In commemoration of Safe Abortion Day on 28 September, this blog presents some of the work that has appeared in the SRHM journal on abortion during the COVID-19 pandemic.
As the novel coronavirus (COVID-19) spread around the world and healthcare systems faced unprecedented demand, many experts warned of the potential consequences this crisis could have on sexual and reproductive health (SRH). In many countries, stay-at-home orders mean that access to contraception is significantly limited, while the risk of domestic violence has increased, both leading to a potential increase in unwanted pregnancies.[1] In addition, social distance and isolation coupled with existing power hierarchies and ongoing domestic violence may be exacerbated by the virus as economic stressors increase household tension.[2] Additionally, “changes in financial stability due to layoffs and layoffs, concerns about personal or family member health, and anxiety about birth and child-rearing during a pandemic are likely to affect decision-making and access to abortion care.”[3]
Policies and Definitions
The evidence clearly shows that restricting access to abortion does not reduce the demand for this procedure, but instead leads to unsafe abortions. Despite this fact, not all experts agree that abortion should be designated as a basic health service.[4] However, many are convinced that ensuring women and pregnant women worldwide have access to safe abortion is more critical than ever.
While health care systems continue to adapt to the mutated virus, several countries have designated abortion as an essential service according to World Health Organization (WHO) guidelines. Ireland, England and France recognized the risks of the pandemic relatively early and temporarily turned to telemedicine for people seeking first-trimester abortions. Scotland also now allows mifepristone and misoprostol to be used at home. Lawyers in India, Brazil, Ghana, South Africa, Ethiopia and Mexico are seeking similar policies. [5][6] Telemedicine has many advantages, allowing people with underlying conditions and those who fear the virus to reduce their potential exposure to the disease, while also reducing pressure on overcrowded health facilities.
In contrast, many countries have refrained from commenting on access to safe abortion as a public health issue, and others have gone so far as to try to reduce access to abortion. In the United States for example, the situation for people seeking an abortion is alarming. Indeed, 13 states have tried to restrict access to abortion services, claiming it is unnecessary. Vague legal definitions of essential versus non-essential services have led to clinics being open one day and closed the next. [7] Similarly, the Polish government also tried to pass an anti-abortion bill during the pandemic, a time when mass opposition protests were not allowed.[8] Activists in Latin America and the Caribbean faced similar challenges and “have been exposed [the] additional difficulties faced by those who qualify for abortion on the few grounds for which it is legal.”[9]
Resources and supplies
A global contraceptive shortage has been seen with the closure of factories and borders, particularly in India and China, two of the largest manufacturers of contraceptives. “The consequences of an unmet need for contraception can be devastating for women, leading to high maternal mortality and unsafe abortions.”[10] UNFPA estimated that about 47 million women in 114 low- and middle-income countries would not be able to use contraception, and this could lead to 7 million unwanted pregnancies.[11]
Globally, the pandemic has forced maternal health resources and staff to be reallocated to serve patients with COVID-19.[12] Medical supplies, including personal protective equipment (PPE), were also in short supply due to increased global demand and limited international production and shipments.[13] This is particularly problematic in humanitarian settings where health services are already limited. The pandemic may also lead to the redeployment of skilled attendants to their home countries and redirect funding away from ongoing crises that result in fewer abortion services. “In development and humanitarian contexts, […] Low access to SRH can indeed have life and death consequences.”[14]
Low- and middle-income countries face similar challenges. The Kenya Health Data System reported that the unmet need for family planning is already at least 18%. this number is likely much higher, as adolescent girls, women in certain ethnic groups, and those living in rural areas and with low educational and socioeconomic levels are underrepresented in national statistics.[15] The research warns that “negative consequences for maternal and neonatal mortality appear inevitable as a result of this pandemic”. [16] COVID-19 risks major setbacks for hard-won improvements in SRH and abortion access for Kenyan women.[17]
Movement and Access
Around the world, movement restrictions due to lockdown measures have directly affected access to abortion, which is a time-sensitive service.[18] Travel bans and public transport closures increase the logistical challenge of accessing a medical clinic – for both patients and staff. For those traveling longer distances to medical facilities, finding accommodation can be difficult as many hotels remain closed or operate at limited capacity. In the United States, police have set up roadside checkpoints in some states to track people’s movements as a public health surveillance measure. Such initiatives could lead to travel stress especially for people of color and undocumented people who have historically been targeted by law enforcement.[19]
In India, although the Ministry of Health has recommended that SRH services not be disrupted, the near non-existent public transport options due to COVID-19 have meant that few people have been able to reach medical clinics. Abortion services were already scarce in India, but the pandemic has further reduced access.[20] The suspension of buses, trains and flights due to the pandemic has also affected access to abortion. In Malta, a country with one of the most restrictive abortion laws in the world, the lack of flights meant that people seeking an abortion could no longer travel to undergo the procedure safely and legally. This has led many people to turn to activists for help ordering abortion pills online.[21]
People seeking late-term abortions now face several new challenges, including those delayed by a lack of medical appointments. To ensure proper physical distancing, some clinics split appointments leading to less availability and thus longer wait times. Limited funding and resources also meant delays in the procurement of necessary PPE. [22] WHO guidelines suggest that medical abortion with pills can be safely administered during the first 12 weeks of pregnancy, leaving later pregnancies in a difficult position.[23]
The lockdown measures also meant that voluntary groups supporting those seeking abortions, including school health centres, could no longer offer their full range of services, such as coordinating walks. The support they provided to minors, undocumented people, people with disabilities, rural populations, people experiencing intimate partner and same-sex violence, lesbian, bisexual, transgender, queer and intersex adults and adolescents, and others who face barriers to accessing health care was vital.[24] A person seeking an abortion may now have not only resources but also privacy from being confined to the home. [25] This extends to refugee camps where social distancing is almost impossible.[26]
New Opportunities
Despite the challenges, the pandemic also offers an opportunity to make self-administered abortion the new norm everywhere and not just a temporary solution in some countries in times of crisis. Activists around the world have been pushing for it for decades, and their claims are backed by extensive research showing that self-administered pills for early abortions with limited involvement of health professionals are just as effective as medical abortions in health facilities.[27] “Furthermore, the use of abortion pills outside of formal systems is credited with reducing abortion complications and maternal mortality worldwide, but particularly in low- and middle-income countries.” [28] Self-administered abortion allows for a cost-effective, non-judgmental and private experience, which can be particularly beneficial for marginalized communities who have not always felt respected by the formal health system. [29]
The COVID-19 pandemic has exacerbated the problem of access to safe abortion in various parts of the world. From inconsistent definitions and policy measures to reduced resources and reduced supplies to severely restricted movement and access, the pandemic has led to a wide range of challenges. However, new opportunities for improved self-management may arise as a result of recent changes in medical and health care delivery. Ensuring access to safe abortion for women and pregnant women has always been a human rights issue, during the COVID-19 pandemic and beyond.
For more information, see the collection of SRHM documents below:
Abortion in the context of COVID-19: a human rights imperative
Jaime Todd-Gher & Payal K Shah
The reproductive health implications of a global pandemic
Julie G Thorne, Marie Buitendyk, Righa Wawuda, Brianne Lewis, Caitlin Bernard & Rachel F. Spitzer
Intersectionality as a lens on the COVID-19 pandemic: implications for sexual and reproductive health in development and humanitarian contexts
Michelle Lokot & Yeva Avakyan
Reproductive health under COVID-19 – coping challenges in a global crisis
Kathryn Church, Jennifer Gassner and Megan Elliott
Access to late-term abortion in the United States during COVID-19: challenges and recommendations from providers, advocates, and researchers
Samantha Ruggiero, Kristyn Brandi, Alice Mark, Maureen Paul, Matthew F. Reeves, Odile Schalit, Kelly Blanchard, Katherine Key & Sruthi Chandrasekaran
Abortion in the age of COVID-19: Perspectives from Malta
Lisa Caruana-Finkel
The impact of COVID-19 on family planning services in India
Kranti Suresh Vora, Shahin Saiyed & Senthilkumar Natesan
Because self-administered abortion is much more than a temporary solution for times of pandemic
Mariana Prandini Assis & Sara Larrea
Sexual and gender minority adolescents must be prioritized during the global public health response to COVID-19
Jessica DeMulder, Cara Kraus-Perrotta & Hussain Zaidi
The effects of COVID-19 on maternal health in Kenya
Cynthia Khamala Wangamati & Johanne Sundby
