The Pandemic And Legal Abortion: What Happens When Access Is Limited?
In April, Johanna Cruz terminated her pregnancy with drugs obtained through a telemedicine consultation.
Abortion is legal in Colombia. And Cruz, a street performer from Chile who was backpacking through the Colombian state of Antioquia, did not feel she was in a position to raise a child. She didn't have a steady income or stable housing. And with stay-at-home orders in place to control the spread of coronavirus, she found herself facing homelessness in the town of San Rafael and unable to travel to Medellin, the nearest city with an abortion clinic.
But one program offered an alternative. In Colombia, patients can now consult with a doctor on a video call to request the medications that induce abortion. They're shipped directly to a patient.
Around the world, the pandemic has made it harder for women — especially young women and women in lower-income or rural settings — to access contraception and abortion services. The International Planned Parenthood Federation reports that over 5,000 reproductive health clinics globally have closed since the start of the pandemic due to COVID-19 lockdowns and social distancing measures. In some cases, they have closed because of a lack of personal protective equipment to keep doctors and patients safe from contracting the virus.
The pandemic also creates new stressors on women trying to seek this type of care. In many countries, there's already stigma associated with sexual and reproductive health services, says Abebe Shibru, country director for Marie Stopes International in Zimbabwe — and for this reason, women often seek out these services in secret. Lockdowns have made it harder for women in Zimbabwe to discreetly access sexual and reproductive care, he adds, because now family members may want to know where they're going order. Women may also face harassment from police officers enforcing stay-at-home orders.
The United States is also trying to de-prioritize sexual and reproductive health services amid the global coronavirus response. In May, the U.S. sent a letter to the U.N., requesting that the agency remove references to "sexual and reproductive health" — including abortion services — in its COVID-19 plan. Women's health groups expressed concern, saying these services are an essential part of health care in an emergency like the pandemic. The U.S. gives more money to the global COVID-19 response than any other country, according to the Kaiser Family Foundation.
Despite the obstacles for health groups as well as their clientele, family planning organizations are finding ways to provide reproductive health services to women. In countries with stay-at-home orders, such as Zimbabwe and Nepal, for example, Marie Stopes International is currently operating call centers that connect women to the nearest clinics. MSI Nepal and Ipas Development Foundation, an organization that promotes access to safe abortion in India, are advocating for local governments to make medical abortion legally accessible from home, either through a trained provider coming to women directly or through a telemedicine consultation.
The virtual option is already happening in Colombia, where Cruz got her abortion.
She reached out to Fundacion Oriéntame, a health group that provides reproductive health care and education. It started using telemedicine to offer abortion services in late March, when the country's stay-at-home order forced several of its locations across Colombia to close or operate under limited hours. Colombia began to relax its stay-at-home measures on June 1, but Oriéntame's clinics will keep their modified schedules until at least July.
Diana Ibeth Díaz Rojas, one of two doctors prescribing medical abortions via telemedicine for Oriéntame, says the lockdown pushed the organization to rapidly launch a virtual software program it had been developing for several months prior to the COVID-19 crisis.
The software facilitates a private and secure video call between the doctors and patients to protect the patient's personal information. The caller can tap in via phone or computer.
During the call, the doctor determines if assesses that the patient qualifies for abortion under Colombia's laws and meets an extra set of requirements for the telemedicine services, including: she must be no more than 9 weeks weeks pregnant and must not have any preexisting conditions that would put her at risk of complications from taking the medications, such as hemorrhaging or ectopic pregnancy. The doctors then prescribes mifeprostone and misoprostol and thoroughly explains how to administer the doses.
"On top of their regular concerns and personal risk factors, a lot of women we've spoken with have also said they feel that the pandemic is an abysmal time to continue a pregnancy," says Díaz Rojas. "There's so much uncertainty surrounding their health, the health of their loved ones, the loss of employment — there are all these added vulnerabilities during this time."
Patients are required to notify Díaz Rojas or her colleague as soon as they take the pills: first the mifeprostone and then the misoprostol 24 to 48 hours later. They are provided with as much virtual support as they need, through video call follow-ups or WhatsApp text messaging, while monitoring the symptoms and reactions — bleeding, pain level, cramps — and be on call in case there are any abnormal reactions resulting in the need to go to an in-person facility.
Still, some health experts are unsure whether abortion via telemedicine is safe. When MSI Nepal proposed it as an alternative method of care during lockdown, the Ministry of Health told the group that they were concerned about how a patient would manage complications that could result from taking the medications — like abnormal bleeding or severe cramping — if she is alone at home without a health care provider nearby.
Patrina Mosley, who focuses on women's issues at the pro-life organization Family Research Council, sees the transfer of abortion services to telemedicine as highly risky.
"Abortions require a high level of physical interaction between the mother and a physician who can examine, diagnosis, evaluate and treat her. Skyping with a doctor and filling out a questionnaire carries many of the same risks as ordering pills online from a doctor you have never met and who cannot physically assess you. Pretending for ideological reasons that chemical abortion can be done remotely or even as a do-it-yourself, is extremely dangerous and negligent."
A study conducted from 2008 to 2015 in the United States and published in the peer-reviewed journal Obstetrics & Gynecology found that the telemedicine model of abortion "is noninferior to in-person provision with regard to clinically significant adverse events."
Although several Colombian insurance providers cover in-person abortion services at Oriéntame, Díaz Rojas says the coverage has not yet extended to telemedicine. The entire procedure — including the first consult, the pills and subsequent conversations — currently costs a little under $100, and the organization has a "justice fund" to lower expenses for women who face economic barriers.
Cruz received her procedure free of charge.
And the conversations with Oriéntame staff are not just about termination of a pregnancy. Some of Díaz Rojas' abortion patients have noted that the lockdown is making it difficult for them to access birth control because they can't renew prescriptions or travel to a pharmacy. So, during the consultation, Oriéntame discusses contraceptive options. They can either choose a method that can be shipped directly to their homes — like birth control pills — or opt for an IUD prescription that a health-care provider can implant when lockdown guidelines are lifted.
"We weren't sending [contraceptives] at the beginning, but we identified a recurring need for emergency birth control as we spoke to more and more patients," says Díaz Rojas. Because they're spending more time at home with their partners, they may be engaging in sex more often, she explains — and "without their usual method of protection, the risk of pregnancy increases."
Some see Colombia's telemedicine services as a model for the rest of the world during the pandemic crisis. Paula Avila-Guillen, who leads the Latin American initiatives program at the Women's Equality Center — which supports global women's groups — says she can see the telemedicine program being deployed across Latin America and eventually becoming commonplace around the world, especially in countries with widespread internet access. It's already being offered in 13 states in the U.S. as a research study with the Food and Drug Administration and in the U.K., where the government approved abortion by telemedicine in March on a temporary status — for two years, or until the coronavirus emergency ends.
"[The doctors at Oriéntame] are really breaking some of the biggest barriers in terms of access. In a country like Colombia where there are so many rural areas, it is very hard for women to actually go to the clinic," she says. "Women have to travel to a certain place to get the procedure — sometimes multiple times [for various consultations and medical appointments] — and they are trying to eliminate the need for travel through telemedicine."
Because the telemedicine services allow Oriéntame to provide abortion services to women who live far away from clinics — women who, Díaz Rojas says, often lack the most education about the procedure and are at higher risk of unsafe abortions that could result in medical and legal repercussions — the clinic will keep its telemedicine option even after the pandemic subsides.
Since beginning to offer the service on March 24, has provided 93 women from dozens of municipalities throughout Colombia with abortion services over telemedicine.
But that number is a concern to Díaz Rojas. She says she'd usually see that same number of patients over the course of a couple of weeks at Oriéntame's biggest clinic in Bogota. The disparity in numbers could be attributed to women not knowing about the availability of the services, she says. Or — given the stigma associated with abortions in Colombia, she notes — perhaps women are unable to hide the symptoms the at-home procedure causes, such as bleeding and cramping, from the people they live with during a time of lockdown. She and other experts wonder how many women aren't able to get access to the service.
Avila-Guillen also notes that because the service is provided through a smartphone and internet, that could be an issue, especially in rural areas and areas that don't get internet access. As of December 2019, Colombia's Ministry of Information Technologies and Communications reported that nearly half the country lacks mobile internet access.
Cruz thankfully did not suffer from any complications during her abortion. Over WhatsApp, she wrote that she never felt alone during the process — even while undergoing a stressful living situation.
"[Oriéntame] followed my situation very closely [as I moved from place to place] and called me to check in until I was finally able to do the procedure in a safe environment," she says. "They were very attentive throughout the entire process."
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