Written by Patty Skuster, Senior Legal Advisor, Ipas

While governments around the world reform laws to make abortion less restrictive, self-managed abortion—ending a pregnancy without formal supervision by a health-care provider, often with pills—remains unauthorized in most countries. The Policy Surveillance Program at Temple University School of Law, USA and Ipas released new data that show how abortion laws around the world apply to self-managed abortion.

The practice of self-managed abortion has been rising over several decades and is an even more important means to end a pregnancy in the midst of Covid-19, as health facilities and providers are burdened, and movement is restricted. Increasingly, people who want to end a pregnancy, do so by getting pills directly through medicine sellers, pharmacies, or online, and without supervision of a health professional, regardless of the legal context where they live. Self-managed abortion can be clinically safe, and evidence supporting the clinical safety of self-managed abortion continues to grow. The World Health Organization recommends self-managed abortion early in pregnancy with clinically-proven medicines, so long as the pregnant person has a source of accurate information and access to a health care provider if they need one.

Self-managed abortion offers promise for abortion care, particularly amid the global pandemic. Pregnant people can end their pregnancies safely without supervision of a trained health care provider, which may be the best option if going to a health care provider is undesirable or impossible. During Covid-19, self-care is essential for a range of health needs. But abortion laws around the world require abortions to be performed by a health care provider, with criminal penalties for people self-managed abortion or individuals who help them.

The new data, depicted on a map,  was created through an analysis of key features of abortion laws as they related to self-managed abortion in 180 countries and 40 sub-national jurisdictions. The data can be used by researchers and advocates working to understand how abortion laws relate to self-managed abortion and work for reform.

Through the World Health Organization Global Abortion Policies Database, researchers identified and compiled text relevant to the regulation of self-managed abortion. We then coded each law to elicit how laws apply to self-managed abortion, using the following definition of the practice: “provision of drugs from pharmacies, drug sellers or through online services or other outlets, without a prescription from a clinician, followed by a, [individual’s] self-management of the abortion process, including care-seeking for any complications.”

We coded laws according to:

• Which health providers are legally permitted to provide abortion care, because self-managed abortion occurs without formal supervision of a health professional
• Where abortion is legally permitted to take place, because self-managed abortion tends to take place outside a health facility
• What tests were required, because some laws require testing in a health facility who is subject to penalties for participating in an unlawful abortion, to elicit whether a person who self-manages their abortion and people who help them are criminalized by law

What the data show

We used policy surveillance to form a global understanding of how abortion laws around the world relate to self-managed abortion. While the methods do not illuminate how laws are interpreted or enforced, we generated the data for further inquiry and analysis by researchers and advocates who seek to understand how abortion laws relate to self-managed abortion. For example, the data can help us understand specifically how liberal abortion laws relate to self-managed abortion:

• Fifty-seven countries (and a handful of sub-national jurisdictions, which are omitted for this analysis) allow abortion on economic grounds, social grounds, or any grounds
• Self-managed abortion is not performed by a health professional, but of these 57 countries with liberal laws, 42 require a specified health worker to perform an abortion for the abortion to be legal. One authorizes a lay health worker.
• The laws of 14 countries do not specify which type of health provider is required, but three of these criminally penalize individuals who provide abortion who do not have a medical education or do so outside of medical practice.
• Of the remaining 11 countries that do not specify who is authorized to provide abortion, seven require the abortion take place in a specified health facility.
• In this study, researchers identified no requirements that would limit self-managed abortion early in pregnancy in only four countries: Bolivia, Czechia, Denmark, and Turkey.

How to use the data

Researchers and advocates can use this global overview of how abortion laws relate to self-managed abortion to spotlight the problem of criminalization of self-managed abortion and further a better understanding of the relationship between abortion law and practice. For example, United Nations Human Rights treaty bodies have recommended that states remove specific legal barriers to abortion care but are silent on legal barriers to self-managed abortion, such as requirements that a health professional must provide the abortion. Advocates can use the data in their work with treaty monitoring bodies, as well as national governments, to further develop standards on self-managed abortion.

Advocates can also bring attention to the need for decriminalization of abortion and create awareness of legal contexts, using data from this project. Advocates and government officials working to loosen restrictions on abortion laws can be better informed on how to avoid requirements that criminalize self-managed abortion. Additionally, empirical researchers could design comparative studies that examine the relationships between abortion law and abortion practice across jurisdictions to equip advocates and policymakers with evidence to shape law to improve health outcomes.

Narrowing the gap between law and practice

Researchers hope that the data developed through this project can draw attention to the problem of the gap between abortion law and practice. While people have been self-managing their abortions for millennia, an increasing number are doing so and the global abortion field is spending attention and resources to the growing use of clinically proven abortion medicines, which has improved the safety of self-managed abortion. At the same time, governments are taking steps to liberalize abortion laws but as laws are changed, they continue to criminalize self-managed abortion. By generating data on how laws around the world relate to self-managed abortion, we aim to aid efforts to understand and advocate for the decriminalization of self-managed abortion.

Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organisation.