Abortion an essential health service, can't be banned by US states amid coronavirus pandemic: Experts
The governors of many US states have called for a halt to abortion care throughout the coronavirus pandemic. However, US health experts have now written that abortion is an essential health service that women must have access to.
Abortion cannot be categorized as an "elective" or a "non-essential" service, say experts from Harvard Medical School, Boston, Brigham and Women's Hospital, Boston, and Northwestern University, Chicago.
"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 a moral judgment than a medical judgment, 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 abortion," write authors in a perspective in the New England Journal of Medicine (NEJM).
According to experts, the new restrictive state policies and the speed with which some governors have suspended abortion care highlight the extreme vulnerability of abortion access in the US.
They say that the coronavirus pandemic has illuminated several weaknesses in the US healthcare system, and one lesson should be that the country's system of abortion care delivery must be strengthened in ways that prevent abortion access from being so easily rescinded in times of health system stress, whether minor or substantial.
"Each year, nearly 1 million women choose to end a pregnancy in the US 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 the economic, social and political equality of women as a group," says the team.
Experts say that classifying a surgical procedure as an elective in the rest of medicine does not 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," they warn.
Current situation
Explaining what states have done, experts write that governors in Texas, Louisiana, Mississippi, Alabama and Oklahoma have ordered or supported the stopping of both medication and surgical abortion, while governors in other states have directed that surgical abortion alone must stop.
Medication abortion here implies the use of pills to end a pregnancy in the first trimester, while 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, 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 authors write. They explain that the orders have had immediate effects on patients, and thousands of women have been turned away from abortion care.
Authors say while 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, this argument does not make sense.
They explain that women who are unable to get 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. 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 healthcare service. Elective abortion has been physically separated from other routine healthcare services; it is predominantly performed in independent clinics, even though it could be performed in most private obstetrics and gynecology practices," they write.
Experts further explain that 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. They argue that during the COVID-19 pandemic, such access is even more important, and the reasons are multiple.
"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," they write.
"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. Quarantine and shelter-in-place orders have increased intimate partner violence, which sometimes includes sexual coercion and assault that may result in unplanned pregnancies," say the authors.
A comment in The Lancet also says previous humanitarian crises have shown the crucial role of contraception and medication abortion for the prevention of unintended pregnancy and maternal mortality.
Experts from the US and London say that a sexual and reproductive health and justice policy agenda must be at the heart of the COVID-19 response.
"Past humanitarian crises shown that reduced access to family planning, abortion, antenatal, HIV, gender-based violence, and mental health care services results in increased rates and sequelae from unintended pregnancies, unsafe abortions, sexually transmitted infections, pregnancy complications, miscarriage, post-traumatic stress disorder, depression, suicide, intimate partner violence, and maternal and infant mortality," they write.
National discourse
Experts say that the national discourse has also portrayed abortion providers as ‘outside’ healthcare, 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," they write.
The team says the medical fraternity must also be blamed. They say that the procedure has been marginalized by healthcare 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 US 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 physicians who are providing pregnancy-termination services amid a pandemic more vulnerable than ever," say experts.
What are medical bodies saying?
The American Medical Association (AMA) issued a statement on March 30 in support of continued access to abortion. The letter emphasizes that physicians, not politicians, should decide which procedures are urgent, and which ones can be delayed.
"While many physicians and healthcare workers are on the front lines in the COVID-19 pandemic, it is unfortunate that elected officials in some states are exploiting this moment to ban or dramatically limit women’s reproductive health care, labeling procedures as 'non-urgent'. The AMA will always defend shared decision making and open conversations between patients and physicians, and fight government intrusion in medical care," says the statement.
The American College of Obstetricians and Gynecologists (ACOG) and other reproductive health professional organizations also issued an unequivocal statement on March 18, stating that they "do not support COVID-19 responses that cancel or delay abortion procedures."
"Community-based and hospital-based clinicians should consider collaboration to ensure abortion access is not compromised during this time. Abortion is an essential component of comprehensive health care. It is also a time-sensitive service for which a delay of several weeks, or in some cases days, may increase the risks or potentially make it completely inaccessible. The consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being," reads the statement.
Writing in the NEJM, authors also recommend that the medical profession’s response to the COVID-19 pandemic must include continuing to meet other urgent healthcare needs, including the need for time-sensitive 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," say experts.