Mridula Shankar
On 24 June 2022, women in the United States (US) lost their constitutional protection to legal abortion. On this day, the Supreme Court reversed a landmark 1973 ruling, known as Roe v Wade, that recognised abortion as a fundamental liberty guaranteed by the right to privacy. In simple terms, a reproductive aged woman living in the US today has less right over her bodily autonomy than her mother or grandmother did over the past 50 years. This decision makes the US only one of four countries to have tightened legal restrictions on abortion since the 1990s. Once again, the lives and health of women have been used and misused as political and ideological battlegrounds to re-assert patriarchal control and surveillance by the state.
Public health data on abortion consistently support key facts that remain at odds with the imposition of legal restrictions. First, the reality of human reproduction is that abortion is a universal and common reproductive experience for all women1. Second, when abortion is made accessible as a legitimate healthcare service, it is one of the safest obstetric procedures that women undergo2. Third, punitive laws restricting abortion do little to reduce its frequency3; instead, they harm the health and wellbeing of women by creating an environment where information and services for safe abortion care are withheld by the state, forcing women to seek less safe or unsafe means of pregnancy termination, exposing them to the risks of preventable complications and death4. Fourth, restrictions on abortion disproportionally affect women who are economically and socially disadvantaged, whether due to poverty, race, social class, caste, age etc., by exacerbating barriers that deprive public access to an essential reproductive healthcare service5. The result is that marginalised communities experience an undue burden of the health and social consequences of abortion criminalisation, rendering such laws discriminatory and unjust at their very core.
Even when guaranteed by law, abortion regulation is almost always accompanied by a set of grounds under which it is legally permissible, making it an “exceptional” healthcare service, when available6. This is because, in most societies, abortion remains a contentious matter of morals. The personal and private choice of a woman to decide and act on matters related to her body and to do so safely is pitched in stark contrast to the moral value and personhood status of the fetus, and the state’s assumed responsibility to protect the life of an “unborn child”. Often, central to this debate is the notion that motherhood is fundamental to womanhood. To choose to avert a birth, counters the prevailing view of women as nurturers and carers. In doing so, women assert their autonomy in ways that can be deeply threatening to patriarchal structures.
In the ensuing battle, myth-making imagery of careless and sexually promiscuous women who indiscriminately (mis)use abortion to evade unwanted motherhood is one among many strategies used to reinforce moral arguments in the public’s imagination to justify abolition. Findings from research with women on why they seek abortions belie such rhetoric. Instead, they offer a nuanced picture of the complexity of women’s lives in relation to childbearing. Women describe the importance of considering their individual socio-economic contexts, including aspects such as financial ability to provide for a child, relationship stability and quality of intimate partnerships to support parenthood, care-giving responsibilities to existing children and other family, and competing priorities such as educational attainment, financial independence, and workforce participation7. Many describe their decisions to undergo abortion as necessary and the right one for them, given their personal contexts. Women take the timing of their births and whether and when to begin or grow a family very seriously. In turn, access to safe and non-judgmental abortion care is integral to their ability to exercise their right to control their individual destinies.
Beyond the letter of the law, women’s pathways to abortion care are strongly conditioned by service availability and gatekeeping actions of partners and other family members, and medical and healthcare staff. In India for example, abortion is legally permissible under broad social and economic grounds as specified in the Medical Termination of Pregnancy Act (amended in 2020)8; yet of the approximately 15 million abortions that occur annually, nearly three quarters occur outside health facilities using medication abortion drugs sourced informally from pharmacies and chemist shops9.
Self-administration of medication abortion drugs can be empowering when accompanied by adequate and accurate information on use and access to high-quality clinical support when needed. Yet interviews with women who underwent abortions in Rajasthan suggest that access to these drugs is predicated on husbands’ serving as critical intermediaries both for sourcing the medicine and obtaining information on their use10. Women rarely approached healthcare facilities on their own for fear of being treated with disrespect and accompanying demands for spousal consent (not required by law) or to minimize the threat of being subjected to clinical consultations with male healthcare providers. In one instance, Jyoti (pseudonym) a married woman in her thirties approached four different doctors for an abortion, all of whom denied her care. Her situation left her no choice but to undergo a dangerous surgical intervention in her home; bleeding heavily in the days after, she was rushed to hospital where she received lifesaving postabortion care. The stigma associated with seeking and obtaining an abortion is particularly strong for unmarried women. Viewed as repositories of family honour, a socially ill-timed pregnancy can bring considerable shame and guilt. These feelings can be exacerbated when the personal biases of healthcare professionals pose barriers to their ability to access non-judgmental and timely care. Often, framing of “good” versus “bad” abortions, tied to personal judgments about women’s sexuality and behaviour shape whether healthcare providers facilitate or impede women’s agency in abortion care-seeking11. Thus, despite a liberal law, access remains limited and considerable work is left to be done to dismantle the stigma and discrimination within health systems that prevent women from exercising their right.
In this context where the fight for protection and fulfilment of sexual and reproductive rights is far from over, the Supreme Court decision in the US is a major blow to the slow and gradual progress that has been made to date. This judgment will likely embolden transnational anti-abortion alliances to push through regressive national agendas that resist and reverse reproductive freedoms in other countries. At the same time, there is much hope that the collective mobilization of social and feminist movements and the strengthening of alliances between community activists, researchers and progressive policymakers will once again rise to the challenge of defending women’s freedom and autonomy.
1. Bearak JM, Popinchalk A, Beavin C, Ganatra B, Moller A-B, Tunçalp Ö, et al. Country-Specific Estimates of Unintended Pregnancy and Abortion Incidence: A Global Comparative Analysis of Levels in 2015–2019. BMJ Global Health. 2022;7(3):e007151.
2. Kapp N, Lohr PA. Modern Methods to Induce Abortion: Safety, Efficacy and Choice. Best Practice & Research: Clinical Obstetrics & Gynaecology. 2020;63:37-44.
3. Bearak J, Popinchalk A, Ganatra B, Moller AB, Tunçalp Ö, Beavin C, et al. Unintended Pregnancy and Abortion by Income, Region, and the Legal Status of Abortion: Estimates from a Comprehensive Model for 1990-2019. Lancet Global Health. 2020;8(9):e1152-e61.
4. Ganatra B, Gerdts C, Rossier C, Johnson BR, Jr., Tuncalp O, Assifi A, et al. Global, Regional, and Subregional Classification of Abortions by Safety, 2010-14: Estimates from a Bayesian Hierarchical Model. Lancet. 2017;390(10110):2372-81.
5. Erdman JN, Cook RJ. Decriminalization of Abortion – a Human Rights Imperative. Best Practice & Research: Clinical Obstetrics & Gynaecology. 2020;62:11-24.
6. Center for Reproductive Rights. The World’s Abortion Laws 2021 [Available from: https://reproductiverights.org/worldabortionlaws.
7. Bankole A, Singh S, Haas T. Reasons Why Women Have Induced Abortions: Evidence from 27 Countries. International Family Planning Perspectives. 1998;24(3):117-52.
8. The Medical Termination of Pregnancy Act No.34, (1971).
9. Singh S, Shekhar C, Acharya R, Moore AM, Stillman M, Pradhan MR, et al. The Incidence of Abortion and Unintended Pregnancy in India, 2015. Lancet Global Health. 2018;6(1):e111-e20.
10. Shankar M. Investigating Factors Shaping Women’s Abortion Care Pathways and Measuring Quality of Informal Medication Abortion Care: A Comparative Analysis in Nigeria and Rajasthan, India Johns Hopkins University; 2021.
11. Nandagiri R. “Like a Mother-Daughter Relationship”: Community Health Intermediaries’ Knowledge of and Attitudes to Abortion in Karnataka, India. Social Science and Medicine. 2019;239:112525.
