Debates about human rights, the sanctity of life and the rights of the unborn continue to play out internationally, often placing women seeking abortion in the crosshairs of politicians, faith leaders, community members and others who consider abortion a moral ill rather than a health need. Abortion accounts for up to 13.2% of maternal deaths globally, much of it preventable. While the World Health Organisation (WHO) recognises that access to safe abortion is critical for the health of women and girls, and while abortions that are performed in accordance with international standards by trained health workers carry a negligible risk of severe complications or death, almost half of all abortions conducted worldwide are unsafe, with most occurring in countries where abortion is either completely banned or permitted only to preserve the woman’s life or physical health.
This international collection of papers from contexts with variable social and legal restrictions on abortion, offers progressive insights into community activism, abortion-related healthcare, and community attitudes, including how women perceive abortion and value abortion care. Many of the papers deal with the stigma, shame and secrecy women experience when they seek abortion. Setting the stage is a theoretical exploration of abortion stigma, which Anuradha Kumar and colleagues (2009) link to the perceived contravention of three ‘feminine’ ideals: perpetual fecundity, the inevitability of motherhood, and instinctive nurturing. The impact and intensity of these ideals vary by time and space, as explored by other papers in the collection.
The timing of an abortion influences experiences of stigma and shame by confronting women with particular ethical dilemmas. Highlighting the primacy of marital status on childbearing, Amanda Cleeve and colleagues (2017) report that young Ugandan women consider the stigma of unmarried motherhood greater than the stigma of seeking an illegal abortion despite the possibility of death from unsafe practices and delayed care-seeking. On a metaphysical level, cultural boundaries of when a foetus attains personhood also distinguish acceptable and unacceptable abortions, as Sarrah Shahawy and Megan Diamond (2018) note in the context of the occupied Palestinian territories, where, in line with Muslim teaching, and despite strong social and legal sanctions against abortion, abortion is permitted up to 40 days since the foetus is not yet believed to have a ‘soul’.
Secondly, spatial boundaries across nations, states, and social communities inform women’s decision-making and ability to obtain safe, medically-supervised abortion. Forced to travel due to legal and societal censure, women can become ‘abortion exiles’, as Elyse Singer (2020) describes in her paper on continuing and often racist ‘obstetric violence’ in Mexico. A similar concept is engaged with by Joanna Mishtal and colleagues’ (2022) on the techniques of secrecy employed by women in Ireland who travelled to England for an abortion prior to decriminalisation.
These two dimensions of abortion-related stigma continue to be evident in major political and legal shifts that negatively impact abortion access. In Australia, for example, abortion is decriminalised, but limited access to surgical abortion services for later gestations in some parts of the country requires women and providers to travel interstate, which became impossible when the COVID-19 pandemic caused border closures and quarantine restrictions. The overturning of Roe v Wade by the US Supreme Court in October 2021 has led to an almost complete ban on abortion in 26 of 50 US states, leading women to clandestinely travel interstate to access care while under threat of criminal prosecution for doing so, a threat also faced by health service providers in those states. However, recent advances in medical abortion can effectively put abortion care into the hands of women, thereby disrupting boundaries of time and space. Services such as Women on Web deliver the abortifacient drugs mifepristone and/or misoprostol to women across the globe including those living in countries where abortion is restricted, and the COVID-19 pandemic saw a rapid roll-out in some countries of tele-health services providing safe and effective home abortion with mifepristone and misoprostol up to 12 weeks gestation. Other recent innovations include ‘no test no touch’ medical abortion protocols and digitally driven innovations including mobile phone apps providing self-care advice on post-abortion care, although these advances also carry a risk of increasing ‘digital divides’ and inequities amongst those who lack digital literacy and access.
In addition to examining the factors and experiences of abortion stigma, this collection of papers published in Culture, Health & Sexuality considers what women value in abortion care, including the need for person-centred care with clear communication from providers as highlighted by Sun Cotter and colleagues (2021) in their paper on abortion services in Kenya. Workforce training, including communication skills which encompass kindness and empathy, will be an essential component of abortion care, with increasing recognition that such care can be effectively provided by appropriately skilled nurses and other healthcare workers in addition to doctors. Gaps in the provision of reproductive health services also open opportunities for anti-abortion groups in ways that provide marginalised women with much-valued health services that they are otherwise unable to access. Such is the case of ‘crisis pregnancy centres’ in the USA as discussed by Alexandra Kissling and colleagues (2022), which provide parenting classes, material aid, pregnancy verification and ultrasound services prior to an abortion, even when this might not be necessary, thereby opening up an opportunity to encourage women to reconsider their decision to have an abortion.
Together, these papers also demonstrate the importance of the language used in the context of abortion within health systems, health promotion and social research. For instance, Purcell and colleagues (2020) report that in the UK efforts to normalise community messaging around abortion and to make it a routine part of reproductive healthcare require replacing negative language with positive framing to disrupt dominant stigmatising narratives. Similarly, Aasgard Jansen’s (2021) paper, which reports on misinformation about the physiology of menstruation and fertility amongst students in Madagascar that leads to unintended pregnancy and unsafe abortion, stresses the value of placing abortion care within the framework of sex and relationships education for young people.
Social research has a key role to play in understanding abortion experiences and attitudes. Jennifer Mueller and colleagues (2023) suggest that sensitivity to language is vital in developing locally tailored and standardised validated data collection approaches to address the lack of comprehensive data sets, the influence of stigma on data collection, and under-reporting due to fears of judgement. Under-reporting in particular can lead to mistaken assumptions about abortion needs and funding gaps for services. To accurately measure the impact of interventions for improving abortion access, more information is needed about the prevalence of safe and unsafe abortion in different countries, and about who is, and who is not, having abortions in these countries. Additionally, more needs to be known about what, for example, migrants, justice-involved women, gender and sexuality minorities, and the very young want abortion care to look like. To this end, Mueller et al. provide some suggestions on ways to improve data collection in a manner that is respectful to a diverse range of participants’ feelings and experiences.
Broadly, this collection of published papers moves beyond the false and reductive dichotomy often presented by ‘pro-life’ and ‘pro-choice’ arguments. By considering the temporal and culturally bounded dimensions of abortion, it explores everyday negotiations of autonomy, anxiety and exile, thereby offering insight and pathways towards progressive improvement in health and well-being.
The Authors
Deborah Bateson is Professor of Practice in the Faculty of Medicine and Health at the University of Sydney, Australia. She has worked for over 20 years as a clinician, educator and researcher in the area of sexual and reproductive health including safe abortion care through her prior roles as Medical Director of Family Planning Australia and Global Medical Director of MSI International. She is currently Vice-President of the International Federation of Abortion and Contraception Professionals (FIAPAC).
Purnima Mane is an independent consultant living and working in the San Francisco Bay Area, USA and a founding editor of Culture, Health & Sexuality journal. She has worked extensively in the fields of sexual and reproductive health, holding senior positions in international agencies such as UNFPA and UNAIDS as well as with the Population Council and Pathfinder International.
Editors’ Note
The CHS Collection of papers to which this editorial introduction relates can be found via https://www.tandfonline.com/journals/tchs20/collections/Abortion-Autonomy-Anxiety-and-Exile.