Abortion during the Covid-19 Pandemic — Ensuring Access to an Essential Health Service
Each year, nearly 1 million women choose to end a pregnancy in the United States, and about one-quarter of American women will use abortion services by 45 years of age. Women’s ability to determine whether and when they have a child has profound consequences for their self-determination and for the economic, social, and political equality of women as a group. Because access to safe abortion care is time-sensitive and vitally important, the American College of Obstetricians and Gynecologists (ACOG) and other reproductive health professional organizations issued an unequivocal statement on March 18, 2020, that they “do not support Covid-19 responses that cancel or delay abortion procedures.”
Despite ACOG’s position, governors in a number of states have called for a halt to abortion care throughout the Covid-19 epidemic. Governors in Texas, Louisiana, Mississippi, Alabama, and Oklahoma have ordered or supported the cessation of both medication and surgical abortion, while governors in other states have directed that surgical abortion alone must stop. (“Medication abortion” uses pills to end the pregnancy in the first trimester; “surgical abortion” includes a variety of procedures at various stages of pregnancy.) Politicians in additional states have announced their intentions to issue similar orders.
These governors, who have worked to restrict access to abortion in the past, have categorized abortion procedures as “elective” or “nonessential.” Lawsuits challenging the orders are pending. As of April 8, 2020, temporary restraining orders (TROs) have blocked state bans while litigation proceeds in Ohio, Alabama, and Oklahoma. In Texas, a TRO granted by a district court was reversed by the Fifth Circuit Court of Appeals, thereby halting abortions once more. The orders have had immediate effects on patients; thousands of women have already been turned away from abortion care. Given the potential effects on thousands of more women, if states suspend abortion care throughout the Covid-19 outbreak, the president of the American Medical Association (AMA) issued a statement on March 30, 2020, in support of continued access to abortion and explaining that physicians, not politicians, should decide which procedures can be delayed.
The new restrictive state policies highlight the vulnerability of abortion care in the United States. Abortion is an essential health service. The Covid-19 outbreak has illuminated several weaknesses in our health care system, and one lesson should be that our system of abortion care delivery must be strengthened in ways that prevent abortion access from being so easily rescinded in times of health system stress, whether minor or substantial.
Politicians and others advocating for the closure of abortion clinics claim that their goal is to increase the availability of personal protective equipment (PPE) for medical staff treating Covid-19. But this argument doesn’t make sense. Women who are unable to obtain an abortion will either remain pregnant and require prenatal care and support during delivery or may use dangerous methods to induce an abortion on their own, as was more common historically when abortion care was unavailable. Both these scenarios could lead to much more contact with clinicians and greater need for PPE, thereby increasing risks to both patients and staff.
Rather than being about the preservation of PPE, the abortion restrictions imposed in recent weeks are the latest round in a long-running debate about whether abortion is a legitimate health care service. “Elective” abortion has been physically separated from other routine health care services; it is predominantly performed in independent clinics, even though it could be performed in most private obstetrics and gynecology practices. The national discourse has also portrayed abortion providers as “outside” health care, misrepresenting them as a distinct set of physicians with suspect professional motivations who must be regulated with special laws. The idea of “abortion exceptionalism” is propagated in part by people motivated by a desire to make abortion illegal or inaccessible, and policymakers of this mindset have enacted hundreds of new abortion restrictions over the past 10 years.1
But the procedure has also been marginalized by health care professionals who support abortion care in the abstract yet seek to avoid controversy by distancing themselves from “elective” abortion. The commonness of abortion in the United States suggests that most physicians personally know someone who has chosen to end a pregnancy, and most also care every day for people who have relied on safe, legal, and accessible abortion services. However, a desire not to be associated with the politics surrounding abortion has led to a lack of solidarity in the medical profession that leaves the physicians who are providing pregnancy-termination services in the midst of a pandemic more vulnerable than ever.2
The historical misclassification of most abortions as “elective” is also central to the vulnerability of abortion care. There is no debate that a minority of abortions are necessary to prevent death or serious physical harm. But this strictly medical model fails to capture the reality that the nonmedical reasons that women exercise their constitutional right to abortion are often as important to them and their families as averting a serious health consequence. The long-standing insistence on using the word “elective” to describe the vast majority of abortions frames women’s equality as a luxury and women’s autonomy as expendable. Categorizing abortions as “elective” or “therapeutic” is more of moral judgment than a medical judgment,3 and it allows people who use these terms to determine a woman’s level of deservingness on the basis of her reason for choosing to pursue an abortion.4 In the rest of medicine, classifying a surgical procedure as “elective” doesn’t determine whether or where it will be done. Instead, it denotes that a case can be planned and scheduled, as opposed to an “urgent” case that cannot be delayed without causing harm to the patient. Under the current circumstances, many hospitals are appropriately rescheduling procedures for which the outcome will not be worsened by a surgical delay. However, the surgical complexity of abortion procedures and the associated risks increase with each passing week, and since most states impose upper limits on the gestational age at which abortion can be performed, delaying procedures will mean that many women will be unable to obtain an abortion at all.
In ordinary times, access to abortion is essential because deciding whether and when to bear a child is central to women’s self-determination and equal participation in society. During the Covid-19 pandemic, such access is even more important. Millions of women under quarantine or shelter-in-place orders may have reduced access to contraception; many ambulatory clinics have restricted or halted outpatient visits, including those for placement of contraceptive devices, and women may have difficulty traveling safely to a pharmacy. It is also possible that increased time at home will increase couples’ sexual activity. The Covid-19 response has already brought about substantial financial hardship for many families, and not having the money to support a child (or an additional child) is a leading reason that women choose to have an abortion.5 Finally, quarantine and shelter-in-place orders have increased intimate partner violence, which sometimes includes sexual coercion and assault that may result in unplanned pregnancies.
The medical profession’s response to the Covid-19 pandemic must include continuing to meet other urgent health care needs, including the need for time-sensitive abortion care. The speed with which some governors have suspended abortion care during this pandemic highlights the extreme vulnerability of abortion access in the United States. We believe that the current global crisis requires the medical profession to speak with a unified voice on several topics, including access to abortion care. We call for all medical professionals to stand in solidarity with ACOG and the AMA, with the women and couples who need the option of pregnancy termination, and with their colleagues who serve these patients. If the entire profession can actively support abortion care as an essential health service during the Covid-19 pandemic, such unity could form a foundation for strengthening our abortion care infrastructure for years to come.