Abstract

While the US Supreme Court's 1973 ruling in Roe v. Wade guaranteed a legal right to abortion, universal access to legal abortion has never been achieved in the United States. At the same time, the Helms Amendment, a US foreign-assistance policy, is keeping millions of people around the world, particularly Black and Brown people, from receiving abortion-related information and services. As abortion-rights advocates in the United States look for ways to move forward in the post-Roe era, two sources can offer insights and inspiration: the inclusive, human rights–based reproductive justice framework, and some of the strategies and approaches being used to expand access in countries around the world with restrictive abortion laws.

Around the time Roe v. Wade was decided in the United States, countries such as India, Zambia, and Tunisia also liberalized their abortion laws. Each had its own motivations for doing so, but few countries liberalized abortion to uphold human rights. The prevailing rationale was centered around the idea that nations must limit fertility and reduce or contain their populations to thrive economically; that is, nations must accelerate a demographic transition by increasing access to methods of fertility control such as contraception and abortion. The argument for abortion as an essential aspect of human rights began to gain ground in the early 1990s, particularly through three international conferences: the 1992 UN Conference on Environment and Development held in Rio de Janeiro; the 1993 UN World Conference on Human Rights held in Vienna; and the 1994 International Conference on Population and Development held in Cairo. Declarations from these conferences helped to cement the idea that reproductive rights and women's rights are human rights, animating activism leading to the liberalization of abortion laws in nearly 50 countries over the past several decades (CRR 2022). In the United States, abortion was not always the extremely polarizing political issue that it is today (Williams 2011). In the era just before and after Roe, there was nearly equal support for abortion among Democrats and Republicans. Republican First Lady Betty Ford famously said in 1976 that Roe was “a great, great decision.” But Republicans, looking for ways to expand their base of support, began courting the religious right and social conservatives, particularly in the South. They latched onto abortion as a wedge issue, with great and continuing success (Adams 1997).

Only months after the ruling in Roe, the US Congress approved the Helms Amendment, which has been applied as a complete ban on the use of federal foreign-assistance funds for abortion-related services and information (Moss and Kates 2022). In the Helms Amendment, abortion exceptionalism and American exceptionalism meet. The United States is the only nation that singles out an essential medical procedure—abortion—in its foreign aid, stigmatizes that procedure, and imposes the ideological viewpoint of certain politicians on programs that are meant to help millions of people, particularly Black and Brown people who live thousands of miles away. Even President Richard Nixon's USAID opposed the Helms Amendment for being contrary to US interests, potentially coercive, and antithetical to the prevailing US philosophy of decolonizing aid (Barot 2013).

A series of antiabortion US policies followed in the wake of Helms. In 1984, the Reagan administration enacted the “Mexico City policy” (KFF 2021), also known as the global gag rule. This policy restricts foreign nongovernmental organizations that receive US family planning funds from using their own resources to engage in abortion-related work. It has been used as a political football since 1984—rescinded by Democratic presidents, including Biden, and reinstated by Republican ones. Repealing the Helms Amendment alone could prevent an estimated 17,000 maternal deaths each year, in addition to preventing 19 million unsafe abortions and 12 million cases of abortion complications requiring medical treatment (Guttmacher 2021).

Congress approved a domestic counterpart of Helms, the Hyde Amendment, in 1977. It blocks federal funds from being used for abortion except in cases of rape, incest, and endangerment of the life of the pregnant person. This has dramatically limited coverage of abortion under Medicaid and many other federal programs and has particularly affected access to abortion for women of color, who are more likely than white women to be insured by Medicaid and have higher rates of unintended pregnancy and abortion (Salganicoff, Sobel, and Ramaswamy 2021).

The Reproductive Justice Framework

As these harmful US antiabortion policies show, racial justice and reproductive justice are intertwined. The reproductive justice framework was created in 1994 by 12 Black women: Toni M. Bond Leonard, Reverend Alma Crawford, Evelyn S. Field, Terri James, Bisola Marignay, Cassandra McConnell, Cynthia Newbille, Lorretta Ross, Elizabeth Terry, “Able” Mable Thomas, Winnette P. Willis, and Kim Youngblood (Guerrero 2021). This overarching framework, which combines reproductive health, human rights, and social justice, is of tremendous value in the United States and globally and will help to strengthen abortion rights.

It recognizes intersecting experiences and oppressions and that rights alone do not guarantee access. The inspiration for the reproductive justice framework is the Universal Declaration of Human Rights and the human rights advocacy that its creators saw in countries such as South Africa. The idea was to apply the universal declaration of human rights to the US context to bring human rights home to the United States. In its simplest form, reproductive justice is the right of a person to have basic autonomy over their own body and sexuality. The right to abortion is but one part of this framework. As Loretta Ross, one of the framework's founders, has written: “Reproductive justice centers on three interconnected values based on human rights: the right not to have children by using safe birth control, abortion, or abstinence; the right to have children under the conditions we choose; and the right to parent the children we have in safe and healthy environments.” (Ross 2017). She further notes that addressing white supremacy is a cornerstone of reproductive justice and that the incorporation of human rights is key, as the global human rights framework is “far more expansive and inclusive than the limited US Constitution.”

This inclusive, human-rights based approach is the direction in which the global movement for reproductive freedom is moving (CAP 2014). Feminist movements such as the “green wave” in Latin America, discussed below, are demanding gender equality and using human rights–based framing in their advocacy on abortion rights.

The limitation of relying on the US Constitution for abortion rights cited in the reproductive justice framework has indeed been laid bare by the US Supreme Court's decision in Dobbs v. Jackson Women's Health, which overturned Roe. And Roe itself was limited; even during the Roe era, access to abortion was never guaranteed for many groups of pregnant people, including those who are people of color, who are poor, who live in rural areas, or who are part of the LGBTQ community. As Monica Simpson, executive director of SisterSong Women of Color Reproductive Justice Collective, has written, “Roe ensured the right to abortion without ensuring that people could actually get an abortion. People seeking abortions in America must consider: Do I have the money? How far is the nearest clinic, and can I get there? Can I take off work? Will I be safe walking into the clinic? For more privileged people, these questions are rarely a deterrent. But for many women of color and poor people, they are major obstacles” (Simpson 2022). As of June 2022, nearly 1,400 abortion restrictions had been enacted at the state level since Roe was decided in 1973, leaving entire clusters of states with thoroughly limited access (Nash and Ephross 2022). Abortion in the United States has also been under attack by violent means for decades, with at least 11 attacks resulting in the murder of abortion providers (Stack 2015).

The Post-Roe United States

With the fall of Roe, the United States is now aligned with countries such as Brazil, Nicaragua, and Poland. In Brazil, where abortion is highly restricted, police raided a private family planning clinic in 2007, confiscating the medical records of more than 9,600 female patients. Four staff members at the clinic eventually were prosecuted for participating in abortions and received prison sentences ranging in length from four to seven years (Ipas 2013). In Nicaragua, abortion has been totally banned since 2006, resulting in an epidemic of “child mothers,” among other harms. Hundreds of girls in Nicaragua who become pregnant each year as the result of rape are forced by law to carry their pregnancies to term (Ipas 2016). Poland is one of only two European Union countries where abortion on request is not legal, and a 2021 court ruling has resulted in a near-total ban on abortion there. Even though abortion is legal in cases of rape, for instance, a certified letter from a public prosecutor is needed to prove that the rape occurred.

US abortion rights advocates warned that these types of cases would start occurring in the United States once Roe fell, and indeed, troubling news reports began appearing soon afterward, such as the case of a 10-year-old girl who had become pregnant from rape and was forced to travel out of state to get an abortion (Helmore 2022). The girl's home state of Ohio had a law already in place that took effect once Roe was overturned (known as a “trigger law”) that made abortion after six weeks illegal. She had to travel to Indiana to get an abortion, which turned a spotlight on the harsh new barriers presented by the confusing patchwork of state laws now governing abortion in the United States.

Observations from around the World

As daunting as the US abortion landscape currently is, US activists can draw strength and inspiration from knowing they are part of a transnational movement for reproductive freedom. Here are some ways that global activists have advanced abortion rights and access, even in the face of heavy legal restrictions:

Expand and Protect Access to Abortion Pills

Abortion with pills—also known as medication abortion—puts abortion care literally in the hands of pregnant people. In the United States, medication abortion now accounts for more than half of all abortions and is increasingly the target of antiabortion groups (Jones et al. 2022). Globally, what is known as “self-management” of abortion is on the rise because of the increasing availability of abortion pills. Self-management allows people to manage as much of the abortion process as they want, without the involvement of a clinician. The latest guidance on safe abortion care from the World Health Organization (WHO 2022) says that self-management of abortion in the first 12 weeks of pregnancy is safe, effective, and a “potentially empowering” extension of health systems. A growing body of evidence shows that self-managed abortion is no less effective than medication abortion in clinic settings. For instance, a recent study (Moseson et al. 2022) focused on callers to abortion accompaniment groups in Argentina and Nigeria who were seeking information on how to induce and manage their own abortion. The study found that self-managed abortion with accompaniment group support is highly effective and supports the use of self-managed models during early abortion care. Accompaniment groups such as these have been working for years in Latin America, Africa, and Asia to help people get reliable, evidence-based information on how to safely self-manage an abortion with pills. They generally are anchored within feminist movements, use the language of human rights, work in contexts that are highly stigmatized with respect to abortion, and are using an evolving set of shared practices to assist people with self-managed abortion (Braine 2020).

Build Diverse, Intersectional Coalitions for Change

In Latin America, which has some of the strictest antiabortion laws in the world, a “green wave” of abortion rights activism has led to new, proabortion laws and court rulings in Argentina, Mexico, and Colombia and is even creating change in El Salvador, which totally bans abortion. The green wave movement is a prime example of an intersectional, feminist, and human rights–based movement working to liberalize abortion laws. Known as the green wave because of the green bandanas, scarves, and other symbols its proponents use during street protests, it began in Argentina in 2015 in response to high rates of femicide and other forms of gender-based violence. The movement then began challenging restrictive abortion laws, first in Argentina and then throughout the region (Carpenter 2019).

Another example comes from Benin, where the country's Ministry of Health estimates that unsafe abortions are the cause of up to 20% of maternal deaths (Sasse 2021). During the past several years, organizations from across the country—including feminist and youth-led groups such as the Coalition of Youth Organizations for Safe Abortion, Medical Students for Choice, and the Association of Women Lawyers of Benin—began working together to raise public awareness about the need to expand access to safe abortion in Benin. In 2021, Benin lawmakers approved a progressive new abortion law. Abortion is now legal up to 12 weeks of gestation for a wide range of reasons, such as continuing education, reducing economic stress, and protecting mental health.

Work to Change the Social Norms around Abortion

To make abortion access a reality, deeper social change is necessary. It is recognized that engaging men and boys, in addition to engaging women and girls, is fundamental to addressing sexual and reproductive health and rights for all (Ruane-McAteer et al. 2019). This means educating men on the importance of gender equity and the crucial role they can play as partners, family members, community leaders, and professionals.

At Ipas, these kinds of efforts are part of our work in places such as Ghana, Bolivia, India, and other countries. In Bolivia, for instance, we have worked with men in the military to confront stereotypes around masculinity—such as that “real men” do not use contraception or help a partner deal with an unwanted pregnancy—and to help them learn how and why to be supportive partners for women seeking abortion care. Messages about sexual and reproductive health and rights are now embedded into existing military trainings. In India, we have trained young men to teach others about reproductive health and rights. Their one-on-one conversations about sexual and reproductive health cover topics like contraception and preventing unwanted pregnancy, which is part of a strategy to spread important health information throughout the community and to show men how they can be supportive partners to women.

Put Evidence-Based Information to Use in Advocacy Campaigns

A new guide for activists, Advocacy Lens: 2022 WHO Abortion Care Guideline (Ipas 2022), offers an array of advocacy strategies based on global standards for public health and human rights that advocates can use in the United States and elsewhere. It discusses practical strategies for decriminalization of abortion, elimination of policy and health system barriers, reduction of abortion stigma, and expansion of abortion access for any person who needs it—all of which are desperately needed in the United States right now. An example of using a human rights–based legal argument to decriminalize abortion, for example, comes from El Salvador, which has a total ban on abortion. When Manuela, a woman who had been convicted in 2008 of an abortion-related crime, died while serving her 30-year prison sentence, the Center for Reproductive Rights and its partners in El Salvador—the Colectiva Feminista para el Desarrollo Local and the Agrupación Ciudadana por la Despenalización del Aborto—brought a legal case before the Inter-American Court of Human Rights on behalf of her family. Manuela had suffered an obstetric emergency that resulted in the loss of her pregnancy and had been falsely accused of having an abortion. In a landmark ruling in 2021, the court held El Salvador responsible for Manuela's death and said the government must take action to reform its punitive reproductive health and rights policies (CRR 2021).

A Positive Vision for the Future

Drawing from decades of experience in other parts of the world, I urge US activists to think about how to create a sense of abortion abundance where all people can get the care they need, how they want it and when they want it, without fear, shame, or stigma. We do not have to look far for inspiration: Mexico City liberalized abortion 15 years ago, and it has been available for free in the public health system there ever since. The outcome is more than 250,000 services provided (Government of Mexico City 2022) and zero abortion deaths during 2007–2021 (MVS Noticias2021). By looking around the world, we can see that this is not a pipe dream, but a reality in many places.

Acknowledgements

I would like to thank Margie Snider for invaluable editing assistance.

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