This post is part of the Dialogue series, “When Abortion is Illegal“

Many people may hear the phrase “illegal abortion” and immediately picture wire coat hangers, dirty back alleys, and craven doctors. As we witness the growing criminalization of abortion in many states, some may wonder if we will return to the days of pre-Roe illegal abortion. One place to find clues to what 21^st century illegal abortion might look like is Latin America. In recent decades, Latin America has been the site of extensive abortion activism that uses new technologies to expand access to safe abortion even under the most restrictive regimes.

Women in Latin America have used extra-legal and grassroots strategies to gain and expand access to medication abortion and information, often circumventing the medical establishment. 

The technology of abortion has changed in ways that make it likely that post-Roe illegal abortion will look very different from pre-Roe illegal abortion.  In recent decades the advent of the combined medication abortion regime of mifepristone and misoprostol has created a totally non-invasive way for people to induce their own abortions, often with no doctors required. This is the same medication regime sometimes referred to as RU-486, whose approval caused much controversy first in France and later in the US. If you live in a place where abortion is widely available, then you may be aware of medication abortion as one more tool that doctors can prescribe for first-trimester abortion. 

Medication Abortion in Latin America

In Latin America and other regions with restrictive abortion laws, medication abortion has effectively escaped the formal medical system and become central to activist strategies to expand access. First documented in the 1990s in Brazil, people began using misoprostol, available in pharmacies as a treatment for ulcers, in order to induce abortion. The packaging that warned against using the drug during pregnancy turned out to be an invitation to people seeking pregnancy termination. As the practice spread throughout the region, activists took up the challenge of making sure clear information was available so people could induce their abortions safely.

In Argentina, these activist strategies have evolved over time. Feminist groups started off by setting up abortion hotlines. Based on the idea of freedom of information, and the public health strategy known as harm reduction, activists provided detailed information about how to induce an abortion using misoprostol. Later this strategy was supplanted by what is known as abortion accompaniment, where activists use hotlines and in-person meetings to support people through every stage of the medication abortion process. Beyond Argentina, abortion accompaniment networks have expanded across the region and the world. They provide advice and counseling to women who seek pregnancy termination in all kinds of legally restrictive environments.

Over roughly the same period, medical professionals acting as “insider activists” also began facilitating access to safer abortion from within the state health infrastructure. From within the medical system, groups of abortion-friendly medical professionals began offering “pre- and post-abortion counseling” where they provided information about safely inducing abortion and offered follow-up care. This strategy left the procuring of medication and the actual induction of abortion outside of the medical system. 

Over time, some abortion-friendly medical professionals shifted to offering surgical abortions and abortion medication based on legal exceptions. The law in Argentina allowed legal abortion if the life or health of the mother was at risk, or if the pregnancy was the result of rape.

Using an expansive definition of comprehensive health and wellbeing, these activist health professionals developed protocols that argued that essentially all abortions are life- and health-saving and medically necessary. 

Importantly, both within and outside the health system activists used these strategies to create knowledge about abortion practice and incidence. I use the term feminist epidemiology to refer to this activist-led process of knowledge production. In Argentina, feminist epidemiology helped normalize abortion in ways that may have contributed to the legalization of the procedure in a landmark legislative vote at the end of 2020. Across Latin America, medication abortion has contributed to safe access and successful activist strategies, even for people seeking later abortions.

Medication Abortion in a Post-Roe United States

What lessons can we take from the role that medication abortion has played in legally restricted contexts in Latin America? Evidence suggests that similar medication abortion strategies may already be in use in various ways in the United States. The Dutch abortion-rights activist and doctor Rebecca Gomperts created the initiative Aid Access, which provides medication for abortion through the mail for people who struggle to access safe abortion in the United States because of legal restrictions. There are reports of both abortion pills and activist strategies making their way across the border from Mexico and into the US. These strategies and practices may expand as access to abortion in the medical system is further restricted.

Yet, regulatory differences between the US and Latin America pose a challenge to simply adopting medication abortion activist strategies. Misoprostol is often sold freely in parts of Latin America despite “for sale under prescription” printed on the packaging. It is sometimes available from NGOs or on the black market. Additionally, medical professionals in Argentina experience very little direct oversight, even as they work directly within the government infrastructure. In Argentina, groups of professionals – doctors, lawyers, other medical professionals – organized to support the work of activists, playing a key role in their ultimate success.

The ease of access of medication abortion can also be a double-edged sword. There is often no way to establish medically the difference between a spontaneous miscarriage and an induced medication abortion.

Consequently, all pregnancy loss can come under suspicion, but especially pregnancy loss in poor and marginalized populations. There are important cases in El Salvador that show the devastating possibilities when abortion laws are applied to obstetric emergencies. Lest that seem too extreme to be likely to happen in the US, anti-abortion activism has already resulted in the criminalization of all kinds of obstetric events and behaviors during pregnancy that are seen as endangering the fetus. Attempts to restrict access to medication abortion are likely to result in broad criminalization of many aspects of pregnancy, especially for vulnerable populations.

Pharmaceuticals are likely to be one key battleground in attempts to keep abortion safe, as well as attempts to further restrict it. Anyone interested in keeping pregnancy termination safe and accessible would do well to study the strategies used across Latin America. Activist-led self-managed abortion has been found to be safe and effective around the world. If state governments impose cruel restrictions on abortion access, then creating safe access can be achieved through self-managed abortion strategies as a form of civil disobedience. Unless and until safe abortion in the medical system is widely legally available, medical and legal professionals, non-profits, and government officials who care about the health of people with a capacity to gestate should find opportunities to aid and abet these strategies.