The coronavirus epidemic is changing the models of health care delivery worldwide. This includes abortion. In some countries, abortion has been declared a non-emergency medical procedure during the outbreak, prohibiting clinics from performing them and effectively cutting off women’s access to legal and safe abortion methods. In other countries, governments that typically support abortion restrictions have, on the contrary, accommodated women and activists fighting for their rights by temporarily easing access to them.
One of the consequences of the shutdown was the growing popularity of “teleabortion” – a procedure that does not require a woman to visit a clinic. Like other forms of telemedicine, it is a way to consult with a doctor and receive medical care over the phone or online without visiting a clinic and without exposing oneself to the risk of infection. Doctors and human rights activists fighting for a woman’s right to abortion insist that it is one of the safest methods of terminating a pregnancy, and one that is accessible to the most vulnerable populations. How do “telephone abortions” work, how safe are they, and could they appear in Russia?
23-year-old Isa from Portugal found out she was pregnant at the height of the pandemic. It was early spring, and one European country after another was implementing strict quarantine measures to contain the virus. Because of border closures, Isa was stuck in Germany, in a small town near the Netherlands. When Isа found out she was pregnant, she was scared. She knew she couldn’t abandon the child. Her partner was also stuck in another country – France. Her family in Portugal would not support her. The airline for which she worked as a flight attendant suspended flights due to the quarantine, leaving employees on base pay and without flight benefits. Even if flights resumed, a pregnant woman would not be allowed to work on flights. In addition, due to the losses caused by the coronavirus in the aviation industry, mass layoffs were expected in the company, which Isа is sure would affect her. With the remaining money, Isa managed to find a room in a foreign city. “If I hadn’t had an abortion, I probably would have had to give the baby up for adoption,” she says. Isa is one of millions of women worldwide who have faced this choice during the coronavirus pandemic. And the pandemic has not made that choice any easier. The charity Marie Stopes International estimates that 9.5 million girls and women worldwide were left without access to safe abortion procedures during the quarantine.
We explain quickly, simply, and clearly what happened, why it matters, and what happens next. Episodes The end of the story: Podcast Advertising According to the United Nations Population Fund, women’s access to reproductive health care has been disrupted by the deployment of health workers to fight the epidemic, the closure of clinics, the prohibition or restriction of movement, and women’s own concerns about the epidemic and fear of visiting health facilities to avoid infection. In many countries, with the onset of the quarantine, abortion was declared a non-urgent medical procedure, contrary to WHO recommendations – meaning that it will not be performed in clinics whose resources are tied up in the fight against Covid-19.
When Isa decided to have an abortion, she and her partner planned to fly home to Portugal for the procedure, but the borders were closed. Although abortions were still being performed in German hospitals, Isa was afraid to go to a German doctor: she didn’t speak the language and didn’t want to face misunderstanding and condemnation. She also couldn’t go to a private clinic because of the financial situation she was in due to the coronavirus. “I was alone, I didn’t speak German, and I was embarrassed by the whole situation,” she says. While researching the options available, Isa came across Women On Web, an organization that helps women obtain safe medical abortions from home, without a face-to-face consultation with a doctor. With the quarantine in place, the activities of such organizations are becoming increasingly popular. Because such organizations reduce the burden on health care facilities, health ministries in many countries – such as the United Kingdom, Ireland, and Moldova – are willing to meet them halfway in a health care crisis by simplifying legislation and temporarily lifting restrictions on abortion. In other countries, such as Poland and the United States, telemedicine, which can usually circumvent strict legal bans on abortion, is virtually the only way to obtain a safe abortion during the pandemic.
Isa wrote to Women on Web. In response, she received a letter describing all the other safe abortion options available in Germany. The organization insists that women who have access to more conventional abortion methods should only resort to telemedicine in extreme cases. When Isa explained her situation, which prevented her from using any of the other methods listed, she was sent a 25-question questionnaire about her health – medical abortion is not safe for everyone. “The whole correspondence with the Women On Web doctors took three days,” the girl recalls. “Isa waited another two weeks for the pills to be mailed to her. The package arrived in mid-March. Women On Web provides its services in 22 languages, including Russian, in dozens of countries around the world. “Tele-abortions” are just one of the directions of their activities. They also help women access emergency contraception, provide counseling on other abortion methods, and conduct public campaigns. “Telemedicine allows us to help women who need it most,” says Women On Web coordinator Hazal Atay. The issue of women’s access to safe abortion depends largely on their social status, human rights activists say. “For example, the ability to travel or language skills – these are all socio-economic factors,” Atai explains.
In countries where abortion is legal, it is often inaccessible to those who cannot afford it. For example, a woman in a small village may not have the means to travel to a clinic in the nearest city where a doctor would prescribe the necessary medication; she may not have anyone to care for her children, or she may not be able to take time off work to do so. Conversely, even in countries where abortion is illegal, women can find a way to terminate a pregnancy if they have the means to do so. This was the situation in Poland before the coronavirus: many women seeking abortions traveled to neighboring Germany if they had the means. “But when the borders closed, it also affected wealthy people,” Atai explains. During the coronavirus epidemic, the number of inquiries to Women On Web increased significantly.
Hazal Atay compares the situation with the coronavirus in many countries to the Zika virus epidemic in Latin America in 2015-2016. In an infected pregnant woman, the Zika virus could cause birth defects in the fetus – thousands of children were born with microcephaly and irreversible neurological disorders that affected their quality of life. In most of the region, abortion was (and remains) illegal. For example, in Venezuela, Brazil, and Argentina, abortion at the request of the woman – unless the pregnancy poses a threat to her life – can lead to imprisonment. In some countries (notably El Salvador), contraception is even illegal. “Then all the governments could do was tell women: “Try not to get pregnant,” says Atai. “This is a very similar situation. I don’t think Europe is handling the coronavirus any better in terms of sexual and reproductive rights than Latin America is handling Zika,” the human rights advocate said.
In mid-April, 100 human rights groups signed a statement condemning the inability of European countries to ensure women’s access to safe abortion during the pandemic. “It is important to understand that abortions happen every day,” says Laura Hurley of the international organization SAAF (Safe Abortion Action Fund). Her organization helps others find funding; its pool includes dozens of organizations that help women in Eastern Europe, Africa, the Middle East, Asia, and South America. According to Herli, human rights activists are very concerned that the lack of access to safe abortions often drives women to unsafe methods of terminating their pregnancies. “People in desperate situations will find a way to terminate their pregnancies,” she says. “They will try to get these pills somewhere, or they will go to someone who will perform some kind of surgical abortion. And that is what is really dangerous.” The number of services should remain the same. According to human rights activists, 47,000 women worldwide die each year as a result of unsafe abortions. “And these are just the ones who die. Many more women suffer permanent damage to their health,” says Hazal Atay. “Essentially, what we are doing is harm reduction,” she adds.
Rodika Komendant, Doctor of Science, Associate Professor at the Department of Obstetrics and Gynecology at the Nicolae Testemiţanu State University of Medicine and Pharmacy and Director of the Center for Reproductive Health Education (CIDSR) in Moldova, has been involved in the implementation of medical abortion practices in the country since 2004. As in other post-Soviet countries, the attitude towards abortion is very liberal at the legislative level: abortion at the request of the woman is legal and accessible up to 12 weeks of pregnancy, the woman can choose the doctor and the method of abortion. In addition, the country had a legal framework for the introduction of telemedicine abortion procedures. The launch of the “tele-abortion” program, designed for women who are unable to come to the clinic for the procedure, had long been planned by Dr. Komendant and her team, and the start coincided with the beginning of the quarantine imposed due to the coronavirus.
“We [have] had this idea for a long time: to provide this telemedicine service to women who have difficulty coming to the clinic,” says KOMENDANT. “When the epidemic hit, all clinics were closed, no woman could go anywhere, she was not allowed to leave the house, and people were even afraid to approach hospitals, we were ready to start this project. We immediately realized that in this situation, access to abortion would be very difficult. In the three weeks from late March to mid-April, when Moldova imposed its strictest quarantine measures, nearly 60 women came to CIDSR. “We have never had such an influx of patients. And even today, when the restrictions have been lifted, women continue to seek our help,” says KOMENDANT. The Moldovan Ministry of Health has publicly supported the program.
According to Komendant, medical abortion is considered a “life-saving method, especially during the confinement period” among other methods of abortion. “It is a method that can be delegated to the women themselves, because they are capable of understanding how to take the pills and take care of themselves,” the doctor believes. The procedure involves two drugs: mifepristone and misoprostol. Along with these drugs, a detailed step-by-step guide on how to take the drugs and what to do if they do not work is mailed to the woman. She also receives painkillers and antiemetics, as well as two highly sensitive pregnancy tests. According to the results of numerous medical studies, mifepristone without misoprostol provides an 80-90 percent guarantee that the abortion procedure will be free of complications. Misoprostol increases this guarantee to 98-99 percent. However, this method has a number of serious contraindications. For example, women who have blood clotting problems, who have had an ectopic pregnancy in the past, or who use an intrauterine device cannot take medication. All of this will be discussed during the consultation with the online or phone doctor. In addition, this method is currently approved for use only in the first trimester – a period of up to 12 weeks (although in some countries this period may be shorter at the regulatory level – 7 or 10 weeks).
Isa remembers that the medical abortion experience was not painless. In her case, the first pill – mifepristone – did not work, and three hours later Isa took the second pill – misoprostol. “It was very painful. Like the strongest cramp you can imagine. And it lasted for 24 hours. But it was all without complications,” she says. She had to go through those painful days alone. After one week and then again after three weeks, Women On Web would contact her to check on her well-being and to confirm that there were no complications. If there were complications, they would help the girl get help at a real clinic – in many countries, it is easier to get medical help after an abortion than it is to perform the abortion yourself.
The director of the Russian Family Planning Association, Lyubov Erofeeva, does not believe that “teleabortions” will be possible in Russia in the foreseeable future. “It is unlikely to happen in the near future. Although I think there is a good chance to expand access to contraception and medical abortion,” she says. In Russia, by law, public organizations do not have the right to provide services related to abortion. “In Russia, only commercial structures licensed to perform this activity and state institutions are allowed to do so,” Erofeeva explains.
In addition, only a gynecologist in a certified clinic can provide medication for a medical abortion in Russia. “I see no prospects for this in a regular, standard [government] women’s clinic. It is unlikely that revolutionary changes will have such an impact that the civil service will switch to it,” she said, noting that “private clinics can still do it – prepare the necessary equipment and train gynecologists in remote consultation. At the same time, according to the law on telemedicine, which came into force in Russia in January 2018, such technologies can be used only for consultations on prevention, diagnosis and monitoring of the patient’s health condition, as well as to make a decision on the necessity of a personal appointment. Prescribing treatment or medications is not allowed by law.
At the end of March, in the midst of the coronavirus pandemic, Russian deputies led by State Duma Speaker Vyacheslav Volodin introduced a new bill for consideration that would give doctors the right to prescribe treatment and make diagnoses remotely “in exceptional circumstances and/or in the event of a threat of the spread of a disease that poses a danger to others.” So far, the bill has passed its first reading.
In many countries, the coronavirus and the resulting quarantine have sparked disputes between pro- and anti-abortion groups, including those related to the expansion of telemedicine. In Britain, the government temporarily allowed women (except residents of Northern Ireland) to have abortions at home in the spring, up to 10 weeks into a pregnancy and after consulting with a doctor by phone or online. The conservative religious group Christian Concern challenged the decision in London’s High Court. They insisted that the government was “usurping power” and putting pregnant women in an unsafe position. Government officials argued that they had sufficient evidence that the method was safe. Christian Concern lost the case.
In France, authorities have allowed women to obtain medication abortions at home after nine weeks, rather than seven, with a telephone consultation with a doctor – previously, abortion pills could only be taken in a clinic at this stage. As reported by Le Monde, French doctors continue to insist, based on evidence, that this period should be extended by law to 12 weeks. Meanwhile, abortion opponents in the country have also criticized the government’s decision.
In the Netherlands, the court in The Hague denied women the opportunity to have an abortion during quarantine without going to a clinic. The International Planned Parenthood Federation notes that many countries have used the pandemic to gain control over women’s access to abortion. For example, abortion opponents in eight U.S. states have attempted to use the coronavirus pandemic to restrict women’s access to legal abortion procedures. Governors in Texas, Ohio, West Virginia, Tennessee, Iowa, Arkansas and Alabama have added abortion to the list of non-essential procedures, banning clinics and doctors from providing abortion services and threatening them with the “full force of the law” if they do not comply. Health professionals accused state officials of “exploiting” the pandemic. In Texas, human rights activists challenged the decision in court, but lost. The Polish government also tried to use the pandemic to further tighten already strict laws restricting women’s access to safe abortion. After intense protests, the bill was sent back for revision.
Khazal Atay expects that the temporary relaxation of abortion access laws that some countries have adopted will be reversed after the pandemic. “I think the first impulse of governments after the coronavirus will be to reverse these relaxations,” she notes. “But we know that once a right is given, it is difficult to take it away. Now a woman will ask herself: if it is possible to have an abortion at home during the period up to nine weeks, and you have allowed it once, on what basis do you take that right away?”
“Such restrictions are not medical, not scientific. They are political decisions,” she says. “The problem is that we do not trust women. There are still too many taboos about abortion.”
“I don’t think telemedicine abortion should be the only option available to women. Because that also takes away their choice. Ideally, people should have a choice – whether they want to have a surgical abortion or a medical abortion, in a clinic or at home,” said Laura Hurley of SAAF. Abortion in and of itself, without legal restrictions, is a complex decision for women, says one human rights defender. She believes that the opportunity to consult with a psychotherapist, to meet twice with a doctor, or to take time to reflect should not be mandatory circumstances for having an abortion, but rather options available to women.
Isa is still reeling from what happened. Despite the economic situation she found herself in, the decision was not an easy one. She says what she missed most during this time was moral support. In the future, the girl says she wants to have children.
