Abortion: an essential medical procedure | Covid, Contagion, Cracks in the System

A speculative history on abortion access during the COVID-19 pandemic by Ellie Broeren and Hannah Gellert

Speculative history is a form of storytelling pioneered by academic and writer Sadiya Hartman. It is a useful method of examining events that have not been well documented due to dominant cultural narratives in societies. We utilized this form of storytelling to discuss abortion in a more humanized context. Abortion often carries feelings of shame and guilt in our society, projecting women who seek abortions as failure. This is not true, and in our speculative history, we strived to explore abortion as a more nuanced issue than as it is often portrayed. This speculative history is organized into four vignettes, each focusing on a different geographical region and potential struggle with abortion in the face of the COVID-19 pandemic.

Ohio:

As if being a college student during a pandemic wasn’t hard enough. In March of 2020, Gabrielle, a 20-year-old college student in Ohio, had to move out of her dorm room and back home to resume classes remotely. In the chaos of a pandemic starting, the state of Ohio passed a ban on all non-essential medical procedures on March 17 (1). In that same week, Gabrielle received more life-altering news. What could be more life-altering than being uprooted from her studies due to a global pandemic? Gabrielle learned she was pregnant.

A cascade of emotions flooded over her. Fear, anger, shame, denial. The fear of a young, Black woman being alone in the world. The anger of a young woman who thought she was smarter, better than that, even though she knows becoming pregnant is common. The shame of a young woman for having sex, even though deep down she knows it is nothing to be ashamed of. The denial of a young woman thinking, “this would never happen to me.”

Her initial thoughts?

“I’m 20-years-old, studying to get my degree, and don’t have a full-time job. I cannot have a baby right now.”

In addition to being a college student, Gabrielle did not have the familial or social support to raise a child. She lived at home in a small apartment with her single mother and three younger siblings. Her mother worked two minimum wage jobs and barely had time to care for her own children, let alone a grandchild.

Gabrielle’s heart began to race as she thought of her mother. She is suddenly taken back to when she is 15-years-old, sitting at the kitchen table.

“If you get pregnant, don’t bother coming home.”

Those were her mother’s words of warning. Her mother became pregnant with Gabrielle as a teenager, and didn’t want to see any of her children go through it. Gabrielle knew she couldn’t tell her mother, and would need to keep this hidden. She wanted this problem taken care of as quickly and quietly as possible.

But on March 26, 2020, just 9 days after the initial ban on non-essential medical procedures, Ohio clarified that abortions are included as a non-essential procedure (1). Gabrielle called around, trying to connect with a clinic, but they were unresponsive and understaffed due to the pandemic. Gabrielle began to panic, especially after reading that medical abortions were considered non-essential and therefore banned in Ohio for the time being.

But advocates for reproductive justice quickly challenged state legislators. On March 30th, A federal judge blocked the Ohio abortion ban after the American Civil Liberties Union (ACLU), ACLU of Ohio, PPFA, and local Ohio lawyers filed suit (1). After more than two weeks of uncertainty and anxiety, it seemed like abortion access was opened for all. Gabrielle was able to get in contact with one of the ten abortion clinics in the state of Ohio and made an appointment.

Even though Gabrielle was able to make an appointment and see an abortion provider, laws surrounding abortion in Ohio are not conducive to COVID-19 standards. Because Ohio mandates an in-person consultation with the provider at least 24 hours before the procedure, Gabrielle had to go to the clinic twice, increasing her chances of coming into contact with the virus.

This was another source of anxiety for Gabrielle. If she brought the virus home to her family, she would never forgive herself. Her mother couldn’t afford to take any sick time, and was barely making ends meet as is. She wore a mask and washed her hands frequently, but Gabrielle knew coming into contact with more people meant an increased risk of contraction.

Both the consultation and procedure went smoothly. By the first week of April, Gabrielle was finished with the ordeal and was able to move on. Federal courts kept the ban blocked on April 23, and the Ohio department of health lifted all bans on non-essential procedures on May 1st (2).

But just because all pandemic bans have been lifted doesn’t mean it is any easier to obtain an abortion in Ohio. In recent years, more legislation has been passed to mandate waiting periods and medically unnecessary procedures. In Ohio, the patient seeking an abortion must have two in-person appointments with the provider. The first appointment is a state mandated biased counseling session and ultrasound tests to date the pregnancy and determine if a fetal heartbeat is detectable (3). Detecting a fetal heartbeat is medically unnecessary and therefore another hurdle women must jump through. The second appointment is for the abortion procedure.

And because there are only ten clinics in the state, people looking to have an abortion may have to travel very far for this procedure or pill. Though bans have been blocked by reproductive justice activists, much more work needs to be done to create legislation in Ohio that makes abortion easy and equitible to access.

Texas:

Maria has always had a heightened apprehension towards the government. Her mom crossed the border after her husband died when she was pregnant with Maria, looking for a better life in the United States. Maria was born in the United States and was therefore afforded citizenship; however, she grew up with the fear of deportation looming over her mother. As a rule, her family avoided the law as often as possible. They never went to the doctor unless it was necessary, never sped while driving- nothing that put them at even the slightest risk of government contact. The election of Trump to the presidency has just made matters worse. Their neighbors, racist before, are now even more aggressively so, always threatening to call authorities.

Maria is now 29 years old and still lives in Texas with her mother. Maria and her mother work in the most common industries and occupations for Hispanic women. The restaurant industry employs nearly 11% of Hispanic women in the United States and housekeeping nearly 6.4% of Hispanic women (4). Maria works in two different restaurants, as well as working alongside her mother as a housekeeper when necessary. Her mother has been housekeeping since immigrating to the United States. The people she works for don’t ask too many questions and pay only in cash. She’s grown her business through word of mouth and reputation. She works long days, making barely more than minimum wage. Their life is not easy, always threatening to slip below the poverty line.

In March matters became much worse. The pandemic shut down restaurants, closed schools, sent millions of Americans home, and instilled a sense of fear that caused people to divert their eyes from one another. Maria’s hours got cut back by over half and housekeeping jobs disappeared. Even her mother’s most reliable clients stopped calling after over 20 years of service. No one was letting non-family members into their homes. Maria and her mother were slipping further into poverty day by day. Hispanics in the United States are more likely than any other race/ethnicity to be in poverty, a statistic Maria and her mother have worked their whole lives to avoid (4). As if there wasn’t enough stress yet, Maria just found out she was pregnant.

Maria and her boyfriend had been dating for three years now but have never talked about getting married. Furthermore, Maria’s mom is intensely religious and would not approve of having a baby outside of marriage. Maria also doesn’t feel ready to be a mom. She has always dreamed of going to school and being more financially stable before having a child. When she does have kids, she wants them to have a more secure childhood than she did. Maria knows her boyfriend wants children, but she is afraid to tell him for fear he will pressure her into keeping the baby. Maria discovered she was pregnant on March 15^th and decided she wanted an abortion on March 20^th. On March 22^nd, an executive order was released by the state of Texas, restricting all ‘non-essential procedures,’ under which abortion was listed.

Feeling trapped, Maria doesn’t know where to turn. Getting an abortion in Texas is hard enough already. When searching for abortion centers, Maria keeps accidently ending up on Crisis Pregnancy Center websites, which is not what she is looking for. Crisis Pregnancy Centers operate under a facade of being clinical centers; however, they do not have any sort of oversight regulating their actions. They are typically run by evangelical or catholic organizations that prioritize their ideologies over the health and well-being of the pregnant women seeking help (5). While there are over 4,000 Crisis Pregnancy Centers in Texas (6), there are only 35 Planned Parenthoods, of which only 6 offer abortion services (7), of which the nearest is a 2.5-hour drive away. The fear gripping Maria makes it harder and harder for her to find the answers to her questions, and time will not stop passing. Maria is now 8 weeks pregnant and is afraid her boyfriend and mother will be able to tell she is pregnant soon. She has been able to hide the morning-sickness, but a baby-bump will be much harder to conceal.

In her research Maria stumbles across Aid Access, a way through which women in the United States can order abortion pills online (8). The pills are prescribed by doctors outside of the United States, and often in Europe. However, in early March the FDA began to crack down on online ordering of pills, accusing Aid Access of violating federal law by misbranding and facilitating the improper distribution of the drugs, posing an inherent risk to the consumers of the drug. The FDA ordered Aid Access to stop distributing the medications in the United States or face legal action (8). Maria is getting desperate now and is starting to consider even more back-door ways to get an abortion.

In a last-ditch effort, Maria reached out to one of her bosses at the restaurant she has worked in since she was fifteen. The owner is a tough but fair woman who has cared for her employees more than most other places can say. When Maria explains her situation, her boss offers to cover the cost of a flight to a different state for the abortion. Flight costs have dropped dramatically due to the pandemic (9) and a ticket to Los Angeles only costs $150. All Maria would have to cover is lodging.

By the time Maria reaches a clinic in Los Angeles, she is 11 weeks pregnant- right at the cut-off for being able to receive a medical abortion. However, Maria wants the less invasive procedure, and the doctor cannot identify any other likely or possible complications that might occur. After taking the first pill, mifepristone at the clinic, she returns to her hotel room. She waits twenty-four hours and then takes the second pill (10).

The whole process has been painful and lonely. Maria felt isolated in her pregnancy from the time she initially missed her period to the empty plane ride back to Texas. The process would have been long and complicated without a pandemic. Maria even had to lie to her mother and boyfriend, saying she was traveling to check in on a friend who was in a desperate situation for a week, in order to go to California to get the abortion. Not to mention the financial burden of travel, treatment, and time off from jobs that are restricted due to quarantine as it is. Getting an abortion is never easy, with or without a pandemic it should never be so hard to receive the medical care you need. And at the very least, access to reproductive health care should not be coined non-essential.

Washington:

Olivia had always been determined not to be another housewife. Yes, she wanted kids, but that shouldn’t mean she has to give up her whole career. She worked hard to avoid becoming another domesticated stay-at-home-mom. She went to college, got a degree in computer science from University of Washington, and was hired by Microsoft straight out of undergrad. She worked her ass off, as she has to remind herself every once and again, and was by all standards successful before getting married. Her husband, Liam is great too, he has listened to her and supported her in deciding to go back to work as soon as possible after their first kid and supported her in taking time off after having their second. They are lucky enough that Liam’s mom lives nearby and has been able to help with the kids, but after having her second kid, Olivia wanted to feel less like she was missing out on her children’s childhood.

So, she stayed out of the workforce for a couple years. She decided to try that stay-at-home mom thing she had railed against for so many years. And it wasn’t so bad, spending time with the kids was fulfilling. Olivia was able to go to soccer games and help out in the preschool like she hadn’t been able to before. But 3 years turned into eight before Olivia decided to re-enter the workforce. A lot has changed in the eight years since Olivia stopped working. She realized she isn’t even qualified for her straight-out-of-undergrad job without a graduate degree anymore. And since it has been so long, all those years of ‘prior work experience’ mean even less.

Olivia picks up night classes and puts herself through a graduate program to get her back where she was ten years ago. It hasn’t been easy, and she was back to missing soccer games and ballet recitals and calling Liam’s mom for more and more help. Finally, after years of work to get back to where she left off, Olivia feels success again, not just as a working-mom but as a part of the workforce. She no longer feels like she is financially reliant on Liam. She feels like she’s someone who her 16-year-old self would be proud of again.

Then this thing called COVID-19 starts popping up in the news, and all of a sudden, on March 25^th Washington orders a mandatory stay-at-home order. Which is fine for her job, as a computer software engineer, she can work from home; however, Liam is a pharmacist and still has to go in to work. Furthermore, they can no longer call Liam’s mom for help because of Liam’s increased potential exposure to COVID-19 and his mom being of an at-risk population.

Olivia is starting to feel her grasp on the separation of work and home slipping. She can’t manage both the kids full-time, as their school is now remote, the house, and working without more help. Something has to give. So, she pulls back, and goes to part-time for Microsoft. It is a blow to her morale, but she gets to be a more present mother she tells herself. Alas, Olivia is not alone. The pandemic has disproportionately caused women to exit the workforce. Between August and September of 2020, 865,00 women will leave the labor force, compared to only 216,000 men. Additionally, one in four women will report considering reducing work hours, moving to part-time, switching to less demanding jobs, taking leaves of absences from jobs, or leaving their jobs altogether (11).

To make matters worse, Olivia just found out she is pregnant. If it wasn’t for the pandemic, Olivia may even feel excited about the pregnancy. But she already feels overwhelmed (barely) balancing home life and work life with two kids, much less with three. Furthermore, she’s almost 40 years old, and she doesn’t really want to have a ten-year-old at 50. After talking with Liam, Olivia decides to get an abortion. She has read online about all of the states that are incorporating abortions into non-essential medical procedures but is lucky that Washington is not one. She is able to use the Washington State Department of Health’s website to find a list of abortion centers nearby (12), including an All Women’s Care (AWC), that specializes in pregnancy termination procedures (13).

Olivia is lucky that her state and family made seeking out and receiving an abortion a relatively simple process. However, her situation in regard to working highlights how tenuous the United States’ relationship with progress of women in the workforce actually is. The pressure for a woman to put her family over her career is still present, causing women to leave the workforce at much higher rates than their male counterparts- yet another crack in the system brought to light by COVID-19.

New York:

Tanya is an OB/GYN who has been working in New York City for 15 years. She works at a community health center, where almost all of her patients are people of color. Since the pandemic hit, she’s been grappling with protecting herself and her patients from the virus, providing the best care for her patients, and abiding by state and national mandates.

As an abortion provider, Tanya understands how truly important abortions are for so many people. The American College of Obstetricians and Gynecologists also recognizes this, and issued a statement on March 18th stating that abortion is an essential component of comprehensive healthcare (14). Not only is abortion essential, but it is also essential in a timely manner. For example, associated mortality for medical abortions is 0.1 per 100,000 procedures through eight weeks of gestation. However, this number rises to 8.9 per 100,000 at 21 weeks and above (15). People need continuous access to abortion, and they need access quickly.

Abortion is also incredibly necessary in the time of COVID-19. Tanya found that as stay-at-home orders began, she started receiving more and more appointments and requests for abortions. Increased time at home, decreased access to contraceptives, and increased proximity to sexual abuse in the home could all explain this increase in abortions, as well as general unease about having a child during a pandemic. And this increase in abortions is well documented. According to a new study from UT Austin’s LBJ School of Public Affairs, there was a 27% increase in the rate of requests for medical abortion by mail in the U.S. between March 20 and April 11 compared to the beginning of the year (16). In just three weeks, requests for medical abortions by mail have increased dramatically. Though the increase in by-mail requests could largely be attributed to individuals choosing to stay home rather than come into the doctor’s office, this still well documents the need for abortions.

Abortion is also incredibly important during the pandemic for certain populations. Nationally, sixty percent of people who receive abortion care are people of color, including 53 percent who identify as Black or Latinx (17). This could be due to lack of access to contraceptives, or lack of resources to care for a child. COVID-19 is also disproportionately affecting people of color, which could affect the need for an abortion now.

With strict stay-at-home orders in New York City, Tanya wasn’t able to get into the office for much of the spring. While these mandates were frustrating, she was incredibly grateful to not be in a state where access to abortions was directly attacked. Nine states, Alabama, Ohio, Oklahoma, Tennessee, Alaska, Arkansas, Iowa, Kentucky, Louisiana, Mississippi, West Virginia, and Texas, all attempted to enact legislation to ban or limit abortions in spring 2020 (2). New York, though strict with certain orders, did not attempt to restrict abortions.

This does not mean, however, that it was easy to access abortions in New York City. Tanya found that she had many patients calling to obtain an abortion pill. Tanya could not provide them however, because the FDA has an in-person pill pick-up requirement for mifepristone, the abortion pill (17), and she could not get into the office. Federal limits like this one are limiting abortion from being accessible, especially in the time of COVID-19.

With all of the lawsuits regarding abortions, Tanya is also worried about abortion ban blockings going to the Supreme Court. If these bans go to the Supreme Court, will the court have the authority to overturn Roe v. Wade? Amidst the pandemic, Trump’s appointment of Amy Coney Barret to the Supreme Court makes the future of reproductive rights even shakier. In the back of her mind, Tanya is struggling with this nagging fear of Roe v. Wade being overturned. If this were to happen, abortion would be legal on a state by state basis. Though she knows that abortion would still be legal in New York if Roe v. Wade was overturned, she’s not so sure about other states. She knows that when abortions become illegal, the rate of abortions do not decrease, but instead the rate of unsafe abortion increases (18). This causes her to begin to wrestle with the moral ambiguity of knowing that abortions are safe and essential, but would other providers perform them if abortion is made illegal in their states? Or would she see an influx in patients from out of state? This is also incredibly dangerous, as people getting this treatment wouldn’t be near the provider after the procedure. In times like this, medical professionals should be deciding what is safe and effective, rather than politicians.

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