What can be learned from the Global South on abortion and how we can learn?

After the U.S. Supreme Court's decision opened the door to restrictions on abortion, there has been a surge in interest in international spaces in what we can learn from the Global South on how to overcome unjust barriers in health policies and regulations. As Global South thinkers with experience working on abortion, we have been embracing this interest as a genuine openness to transnational learning. However, the response is not straightforward.

It is not about importing solutions from one community to another. We can tell stories of community and women driven solutions to overcome the existing legal and policy barriers to accessing safe and legal abortion, such as the Green Wave movement in Argentina, the harm reduction strategy pioneered in Uruguay, hotline services in Peru or Nigeria, digital health solutions in Brazil or Poland, and accompaniment networks in Argentina, or Mexico. All these stories are lived realities of the creative resilience of those who have been surviving in some of the most restrictive settings in the world.

Throughout these stories from the Global South, there is a recurring theme of creative resilience and models of woman-to-woman care emerging at the community level and then later being embraced by researchers, policymakers, and institutions. It was poor Brazilian women who, in the 1980s, first identified misoprostol as an effective method for self-managed abortion.1 There was no white coat behind the discovery, but the desperate need of a woman seeking a safe means to have an abortion by reading the package leaflets of random medications to find those that showed increased risks of involuntary miscarriage. Forty years later, misoprostol is the main medication used to induce abortion worldwide, according to the World Health Organization. The stories of women who failed or died in this process of self-experimenting using different methods is unknown.

The validation of women's lived knowledge by science takes time and demands the emergence of a new discourse. A good example is what has been called “harm reduction counseling” to reduce the risk of unsafe abortion. In the Global South, the most popular model for providing harm reduction counseling is through hotlines. The person anonymously calls the service and receives evidence-based information about how to safely perform a self-managed abortion. Sharing information is possible even in restrictive settings, where the medicines are not legally available.

Women and other persons share abundant stories of how these hotlines helped them in a solitary selfcare experience surrounded by stigma and criminalization. However, too often, academics and policymakers do not consider these stories of lived experiences to have sufficient value or significance unless these stories have withstood certain methodological criteria. A recent systematic review analyzed the literature on abortion harm reduction interventions without the provision of medications, and, from a group of 118 studies, just four were included in the final analysis.2 The quality of the evidence from the other studies was classified as “poor”, even though “it appears that persons who participate in these interventions have low complication and high satisfaction rates”.

We do not aim to refute the verdict about the quality of the four included studies;3 rather, we want to call attention to the power at play in defining what knowledge counts as valid, where and for whom. We will give an example from the referenced study: the authors “excluded studies describing other approaches aimed to reducing the harms of unsafe abortion if they did not involve direct counselling of pregnant persons within the healthcare system (e.g., the provision of information via hotlines or to pharmacists)”. Moreover, the authors provide no information about the learnings from the excluded studies, which is unfortunate considering that most of the work on harm reduction counselling for self-managed abortion happens at the community level, not in formal health care settings.

Naomi Braine describes the experiences of harm reduction and self-managed abortion as a case of “autonomous health movements”, e.g. where solutions have been developed more by social movements and communities than by evidenced-based public health strategies.4 Why does such a claim of originality matter to a discussion of ethics? Because counseling on harm reduction and self-managed abortion are tactics of demedicalization, i.e., community-led strategies to redistribute power from health professionals to women and other persons. A good example is the “Miso Song”, a song that GIWYN, an organization based in Lagos, Nigeria, created to share knowledge about how and when to use misoprostol for a self-managed abortion, including how a person can identify the side effects, in case they happen: “so just pick 4 miso, in your hands, put 4 miso, in your mouth, place 4 miso, under the tongue, miso is the way”.5 How can we measure the safety, effectiveness, and acceptability of such a unique harm reduction counseling strategy in the format of collective singing? We do not know.

But this is a misplaced question. Just as we need to learn more about how women in the Global South have been confronting unfair barriers to safe abortion and to spaces to share their creative solutions in a transnational community of learning, we also need to develop new methodologies and narratives to measure the impact of those strategies. To truly learn with others about their creative resilience in oppressive settings demands a shift in the ordinary ways we develop scientific understandings. It demands more than speaking about the experience of others, but also learning how to speak with them about their realities. It demands knowing what matters to them. In the case of harm reduction solutions and self-managed abortion, community solutions have proven to be far more sustainable than those initiatives controlled by health care personnel. Bioethics has been even more distant to these realities than other empirical fields. It is time to seriously consider how our academic agenda reproduces power dynamics and how our findings silence alternative solutions that share power with communities.