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Coronavirus crisis magnifies existing challenges to abortion access

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In our recent book, Obstacle Course: The Everyday Struggle to Get an Abortion in America, David Cohen and I detail the considerable difficulties many people have in accessing abortion care. The relative scarcity of clinics means long travel for many; that abortion patients are disproportionately low-income women of color means hardship in paying for the procedure, particularly since the majority of states do not allow Medicaid funds to be used for abortion; the onerous waiting periods in many states often mean women have to stay overnight in a distant city, leading to the additional costs of lodging and more days of lost wages; confrontations with protestors at the clinic sites themselves can often be deeply upsetting. All these barriers have increased exponentially with the coming of COVID-19, and some new problems have been added as well.

For starters, COVID-19 makes travel risky. And the political attacks on abortion — with a number of states closing down clinics on the spurious claim that abortion is not an “essential service” — mean even more travel for abortion patients. For example, when Texas was in the midst of its recent court battles that temporarily closed clinics, researchers estimated that the average one-way drive for a woman in that state to reach a clinic would increase from 12 miles to 243 miles. The economic devastation that the pandemic has brought, with so many Americans losing their jobs, makes coming up with the money for the procedure, and the attendant costs mentioned above, that much harder for a patient population already desperately poor. Protestors in various places have ignored shelter-in-place and social distancing orders and show up at clinics to aggressively confront patients. (In one notorious recent incident, a protestor, insinuating she had the virus, made a point of coughing on an elderly volunteer.)

The most worrisome new dimension that the pandemic brings is the danger to patient and provider alike from physical contact. The abortion providing community has responded to this challenge with both resolve and creativity. As much as possible, clinics make use of videoconferencing to counsel patients, both before and after procedures. The “patient flow” inside clinics has been changed to permit patients as much distance from other patients as possible. Whereas patients used to move from waiting room to lab room to procedure room to recovery room, clinics now try to have these activities happen with as little movement from place to place as possible. Some clinics have patients fill out paperwork and wait for their appointments in their cars. (As one clinic director remarked on a webinar, “Our parking lot has become our new waiting room.”)

Medication abortion, which involves taking two drugs (mifepristone and misoprostol) and is now used in the United States through the first 11 weeks of pregnancy, has understandably been key in reshaping abortion protocols during the pandemic, because this method involves much less provider-patient contact than aspiration abortion, the other common method of first-trimester abortion (about 90% of abortions take place in the first trimester). In response to COVID-19, a collaborative of reproductive health experts recently called for “no-test” medication abortion, stating that some of the tests for this procedure that had been previously done in clinics could be safely eliminated. Rather, the new protocol involves videoconferencing with patients to ascertain their eligibility for the procedure, counseling them on how to take the medications and on the necessity for a follow-up home pregnancy test, and a check back with the clinic one week after taking the drugs. At the present time, patients are then required to come to the clinic to pick up a packet containing the medications, an instruction sheet, and two home pregnancy tests (in case the test needs to be repeated).

Ideally, however, the entire procedure could be done with no patient-provider contact whatsoever, and no travel, if abortion providers were legally able to send eligible patients the drugs to their homes directly or through a mail-order pharmacy. But it is abortion politics, not scientific evidence, that is preventing this. A regulation put in place by the FDA in 2000, when mifepristone was first approved for use in this country, is hampering the most efficient way to deliver these drugs. Misoprostol was already approved for other purposes, but mifepristone was placed in the REMS (“Risk Evaluation and Mitigation Strategy”) program, a drug safety program for drugs deemed especially dangerous. This categorization has meant that pharmacies cannot stock the drug, and it can be dispensed only at a clinic, in doctors’ offices, or at a hospital. The abortion providing community (along with leading medical organizations such as the AMA and the American College of Obstetricians and Gynecologists, and the former head of the FDA) have long argued that this REMS classification was inappropriate, given the excellent safety record of mifepristone. (The drug is implicated in fewer deaths per year than some common over-the-counter drugs, such as Tylenol.)

In response to the pandemic, the FDA has temporarily loosened the REMS requirement on other drugs in order to get them to sick patients faster. Elizabeth Warren and two other Democratic senators have called for the FDA to similarly temporarily suspend this restriction on mifepristone. Thus far, the FDA has refused to allow any changes in its oversight of mifepristone, COVID-19 notwithstanding.

    Were the FDA to take this compromise step of temporarily suspending the REMS requirement, a paper trail would be created showing the safety of mailing medication abortions directly to eligible patients’ homes. This safety record in turn could lead, theoretically, to the requirement being permanently abolished, which would have lasting significance for abortion access beyond the pandemic. The fact that this medically endorsed step is not being followed at this moment of crisis speaks volumes about the politicization of abortion. The FDA’s failure to act on the evidence of mifepristone’s safety is a prime example of what we refer to in Obstacle Course as “abortion exceptionalism” — the idea that abortion is treated uniquely and unfairly by regulators compared to other medical procedures. Perhaps in a future political environment, abortion will be treated like other health care services, but in the meantime, those needing abortions during this pandemic are facing unnecessary barriers.



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