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From Crisis to Innovation: Empowerment in Self-Administered Abortion

By Ophelia Chatterjee, Lisa Juanola and Nicole Moran

The rituals that help us to care for our own health and that of others have taken on new significance in the age of COVID-19. Familiar, everyday activities such as handwashing assume a heightened urgency (and even their own soundtracks), while the benefits of less familiar precautions are endlessly debated by experts and the public alike – to mask or not to mask?

Many of us are also experiencing physical access to healthcare in new ways. Brutally enforced lockdowns and curfews have left some unable to reach childbirth facilities even during labour, while others are reluctant to travel to clinics for fear of either the virus itself or stigmatisation of those judged to be seeking ‘non-essential care’. Now more than ever, we need innovative and pragmatic approaches to enable people to care for their own health.

Self-care: one solution for time-sensitive and life-changing health services

Luckily, there are some tried and tested routes ahead. Self-care interventions like the expansion of telemedicine are a concrete and empowering way to address the large and growing unmet need for life-changing, time-sensitive services such as medical abortion in the first trimester of pregnancy.

Self-care, as defined by the WHO, “is the ability of individuals, families and communities to promote health, prevent disease, maintain health, and cope with illness and disability with or without the support of a healthcare provider”. For self-managed abortion, this means being able to access mifepristone and misoprostol pills conveniently and discreetly, such as via telephone or digital consultation, and having the option to take these yourself in a non-medical setting such as your own home. With the right access to information and healthcare assistance, this can be done in ways that are safe, convenient and often cheaper for care providers and users.

Self-care can prevent sexual and reproductive services from falling through the cracks in times of crisis

We know from previous global health emergencies such as the Ebola outbreaks that access to sexual and reproductive services like safe abortion is threatened in times of crisis. Even a “modest” decline of 10% in the use of these services over the next year could leave 49 million women in low- and middle-income countries unable to access contraception, resulting in an estimated 15 million unintended pregnancies. Expanding self-care is one answer, providing women with an autonomy-expanding access-point to safe abortions and other vital services such as HIV self-testing and contraceptives.

Self-care approaches to abortion can be empowering for people, allowing them to manage their abortion in the comfort and privacy of their own homes, with less financial burden and stress. Self-care also does not require long-distance travel to abortion clinics, which often prevents many people from accessing safe abortion in the first place. This is particularly true for poorer and younger women without family or social support.

While the pandemic is highlighting many pre-existing fault lines – one of these being the debate over the right to safe, accessible abortion services – the opportunity has presented itself to either severely limit access or use existing, widely available and cheap telecommunications infrastructure to offer a responsible and socially distant way for people to access abortion-related care.

International human rights law recognises universal rights to sexual and reproductive health and bodily autonomy, central to which is our ability to decide whether, when and how many children to have. These rights are not suspended during an emergency, though some political and civil society actors have seized on the COVID-19 crisis to undermine these fundamental rights.

Safe abortion is once again under threat

Throughout the pandemic, abortion care – including self-administered medical abortions – has  been a point of contention globally. We already see access to safe abortion denied or facing  renewed pressure in countries like Poland, the United States and Uganda, where influential forces have long eyed such services with suspicion or downright antagonism.

The delineation between services considered ‘essential’ and those falling outside of this bracket has become an acutely politicised fissure. In the US, anti-abortion activists have succeeded in getting authorities in Texas, Ohio, Mississippi, Louisiana, Oklahoma, and Alabama to declare abortion an elective medical procedure that can be suspended, pointing to shortages of PPE and health staff by way of rationale. Given the time-sensitive nature of individuals’ needs to access abortion services, this is thin cover for an ideological agenda that pushes people towards dangerous alternatives at a time of acute social and individual stress. Within Europe, these tactics have been most acutely evident in Poland, where parliament is preparing to debate a law that would make its already restrictive laws even more so.

Like almost all aspects of our lives, the bureaucracy that regulates access to abortion was not designed for societies under lockdown. This means that in practice, lack of action is equivalent to a denial of service as women find themselves at the mercy of interrupted global supply chains, and no longer able to travel or receive consultations in healthcare facilities or pharmacies. There are no public health outcomes served by denying women access to safe abortion. Denial of access to safe abortion does not lead to increased uptake of contraceptives, nor does it lead to better maternal or neonatal mortality indicators – quite the opposite.

Self-care offers a safe and rights-centred approach to abortion care

Some governments have recognised this, and have taken steps to ensure that those seeking these essential services aren’t hampered by processes designed for societies that, temporarily at least, no longer exist in their familiar forms. For example, in South Africa, Ireland, England and France, remote consultations are now allowed so women can temporarily manage medical abortions at home in line with WHO guidance. The Dutch courts, by contrast, recently rejected an application to allow access to medical abortions without visiting a clinic.

Self-managed medical abortion is supported by organisations such as the WHO and Ipas as a sustainable and rights-centred approach to abortion care, even outside of a pandemic. At KIT, we are actively involved in research and evidence-based advocacy on access to safe abortion care and are supportive of approaches that assist people in accessing the services they need in safe and empowering ways.

However, we cannot help but wonder: is the current crisis enough to make society at large realise that we need more accessible health care interventions, especially with regards to abortion care? As we slowly make our way towards the ‘new normal’, it is imperative that we take these lessons learned and use them as an opportunity to ensure that agency and access are front and centre in supporting all women in the choices they make on their health and well-being journeys.

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