By Jocelyn Fifield, MPH, and Susan Haas, MD, MSc
Abortion has long been among the most fragile pieces of women’s health care, and the current COVID-19 pandemic is exposing and in many cases widening existing barriers to care.
As health care systems adapt, many have delayed or cancelled “non-essential services” to accommodate COVID-19 patients, preserve resources, and protect staff and patients. While this reorganization is necessary to avoid overburdening the health care system, there is currently no consistent framework for reliably determining what is considered “non-essential.” Non-essential does not mean “unnecessary,” nor does it mean “elective;” non-essential services are simply those services that can be delayed for days or weeks or months while the pandemic plays out. This is complex, and there are many nuanced safety and ethical considerations that arise as health systems triage care. However, abortion is not a non-essential service, and delays in care can cause lasting harm.
Non-essential does not mean “unnecessary,” nor does it mean “elective;” non-essential services are simply those services that can be delayed for days or weeks or months while the pandemic plays out … However, abortion is not a non-essential service, and delays in care can cause lasting harm.
In the early weeks of the pandemic while states across the country were declaring public health emergencies, eleven states — Alaska, Texas, Oklahoma, Louisiana, Mississippi, Alabama, Arkansas, Tennessee, Iowa, Ohio, and West Virginia — took action to further limit abortion access using the rationale that abortion was a non-essential service. Each of these states already had existing gestational limits that were shorter than that imposed by the Supreme Court’s viability limit, and many had already increased the burden of access to abortion with long waiting periods and few or geographically distant clinics. This week, The Supreme Court ruled on June Medical Services LLC vs. Russo — a case nearly identical to the 2016 Supreme Court abortion case — and struck down Louisiana abortion restrictions that would have permitted states to impose further barriers to abortion access.
In many of these states, policymakers went to extreme lengths in March and April to ensure that abortion access was limited, such as in Louisiana where the Attorney General monitored compliance and requested confidential files from clinics. These bans have a disproportionate impact on women of color who, due to income inequality, already faced more significant financial barriers to care, are often specifically targeted by anti-abortion rhetoric, and are more likely to live in states with restricted access. Further, a recent survey found that during the pandemic, more than one-third of women reported wanting to delay childbearing. Many women also reported barriers to accessing contraception such as delayed or canceled visits and concern about finances, suggesting that there may be an increased demand for abortion care during this time. Advocates were fighting for improved women’s health care and abortion access long before 2020, and the emergence of this virus cannot be a reason to backslide.
Although there is still much uncertainty about the lasting impact of COVID-19 on our health systems and health outcomes, there is no uncertainty about what happens when abortion becomes inaccessible.
As the American College of Obstetricians and Gynecologists said in a statement earlier this year in reaction to the delay of non-essential services, “Abortion is an essential component of comprehensive health care. It is also a time-sensitive service for which a delay of several weeks, or in some cases days, may increase the risks or potentially make it completely inaccessible.” And yet these bans were implemented. Although there is still much uncertainty about the lasting impact of COVID-19 on our health systems and health outcomes, there is no uncertainty about what happens when abortion becomes inaccessible. This was the reality in the United States before abortion was legalized in 1973 and remains so for large segments of the population that still face significant barriers to care.
Women do not stop seeking and having abortions when they are inaccessible or illegal. Women who are unable to access services may be forced to resort to abortion without clinical oversight. Before abortion was legalized in the United States in 1973, an estimated 800,000 abortions took place every year, and following legalization, morbidity and mortality from unsafe abortions declined by a factor of eight. Self-induced abortion certainly looks different today, and the advent of medication abortion has improved safety. However, medication abortion is most effective and safe earlier in gestation, and many women lack the means and knowledge to access and obtain medication abortion on their own. Unsurprisingly, this differential access will likely fall along lines of privilege. Class and race were predictors of access to abortion before 1973. And not only did access to abortion fall along these dimensions, outcomes did as well. Nearly four times as many women of color died from unsafe abortions as white women. We have already seen the differential impact of COVID-19 along racial and socioeconomic lines, and abortion bans are no different.
With increasing restrictions, history shows that a number of women who would have otherwise chosen to have an abortion will not. Every child should be wanted, and the effects of carrying an unwanted pregnancy to term are profound. They include a higher likelihood of anxiety and depression, living below the federal poverty line, birth complications, and staying with abusive partners. These are all realities many face right now, with or without an unwanted pregnancy.
Further, as many of these bans expire and states resume providing “non-essential” services, abortion clinics may face persisting operational challenges. Sixty percent of abortions in the United States are provided in independent clinics which faced unique operational challenges even prior to COVID-19 such as strict loan terms, volatile insurance, and legal fees. Like other small businesses affected by the pandemic, many may not be able to reopen their doors as social distancing requirements for COVID-19 begin to ease. We saw this effect in Texas after Whole Woman’s Health vs. Hellerstedt in 2016. What was intended to be a short-term change may become permanent.
Particularly as restrictions lift, this is an opportunity to ensure that future health system shocks do not interrupt access to abortion. Here are steps both clinicians and the general public can take to help keep abortion safe, accessible, and essential:
If abortion becomes less accessible, health care providers must be able to recognize when women present with self-induced abortions and treat them medically while also protecting them legally. A number of states criminalize self-induced abortion, but there are no laws requiring health care providers to report women. Health care providers must become allies in this fight. A recently published review article in the New England Journal of Medicine provides clinicians with information on common self-induced abortion methods and how to recognize and treat them.
Expand access to teleabortion
Providing remote consultations to prescribe medication abortions in the first ten weeks of pregnancy is an effective way to improve access to abortion while also limiting in-person contact during COVID-19. Typically, the first of the two pills that are necessary for medication abortions is taken in a clinic and the second is taken at home. However, programs like TelAbortion are providing remote consultations for both medications to be taken at home. Unfortunately, some state laws prohibit this practice, and many women still need to cross state lines to be able to legally have a telemedicine appointment for abortion. You can connect with your state’s abortion advocacy organizations to learn how to advocate for widespread access to telemedicine for medication abortions.
Talk about abortion
During a pandemic or not, stigma is damaging. Educate yourself and others around you about abortion and don’t be afraid to talk about it. Families and men have a role in this as well — all voices need to be heard to make change. Abortion is health care, and by talking about it openly, we can collectively work to depoliticize and normalize it.
We have the historical evidence that when safe and legal abortion is restricted, there is lasting physical, mental, and economic harm to women and their families, with a disproportionate burden falling on those who are already marginalized. This is the time to strengthen access to abortion, not restrict it, and by acting and advocating together, we can create a reproductive health care system stronger than before and identify new and innovative ways to connect people to the services they need.
Jocie Fifield is a Research Manager on the Delivery Decisions Initiative at Ariadne Labs where she leads the Expecting More project, a national campaign to change the narrative about childbirth and highlight the role that every individual and institution has in supporting growing families in the United States.
Dr. Susan Haas is an obstetrician-gynecologist and co-PI for Ariadne Labs’ CRICO-funded work focused on reducing health care system expansion risks to patient safety. Dr. Haas oversees the planning and execution of research and development of tools to reduce risk to patients.
Illustration by Daria Konovalova / iStock