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Study shows COVID-19 disruptions led to less access to medical abortion

A new study shows that the COVID-19 pandemic caused major disruptions to abortion service availability, especially to medical abortions and telemedicine, in the United States between May–August 2020.

The study, published in June, builds on previous studies of abortion clinics to investigate national abortion clinic availability in the first 6 months of the COVID-19 pandemic, with the goal of examining what factors affected clinics’ ability to remain open and provide abortions, the types of abortions provided, and telehealth options offered during the pandemic to reduce in-person contact. Eleven states enacted policies categorizing abortions as non-essential procedures in or before May 2020, as the US experienced the pandemics first wave.

There are two types of abortion services offered in the US, medical abortion and procedural abortion. Medical abortion consists of two pills taken 24-48 hours apart. Clients can often take both doses outside of the clinic, leading to increased accessibility to services. Procedural abortions are sometimes called surgical abortions or suction abortions, in which suction or other medical tools are used to terminate a pregnancy.

Research has shown that medical abortion is over 95% effective and that less than 0.5% of cases result in serious complications. There has been no evidence that medication abortion through telemedicine is unsafe.

Data from a 2020 update of the Advancing New Standards of Reproductive Health’s (ANSIRH)  abortion facility database—which covered identified several disruptions to abortion clinic staffing, financial stability, and service delivery—including the closure of up to 3% of US facilities (mainly in the South and Midwest); a small number of facilities that stopped offering any abortion services; a small number of facilites that began referring clients out for abortion services: and a number of facilities in the West that limited their abortion services to medical abortion only, while others in the Northeast and South offered only procedural abortions and not medical ones. Despite these disruptions to care, projections show that 71,000 women nationwide sought or will seek abortion services each month during the pandemic.

“When clinic capacity decreases, individuals must travel increasingly longer distances to obtain an abortion or are simply unable to obtain one,” Subeksha Sharma, a recent graduate of Berkeley Public Health, said. “Although the ripple effects of this are outside of the scope of this particular study’s results, other research has shown the increase in unwanted pregnancies and disproportionate adverse effects on low income individuals of color.”

Although medical abortions have been shown to be safe, women are sometimes unable to access that care as a telehealth option; often, the nearest clinic, which can be an hour or more away, isn’t allowed to provide medical abortions remotely due to state regulations. In addition, the clinic or even the women themselves may lack the technological infrastructure that would make telehealth care accessible.

Many clinics offer medical abortion only for those who are less than 10 weeks pregnant; others for those between 7 and 11 weeks, and others through the first trimester (12 weeks), depending on state guidelines. Women can receive procedural abortions at up to 24 weeks gestation. Because of the strict cutoffs for each abortion type, when procedural abortions were halted in some areas during the pandemic, the gestational age range at which individuals  could seek abortions narrowed significantly.

Very few clinics will perform surgical abortions at 24 weeks and often, state guidelines and individual clinics differ in how many week a woman can be pregnant at the time of abortion; the lowest Sharma has seen for both medical and procedural abortion is 7 weeks.

“The limit can be 7, 8, 9, 10, 11, etc., depending on the state and the clinic, because even if the state limit is one number, a clinic might set their own lower limit of what they provide,” she said.

In areas where medical abortions are unavailable due to state guidelines, those seeking abortions lost the only possibility of completely contactless care and therefore had less flexibility in terms of telehealth options.

For 492 of the 693 facilities that both were open 2019 and provided abortions in 2020, telehealth options for abortion-related care were all but nonexistent. Many clinics lacked the infrastructure to support telehealth services; others are required by state guidelines to conduct in-person counseling by a clinician or pretreatment ultrasounds before abortions, and could not hold telehealth conferences as a result.

However, the study found that when fully contact-free medical abortion was not feasible, some clinics moved to having virtual consultations or reduced time in clinic as a compromise.

Sharma feels the pre-existing barriers to abortion care were exacerbated by the pandemic and the few ways clinics are able to get around them only show how much further there is to go to increase accessibility. “Telehealth is a step in the right direction, but in the majority of cases there are bigger underlying issues that need to be addressed for this to become a feasible reality,” she said.

This study is authored by Shelley Kaller, M.G. Isabel Munoz, and Subeksha Sharma of Berkeley Public Health. Other co-authors include: Salma Tayel, Chris Ahlbach, Clara Cook, and Ushma D. Upadhyay.