The sola variety of papaya resembles a pregnant uterus, so much so that around the world, humans use the fruit to learn one method of modern reproductive health care: manual vacuum aspiration, or MVA, a low-risk, low-tech method of first-trimester abortion that requires little or no anesthesia. As one doctor remarked at a conference in 1973, where the technology was introduced to physicians from around the world, “it’s something we will be able to bring practically into the rice paddy.”
This, too, is the fruit I have been given to practice on. I’ve placed it on a table across from me, and I’m focused on the neck, where its stem grew, which evokes the cervical os. The tool I’m using is a large plastic syringe with a bendable plastic strawlike thing, called a cannula, where the needle would be. At the top of the syringe is a bivalve to create one-way suction.
I carefully peel the remnant of the papaya’s stem, then set the bivalve by pressing two plastic tabs, then pull the plunger on the syringe. For learning purposes, my cannula is 8 millimeters wide — larger than necessary for a very early procedure — roughly the size of a drinking straw. I press it gently into the brown dot on the fruit. The skin gives, and the instrument slides in.
I’m with a small group of learners in a living room — I have agreed not to say where or with whom — cannulas and vinyl gloves scattered about the coffee table, the smell of tropical fruit in the air. That morning, we had been guided through gentle speculum insertion by willing volunteers. Now with our papaya wombs, our teacher explains that on a real cervix, a provider might need to start with smaller-diameter cannulas to gradually open the sphincter. Gentle pressure and patience can achieve this, she says, without the anesthetic or sedation typical in modern clinics.
Very slowly, I push further into the round fruit until I feel resistance — what would be the uterine “fundus,” then I retract a bit. By flipping the bivalve, the suction I created in the syringe pulls from the cannula, and some bright orange pulp and gray seeds travel through the straw, which prompts me to shout out, “It’s working!”
The MVA with a handheld syringe and plastic cannula is now the standard of care around the world for any “pregnancy loss,” including miscarriage, which allows it to exist in countries where abortion is outlawed. Several studies have found no significant difference in outcomes of women who were treated by physicians and those treated by clinicians without an M.D. A 2012 World Health Organization report concludes, “Abortion care can be safely provided by any properly trained healthcare provider … e.g., midwives, nurse practitioners, clinical officers, physician assistants, family welfare visitors, and others.”
“I would feel comfortable with you doing an MVA on me,” says my teacher later that day, while just she and I are debriefing over tea. I am flattered, but stunned by the fact that I could theoretically do this for someone, were it to come to that.
Maybe it has already? Ninety percent of counties in the United States have zero abortion clinics. Mississippi and six other states have just one for the whole state. Several more have fewer than five. As I write, there is a bill in the Iowa state legislature to ban abortions at six weeks; another in Ohio to ban them altogether; another signed into law in Idaho that mandates clinics offer abortion “reversals.” According to the Guttmacher Institute, just one percent of procedures happen in physicians’ offices. “Keep Abortion Legal” is an iconic NOW protest sign. It was the bare minimum ask, and the Supreme Court is poised to shut it down.
Underground abortion is a thing again. I found my instructor — who is equally fearful of law enforcement and anti-abortion vigilantes and thus doesn’t want to be identified — because others have found her. Over the past five years, a decentralized group of a few hundred providers has grown. They are trading in herbs and pills, reviving the practice of “menstrual extraction,” and even learning to do clandestine MVAs. They’re offering this mostly at low cost or no cost, completely outside the medical system.
Many of these providers are already familiar with vaginal exams and accessing the cervix: They are midwives, though no matter their license, abortion at home is outside their scope of practice. Others have no license to lose: They are students or doulas, or they are just fed up with the waiting periods, enforced ultrasounds, and fictitious scripts clinic patients must hear; or perhaps they’ve had enough of the overpriced, gruff clinic that has a monopoly on access in their community; or they feel compelled by the absence of any clinic at all. Still, it’s all happening on a spectrum of illegal to probably illegal. Thirteen states have criminal abortion laws on the books that could be used against such providers. And abortion seekers themselves could be charged — six states have laws specifically making self-abortion a crime. In any state, a person could be charged with “practicing medicine without a license” or “unlawful dispensation” of a drug. “I would say they face substantial risks in providing care to people if they’re not an abortion provider under the imprimatur of the law,” says Farah Diaz-Tello, senior counsel for the SIA Legal Team, which is working to decriminalize abortion wherever it happens.
Even as access is spotty and legality hangs in peril, the people seeking out these providers “are not desperate in the way we think,” one provider tells me. “They’re desperate for someone to provide them with care that’s compassionate, for someone who cares about their story, for someone who wants to know how they’re feeling months after. They want someone who gives a shit about them. And they want to do it on their own terms, in a place that’s comfortable, with people around them who care about them.”
Typically, these providers start by helping their friends or family, often because they are asked to. Most are dispensing misoprostol, one of the drugs in the two-drug RU-486 “medical abortion” regimen, a.k.a. the “abortion pill.” “Miso,” as it is known colloquially, causes the uterus to contract. Because it has several other uses, it is cheap and easily accessible throughout the world. Midwives carry it legally to treat postpartum hemorrhage. Even your local vet has it to control canine stomach acid. Miso is very effective in causing an abortion on its own, 75 percent to 85 percent effective up until 12 weeks. If the abortion is incomplete, one could present to a clinic or emergency room as if they were simply having a miscarriage. No blood test will detect the drug, and there is no clinical benefit to disclosing that one took it. Advocates have called it a “game changer.”
But this American-grown grassroots provider community is offering more than miso. They know the herbs that disrupt progesterone (the hormone that sustains the pregnancy), others that contract the uterus, and others that soften the cervix. They’re recommending herbs on their own or in the place of mifepristone, the first drug in RU-486, which is expensive and harder to get. Some providers have sterile cannulas of increasing diameter and boxes of vinyl exam gloves and three sizes of plastic specula on hand. And they have security protocols: encrypted emails and apps, pseudonyms, and a healthy mistrust of reporters.
Yet they also want to be known. They want women to know to look for them. They want genderqueer and trans folks to know they’re a nonjudgmental resource. They want women of color, young women, indigenous women, poor women, undocumented women — anyone who for whatever reason can’t or would rather not walk into a clinic— to know they’re there. They have a vision for a different paradigm of care, one that harks back to an era before abortion was “between a woman and her doctor,” when pregnancy, childbirth, and pregnancy loss were managed by women in the community — midwives. They want more providers to start offering this to their communities.
“You could totally do this,” my teacher tells me.
I just look at her. That’s crazy, I say. I admit my greatest fear would be causing someone an infection. What was that movie? The one where the old lady sweetly administers to several London women with the same rubber catheter? (Vera Drake.) I admit to other worries: hemorrhage, puncturing the uterus, or worse, other organs. We run through the scenarios: the cannulas are sterile in their paper and plastic packaging, and so long as they touch nothing else, the risk of an infection developing is extremely low. Plus, we have antibiotics now.
In terms of perforation, the cannula is rounded and closed at the top (there are two openings on either side). It’s soft and flexible, not sharp. If one goes slowly and gently, it would be extremely difficult to injure the uterus. The illegal-era tragedies happened with razor-sharp curettes, which are looped metal instruments, or knitting needles, hair pins, the infamous coat hanger — whatever women could get their hands on, if their own hands were all that they had.
Think about the “Janes,” she tells me. Between 1969 and 1973, this underground network of housewives and college students in Chicago learned how to do D&Cs — that is, they dilated cervices and scraped out uteruses with those sharp curettes, which they were responsible for sterilizing. And they did this with just local anesthetic (for safety reasons, in case everyone needed to leave a location quickly), at a time when physicians would put women under general anesthesia in the operating room for the same procedure. The Janes performed some 11,000 D&C abortions without a single death. “What we’re doing is way less risky than what the Janes were doing,” she says.
When I was around 12, my friends and I watched Dirty Dancing on VHS at every sleepover. The image of Penny sweating and shaking on a bed after her back-alley abortion became for me the nightmare scenario of what a reversal of Roe might create. It’s no coincidence that Penny is saved by a legit doctor with clean instruments and an IV bolus. In her definitive history When Abortion Was a Crime, published in 1997, Leslie Reagan writes in the epilogue that if abortion once again becomes illegal, “the history of when abortion was a crime suggests that the results would be dire indeed … some women will die; many more will be injured. The old abortion wards will have to be reopened, a public health disaster re-created.” This has been the pro-choice narrative for two generations. But abortion wasn’t always this dangerous or illegal. And medical technology has changed since the ’60s.
As Reagan details in her book, both midwives and physicians in the United States continued to perform abortions after it was criminalized state by state in the mid-1800s. Law enforcement cracked down on the practice after 1900, interrogating women on their deathbeds, arresting lovers, and deputizing physicians, who grew reluctant to get involved in treating women with complications. Then the Depression hit, making “vivid the relationship between economics and reproduction. Women had abortions on a massive scale.” With hardly any midwives left in northern cities, the pressure was on physicians.
Reagan reports that most cities had several physician abortion providers and so did many small towns. There was a chain of abortion clinics on the West Coast. In New Jersey, around 1,000 women bought into a “club” that functioned as abortion insurance. Dr. Josephine Gabler ran a clinic in Chicago that performed 18,000 procedures between 1932 and 1941. Even physicians who didn’t perform them frequently referred to those who did. They happened in doctor’s offices with receptionists just like any other medical procedure. “The proverbial ‘back-alley butcher’ story of abortion overemphasizes fatalities and limits our understanding of the history of illegal abortion,” writes Reagan.
The period that we in the 21st century associate most with the dark days of illegal abortion began around 1940. Whereas law enforcement had previously worked backward from abortion-related deaths to prosecute incompetent providers, now police were raiding reputable practices, most physician-led. Patients were apprehended by police and forced to undergo exams by colluding gynecologists. Referring physicians were intimidated or arrested. The Red Scare was aligning the country into conformity, and abortion had the stain of communism (it was legal in the Soviet Union). Women were also gaining economic power, wearing pants, and collecting real paychecks while the men were at war. Reagan and others see the crackdown on abortion as a way to keep women’s power in check.
“Therapeutic abortion” had long been a workaround for physicians to perform aboveboard procedures. But now hospitals were forming committees to decide which women qualified. Physicians participated as a kind of liability insurance — strength in numbers. As the years wore on, committees approved fewer and fewer cases. As a result, abortions in the 1950s and ’60s were “harder to obtain, more expensive, and more dangerous,” writes Reagan. If they could access underground providers, women would often be blindfolded, taken to an unknown location, and prone to someone with unknown skills or credentials — just like Penny in Dirty Dancing. Tens of thousands of women showed up at hospitals with infections and injuries annually during these years, and as Reagan points out, the rate of abortion-related deaths actually increased from previous years, with four times as many black women dying as white women.
But the era of dangerous, illicit, surgical abortion was a blip in history, less than 100 years, says Molly Dutton-Kenny, a licensed midwife in Canada who advocates for midwifery to return to its full-spectrum roots. “What I try to remind people is that home abortion is not dangerous, criminalizing traditional providers and taking away their knowledge is dangerous.”
Illegal abortion looks very different now. “Handmaid’s Tale IRL: What If Roe Were to Go?” asked a 2018 panel at South by Southwest. The three panelists all spoke of how women are getting their hands on misoprostol and calling on friends or doulas (or friends who are doulas) to hold their hand. Groups are forming to support the self-inducers, they said, collecting and dispensing pills. One of the panelists, Judith Arcana, was an original Chicago Jane. “What’s going to happen when Roe is overturned is that a lot of people are going to use a variety of methods, and it’s going to be the task of people who mean to do good and right and be righteous folks in the world to learn about all the kinds of things in addition to pills.” she said. “There will be such people. There are such people now.”
The election of Donald Trump is a major touchstone for several off-grid providers I talked to, but this community had been building during Obama’s second term, during which time hundreds of restrictions were passed and abortion declined to its lowest level since 1972. Out of the robust birth-doula movement grew a more political group of “full spectrum” doulas, who connected their work with the reproductive-justice movement: They would support any pregnant person no matter the outcome — abortion, miscarriage, birth, stillbirth.
For some doulas who were accompanying women to clinics and seeing them through medical procedures or hanging with them at home while they took the pills, it wasn’t a huge leap to begin offering options that would save their friends the time, expense, hassle, and indignities of the system.
“Overall, uterine aspiration is really safe, and it doesn’t actually require years and years of medical training to do it,” says Sarah Prager, an OB/GYN and director of the family-planning division at the University of Washington. I tell her about my experience with the papaya, and how my teacher encouraged me, and how it echoes the ’70s feminist speculum self-exam epiphanies — we can do this. “Anyone can. You don’t need to be a physician to do this. I agree with that statement. It’s not hard. But you know, just like anyone can build a cabinet, some people can do that a lot more beautifully than others, you know what I mean? And I really do look at it the same way. Some people are more skilled in some areas than others. Not everybody has great hands.”
Prager is more concerned about access to care writ large than about the safety of community abortion. She’s worried that by promoting or even condoning at-home abortion, clinic care will be further marginalized — that movement energy will be drawn away from fighting “to make sure safe, legal abortion in medical facilities is accessible and inexpensive” and instead advocates will figure “people can just go to their local doula and get herbs.” But Prager recognizes that fight is being lost, as fewer and fewer clinics can keep their doors open. Clinics “were a great concept in many ways, but what it did was marginalize the procedure outside of normal health care, and we’re paying for that now.”
My instructor is confident (or cocky, some would say) that most people, with minimal training, could offer various methods safely. “Pills?” she laughs. “Anybody can do pills.” A quick Google search will turn up the proper dosage of misoprostol depending on the week of gestation. The World Health Organization spells it out. The European NGO Women on Web, led by Dutch gynecologist Rebecca Gomperts, has been sending pills to women all over the world for a dozen years. But even MVA with a sterile cannula is low risk — minimally trained providers around the world have proved it so.
“This is not your grandmother’s illegal abortion,” she says
From Everything Below the Waist, by Jennifer Block. Copyright © 2019 by the author and reprinted by permission of St. Martin’s Press