Overcoming challenges in research on self-managed medical abortion: lessons from a collaborative activist–researcher partnership

Throughout history, across cultures, and continents, people have had abortions. Historically, people relied on a range of methods to terminate unwanted pregnancies, from herbs and massage, to physical trauma and ingestion of toxic substances – sometimes on their own, sometimes with support from a healer or trusted person. Surgical abortion entered the realm of options during the 1700–1800s and helped to make abortion safer than many alternatives, but also prompted a major shift of abortion care from something that was self-managed, to something that was medicalised. The advent of safe and highly effective medical abortion in the late twentieth century, however, marked a turning point yet again. Medical abortion (misoprostol alone, or in combination with mifepristone) offered a glimpse of a new future, one in which safe, effective abortion practices could be self-managed, rather than needing to rely on clinical intervention or supervision. Since the discovery of the abortifacient properties of misoprostol by women in Brazil, and the advent of mifepristone, decades of rigorous research have established the safety and effectiveness of medical abortion in clinical settings. When these medications are accessible, a safe abortion can be as easy as taking a few pills. Yet, legal restrictions, logistical factors, and stigma impede or prevent access to these medications throughout much of the world. Where legal restrictions create barriers to abortion access, people must find their own ways of ending a pregnancy outside of health facility settings. Even in countries where abortion is legal, people selfmanage abortions because they cannot afford or otherwise access clinical care, or because they prefer the experience of a self-managed abortion for reasons of privacy, security, and/or experienced stigma. Initially frustrated by the persistent harms experienced by women and pregnant people as a result of unsafe abortion methods, activists around the globe, in a variety of legal contexts, decided to do something. In Argentina, Nigeria, and more than fifty other countries, activists – known often as “accompaniers” – provide information and support to people seeking to end a pregnancy. Known as safe abortion hotlines or feminist abortion accompaniment networks, these groups provide evidence-based information to pregnant people on how to safely use medications to end a pregnancy. These groups aim to provide information and support in a way that empowers, validates, and affirms COMMENTARY