Abortions are for everyone – it’s time for fully inclusive services

A conversation on how we think about abortion access and how inclusive our services are is long over due. For far too long, the abortion movement has championed access for all those that require abortion care but with little acknowledgement of the wider structures that govern our reproductive health.

While it is estimated that a quarter of all pregnancies end in abortion - the idea that abortion is always a clear choice is far too simplistic and minimises the experiences of lots of those seeking abortion care. Recent Department of Health and Social Care (DHSC) data revealed that black women are more likely to report a consecutive abortion compared to their white and Asian counterparts.

While the difference is small, there are many reasons for this that typical pro-choice narratives simply fail to address. Those racialised as non-white are likely to be paid 10% less than their white counterparts even when educational attainment is adjusted for. Black women are at heightened risk of experiencing intimate partner violence and less likely to receive adequate support when they do report it.

Black motherhood is plagued with sterotypes of young black teenage mothers who are incompetent or dependent on governement welfare. A recent report into maternal deaths within the UK revealed that black women are five times more likely than their white counterparts to die in childbirth and black babies are more likely to be stillborn. These statistics are not clearly explained by increased comorbidities (the presence of more than one disorder in the same person) or socio-economic conditions amongst black people. A recent Royal College of Obstetric and Gynaecology event highlighted how prejudice and unconscious bias affects the healthcare provided to black patients, including having their pain taken less seriously.

For many black women, becoming pregnant goes beyond traditional anxieties like “how will I cope?” Instead, some consider the rather traumatic question: “Could I die?”

The circumstances for gender non-conforming people is even more bleak with very few medical studies on their experiences of accessing healthcare. In one small study, the majority of respondents were not using contraception, as they incorrectly believed that gender-affirming hormones would also act as contraception, leaving them at possible risk of unplanned pregnancy. While data from the US shows that poor reproductive health is even greater among black trans and non-binary people, with significant rates of sexually transmitted infections and HIV; there is very little information on their experiences of accessing healthcare within a UK context.

It is difficult to determine how many gender non-conforming people are accessing abortion services as the current Department of Health reporting forms fail to include a box that collects gender information. However, the same form still includes a section on marital status, which is as useful as my passport has proven to be in 2020. Despite limited public health data, we do know that trans and non-binary people have poor sexual and reproductive health, but our institutions still treat this population as if they do not exist. How can you advocate for service improvement for populations that are not recorded as existing in the first place?

William Horn, a freelance writer who was originally based in London but now lives in Brooklyn, started taking gender affirming hormones nearly 10 years ago. He told me he feels that healthcare providers fail to consider anything outside of taking hormones.

Frequently, arguments against trans inclusive facilities position trans people as a threat to our safety - despite the data actually showing that cis-gender people continue to be much more of a threat to theirs. For those trans men and non-binary people who do continue with their pregnancy, there is little medical information available and many experience transphobia and erasure from services. There is an increase in intimate partner violence experienced by pregnant people, so we as providers should consider the additional mental burden that continuing with a pregnancy may take on those that already live in a world where survival can be a challenge.

The idea that individuals choose to have an abortion is outdated and fails to account for the structural dimensions that can lead some groups to have an one. Until we start to both acknowledge and understand these within our healthcare system, our abortion services will continue to overlook large groups of people and fail to take a holistic approach to their life circumstances.

In the United States, more providers are familiar with terms such as reproductive justice, a term coined by women of colour to highlight how structural oppression affects reproductive health - the application to the UK continues to lag behind. Recent Black Lives Matter protests where black pregnant women hold signs expressing their concern for the safety of their unborn child has brought to the fore how these issues overlap and intersect; we can longer address them in isolation.

Mara Clarke founder of the Abortion Support Network, an organisation that ensures those that require an abortion have access to the financial means to do so, says: “We know that many of our clients have been migrants, refugees, asylum seekers, members of the Irish traveller community. We don't ask our clients who they are or how they got pregnant. We don't ask if they are women or what their gender identity is. We don't care, and we know that women and pregnant people with money can access services without having to explain or justify themselves. As an abortion fund, we want any person who needs an abortion to have that same experience.

While many in the sector are starting to understand the importance of acknowledging the diverse experiences of abortion, it is integral to providing good quality care that we go a step further and demand better research, data collection and information on the experiences of those that are most marginalised by society.

It is time that we build our movements with diverse experiences in mind and it is time that our abortion services reflected the stories of the communities that we serve.