This post is from Dr Sydney Calkin of the University of Durham
Abortion access is fundamentally geographical: looking at abortion as an issue of space and power can help us to understand the continuities between contexts where abortion is illegal and where it is legal, as well as the gaps between abortion law and access in practice. In this post, I draw on a geographical approach to abortion to make two arguments: first, spatial strategies to restrict abortion access often take the form of regulation of medical care that do not directly attack the legality of abortion but make it practically unavailable by making willing doctors scarce or distant. Second, medication abortion is transforming this landscape by challenging medical control over abortion and is prompting the state to respond to re-assert control.
Laws that ban abortion do not operate in a geographical vacuum: in a world of increased mobility, low-cost travel, and cross-border social networks, women who live in states with highly restrictive abortion laws can (and do) access abortion by going abroad. In Ireland, for example, 9-10 Irish women still travel to Englandevery day in pursuit of abortion access. Irish women are dependent on medical services in England, so that changes in healthcare availability in England has serious consequences for non-residents. The reliance on abortion trails is not limited to inter-state travel between states with different abortion laws; it happens as well within states where abortion access is deliberately constrained and made scarce. In places where there is legal provision for abortion, opponents of abortion rights deliberately create extra-legal obstacles that widen the spaces between women seeking abortion and doctors willing to provide it. Geography becomes a useful tool for widening and compounding inequalities to access and making abortion access dependent on a woman’s mobility, as a factor of her wealth or migration status.
In the USA, space is used as a deliberately strategy to create obstacles to access. Opponents of abortion access have passed a variety of measures that attempt to restrict abortion without rising to the level of violating the constitutionality of the right to abortion (as it falls under privacy with the doctor) established in the Roe v. Wade decision.These often take the form of the imposition of obstacles that build up extra-legal barriers to access. Targeted Restrictions on Abortion Providers(TRAP laws) have attempted to shut abortion clinics by requiring them to modify their facilities at the level of the clinic (for instance by widening hallway space) or by shutting them down by virtue of their location (for instance by requiring them to negotiate special admitting privilegeswith nearby Catholic hospitals who will not grant such privileges). Waiting periods have attempted to raise the cost of abortion access, because in large states with few clinics, abortions that require mandatory multiple appointments and waiting periods mean women must travel long distances several times, including overnight stays and several days out of work. In some states, waiting periods between initial counselling and the abortion itself are even further drawn out: South Dakotalaw says weekends and holidays cannot count in the waiting period. In such contexts, seemingly minor legal obstacles translate directly into financial obstacles and map onto existing inequalities. Where courts have found abortion to be constitutional, and explicitly ruled against its complete prohibition, opponents have adopted spatial strategies to create large zones where abortion is legal but inaccessible. Opponents of abortion use spatial strategies to create patchy geographies of access and large zones of exclusion where abortion is legal in theory but unavailable in practice. It’s no surprise, then, that studies have found Google search results for “DIY abortion”correlate to areas with the most restrictive laws.
However, just as space is used as a resource to restrict abortion access, such creative use of space is also a resource for the expansion of reproductive freedom. Medication abortion (with pills) is a cheaper and more mobile form of abortion whose increasing availability holds out the promise of a future where abortion is not so spatially bound. These pills can cross borders more easily than women can travel across borders, and they hold out the freedom for a private abortion at home without the burden of travel. These operate in a few different ways, each with the intention of expanding the available modes of access to abortion and challenging the state by deliberately violating its laws or pushing their boundaries in productive ways. High profile campaigns by the activist group Women on Waves with shipsand droneshave raised awareness of the mobility of medication abortion, but the majority of the increases in access have come through online networks who help ship pills or provide advice.
Safe abortion hotlines and online networks operate across the world to provide advice to women who seek abortion pills. They can advise women on how to access pills that must be shipped into the country, bought on the black market, or where sold for other medical conditions. Research has shown they can provide a good standard of advice and care, with medical outcomes as generally as good as clinical outcomes.Over the last few years, access to medication abortion pills through online networks like Women on Web and Need Abortion Irelandhas transformed the landscape of abortion access in Ireland, where numbers of Irish women travelling to England for abortion have dropped steeply as numbers of women accessing pills has risen.More formalized telemedicine technology that has been developed for rural medicineis being used to connect doctors and patientsover great distances. While ordering abortion pills online is generally illegal, and in some places prosecuted severely, formal telemedicine consultation with doctors provides a legal pathway for abortion care across distances.
These kinds of activist efforts are pushing abortion access beyond the nation-state framework – deliberately breaking the law of the state in order to facilitate access to abortion. In doing so, they’re showing us how feminist activism that starts in the home or the community can transform public policy – what Leslie Reagan calls the “private invading the public” and forcing change at the state level.In short, there are important continuities between jurisdictions where abortion is legal and illegal, because anti-choice forces have been effective in places at curtailing access in practice by making abortion care geographically distant or raising the extra-legal barriers to access. The use of medication abortion to work around restrictive abortion laws points to the potential for wider access regardless of state laws, but it also points to the potential for changing patterns of abortion access to drive political change.
Grossman, D., & Grindlay, K. (2017). Safety of medical abortion provided through telemedicine compared with in person. Obstetrics & Gynecology, 130(4), 778-782; Aiken, Abigail RA, Rebecca Gomperts, and James Trussell. “Experiences and characteristics of women seeking and completing at‐home medical termination of pregnancy through online telemedicine in Ireland and Northern Ireland: a population‐based analysis.” BJOG: An International Journal of Obstetrics & Gynaecology 124, no. 8 (2017): 1208-1215.
Sheldon, Sally. 2016. “How Can a State Control Swallowing? The Home Use of Abortion Pills in Ireland.” Reproductive Health Matters24(48): 90-101; Aiken, Abigail RA, Irena Digol, James Trussell, and Rebecca Gomperts. “Self reported outcomes and adverse events after medical abortion through online telemedicine: population based study in the Republic of Ireland and Northern Ireland.” BMJ 357 (2017): j2011.