Inequities in reproductive health care, including abortion, have long existed in the United States. State legislatures have sought to erode Roe v. Wade by enacting policies that restrict or delay access to and provision of abortion services. This has primarily impacted Black, Indigenous, and People of Color (BIPOC), adolescents, and families living below the federal poverty line. With this restrictive policy climate, the ongoing coronavirus (COVID-19) pandemic has burdened health centers and patients with unprecedented logistical, financial, and medical challenges. One in three women* surveyed by the Guttmacher Institute reported that due to the pandemic, they’ve had to delay or cancel visiting their clinician for reproductive health care, or have had trouble getting their birth control.
In this article, we describe three areas of inequity (telehealth, access, and policies) observed during the pandemic and discuss potential strategies that can ensure equitable access to reproductive health care while protecting the public from ongoing COVID-19 exposure.
Inequities in Telehealth Access and Use
US health centers have rapidly adopted telehealth services to provide patients with needed continuity of care during “Stay at Home” orders and sustained social distancing measures, while also protecting patients and health care personnel from risks of virus exposure. Telehealth technology has long been used to facilitate access to health and medical information, education, and services. Reproductive health care delivery has also been part of this telehealth expansion, as much of it is well-suited to virtual interactions, such as: counseling for contraception decision-making, pregnancy options, miscarriage management options; post-abortion follow-up care; and prescribing birth control methods. In response to COVID-19, many organizations, like RHAP, have developed protocols to support “no test” or minimal touch reproductive health services such as medication abortion and contraception care.
While expanding telehealth for reproductive health care is incredibly important to reduce risks of COVID-19 exposure, this technology may not be impacting all patients equitably, particularly those already lacking access to affordable, high-quality care pre-pandemic. Engaging with the health care system through telehealth can be difficult simply due to having insufficient or inconsistent mobile phone reception or internet access. 39% of rural Americans (23.4 million people), compared to four percent of urban Americans, lack basic fixed internet service. Black and Latinx folks are less likely to have a broadband connection at home, as compared to white people. Technological issues can make it challenging to get a telehealth visit started, to provide counseling for contraception, abortion, and miscarriage care, and to ensure that patients fully understand the treatment plan.
Even with excellent phone and internet connection and availability, home may not be the safest place to have a telehealth appointment. Especially in urban areas where families live in small spaces, adolescents, for example, may not have a private, confidential space to fully open up about sensitive health concerns, such as reproductive health needs, questions, and services, without the risk of parents or guardians overhearing. Typically with in-person visits, clinicians are able to separate family and confidential conversations with adolescent patients. This division can be difficult to coordinate over telehealth, as the clinician does not have full control over the environment.
For patients with language barriers, providing reproductive health care through an interpreter over telehealth presents additional challenges. Important nonverbal cues for communication, such as body language and facial expressions, can be lost when video capability is not available. When a clinician, interpreter, and patient are trying to talk about sensitive and emotional topics, like pregnancy options or miscarriage care treatments, it can be challenging to understand a patient’s emotions, be responsive to their feelings, and support them to make informed decisions.
Restricting Access to Abortion Care
When the COVID-19 pandemic began, ten states defined abortion as a “non-essential,” or an “elective” health procedure, effectively banning abortion care until the end of the pandemic. Although these bans have been lifted, pregnant people experienced drastic consequences. In Texas, this ban lasted 31 days, leaving hundreds of pregnant people – who were in the middle of receiving options counseling, scheduling their appointment, abiding by the mandatory waiting period, driving long distances to their abortion – were thrown into limbo as to whether they could have an abortion in time, or be forced to carry an unwanted pregnancy to term. RHAP has been at the forefront of training and supporting clinicians to use a “no-test” protocol to provide medication abortion to patients. This has allowed clinicians to maximize remote care and minimize the need for patients to travel during the pandemic.
Although all counseling, needed tests, and taking the pills can be done at home, rules by the US Food and Drug Administration (FDA) require clinicians to stock and dispense mifepristone – one of the medications used in a medication abortion – onsite, in-clinic. However, experts concur that decades of safety data indicate that this regulation is not necessary. While the FDA quickly suspended similar restrictions on other less-safe drugs in recognition that these rules “put patients and others at risk for transmission of the coronavirus,” the rules on mifepristone remained in effect. This changed after a court case challenging these restrictions was heard in the spring of 2020. In ACOG v. FDA, the judge issued a preliminary injunction to temporarily suspend the regulation starting July 15th, allowing clinics to mail mifepristone to patients seeking a medication abortion. Yet, state laws continue to interfere: 19 states require the prescribing clinician to be physically present when medication abortion is provided, banning the use of telehealth for abortion care, including mailing pills.
Bodily Autonomy and Preferences for Care during COVID-19
To reduce risks of exposure during the pandemic, some health centers had been limiting the types of appointments and services available for an in-person visit. Some were urging patients to wait until conditions improve to schedule an in-person visit. While establishing such procedures allows for prioritizing services that absolutely require in-person care, it is essential to ensure that these policies do not undermine people’s bodily autonomy, agency, and preferences for health care. For example, studies demonstrate that it is safe to leave a contraceptive intrauterine device (IUD) beyond the FDA approved time of use. However, young adult women of color have reported that their preferences regarding contraceptive selection or removal are not always honored by their clinicians. Honoring patient preferences for health care and bodily autonomy, especially in situations like using long-acting reversible contraception (LARC) – in which patients mostly depend on their clinician for insertion and removal – must not be sacrificed.
Addressing Reproductive Health Inequities During COVID-19
In order to ensure that everyone has access to high-quality, patient-centered reproductive health services with dignity and compassion during and after this pandemic, we must work with the communities most vulnerable to experiencing health inequities and disparities. Eliminating inequities in reproductive health care necessitates addressing root causes and pursuing structural change in areas like housing, education, policing, economic opportunity, and neighborhood contexts, as well as dismantling laws and systems that undermine bodily autonomy. As the fight for structural change continues, the following immediate strategies may be undertaken by organizations, health centers, and individual clinicians to ameliorate additional reproductive health care inequities caused by COVID-19.
- To prevent people from losing their existing internet and phone services due to economic hardship, states and organizations working to strengthen telehealth should pressure internet and phone service providers to sign onto the Federal Communications Commission’s Keep Americans Connected Initiative.
- Service providers should also offer households that cannot afford services basic low-cost internet and phone plans to ensure that people can remain connected to the services they need during and after the pandemic.
Enhancing Privacy through Telehealth
- Clinicians can ask patients to try to move to private spaces, offering examples of non-traditional options, such as going outdoors, to a bathroom, or a locked bedroom.
- Clinicians can encourage patients to wear headphones and create background noises, such as turning on a fan or soft music, to limit the ability of others to hear their conversation.
- Telehealth calls can be set up for parents or guardians and the adolescent to call in from separate devices so that one can be easily removed from the visit during confidential discussions.
- Organizations have long been developing Mobile Health applications delivered on cell phones and tablets to provide interactive programs for adolescents. Expanding such technologies to support answering adolescents’ questions about their reproductive health, providing counseling, and other services amenable to remote interaction may help expand access to reproductive health care while enhancing privacy.
Medication Abortion Implementation and Ongoing Advocacy
- In response to the preliminary injunction, RHAP is working with clinicians to coach them to work through the logistical implementation challenges of mailing mifepristone. This involves developing new health center policies and protocols and navigating any legal restrictions that must be followed with the injunction, like mandatory waiting periods.
- Organizations should continue to engage in advocacy to urge the FDA to amend regulations for dispensing medication abortion during and after the COVID-19 crisis.
Offering Both Telehealth and In-Person Visits as Desired
- Develop policies and procedures within health centers that allow for both telehealth and in-person appointments, with appropriate infection prevention measures.
- To honor bodily autonomy, preferences, and informed decision-making, reproductive health care counseling must include a discussion of all possible care options. For example, patients may keep their IUD in longer than the FDA approved time, learn options for self-removal, or go to their clinic to have it removed in a timely manner.
- Moreover, reproductive justice organizations have developed a LARC Statement of Principles that acknowledges the history of bias and reproductive coercion BIPOC populations have and continue to experience. It outlines principles to support people in making the best decisions for their health and unique circumstances in order to respect their bodily autonomy, agency, and dignity.
*The term “women” in this article is used when referring to data in which only cis-gender, women-identifying people were studied. We acknowledge that gender non-binary, trans folks, and other people who may not identify as “women” can also get pregnant and need reproductive health care.
This commentary was written by Silpa Srinivasulu, MPH, RHAP’s Research and Evaluation Manager, and Board Member Sandra Echeverría, MPH, PhD.