EXECUTIVE SUMMARY

Some states used the COVID-19 pandemic to stop abortion clinics from operating, saying abortions were nonessential medical services. Lawsuits helped reopen some sites, but abortion access was limited.

  • The Center for Reproductive Rights and other organizations sued states over their closing abortion clinics. Rulings and agreements led to some clinics reopening.
  • A poll from the National Family Planning & Reproductive Health Association revealed that women need access to birth control measures to prevent or delay pregnancy during a pandemic.
  • One option for some women seeking an abortion during crises in which access is an issue is a no-test medication abortion model that provides services through telemedicine and a mailed prescription.

Healthcare providers have seen a surge of telemedicine during the pandemic, keeping patients home to reduce their risk of transmission of COVID-19. National medical organizations issued recommendations to suspend elective surgeries, and some states mandated some emergency changes. Not all state decisions were evidence-based.

For instance, one of the first changes eight states made when the COVID-19 pandemic hit was to temporarily close abortion clinics, claiming they were nonessential medical services. This led to lawsuits from the Center for Reproductive Rights and other organizations. (More informaton is available at: https://reproductiverights.org/story/center-files-emergency-lawsuit-texas-protect-essential-abortion-access-during-pandemic.) Court rulings and agreements allowed for abortion care to continue in Louisiana, Oklahoma, Tennessee, and Texas. Other lawsuits were pending through mid-May 2020.

By mid-May, Arkansas was the only state in which patients continued to face restrictions on care because of COVID-19-related policies, says Ruth E. Harlow, senior staff attorney for the Reproductive Freedom Project with the American Civil Liberties Union of New York. “Clinics in Arkansas remain open, but patients are severely hindered by the requirement that they access COVID-19 testing and receive negative test results back immediately prior to surgical abortion procedures, although testing with quick results is not yet widely available,” Harlow explains.

In Arkansas, officials created a rule that required anyone seeking elective surgery, including an abortion, to obtain a negative COVID-19 test 48 hours before the procedure. But at that time — April 27 — the state had limited access to testing, making it extremely difficult for asymptomatic people to obtain a test. (More information is available at: https://rewire.news/multimedia/podcast/arkansas-void-19-test-abortion-lawsuit/.)

Reproductive health organizations have continued to provide women with full access to contraceptive and abortion care during the pandemic, but problems arose. Some access issues are tied to the logistics of continuing contraceptive counseling and care during a pandemic, but others are the result of new rules by state governments.

“As recent actions in Congress and several states have revealed, anti-choice politicians have been willing to exploit our current public health crisis to hinder access to comprehensive reproductive healthcare,” says Julie Rabinovitz, MPH, president and chief executive officer of Essential Access Health in Berkeley, CA. “It’s unfortunate and alarming that this needs to be said, but attacking a woman’s ability to obtain essential health services during a global pandemic is unethical and absurd.”

Healthcare access is vulnerable during a pandemic, and abortion access is particularly difficult, notes Alice Mark, MD, medical director of the National Abortion Federation (NAF) in Washington, DC.

“There are many places in the United States where the distance to get to abortion providers is extreme,” Mark says. “When people are home with no money, no child care, no transportation, it makes it difficult to get to a clinic and access services.”

The notion that abortion is not an essential service is incorrect, Mark says. “NAF and other organizations have said that abortion is an essential health service. It’s very time-sensitive because any delay poses a risk to health,” she adds.

As states began lifting restrictions for nonessential medical services, abortion care was expected to resume in the states that had deemed abortion nonessential, says Michelle Bayefsky, MD, resident in obstetrics and gynecology at New York University.

“While it is relieving that women will no longer have to travel out of state to obtain a timely abortion, concern remains about women who may have tried to self-induce an abortion or may have advanced beyond the legal limit for an abortion, while abortion care was prohibited. Moreover, many women will now be having abortions weeks later than desired, exposing them to the pre-COVID norm,” Bayefsky says. “We must continue to advocate for safe abortion care as an essential health service for women so that access cannot be so easily rescinded in the future.”

The COVID-19 outbreak underscores the importance of ensuring people receive the care they need, Rabinovitz says.

“The current health and economic crisis has only highlighted the urgency of doing everything we can to make it easier — not harder — to get time-sensitive healthcare, including abortion and contraception,” she says.

The results of a poll conducted by the National Family Planning & Reproduction Health Association indicated women believe access to birth control to prevent or delay pregnancy during a pandemic is essential. “Sixty-five percent of poll participants think that now is a bad time for individuals and couples to try to get pregnant,” Rabinovitz says. (The poll’s key findings are available at: https://www.nationalfamilyplanning.org/document.doc?id=4211.)

One likely outcome to the abortion access upheaval is that reproductive health organizations will be better prepared for the next crisis. It also has spurred additional support for maintaining abortion services.

“Witnessing the repeal of abortion access during COVID-19 has spurred a number of states, such as Massachusetts, to state categorically that abortion care is an essential health service,” Bayefsky says. “It is heartening to see physicians and politicians openly supporting access to abortion care. These actions will strengthen our ability to continue providing safe abortion care in the future.”

The pandemic should spark states to swiftly adopt measures that expand access to birth control and support continuous use before the next crisis hits, Rabinovitz says.

“With the future of the federal contraceptive coverage mandate in question, strong contraceptive coverage laws are needed in every state to help ensure that women can get the method that works best for them, without having to worry about out-of-pocket costs,” Rabinovitz adds. “Public and private health plans must also be required to cover a 12-month supply, dispensed at one time.”

More infrastructure and resources are needed to improve abortion access, Harlow says.

“The unfounded and opportunistic restrictions we have seen point to the need to keep building infrastructure and resources all across the country to support patients’ ability to travel to and access abortion care when they need it,” Harlow says.

Another tactic is to increase access to medication abortions.

“As states across the country continue to enact draconian abortion restrictions and the COVID-19 public health emergency has greatly reduced provider capacity to provide hands-on services, there is an urgent need to expand access to early, safe medication abortion,” Rabinovitz says. “We have to find ways to ensure that women are able to receive abortion care when and where going to a health center is no longer an option.”

For instance, a no-test medication abortion model could reduce barriers to mifepristone and misoprostol. Instead of requiring women to visit an abortion clinic for an ultrasound or pelvic examination and blood tests, this in-person visit could be bypassed. For more than 15 years, international organizations have provided medication abortion to tens of thousands of patients by mail. They are screened only for medical history.1

“In every area of medicine, there’s been a rapid expansion of the use of telehealth. It makes sense to apply this technology to abortion services,” says Daniel Grossman, MD, professor in the department of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco. “There are lots of opportunities to continue this beyond the pandemic because patients in many parts of the country face significant barriers accessing abortion care.”

“Medication abortion, at first, was multiple visits for patients,” Mark adds. “Each patient needed quite a bit of testing before the abortion procedure, including an ultrasound, and many of these procedures are not needed.”

Plus, clinicians can follow up with patients, remotely, after the procedure, she says.

Instead of patients returning to the clinic for an ultrasound, they can take a pregnancy test at home, Mark adds.

The no-test medication abortion model that Mark and co-researchers published could include these basic steps:

  • Patient selection. Clinicians could specify an upper gestational age limit of 77 days, as estimated from the first day of the last menstrual period. That limit is consistent with guidelines from NAF and Planned Parenthood Federation of America.
  • Pre-treatment lab testing. The newest research suggests that the risk of Rh sensitization after early abortion is negligible, suggesting clinicians can forgo Rh typing.
  • Treatment regimen. Providers dispense a standard regimen of 200 mg of oral mifepristone, and 800 mcg of misoprostol, vaginally or buccally. Patients also take an extra 800 mcg dose of misoprostol.
  • Follow-up. To confirm pregnancy termination and to identify complications, clinicians can tell patients to take a high-sensitivity urine pregnancy test at home.1

“If a patient comes in, and she’s sure of her last menstrual period and doesn’t need an ultrasound or blood typing and is eligible for medication abortion, she can take the pills home with her,” Mark says. “Follow-up can be provided remotely.”

This model reduces the amount of time patients are in the clinic, making medication abortion practical during the pandemic. Even better, clinicians should be able to provide the medication abortion without clinic or pharmacy visits, Bayefsky says.

“To further reduce barriers to accessing abortion services — both during a pandemic and outside the pandemic setting — we should consider allowing patients with known gestational ages to have the medicine needed for a medication abortion mailed to their homes,” Bayefsky says. “Combining telehealth with mailed prescriptions will make obtaining a medication abortion significantly easier for patients, and it will also reduce the need for in-person appointments during COVID-19.”

Researchers of a multisite study are assessing medication abortion access via mailing prescriptions to people’s homes, Mark says.

One barrier to offering women the option of having their medication abortion prescription mailed to their homes is a Food and Drug Administration restriction on how mifepristone is distributed, Mark adds.

More than a dozen states also ban the use of telemedicine for abortion care, Grossman says. “Outside of a study setting, most patients cannot receive the abortion medication that way. The real potential in the long run is to expand access to medication abortion, using a model that involves screening patients through telehealth, and then those who are eligible could receive the medication directly to their homes.”

The pandemic has revealed the importance of helping women maintain access to contraceptives and abortion services through telemedicine.

“COVID-19 also has accelerated the need to adopt measures that support access to time-sensitive care through telehealth. Recent news articles have pointed to a surge in people using mobile apps to get their birth control delivered while stay-at-home orders are in place,” Rabinovitz says. “The federal government and states have made progress in making telehealth care more accessible to low-income and uninsured patients.”

But, it should not stop there: “We have to make sure the policy changes that have been made to date extend beyond our current public health emergency,” Rabinovitz says.

“Our nation has come to realize that the COVID-19 pandemic has changed everything,” says Robert Hatcher, MD, MPH, professor emeritus of obstetrics and gynecology at the Emory University School of Medicine in Atlanta. “This article demonstrates how the pandemic is being used by individuals opposed to abortion to make obtaining an abortion extremely difficult for some women.”

REFERENCE

  1. Raymond EG, Grossman D, Mark A, et al. Commentary: No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond. Contraception 2020;101:361-366.