The impact of COVID-19 on abortion access: Insights from the European Union and the United Kingdom

Constitutional enshrinement as a way of safeguarding abortion rights: The case of France

France's landmark constitutional amendment in 2024 enshrines abortion freedom in its supreme legal framework, representing a profound milestone against the backdrop of shifting global political and social attitudes toward abortion. This decision, influenced by disruptive events such as the COVID-19 pandemic and the overturning of constitutional abortion rights in the United States, places France to the forefront of protecting abortion access. Despite ongoing challenges in accessing services in certain areas and circumstances, this amendment sets a precedent for other nations considering similar protections. We offer key insights into this case and reflect on how it can potentially shape legislative trends in abortion rights worldwide.

Medication abortion during the COVID-19 pandemic in France: A research based on the French national health insurance database

OBJECTIVES

During the COVID-19 pandemic in France, abortion was recognized as an essential service that cannot be delayed, and such care was therefore presumed to be maintained. The aim is to analyze the changes in the practice of abortion in 2020 to identify the consequences of the two lockdowns and the effects of the extension of the legal time limit.

METHODS

We analyzed the data collected by the French national health insurance system, which covers 99% of the population. All women who had an elective abortion, either surgical or with medication, in France in 2019 and 2020 were included in the study. Trend changes in abortions were analyzed by comparing the ratio of the weekly number of abortions in 2020 with the weekly number in 2019.

RESULTS

Both 2020 lockdowns were followed by a drop in abortions, particularly after the first and stricter lockdown. This may be explained not by an abrupt shutdown of access to abortion services, but rather by a decrease in conceptions during the lockdown weeks. The decrease was more marked for surgical abortions than for medication abortions in a hospital setting, and less so for medication abortions in non-hospital settings. Moreover, the proportion of the latter type of abortions continued to increase, showing the reinforcement of a previous trend.

CONCLUSIONS

Our findings indicate that expanding the legal time limit for abortion, diversifying the settings where abortions can be performed and the range of abortion providers help to facilitate access to this fundamental reproductive care.

North Korea's COVID-19 policy dilemma: epidemic prevention conflicting with trade

BACKGROUND

Amidst the COVID-19 pandemic, striking a delicate balance between sustaining economic activity and safeguarding public health has become a crucial concern. The border closures for COVID-19 prevention have further intensified concerns for North Korea, which conducts over 90% of its trade with China and Russia, countries sharing its borders.

METHODS

This study aims to scrutinize North Korea's response to these competing imperatives by examining the impact of border closures on the country's trade dynamics with China and Russia. This study employed the difference-in-difference (DID) method to analyze transformations in North Korea's economic activity before and after the border closures, utilizing trade data and nighttime satellite imagery captured in 2019 and 2020.

RESULTS

The results reveal that North Korea actively reoriented its trade priorities towards Russia and accorded precedence to its epidemic prevention system over its economy during the pandemic. A noticeable increase in imports of food and pharmaceuticals was observed, indicating a significant rise in the inflow of these essential commodities.

CONCLUSION

The findings of this study suggest that during the early stages of the COVID-19 pandemic, North Korea placed significant policy emphasis on preserving public health. However, due to economic hardships and food shortages, if the pandemic persists in the long term, it indicates the possibility of partial or complete lifting of border closures to mitigate these challenges.

The impact of COVID-19-related restrictions on pregnancy and abortion rates in the Republic of Georgia

BACKGROUND

The Republic of Georgia implemented COVID-19-related restrictions starting on 31 March 2020, when it imposed a 1-month strict lockdown, after which the country continued with some form of restrictions for 1 year. These restrictions created barriers to healthcare access, affected healthcare services, caused severe economic degradation, and changed reproductive behavior. The aim of this study was to explore the impact of COVID-19-related restrictions on pregnancy and abortion rates in Georgia.

METHODS

Information on pregnancy, abortion, and related variables was extracted from the Georgian Birth Registry from January 2018 through April 2022. The final study sample included 232,594 pregnancies and 86,729 abortions. We used interrupted time series analysis to study the impact of COVID-19-related restrictions.

RESULTS

There were slightly decreasing trends in pregnancy and abortion rates in the pre-pandemic period (1 January 2018-31 March 2020). During the 1-month strict lockdown (1 April-30 April 2020), pregnancy and abortion rates decreased in all investigated age groups. There were no substantial differences in pregnancy or abortion rates in the pandemic period (for pregnancies: 1 April 2020-30 June 2021; for abortions: 1 April 2020-30 April 2022) compared to the pre-pandemic period. The precision of all estimates suggested that both small increases and decreases in pregnancy and abortion rates are reasonably compatible with our data.

CONCLUSIONS

Despite the 1-year-long COVID-19-related restrictions, our results did not indicate substantial long-term changes in pregnancy or abortion rates during the study period for any age group. This may indicate that the restrictions did not substantially influence access to contraception, abortion services, or reproductive behavior.

Prevalence of Abortions Prior to and During the COVID-19 Pandemic in a Large Health Care System

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic presented patients with numerous barriers to accessing health care, including access to reproductive health services. The goal of this study was to assess the prevalence of abortion prior to versus during the COVID-19 pandemic within a large health care system to better understand if patients were able to access abortion care.

METHODS

This was a retrospective, data-only cohort study examining the prevalence of abortion among patients aged 15 to 44 within Kaiser Permanente Northern California (KPNC) in the first 6 months of the COVID-19 stay-at-home order (April 1 to September 30, 2020) compared with a 6-month period in the year prior to the COVID-19 pandemic (April 1 to September 30, 2019). Analyses were conducted using χ2 and t tests, with a P value < .05 considered statistically significant.

RESULTS

The prevalence of abortion among patients at risk of pregnancy in 2019 and 2020 was identical, at 0.04% (P = .93). Baseline characteristics were similar between the 2 periods. The prevalence of smoking among patients who had an abortion in 2019 was 11.24%, compared with 9.04% in 2020 (P = .0009). Additionally, 85.80% of patients had KPNC insurance 6 months after the abortion in 2019, compared with 89.53% in 2020 (P < .0001).

DISCUSSION

The prevalence of abortion remained similar prior to and during the first 6 months of the COVID-19 pandemic within KPNC. Patients seeking abortion were less likely to smoke and were more likely to have consistent insurance 6 months after their abortion in 2020 versus 2019, potentially suggesting the COVID-19 pandemic resulted in healthier behaviors and more consistent access to health care. Despite stay-at-home orders and canceling of in-person clinic visits, abortion services remained accessible to a diverse population within a large health care system.

Accessing abortion in a highly restrictive legal regime: characteristics of women and pregnant people in Malta self-managing their abortion through online telemedicine

OBJECTIVE

To examine the numbers and characteristics of women and pregnant people in Malta seeking at-home medical abortion using online telemedicine from 2017 to 2021.

DESIGN

Population-based study.

SETTING

Republic of Malta PARTICIPANTS: Between 1 January 2017 and 31 December 2021, 1090 women and pregnant people requested at-home medical abortion through one online telemedicine provider (Women on Web). Mifepristone and misoprostol were shipped to 658 women (60.4% of requests).

MAIN OUTCOME MEASURES

The numbers and demographics of persons to which abortion pills were shipped, their reasons for accessing abortion, and reasons for requesting medical abortion via telemedicine between January 2017 and December 2021 were analysed. Selected data were compared across different groups.

RESULTS

The number of people in Malta to whom medical abortion pills were shipped increased significantly in the 5 years analysed. Women and pregnant people requesting medical abortion were diverse with respect to age, pregnancy circumstances and reasons for seeking an abortion. More than half had existing children and over 90% reached out to Women on Web at <7 weeks. Among those completing a medical abortion, 63% did not use contraception, and in 30% there was contraception failure. The most common reasons for ordering medical abortion pills online were difficulty accessing abortion because of legal restrictions (73%) and abortion pills not being available (45%) in the country.

CONCLUSIONS

Despite a complete ban on abortion, the number of women and pregnant people residing in Malta completing at-home medical abortions is considerable and has been steadily increasing.

"In some clinics, they said it's elective, and then they would refuse": A Mixed-Methods Study on the impact of the COVID-19 pandemic on access to abortion services in Germany

OBJECTIVE

The World Health Organization recognizes abortion as essential health care and has encouraged governments to ensure access to abortion services throughout the COVID-19 pandemic. However, the threat of infection combined with government responses to COVID-19 have impacted access to abortion services globally. This study explores access to abortion in Germany during the pandemic.

METHODS

This study used a mixed-methods design. An analysis of data collected by Women on Web (WoW) was carried out to assess women's reasons for choosing telemedicine abortion outside the formal health system in Germany during the pandemic. Descriptive statistics were generated for 2057 requests for telemedicine abortion received by WoW between March 2020-March 2021. Semi-structured interviews were conducted with eight healthcare professionals involved in the provision of abortion services to explore how they perceive of women's access to abortion services in Germany during the pandemic.

RESULTS

The quantitative analysis found that preferences and needs for privacy (47.3%), secrecy (44.4%) and comfort (43.9%) were the most common reasons for choosing telemedicine abortion. COVID-19 was another important reason (38.8%). The thematic analysis of the interviews was organized into two overarching themes: service provision, and axes of difference.

CONCLUSIONS

The pandemic affected the provision of abortion services as well as the circumstances of women seeking abortion. The main barriers to access were financial constraints, privacy issues, and lack of abortion providers. Throughout the pandemic, accessing abortion services was more difficult for many women in Germany, especially women experiencing multiple and overlapping forms of discrimination.

SDG5 "Gender Equality" and the COVID-19 pandemic: A rapid assessment of health system responses in selected upper-middle and high-income countries

Introduction

The COVID-19 pandemic disrupted healthcare and societies, exacerbating existing inequalities for women and girls across every sphere. Our study explores health system responses to gender equality goals during the COVID-19 pandemic and inclusion in future policies.

Methods

We apply a qualitative comparative approach, drawing on secondary sources and expert information; the data was collected from March-July 2022. Australia, Brazil, Germany, the United Kingdom, and the USA were selected, reflecting upper-middle and high-income countries with established public health and gender policies but different types of healthcare systems and epidemiological and geo-political conditions. Three sub-goals of SDG5 were analyzed: maternity care/reproductive health, gender-based violence, and gender equality/women's leadership.

Results

We found similar trends across countries. Pandemic policies strongly cut into women's health, constrained prevention and support services, and weakened reproductive rights, while essential maternity care services were kept open. Intersecting gender inequalities were reinforced, sexual violence increased and women's leadership was weak. All healthcare systems failed to protect women's health and essential public health targets. Yet there were relevant differences in the responses to increased violence and reproductive rights, ranging from some support measures in Australia to an abortion ban in the US.

Conclusions

Our study highlights a need for revising pandemic policies through a feminist lens.

Seeking abortion care in Ohio and Texas during the COVID-19 pandemic

OBJECTIVES

Political and public health responses to the COVID-19 pandemic changed provision of abortion care and exacerbated existing barriers. We aimed to explore experiences of individuals seeking abortion care in 2 abortion-restrictive states in the United States where state policies and practice changes disrupted abortion provision during the pandemic.

STUDY DESIGN

We conducted 22 semistructured interviews in Texas (n = 10) and Ohio (n = 12) to assess how state executive orders limiting abortion, along with other public health guidance and pandemic-related service delivery changes, affected individuals seeking abortion care. We included individuals 18 years and older who contacted a facility for abortion care between March and November 2020. We coded and analyzed interview transcripts using both inductive and deductive approaches.

RESULTS

Participants reported obstacles to obtaining their preferred timing and method of abortion. These obstacles placed greater demands on those seeking abortion and resulted in delays in obtaining care for as long as 11 weeks, as well as some being unable to obtain an abortion at all.

CONCLUSIONS

Political and public health responses to the COVID-19 pandemic - exacerbated pre-pandemic barriers and existing restrictions and constrained options for people seeking abortion in Ohio and Texas. Delays were consequential for all participants, regardless of their ultimate ability to obtain an abortion.

IMPLICATIONS

During the COVID-19 pandemic, state executive orders and clinic practices exacerbated already constrained access to care. Findings highlight the importance of protecting timely care and the full range of abortion methods. Findings also preview barriers individuals seeking abortion may encounter in states that restrict or ban abortion.

[Single dose of misoprostol for abortion until 9 weeks of gestation]

OBJECTIVES

The primary objective was to compare the efficacy of a single-dose misoprostol for abortion before 7 weeks of gestation and between 7 and 9 weeks of gestation. The secondary objectives were to compare the amount of misoprostol required for complete expulsion, the need for endo-uterine aspiration, and to assess pain and patient experience in these two groups.

METHODS

This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020.

RESULTS

A total of 306 patients were included, 150 in the group before 7 weeks of gestation and 156 in the group between 7 and 9 weeks of gestation. There was no significant difference in the success rate of the single dose of misoprostol between the two groups with 34.7 and 37.8% respectively (P=0.63). After taking painkillers, there is no difference in terms of pain relief (EN ≤ 4 for 92 et 95% of patients P=0.37).

CONCLUSION

The single dose of misoprostol for in-hospital abortion is as effective between 7 and 9 weeks of gestation as it is before 7. By extension, therefore, we would suggest that there should be no difference in efficacy between home abortions before 7 weeks of gestation and between 7 and 9 weeks of gestation and therefore suggest that home abortions can be performed up to 9 weeks of gestation without fear of a decrease in the rate of complete expulsion and the efficacy of analgesia, with potentially less use of misoprostol compared with the hospital setting.

Reflections on abortion rights: From policy to medicine

On June 24, 2022, the US Supreme Court overturned Roe v. Wade, which marked a further restriction on women's abortion rights in the US. It has sparked a wide range of societal reactions around the world. Women in different countries enjoy diverse abortion rights due to conditions in their respective nations and cultures. Abortion protects women's rights to a certain extent, and especially in the event of unintended pregnancy. An inappropriate abortion ban will affect women's health and lives and all aspects of medicine, including the lives of doctors, patient access, and the development of medical technology. This review provides a gynecologist's perspective on the impact of abortion policies on women's health and the medical system. This review also attempts to determine the reason for the government's abortion ban.

The impact of the coronavirus disease 2019 pandemic on abortion access and pre-abortion mental health in Shanghai

OBJECTIVE

To understand the barriers to abortion in Shanghai during the COVID-19 pandemic, and to compare pre-abortion mental health status before and during the crisis.

METHODS

In this case-control study, two groups of women seeking abortion (age ≥18 years, pregnancy duration <98 days) were recruited from March to September, 2021 (n = 1070) and from February to April 2022 (n = 625). The evaluation included COVID-19-related abortion stress questions, the Symptom Checklist-90 Revised questionnaire, the Pittsburgh Sleep Quality Index (PSQI), and the Family Environment Scale Chinese version. The researchers conducted interviews and collected questionnaires.

RESULTS

The median pregnancy duration at abortion among women during the pandemic was 65 days, compared with 51 days in the pre-pandemic group (P < 0.001). Anxiety and depression symptoms increased during the crisis (P < 0.001). Sleep disturbances were more common. Higher PSQI scores were related to increased anxiety and depression symptoms. A more negative family climate was described during the pandemic.

CONCLUSION

During the COVID-19 pandemic, abortion access was delayed and pre-abortion mental disorders increased. More attention should be paid to the mental health of women seeking abortions, and innovations should be promoted to ensure abortion services without delay.

Advancing Reproductive Health through Policy-Engaged Research in Abortion Care

Mifepristone medication abortion was first approved in China and France more than 30 years ago and is now used in more than 60 countries worldwide. It is a highly safe and effective method that has the potential to increase population access to abortion in early pregnancy, closer to home. In both Canada and the United States, the initial regulations for distribution, prescribing, and dispensing of mifepristone were highly restricted. However, in Canada, where mifepristone was made available in 2017, most restrictions on the medication were removed in the first year of its availability. The Canadian regulation of mifepristone as a normal prescription makes access possible in community primary care through a physician or nurse practitioner prescription, which any pharmacist can dispense. In this approach, people decide when and where to take their medication. We explore how policy-maker-engaged research advanced reproductive health policy and facilitated this rapid change in Canada. We discuss the implications of these policy advances for self-management of abortion and demonstrate how in Canada patients "self-manage" components of the abortion process within a supportive health care system.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave

BACKGROUND

There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium.

METHODS

Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence.

RESULTS

Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy.

CONCLUSIONS

Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

The International Sexual Health And Reproductive Health Survey (I-SHARE-1): A Multi-Country Analysis of Adults from 30 Countries Prior to and During the Initial COVID-19 Wave

Background

The COVID-19 pandemic forced billions of people to shelter in place, altering social and sexual relationships worldwide. In many settings, COVID-19 threatened already precarious health services. However, there is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of COVID-19 disease. To address this gap, our team organized a multi-country, cross-sectional online survey as part of a global consortium.

Methods

Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service utilization, and we compared three months prior to and three months after policy measures to mitigate COVID-19. We used established indicators and analyses pre-specified in our protocol. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence using Cochrane methods. Descriptive analyses included 22,724 individuals in 25 countries. Five additional countries with sample sizes <200 were included in descriptive meta-analyses.

Results

Respondents were mean age 34 years; most identified as women (15160; 66.7%), cis-gender (19432; 86.6%) and heterosexual (16592; 77.9%). Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%) people and 640 (14.1%) people reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063/15144, 7.0%) compared to the period before COVID-19 measures (1469/15887, 9.3%). COVID-19 measures impeded access to condoms (933/10790, 8.7%), contraceptives (610/8175, 7.5%), and HIV/STI testing (750/1965, 30.7%). Pooled estimates from meta-analysis indicate during COVID-19 measures, 32.3% (95% CI 23.9-42.1) of people needing HIV/STI testing had hindered access, 4.4% (95% CI 3.4-5.4) experienced partner violence, and 5.8% (95% CI 5.4-8.2) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy.

Conclusion

Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.