Abortion

When I was pregnant with my first child, I worked for a reproductive health organization that promoted safe abortion.

Interestingly, the more my belly rounded, jutting into table edges or obscuring a lap full of paperwork, the more people around me began to see my job as a contradiction and yet, in my mind, it made perfect sense. In fact, the longer my pregnancy went on, the more I believed in the right to safe abortion that I was fighting for.

Around the world, almost half of all pregnancies are unintended—meaning they’re either mistimed or unwanted altogether.

That means a lot of women, at any given time, are grappling with a life-changing situation with no advanced planning and often without the benefit of thorough discussion or sound advice on options.

In a perfect world, the root of unplanned pregnancy—sex—would always be consensual. It would take place between two partners of equal power and economic status and it would be accompanied by contraception every time a pregnancy was unwanted, using a method that matched the needs of both partners.

In reality, sex happens all the time in scenarios where power, economics or needs are not equal; where sex is transactional—a commodity stolen, traded or given in exchange for something else. Sex is used for companionship, control, currency, and survival. And even where sex between two partners is consensual, it still happens without planning (or contraception) and can result in an unintended pregnancy.

My own first pregnancy was unintended in that it was mistimed.

Following a miscarriage and a difficult time getting pregnant afterwards, I was told by my OB that a viable pregnancy would probably take a greater investment of time, resources and doctors than my partner and I had at that moment. We were in transition after several years of marriage, with a relocation on the horizon, so plans for a child were temporarily put on hold. I had just started my job with Ipas (a great reproductive health organization based in North Carolina promoting safe abortion) while my partner finished his post-doc in Brazil, an agreement that meant a year of long-distance living to eventually get us where we wanted to be—together—the year after.

Imagine my surprise, just weeks after my move, to discover that I was pregnant.

After years of working with community health workers and traditional birth attendants on pregnancy, I had somehow missed all signs of it myself. The nausea, exhaustion and delayed period I attributed to a stressful continental move, constant international travel (between several time zones) and a lingering tropical illness. I remember reassuring my doctor, when she asked if I could be pregnant, that it was highly unlikely. But before taking the pregnancy test she insisted on, I humored her by answering her questions:

“What would a negative test mean for you?” Relief. Some disappointment.

“What about a positive test?”

That was more complicated—and seemed, until that very moment, impossible.

“It would be highly inconvenient, but…welcome.”

Later that morning, with nothing more than good advice on how to ease my queasy stomach, I listed all the resources that would allow me to carry that pregnancy to term on my own: a good job, a good income, health insurance to cover my well visits and hospitalization, a supportive (though long-distance) partner, and an extended family that I could call on for help. I knew myself capable of surviving war, drought, malaria and long separations from family and friends. How much harder could a solitary pregnancy be?

How ignorant I was.

The next few months were hell.

With most of my work in East Africa and Europe, I continued my travels as if nothing had changed. But in addition to my growing nausea and general malaise, my body soon added the need to wretch and puke violently to my growing list of symptoms, tossing me into any number of humiliating situations: running out mid-speech at a UN conference; reaching for a paper bag from the seat back in front of me, mid-landing; searching for privacy on a ceremonial opening of a new clinic in Uganda with an entire village looking on.

In between travels, back in the U.S., I coped with no family nearby, a husband working between two continents that were neither of the ones I was working on, a new job and a reputation at stake, fighting my body the whole time.

Many a day I felt totally oppressed, having no control over how my body was reacting or with how my life had taken such an unexpected turn. And yet—I wanted that pregnancy. I was willing to put up with maximum discomfort, embarrassment, and difficulty because I wanted to carry that pregnancy to term. But the experience allowed me, in a new and personal way, to imagine what it might be like to continue a pregnancy that was not only mistimed, but truly unwanted. As my hormones raged, my body morphed and my expectations of what I could do and how, diminished, I could only imagine how a forced pregnancy might feel something like a form of torture.

Because we live in a culture where children are part of the fairy tale we’re all taught to want, we don’t talk enough about unwanted pregnancies. Yet most women spend the majority of their reproductive lives avoiding pregnancy.

In the U.S., on average, women report wanting 1-2 pregnancies over a lifetime. That means they will spend 2-3 years of their lives pregnant, pre- or post- partum but more than 3 decades avoiding pregnancy.

Why don’t we talk about this?

We also know that unplanned pregnancies increase the risk of partner violence—and in the U.S., increase a woman’s risk of homicide.

Unintended pregnancy, especially among younger women, lowers educational and employment potential, increases the chance of poverty, and leads to poorer outcomes for the children of those pregnancies.

Again—half of all pregnancies are unintended—and yet we rarely talk about the reality of unplanned pregnancies.

About halfway through my solo pregnancy, I realized that my loving, supportive partner barely thought about it. He was planning for a change of life once the baby arrived, but I was already living it, a situation reflected every time I saw the reality of other pregnant women in the world, on my visits to clinics and villages for work.

Women of childbearing age assume most, if not all, the responsibility of pregnancy. In addition to their other responsibilities of work, family, home life, and farming (women do most farm work where I’ve lived) they often manage, too, the daily logistics of organizing other people’s lives: parents, children, in-laws. With pregnancy, many of those standard obligations get more difficult and rarely is any work eased. Women with social and financial support may rise to the new challenge, but for those without support, an unwanted pregnancy can easily overwhelm the balance they need to maintain the responsibilities of daily life.

From research, we know there’s almost never just one reason a woman chooses to end a pregnancy: financial reasons play a key role, but also the wish for child spacing or delayed childbirth, partner-related reasons, or the need to focus on other children. The fact that so many women seek an abortion to improve their chances of being a better mother to a current child or a better-prepared mother later on is rarely recognized or discussed in the debate around abortion. Rather, the discussion is often framed along lines that categorize women seeking abortion as selfish or irresponsible.

And yet, most women, in my experience, are more than capable of processing the many possible ramifications of both an unplanned pregnancy or an abortion on both themselves and the people around them and are best able to take that into consideration before making a choice they feel increases their chance for a safe, manageable and better life.

Why do we not honor their thought process with our respect for their choice?

As my second trimester edged into my third, many of the discomforts of pregnancy eased. I still had to deal with massively swelling feet every time I got on a plane and dissolved into tears over the decision of whether to take malaria prophylactics or not during my trips to East Africa, but more and more I settled into my situation. Meanwhile, everywhere I traveled, I met women with vastly different experiences of pregnancy than mine. I was reminded, over and over, that women who do not want or are not able to carry a pregnancy to term will seek a way to terminate that pregnancy whether there is a safe method available or not. They will harm themselves, put their life, their livelihood, their survival at risk because an unwanted pregnancy very often puts all of those things at risk anyhow and the gamble of an unsafe abortion offers them, potentially, a solution that childbirth does not.

This is perhaps the most critical piece of information that is missing from discussions of abortion today in the U.S. because we are far from the days when women had to seek unsafe abortion. But if you look at the health record of the U.S. before Roe v. Wade, unsafe abortion was the most common reason for admission to hospital gynecological services. Many women died from unsafe abortion every year—as they continue to do so around the world where there is no access to safe abortion. I could fill pages with gruesome stories and tragic outcomes but the greatest pity is that those tragedies are avoidable.

By the time I rolled around to my 8^th month of pregnancy—less sick, still traveling—I joined my two nearest African counterparts in Nairobi for a conference on reproductive health.

At the time, all three of us were hugely pregnant.

Between us, we were married, partnered and single. Two of us were pregnant for the first time, and one had a nine-year old daughter. We were Kenyan, Uganda, American and we had each chosen our pregnancy. We entered the conference building like three full-bellied ships sailing into port, an armada ready to fight for the right of other women to choose their reproductive health outcomes the way we had.

Although we spoke most vociferously about the right to safe abortion, we also tied that right to expanded reproductive health services that allowed women the right to plan their pregnancies, to expect healthy pregnancies and to have access to trained medical practitioners. We wanted contraception to include men—not only in the discussion of it, but in the responsibility for it.

We didn’t see safe abortion as a topic on its own but as part of a whole new dialogue around women and health care centered on their needs and choices. And we recognized—even among ourselves as reproductive health professionals—what a difficult and tricky continuum it was to define the morals and codes that normally diffuse the topic of abortion from its place as one of the safest, most standard medical practices into something fraught with judgment.

In fact, one of the most mind-expanding experiences of working for Ipas was the realization that even among those of us who were pro-abortion, each of us still held our own understandings about it: our own questions, our own discomforts. We thought about it personally, based on our own family and upbringing and culture and religion—which is exactly how the decision should be framed. Personally. Independently—or in consultation with the family and friends chosen by the woman to guide her through that decision.

During my time at Ipas, not unexpectedly, a few beloved friends shared with me their news of an unintended pregnancy. Most wanted to talk about what to do next, and those discussions often included abortion. My response was always directed to the woman according to her own individual situation. What was the context of her life, her support system, her finances, her wishes, her wants? Because even as I fought for abortion rights, I didn’t believe it was the only choice for an unintended pregnancy.

I just always wanted it to be a safe one.

By the time my own pregnancy ended—with a hospital birth at the experienced hands of a trained midwife—I had discovered through a screening process that I had a genetic disposition for hemorrhage, the leading cause of maternal death. Luckily, for my birth I had access to a hematologist, an expensive IV drug to stop my bleeding, trained nurses all around, and the proximity of high-end care if anything went wrong. Once again, I reflected on how differently my pregnancy might have gone had I been anywhere else in the world. And I thought about the risk of death that my pregnancy brought with it—one that comes automatically, still, for so many other women around the world.

I could not have been happier with my own pregnancy outcome, but I recognize all the many and varied supports that gave me a healthy child at the end of that process. There were a thousand other ways, and a million other scenarios how my pregnancy could have gone.

For a useful discussion of abortion, I think it’s essential to think outside our own lives and imagine all the practicalities, the risks, the myriad situations that women find themselves in—and offer them the greatest ability to choose for themselves the options and risks they are willing to take to build the life they want for themselves.