A group of women from the feminist collective Adona’t Vic holds a banner reading “Abortion available and free for all” during a 2016 protest they staged in front of the Vic Cathedral in Catalunya. Laura Busquets / ACN. Via Públic.
Comparing the US and Catalunya
Induced abortion is a widespread phenomenon worldwide. More than one hundred million pregnancies occur each year that were unintended or ill-timed; more than half of these are terminated. Whether it is legal, restricted, or else completely criminalized, rates of and demand for abortion remain similar across different settings. What does vary between these settings is how accessible and safe getting an abortion is, and the amount of social stigma linked to abortion.1
In the wake of the United States Supreme Court’s recent widely anticipated but nevertheless horrifying Dobbs ruling that effectively ends or threatens access to legal abortion in more than half the country,2 it is critical to look at historical examples as well as other geographic settings where abortion legality and accessibility have also expanded and contracted. A broader view allows for greater understanding of how people seeking and providing abortions have responded and can continue to respond to legal, political, and practical threats to abortion access, and what obstacles are likely to be the most persistent and challenging.
As an applied medical and reproductive anthropologist studying access to abortion in publicly funded health systems, since 2009 I have conducted fieldwork in Catalunya, a contested autonomous region bordering northeastern Spain and southwestern France. In 2010, abortion became “more-legal” in Spain and Catalunya than it previously had been. The new law allowed for a pregnant person to terminate a pregnancy for any reason within the first trimester and maintained previously established justifications for terminating a pregnancy on the grounds of physical or mental health, or fetal anomaly after the first trimester. As part of the implementation of the law, abortion care also became integrated into public health systems, ostensibly expanding and improving access including for lower-income and migrant residents. Public health system accessibility to unregistered (what in the US might be called undocumented) migrants is comparably greater in Catalunya than in most autonomous regions of Spain; migrants “without papers” in Catalunya can obtain a health card for the public health system.
Thus, when I embarked on longitudinal clinic-based fieldwork exploring access to legal, publicly funded abortion in Catalunya from 2012 to 2017, it was with an eye to understanding to what extent the most marginalized pregnant people truly benefitted from policies that, on paper, stood to improve access. Furthermore, I intended to identify what obstacles to abortion access appeared to be the most persistent, despite access-oriented policies. At a time when the United States faces a patchwork of growing restrictions, drastically narrowing pathways to safe and accessible abortion, the lessons Catalunya can offer are useful for thinking about the obstacles that persist even in an arguably more accessible policy setting.
Learning from People’s Experiences Navigating Legal, Publicly Funded Abortion in Catalunya3
At the time of the fieldwork I conducted, migrants (individuals not born in Catalunya) had a higher abortion rate than did Catalans,4 attributable to reduced awareness of and access to sexual and reproductive health education and contraceptive services through the public health system, in part because the hours of health system offices are often at odds with service sector employment.5 Though financial precarity is cited as a reason for seeking an abortion, especially following the global economic recession beginning in 2007–2008,6 prior research suggests that the abortion rate in Catalunya remained the same just before and in the years considered the height of the economic crisis (“La Crisis”). Aside from limitations in public hospitals, other obstacles to publicly funded abortions in Catalunya included delays in obtaining the required referral voucher that covers the costs of an abortion. Those most vulnerable, including migrants, people at later gestations, and patients from outside Barcelona, reported longer waits, while voucher delays pushed some patients into the second trimester. The three main factors I will examine here that arose as key motivations for and obstacles to obtaining an abortion are: pregnant people’s economic situations (often produced by larger policies of austerity); gendered violence and intimate partner violence (IPV); and abortion stigma and experiences with stigmatizing treatment.
Economic conditions. Unprompted, participants in my Catalunya fieldwork often discussed economic motivations for seeking an abortion, particularly patients who already had children in their care. During participant-observation in the clinic, multiple patients with young children stated, nearly verbatim, that “the economic situation does not permit another child.” A participant who chose the pseudonym Kati said, “[I’m] supporting two kids, so to have a third, already? No.” (All participant names are pseudonyms.) Likewise, Salma, a thirty-six-year-old Moroccan woman who was very early in the first trimester when she sought a health system referral voucher and came to the contracted clinic, commented, “Sometimes things happen that shouldn’t happen to you. I have three kids, one was just born [six months ago]! … My husband [is] without work … My kids are close in age, like twins.” Salma told me that she and her husband had been chronically unemployed or underemployed as a lingering effect of the global economic recession. Another patient arrived with a voucher that specified in writing that she was referred for a second trimester abortion “due to the end of a relationship causing financial precarity and economic instability, and the need to care for another child.” While this was a justification that the contracted clinic psychologist could and often did document (by talking with a patient and noting in their chart that financial stability and the ability to care for existing children would be jeopardized by having another child), it was unusual to see it directly documented by health system staff on a referral voucher.
Gendered violence. Patients also described experiences with gendered violence, in the form of intimate partner violence (domestic violence) as both a motivator for and obstacle to abortion access. Some pregnant people in the clinic talked about a current abusive partner responsible for the pregnancy as their reason for terminating, and/or as a factor that delayed them from being able to obtain an abortion as quickly as should have been possible according to policy. As is well documented, such delays in turn increased their risks of exposure to escalating violence. For example, when a clinic social worker asked a patient who was mid-second trimester by the time she reached the clinic why she was so far along (also revealing the potential for staff stigmatization of certain patients), the patient explained that a “situation of mistreatment” delayed her. She indicated that her abusive partner destroyed the health system referral voucher she had obtained earlier. Another patient, Emile, twenty-nine years old and Argentinian, was late in the first trimester when she reached the clinic:
I come from bad treatment [by my partner], and that’s very important, it could be that this child could have suffered many beatings; so it’s understandable [that I have an abortion]. When I’m going to have the baby is when he returns (after leaving during pregnancy) … He prohibited contraceptives and every night [he’s] trying to have a baby [sic] … I got in contact with the health system and I didn’t know that one could do this. Or, I knew one could do it and it was free, but maybe not in my situation, you know? Like I thought it was more for economic reasons, but well, the [public] social workers told me, to the contrary, it would be better if we abort than to repeat the [IPV] story again.
Gendered violence, especially in the form of intimate partner violence, can act not only as a direct practical obstacle to accessing care but can also compound (and be compounded by) other practical and social obstacles.7
Abortion stigma. While abortion stigma is not heavily prevalent in Catalunya (as compared to other European countries like Italy and Poland), it is well-documented that, when present, stigma acts as an obstacle to abortion access and also compounds other obstacles.8 Functioning here as a form of “civilized oppression,”9 as defined by Jean Harvey, which results from structural violence and oppression linked to gender role expectations and playing out within healthcare bureaucracies, abortion stigma manifests and is enacted within public and publicly funded health systems and other social services all over the world.10 Stigma toward abortion at both societal and interpersonal levels threatens abortion legality and increases risks for complications.
Even in Catalunya, there were many instances of stigma from health system workers themselves. Some described reluctance on behalf of public health system staff to assist with abortion referrals. Patients explicitly recounted how, in their experience, this contributed to delays in receiving vouchers. Clinic staff also spoke of patients who reported more delays and difficulties obtaining referral vouchers and were in the second trimester by the time they reached the contracted clinic. The clinic social work director described the story of a migrant woman who was referred for a late second trimester abortion only because the sexual and reproductive health unit at the patient’s neighborhood health system center caused multiple delays at earlier gestations. The patient had first sought a referral voucher for a contracted clinic when she believed herself to be in the first trimester. So, health system staff referred her to another contracted clinic, where she proved to be slightly farther along than that clinic was authorized to provide abortion care for. When she returned to her neighborhood health system center, they referred her to a public hospital for blood tests that are not usually required, after which she had to return to again seek a referral voucher for the fieldwork clinic. By the time the patient reached the clinic, she was nearly at their much later gestational limit as well. As the director of social work commented, expressing dismay about the public health system staff who had delayed the patient, “Why are you messing around with the [trimester] limit like that?!”
Abortion Obstacles in the US
Post-Dobbs, people in the United States seeking and providing abortion care, and those assisting them, face a landscape of greater restrictions, escalated legal and physical risks, and reduced practical access, exacerbated by socioeconomic and sociocultural obstacles. Such challenges have the greatest intersectional effects on those who are already most marginalized: low-income and rural folks, Black, Indigenous, and people of color, teens and other young people, people with disabilities, LGBTQIA+ people (especially trans men and nonbinary people whose pregnancy experiences are obscured in outdated rhetoric about “women’s rights”), as well as anyone with vulnerabilities to surveillance and criminalization, such as pregnant people who use drugs, anyone already subject to criminal-legal processing, and so on. For example, well before Dobbs, even in Oregon—a state with no legal restrictions on abortion, state-level Medicaid that fully covered abortion up to the federal legal gestational limit, and state social service policies ostensibly in place to expedite pregnancy-related Medicaid coverage—the most marginalized pregnant applicants still waited the longest and encountered the most obstacles to reaching an abortion clinic.
It is not difficult to extrapolate the implications of these conditions to a post-Dobbs context. Pregnant people in the US in precarious economic conditions are arguably even more likely than someone in Catalunya to consider the need for an abortion based on economic reasons.11 The US lacks guaranteed subsidized prenatal, postpartum, and pediatric healthcare, as well as parental leave, childcare, and other forms of public assistance that might make an ill-timed pregnancy less dire. Likewise, accessing an economically motivated abortion will predictably be much more difficult in the US given that people in a setting with ample public health system services nevertheless had trouble. It already was more difficult for the lowest-income folks in the US to access abortion, especially in states where Medicaid does not cover abortion.12 Dobbs will only worsen the situation.
Likewise, gendered violence is unfortunately pervasive cross-culturally and internationally and operates similarly in pregnancy regardless of nationality and abortion legality. Unlike Catalunya, in post-Dobbs US differing state laws mean that in many cases a situation of IPV may have no bearing on exceptions to abortion bans. We can anticipate increasing numbers of pregnant people in abusive circumstances being subjected to greater relationship violence and even death as they have to arrange travel to reach a clinic in a different state. Some will be delayed further into their pregnancies that in turn become harder to conceal, necessitating later procedures that are also harder to access.
Finally, if stigmatizing treatment, especially from public health system staff, produced delays for people accessing abortion in a setting with comparatively less societal stigma toward abortion, we can easily predict that pregnant people in the US will also experience stigma-related delays and difficulty accessing abortion where it remains available. This may take the form of the spread of predatory misinformation by so-called Crisis Pregnancy Centers, primary and gynecologic care providers that refuse referrals to abortion providers, or social services workers that fail to expedite pregnancy-related Medicaid applications in states where public healthcare does cover abortion. In all these cases, abortion stigma among healthcare and social services system representatives may enact and intensify the very delays and obstacles legitimized by Dobbs.
What Can Be Done?
I offer this litany of threats to access not to further depress and discourage readers already upset about the Dobbs decision, or the overall state of reproductive (in)justice in the US and elsewhere. Rather, I hope to highlight what may be some of the thorniest and most vulnerable aspects of the fights ahead. Which groups of pregnant people may be in greatest need of practical support and mutual aid? In what regions of the country might abortion funds and independent clinics need the most immediate and ongoing financial assistance? Based on what I observed during fieldwork in a “best-case scenario” setting where people experienced financial precarity, intimate partner violence, and were affected by abortion stigma within a publicly funded healthcare system, I have a few ideas.
Pregnant people in the US with the fewest economic resources, especially those in poverty and those in states where Medicaid does not cover abortion care (which, not coincidentally, are also more likely to be states with total abortion bans or the greatest number of and the most insurmountable restrictions), are likely both to have more practical motivation to seek an abortion and to encounter more obstacles to accessing care. They will need more financial assistance to travel to a clinic, potentially out of state, where they can obtain a legal, high-quality abortion. Being away from work will be a greater hardship. Arranging childcare may be a greater burden. Finding a reliable vehicle or paying for gas may be more challenging. This will be even more true for pregnant folks affected by intersectional forms of oppression or another legal vulnerability: BIPOC communities, anyone with a disability, LGBTQIA+ people, undocumented people, teens, and so on.
For pregnant people in situations of intimate partner violence, increased vulnerability to and risks of escalating violence while pregnant will make any delay in accessing abortion that much more dangerous. These folks will need greater support in getting abortion care in a timely manner, and access to any resources for IPV that they are interested in.13
The impact of abortion stigma, especially from healthcare and social services representatives, will be especially hard to address as it is woven into the cultural fabric of US society and widely seen to fall under the category of “personal belief” rather than being a form of violence and civilized oppression which, when enacted by an employee toward a patient or client, is the height of unprofessionalism and harm. Everyone can play a part in being watchful for expressions of abortion stigma from those working in settings where they may control the allocation of healthcare or public resources—and call it out when observed.
What else can we do? Donate to grassroots abortion funds, especially in the South, Appalachia, rural areas, and in parts of the US most affected by post-Dobbs abortion bans and restrictions. Donate to or assist with mutual aid efforts in the areas where you live. Donate to existing bail funds that prioritize women and LGBTQIA+ BIPOC folks—we will see people arrested for crossing state lines to seek abortion. Donate to or volunteer with groups that support survivors of intimate partner violence. Get involved in local efforts to help folks travel to independent abortion clinics if there are any in your region that will remain open. Help independent clinics stay open.
All hope is not lost, and we certainly cannot afford to stay in a place of despair. Look to those places where abortion is legal, available, and funded—and remember that in many of these examples it has not been the case for long. See what obstacles remain even in better circumstances and how those might now apply to the US context. We have work to do.
Related resources:
Grassroots abortion funds, especially in Southern & Appalachian states disproportionately affected by post-Dobbs abortion bans and restrictions:
https://abortionfunds.org/ways-to-give
https://arc-southeast.org/donate
https://www.msreprofreedomfund.org
To find bail funds:
https://reprolegaldefensefund.org/about-us
https://www.communityjusticeexchange.org/en/nbfn-directory
To find local groups that support survivors of intimate partner violence:
https://www.thehotline.org
To help independent clinics stay open:
https://abortioncarenetwork.org/donate
Bayla Ostrach, “This Tangled Web of Reproductive Morbidity Risk: Abortion Stigma, Safety and Legality” Frontiers in Women’s Health 1, no. 2 (2016).
Center for Reproductive Rights, “Supreme Court Case: Dobbs v. Jackson Women’s Health Organization,” June 24, 2022 →.
The accounts shared here are based on data I collected in two phases of research in 2016 conducted six months apart at a Barcelona abortion clinic contracted with the Catalan public health system. Located in a fairly central district of Barcelona otherwise known for a combination of medical facilities and shopping centers, the clinic was, during much of the fieldwork period, the only one contracted by the Catalan public health system that was providing care throughout the second trimester and thus served patients from all over Catalunya. I was granted long-term, periodic access to this site on an ongoing basis and invited for research visits. I also received input from the clinic director and other staff about topics for ethnographic investigation. For further accounts see: Bayla Ostrach, Health Policy in a Time of Crisis: Abortion, Austerity, and Access (Routledge, 2017); B. Ostrach, “Social Movements, Policy Change, and Abortion Access in Catalunya,” Anthropology Now 10, no. 2 (2018); B. Ostrach, “Publicly Funded Abortion and Marginalised People’s Experiences in Catalunya: A Longitudinal, Comparative Study,” Anthropology in Action 27, no. 1 (2020).
A. Llácer Gil de Ramales et al., “El Aborto En Las Mujeres Inmigrantes. Una Perspectiva Desde Los Profesionales Sociosanitarios Que Atienden La Demanda En Madrid,” Index de Enfermería 15, no. 55 (2006); Gispert Magarolas et al., “Diferencias En El Perfil Reproductivo de Mujeres Autóctonas e Inmigrantes Residentes En Cataluña,” Gac Sanit 22, no. 6 (2008); and Serret and Pairó, “La Interrupció Voluntària de l’embaràs a La Catalunya Del Segle XXI.”
Bayla Ostrach, “‘Yo No Sabía…’—Immigrant Women’s Use of National Health Systems for Reproductive and Abortion Care,” Journal of Immigrant and Minority Health 15, no. 2 (2013).
Gloria Perez et al., “The Impact of the Economic Recession on Inequalities in Induced Abortion in the Main Cities of Spain,” European Journal of Public Health 29, no. 2 (2019).
Gretchen Ely and Nadine Murshid, “The Association between Intimate Partner Violence and Distance Traveled to Access Abortion in a Nationally Representative Sample of Abortion Patients,” Journal of Interpersonal Violence 36, no. 1–2 (2021); Lisa Colarossi and Gillian Dean, “Partner Violence and Abortion Characteristics,” Women & Health 54, no. 3 (2014).
Alison Norris et al., “Abortion Stigma: A Reconceptualization of Constituents, Causes, and Consequences,” Women’s Health Issues 21, no. 3 (2011); Judy Margo et al., “Women’s Pathways to Abortion Care in South Carolina: A Qualitative Study of Obstacles and Supports,” Perspectives on Sexual and Reproductive Health 48, no. 4 (2016); Bayla Ostrach and Roula AbiSamra, “Abortion Complication Syndemics: Pathways of Interaction between Structural Stigma, Pathologized Pregnancies, and Health Consequences of Constrained Care,” in Stigma Syndemics: New Directions in Biosocial Health (Rowman & Littlefield, 2017); B. Ostrach and Melissa Cheyney, “Navigating Social and Institutional Obstacles: Low-Income Women Seeking Abortion,” Qualitative Health Research 24, no. 7 (2014).
Jean Harvey, Civilized Oppression (Cambridge University Press, 1999).
Bayla Ostrach, “Did Policy Change Work?: Oregon Women Continue to Encounter Delays in Medicaid Coverage for Abortion,” Anthropology in Action 21, no. 3 (2014).
The majority of people seeking abortion in the US are already parenting. See Guttmacher Institute, “U.S. Abortion Patients: Demographics,” May 9, 2016 →.
Amanda Dennis, Ruth Manski, and Kelly Blanchard, “Does Medicaid Coverage Matter?: A Qualitative Multi-State Study of Abortion Affordability for Low-Income Women,” Journal of Health Care for the Poor and Underserved 25, no. 4 (2014).
Reminder: the person experiencing gendered violence is always the authority on what they need and when is the safest time to leave, if they decide to do so. Pregnancy can be a dangerous time to leave, and when a person leaves is the most dangerous time.