Authors:
Sydney Calkin
Restrictive abortion laws don't stop abortion—they just make abortions less safe. A little over half of all pregnancies worldwide are unintended; of these unintended pregnancies, 61 percent end in abortion. Every year, 25 million unsafe abortions occur globally [1]. These unsafe abortions are the product of political choices: They are overwhelmingly concentrated in countries with the most restrictive laws. While the general trend worldwide is toward more progressive abortion laws, dramatic rollbacks of abortion rights are taking place in the U.S., Poland, and several other countries.
Insights
→ Medication abortion pills have transformed the safety and accessibility of abortion.
→ Their impact has been especially significant in countries with restrictive abortion laws.
→ Medication abortion pills easily cross borders, facilitated by activist networks, and governments are frequently unable to stop their use.
Where antiabortion lawmakers impose restrictions, making abortion harder to access or more harshly criminalized, activist groups and abortion providers devise new ways to facilitate safe abortions. In this effort, technologies are essential. However, the most important technological innovation that improved the safety and accessibility of abortion is not a piece of hightech medical equipment or even a digital platform. Instead, it is a pharmaceutical technology developed in the 1980s, now cheaply manufactured in pharmaceutical hubs across the world: medication abortion pills. Self-managed abortion today is markedly different from the illegal abortion of previous eras, perhaps most commonly associated with the backstreet surgical abortion performed by an unqualified provider, in an unsafe setting, or self-induced. Today, abortion can be safely self-managed outside of clinical settings with a handful of pills.
Medication Abortion Pills
Where abortion is illegal, people use these medications to self-manage illegal abortions (meaning they perform their own abortion without any medical supervision). What's illegal may not be unsafe, however. Medication abortion has transformed the safety and accessibility of abortion outside of formal medical settings to the extent that public health authorities have introduced new safety categories. A safe abortion, they indicate, does not necessarily require direct medical supervision or even a clinical setting [2].
Medication abortion usually involves two drugs: mifepristone followed some hours later by misoprostol. Mifepristone blocks the hormones that sustain a pregnancy, while misoprostol induces uterine contractions that expel the pregnancy. As pharmaceutical technologies, these two pills have very different histories. Mifepristone was developed in the 1980s by the French pharmaceutical company Roussel Uclaf; from its introduction it was marketed as an abortion medication. Misoprostol, by contrast, was developed in the 1970s by Searle and was marketed as a treatment for ulcers. Feminist activists in Brazil, where abortion was unavailable, discovered its "second use" as an abortifacient when they saw the misoprostol package's warning not to take during pregnancy and realized it could be used to induce an abortion [3]. Knowledge about how to use misoprostol as an abortifacient spread from Brazil across Latin America and then further afield. Because misoprostol is illicitly sold over the counter in many countries where abortion is illegal, it is a widely used method for self-managed abortion in restrictive legal contexts.
Together, mifepristone and misoprostol have transformed the safety and accessibility of abortion. They are small, easy to move, cheap, and straightforward to use. The most important systems to distribute these medications and information about them are communications technologies (phone and the Internet) and the postal system. Where misoprostol can be easily (albeit illegally) bought over the counter, hotlines are essential for sharing information about how to safely use the pills. Where neither misoprostol nor mifepristone can be bought locally, feminist activist networks have developed sophisticated cross-border supply routes. These networks use online platforms to conduct consultations with abortion seekers and support them during the process of obtaining and using abortion pills. They obtain abortion medications from manufacturers and distributors in the Global South, usually India, who will then ship the medications to the homes of abortion seekers around the world. These networks engage in border work, mapping a state's abortion laws, customs procedures, medication regulations, border infrastructure, postal systems, cross-border transport links, and activist mobilization in the region [4].
Medication Abortion by Telehealth
The U.S. is an important place to explore the geography and technology of medication abortion because abortion laws vary widely between states, and because of the recent restriction in abortion rights that is rapidly changing the landscape of abortion care. Even before the 2022 U.S. Supreme Court decision that overturned the constitutional right to abortion known as Roe v. Wade, many states had only a few abortion clinics serving vast territories and populations dispersed over hundreds of miles. In these settings, medication abortion and communications technologies together transformed abortion access by bridging geographical distances to make abortion more accessible for rural populations.
Abortion providers in Iowa were the first to introduce abortion telehealth technology in 2008 [5]. At the time, many states had laws that specified only physicians could prescribe medication abortion pills, so telehealth technology for abortion was developed to increase the number of clinics that could offer abortion, allowing one physician to remotely prescribe for patients in many locations. The earliest telehealth systems for medication abortion in the U.S. connected a physician and patient over two-way video, with the physician in the abortion clinic and the patient in a different location, usually a local health facility that could perform preliminary tests but not abortions. When the doctor was ready to prescribe the medication, they would press a button to remotely operate a medicine cabinet in front of the patient, dispending the abortion medications [6]. The doctor could watch over video as the patient consumed the first medication; the patient would take the second medication home for later use.
Self-managed abortion today is markedly different from the illegal abortion of previous eras.
Over time, telehealth abortion technology has been substantially simplified, including in Iowa. "No-touch" abortion protocols today allow patients to obtain abortion pills through the mail after a phone or video call with a provider. This method does not require any in-clinic consultation. No-touch abortion models have been advocated for years by activists who criticized what they perceived as the overmedicalization of abortion pills, but abortion telehealth has frequently been resisted by policymakers. Its adoption was accelerated by the Covid pandemic, when any in-clinic visit to have a consultation with a doctor or to pick up medications was deemed an unnecessary health risk.
No-touch telehealth models proved successful during the pandemic, leading to better outcomes overall in terms of ease of abortion access, reducing wait times, and lowering the gestational age of abortions. As a result, many places have decided to make telehealth for abortion a permanent service [7]. In the U.K., for example, abortion laws were relaxed during the pandemic to let people obtain abortion pills through the mail after a phone consultation, without any requirement to visit a clinic. Even a relatively abortion-permissive context like the U.K. puts numerous regulations on medication abortion that impose significant barriers to care. As a result, before telehealth technology was permitted in abortion care, people in the U.K. would turn to the Internet to seek out abortion pills from foreign providers or online pharmacies. Once a "pills by post" telehealth service was instituted, the number of people trying to buy abortion pills online dropped by 88 percent [8]. Telehealth technology for accessing medication abortion can substantially lower barriers to access. In recognition of its effectiveness, the U.K. government ultimately decided to make the telehealth abortion service permanent.
Medication Abortion in the U.S. After Roe v. Wade
In the U.S., the legal status of abortion is different in each state, so the availability of telehealth technology for abortion varies depending on local factors. No-touch telehealth services that offer remote consultations and send abortion pills by mail are limited to the states that have liberal abortion laws. After the 2022 Supreme Court decision that overturned Roe v. Wade, and thus removed any constitutional protections for abortion, many states have banned abortion altogether. Others ban telehealth abortion, even where they permit abortion in some circumstances.
Before Roe v. Wade was overturned, states could limit abortion but not ban it outright. After Roe v. Wade was overturned, states can now impose total bans on abortion within their territories. A state-level abortion ban, in a federal system, has limited impact: Residents can drive to another state with different laws (provided they have the financial means and transportation to do so). This has been a fact of life in the U.S. for many years before Roe v. Wade was overturned. For example, in 2020, while abortion remained officially legal in Missouri, only 167 Missourians obtained abortions in their own state; 3,300 of them traveled to Illinois or Kansas for abortions [9].
Abortion travel between states will clearly continue in the U.S. But medication abortion means that pills can travel when people cannot. When safe abortion can be obtained by ordering medications online, abortion access no longer requires in-person access to a brick-and-mortar clinic. This poses a problem for antiabortion lawmakers, because the abortion bans they impose stop at the state's border [10]. For pro-choice doctors and activists, however, the mobility of abortion medications across borders presents an opportunity.
Mobile abortion technologies are reshaping the geography of abortion in the U.S., in the wake of the Covid-19 pandemic and the 2022 Supreme Court decision to overturn Roe v. Wade. A growing number of no-touch telehealth abortion services operate in abortion-friendly states. They offer remote consultations with doctors and dispense medication through the mail without in-person visits. These digital health services, however, are still physically tethered to those territories with laws that permit telemedicine abortion. For all the technological potential of digital abortion services, abortion seekers are often required to travel to a state where telehealth abortion is legal before they can have a consultation with no-touch telehealth services. Some abortion providers track the IP address of clients to ensure that they live in a state where it is legal to obtain abortion through telehealth [9]. This means abortion travel takes on new spatial forms. A Texan may not be able to order pills from their home, but rather than traveling to a New Mexico clinic for an in-person consultation, they can drive across the state border to physically be in the state while they conduct the online consultation call.
Telehealth technology for accessing medication abortion can substantially lower barriers to access.
Geographical and technological work-arounds can help close gaps in access to care. Some telehealth abortion providers are developing mobile clinics that will offer services on the border of abortion-hostile states, like the Texas—New Mexico border, or reduce travel time in large states with dispersed populations. Some telehealth abortion services do not monitor the caller's location, so they are limited in where they can ship the medications but not where their clients can call from.
Where people cannot move, the medications are moved instead. Some people use virtual private networks to disguise their physical location when requesting pills from out-of-state providers, post office boxes in border towns to collect pills, or mail-forwarding services to ship pills via abortion-friendly states. Abortion activists strategize with abortion seekers to develop techniques for moving pills across borders and to share information with people in need through encrypted communications with clients and public-facing information about pathways to obtain pills (e.g., https://www.plancpills.org/find-pills).
The Future of Abortion
Small, easy to move, cheap, and supported by digital networks of feminist activists, medication abortion travels in ways that surgical abortion cannot. The pills can be smuggled by people crossing borders or shipped discretely inside envelopes with other goods. Whether this is one person taking a short bus trip over the border to pick up their own pills or a doctor crossing the border with a suitcase filled with them, medication abortion pills can move when people do. Activist networks collaborating across borders have developed sophisticated assessments of medical regulations in different countries and they use this information to keep medications moving to where they are needed. This dynamic plays out in many countries that try to restrict access to abortion (for example, Poland, Malta, Brazil, Ireland and Northern Ireland [before 2019] and much of Latin America [before the recent wave of legal reforms]). As with the 2022 Supreme Court decision in the U.S., it is likely that abortion laws will be a stark patchwork of total abortion bans, progressive abortion protections, and something in between. Such a legal system will create new pathways for people and medications to move, coordinated through cross-border networks of activists organized on digital platforms, while embedded in on-the-ground activist circles in their countries of residence.
Laws to ban abortion operate on the incorrect assumption that increasing the cost of abortion, reducing the number of clinics that provide it, or imposing other barriers will eliminate abortion. Self-managed abortion with pills remains safe; the digitally mediated feminist networks that make them accessible will continue to exist; and both will remain a lifeline for people around the world.
References
1. Guttmacher Institute. Abortion Worldwide 2017: Unequal Progress and Unequal Access. Guttmacher Institute, Washington, D.C., 2019
2. World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. World Health Organization, Geneva, 2012.
3. de Zordo, S. The biomedicalisation of illegal abortion: the double life of misoprostol in Brazil. História, Ciências, Saúde-Manguinhos 23 (2016), 19–36. DOI: 10.1590/S0104-59702016000100003
4. Calkin, S. Transnational abortion pill flows and the political geography of abortion in Ireland. Territory, Politics, Governance 9, 2 (2021), 163–179. DOI: 10.1080/21622671.2019.1704854
5. Calkin, S. Legal geographies of medication abortion in the USA. Transactions of the Institute of British Geographers 47, 2 (2022), 378–392. DOI: 10.1111/tran.12506
6. Samuels, A. The safer, more affordable abortion only available in two states. The Atlantic. Oct. 10, 2014; https://www.theatlantic.com/business/archive/2014/10/the-safer-more-affordable-abortion-only-available-in-two-states/381321/
7. Upadhyay, U.D., Schroeder, R., and Roberts, S.C.M. Adoption of no-test and telehealth medication abortion care among independent abortion providers in response to Covid-19. Contraception: X 2 (2020), 100049. DOI: 10.1016/j.conx.2020.100049
8. Aiken, A.R.A., Starling, J.E., Gomperts, R., Scott, J.G., and Aiken, C.E. Demand for self-managed online telemedicine abortion in eight European countries during the COVID-19 pandemic: A regression discontinuity analysis. BMJ Sexual & Reproductive Health 47, 4 (2021), 238–245; https://srh.bmj.com/content/47/4/238.info
9. Cohen, D.S., Donley, G., and Rebouché, R. The new abortion battleground. Columbia Law Review. (Forthcoming 2023). Draft available on SSRN. DOI: 10.2139/ssrn.4032931
10. Some states are looking to criminalize residents who seek abortion out of state. Whether they will be able to pass these laws, whether such laws are constitutional, and whether they can be enforced are all subject for debate [9].
Author
Sydney Calkin is a senior lecturer in geography at Queen Mary University of London. Her research explores the cross-border movements of people and medications in pursuit of safe abortion. [email protected]
Copyright held by author. Publication rights licensed to ACM.
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