups of people—particularly Black and Hispanic women—about forms of reproductive health care that require more rather than less involvement with a clinician. For example, Watson notes that Black and Hispanic women were more likely to favor certain forms of contraception because they do not require as much clinical oversight (Watson 2022).

Self-managed abortion—which may be defined in various ways but is generally understood to mean inducing an abortion outside of a traditional healthcare setting—has been shown to be safe and effective (Aiken et al. 2022). Self-managed abortions achieved through medications, which can be mailed to patients along with instructions for their use, are often more comfortable and convenient for patients because they can be done at home or in another private setting. They generally do not require patients to travel to a clinic (barring state laws to the contrary). They may be experienced as more natural and less invasive than surgical methods. And they may give patients a greater sense of control over their pregnancies and their bodies, as patients are deciding when and where to begin the process, accompanied by whomever the patient chooses as a support person or companion. The SMA process thus centers the self-determination and autonomy of the pregnant person. In its focus on autonomy for the pregnant person, grounding in community support, and reliance on non-clinicians, it shares an affiliation with the reproductive justice-based movement toward providing Black doulas to address the crisis in maternal and infant mortality in the Black Community (Villarosa 2018).

Safe SMA will not be possible for everyone in the U.S. post-Roe, however. Some people will not have access to the information or resources needed to order the drugs online. Some individuals do not have safe, private spaces in which to manage their abortions. Thus, the disparities highlighted by Professor Watson may be replicated in access to SMA. Empowering communities as well as individuals with knowledge about SMA will be critical to ensuring this access. This may include mobilizing the “accompaniment model” of abortion care, in which non-clinicians are trained to provide information and support to people who are self-managing care (Moseson et al. 2020).

Moreover, since medication abortion is most effective during the first trimester of pregnancy (Aiken et al. 2022), it will not be an option for many people who need abortions later in pregnancy. The need for access to safe abortion in a clinical setting will remain. Thus, de-medicalization provides a complementary rather than conflicting approach to the health-disparities and reproductive justice lenses that Professor Watson advocates. Abortion is both the practice of medicine and self-care. The challenge for the future of abortion advocacy will be to recognize and advance both aspects. Advocates, ethicists, and others should seek to center pregnant people in discussing abortion, while still maintaining powerful and caring allies among medical professionals and medical institutions. De-medicalization is yet another, important perspective on this most essential form of medical—and self—care.