By Caroline McKenna
While the impact of COVID-19 is felt worldwide, women and girls are disproportionately affected. Pre-existing gender inequities are exacerbated, including gender-based violence and access to healthcare1. During the pandemic, sexual and reproductive health (SRH) care remains an essential service. Abortion is a time-sensitive and essential health service, and cannot be neglected without serious consequences for women and girls. In Canada, 1 in 3 women of child-bearing age will have an abortion2. Globally, 214 million women have an unmet need for contraception3. The WHO classifies sexual and reproductive healthcare, including abortion, as essential during this pandemic, regardless of the patient’s COVID-19 status4. Yet, in Canada and globally, we see SRH access profoundly diminished, which could result in increased risk of unintended pregnancy, unsafe abortion, and maternal and newborn morbidity and mortality5.
Travel and Financial Barriers: With concerns over exposures associated with public transit, travel is a major obstacle to seeking SRH care for lower-income individuals6. Furthermore, job layoffs significantly reduce financial access to healthcare in private health systems. It is known that women are less likely to prioritize their health if they cannot afford childcare and must bring children to appointments. This is exacerbated by school and daycare closures, and reluctance to bring children to appointments due to fears of exposure risk6. In the US, 59% of women seeking abortions have children7, highlighting how widespread this barrier is.
Availability of SRH Services: The diversion of healthcare providers and equipment towards pandemic efforts draws time and resources away from other areas of healthcare, including SRH. Limited in-person appointments creates longer wait times and difficulty scheduling intrauterine-device (IUD) and hormonal implant insertions, as well as access to oral contraceptives which often require appointments for initial prescription and subsequent refills8. This also perpetuates the unmet need for abortion care, especially in countries with policies restricting medical abortion to in-hospital services1.
Availability of SRH Supplies: The strain that COVID-19 has placed on supply chains disrupts the availability of nearly all forms of contraception and medical abortion medications, which are critical for women’s health and empowerment. DKT International, one of the largest suppliers of family planning items, reports that drug-manufacturing plant closures in China are causing delays at plants in India that produce generic drugs including contraceptives, antiretrovirals for HIV, and antibiotics for STIs9,10. In addition, supply of progesterone, an essential hormone used in many contraceptive options, is impacted and manufacturers are forced to find new suppliers9. As of April 9, Laura Neidhart, director of Action Canada, said that Mifegymiso, a combination medical abortion medication consisting of Mifepristone and Misoprostol, remains available in most areas of Canada11.
Decision-making at household and political levels: Additional sociopolitical factors play a role in reducing women’s autonomy in accessing essential SRH services. Crises tend to diminish women’s decision-making power, resulting in unmet SRH needs. This was seen in countries affected by Zika virus where women’s lack of participation in SRH decisions was exacerbated by inadequate access to healthcare1. Additionally, abortion is often the first area to be cut for funding reallocation, as seen in several US states that have quickly declared abortion to be “non-essential”12. Pre-existing policies on gestational limits, the Domestic and Global Gag Rule13,14, and refusals of care8 further hinder access. In Italy, 70% of gynecologists currently refuse to provide legal abortion on the basis of conscientious objection15, superimposed by intensive COVID-related restrictions16. In Canada, abortion has been deemed an essential medical service, yet access to time-sensitive surgical abortion is significantly decreased, especially for abortions past 23 weeks11.
It is imperative that comprehensive sexual and reproductive healthcare remain a priority as SRH needs do not disappear during crises. To ensure continuity of services, the International Medial Advisory Panel recommends implementation of telemedicine for appointments regarding contraception, abortion, and counseling2,17 and delivery of contraceptives and medical abortion via mail where possible. Additional recommendations included the promotion of long-acting contraception options and national efforts to monitor SRH supplies and forecast demand5. Various groups are also advocating for policies that protect SRH rights1,2,8. Universal access to contraception and abortion is critical during COVID-19 when sexual and reproductive health and rights are more important than ever.