Health human rights Reproductive Justice SI Podcast

Abortion Pills Go Global

Regardless of the law, women can now access their own safe and effective abortion procedures in the form of these pills.
Sydney Calkin. Photo courtesy of guest

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After Ohio’s recent vote to enshrine the right to have an abortion into the state’s constitution, host Robert Scheer dives deeper into one of the underappreciated and underreported aspects of the fight for abortion rights on this episode of the Scheer Intelligence podcast.

Sydney Calkin, a senior lecturer in the School of Geography at Queen Mary University of London, discusses her newest book, “Abortion Pills Go Global: Reproductive Freedom Across Borders,” and breaks down the myths and misconceptions about one of the biggest tools for bringing women’s reproductive rights to the forefront.

Calkin makes the case that abortion pills provide a safe, often cheap and even potentially undetectable means for women to have an abortion. Using years of research, studying various countries,  including the United States, under varied legal circumstances with regard to reproductive rights, Calkin comes to a powerful revelation: regardless of the law, women can now access their own safe and effective abortion procedures in the form of these pills.

“The debate has really moved beyond whether a government can regulate what an abortion provider does in a clinic and ban abortion by restricting that abortion provider. People are going online and they’re getting their own pills,” Calkin said.

While these pills should not necessarily directly substitute real legislation, Calkin explains that support for this sort of self-care movement believes it will force the hand of government: “They think that creating access on the ground to abortion pills is what will trigger reform in legislatures and in courts. They think that making it so that people can access pills regardless of the laws under which they live will eventually show the public and show lawmakers that abortion bans simply don’t work. They’re inhumane, they’re unenforceable, and that there will then be reform and there will then be decriminalization of abortion.”

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Robert Scheer


Joshua Scheer


Diego Ramos


This transcript was produced by an automated transcription service. Please refer to the audio interview to ensure accuracy. 

Robert Scheer Hi, this is Robert Scheer with another edition of Scheer Intelligence where the intelligence comes from my guest, and in this case it’s Sidney Calkin, who is at—I got this wrong before—Queen Mary University in London. She’s written a book for the University of California Press, which describes the shifting of the plates on the whole question of abortion, choice and so forth. And it comes at a time when people who think there should be a choice and it should be a woman’s choice, we’re feeling great despair and it was reflected in the most recent election and helped the Democrats for being against it. But, you know, the image that comes out in this book and I always promise I’m not going to go on long with these intros. But, you know, having been with your book for a while, everybody has this idea that somehow either this full legalization, which there certainly should be empowering women to make choices about their body, but they always hold up the image of a coat hanger or something very primitive, which would be the illegal choice. And it was obviously very risky, terrible. People died trying to self-abort or they went to other places that might not have been safe and so forth. But actually, the image is different because there actually is a safe, relatively safe, way of having an abortion. And I’m going to leave it up to Sydney Calkin to describe it, but basically it involves either taking one or two pills and one pill would be to prevent the fetus from being nourished or supported and therefore will be rejected by the body. But the one that could be used alone would be one that would get the body to eject and at first, I’ll leave you describe the science, but you make a compelling case in this book. And I think it doesn’t mean it shouldn’t be legal, it doesn’t mean it solves the problems, but it does mean that there were a lot of abortions taking place that are relatively safe. And the people who want to make it illegal are actually encouraging this other practice. And this other practice, fortunately, is a lot safer than that image of the coat hanger. So I’ll just turn it over to you now. 

Sydney Calkin Great. Well, thank you for that introduction. Thank you for inviting me on the show. I totally agree with your characterization of the argument. What I’m trying to show in the book is that medication, abortion or abortion pills have really changed the relationship between what is legal and what is safe. Like you say, I think maybe we’re used to thinking about illegal abortions as necessarily being unsafe abortions. You know, you can see this in the kind of language around the back street abortion. There’s this idea that if something was illegal, it was necessarily done with very unsafe methods or by people who were just sort of like profiteering. This is the image that people always talk about. But in fact, medication abortion has completely revolutionized access to abortion in context, where the laws are very restrictive because it’s made it possible for people to have relatively safe abortions with pills, regardless of the legal context in which they live. And the coat hanger image that you bring up is a really evocative one, and it’s one that I start the book with because I’m trying to make the argument that in the wake of the Dobbs decision, you know, some people talked about, you know, kind of going back to the coat hanger and how that would be the future of illegal abortion in the U.S. But the argument I’m trying to make is that, you know, abortion now it looks radically different than it did in the 1970s. And the future of even illegal abortion will look different because of medication, abortion pills that allow for safe, self-managed abortion. 

Scheer So where are these pills produced? India comes up in in your book. I mean, they’re made under safe sanitary procedures, right? Generally. 

Calkin Yeah. 

Scheer Well, it’s not like buying a back alley drug and you don’t know what’s in it or something. 

Calkin Yeah, this is a really important point. I mean, medication abortion pills are manufactured all over the world because they are a primary abortion method all over the world. It’s important to say medication abortion pills are also the method used in the majority of abortions in the U.S. But medication abortion is widespread all over the world. And so these pills are produced by pharmaceutical manufacturers across the world. In my book, I look into medication abortion pills made in India, because I look a lot at the kind of online marketplace in abortion pills, on pharmacy websites. And I look at a few feminist activist networks that ship medication abortion pills around the world, the online pharmacy sites that I study in the book, and the feminist networks that I trace in the book, they mainly source their pills from Indian manufacturers. The pills are made in India, primarily because India is a manufacturer of a huge number of generic pharmaceutical products. By no means do they specialize in abortion pills. I mean, many, many medications that people in the U.S. use are manufactured in India, which has kind of built itself up as a specialist in producing generic pharmaceuticals. And the fact that the pills are often bought online, I agree, it might call to mind the idea of maybe dangerous products, maybe adulterated products. But actually, the best evidence we have, it shows that the kind of pills that are sold by online pharmacies and shipped from India, they’re good quality generic medications. They’re just not the brand approved by the FDA. 

Scheer Okay, let’s first of all, to be clear, we’re talking about the first trimester, right? 

Calkin Yes. Medication abortion pills are used in clinical settings at various, different points in pregnancy. But for self-managed abortion, they’re mainly used in the first trimester. That’s when it’s safest to use them. And my book mostly deals with people that use them in the first trimester. Yes. Yeah. 

Scheer And there’s two pills. The names are… Why don’t you give them to us. 

Calkin So as you said, a bit in the introduction, we’re mainly talking about two pills, but it’s worth explaining because they can be used in combination and one of them can be used on its own. So if we’re talking about the sort of combination of the two pills, which would be the standard way that people would use abortion pills in a abortion clinic in the US, for instance, the first is called mifepristone and mifepristone Yeah, it blocks the hormone that sustains a pregnancy. The second pill, well, it’s actually a few pills, that would be taken a few separate tablets, but the second pill is called misoprostol. So someone would take mifepristone, and then 48 hours later, they would take a few different doses of misoprostol, and misoprostol would make the uterus expel the pregnancy. So those if you were to go into a clinic in the U.S., you would get mifepristone which is sold under the brand name Mifeprex, in the U.S., it’s also known as RU486, sometimes in the US, followed by misoprostol. But misoprostol can also be used on its own. It’s a little bit less effective, but it’s still mostly very, very effective to end a pregnancy by itself. And it’s important to bring this up because in a lot of places where mifepristone is very hard to access, misoprostol is easier to buy sort of over the counter, on the black market or, you know. And so in a lot of places, especially across Latin America, where people can get misoprostol but they can’t get mifepristone, the use misoprostol all by itself. 

Scheer Yeah. And I think the significance of the the first trimester is the ejection process. There’s no need for vacuuming or surgical procedure or what have you. And actually you point out in your book it’s never really a surgical procedure and that there are sutures and and so forth. But yeah, a professional would be safer and better, professional medical care for after the first three months. I guess. that’s what I got out of your book. I just want to capture the spirit of your book. You’re not advocating for this as an alternative to a safe, legal, medically sponsored or supervised abortions. You are saying this is going to happen anyway and it’s much, much safer than what people imagine if it’s done in the first three months. Is that a good summary of that? In other words, for the people in what’s called a, you know, pro-life movement or so forth, who are just objecting to the whole process of planning really, and being able to control what happens to your body, the argument or your book is that train has left the station, that throughout the world people are already turning in large numbers to medical abortion and that it is successful. I guess you use the figure 95% or something. And even when it’s not, I don’t know, what does it mean not to be successful? Is the woman’s life at risk or…? 

Calkin No, it’s a very, very safe medication. I mean, it’s important to tell your listeners. I mean, these medications are on the WHO’s essential medicines list. And the WHO has even released new guidelines to change the way that abortions are classified. To explain that self-managed abortion with pills helped by a trained support person is not classified as an unsafe abortion. So they’re very, very safe and they’re used around the world. I think you’re capturing something really important about the book. You know, the book isn’t a kind of polemic. It’s not a kind of like activist work. It’s a work of research because I’ve been interested in the question of how have medication, abortion pills been changing access to abortion in places where the laws are restrictive? And you’re absolutely right. What I found through the research and I’ve been conducting this research since 2016. What I found with the research is that medication abortion it’s cheap, it’s safe, it’s easy to obtain, it’s safe to use. And what that means in summary is that, you know, legislatures that try to restrict abortion, courts that try to restrict abortion, you know other government agencies that try to restrict it, they’re just less effective than they used to be because they simply can’t stop people who are self-managing abortions. 

Scheer Yeah, that’s an important point, because even in the, you know, the worst, most repressive of times, people who had money could get on an airplane and go somewhere else to get a perfectly legal, safe abortion. And, you know, but it really punished people without those resources. My mother happened to have, she discussed this very late in life, she was an unwed mother, even in my case. But she was a garment worker, didn’t have much resources and had had abortions before. And they were risky and they were done not back alley, but they were done by someone who claimed they knew what they were doing in Manhattan or the Bronx. And other people could go, I forget where they went was it Sweden or someplace and had very good doctors or I think Mexico was kind of a gray area, that there were people who performed them. And, you know, sometimes it was safe and not others. But the power of your book, as a matter of fact, and I do agree you’re doing serious journalism and research here, it’s not an advocacy book, but it makes a powerful point that in a way, this debate is besides the point, not that it shouldn’t be settled, that women should control their bodies and so forth. But you’re saying it’s really becoming prevalent. And why don’t you talk about the four countries that you do… Basically, the book is a study of four countries, Poland, the United States, which are being regressive on this issue. And then you have Ireland and Northern Ireland, I think. So why don’t you discuss your basically the structure of the book? Because this is a serious work. This is not anecdotal and it’s you know, and it’s not advocacy, not that there’s anything wrong with advocacy. But then people start to think you’re stacking the deck. This is a serious work of journalism. So tell us what you set out to do and how you did it. 

Calkin Yeah, I’m absolutely an advocate of free, safe, legal, local abortion. I don’t mean to hide that. I just want to make the point that the the book is based on years of research that I’ve been carrying out. And so, as you say, it looks at the impact that abortion pills have had in four countries. So the U.S., as I’m sure your listeners all know, has gone from having your constitutional right to abortion to all of a sudden no constitutional right to abortion. And now it’s a real patchwork of different laws across different states. The point you made about people having to travel for abortion and, you know, rich people being able to go to a state where it’s legal, we see that in the U.S., you know, every day today. So the U.S. has gone from this constitutional right to no constitutional right on abortion over the course of the study. Poland already had quite a restrictive law and has since made that law even more restrictive. By comparison, the two other countries that I look at in the book have gone from very restrictive laws to more liberal laws. So the book also looks at the Republic of Ireland and Northern Ireland. Northern Ireland is just a region of the United Kingdom, but it’s self-governing to some extent. So I look at it separately to the rest of the UK. So in the Republic of Ireland they had a constitutional abortion ban until 2018, but in 2018 they had a referendum on removing that constitutional amendment and they did vote to remove that constitutional abortion ban. And they brought in legal abortion and an abortion care service in the health system. In Northern Ireland, there was effectively an abortion ban there. And in 2019, they decriminalized abortion there through a series of quite complicated legislative maneuvers that I won’t get into here. But what my book tries to understand is what impact did abortion pills have in those countries before and after the changes that they made? So some of the countries that I studied went from more restrictive to more permissive, and then some went from more permissive to more restrictive. And I try to understand how did abortion pills shape any kind of political reform that they went through, if it was to liberalize? And how was abortion pills shaped, clandestine, illicit access to abortion? If it’s in a country that maintains restrictive abortion laws or has made its laws more restrictive. 

Scheer And so, I think people might be getting confused here. The two pills that we’re talking about are accepted regular medical practice in countries where abortions are legal. 

Calkin Yes. 

Scheer It’s part of safe, legal, so forth, right? And so however it’s done in a hospital setting or you don’t actually do it at home, do you? Or you can? 

Calkin Well, that depends. I mean, you’re absolutely right to say that the medication abortion pills are standard practice across the world. I mean, in many European countries there, the majority of abortions are carried out with medication abortion. Medication abortion has been widespread in use across the world since the 1980s. 

Scheer But used in their home or used in a medical setting? 

Calkin Well, that depends. So over time, the procedures have changed. I mean, initially in the U.S., for instance, both pills would have been taken in a clinic. Increasingly, well, let’s see, this is all kind of up in the air with this current lawsuit that might go before the Supreme Court. But in 2016, the FDA did say that the pills could be taken at home in the U.S., in countries across Europe, the pills can be taken in a medical setting or at home, depending on what people prefer. So the place that they’re taken kind of differs depending on the country that we’re talking about. But you’re right to say that it could be one person in one country where the laws are liberal. They could be using the exact same medication that someone across the border is using, but that person across the border might be committing a crime by taking those exact same pills, if abortion is banned in their country, but it’s the same medication that we’re talking about. 

Scheer But aside from the risk, the very real risk that they might be arrested for exercising their choice over their own body, is there any evidence that you can refer to about whether doing it at home has increased the health risks? Or is just so obvious and simple that it doesn’t have to be done in a medical setting? 

Calkin It’s a good question, and there is not evidence that allowing people to take the pills in the place of their choosing makes it any more dangerous. I mean, this was the basis for this decision that the FDA made in 2016, to basically say you no longer have to take all the pills in a clinical setting. And, you know, across the U.S., for instance, in states where abortion is still legal. There are telemedical abortion services that shipped pills to people through the mail, and they can take them without ever having to set foot in a clinic. And there’s years and years of good evidence that it’s no less safe to do this. In fact, there’s evidence that allowing people to obtain pills through the mail makes it easier and faster for them to obtain an abortion. And so it lowers the gestational age at which they obtain that wanted abortion because it lets them get over or it lets them kind of bypass some of those barriers that they might have faced. Like, for instance, you know, driving to the clinic if it’s far away and other kinds of barriers. 

Scheer So that is really the power of your book and your analysis. And that’s why it really distorts the whole debate to bring up the coat hanger as a symbol or any other high risk alternative. The fact of the matter is, and again, I stipulate there should be free legal choice, we’re not debating that. We’re not saying that this pill takes away the need to make it legal. That should be a human right that women have. And so we don’t want to cloud that. However, to pitch it as say, let’s say you are a person who wants to discourage abortion or even prevent it, you’re not going to win this argument by making it illegal. The fact is, science has trumped that, medical science, and it isn’t a coat hanger. It’s actually a very safe procedure that can be sent to you in the mail. That is the pills that are made by regulated institutions that make other pills that you can get in the mail and that there is no evidence that doing that is dangerous. And, you know, so the fact of the matter is the people who think they’ve won a great victory with this court decision, as a matter of fact, they probably will, as it works out well, then people will maybe make the decision earlier or use these pills to accomplish what they want to do. And maybe the debate is kind of odd right now for both sides. It won’t be as terrible as the pro-choice people feel because people all over the world have now a way of managing, planning their lives and making their decisions. Yes, it should be legal, should not have to be done this way. But on the other hand, the people on the what they call the pro-life side or the anti-choice side are going to lose anyway, right? Is that not a fair summary of what your book says? 

Calkin Yes. And I’m glad that you’ve made this point kind of emphasizing that the book isn’t arguing that self-managed abortion with pills obtained online is a replacement for legal reform. That’s certainly not what I’m arguing. What I show in the book is that the movement for self-managed abortion across the world is operating with a different kind of political strategy almost. This kind of movement for self-managed abortion is not seeing the court system as the starting point for their activism. They think that creating access on the ground to abortion pills is what will trigger reform in legislatures and in courts. They think that making it so that people can access pills regardless of the laws under which they live will eventually show the public and show lawmakers that abortion bans simply don’t work. They’re inhumane, they’re unenforceable, and that there will then be reform and there will then be decriminalization of abortion, or they aim for decriminalization of abortion. So it’s absolutely not to say that the ability to buy abortion pills in the mail means we don’t need to decriminalize and reform abortion laws. We absolutely do. It’s just to say that, I mean, as you put it, kind of the horse has bolted on this one. A lot of the Irish politicians who I talk about in the book, they used to use this phrase and say the genie is out of the bottle. I think that captures it quite nicely. Like you said, the debate has really moved beyond whether a government can regulate what an abortion provider does in a clinic and ban abortion by restricting that abortion provider. People are going online and they’re getting their own pills. One thing I do want to say, though, is that the kind of barriers to abortion access that you mentioned previously, you know, you talked about how people who had wealth could travel to other places and obtain an abortion there. I mean, those kind of barriers around class, around race, around immigration status, geography, those kind of barriers still do impact people in their ability to get abortion pills. So you can go online and buy abortion pills, but they still might cost much, much more than someone can afford to spend on them. A lot of people don’t know about abortion pills. A lot of people don’t have, you know, digital literacy and access to these kind of online networks. So there are still a lot of barriers that mean it’s difficult for some people to get abortion pills and use them. And there’s still people who would prefer not to have to self-managed abortion. There’s people that would prefer to go into a clinic and have that contact with a physician. So I’m not arguing this is a replacement for good, you know, abortion laws and regulations that provide free, safe, legal and local access. I’m just trying to make the point that they have really transformed what happens on the ground right now. And the political debate is quite out of step with that. 

Scheer So how much has it transformed? I mean, you have numbers. How many people how many women in the world are turning to this, whether it’s legal or or not, because it’s convenient? It does, you know, involve… I mean, the cost was for many people in the world, cost is real. You know, a visit to the doctor, unless it’s somehow sponsored by some organization or the government or something, could break their budget. And reading your book, I have the sense that if it were made legal or where it is legal, it could be a quite, you know, be good. First of all, there are people who have to confront their family or other social pressure or what have you. It is liberating and that you can really make this decision without, you know, destroying your privacy or what have you. And it is, you know, legally it was should be cheaper. Right? You don’t have to book operating rooms or whatever. You know, even though you point out it’s not actually in operation but still you’re paying for all of this. So in a sense, the science has done something very liberating, right? It took the mystery out of the whole thing and the heightened danger. And, you know, it’s it’s sort of like the development on the other end of birth control mechanisms that weren’t so intrusive and so, you know, are easier to use. So it sort of becomes, I guess from my original point, it helps it become a more normal thing for women to exercise choice about their body. Right. I mean, that’s really what the argument is, is there’s some scripture or some male figure or is is some law or some cop that makes the decision, or do people get to be open to information and do it in a safe way and also keep the costs down and make it just part of a normal family planning, personal planning, life. And your book has that attitude. It’s not advocacy. You’re really arguing basically for the liberating effect of good science. 

Calkin Mm hmm. It’s a really important point. I mean, part of the reason that people see medication abortion pills as transformative. One of those reasons is because it changes the relationship between what’s safe and what’s legal. And it does allow this access in countries with restrictive laws. But another reason that people see it as transformative is because it really challenges our assumptions about what abortion is and where it takes place and kind of how people experience it. As you say, it doesn’t need to take place in a clinical setting. It doesn’t need to take place with a physician. People can take the pills at the time and the place of their choosing, in the privacy of their own home if they want to. It’s been studied as something that can kind of blur the lines between a menstrual period, a miscarriage and abortion. Those are kind of categories we tend to think of as quite separate. But there’s been a lot of studies showing that people that use medication, abortion pills, experience this as a kind of something entirely different. That’s part of the political power of medication, abortion, and also a bit of a part of its risk medically taking abortion pills produces a miscarriage that’s indistinguishable from a spontaneous miscarriage. So in places where the law is very restrictive and someone uses abortion pills, if they go in to see a doctor, the doctor isn’t able to perform some tests to tell whether they had an abortion or whether they had a miscarriage. And you can imagine in places where it’s a crime to have an abortion, this kind of ambiguity can be quite useful because it can allow people to seek out medical care without fear of being criminalized by doctors, which is something that regularly happens. 

Scheer Yeah, And that’s I would like to conclude that on that note, because again, this is not a question of scaring people of, you know, you’re going to put your life on the line in some unhealthy clinic or by some person who doesn’t know what they’re doing. So that’s the good news. And I think anybody who cares about human beings and their freedom and their choice and so forth, which presumably should be everybody, because you know what, whether you’re a woman or not or you’re related to a woman or you care about a woman. And, you know, you should want, what you said before, any control over their body to be exercised in a safe, reasonable, not very costly [way]. What you’re really talking about is trying to make it more part of the normal rhythm, I don’t want to invoke the rhythm method here, but the normal rhythm of life that people do not want that outcome and instead of a dangerous procedure, science is actually given us a safe way of doing it. And I think everyone should read this book, even if they, when they pick up the book, have a harsh, you know, so called “pro-life” position because presumably they care about life. That’s the advertisement. And the book is called “Abortion Pills Go Global: Reproductive Freedom Across Borders” and the University of California Press, which somehow or other comes out with one terrific book after another. I only know this because every week I review books and quite often I get it from them. And somehow or other they’re really one of the best university presses and they pick up, you know, controversial subjects, but they do them in rigorous ways. And I agree with you, having read your book this, you know, I am not against advocacy. I’ve advocated much of my life for different things. But the strength of this book is it’s really good journalism. It’s good science reporting, and it’s something people have to deal with. Whatever they understand at the moment is on this issue. Abortion pills, they are going global and they’re going global because they’re not high risk and they’re not super expensive. And actually they are legal and they are used even here now in our country and have been used. So I think the title kind of says it all and people should get it, read it. Abortion Pills Go Global: Reproductive Freedom Across Borders. University of California Press. Sidney Calkin. And let me also thank you for doing this. Let me also thank Laura Kondourajian and Christopher Ho, KCRW, the terrific NPR station here in Santa Monica for posting these shows. I want to thank our executive producer, Joshua Scheer, who drove me crazy to do this book. He said, you have to read it. You have to get this woman and so forth. And even though there’s a lot going on in the world, you know, the fact is this is a huge issue and your book really makes an important contribution. I want to thank Diego Ramos and Max Jones, who do the video, and Diego writes the introduction. And I want to say particularly thank the J.K.W foundation in memory of a very strong independent reporter, Jean Stein, who wrote very important books about the complexity of being a woman like the book, Edie, and so forth, for providing some resources to be able to do this show. See you next week with another edition of Scheer Intelligence.

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