Abortion care is changing right now. Due to the COVID-19 crisis, the way people access abortions, and the way clinicians provide them has come under careful consideration. In most cases, this has meant decreased in-person contact and eliminating a lot of the peripheral things that come along with abortion provision, like bloodwork, ultrasound, and counseling. As someone who has long supported out-of-clinic abortion care, these changes are encouraging, to see an abortion care system I usually perceive as rigid starting to relax and take a look at evidence-based, client-centered care principles. The flexibility and adaptability in the face of a pandemic ensures abortions, which are absolutely essential medicine, continue. The real test will be in seeing which of these changes stick when the pandemic starts to ease, which regress, and why.
Abortion care has long been highly regulated. From who can provide abortions, to where they can be provided, to how they can be provided, at which gestational ages, and whether additional restrictions are factored in due to age of the client, health conditions, financial and immigration status, etc. abortion remains one of the most regulated medical procedures in clinical healthcare. Many of these regulations over time have created an abortion care system that mandates conversations, procedures, and other supportive care, even in the face of evidence to the contrary. However, writing this in 2020 through the COVID-19 pandemic, we are not in normal times for healthcare. While some have used this opportunity to even further restrict abortion, and not classify it as an essential medicine, others are relaxing their regulations around provision to take a look at evidence-based abortion provision in a new light. To be clear, all of these changes have been studied at length, shown to be safe and effective, and in many cases work better for clients always, not just during a pandemic.
Gestational Age Limits
In many cases, clinicians are considering expanding gestational age limits for access to certain abortion care methods, namely medication abortion. Historically restricted to a limit of 8, 9, or 10 weeks gestation, many places are expanding their limits up to 11 or 12 weeks, as supported in the literature, and common practice in other countries. Some clinics are also seeing a pattern of delayed access to abortion care during the pandemic and needing to tend to clients with more advanced pregnancies in a clinic. While some places with skilled providers have expanded their gestational limits to support this pattern, still others have had to restrict previous flexibility in gestational age limits due to facility restrictions.
Encouragement of Medication Abortion
In general, many clinicians are more strongly encouraging medication abortion in the first trimester as it requires less contact and can be completed at home. While medication abortion is not the right choice for everyone, it can be an excellent choice for most first-trimester abortions.
Telemedicine
Many clinicians have been able to change their “visits” with clients to be over the phone, or over video chat, saving clients a trip to the clinic altogether. They’re able to conduct many assessments just from the client’s history and help clients access any needed requisitions and prescriptions by fax/email. In some cases, they’re able to help clients access medications through the mail or by prescription at their local pharmacy. Clinicians do not need to personally dispense medications or watch as clients swallow them.
Routine Ultrasounds
In many cases, with clients in the first trimester who have a good idea of their dates, and no specific risk factors for ectopic pregnancy, clinicians are no longer requiring a routine ultrasound. Rather, menstrual history and a positive home pregnancy test is enough.
Routine Labwork
Required lab work typically includes blood type and screen, CBC (usually screening for low platelets and low iron), and select sexually transmitted infections. Clinicians are finding that telemedicine is enough to screen someone for STI risk and previous history with anemia. When these risks are present, clients are emailed a requisition for bloodwork or urine samples at their local lab. Additionally, evidence has shown that when a pregnancy is ten weeks or less, knowing blood type and screen may be irrelevant anyway (see below-Routine RhIG). At this time, many people are able to access abortion with no labwork whatsoever.
Routine RhIG (Rhogam)
A small portion of the population has Rh-negative blood type (O-, A-, B-, AB-). When this is the case, if the person whose sperm helped form the embryo had Rh-positive blood type (O+, A+, B+, AB+), the embryo might have a positive blood type as well. So, you’ve got a person with typically negative blood carrying an embryo with positive blood. Normally, this wouldn’t be a problem as the placenta does an excellent job keeping the blood supplies separate. However, certain events could cause disruption of the placental site, and perhaps allow the mixing of the bloodstreams. If enough blood mixes, this could cause a sensitization reaction in the person carrying the pregnancy, which could potentially cause issues in future pregnancies. Due to this complexity, clinical abortion care has traditionally screened everyone’s blood type accessing care, and if the client has Rh-negative blood, they’ve routinely been given Rh immunoglobulin (RhIG/Rhogam) as a preventative medication to stop a sensitization from developing if there was a blood mixing reaction. However, good science has long shown us that even if every drop of embryonic/fetal blood mixed, there’s physiologically not enough blood to cause a sensitizing reaction in a pregnant person before about 11 weeks gestation. So, routine administration of RhIG “just in case” has no proven scientific benefit in most of the first trimester. Despite this clinical knowledge, changing these protocols has been very slow in abortion care contexts but is finally being dropped from routine care when appropriate during the COVID-19 pandemic.
Counseling
While pregnancy options and abortion counseling plays an important role in many people’s abortion experience, excellent research has shown that the vast majority of people presenting themselves for abortion care have already made up their mind fully and don’t feel they need further counseling. Some clinicians are forgoing counseling in clients who say they have their minds fully made up at this point, and reserving the skilled counseling sessions for people expressing ambivalence.
Follow-Up Care
Most people are scheduled for routine follow-up appointments at abortion clinics about 2 weeks post abortion that usually encompasses routine ultrasound to ensure resolution and complete abortion, and any other necessary checkups. At this point, many clinicians are forgoing these ultrasounds and in-person appointments and instead of asking clients to take a pregnancy test a few weeks after the abortion to ensure it comes up negative, and doing a check-in over the phone by telemedicine.
This low-touch, low-tech care might not be appropriate for everyone. From a clinical standpoint, this care is offered only to low-risk people in the first trimester (and often <10-11 weeks). There will always be people with individualized risk factors or more advanced gestational ages that require in-person care.
We know, statistically, that the majority of abortions are uncomplicated, first trimester abortions. That means that many abortions at this time could easily be achieved completely over telemedicine, where a care provider support a client in gathering knowledge about abortion options, supports home pregnancy tests for confirmation of pregnancy, skips lab work and ultrasound, helps the client access the medications, makes available contact in case of complications, debriefs the abortion over the phone, and confirms completion at home. A client would actually never have to go into a clinic or see a provider in person. They could manage their abortion at home, with their chosen supports, and backup medical care. Frankly, in most cases, this is how it always should have been.
I have to admit, as excited as I am to see some of these changes reflecting evidence-based medicine, it is frustrating to see them pushed through only in the case of emergency and not because they are an excellent standard of care. Additionally, this has shown a resurgence in the public and clinical exploration of and support for “self-managed” abortion (abortion provided and accessed personally or in a community without the help of clinicians at all) as the care during “self-managed” abortion and clinical abortion is starting to look pretty similar. It can be frustrating to hear some of the same clinicians who demonized “self-managed” abortion as dangerous promoting these new pandemic protocols as very safe. They are, and they always were, with and without the clinic.
The real test will be in seeing what happens with abortion care when this pandemic starts to ease. As someone who works and supports abortion in both the United States and Canada, I can see a few possible pathways forward. In a for-profit medical system like the United States, where abortion clinics are chronically underfunded and under attack from legislatures (regional and federal) and local individuals, it may be really difficult to keep some of the progress made during the COVID-19 pandemic once the pandemic eases. Clinicians long-term may not be able to bill for care provided by telemedicine and may need to do everything in-person. The revenue from marginal markups on lab work and ultrasound really help some clinics stay afloat. Regulations mandating the information from ultrasound and lab work may resume. Telemedicine and alternate access to medications may not be allowed to continue when legislatures no longer see them as emergency provisions. I imagine abortion care is likely to return largely to pre-COVID “normal”.
Whereas in a system of government-provided universal healthcare such as in Canada, I could see many of the changes we’re implementing during the COVID-19 pandemic sticking around long term. If physicians can continue to bill for telemedicine visits and can justify paring back on services like lab work, ultrasound, and in-person follow-up care, it actually saves the government a bundle of money on this facet of healthcare provision.
Ultimately, I worry whether science, experience, and community demand will prevail in keeping new, common-sense, low-tech, low-touch abortion methods as a viable pathway for clinical abortion provision, or whether profit and politics will drive what makes sense for clinical abortion provision. We’re all well aware of the detrimental over-politicization of abortion care for client experience, but it is less comfortable to talk about the profit or cost of clinical abortion provision and how that might be undermined by continuing pandemic-style care for better or worse. I hope this will be a time for clinicians and health systems to carefully analyze whether routine surgical procedures, lab work, ultrasound, counseling, mandated waiting periods and other regulations around abortion provision were always for the health and safety of clients, or whether they had more to do with politics and profit than anything. And if, as I strongly suspect it will, pandemic-style abortion care proves itself safe and effective, how we will justify regressing back to care that was largely unnecessary.