Making Abortion Safe Outside of the Legal System: A Q&A on Self-Managed Abortion

From 2017 to 2019, sociologist Naomi Braine, a professor at Brooklyn College, traveled in Latin America, sub-Saharan Africa, and Europe to study what she terms a global feminist movement for self-managed abortion (SMA). The result is her new book, Abortion Beyond the Law: Building a Global Feminist Movement for Self-Managed Abortion (Verso, 2023).

The story of self-managed abortion starts from the fact that, according to the Guttmacher Institute, at least half of all abortions around the world in 2017 were medication abortions, in which people used drugs to end their pregnancies. (The ambiguous legal status of abortion in many countries means that the data is incomplete.) This contrasts with the common image of so-called “procedural” abortion, which occurs under professional medical care and mostly or entirely in a clinic or hospital. 

A portion of medication abortions, and a majority of them in the United States, are facilitated by licensed doctors. But in the countries where Braine focused her research, a larger portion of the total are “self-managed” without licensed medical personnel. This doesn’t mean that patients are isolated; thousands, in Braine’s reckoning, have received support from activists who have walked them through the process virtually or in person.

SMA activists often work in a “gray zone” between what is clearly legal and illegal. “The movement for SMA,” Braine writes,“refuses to comply with laws that limit or ban abortion, and this work enables people with unwanted pregnancies to safely end those pregnancies regardless of the law. In effect, this is civil disobedience without a press release.”

Braine started thinking about movements that operate in legal grey zones, and don’t seek visibility, even before researching SMA—as a participant herself in the movement for sometimes-illegal “harm reduction” practices that reduce death among drug users.

We spoke in January 2024, a year and a half after the Supreme Court overturned Roe v. Wade and allowed 21 states to impose new abortion restrictions. This in turn caused dozens of clinics and other health care providers to stop offering abortion care or to close entirely, sending thousands of abortion-seekers in search of ways to end their pregnancies outside of professional medical settings.
—Felicia Kornbluh

Felicia Kornbluh: Your book is about “self-managed abortion” (SMA), a phrase that might call to mind isolated pregnant people ending their pregnancies by using herbs or devices made out of coat hangers. Or it might bring to mind pre–Roe v. Wade referral networks, like the Clergy Consultation Service on Abortion, whose history I tell in my book, or feminists providing abortions clandestinely, as the Jane collective did in Chicago before Roe. Are any of these images accurate?

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Naomi Braine: When we talk about self-managed abortion [today], what we are talking about is medication abortion, which is incredibly safe. It does not create the classic risks of abortion outside of the medical system. Essentially it induces a miscarriage. It can be done with either two pills or one: mifepristone, which stops a pregnancy from advancing, and misoprostol, which initiates the process of expelling the material from the person’s body. It can also be done with misoprostol alone and is around the world.

This movement really began in Latin America in the 1980s, when misoprostol was marketed as an ulcer medication with a black box warning that it might cause miscarriage. And there were people who took that as a kind of invitation. Around the same time, French [researchers] released RU-486, the original name of what today we call mifepristone.

These two pathways converged in the early 21st century, as a grassroots movement, particularly in Latin America and later in sub-Saharan Africa, embraced them together.

New technology created possibilities for new political practice. All somebody needed were the pills and a set of instructions that can fit on one page. If somebody has good information about what to expect in terms of cramping and bleeding, then it’s pretty simple. What we’re calling self-managed abortion is not very different from a telemedicine abortion. The only difference is that in the telemedicine abortion there is an exchange of e-mails with a credentialed doctor.

The activists I talked to, especially in Latin America, considered Jane to be a direct antecedent. They understand themselves as a feminist movement, as building out multiple histories, including long histories of activists and community-based healers assisting women.

To connect this a little bit to the United States: Almost all of the cases of people who have been prosecuted for abortion since 2020 have been charged at 17 weeks pregnancy and later. And abortion isn’t the charge: the charge is improper disposal of a corpse, abuse of a minor, or chemical endangerment of a minor. That tells us that people have been self-managing second-trimester abortions for upwards of 20 years. All the women who have been prosecuted in the United States are women of color, or immigrant women, and often low-income. The big difference [between what those women have gone through] and activist accompaniment is that someone is less likely to be making decisions in a state of panic. The process will be different.

FK: The idea of “accompaniment” seems key to SMA as feminist and as a social movement. Can you explain that concept?

NB: The hotlines were the first strategy: You would call a number and get the basic information, anonymously. And you can call back if something is unclear. Accompaniment emerged as a more engaged response. You might still be reaching out by text message, but it was to a particular person who would be available to you through the procedure. It was about providing greater care, connection.

The language of acompañimiento first emerged in Guanajaca, Mexico, with a group doing work around domestic violence that gradually started doing medication abortion. Accompaniment is a strategy of presence (presencial). Activists use the phrase “solidarity” or accompaniment as a standing with, standing next to, comforting someone when they are frightened, a deep recognition of the fundamental humanity of someone who is going through a difficult social, biological, and physical process that they should not have to go through alone.

FK: Your book emphasizes that activists in the global South are leading this movement.

NB: Since [the so-called “heartbeat bill” that makes abortion illegal at approximately six weeks] SB 8 was passed in Texas, the Global North is being rescued by the Global South. At this point activists all across Latin America are providing accompaniments to patients in the US. They made a very clear public statement that they will accompany anyone who needs an abortion.

FK: You said in the book that there wasn’t an infrastructure for SMA in the US comparable to the ones in Latin America and sub-Saharan Africa. That was before Dobbs. Is there one now? 

NB: The situation in the US is fundamentally different from much of Latin America and Sub-Saharan Africa in two ways: We are like Poland in that we went from legal to illegal. This makes abortion intrinsically political, and it means that there is mileage in prosecution. 

Part of the fundamental change with the fall of Roe is that doctors are now scared. Before, it might have been almost impossible to get to a clinic in the Rio Grande Valley, for example, but if you were having a miscarriage of any variety, you could go to an emergency room and receive care.

FK: That’s the bad news. Is there also some good news? 

NB: Shield laws [which protect healthcare providers prescribing medication abortion outside of their states] have meant that pills can go to all 50 states. What we have in the U.S. is mostly telemedicine-supported self-managed abortion in all the places where abortion has been banned. There are two national hotlines—M+A Hotline, staffed by medical providers, and Reprocare, an activist hotline modeled on those in Latin America and Africa.

Activists in the US are not doing what activists in Latin America did, which was to go out at night with stencils and spray cans and write the hotline number on the sides of buildings. What’s happening here is happening very close to the ground: Networks are distributing pills. There’s a little bit of a cell-like structure, so no one person could talk and take down the entire network. Accompaniment is happening. 

From the Southern Cone to Nova Scotia, sharing information, sharing specifically the World Health Organization (WHO) protocol for medication abortion, is legal. And even in the United States, I invite people to imagine the reaction of a judge to sharing information in a WHO protocol.

Doulas are also helping people self-manage abortion. This is a little more professionalized than some SMA around the world, but it is also accompaniment. In addition, at least one sex worker hotline is providing information on medication abortion, and I can speak to the fact that every harm-reduction conference for at least the past five years has had panels on the connections between harm-reduction practices for drug users and SMA. 

FK: What is the relationship between the practice of SMA and liberalizing public policies on abortion? Can this kind of grassroots self-help lead to legal change?

NB: The Green Tide [the feminist and abortion rights-movement in Latin America] is absolutely connected to SMA in that region. SMA is distinct enough that it is worth thinking about as a distinct strand of feminist movement: Its form of action is about mutual aid rather than screaming in the streets. But pretty much all of those activists also scream in the streets. 

The Argentine group Las Socorristas used to march in demonstrations with signs that said “Abortionists.” They’re kind of unique, but everywhere the SMA activists are involved perhaps through other organizations, or as part of coalitions. La Mesa in Chile brings in everybody, from mainstream feminists to radicals.

FK: Apart from particular tactics, what do US feminists stand to learn from their encounters with SMA activists around the world?

NB: SMA works against abortion stigma. By making abortion safe outside the medical system activists began to destigmatize it and normalize it. They created a process of “social decriminalization.” We don’t link those phrases in the United States.

Latin America has no language of choice. It’s important to understand the emergence of feminism there as part of resistance to military dictatorship. It is a radical mobilization of global human rights discourse, a notion that women’s rights are human rights—not “privacy,” not medicine, not anything else. It’s a fundamentally different way into the whole issue of abortion. 

Abortion rights as human rights is becoming more of the dominant discourse and something American activists desperately need to learn from the rest of the world. African American women, like the leaders of the reproductive justice group SisterSong, have been telling us this—and I say “us” because I’m white. They have been recognizing the intersectionality of oppression, and full complexity of people’s reproductive lives. We need to take that seriously.