Abortion Access and Safety with COVID-19 – March 2020 guidance

The COVID-19 crisis has created unprecedented strains on health care systems, including inpatient and outpatient, emergency care and surgical services. Regardless of these constraints, women will always need sexual and reproductive healthcare, including access to safe abortions. In fact, the profound impact of this crisis on people’s lives is likely to mean they will have more need of reproductive health care, including decisions about preventing pregnancy, continuing a pregnancy affected by factors such as exposure to COVID-19, loss of income and many other health concerns brought on by the pandemic. Women will also be at increased risk of rape and domestic violence.

The unfolding COVID-19 crisis is restricting access to contraception and safe abortion services, with the poorest and most marginalised women and girls being worst affected. From the mountains of Nepal, to the plains of Kenya, disruptions in supply chains are leading to a shortage of medications and contraceptives. Economic insecurity is restricting people’s ability to pay for services. The contagion is thinning the ranks of doctors and nurses. Quarantines, travel bans and closed borders are making physical access to safe services increasingly challenging.

Globally around 150,000 pregnancies end in abortion every day. As the COVID-19 pandemic continues to spread, medical services and health systems are stretched, in some places, to breaking point. The provision of Safe Abortion is an extremely time-sensitive, essential health service that cannot be forgotten. It is an essential element of women’s health care and must be maintained even where non-urgent and elective services are suspended. Access to abortion care is time-sensitive and delay can force women over gestational thresholds, adding further strain on hard pressed surgical services and exposes our health care workers to additional risks.

Mortality and morbidity with abortion is low, and lower than continuing a pregnancy to term. Risks increase exponentially for each additional week of pregnancy after 8 weeks of gestation. There is evidence that abortion rates are similar whether access to abortion is freely available or restricted, but where access is restricted women are more likely to resort to unsafe abortion outside of medical regulation. These conditions are detrimental to women, their families and the healthcare system.

However, there are effective and easily implemented solutions that will release the pressure on the health system, free up providers and ensure access to lifesaving services are maintained. These solutions include telemedicine; easy access to mifepristone and misoprostol; removal of unnecessary waiting periods; digital patient education initiatives highlighting the safety of abortion and ensuring the availability of abortion in different settings to the full extent of the local law.

Telemedicine is a safe and private way to have an abortion in early pregnancy without having to visit a clinic, vital for those who are self-isolating, as much as for women living in remote communities, or whose childcare responsibilities mean they cannot leave the house. During this COVID-19 pandemic, telemedicine offers a means of safeguarding women and providing for their critical health care needs. The evidence is clear that an in-person meeting is not essential to the provision of safe and effective abortion services, with the World Health Organisation recommending that women can safely self-manage medical abortion in circumstances where they have access to appropriate information and to health services should they need or want them at any stage of the process.

This modern and practical way to provide abortion care is already in use by Marie Stopes Australia. In the UK, telemedicine is also used to consult with doctors via the web and access medicine remotely. Yet the 1967 law governing abortion provision does not allow the same practicalities for women with an unwanted pregnancy. However, in response to the need to minimise the risk of spreading infection to women and their health care workers during the Covid-19 crisis, the Department of Health in England and also in Wales have announced they will make the simple changes necessary to allow women to take both sets of pills required for an early medical abortion in their own homes, without the need to attend a hospital or clinic. It is hoped that this example will be used as a catalyst for change in other countries. In the United States, individual states are interpreting cancellation of elective procedures as a means of eliminating access to abortion. As ACOG points out, although most abortion care is delivered as an outpatient as it is in many countries around the world e.g. India where over 90% is carried out in this way, some cases need a hospital-based setting or access to surgical facilities. Abortion is an essential component of our health care system, and a time-sensitive procedure. Any delay, whether days or weeks, has the potential to profoundly impact the health and well-being of women

India was one of the earliest countries to legalise abortion up to 20 weeks of pregnancy for a variety of conditions and attempts are currently underway to bring the law up to date. At a time when abortion and reproductive rights are under threat in a large number of countries in the world, the timing and scope of the amendments to the Indian abortion law is especially laudable although it is unclear how the services will still continue with the COVID 19 pandemic.

FIGO supports services and these must be sustainable and resilient. It has committed to serve women safely as we navigate these uncharted waters and we call on governments to do the same. Changes need to be implemented swiftly to save lives and prevent further strain on medical services and we also need long-lasting changes that will safeguard women forced to seek unsafe methods.

Women will always need abortions. Whether they can access them safely and with dignity depends upon every one of us to rise to the challenge to provide them.