Self-managed abortion: a constellation of actors, a cacophony of laws?

Abstract

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. selfadministered 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 9–11 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. For example, feminist actors on the ground and the networks procuring pills, disseminating information and providing assistance over the course of people’s abortion trajectories have enabled SMA. They have also, *Lucía Berro Pizzarossa and Rishita Nandagiri equally drafted, contributed to, and reviewed this article and share joint first authorship. COMMENTARY