The disparity between abortion and childbirth safety is not surprising. Pregnancies ending in abortion are substantially shorter than those ending in childbirth and thus entail less time for pregnancy-related problems to occur. Many dangerous pregnancy-related complications . . . manifest themselves in late pregnancy; early abortion avoids these hazards. (Raymond and Grimes 2012)

There is never a reason to take the life of an unborn child since there is no maternal condition that requires the death of the fetus to save her life. The infant may need to be delivered prematurely and die as a result of that, but it is not necessary to take the infant’s life. (Calhoun 2019)

The above statements may seem to contradict one another. Raymond and Grimes—eminent clinician-researchers with backgrounds in complex family planning—calculate that childbirth is associated with a fourteen-fold increase in maternal mortality compared to abortion, and explain why. Calhoun—a maternal-fetal medicine subspecialist and professor of obstetrics and gynecology who has taken a vocal public stance against abortion—concludes the opposite: that abortion never reduces the odds of maternal death. Both claims have been cited widely in the aftermath of the Supreme Court’s Dobbs v. Jackson Women’s Health Organization decision.

How can trained professionals come to such wildly different conclusions, and how are their divergent claims about medicine and epidemiology mobilized in the service of ensuring or erasing abortion access in the United States?

We pen this essay coming from overlapping vantage points. Both of us are medical anthropologists and obstetrician-gynecologists. We are explicit in our support of reproductive autonomy and access to abortion. We have cared for people suffering complications of abortions performed by unskilled individuals, and we ourselves have directly provided comprehensive reproductive services, including abortion. Our anthropological scholarship, while spanning different continents and venues, shares a focus on the production, transmission, and reification of knowledge through medical training and practice—a focus sustained in this essay.

We call for anthropologists to investigate changing uses and kinds of evidence about abortion. A piece of evidence—such as a mortality rate—is not a simple fact. Specific people produce it through practices validated in particular communities; it then moves, alongside other selected pieces of evidence, among some groups of people but not others. Anthropologists are well-positioned to understand and describe the social lives of evidence. We can explicate tacit assumptions about the legitimacy of modes of knowledge acquisition, show how different forms of knowledge become translatable as “evidence,” and demonstrate how evidence is made to circulate (or not) at multiple levels of discourse.

In the wake of Dobbs v. Jackson WHO, claims from doctors have been circulating in clinical, public, and juridical contexts where physicians’ authority is powerful. Building on anthropological studies of the social lives of medical evidence, we raise three questions about these claims for further investigation:

1. How do reproductive health practitioners and professional organizations assess maternal risks when abortion is medically indicated and legally fraught?

Clinicians working in perinatal care often face a dilemma: How sick does a pregnant person have to be before abortion can be offered?[1] The answers weave together clinical and juridical concerns. Premkumar has spoken with physicians in the southern United States who seek lists of medical indications that would “justify” an abortion to prevent maternal complications. Other clinicians oppose such lists as threats to clinician judgment and patient autonomy. If an individual is “sick enough” by some a priori criteria but not others, will their doctor be caught between hospital protocols and felony charges? What happens if listed indications become targets for hostile state legislatures, a concern colleagues in the midwestern United States have raised to Wendland? Anthropologists are equipped to study what happens when the gray areas of clinical evidence encounter the fraught worlds of political and legal action.

2. How is epidemiological evidence on the relationship between abortion provision and maternal health marshalled in medical training, and which evidence is made to count?

The tide is set to sweep away training in abortion provision for more than 40 percent of obstetrics and gynecology residencies (Vinekar et al. 2022), a change that will hinder abortion access. Multiple news outlets have highlighted obstetrician-gynecologists who deem training in abortion unnecessary or objectionable. Some, like Calhoun, deny the dangers of pregnancy. Meanwhile, some pro-choice physicians evoke the affective imaginary of unsafe “back-alley” abortions; others claim that self-managed medication abortion makes this imaginary obsolete. How do these clinicians mobilize or dismiss evidence connecting abortion provision with improved maternal outcomes, as they argue for or against abortion training? Wendland has faced critique from medical students who considered any teaching about this epidemiological evidence from “an abortionist” illegitimate—yet medical students elsewhere are fighting for abortion to be included in their curriculum. Anthropologists can study how the politicization of abortion has affected the kinds or sources of evidence that are (in-)validated in medical-education contexts, and (de-)legitimated in battles over curricula.

3. How are fetuses made to count, and when do they not, in clinical spaces? What new political imaginaries does the fetus-as-evidence open, and what are the consequences within and beyond clinical care?

Ethnographers demonstrate that the fetus is an assemblage of moral, political, biomedical, and historical ontologies that organizes people around it to speak and act—sometimes, to speak and act for it. Some antiabortion physicians have disputed calculations of abortion safety by moving embryo deaths to the “mortality” column. Others have used higher rates of abortion—and not structural or medical racism—to explain elevated rates of maternal mortality among Black people. These physicians build on an anti-choice rhetoric that characterizes abortion as “Black genocide.” Yet the fetus-cum-child threatened by abortion is also used in arguments for expanded social safety nets by both reproductive-justice and (some) anti-abortion activists. We ask anthropologists to attend to how fetuses are made to count (or not count) in clinical worlds, and how images, artifacts, and rhetoric allow the fetus-cum-child to move between medical and public spaces.

We hope these questions will be starting points for inquiry about how epidemiological and clinical evidence about abortion is born, lives, and dies in a post-Roe world. To trace the life of clinical evidence within the spaces where it is replicated, refuted, ignored, or uplifted is, for us, more than just an opportunity to engage with critical theory. The social life of evidence bears directly on the lives of clinicians we work alongside and of patients we swore not to harm. But it also reaches beyond clinical spaces: The authority given to physicians ensures that their uses of evidence will shape the future of abortion care.

Notes

[1] We stand in solidarity with scholars like Katie Watson (2018), who resist the demand to invoke the “indication” for an abortion. News media have focused on the sick pregnant person as a key figure that will be harmed by antiabortion legislation. Watson notes that characterizing terminations as “medically indicated” or “elective” may signal important information to clinicians; however, these adjectives have the consequence of creating a moral hierarchy of deservingness for abortion based on indication (see also O’Shaughnessy, this series).