Pandemic has widened existing gaps in access to abortion services across Europe

October 08, 2020

The coronavirus pandemic has widened existing gaps in access to abortion services across Europe, finds a review of country-wide policy changes in response to COVID-19, published in the journal BMJ Sexual & Reproductive Health.

But enforced innovations adopted in some countries, such as telemedicine and the provision of abortion at home, could reverse that trend and prompt long lasting change for this essential health service, suggest the researchers.

Abortion is one of the most common procedures for women of reproductive age in Europe, ranging from 6.4/1000 women aged 15-44 in Switzerland to 19.2/1000 in Sweden. The need for it is likely to have increased in the wake of COVID-19, because of economic uncertainties, increased exposure to sexual violence, and limited access to contraception, say the researchers.

In light of the extensive public health measures restricting freedom of movement at the height of the pandemic, they wanted to find out what impact these might have had on access to abortion services across Europe.

They therefore compiled information on practice in 46 countries/regions. Survey information, filled in by national experts, was collected for 31, while desk research was carried out for the remaining 15.

The data revealed that European countries adopted different approaches in response to the pandemic, ranging from imposing restrictions to relaxing certain requirements.

New restrictions included delay or denial of abortion care to women with COVID-19 symptoms, or living with those who had them, and decreased availability of surgical abortion. A few countries expanded medical abortion availability via telemedicine, and relaxed regulations around the use of drugs to induce medical abortion.

In detail, abortions were banned in six countries (Andorra, Liechtenstein, Malta, Monaco, San Marino and Poland) and suspended in one (Hungary).

Access to surgical abortion was restricted in 12 countries/regions and services weren't available at all, or delayed, for women with COVID-19 symptoms in 11: The Netherlands, Belgium, Germany, Iceland, Latvia, Luxembourg, Montenegro, Slovenia, England, Wales and Scotland. No country expanded its gestational limit for abortion.

Changes to reduce face to face consultations were made in 13 countries/regions (Belgium, Estonia, Ireland, Finland, France, Germany, Norway, Portugal, Switzerland, England, Wales, Scotland and Northern Ireland).

But only seven countries/regions offered abortion by telemedicine. In two this was already provided before the pandemic (Denmark and the Stockholm region of Sweden) and five other countries adopted it (England, Wales, Scotland, France and Ireland).

Eight countries/regions provided home medical abortion with mifepristone and misoprostol beyond 9 weeks (up to 11 weeks+6 days) while 13 countries/regions did so up to 9 weeks.

Pharmacy access to prescribed mifepristone was permitted in two countries/regions: Denmark, where it was permitted before COVID-19, and France, where it wasn't permitted before. And these drugs could be delivered by post in England, Wales, Scotland and Georgia or home delivered in England, Wales, Scotland and Ireland.

"Abortion is an essential component of women's sexual and reproductive care. While extremely safe under recommended procedures, it is responsible for substantial maternal morbidity and mortality when women do not have access to safe abortion care," emphasise the researchers.

Abortion services are particularly vulnerable to any move to restrict provision, because "politics often trumps evidence," they point out. "With each passing week of political inaction, thousands of women are denied treatment that cannot be postponed,and face the prospect of carrying an unwanted pregnancy to term or of undergoing unsafe procedures," they add.

"Altogether, the diversity of pre-COVID-19 rules regulating abortion coupled with inconsistent responses to the COVID-19 crisis has exacerbated a heterogeneous landscape of abortion provision in Europe," write the researchers.

"The lack of political will to lift unnecessary regulations is discouraging, yet we recognise the concerted efforts of some governments and providers who swiftly acted to sustain abortion care during COVID-19 disruptions," they note.

And they conclude: "The lack of a unified policy response to COVID-19 restrictions has widened inequities in abortion access in Europe, but some innovations including telemedicine deployed during the outbreak, could serve as a catalyst to ensure continuity and equity of abortion care.

"We believe that these advances, mostly conceived as temporary responses to a health crisis, could serve as catalyst towards 'liberalising' abortion provision and that they should become the standard of care."

Dr Edward Morris, President of the Royal College of Obstetricians and Gynaecologists (RCOG), which co-owns the journal, comments: "This review has shone a light on some of the shocking inequalities in access to abortion care that women face across Europe during the COVID-19 pandemic."

He continues: "The abortion telemedicine pathway introduced into England, Scotland and Wales has enabled thousands of women to access safe abortion care during the COVID-19 pandemic. This is during a time when access to other essential women's health services were hampered.

"We have seen huge benefits for women arise out of this simple, yet effective, innovation. There has been a reduction in waiting times for women who have requested an abortion, visits to clinics have reduced, which has limited the transmission of the COVID-19 virus among both women and staff, and complications related to abortion have decreased."

He adds: "We welcome the steps taken by those governments that have ensured that abortion care has continued to be provided in a safe, timely and compassionate manner and applaud in particular the new innovative ways to abortion care provision, including the introduction of telemedicine in some countries, including Great Britain. We would urge governments to ensure that these positive changes remain in place beyond the pandemic."
Externally peer reviewed? Yes
Evidence type: Observational
Subjects: Women of reproductive age


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