Will Covid-19 change how women access abortions?

States across the United States including Texas and Ohio have responded to coronavirus by attempting to further restrict abortion by targeting clinics with expensive lawsuits. Meanwhile, the Polish parliament began to debate outlawing the procedure in cases of foetal anomaly while its citizens were locked down at home.

These two examples show that the coronavirus pandemic has made abortion more difficult in many ways. Outside of legal restrictions, financial hardship and health systems overloaded by the need to respond urgently to COVID-19 cases have also made terminations more difficult.

But alongside these temporary difficulties, there has also been a quiet transformation in the accessibility of medical abortions with many people finding themselves able to manage their own terminations safely at home for the first time.

In March, the UK government authorised the use of abortion pills at home to terminate unwanted pregnancies during the pandemic to prevent patients needing to travel to clinics to take the medication in the presence of a doctor. Canada has made similar moves, and Australia has made remote consultations available on the public health system for the first time.

Now some researchers and advocates are campaigning to make temporary rulings in countries like the UK, Australia and Canada that expand access to abortion more permanent. In some places, the result of the coronavirus pandemic may be that abortion becomes cheaper and easier to access.

The Abortion Pill Revolution

A medical abortion involves taking two pills – mifepristone and misoprostol – over a period of a few days to induce a miscarriage. This is usually done in the presence of a doctor, but can also be done safely at home in a phone consultation with one.

The World Health Organization recommends that abortion pills can be used safely up to 12 weeks’ gestation, though it is often restricted to shorter durations than that. In the US, the Food and Drug Administration authorises the use of the pills up to 10 weeks. In Australia, the pills are covered on the Pharmaceutical Benefits Scheme up to 9 weeks. France recently extended the gestational limits on medical abortion from five weeks to seven.

The pills have also provided abortion care in countries with severe restrictions on the procedure such as Poland and Malta, and, previously, Ireland and Northern Ireland before those counties liberalised access. Activists from Women on Web and Women Help Women mail the pills out to people who then self-manage their abortions at home despite domestic restrictions on the practice.

Sydney Calkin, a lecturer in human geography at Queen Mary University of London, said efforts like these are making formal abortion restrictions less relevant in many countries.

“The availability of abortion pills and the safety, access and acceptability of self-managed abortion means that abortion access is changing, regardless of the law,” she said.

In the US, where abortion is legal in all 50 states but heavily restricted in some of them, Calkin said the availability of pills through the mail often prevents people having to travel significant distances to have an abortion in a clinic.

“Even before COVID the availability and safety of pills were starting to change the way people thought about abortion and the lengths to which they were willing to go to access an abortion in a clinical context. And I think that COVID will really accelerate that.”

Australia, like many countries, has seen some people lose ready access to abortion due to financial hardship and a drop in the availability of services, both as a result of COVID-19. But for the first time, medical abortion provided in a telehealth consultation has been made available on the public health system.

Previously telehealth abortions – where a patient is assessed by a doctor over the phone before being prescribed the necessary pills – was only available through private providers such as Marie Stopes. This costs around AUD$500, leaving the procedure out of reach for many. As part of the government’s response to the pandemic, however, telehealth abortions have been authorised on the public system in all states except South Australia for a period of six months, bringing the cost down to as low as AUD$6 for someone with a special healthcare card for people on low incomes.

Australian law still requires a patient to get an ultrasound and a blood test before securing a medical abortion via telehealth. This is not the case in Canada or the UK, where the pandemic abortion care guidelines allow terminations to be carried out entirely at home in most circumstances.

Daile Kelleher, the manager of Children By Choice, an Australian non-profit that advises people on unplanned pregnancy options, is part of a coalition that is advocating for pills to be made available up to 10 weeks, and for the requirement for a blood test and an ultrasound to be dropped. She said it’s a particular issue for people in rural Australia, where poor access to healthcare and vast distances make getting a medical abortion challenging, even with a telehealth model.

In rural Australia, it’s entirely possible that someone would need to travel 200 kilometres one way to get an ultrasound, 100 kilometres another way to get a blood test and then a few hundred kilometres more to get the medication, she said.

“How wonderful would it be if it got to that stage with early medical abortion where you just go to the pharmacist, get the medication that you need, and you're able to go through with the abortion in the comfort of your own home in your own space, your own time?”

Making COVID measures permanent

Many of the measures relating to abortion introduced during the coronavirus pandemic are temporary. But advocates for greater access are using the advances made during this time to call for more permanent change.

Calkin said it can often take a while for legislation to catch up with practice when it comes to abortion. The law in the UK, for example, which stipulates that an abortion must take place in a clinical setting, was written in 1967 with surgical abortions in mind, long before the invention of abortion pills. That provision has only been suspended due to the pandemic.

“Abortion laws are often written in order to limit and restrict rather than to enable, and so expanded access in practice often kind of runs ahead of what the law is doing,” she said.

The UK directive on self-managed abortion applies for two years or for the duration of the pandemic, whichever is sooner. But Calkin warned that it may be unpopular to revert to business as usual afterwards.

“As the medical practice evolves we see that pills are extremely safe, and in a lot of cases, they're much more acceptable to the people taking them. So I think that the challenge for any government who wants to roll back telemedical provision is going to be to justify why it's necessary,” she said.

In Australia, Keller said providers and advocates will push the government to keep telehealth medical abortion available on the public system after the pandemic is over.

“This is the new change – it's not going to go back to normal. Self-managed abortion is something that we wanted to move towards, this has forced us to do that and it's not like we're going to roll things back afterwards,” she said. – Megan Clement