In commemoration of Safe Abortion Day on September 28, this blog signposts some of the papers that have appeared in the SRHM journal on abortion during the COVID-19 pandemic.
As the novel coronavirus (COVID-19) spread around the globe and healthcare systems faced unprecedented demand, many experts warned of the possible consequences this crisis could have on sexual and reproductive health (SRH). In many countries, stay-at-home orders mean that access to contraception is considerably restricted while the risk of domestic violence has increased, both leading to a likely spike in unwanted pregnancies. In addition, social distancing and isolation combined with existing power hierarchies and ongoing violence in the home may worsen due to the virus, as economic stressors increase tension in the household. Furthermore, “changes in economic stability due to furloughs and layoffs, concerns about personal or family members’ health, and distress around birthing and parenting during a pandemic are all likely to impact decision-making and access to abortion care.”
Policies and Definitions
Evidence clearly shows that restricting abortion access does not decrease the demand for this procedure but instead results in unsafe abortions. Despite this fact, not all experts agree that abortion should be defined an essential health service. However, many are convinced that ensuring women and pregnant people worldwide have access to safe abortion is more crucial than ever.
While healthcare systems continue to adapt to the mutating virus, several countries have defined abortion as an essential service as per World Health Organization (WHO) guidelines. Ireland, England, and France recognized the risks of the pandemic relatively early and temporarily shifted to telemedicine for individuals seeking first trimester abortions. Scotland also now permits home use of mifepristone and misoprostol. Advocates in India, Brazil, Ghana, South Africa, Ethiopia, and Mexico are seeking similar policies.  Telemedicine presents many advantages as it allows for people with underlying health conditions and those who fear the virus to reduce their possible exposure to the disease while simultaneously decreasing the pressure on overcrowded health facilities.
In contrast, many countries have abstained from commenting on access to safe abortion as a public health issue and others have gone as far as to try to decrease abortion access. In the United States for example, the situation for people seeking an abortion is worrisome. Indeed, 13 states have attempted to restrict access to abortion services claiming it to be a non-essential. Unclear legal definitions of essential versus non-essential services have led to clinics being open one day and closed the next.  Similarly, the Polish government also attempted to pass an anti-abortion bill during the pandemic, a time where mass opposition protests were not permitted. Activists in Latin America and the Caribbean faced similar challenges and “have exposed [the] added difficulties faced by those who qualify for abortion on the few grounds where it is legal.”
Resources and Supplies
A global shortage of contraception has been observed with factories and borders closing, namely in India and China, two of the biggest manufacturers of birth control. “The consequences of an unmet need for contraception can be disastrous for women, leading to high maternal mortality and unsafe abortions.” UNFPA estimated that about 47 million women in 114 low- and middle-income countries will not be able to use contraception and this could result in 7 million unintended pregnancies.
Worldwide, the pandemic forced resources and personnel meant for maternal health to be reallocated to cater to COVID-19 patients. Medical supplies, including personal protective equipment (PPE), were also in short supply due to increased global demand and limited international production and shipments. This is particularly problematic in humanitarian settings where health services are already stretched thin. The pandemic may also result in redeployment of skilled attendants in their home countries and redirect funding away from ongoing crises resulting in fewer abortion services. “In development and humanitarian contexts, […] low access to SRH may indeed have life and death consequences.”
Low- and middle-income countries face similar challenges. The Kenya Data Health System reported that the unmet family planning need is already at least 18%; this number is likely much higher since adolescent girls, women within some tribes, and those living in rural areas and with low educational and socioeconomic status are underrepresented in national statistics. Research warns that “negative consequences for maternal and neonatal mortality seem inevitable as a result of this pandemic”.  COVID-19 risks major setbacks for hard-earned improvements in SRH and abortion access for Kenyan women.
Movement and Access
Around the world, limitations in movement due to lockdown measures directly affected access to abortion which is a time-sensitive service. Travel bans and the closure of public transportation increase the logistical challenge of reaching a medical clinic – for both patients and staff. For those travelling greater distances to medical facilities, finding accommodation can be difficult as many hotels remain closed or operating at limited capacity. In the United States, police have set up road check-points in some states to monitor people’s movements as a public health surveillance measure. Such initiatives could lead to travel anxiety particularly for people of colour and undocumented people who have historically been targeted by law enforcement.
In India, although the Ministry of Health recommended SRH services not be interrupted, the almost non-existing public transportation options due to COVID-19 meant few people could reach medical clinics. Abortion services were already scarce in India, but the pandemic reduced access even further. Suspended buses, trains, and flights due to the pandemic also impacted abortion access. In Malta, a country with one of most restrictive abortion laws in the world, the lack of flights meant that people seeking an abortion could no longer travel to receive this procedure safely and legally. This led to many people turning to activists for help ordering abortion pills online.
People seeking later term abortions now face several new challenges, including those who were delayed due to lack of medical appointments. To ensure proper physical distancing, some clinics spaced out appointments leading to less availability and thus longer waiting times. Limited funding and resources also meant delays in procuring necessary PPE.  WHO guidelines suggest that medical abortion with pills can be safely self-managed during the first 12 weeks of gestation, leaving those at later gestations in a predicament.
Quarantine measures also meant that volunteer groups who supported those seeking an abortion, including school health centers, could no longer offer their full range of services such as coordinating rides. The support they offered to minors, undocumented people, individuals with disabilities, rural populations, people experiencing intimate partner violence, and gay, lesbian, bisexual, transgender, queer, and intersex adults and adolescents, as well as others who face barriers accessing healthcare was crucial. An individual seeking an abortion may now lack not only resources but also privacy from being confined at home.  This extends to refugee camps where social distancing is nearly impossible.
Despite the challenges, the pandemic also presents the opportunity to make self-managed abortion the new norm everywhere and not just a temporary solution in some countries in times of crisis. Activists worldwide have been pushing for this for decades and their claims are supported by extensive research which shows that the self-administration of pills for early abortion with limited involvement of health professionals is as effective as medical abortions in health facilities. “Moreover, the use of abortion pills outside of formal systems is credited with the decrease of abortion complications and maternal mortality worldwide, but particularly in low- and middle-income countries.”  Self-managed abortion allows for a cost effective, non-judgemental, and private experience which might be particularly beneficial for marginalized communities who have not always felt respected by the formal health system. 
The COVID-19 pandemic exacerbated the problem of access to safe abortion in various parts of the world. From inconsistent definitions and policy measures to reduced resources and diminished supplies to vastly limited movement and access, the pandemic has resulted in a wide array of challenges. However, new opportunities for improved self-management may arise as a result of recent changes in medicine and healthcare delivery. Securing access to safe abortion for women and pregnant people has always been a question of human rights, during the COVID-19 pandemic and beyond.
For further information, please see the collection of SRHM papers below:
Abortion in the context of COVID-19: a human rights imperative
Jaime Todd-Gher & Payal K Shah
The reproductive health fall-out of a global pandemic
Julie G Thorne, Marie Buitendyk, Righa Wawuda, Brianne Lewis, Caitlin Bernard & Rachel F. Spitzer
Reproductive health under COVID-19 – challenges of responding in a global crisis
Kathryn Church, Jennifer Gassner & Megan Elliott
Access to later 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 time of COVID-19: Perspectives from Malta
Impact of COVID-19 on family planning services in India
Kranti Suresh Vora, Shahin Saiyed & Senthilkumar Natesan
Why self-managed abortion is so much more than a provisional solution for times of pandemic
Mariana Prandini Assis & Sara Larrea
Sexual and gender minority adolescents must be prioritised during the global COVID-19 public health response
Jessica DeMulder, Cara Kraus-Perrotta & Hussain Zaidi
The ramifications of COVID-19 on maternal health in Kenya
Cynthia Khamala Wangamati & Johanne Sundby