by Marge Berer
Answering this question has been the subject of much attention in the media and in the newsletters, reports, statements, webinars and literature by advocates for sexual and reproductive health and rights (SRHR) in many countries since the Covid-19 pandemic began. It’s a vexed question. This discussion paper is an attempt to provide at least a partial answer grounded in the complexity it deserves. The paper considers the following aspects:
- the expression of concerns and fears that services will stop in many published reports and articles;
- the role of estimates of what might happen in the absence of services, based on historical data vs. current and actual evidence;
- why services were reduced or shut down, that is, whether it was a consequence of the pandemic, which affected many other services, or because the motive was anti-abortion, and
- whether or not restricted access to services manifested early in the pandemic remained static or evolved during the months the virus has been around.
On the basis of the evidence I’ve been able to find since March 2020 to share in the Campaign newsletter, I believe the widespread fear that the pandemic would be taken advantage of to close abortion services for anti-abortion reasons did not materialise to the extent that was anticipated. Far more evidence is needed from more countries to confirm this, but if this is true, it is a sign that governmental acknowledgement of the need for safe abortion as an essential health service has grown substantially in recent years.
The role of concerns and fears
Nothing gets people’s attention like a good scare story. The media know this and use it to popular effect all the time, and we SRHR advocates are not above doing the same when we are trying to get attention to an issue the world is ignoring. Widespread concerns and fears of loss of SRH services, especially for safe abortion, have been expressed far and wide since the beginning of the pandemic. Nor were those fears necessarily unlikely.
In one country after another, deluged with cases of Covid-19 and unprepared for what hit them, a lot of healthcare services did go into emergency mode and stop much of their normal functioning. A lot of healthcare workers fell ill and/or had to stop working for a range of reasons. And a lot of hospital space and staff who normally provide a wide range of services, including those who deliver babies and provide abortion care, and much else, were taken over to care for Covid-19 patients.
Because the spread of the virus between countries has been gradual, affecting some countries much earlier than others, stretching from January until now, regular reports of disrupted services have appeared in the international news. Whether, to what extent and for how long these disruptions have continued in each country has been reported far less.
At the best of times, there is good reason to criticise many aspects of healthcare services – not adequate or of good quality, stigmatised, not accessible to everyone who needs them – especially not the poor, rural, ethnic minority, young and single people. Or they are too far away and cost too much. In addition, we are so used to seeing these services restricted on the smallest excuse, especially abortion services, that perhaps we just assumed that of course the pandemic would be used to justify shutting them down, perhaps altogether. And in some cases that certainly happened. But not everywhere, not by a long shot. Yet I found a complete journal article on the effect the authors expected the pandemic to have. Apart from a few documented examples of actual effects, the article is full of speculation, based often on what is (thought to be) happening in other countries.
But it hasn’t just been a question of whether “the man” decides to close the clinics. There have been many reports that people who have needed services were too afraid to go out and access them, even though the services had not been closed down at all. Articles and e-newsletters have sometimes shouted out: “We are open!!!” “Contact us!” This has happened not just with SRH and abortion services, but also, for example, with child vaccinations.
Anti-abortion groups have certainly tried to shut down services but not as often as expected
In several countries, anti-abortion movements have certainly attempted to close down abortion services, in addition to those based in hospitals that were at risk of temporary closure for legitimate reasons, i.e. because staff were ill or self-isolating and/or they were taken over to look after Covid-19 patients.
The reasons given in these instances have included that abortion was being treated like other services considered routine, inessential, non-emergency, or not a priority. This inevitably happened in the USA in states with Republican-controlled governments whose anti-abortion efforts have been non-stop for years. On the other hand, there are 13 US states where telemedicine for access to abortion pills and self-managed abortion at home are now permitted. Moreover, the Planned Parenthood Federation of America, who have clinics across the USA, have committed to staying open throughout the pandemic, despite Trump-backed efforts to strip them of government funding.
Slovakia, Lithuania and Poland are all examples in Europe where already active anti-abortion movements went into high gear to try and stop abortions. In Slovakia, four punitive anti-abortion bills were tabled in the parliament by different political parties in hopes of getting at least one of them into the law books. Austria at one point had only five clinics that remained open.
These examples show the differences in behaviour between countries over the long months of the pandemic to date. Not all or even most reported clinic closures or reductions in services have been motivated by anti-abortion policymakers and/or service providers. However, there are countries with active anti-abortion movements and active conscientious objection that we know nothing about yet. Maybe things couldn’t get worse in some places.
Estimates of future loss of access to services and the consequences
For the most part, and especially in the early days of this pandemic, little of what was happening on the ground was documented or quantified.
The Guttmacher Institute published estimates of the consequences during this pandemic if SRH and abortion services are not available – for example, estimated numbers of women unable to obtain a contraceptive method who end up with an unwanted pregnancy, or estimated numbers of women who were unable to access a safe abortion and had to have an unsafe one, or had no choice but to have a baby they didn’t want. These data tend, for good reasons, to include worst case scenarios, as the aim is to ensure policymakers recognise the seriousness of the situation – in order to prevent it from happening. Guttmacher’s April 2020 report with these estimates covers low- and middle income countries. It discusses disruption to the supply chain (contraceptives, abortion pills), diversion of equipment and staff in hospitals to treat Covid-19 patients, effects of movement in public restricted or banned, as well as suspension of services not considered essential. It concludes that : “Without concerted action, access to essential sexual and reproductive health services, and the quality of any care that is provided, will likely decline.” And goes on to comment that: “Previous public health emergencies have shown that the impact of an epidemic on sexual and reproductive health often goes unrecognized.…”
This lack of recognition of the value of SRH services for women was certainly the case during the first years of the HIV pandemic, which I lived through, though that changed once the extent to which women were being infected and infecting others was understood, as well as how HIV affected pregnancy, breastfeeding and STIs. However, in this pandemic, I believe the need for SRH services has been recognised from the start. My overall impression from the country reports summarised in the Campaign newsletter in the past four months is that SRH services have been recognised as essential services by many governments, and that has included abortion care in countries where at least some abortions are legal. Even when these services have been reduced or closed for a period of time, this has occurred alongside many other services considered essential as well, e.g. cancer treatment. And efforts are then made to re-open them and get them going again as soon as possible. This culminated on 1 June 2020 when the Wold Health Organization said that abortion was an essential public health service in Maintaining Essential Health Services: operational guidance for the Covid-19 context, 1 June 2020.
Another report, Compromised Abortion Access due to Covid-19, by the Ipas Development Foundation India, is a sophisticated example of such an estimate, because it is based on the expectation that the pandemic would go through stages and that (lack of) access to services would change quite quickly over time, not remain static. Based on historical data, they estimated how many women would not be able to access public abortion services compared to private ones, and how many would turn to self-managed abortion with pills without seeking help from a clinic – a practice that is already widespread in India and has been for a long time. Overall, their estimates assumed that, in the initial period, things would be at their worst and would improve over time as services got a grip and resumed. They estimated that 59% of total abortions (nearly one million in number) would not be available from a clinic/doctor during the first 40 days of the lockdown period, when the whole country was under the strictest conditions. This percentage was expected to decrease to 33% of the total in the recovery period – indicating improvement in abortion access with successive time periods due to relaxations in government guidelines. They also estimated that 80% of inaccessible clinic-based abortions could be attributed to the higher medical abortion pill sales from pharmacies. In other words, most abortions that were not accessible in clinics did take place, self-managed at home. They concluded that:
- some women were able to access abortion, though with some delay,
- some might not have their first choice of method but would still get a safe abortion,
- others would require a later abortion than usual, and
- only some would have an unsafe abortion or no abortion at all.
They made strong recommendations for ensuring that as many women as possible would be able to have safe abortions. It seems at this stage this is what actually happened (Shilpa Shroff, personal communication based on information from the Ipas Development Foundation, 8 July 2020) though it remains to be confirmed.
Why else there have been reductions in and closure of existing services
In many cases, hospital appointments for scans and other investigations, and procedures like surgery that were considered safe to postpone have in fact been postponed, not because they were unimportant but because there was a trade-off of what was less urgent to ensure that what was more urgent was provided.
At the same time, many patients have cancelled booked appointments themselves – either because they were told they had to stay home, or were afraid to go out, and because they themselves did not want to attend the appointment. Many felt that going to see a doctor would itself put them at risk, e.g. having to use crowded public transport or because the hospital had Covid-19 patients in it and it didn’t feel safe, even if it was.
There have also been several important surveys of the extent to which the multi-country clinics of international NGOs, such as IPPF and Marie Stopes International, have had to shut down for a period of time or have remained open. The best known survey was that of IPPF in March 2020, covering all its member clinics. It found that “5,633 static and mobile clinics and community-based care outlets [had] already closed because of the outbreak, across 64 countries. They [made] up 14% of the total service delivery points IPPF members ran in 2018”. But this means that 86% of these clinics had not closed. Moreover, only 11 countries reported more than 100 such closures. The report goes on to say that “dozens of countries” reported scaling down services, including those related to HIV testing, provision of certain contraceptives, and services for gender-based violence. They reported that 23 national IPPF members reported reduced availability of abortion care. Shortages of key commodities and supplies and delays in receiving them, such as contraceptives and HIV-related medicines, were also reported. While not wishing to minimise the serious effects of these closures, what is missing is information on how long these conditions persisted.[1]
In general, many reports have concentrated their attention on the bad news, as this one did, and not reported whatever good news there was. There are no numbers provided, for example, of how many thousands of IPPF clinics were able to stay open. Or how many women were still able to have a safe abortion.
In contrast, an interview IPPF did with Niall Behan in Ireland (head of IFPA, national member of IPPF) showed a more positive picture. It reports, for example, that “frontline workers continued to provide essential services” even though travel was banned, businesses, schools and colleges were closed, and more. He described a significant negative effect on some essential SRH services, e.g. national cervical and breast screening programmes were paused, the vast majority of public STI testing clinics were closed, and long-acting contraceptive provision was reduced. At the same time, however, pharmacies remained open for other contraceptives and condoms, and abortion began to be provided early on by telemedicine. All in all, what happened was that services involving a lot of face-to-face contact between providers and patients were reduced for health protection reasons, not because they were considered inessential. And Ireland become the first country to permit telemedicine for abortion.
A report from Nigeria provides another, more complex picture. In a webinar on 3 June 2020 chaired by the Center for Global Development, Salma Anas-Kolo, Director/Head, Department of Family Health, Federal Ministry of Health, Nigeria, acknowledged that at first, things initially went very wrong. For example, fear of infection amongst both health workers and patients stopped patients from attending clinics and stopped healthcare providers from going to work and running the clinics. Seeing this, the Ministry of Health communicated with their focal points at state level and they in turn more locally and worked together to develop a multi-faceted programme to:
- increase the health workforce by engaging retired nurses and midwives,
- provide awareness-creation activities to let the public know services were open, such as adolescent-friendly services,
- find new ways to ensure that commodities including contraceptives and other medicines could come into the country, be transported from the borders and delivered locally, and
- plan for how services would need to adapt to ensure access – including SRH services and particularly primary care services, where women, adolescents and children get most of the health care they need.
Most abortions are illegal in Nigeria, but the government at least recognised the risks involved, just as they were concerned about the risk of an increase in maternal deaths more widely if antenatal and delivery care were abandoned. Who knows, this may influence abortion law and service delivery reform later, with the right encouragement.
Meanwhile, the staff of the Ms Rosy Hotline, the reproductive health information hotline in Nigeria of the Generation Initiative for Women and Youth Network (GIWYN), were taking calls (working from home) from women who needed information and help. In light of those calls, they expanded the topics they covered to include more forms of self-care. The numbers of calls quickly increased by 16% from 2,700 to 3,020 per month soon after awareness of the growth in Covid-19 cases became known. They learned that the price of commodities in pharmacies had increased and that it sometimes took 2-3 days to obtain contraceptives or abortion pills. Loss of work and income exacerbated these problems for women, as well as access to the methods.
Increased demand for certain SRH services due to the pandemic, including abortions
Not surprisingly, there has been an increase in demand for certain services due to the pandemic. For example, it has been reported from a good number of countries that calls to helplines from women experiencing violence at home have increased a great deal. It has also been suggested that some women with early pregnancies might decide that the pandemic is not a safe time to have a baby, and that they will seek unplanned abortions for previously wanted pregnancies. For example, in a report from Thailand the Tamtang Group and the Thai Unwanted Pregnancy Hotline 1663 showed that the numbers of women seeking an abortion had significantly increased in the first two months of the pandemic, even while barriers to obtaining an abortion had also increased, such as travel bans.
Below, I note similar findings from Britain, and it is not unlikely that other countries may find the same.
The contribution of safe abortion information hotlines, funds and support networks to ensuring access
There are currently safe abortion information hotlines in about 10% of countries worldwide, most of them in Latin America, sub-Saharan Africa and Asia, almost all in countries where access to abortion is legally restricted. All of them have been super-busy advising women. There are also two major international hotlines, who are working hard to compensate for the loss of clinical access. Lastly, there are abortion funds and support networks in a number of countries – e.g. USA, Mexico, and the new Abortion without Borders Network covering six European countries – who have all helped women, e.g. by funding their costs, somewhere to stay and any travel to reach a clinic. Almost all of them have noted an increase in calls for help during the pandemic, which they have been doing their best to meet.
Advocacy for increased access to safe abortion has not stopped either
Action on the part of NGOs and advocates for the right to safe abortion have also been ongoing in many countries, including those seeking to challenge additional barriers to legal abortions. In Thailand, a large group of NGOs sent a letter to the Director of the Department of Health of Thailand, calling for access to contraception and safe abortion to be ensured during the Covid-19 pandemic. It proposed the following amazing list of recommendations:
- ensure that women can travel outside their province to access abortion services if need be;
- initiate measures to prevent unintended pregnancy by providing both short-acting and long-acting reversible contraceptives, particularly making post-abortion contraception accessible and widely available;
- seek strategies with other concerned agencies to ensure there is no shortage of abortion pills;
- consider integrating telemedicine for abortion into health services for the safety of both women and providers;
- raise awareness of the public and all Ministry of Public Health service providers of safe abortion services and women’s access to services:
- collect national data on current barriers to accessing safe abortion during Covid-19;
- ensure that governmental hospitals are ready to provide post-abortion care to women with complications from clandestine abortion;
- develop policies and long-term strategies to increase the number of governmental hospitals providing safe abortion services in at least one hospital in each province.
In the Philippines, on 28 May 2020, the International Day of Action for Women’s Health, Clara Rita Padilla of EnGendeRights, a member organisation of the Philippine Safe Abortion Network (PINSAN), posted a photo of herself on Facebook holding a copy of a proposed bill to decriminalise abortion in the Philippines, which went viral.
In Namibia, on 11 June 2020, in the media, a young woman called on Namibians to support a petition to make abortion legal and to change the 1975 law imposed by South Africa, whose own abortion law changed dramatically in 1996. In launching the petition, she said that the right to access legal abortion in Namibia should be accompanied by education relating to sexual health and reproductive rights, to prevent unwanted pregnancies, baby dumping and encourage safe, legal abortions. She further urged the government to ensure that women and young girls in Namibia are aware of their right to sexual and reproductive health, control of their health, lives and bodies, and to achieve gender equality. In response, the Deputy Health Minister Ester Muinjanguesaid she would bring this up in parliament. Perhaps the President Hage Geingob will make good on his acknowledgement last year that government would have to legalise abortion to prevent needless deaths from backstreet abortions.
Disputed reports: Clinics are closed/No, they’re not / Women can’t get abortions/Yes, they can
It is especially important to take note of disagreements between advocates as to what has been happening in their own countries. We depend on Campaign members and others to send accurate information to us, backed by evidence, to share in the newsletter and on social media. Thankfully, it is rare for such disagreements to occur, yet this has happened more than once since the Covid-19 pandemic began. The countries involved have included Russia and Romania.
In the case of Russia, a women’s group told a news channel that a large number of women were at risk of unsafe abortions in Moscow because all but three of the 44 abortion clinics were not providing abortions, based on a survey she had done of all of them. She said this had resulted from an emergency decree by the mayor’s office calling for all non-urgent operations to be postponed so that facilities could be used for Covid-19 patients. What was considered non-urgent was not defined, but it led to many abortions being postponed as “not posing a threat to life”. The clinic closures were disputed by the health department at the mayor’s office, who claimed that only one maternity ward, re-purposed for Covid-19 patients, had discontinued abortions. A Campaign member told us this re-purposing had happened as well, without stating how frequent it was. She pointed out that this was because abortions take place in the gynaecology departments of hospitals. She also noted that in a few regions outside Moscow, local health authorities had tried to stop providing abortion services for a while, claiming it was not an emergency service but that her NGO had challenged them and they had begun services again.Later, another of our members contacted senior figures in all eight federal districts of Russia. In their responses, all regional leaders said that abortion is a form of emergency medical care, even during Covid-19, not routine care, which could have limited them, and were firm that the consequences of not having access to abortion would be unacceptable. Therefore, they said, all abortions take place without delay, and in the usual manner. See Conflicting reports on whether abortions have been stopped in Moscow (29 April 2020) and All eight federal districts providing abortions (7 May 2020).
In the case of Romania, a long-standing Campaign member sent us a published report in July 2019 that said 30% of public hospitals were refusing to provide abortion services. In mid-April 2020, we received a report that had been published early that month, which said that all on-request abortions had been suspended across the country due to the pandemic – notwithstanding statements made by the Minister of Health and the president of the Ob-Gyn Society of Romania supporting abortion provision in line with current law. On 10 April, 15 women’s rights organisations wrote urgently to the Minister of Health to ask him to restoreseveral essential women’s health services, including abortion on request up to 14 weeks, as per the law. On 27 April, the Ministry of Health Obstetrics & Gynaecology Commission sent a circular to all District Health Authorities, recommending the inclusion of abortion among the emergency services being provided during Covid-19, as follows: “Women who request an abortion within the legal time limit shall have unrestricted access to a specialist consultation and medical assistance.” One of the NGOs decided to monitor what then happened on the ground. They learned that of 60 hospitals contacted, 31 public hospitals and 5 private hospitals/clinics were again providing abortions on request. Their report was published on 30 April, and we reported this in the Campaign newsletter on 28 May 2020.
Meanwhile, the Campaign press officer had been contacted by a BBC team working on a video entitled Women turn to backstreet abortions during coronavirus. It was to be on how the pandemic was affecting access to abortion services, including in Romania. Their video was published on YouTube on 29 June 2020. In it, when Romania comes up, a fictional character is shown saying she had called hospitals trying to get an abortion but was refused. Then a woman from a Romanian women’s group states that more and more hospitals are refusing to do abortions and using the pandemic as an excuse. The video shows her phoning a hospital on 4 May to ask for an abortion; the reply she gets is that they have not done abortions since the end of March. Off the phone, she repeats that no hospitals are doing abortions; that that is how desperate the situation is. The previously shown fictional character is then portrayed as about to have an abortion with pills on her own, not by her own choice and very frightened. The information about Romania that we had provided to them was not reported.
The BBC team also interviewed Mara Clarke of the Abortion Support Network (ASN), who told them about many of the women that ASN and Abortion Without Borders have been helping to find abortions during the pandemic. She also told them about the experience of one of only two women whom they had not been able to help during the pandemic – among the hundreds of women theyhadhelped access safe abortions. Mara asked for assurance that the story would show that safe abortion access was still happening. Instead the piece focused solely on worst case scenarios. Afterwards, Mara described the BBC video on Facebook as scaremongering and dangerous to women, reporting only the worst case scenarios and not providing resources or even hope to women who might need abortions during the pandemic.
This video had had 2,914 views on 14 July 2020 when I last watched it. Yet it is an example of false news pretending to be pro-choice. It’s not just that reports like these may contribute to people thinking things are much worse than they are. Some women may not even try to find services because they think the services are all closed, and that no one gives a damn.
Evidence of how quickly a change of policy can change what is true
Earlier, I said that what was true in the first 1-2 months into the pandemic may well change in the third, fourth and subsequent months in many different ways. On one hand, a country may have been in total chaos at the beginning but then begin to get control over the situation, decide to allow people to use public transport to access healthcare and re-open services that were closed. Or the opposite may happen. Every country has been a different story.
Here’s an example from Britain of how quickly things can change. On 18 May 2020, an article was published in the Journal of Law and the Biosciences on ensuring access to abortion care during the pandemic, focusing on Britain and the USA. It reported that Bpas, the largest independent British abortion provider, provided 72% of all abortions in England and Wales in 2018. The article stated that when the virus hit Britain, Bpas was forced to close 23% of their clinics due to staff shortages related to the virus. It also reported that Bpas had estimated that at the end of March 2020 there would be some 44,000 people needing abortions in April, May and June 2020 and that an estimated 15,000 people had already conceived by 23 March 2020, when lockdown began, and would require an abortion during lockdown. The authors expressed grave concern that all these people were “at risk of either ending up continuing unwanted pregnancies or having second trimester abortions, which have a higher rate of complications” –and quoted a range of sources to support these concerns.
But what has actually happened. Two Bpas staff members, Clare Murphy and Rachael Clarke, have confirmed that these early figures were accurate. However, almost two months before the journal article was published, a great deal changed almost overnight. Telemedicine for early abortions was permitted by the British government starting on 30 March 2020 and for the duration of the pandemic. This meant women could obtain approval for an abortion telemedically, receive abortion pills by post, self-manage their abortion at home, and have post-abortion follow-up telemedically as well. Hey presto! None of the dire predictions of the journal article came true.
Clare Murphy said: “In June we still had some clinics closed although this was not really due to staff shortages but because the new model (telemedicine) meant we didn’t need to have so many open as most women were receiving care at home. They prefer to do this rather than travel to a clinic, which may be some distance from where they live.” (E-mail, 13 July 2020)
Rachael Clarke, added: “The clinic closures helped to convince the government to approve both home use of mifepristone and telemedicine. Once that was in place (in Bpas clinics from 8 April), although some smaller clinics remained closed, there was not the impact on accessibility. On the contrary, at the end of April 2020, we treated 35% more women than usual, and that is now hovering around 10% above pre-Covid-19 levels. We have provided over 15,000 remote early medical abortions since it was introduced. We’ve also seen a decline in staff sickness and self-isolation and a decline in issues such as shortages of personal protective equipment, which forced consolidation of services. We’re also now going to see a public consultation by the government on whether to keep this system in place permanently, which was what we were pushing for, so we’re really happy about that.” (E-mail, 14 July 2020)
It took Britain decades to allow self-managed abortion with pills and add in telemedicine. Then it happened almost overnight.
Conclusion
There are many countries we haven’t heard from yet on these matters, particularly those with the most restrictive abortion laws and practice. Nor, as far as I know, has anything been published on the effects of the pandemic on post-abortion care.
In conclusion, I hope that in the midst of this terrible pandemic, which has shown how little so many people understand about global public health and preventing pandemic diseases, we can look into the mirror of history and say that at least in a substantial number of countries, there has been a recognition of the public health need for safe abortions, as one part of the right to decide whether and when to have children. How we go forward after this pandemic ends, I believe, needs to be placed in the larger context of achieving global public health – a small but essential part of which is universal access to safe abortion as a woman’s right.
Postscript
To fill the gaps in knowledge identified here, we invite reports on what is happening in countries that the newsletter has not yet covered – reports based on evidence, not on fearmongering.
[1] I have been unable to locate the May 2020 follow-up survey on the IPPF website, which would answer this question.