Sydney Calkin is a senior lecturer in human geography at Queen Mary University of London and the author of a forthcoming book, “Abortion Beyond Borders: Abortion Pills and the Future of Reproductive Freedoms.” Her work has focused on cross-border abortion access and activism, an area where politics, gender and reproduction overlap. Our conversation has been edited for length and clarity.Clara Ferreira Marques: After the leaked draft majority opinion this month, the US Supreme Court appears poised to overturn Roe v. Wade, the landmark abortion ruling. How will that leave the US in comparison with the rest of the world?
Sydney Calkin: When I began this work in 2016, I chose Ireland, Northern Ireland, Poland and the United States as my countries of study, and it’s been interesting to watch how they have diverged. When I started, Ireland had a total ban, as did Northern Ireland, and the US was seen as a liberal bastion.
The fact that the US is moving backwards on abortion rights paints a gloomy picture, but it’s important for people to understand that the US is an outlier in its direction of travel. There are very few countries that are moving backwards, with the United States and Poland prominent among them. Globally, the trend is towards more progressive abortion laws. Latin America is a great example, just over the past 18 months.
CFM: Abortion itself has also changed quite a lot, even over recent years, not least with the advent of abortion pills.
SC: Medication abortions accounted for the majority of abortions in the US for the first time in 2021, partly due to the pandemic. Basically, this is an abortion with a set of pills, approved by the Food and Drug Administration for use in the US since 2000. That’s about 15 years after it was approved around Europe, where these have made up the vast majority of abortions for a long time. The FDA has recently extended its approval to up to 10 weeks after the last menstrual period. [One] thing that gets lost in the abortion debate in the US is that the vast, vast, vast majority of abortions are first trimester, early abortions.
CFM: How has this option affected clandestine abortions?
SC: It’s really important for people to understand is that medication abortion is extremely safe. The gold standard is abortion supported by a medical professional in a clinic or through telemedicine, but to have an abortion with pills at home, supported by a community provider, is not an unsafe abortion. This has transformed the landscape, especially in contexts where laws are restrictive. It’s no longer the case that every illegal abortion is unsafe. In fact, now it’s entirely possible for people to have illegal but safe abortions with pills.
CFM: Pills will not be the answer for everyone, though.
SC: The best evidence we have now shows that people in the first trimester who are choosing between surgical and medication often prefer medication abortion, because it’s more autonomous, more private, less invasive. But people need abortions across the duration of pregnancy for many different reasons, like with a severe fetal anomaly found late in the second trimester.
As far as the legality of medication abortion across state borders after Roe is overturned, it’s hard to say, in part because the conservative legal movement is fiendishly creative in the mechanisms they develop to criminalize abortion — as we’ve seen in Texas with private prosecutions, this model of allowing people to bring civil actions against anyone for assisting with an abortion in their state.
Right now, medication abortion follows some of the same patterns as surgical abortion, and telemedicine services can be limited by state licensing. So if you live in Texas, a provider in California can’t necessarily send you pills. If pills are going to move across state borders, which they already do, it’s going to be in clandestine formats. In fact, what we’re going to see is probably just the increase in international providers like in Aid Access, based outside but able to ship pills directly to people in the US, in a kind of legal gray area.
CFM:Â Does this effectively undermine the law?
SC: For me, that is one of the most interesting political dimensions of medication abortion. As a medical technology, it’s dramatically transformed the safety and accessibility of abortion. But as a political technology, it’s really transformed the relationship between pregnant people and the state. It’s challenging the extent to which the state can regulate abortion, because, historically, states have tried to criminalize abortion by regulating the abortion provider, by criminalizing doctors and their actions. Plenty of places, like Poland for instance, don’t criminalize the person who obtains an abortion, which can provide a kind of interesting legal loophole for activists to use.
The case of the Republic of Ireland is an interesting one, because they had penalties in their laws that allowed for up to 14 years in prison for someone who used abortion pills, but they never brought a single prosecution against a pill user. Whereas in Northern Ireland, they had different laws also criminalizing the use of abortion pills, but they did bring a few cases. Those provoked such backlash, they actually of accelerated changes in public opinion. When the public was confronted with the idea that abortion laws actually mean sending individual women to prison, people were unhappy with that. By contrast, in Poland, there have been more aggressive efforts to prosecute — right now, we’re seeing an activist be prosecuted for giving pills to someone who was trying to obtain an abortion while in an abusive relationship.
CFM: What about in the US?
SC: In the US, we’ve also seen prosecutions of people for self-managed abortion. But as with so many things in the American criminal justice system, it’s the poorest people who are being prosecuted, those who need to wait to raise money or find time off work. Prosecutions in the US, they’re also hyperlocal. And they really depend on kind of what your state laws are and whether your local prosecutor really wants to pursue this case. A motivated prosecutor who wants to criminalize someone for a self-managed abortion, they use a variety of arcane laws, everything from feticide, infanticide, sometimes practicing pharmacy without a license.
Medication abortion is medically indistinguishable from a spontaneous miscarriage, so if you were to have a self-managed abortion and present to a doctor, they wouldn’t be able to tell whether that was a spontaneous miscarriage — so the prosecution would have to use digital records. Just in recent years they have used people’s emails, their text messages, their Google searches, etc.
CFM: How will the wider use of self-managed abortion change the dynamic, and the broader debate?
SC: In Ireland, pills had a huge impact on the conversation about abortion, because the abortion ban operated on the basis that a termination was a surgical abortion —  something you could go and get in England, but that was not taking place in the Republic of Ireland. The availability of medication abortion, the extent to which people were actually sourcing pills inside Ireland, transformed the debate among politicians. Once they saw the prevalence of pills, they started to talk about abortion as an issue of democratic accountability, of legitimacy. In their parliamentary debates, they were saying things like we can’t shut down the internet, we can’t search every package, the law doesn’t have authority anymore. They kept saying the genie is out of the bottle.
There I think it did alter that debate, because it showed them that abortion was already happening in homes in Ireland.
CFM: Whatever happens in the coming weeks and months, abortion pills do change the face of resistance too, changing what is possible.
SC: I think Poland provides us with a really interesting example here, because it has a near-total abortion ban, and they’ve made it even more restrictive in the past two years. But there’s a European network called Abortion Without Borders, and what they do is gestational, geographical triage. So when someone comes to their service, they ask about where they live, how many weeks pregnant they are, can they travel — and based on that they can help them to get pills or to get to Germany, Holland, England, Spain.
We might see something kind of parallel to this system in the US. That already is happening to a certain extent, but I think we might see an expansion of that. I feel like almost every day there’s a new bill introduced in a state house somewhere in the US that tries to criminalize an aspect of abortion, so there is a lot of legal risks for activists in the US which activists in Europe don’t face. The activists in Poland are only doing things that are legal in Poland — they’re not physically providing the pills, those are being sent by groups that are outside of Poland. It’s a really different legal context here, but at a practical level we might see this kind of cross-border network develop.
CFM:Â Â Anti-Roe activists are really hoping that overturning that ruling will stop abortions from happening. Will it?
SC:Â No, the ruling will not stop abortions from happening in the US. It will just mean more people will self-manage abortions with pills outside of medical settings (for early abortion) and more people will travel long distances to access abortion care in other states (for later abortion).
Across the world, there is absolutely no evidence that allowing abortion increases the rate of abortion. In fact, the best evidence we have shows the opposite. It shows that there are more and more unsafe abortions in countries where there is restrictive access to abortion, restrictive access to contraception.
The only thing that criminal abortion laws do is increase the proportion of abortions that are unsafe, and there’s decades of evidence from across the world that show this. In countries with the most restrictive laws, 75% of abortions are classed as unsafe. Compare that with in countries with the least restrictive laws, where only 13% are characterized as less safe or least safe.
Unsafe abortion? Frankly, it’s a political choice.
This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.
Clara Ferreira Marques is a Bloomberg Opinion columnist and editorial board member covering foreign affairs and climate. Previously, she worked for Reuters in Hong Kong, Singapore, India, the U.K., Italy and Russia.
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