Down a Garden Path

We have seen too often how advocates, funders and policymakers have sought to prioritize support for contraception and avoided mentioning or even downplayed the importance of access to abortion care. Of course, we know that these reproductive health options are not an either/or proposition, but contraception is often posed as a solution to “prevent abortion,” “reduce the need for abortion” or even as an out and out substitute for abortion.

This is bad science and a missed opportunity to support choice.

Our panel of reproductive health exports debunked the idea that family planning initiatives could prevent women from needing abortions. But we also asked them how these two aspects of reproductive healthcare have become so unfairly counterposed.

Conscience: Why do women seek abortions?

Carole Joffe: The simple answer is because they’re pregnant and don’t want to be. Tracy Weitz wrote a fantastic article in 2010 called “Rethinking the Mantra that Abortion Should be Safe, Legal and Rare.” She provided data from the US showing that, even with perfect use of the most effective contraceptive methods, there would be approximately 200,000 unintended pregnancies per year.

And then, an initially wanted pregnancy can become unwanted—either for health reasons of the fetus or the mother or the breakup of relationships or the loss of income.

Marge Berer: I think social and marital status come into it, particularly for young women whose partner is not interested in supporting the pregnancy or the woman in having the baby. Then there are all the other life issues for women who have more children than they cope with.

Angel Foster: We know that there are commonalities across the world in terms of what women say when asked why they’ve made a decision to terminate a pregnancy. But I think it’s also important to note that women’s stories are very individualized. They make decisions about whether or not to continue a pregnancy and parent based on their experiences and their lives, as well as their social reality. They consider the context of their financial means and their family’s needs and their community context.

Conscience: If these are circumstances that will always affect women, why do we so often hear Clinton’s refrain of making abortion “safe, legal and rare”?

Marge Berer: This “abortion should become rare” business has always annoyed the hell out of me. I was teaching a postgraduate class a couple of weeks ago, and I said that abortion would never become rare unless women stop having sexual intercourse with men.

We really have to tie abortion, not just to unwanted pregnancies, but see pregnancy as a consequence of sexual intercourse with men. Because then the woman hasn’t gotten pregnant by herself.

Pregnancy makes women subsumed to their bodies. And the only way to be independent of your body is to have access to contraception and abortion.

There is this firm, culturally entrenched belief that a woman’s role in life is to be a mother, first and foremost. This seems to be the basis of opposition to abortion—by men, but also by some women.

Remember the book Abortion & the Politics of Motherhood by sociologist Kristin Luker, when she interviewed all these antiabortion activists who were women? She found that they didn’t want to see women becoming independent because it frightened them, and they didn’t want it for themselves.

Jon O’Brien: What you’ve just said really goes to the heart of the issue. The lack of support for women’s autonomy and women’s moral agency absolutely drives the type of judgment that’s made about women who have abortions. “I don’t want to be pregnant,” is what Carole said at the beginning, and that should be a good enough reason for us. Not even “I can’t be pregnant” but “I don’t want to be pregnant” should be sufficient, but it’s not.

People argue that there are good abortions and there are bad abortions. Unless you took steps to prevent the abortion, you’ve done something wrong, and I find that our own community can be very judgmental about it.

Way back in 1990, at a World Health Organization conference held in Tbilisi, Georgia, Marge Berer took on the assertion that people in the former Soviet countries all needed to start moving in the direction of the conference title, which was  “From Abortion to Contraception.” She asserted that real women in the real world use abortion to plan their families and that their decision-making should not be derided as irresponsible or bad simply because it wasn’t what some doctors imagined they should be doing.

Women seek abortions when they have unwanted pregnancies, legal and safe or not, because it’s too late for contraception. From many women’s perspectives, there is no split between contraception and abortion; they are two sides of the same coin. Marge has argued many of the biggest supporters of “family planning” refuse to support women’s need for safe, legal abortion. Even worse, they often talk about abortion in negative terms. They mention it along with STIs, as if it were a disease, or treat it as an annoying problem that they wish would go away, and consider it inferior to use of contraception. They even claim that use of contraception will (or should) make abortion go away. But it won’t, because it’s about the realities of people’s sex lives and how sex happens.

[sidebar]

[sidebar_img][/sidebar_img]

[sidebar_text]

How does splitting abortion from contraception affect research?

Angel Foster

The way that we are developing contraceptive technologies has been influenced by our attempts to create these really bright lines about what is or isn’t an abortifacient medication. In fact, we’ve done less robust work on a range of technologies. This applies to pericoitals, or contraception that is used around the time of intercourse. It also relates to discussions about what it would be like to have a method with mifiprestone like a “monthly mifi,” or some kind of “bring down your period pill” that would induce menstruation early on into a possible pregnancy.

There’s been a lot of resistance to moving forward with those technologies because of concerns about the possible implications of their mechanism of action. What would it mean for a method to be operating in a spectrum where there’s not these clean bright lines between what is an abortion and what is the prevention of a pregnancy?

We also haven’t necessarily had as much research on abortion technology, and this has limited the kinds of contraception that have been developed. We aren’t very comfortable with any method that would intercept any gestational processes because of this bleed with abortion.

From women’s perspective, we know they are using all kinds of strategies throughout this sort of overarching process to prevent pregnancy, to terminate pregnancy, in order to make the decisions about whether or not to continue a pregnancy. And so pericoitals or postcoital contraceptive methods are things that get highly politicized in a number of contexts.

But most women are not as preoccupied with these issues of mechanism of action. So I think that we have sometimes limited our technological development on the spectrum of contraception to abortion because we want to create bright lines that don’t exist.

[/sidebar_text][/sidebar]

Angel Foster: I think that for a number of different reasons, abortion has been siloed away from other elements of sexual and reproductive health—and healthcare in general. That, of course, has affected the way that our health professionals are trained and educated in abortion care, whether that’s in the United States or abroad.

Marge Berer: Everybody says that if you’re an abortion doctor, your career is going to be incredibly restricted. And I think about After Tiller, the film that came out recently about the late abortion providers LeRoy Carhart, Warren Hern, Shelley Sella and Susan Robinson. It’s true here in the UK as well; there’s this stigma attached to providing abortions. It’s meant to be a career killer.

The separation of family planning and abortion goes back 100 years. They’ve talked about it in Britain, and even before the Second World War there were two movements: a contraception movement and an abortion movement, and they didn’t work together.

Jon O’Brien: In recent times, this tension between family planning and abortion has become worse as a result of a couple of factors. The first is political.

In the United States we saw the Third Way think tank developing a series of message points that were basically meant to help politicians avoid having to say that they support a woman’s right to choose and women’s autonomy, and pivot towards family planning.

Antichoice groups have been incredibly successful in making abortions such a controversial issue on a political platform. People don’t want to get up and say that they support it for fear of the consequences of attacks from the range of antichoice forces out there.

So I think abortion has been isolated, even in places like the United States. On a professional level, I also think that there have been various changes. One of the things that has happened is the influence of donors in the world of women’s reproductive healthcare.

Angel Foster: As Jon has said, the abortion discussion has been heavily influenced by what’s happened within the donor community. We know that the politicization of abortion, and removing abortion from healthcare, have been a strategy that’s been used to focus on contraception. Certainly within the reproductive health and justice communities, that has been historically done for expediency—in order to move forward with other priorities.

Jon O’Brien: Melinda Gates has said that her foundation will make a huge contribution to women’s health, but those resources will not be used for providing safe abortions. I think she has contributed what amounts to the GDP of a medium-size country.

With that type of money in the field, I think it creates another isolating factor for people who are working on unsafe abortion in places in Africa or Asia where women can die. Having such a huge donor who excludes abortion skews the playing field. But Melinda Gates is not the only one who does that.

Within the donor world, I find it rather ironic that donors are spending money on projects to look at abortion stigma, but if you actually look at the websites of most donors—we’re not just talking about the Bill & Melinda Gates Foundation, but most other donors—you’ll not find very explicit mention of abortion on many of them. And you won’t find an explicit sort of transparency about the work that they’re doing.

This is further exacerbated by faith-based organizations playing such a huge role in the development and in the provision of services in developing countries in areas related to sexuality. The implicit contract between the donors and faith-based organizations is that they will not deal with unsafe abortion—they will not deal with abortion, period.

So therefore, contraception in some way becomes the best solution to unsafe abortion, as opposed to dealing with legalizing abortion and ensuring that those services are provided safely. So, I think that this combination of factors has given a particular edge to the question of family planning versus abortion.

Angel Foster: In Canada, Prime Minister Steven Harper’s administration has pledged a tremendous amount of funding toward reducing maternal morbidity and mortality, but has explicitly said that abortion is not a part of maternal health. And it isn’t going to be part of funding on an international level, because it has been made clear that abortion won’t be funded through these Canadian government streams.

This applies even in cases of rape or incest or where there’s a life endangerment issue, or a health or a physical health issue. And we have reached a point where you can have politicians get up there and say with a straight face that abortion isn’t part of healthcare, or abortion isn’t part of maternal health, and they’re met with relatively little pushback.

Jon O’Brien: In the medical community you still find judgments about becoming pregnant when you don’t want to be—and especially, the reasons why you would want an abortion. I think this goes to a very personal view of whether you believe that women are autonomous agents, or whether you believe that we should regulate people’s health and be prescriptive about what they do and what they don’t do. This ambivalence even reaches activists.

Real women in the real world use abortion to plan their families and their decision-making should not be derided as irresponsible or bad.

Marge Berer: The doctors who were around in the pre-Roe era were dealing with a lot of complications from unsafe abortion—injuries, morbidity and deaths—as they still are in many countries. They tended to be more sympathetic than younger doctors coming up now in countries where abortion has been safe and legal for, say 35–45 years, now.

Carole Joffe: Today’s provider community in the US is small but very strong. Paradoxically, this is in large part because the opposition has made them into a true community. I have the great joy of teaching several webinars to two different groups of doctors, one for a fellowship program, another for Physicians for Reproductive Health. These are not simply the old guys from the pre-Roe era who provide abortions because they saw the horrible ravages of illegal abortions. That generation, for the most part, has either retired or has passed away.

Angel Foster: What you said is also true in places like Canada or most of Western Europe, where it has become increasingly rare for practicing clinicians to see the horrors associated with unsafe abortion that happened in the pre–Roe era.

Carole Joffe: But what I see now at a NAF meeting or a Society for Family Planning meeting is a very robust community. The provider community in the US is actually stronger than those in some other countries. This is in no way minimizing both the physical and the cultural attacks providers face elsewhere.

One of the few bright spots in the context of a very, very serious situation in the US, especially in the conservative states, is that we have a growing, very committed—I would use the word upbeat—provider community. It was created by the opposition, the way social movements create other social movements.

Angel Foster: We’ve seen something in the last 20 years in the United States that is really starting to grow into an international movement. There are active and mobilized medical students and residents who are demanding the opportunity to get information, education and training opportunities in comprehensive family planning, contraception and abortion care. Now we have a new generation of abortion providers who are emerging because of the efforts of Medical Students for Choice, the Ryan Residency Training Program and the Fellowship in Family Planning at UCSF.

Just last week I was in both the Republic of Ireland and in Northern Ireland. I met with two students at Queens University in Belfast about starting a Medical Students for Choice chapter there. That’s a really exciting place, to echo what Carole was saying about the provider community.

I think there’s a wonderful opportunity here, where we are in the midst of having a really growing movement of health service providers who are trying to reclaim abortion as part of mainstream medical care and as an essential part of women’s reproductive health. And, as you know, there are lots of challenges to making sure that training opportunities are available and standardized, but I think there’s been a lot of gains made over the last two decades, and it really has become a very strong part of the movement overall.

Conscience: What about the people in reproductive health who are less strong about abortion?

Marge Berer: I can remember fighting with people on the left in Britain in the late ’70s and early ’80s about the need for a comprehensive sexual and reproductive health perspective, and I had a very unpleasant parting of ways with them. They were afraid that programs providing abortion care in addition to contraception would lose the vertical perspective that the family planning people think is so crucial—so, for reasons of political expediency, abortion got excluded.

But I recall that some of the reasons why we said why it was important to have that broader perspective was that some people in our movement didn’t even feel able to say the word abortion out loud, even though they were prepared to support a woman’s right to decide the number and spacing of her children, for example, as well as contraceptive services.

Until you make abortion part of a broader spectrum of health needs and health rights, and you treat abortion as a integral part of those, you are helping to stigmatize it on a certain level, or at least making it separate.

Jon O’Brien: Some people see it as pragmatic to take this stance that abortion is bad, family planning is good. This message gets you a hearing from the majority of politicians who also believe in that mantra. It gives you an in to working with faith-based organizations and developing countries. There is a contingent that wants to concentrate on reducing the number of abortions, as opposed to recognizing autonomy.

I wonder whether there is now less emphasis in our community on the ideology that drove support for abortion rights. In my opinion, there was a women’s health imperative that was very medical and feminist. These were the two major forces that created a commitment to ensuring that abortions are safe and legal. I think now there’s a de-emphasis on the ideology that drove us to support abortion rights generally within society, and even within those who would be progressives.

Carole Joffe: There have been all kinds of shifts and there are several ways to explain that. If you think back to the period right before Roe, we, namely the abortion rights movement, had a moral high ground. The message was: women are dying. This is ridiculous. They don’t have to die. It’s a simple procedure when done safely.

It’s true that today we probably will see some more women dying, like in Texas’ Rio Grande Valley, where clinic closures have led women to self-induce abortions using black-market medication from Mexico.

In the US, there was the progressive wing of the medical community in the ’60s and early ’70s, the feminist health activists driving the legalization of abortion in its initial phase. They were college educated, very articulate women, a lot of whom had access to the media. Today, the face of abortion patients in the United States is disproportionately the most vulnerable women in American society: women of color and women of very low income. In other words, a group that has no political power to speak of, although they have their sympathizers in very hardworking advocacy groups and healthcare professionals. These women do not, by and large, have the support or even the awareness of the vast majority of American people.

Angel Foster: I find that in my work, the way I frame abortion may shift depending on the context where I’m doing work. Sometimes it’s very much focused on autonomy; sometimes it’s social justice. Sometimes I use a more public health frame, sometimes it’s about human rights.

Working in areas where abortion is severely legally restricted, public health arguments can still resonate in a way that is quite different from our discussion in the United States now. For me, all of those frames are appropriate in talking about abortion.

What I try very consciously to do is when using one frame, not to undermine other frames in the way that I talk about it. So, not to pit the public health argument against the autonomy argument.

That’s actually something that I wish we were doing more as a movement within sexual and reproductive health, or within the progressive movement in general.

As someone who works internationally, I appreciate that often there is just a small group of people who are doing the abortion work, and then there’s all of these different areas in reproductive health and beyond. I don’t necessarily expect that everyone is going to take on abortion as their primary thing. I know lots of pragmatic, political, ethical reasons why organizations and individuals don’t take on abortion work.

Marge Berer: But the people who are still concerned about abortion use abortion in the same sentence with sexually transmitted infections—that’s a problem. Those people are really a drag on what we do. They’re always trying to make it seem as if we’re promoting a second rate issue somehow.

Angel Foster: I’d like to think about ways of messaging our work so that the folks who are doing really concentrated work on contraception, emergency contraception or STIs and HIV aren’t undermining the work of those of us who work in the abortion field by pitting these things against each other. One can promote emergency contraception without pitting it against abortion.

Conscience: Are there ways of injecting backbones into the policymakers who say that they are very much on our side but when it comes down to it are less than vocal?

Marge Berer: I think they’re hopeless.

Jon O’Brien: I think sometimes with politicians you want them to lead, but more often than not they follow. And I think that as a reproductive health community, the responsibility is on us to create the type of support for reproductive health in professional organizations, in professional spaces, at the grass roots level, in other nongovernmental organizations that politicians understand it can cost them dearly to not support it.

Marge Berer: I would add that politicians need to believe that supporting these rights is a vote winner as opposed to a vote loser. Many of them just want to be elected—they don’t give a damn what for.

[sidebar]

[sidebar_img][/sidebar_img]

[sidebar_text]

How does splitting abortion from contraception affect research?

Marge Berer

People don’t want the line between contraception and abortion to get fuzzy. And yet it seems to me that where everything has been going is in the direction of making it fuzzy.

And we really have to encourage that. I always had this idea in my head that you could take medical abortion pills as early in pregnancy as about six weeks after the last menstrual period.

They looked into that at WHO and told me that no, you can take the medication too early. Seven weeks seemed to be the earliest starting point. Then this new emergency contraceptive came out, ulipristal acetate, name brand Ella or EllaOne.

This came up last year during the Population Council at the European Conference on Contraception and Abortion. I asked about Ella: “Well, this is a mifepristone-type medication, so why can’t it be used for really, really early abortion?”

The man from the Population Council said it’s not worth his life to sell the medication in that way because nobody will want it to be out there. Ella is many times more effective as an emergency contraceptive than Levonorgestrel, or Plan B, and it can be used as an early abortifacient, but he doesn’t feel he can stick his neck out and say so.

That’s the big kicker, because there are all these complaints about abortion being too late, and then this method comes along and it can be incredibly early. But you’re not allowed to say what it is because nobody will want to buy it, or nobody will want you to promote it.

This is an area for growth for us. I like using a timeline when I talk to people so I can explain: this is the bit where contraception works, this is the bit where emergency contraception works. There are various types and they’re not all in the same bit. Then you have a conception, and it shifts over to being abortion, but the line between them gets very blurred if you think about it that way.

[/sidebar_text][/sidebar]

Carole Joffe: With the struggles for abortion that we’re facing now, obviously we need more politicians who are truly committed, who will do stuff. But the battles are not just taking place in Congress or even in the state legislatures, although the states have become in many respects much more crucial agents of attacking abortion.

Consider the health departments in Virginia or North Carolina. In these states, politicians imposed crazy restrictions that would subject abortion clinics to the same standards as ambulatory surgical centers, but left it up to the health departments to write the new regulations.

Angel Foster: I wanted to share something that’s happening politically north of the US border, because it’s interesting to think about the dynamics in Canada. About a month ago, Justin Trudeau, head of the Liberal Party, which is currently in the opposition, announced that for the next election, anyone who was running for a seat with the Liberals had to pledge that they would vote prochoice on any issue that came up related to abortion. Now Trudeau has also said that they’ll sort of grandparent in those members of the Liberal party who are on record as being antichoice, but that anyone new who comes into the party has to make that commitment.

I’ve been following this story and find it fascinating. Because it is often the case in Canada that a lot of the politics of the United States move up north. But with Trudeau, I think we’re actually seeing some very proactive statements come out of a major political party. It will be interesting to see where that goes with the elections, and how strong this prochoice commitment is. But it has been a reminder that when politicians really stand their ground it can generate important discussion and debate.

Carole Joffe: We are at a moment in the United States where all us chicken littles who have been saying the sky is falling.… I mean, the sky really is falling.

Marge Berer: I think the US is possibly the worst place in the world right now in terms of the antiabortion movement—with the possible exception of Russia. I see more ugliness from the US opposition than anywhere in the past, and this is probably due to the anti-abortion groups getting advice from PR firms.

It’s been very good about stigmatizing bits of abortion instead of abortion itself. Because nobody wants to hear that you’re against abortion, they just want to hear that you’re against sex selective abortion or you’re against abortion in the case of fetal anomalies.

Carole Joffe: We are in such a serious situation in places like Texas and Mississippi, where one clinic is hanging on by thread. North Dakota has one clinic. A number of states are down to one.

So, in terms of real, live women able to get access to abortion, we’re in a very serious situation.

Marge Berer: I was going to bring up the Jane Collective, the women who, before Roe, ran their own underground abortion service in the US. Now, the country must be at a point where this history has to be brought out of the wallpaper to do its thing with modern medication abortion—whether with misoprostol alone or with mifepristone.

That’s the last card in the deck basically—women taking control of abortion provision.

Carole Joffe: Compared to the abortion access level, I think politically it’s a little different. I’m seeing indications—and I hope it’s not wishful thinking—of the political pendulum beginning to swing.

The antiabortion movement has overreached. They’ve overreached both by their drastic moves in clamping down on abortion, but I think more significantly they’ve overreached on the attacks on contraception.

Jon O’Brien: What we’ve seen the last couple of years with regards to the issue of abortion and the White House here in the United States, has been an administration that is far less forthright than the Clinton administration in its support for a woman’s right to choose.

Taking that type of position politically leaves the door open for conservatives to begin to attack access to contraception. I thought it was very interesting what Carole said about the idea that, as the two issues are conflated, it can actually serve the purpose of increasing support for abortion rights because there’s an understanding that you can’t negotiate with unreasonable people.

The United States Conference of Catholic Bishops is not interested in stopping abortion. It’s interested in stopping everything it disagrees with, and that includes contraception. The idea of politically negotiating away abortion in order to win contraception has been shown to be ineffective by some of the recent cases.

Marge Berer: But looking at things from a global level, I’ve been working on this listserv for the International Campaign for Women’s Right to Safe Abortion for a year now. And I am drowning in e-mails about abortion from all over the world.

The media is just publishing articles everywhere, constantly. People are making videos; they’re writing journal articles; they’re writing reports; they’re telling women’s stories. I can’t keep up with it. It’s an extraordinary amount of information coming out.

There’s changes happening in the law in a lot of places—little changes, not major ones—but more one step at a time. Perú had a law allowing therapeutic abortion on the books for 90 years, but they just passed some regulations that may actually allow some hospitals to provide it. And the country also has a campaign in support of legalizing abortion on grounds of rape.

But I feel more worried about the Gates Foundation’s effects on things, because I think theirs is such a retrograde approach. Ideologically, it’s supposedly prochoice, but it’s very, very antichoice on many levels.