On a Thursday in early April, Shanthi Ramesh saw three patients back to back. They were all healthcare workers on the front lines of the coronavirus pandemic. Two of them worked in a local emergency room, while the other was driving up to New York the next day to volunteer at a hospital.
They had another thing in common: All three women had gone to Ramesh’s clinic to get an abortion.
“I was so struck by the juxtaposition of this conversation that we’re having on this high level around abortion as essential healthcare, and how essential that care was for these women,” says Ramesh, who is the medical director at the Virginia League of Planned Parenthood. “There actually are healthcare workers who need to access this service in order to continue to care for our community.”
One of them was an emergency room clerk and single mom who was socially distancing from her daughter. “I was so struck by what she said about how she is trying to keep her daughter safe by keeping her at her parents’ house,” Ramesh says. “That way, she was able to still go to work—and she really needed her abortion in order to be able to continue to do that.”
These women could get abortions—and continue acting as essential workers because they had access to that care—even amid stay-at-home orders. In Virginia, abortion is still considered an essential service. But since the coronavirus took hold, states with restrictive abortion laws have seized on the opportunity to further erode access to abortion, citing public health concerns. In recent weeks, eight states—Arkansas, Alabama, Iowa, Louisiana, Ohio, Oklahoma, Tennessee, and Texas—have sought to ban abortion by classifying it as an elective procedure and citing the need to conserve personal protective equipment for healthcare workers treating COVID-19 patients.
Many abortion advocates see it as an opportunity for politicians to further an anti-abortion agenda. “These orders exempt all types of essential, time-sensitive healthcare and leave to the physician’s discretion the ability to determine what types of medical care and procedures can be delayed and what cannot,” says Molly Duane, a staff attorney at the Center for Reproductive Rights. “And yet, [they] single out abortion providers as unable to make those similar determinations in consultation with their patients.”
By now, the majority of orders have been blocked due to lawsuits filed by Planned Parenthood and the Center for Reproductive Rights. But many of the states in question had already chipped away at abortion access long before the coronavirus hit, through stringent anti-abortion measures. In Texas, a state with a population of about 29 million people, each week has brought a new ruling by the courts, as a legal tug-of-war over its abortion ban has been appealed up to the Supreme Court. Last week, the state caved, walking back the restrictions that had effectively barred abortion across the state.
But those seeking access to abortions in Texas over the last month have been at the mercy of the courts. “We’ve been hearing that people are frustrated and confused,” says Kamyon Conner, the executive director of the Texas Equal Access (TEA) Fund, a fund that provides financial and emotional support to people seeking abortions in northern Texas. “They have an appointment one day—and then they don’t have an appointment because the state keeps going back and forth. The same people who are losing their jobs and walking into empty grocery stores are calling clinics to figure out how to get an abortion that they desperately need.”
Some providers have been forced to send patients home the day they were scheduled to get an abortion, as the courts repeatedly overturned attempts to block the abortion ban in Texas. Bhavik Kumar, an abortion provider with Planned Parenthood Gulf Coast in Houston, was in the middle of a procedure when a circuit court overturned a block on the state’s abortion ban.
“With all of these restrictions, including what’s happening now, physicians and our staff become the face of having to enforce them,” Kumar says. “There were a couple of days when we were in the health center with patients and had to look them in the face and say, ‘We technically are able to do this. We have the means. We have the training. We have the skills. We have everything here. But we’re not allowed to do it.’ And to hear people’s frustration, to have them beg you for help—it doesn’t feel good. It feels inhumane to treat people that way, and it leaves us speechless.”
The risks of abortion care during lockdown
The process of getting an abortion is already complicated in a state like Texas. Under state law, all providers must abide by a 24-hour mandatory waiting period within 100 miles of a clinic, which means women are typically required to show up in person for both a counseling session and the actual procedure. Providers also have to conduct an ultrasound before performing an abortion, which many advocates call medically unnecessary.
Even a medication abortion—which is noninvasive and involves taking a combination of pills, mifepristone and misoprostol—must be done in person and is only an option for women who are up to 10 weeks pregnant. A study published in Obstetrics & Gynecology last year reinforced previous findings that indicate medication abortions via telemedicine are just as effective as those conducted in person. And last year, a number of states tried to introduce laws that would ban abortions later than six to eight weeks into a pregnancy.
Limiting exposure to the coronavirus is yet another hurdle for providers and patients alike. To help protect both parties, many clinics are using telemedicine for screenings and counseling where possible. Many patients are being requested to stay in their cars up until the procedure, to reduce foot traffic in waiting rooms.
“We’re asking [members] to be very careful about their procedures to allow for social distancing within the clinic,” says the Very Reverend Katherine Ragsdale, the president and CEO of the National Abortion Federation (NAF). “They’ve been expanding their hours so that they can have fewer patients in the clinic at any one time. Many of them have been asking companions not to come into the clinic with the patients.”
Of course, patients and staff are still vulnerable to other risks: Anti-abortion protests have shown no signs of letting up, with many organizers encouraging people to show up at clinics in spite of stay-at-home orders. “Protesters are taking advantage of that,” Ragsdale says. “They’ll surround the car and scream at the patient, which has always been a tactic. But now in addition to screaming at them while they’re sitting in their cars, they don’t give them room to get out of the car and get into the clinic without being touched or coughed on.”
This month, a group of protestors was charged for gathering outside one of NAF’s member clinics in North Carolina, and just weeks earlier, the clinic had been thronged with 150 protestors, after the state had barred gatherings of more than 100. In Michigan, the state has exempted religious services from its ban on gatherings, so anti-abortion groups there are invoking religion to defend their protests.
Ramesh adds that the usual group of protestors has continued frequenting multiple Planned Parenthood affiliates in Virginia, as well. “It’s just completely disrespectful in this moment of public health crisis, to be blatantly ignoring rules around social distancing,” she says. “They have their own agendas and clearly don’t care about what’s actually happening in our health centers and the people we’re taking care of—[one of whom] may be an ER nurse who saves their life when they get the coronavirus.”
Even under normal circumstances, women who live in states with few clinics often have to jump through hoops to obtain any kind of abortion. According to the Guttmacher Institute, a research group that supports abortion rights, about 89% of counties across the country did not have an abortion clinic as of 2017. In rural parts of Texas, for example, patients might have to travel more than 300 miles to get to their closest clinic. A number of states, including Missouri, have just one abortion clinic.
Abortion funds like the TEA Fund have always helped women pay for and access abortions, including out of the state. Now, as a result of the restrictions in Texas and other states, these funds have seen an increase in women trying to leave their home state for abortions.
One woman in Houston had to travel about 1,500 miles to get an abortion in Atlanta despite living three miles from a clinic.
In the current climate, the lack of abortion access near their homes forces patients into a situation where they risk greater exposure to the coronavirus. For organizations that help patients travel for an abortion, this presents yet another challenge. “This pandemic is really hitting at the heart of our work and makes it more needed than ever—but also certainly more complex,” says Odile Schalit, the executive director of the Brigid Alliance, which provides travel assistance to those seeking later abortions. “So systems that we used to be able to rely upon, like airlines, are now both a combination of less safe and also less reliable.”
When possible, the Brigid Alliance has helped patients rent cars in lieu of flying: One such trip was nearly 18 hours and took a patient from Alabama to New Mexico, according to Schalit. But some women can’t take off enough time to drive long distances, which means they have no choice but to fly.
Hotels, too, have shut down or are operating with limited headcount, which makes it harder for these organizations to find accommodations for traveling patients. Usually they might fall back on volunteers, but that’s no longer a safe option.
“We’ve got hundreds of people who have extra rooms in their homes, mostly in Chicago and some in the Twin Cities,” says Diana Parker, the incoming executive director for Midwest Access Coalition, which offers practical support and assistance to abortion patients traveling to or from the Midwest. “That is the first thing we put a pause on because we didn’t want to put hosts in a position to have to say, ‘No, I want to take care of myself.’ We didn’t want them to feel guilty. We also just didn’t want to help spread the virus among our clients or our volunteer base.”
Since the coronavirus hit, Parker says her organization has fielded more complex cases, including an uptick in patients who are minors, as well as far more calls from patients in Texas. But she says the majority of their clients have always been mothers. And while stay-at-home orders have made their work harder, abortion funds are accustomed to navigating all kinds of hurdles to access. “Our resources are more restricted right now, and we’re needed more so than ever,” says Schalit. “But the concept of these types of barriers to care is not new to us.”
The case for telemedicine abortions
During the lockdown, Americans across the country are conducting business over video platforms. Pro-abortion rights advocates have pushed a similar approach to abortion care. Medication abortions can be administered virtually—albeit only until 10 weeks into a pregnancy—and are a safer option for patients and providers. Some are calling for the FDA to temporarily lift restrictions on medication abortions, so that women can access those drugs at the pharmacy or via mail.
But the promise of telemedicine abortions is curtailed by laws that don’t allow for a seamless, virtual process from beginning to end, particularly in states with limited abortion access. Planned Parenthood, for example, has to conduct telemedicine abortions through the site-to-site model, which means patients still have to go into a health center for a video consult with a physician and to obtain the pills. In response to the coronavirus, Planned Parenthood has now rolled out more robust telehealth services across every state—but that won’t be much use in states like Texas that make legal telemedicine abortions virtually impossible.
In a handful of states, there’s one viable option for women seeking in-home abortion care that is above board: the TelAbortion study, a telemedicine abortion service by research organization Gynuity that allows patients to consult with doctors from anywhere and receive abortion medication by mail. Since launching in 2016, TelAbortion has partnered with nine providers across 13 states, reaching about 750 patients. As stay-at-home orders started rolling out, the study saw a 30% increase in virtual visits. For patients who can’t leave their house, TelAbortion has been able to waive the ultrasound requirement on a case-by-case basis.
“We are really trying to see how we can reach the remainder of the states that don’t have a ban, just because the need is so great now,” says Erica Chong, a director at Gynuity who is co-leading the study. It’s unlikely the study will get the greenlight to operate in states with restrictive abortion bans, so the goal is to expand into neighboring states.
Chong says TelAbortion has generated a lot of interest from providers and clinics given the circumstances. “Unfortunately because it’s a research study, it’s slow and cumbersome and expensive,” she says. “We can’t just add on everybody that wants to be a part of it. We’re trying to figure out how we can ask them for referrals and best incorporate them.”
One of TelAbortion’s existing partners is Carafem, which has four health centers in Chicago, Atlanta, Nashville, and Washington, D.C. “We’ve expanded that program now,” says Melissa Grant, the chief operating officer of Carafem. “Within the last two weeks, we moved it from being available only in Georgia to also being available in Illinois and in Maryland.”
Carafem has also heard from physicians who want to lend a hand. “We’ve had some private physicians who’ve reached out asking about how they can assist us in this work,” Grant says. “We just need to make sure the current systems are working, and our clients are being taken care of. But I would be open to either having more physicians helping us with telemedicine or potentially expanding to other areas, if we think it could be incorporated in that state.”
An unequal burden
For many people seeking abortions, the impact of coronavirus on reproductive care only compounds the pandemic’s effects on their livelihood and overall health. Women getting abortions are already more likely to be poor: In 2014, about 50% of women who had abortions were living in poverty, twice the share of low-income women who got abortions in 1994, according to the Guttmacher Institute.
“People are struggling to make ends meet,” says Candace O’Brien, who works at the Yellowhammer Fund, which offers financial support to people seeking abortions in Alabama. “And that [has] added a barrier to abortion access for people because now they have a more restrictive financial barrier. They have the geographical barriers because people have to drive an hour or more to get to a clinic depending on where they live. And then you have childcare being an issue too, because they now have the children at home and have to find people to take care of them.”
Some reports have already shown the fallout from coronavirus is disproportionately affecting women financially, and particularly women of color. Women also account for a larger share of essential workers. Whether they are doing essential work or burdened with a loss of income, many women who cannot afford an unplanned pregnancy opt for an abortion. Ragsdale hopes that, in a moment of public gratitude for so many workers, abortion providers and clinic staff will get their due.
“We are rightly celebrating the nurses in the hospitals and the pizza delivery guys and the people in the grocery stores—all those people who are being celebrated as the heroes that they are,” she says. “But nobody is celebrating our folks, who have been heroes every day for years, and continue even in the midst of all of this.”
Correction: An earlier version of this story overstated the distance traveled by a patient in Houston who went to Atlanta for an abortion.