Protecting Access To Abortion During The COVID-19 Pandemic

Illustration by Brett Ryder

Mary, a woman in her late twenties with chestnut eyes, bronze skin tone, and a shy demeanor, hadn’t known immediately that she wanted to have an abortion. “I would do it,” she told me as we began her visit in the consult room, sitting six feet apart from one another. It was the day after Easter 2020. “I mean, in different circumstances I might continue the pregnancy. But now?”

She looked up at me as I nodded. I tried as best as I could to convey empathy through my pale surgical mask.

“How could I be pregnant during this pandemic? How could I even get to appointments? What if I got sick?” She sighed thoughtfully. With diabetes and kidney disease, and with three other children at home, “getting sick” with COVID-19, the disease caused by the novel coronavirus, and missing prenatal appointments would threaten her safety, the health of her pregnancy, and the well-being of her family.

I reassured Mary that having an abortion is, for many patients, a sign of actively good mothering. To assuage her guilt, I let her know that most women who have abortions already have children, and they make tough decisions based on what they deem best for their families, carefully weighing the pros and the cons of their options. “You’re right,” I responded, “it would be more complicated with the coronavirus.”

I reassured her that as a general obstetrician/gynecologist (OB/GYN), I would be her doctor either way. She decided to undergo a surgical abortion, which took a total of six minutes using local anesthesia and minimal personal protective equipment (PPE). She drove herself home to her family shortly thereafter. It was her daughter’s fifth birthday the next day, and Mary had to get home to bake her favorite chocolate cake with raspberry icing.

In the face of the pandemic, pregnant women are being tasked with considering the potential effects of a virus with many unknowns. Although OB/GYNs do not think that pregnancy puts patients at increased risk for complications from COVID-19, data are sparse. We know very little about the effects of the virus on pregnancy itself, or its effects on newborns. The information we have is reassuring so far, but it is woefully incomplete.

In this uncertain environment, pregnant women make the best decisions they can. Women closer to delivery decide whether to give birth in the hospital or at home, how to care for a newborn if they or a family member fall ill, and whether pediatrician appointments and postpartum visits (including for birth control) are essential. Women with unplanned pregnancies decide whether or not to parent in a world where they feel less secure every day. Patients seeking an abortion consider whether it is safer to take public transportation or an Uber to get to a health care facility. The decisions women are making are not entirely new to this pandemic, but they are more complicated because any encounter with the health care system feels risky.

Unfortunately, patients with unwanted pregnancies are facing more than just the burden of accessing care during COVID-19; in some places they are up against leaders who seem to be willing to take advantage of a crisis for their own political agendas.

Abortion Bans

Early in the pandemic, health systems canceled all nonessential procedures, both to preserve resources and to limit patients’ and providers’ exposure to the novel coronavirus. Although experts in women’s health care, including the American College of Obstetricians and Gynecologists, quickly and in no uncertain terms deemed abortion an essential, “time-sensitive service” that cannot be delayed, some state governors issued executive orders that banned abortion during the crisis. These orders were purportedly intended to preserve PPE, but this rationale is medically unsound, given that a continuing pregnancy and delivery will almost certainly require more PPE than an abortion obtained early in pregnancy.

As a result of the orders, surgical and medication abortion services immediately ended in some places. Patients were called and told that their appointments had been canceled. The American Medical Association, lamenting that “elected officials in some states are exploiting this moment to ban or dramatically limit women’s reproductive health care,” stressed that physicians, not politicians, should decide which procedures are urgent, emergent, and essential. As of the end of June, eleven states had attempted to suspend abortion services during the pandemic, according to a Kaiser Family Foundation report.

Indirect Victims

The same day I treated Mary, I saw a patient whom I’ll refer to as Jessie. Jessie had recently lost her secretarial job in Indiana and had saved up for gas money to drive three hours on winding roads to have an abortion across the state border in Illinois. She worried that our office would close before she arrived, as she had heard of clinic closures in other states during the pandemic. She entered the building more than an hour early for her appointment, waiting patiently, if anxiously. She told the woman checking her in at the front desk that she was skeptical that she would actually be seen. She filled out her medical history forms carefully, paid her cash fee exactly, swallowed one pill in our clinic, and planned to return home to take the other four pills that would complete her medication abortion. Before she left, she asked me: “What will people who can’t pay for travel in those other states do? What happens if there are no abortions?”

I’ve often asked myself the same question: What happens when women like Mary with her health problems, or Jessie with her financial constraints, cannot end an unwanted pregnancy safely? What happens when state governments go against medical authorities?

Texas was the first state to deem abortions nonessential by executive order during the pandemic, and the downstream effects of that order provide a window into what happens without federal protection of abortion. If abortion services cease in a state, pregnant women either continue their pregnancies or find another place to end them. In Texas in 2014, approximately 11 percent of 534,000 pregnancies, or almost 5,000 per month, ended in abortion, according to data from the Guttmacher Institute. It is impossible to know what happened to the patients who were denied abortion services in Texas during the time that the executive order (now expired) was in effect. But we do know that women who cannot access the abortions they seek suffer from long-term physical, mental, financial, and social consequences, as Diana Greene Foster and colleagues learned in the Turnaway Study.

Some women, like Jessie, could travel to other states to terminate their pregnancies if they could manage it. According to the Guttmacher Institute, a woman in Texas would have had to drive an average of 243 miles each way to access an abortion during the COVID-19-related abortion ban, up from an average of 12 miles before the ban. Patients who couldn’t make the trip might have made a choice to perform their own abortions, without medical supervision, and with greater risks to their safety. Quietly, painfully, they would become indirect victims of the pandemic, succumbing not to COVID-19 but to the dangerous adverse effects of unjust policy.

An Opportunity To Protect Women

After I treated Mary, Jessie, and my other patients that day, I changed out of my scrubs, meticulously sanitized my hands after every doorknob I touched, and finally arrived at my car on the second floor of the parking garage, eager to get home and relax with my family. The day had been long, made unusually tiring from the constant act of cleaning and recleaning surfaces, protecting my single yellow face mask, screening patients for symptoms, and keeping six feet distant from colleagues.

On my car window sat a crimson, business card–size piece of paper, showing a scientifically inaccurate but bloody and gruesome depiction of an aborted fetus at ten weeks. “CHRIST DIED FOR YOUR SINS,” the card read in bold, all-capital lettering. “YOU DO NOT HAVE TO MURDER YOUR BABY TO COVER THEM UP.” Taken aback, I considered how strange it was that someone felt it their religious duty to brave the virus and come to a hospital during a pandemic to spread this message. Had Mary and Jessie seen this same card? I surveyed my car to make sure no one was hiding in the backseat. Holding my breath, I opened and closed my empty trunk, and only then felt safe enough to begin driving. I hoped that my patients were safe, too.

The event demonstrates to me that although the COVID-19 pandemic has been likened to a war, its effect on abortion is simply to complicate a war that Americans were already fighting. Before COVID-19, and now despite COVID-19, the battle rages on for control of women’s reproductive autonomy.

During the COVID-19 pandemic, more than ever, women are demonstrating the triumph of their self-determination and the importance of reproductive health access over false propaganda and burdensome policies that are not based on medical evidence. They are making brave, complicated, and responsible decisions; balancing their own needs and those of their loved ones; and weighing the many risks and benefits involved as they do so. This is the narrative about abortion that I wish would resonate, rather than the stigmatized version that marks these women as thoughtless and selfish. The pandemic presents an opportunity to change that narrative.

The COVID-19 pandemic also has encouraged innovation in medical care for abortion, advocacy on behalf of abortion patients, and other steps to improve abortion access. For example, whereas women previously came to reproductive health care facilities for a follow-up visit after a medication abortion, they now have the option in many places to complete follow-up remotely. So a patient like Jessie need not drive across state lines to see me for follow-up but, instead, can expect a call during which I will check on her symptoms and ask her to take a pregnancy test at home in a few weeks.

Also in response to the pandemic, the American College of Obstetricians and Gynecologists and other groups sued the Food and Drug Administration to prompt the agency to remove Risk Evaluation and Mitigation Strategy requirements on mifepristone, one of the two medications used for medication abortion. As part of the current requirements, provision of mifepristone can only occur under the supervision of a certified prescriber in a clinic, medical office, or hospital, despite the medication’s excellent safety record. As a result, a pharmacy closer to a patient’s home cannot dispense the medication, and the medication cannot be mailed. In the time of COVID-19, the requirements needlessly increase exposure to the coronavirus for patients and providers, the lawsuit argues. As this article went to print, the plaintiffs had prevailed, which is a huge win for abortion access.

Courage

When Jessie asked what women in states without access to abortion would do, I answered: “Women will figure it out. Somehow, they always manage.”

It takes courage to continue a pregnancy during the pandemic, and it takes courage to end one.

Seeming satisfied with my answer, she zipped up her cinnamon-colored coat and stood up to gather her belongings as she prepared for her long journey home. I had given her a bag of four cookies earlier to help with her pregnancy-related nausea so that she would be able to swallow the pill I had provided her, and she grabbed the two that were left and stuffed them into her purse for later. She nodded, thanking me silently, and walked out. Women in need of abortions have, throughout history and regardless of the danger, confronted the toughest of circumstances to access care. It takes courage to continue a pregnancy during the pandemic, and it takes courage to end one.

If nothing else good comes of this virus, let’s come together as a society, in a time when togetherness is very much needed, to change the abortion narrative to one that conveys more understanding and to protect women’s reproductive autonomy.