MNÁwesome: What Happens When We Legalise Abortion?

Via The Irish Times

If you follow me (or probably any other Irish person) (or read Irish news) (or are passingly aware of when Ireland makes foreign headlines), you probably heard that the Republic of Ireland voted last month to repeal the 8th Amendment of the Irish Constitution (Bunreacht na hÉireann). It was a massive, multiyear campaign that took off running after the tragic—and completely preventable—death of Irish dentist Savita Halappanavar.

I know that this topic is hard for many people and that there are a lot of very strong emotions. As a devout Roman Catholic, I’m familiar with both sides of the issue. I’m not going to dig into the intricacies of the philosophy on when life begins, but I will say this: I desperately wish that I lived in a world without abortion. I wish that I lived in a world in which every pregnancy was planned and healthy and no one ever had to make the decision whether to terminate their pregnancy. I wish I lived in that world, but it doesn’t exist. It is not my place to tell someone else what they need to do with their body and in no other instance do we insist that it is.

If my sister, whom I love, was dying and needed my kidney, the government could not even take it from my dead body without my consent because the government believes I own my kidney in a way it does not feel applies to my uterus. If I have cancer and am pregnant, that is very sad for many reasons, but my life is not less valuable and no less deserving of treatment because I am carrying a human in me. It also does not mean that my son Rónán, who is already alive in the world, no longer needs his mother. It is not my place to tell another human what to do when faced with this choice, but it is equally not the place of another to tell me what I should or must do.

What is an abortion?

There is a lot of misinformation on the internet about what an abortion is—and what it is not. There are two primary types of pregnancy terminations: medical and surgical abortions. Different countries, states, and local municipalities have various laws surrounding when it is legal (if ever) to have either type.

Medical Abortion - Medical abortions are done using two medications: mifepristone and misoprostol, which are often collectively called the abortion pill. In America, usually the first pill (mifepristone) is given at the clinic and then you take the second dose at home. In the UK, both doses are given at the clinic on separate visits. Regulations on when you legally may have a medical abortion vary, but medically the medical abortion is effective until about 9 weeks from the first day of your last period.

Surgical Abortion - Surgical abortion is a minor procedure that is typically done in an outpatient setting (you get to go home at the end rather than having to stay overnight). In comes in two forms: vacuum aspiration and dilation and evacuation (D&E). Vacuum aspiration can be used through the 15th week of pregnancy (unless the law limits that or prevents it entirely).

After the 15th week, it is necessary to use the D&E method. Because the pregnancy is more advanced, the procedure is more complex than those available earlier in pregnancy. The cervix (the opening to the uterus) is dilated (opened) in advance of the appointment. Forceps are then used to remove the products of the pregnancy from the uterus while the patient is under conscious sedation.

It is important to know that this kind of abortion is very rare compared to the others and almost invariably done because of grave illness in the pregnant person or a fatal foetal abnormality (FFA). An FFA is a condition which means the pregnancy with either not result in a living child or will result in a child who lives a short and painful life. I know families who have made the choice to end their desperately wanted pregnancies and say goodbye to the baby they have barely had the opportunity to know. Ending such pregnancies is not the right choice for every family, but those terminations are far from heartless—they are acts of deep compassion for the little human they love.

It’s also possible that the abortion was delayed for an extended by domestic violence or the challenges to accessing care where the pregnant person lives. I’ll discuss some of those types of barriers more below.

What does a ban do?

To understand what happens when a country (or state or whatever) legalises abortion, it’s necessary to understand what happens when we restrict or otherwise ban access to abortion. While banning something does sometimes make it go away, this isn’t always the best way to decrease use or prevalence. Banning those plastic beads from soaps was an effective way to stop companies from putting them in face wash, but abortion isn’t one of those things—banning abortion just makes it unsafe.

In 1966, the Romanian government under Nicolae Ceauşescu issued Decree 770, which made both contraception and abortion illegal. Between 1967 and 1989, the landscape of maternal mortality in Romania underwent a dramatic—and tragic—shift, with abortion-related deaths accounting for the majority of total maternal deaths. Enforcement of Decree 770 was as draconian as you might expect, with all women monitored monthly to promptly record conceptions and secret police monitoring operations in hospitals. Even as overall maternal mortality began to decline across Europe, it continued to rise in Romania, eventually overtaking all of its neighbours.

Even with the overwhelming number of deaths, there were still many, many babies born during this period. Despite the government's clear desire to increase the Romanian birthrate and grow the population, there was insufficient care given to how families would feed, clothe, and house the children they were forced to conceive and birth. As a consequence, an estimated half million Romanian children were raised in deplorable conditions between 1967 and 1990. When Romanians threw off Ceauşescu and his government, the world saw how the children were living and was outraged. Among the horrors of beatings, starvation, unhygienic conditions was the reality than an estimated 10% of the children under 3 years had contracted HIV and were not being treated.

Wealth and health

As is still the case, wealthier pregnant people were better able to circumvent the law by obtaining blackmarket contraceptives or travelling for care and, when they did have a child, they were better able to care for them (and therefore less likely to have to give their child over to a state orphanage). We see this same outsourcing of reproductive care in the horrific way pregnant people are still forced to travel to access abortion. We've discussed before the ways that health is intrinsically linked to social factors like health and reproductive health is certainly not an exception to this rule.

In the United States in 2014, 32 states and the District of Columbia had fewer than 10 abortion clinics and 25 had 5 or fewer abortion clinics. In addition to the high cost and long distances between where people live and where they can access care, many states also have waiting periods, which means more work missed, more childcare necessary, and overnight lodging costs. Adding all these up, it can cost thousands of dollars a person simply does not have to access an abortion. Groups like the Northwest Abortion Access Fund help people access the care they need in the Pacific Northwest, serving people who travel from Idaho, Alaska and the rural areas of Oregon and Washington to access the care they need.

In Ireland, it's a more extreme version of the same story on both sides of the border. There is no access to abortion in the Republic of Ireland except in cases of danger to the life of the pregnant person (and often not even then, as in the case of Savita and so many others) with a maximum punishment of 14 years in prison. In Northern Ireland, it is illegal to procure your own abortion (e.g., taking abortion pills ordered over the internet) with a maximum punishment of life imprisonment. This means that every year thousands of pregnant Irish people travel (usually England) to access abortion services. Since 1980, there have been an estimated 170,000 individuals to make this journey for healthcare. Patients from the Republic of Ireland must pay out of pocket for the procedure and, until recently, patients from Northern Ireland did as well, despite Northern Ireland being occupied by the United Kingdom. Like in the United States, there is funding available from private organisations to offset the cost of the procedure, but it is simply inhumane to force a person to leave their homeland to seek medical care that rightly should be available in their own country.

The Republic of Ireland has now repealed the 8th Amendment, but still lacks the legislation necessary to make abortion safe and legal in the country, and the North is no closer to legal abortion than it was 6 months or 6 years ago. Articles 58 and 59 of the Offences Against the Person Act 1861 bans abortion along with such crimes as kidnapping, murder, and blowing up buildings with the intent to harm. The Abortion Act 1967 makes abortion legal with the recommendation of two physicians in England and Wales (Scotland has independently legalised abortion), but the Act was not extended to Northern Ireland. With the 8th repealed, activists have turned their eyes north, but the road ahead seems long since both the DUP and Westminster have been unwilling to act to protect the health of Northern Ireland.

So what does it all mean?

As we've discussed, banning abortion simply doesn't stop it. Rather, it forces people who are pregnant and do not want to be into situations in which (if they are poor) they bear children they cannot support or seek dangerous back alley abortions, or (if they are wealthy) they must leave their homes and travel long distances to access the healthcare they need. Banning abortion endangers the lives of the people who are pregnant and does not make them any less likely to at least attempt to terminate their pregnancy.

So, what can we do instead?

Support comprehensive sexual health education. When we know how to prevent pregnancy, we are less likely to become pregnant when we do not want to be. In America right now, just under half of all pregnancies are unintended and we know that comprehensive sex ed reduces unintended pregnancies, particularly among young parents.
Make contraception freely available and oral contraceptives available over the counter at pharmacies. When contraception is more accessible and we remove the cost barrier, people are more likely to use it. When I took oral contraceptives, I was on my father's Catholic employer healthcare plan and I had to pay $80 every month that I honestly couldn't afford for my medication. If I didn't have health insurance right now, my own beloved IUD would have cost $900. That's a lot of money, but contraception is a great investment on the part of insurers and societies—for every $1.00 spent on contraception, the investment returns $7.09 in savings.
Improve supports for families to reduce the cost barrier to raising children. Childcare is as expensive (sometimes more!) than housing in many communities and childbirth costs tens of thousands of dollars even for uncomplicated vaginal births. If having a child weren't terrifyingly expensive and parents had actual leave, having more children would be a more realistic prospect.

If we really want to reduce the number of abortions in our societies (and I believe that we should), the best and only effective way to accomplish that is to reduce the number of pregnancies and make barriers parenting less daunting. That won't eliminate all abortions, since there will always be the need to account for the individual needs of pregnant humans and the health of individual pregnancies, but it will go a long way to dropping the number of abortions in communities.

What does makimg abortion free, safe, and legal do? It promotes public health.