As the prospect of losing the constitutional protection to abortion becomes more real, I am struck by how disconnected the political rhetoric is from medical reality. The facts are clear: Making abortion illegal does not make it go away. Yes, some patients will be prevented from getting a wanted abortion, but others will still end their pregnancies, either by traveling for safe and legal care or by taking matters into their own hands.
I have worked as an OB-GYN in several countries where abortion is highly legally restricted. In Kenya and Mali, I’ve seen patients present with damage to their internal organs after visiting an untrained provider; while in Mexico and Peru, I’ve met many women who have taken medications like misoprostol on their own and generally have had an uncomplicated abortion. If we truly are on the brink of Roe v. Wade’s demise, it’s critical that clinicians in the United States consider what role we might play in ensuring that our patients remain safe and healthy in the face of dwindling clinic-based options.
Here’s where the harm-reduction approach comes in. Harm reduction aims to minimize the negative consequences of a potentially risky or criminalized behavior and is commonly associated with efforts to reduce the dangers of injection drug use. Injection drug use is illegal, but medical professionals can help reduce the risk of HIV transmission and other infections by providing clean needles and syringes. Other interventions that may improve drug users’ health include creating safe spaces for injecting and treating any medical complications related to drug use without involving the police. Harm reduction is a common-sense approach that looks at the reality of our patients’ lives and tries to address their needs in the safest way possible, particularly when their bodies and health care are criminalized.
This approach can also be applied to safe abortion in settings where it is legally restricted or otherwise not available. It was first described in Uruguay, where doctors, nurses, and counselors implemented the model at public-sector hospitals to reduce the risks of unsafe procedures before the country decriminalized abortion in 2012. The harm-reduction model posits that while the abortion procedure itself may be illegal, there are moments before and after the abortion when health-care professionals can—and, indeed, have a responsibility to—intervene to ensure the safest possible outcome for our patients.
Before the abortion, health-care providers who come into contact with a patient may assess them for health risks and to determine the gestational age and viability of the pregnancy. They may be found to have a health condition that makes them eligible for a legal abortion, or they may have a nonviable pregnancy and can receive treatment for miscarriage.
If the patient has decided to self-manage their abortion, the health professional can counsel them about what methods are the safest to use on one’s own and what methods might be more risky. The World Health Organization publishes evidence-based regimens for medication abortion, which is recommended for use up through 10 weeks of pregnancy. If the patient is found to be in the second or third trimester, providers may counsel them about the increased risks of self-managing the abortion with medications and discourage them from doing anything on their own.
With the harm-reduction approach, patients are not given medications like mifepristone or misoprostol at the clinic—they have to find those on their own. In many countries in Latin America, misoprostol is available without a prescription in pharmacies, although some women report it can be hard to obtain. In the United States, people have reportedly obtained effective abortion-inducing medications through online pharmacies. In a recent study published in the journal Contraception, researchers tested mifepristone and misoprostol products ordered online and found that they generally contained what they were supposed to contain, although sometimes at a lower dose.
Patients are also given warning signs about when to seek care, for example, in case of heavy bleeding or signs of infection. In settings where abortion is criminalized, providers commonly tell patients not to mention they took something since the management of complications after miscarriage is identical to the treatment of the same conditions after medication abortion.
Assuming they don’t have a complication, patients are encouraged to return to the clinic for a follow-up visit to ensure the abortion is complete, treat any complications, and provide contraception, if desired. If they’re found to have an incomplete abortion that is no longer viable, a vacuum aspiration can be performed. Perhaps most important, creating a safe space where people know they can obtain post-abortion care and not face judgment or risk of arrest can go far to reduce the risk of complications from unsafe abortion by ensuring access to timely, patient-centered services.
The harm-reduction model has been evaluated in several Latin American countries. In Uruguay, the harm-reduction approach was associated with a reduction in maternal mortality. In Peru, women using a harm-reduction program were found to safely and effectively use misoprostol on their own to induce abortions with a low risk of complications.
I hope we don’t get to the point where my patients can’t get the abortion care they want and need from a clinic. But if we do get there, the medical community will not sit by idly and watch from the sidelines. At the very least, we will need to care for patients who present to emergency departments with complications of unsafe abortion, which undoubtedly will become more common. But I hope my medical colleagues will play a more proactive role in keeping our patients healthy and reducing the harms of unsafe abortion before they occur. We can learn a lot from the brave Latin American clinicians who refused to let bad laws get in the way of their patients’ health.