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Abortion restrictions during COVID-19 pandemic

A study in the journal Contraception found that, within the first year of the COVID-19 pandemic in the US, abortion clinics in states with low or medium hostility to abortion were significantly more likely to embrace innovative medication abortion practices such as changing ultrasound requirements, offering telehealth or dispensing medications without a physical exam, compared to abortion clinics in states with high or extreme hostility to abortion.

The study conducted a longitudinal nationwide survey of 57 abortion providers (some with more than one clinical location) in 31 states.

Among the 57 clinics, 60% were classified as having low abortion restrictions, followed by 18% with extreme restrictions, 12% with high restrictions and 11% with medium restrictions.

Overall, 18% of clinics required in-person visits for medication abortions, due to state-level abortion restrictions.

Compared to clinics in states with high or extreme abortion restrictions, clinics in states with low or medium abortion restrictions were more likely to change their ultrasound policy, so that fewer patients were required to undergo the imaging in order to minimize in-person contact before the abortion (33% vs 0%); adopt low- or no-test abortion (LNTA) protocols (40% vs 18%); permit “curbside” medication abortion pick-up (13% vs 6%); offer mail delivery of medication abortion (13% vs 0%); and provide telehealth for follow-up (85% vs 47%).

Similarly, compared to clinics in states that required in-person visits for medication abortions, states without that requirements were significantly more likely to change ultrasound requirements (28% vs 0%); adopt LNTA protocols (38% vs 10%); permit curbside medication pick-up (13% vs 0%); offer mail delivery of medication abortion (11% vs 0%); and provide telehealth for follow-up (79% vs 50%).

“Clinics in more hostile states were less likely to offer patients options to mitigate their risk of acquiring SARS CoV-2 infection in healthcare settings,” wrote the authors.

They also noted that there was no state-level regulation requiring in-person dispensing of the abortion medicine mifepristone.

Although the study sheds light on legislation on the state level about adoption of public health best practices, the small sample size may underestimate the true influence of abortion restrictions on service delivery innovation during the early COVID-19 pandemic.

The survey was also limited to changes made during the pandemic from January to November 2020, not previous adoption of these innovative practices. For example, telemedicine abortion outside of a site-to-site model was not included, except as part of a research protocol prior to the pandemic. Likewise, waiving ultrasound requirements may have been adopted at some clinics before 2020.

Nonetheless, evidence of the safety and efficacy of telehealth abortion has increased during the COVID-19 pandemic, according to the authors, prompting the Food and Drug Administration (FDA) to review the risk evaluation and mitigation strategy (REMS) for mifepristone and removing the in-person dispensing requirement in December 2021.

“This change could vastly improve access to medication abortion via telehealth,” wrote the authors. “However, as our findings indicate, the positive impact of this change on abortion access may vary substantially depending on other state-level abortion restrictions.”

Reference

Janiak E, Belizaire C, Liu J, et al.The association of U.S. state-level abortion restrictions with medication abortion service delivery innovations during the early COVID-19 pandemic. Contraception. 2022 Sep;113:26-29.