COVID-19: How does it affect women’s sexual and reproductive health?

In a previous Special Feature, we covered the role of biological sex differences in the spread of the new coronavirus. Here, we look at how the pandemic is affecting women’s sexual and reproductive health in the United States and across the world.

The coronavirus pandemic has affected people differently based on their sex and gender. And, as we explained in our previous feature, gender has played an important part in the primary and secondary impacts of the current health emergency.

Although our previous article used sex-disaggregated data to focus on the primary effects of the virus, such as viral transmission and mortality rates, this feature will examine some of the secondary effects that this crisis is having on women — with a special focus on sexual and reproductive health.

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From a primary impact point of view, men seem to be much more likely to have a severe form of COVID-19 or die from the disease.

However, on a societal level, the pandemic has had a range of serious consequences for cis and trans women everywhere — including the higher risks they face as a result of their traditional roles as carers, the rise in domestic violence, and their lack of decision making power in their own sexual and reproductive health.

COVID-19 threatens abortion rights

Many have argued that there has been a power imbalance in the COVID-19 response, and that the insufficient number of female leaders places women at a disadvantage.

For instance, the initial U.S. coronavirus task force consisted entirely of men until two women joined in February 2020. In addition to these imbalances, the existing power dynamics on a political level have resulted in decisions that may jeopardize women’s reproductive health.

For example, government officials in the states of Texas, Ohio, Alabama, and Oklahoma have tried to ban most abortions — that is, those that are not required to preserve the life or health of the mother — on the basis that they do not consider them urgent or medically necessary during this pandemic.

They allegedly made this decision to preserve hospital beds and other medical resources and facilities that are necessary during the pandemic.

Although federal judges have tried to block these attempts, further efforts to appeal them have resulted in a decision to ban the procedure in Texas.

The U.S. appeal court ruled in favor of the state on April 20, 2020, banning all nonessential abortions, including those done by ingesting a pill, which account for a third of all abortions. This is despite abortion providers’ protestations that medical abortions are not surgical procedures that require the use of medical facilities, resources, or protective equipment.

However, a new order that took effect on April 22, 2020, has allowed abortion facilities in Texas to resume both medical and surgical abortions in return for preserving a certain number of beds for COVID-19 patients.

Texas is not the only state where abortions were in danger of receiving a ban because they were not deemed “essential healthcare.” In fact, officials in many states are continuing to contest a woman’s right to have an abortion.

In Utah, Indiana, Ohio, West Virginia, Kentucky, Tennessee, Alabama, and Louisiana, officials are currently contesting a woman’s right to an abortion. Abortions are already restricted in Alaska, Arkansas, and Mississippi.

Are abortions ‘essential healthcare’?

In an interview, Dr. Erin King — who works as an obstetrician-gynecologist in Missouri — explains why abortions are essential healthcare.

She said, “It’s important to remember that people [seeking] abortion care need that care when they need it.”

“They know their bodies best, their social situations best, their lives best. And if it is not the right time for them to be pregnant, that pregnancy is not waiting for the end of a pandemic. Although abortion is safe pretty much all of the time, the earlier you are in your pregnancy it’s an even safer procedure.”

– Dr. Erin King

When asked about the argument that abortions are not medically necessary during a pandemic because they are considered “elective,” Dr. King said: “Abortion in general is medically necessary, and for patients seeking abortion, they can’t wait. Their pregnancy is continuing to grow regardless of what’s happening outside their bodies.”

Furthermore: “There are patients with medical conditions that will worsen if they don’t access abortion care as quickly as possible. There are patients with fetuses that have multiple anomalies, and they may end up actually being past a gestational age where they can access abortion care if they wait.”

Dr. King is certainly not the only healthcare professional who thinks that abortions are essential healthcare.

The American College of Obstetricians and Gynecologists, in collaboration with other institutions, have recently released a statement on abortion access during the COVID-19 outbreak.

“Some health systems, at the guidance of the CDC [Centers for Disease Control and Prevention], are implementing plans to cancel elective and nonurgent procedures to expand hospitals’ capacity to provide critical care,” they say.

“To the extent that hospital systems or ambulatory surgical facilities are categorizing procedures that can be delayed during the COVID-19 pandemic, abortion should not be categorized as such a procedure.”

“Abortion is an essential component of comprehensive healthcare. It is also a time-sensitive service for which a delay of several weeks, or in some cases days, may increase the risks or potentially make it completely inaccessible. The consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being.”

Women’s well-being under strain

Restricting access to abortions has already had immediate consequences on women’s physical and emotional well-being. Many now have to travel long distances to seek the care they need.

For example, a report from the Guttmacher Institute estimated that the average driving distance to an abortion clinic for a woman in Texas could have increased by almost 2,000% had legal abortion care centers shut down.

Although there are have been no studies on the impact that such measures might have on the mental health of those refused abortions during COVID-19, there are studies that suggest that unintended pregnancies in general are associated with poor mental health outcomes.

In fact, experts have found significant increases in depression both in the short term and in the longer term, nearly 20 years later, in women who had unintended pregnancies.

It is worth noting that emerging studies show that women are already at a higher risk of mental health concerns as a result of caring for patients with COVID-19 in healthcare settings. This is due to the fact that women tend to dominate healthcare roles.

In addition, women provide “unseen” and unpaid care in families, which contributes to this strain. According to a policy brief from the United Nations (UN), “Before COVID-19 became a universal pandemic, women were doing three times as much unpaid care and domestic work as men.”

Furthermore, the same report also suggests that the school closures during the pandemic “have put additional strain and demand on women and girls,” adding that currently, 1.52 billion students are at home as a result of COVID-19.

Additionally, most of the 60 million teachers who are now at home are also women, which compounds the childminding responsibilities that societies have traditionally placed on this gender.

In this context, it is essential to remember that the strain on women’s well-being as a result of restricting their access to reproductive health services will likely compound the already existing pressures and expectations they face.

Birth control and family planning 

Abortions are not the only aspect of sexual and reproductive health that the current crisis is affecting. The fact that many health centers are offering restricted services may also affect people’s ability to obtain birth control.

As a result of intersectional inequalities, these changes are likely to affect certain sociodemographic groups that are more vulnerable than others.

For instance, the UN appreciate that in Latin America and the Caribbean, “an additional 18 million women will lose regular access to modern contraceptives” as a result of the pandemic, putting teenagers in particular at risk and raising the likelihood of teenage pregnancies.

As the brief warns:

“Sexual and reproductive health services […] are central to health, rights, and well-being of women and girls. The diversion of attention and critical resources away from these provisions may result in exacerbated maternal mortality and morbidity, increased rates of adolescent pregnancies, HIV, and sexually transmitted diseases.”

In the U.S., certain communities were already particularly vulnerable.

Speaking to Medical News Today, Dr. Amy Roskin — head of clinical operations at the online birth control provider Pill Club — said that in the U.S., obtaining birth control is already immensely challenging for the nearly 20 million women living in so-called contraceptive deserts. These are areas that do not have a health clinic that offers a full range of contraceptive services.

Traveling to a pharmacy or another state to get adequate reproductive healthcare is not a viable solution during COVID-19. Furthermore, Dr. Roskin said, women who already have intrauterine devices may find it difficult to get them changed, as most clinics have been canceling a variety of health services they wrongly deem nonessential.

Dr. Roskin also drew attention to the possibility that unintended pregnancies could spike as a result of more women staying at home with their partners during the lockdown.

“In early March, we received about 30% more […] requests,” said Dr. Roskin, adding that, “Pill Club shipped [about] 20% more emergency contraceptives to [people] in March compared [with] February.”

The pandemic is not just negatively affecting people who do not wish to have children, but also those who do. A U.S. survey of nearly 2,000 people found that almost a third of respondents had changed their reproductive plans due to COVID-19. In addition:

  • Around 61% of respondents said that they feel anxious and stressed about fertility and family planning due to COVID-19.
  • Of those who are changing their plans, nearly half said that they were concerned about access to prenatal care, and about 1 in 4 said that they were delaying having children because their fertility clinic has paused treatments.
  • Furthermore, people listed “access to prenatal care” and “financial reasons” as the top two reasons why COVID-19 has delayed their plans for having children.

Financial concerns in the midst of this pandemic could also mean that only people with very high incomes could have access to fertility treatments in the U.S. This has already happened in other countries.

Lessons from previous pandemics?

Advocates for gender equality in healthcare have already pointed at previous epidemics to warn about the dangers of diverting resources away from women’s healthcare.

In a report appearing in The Lancet about the gendered impact of the COVID-19 outbreak, authors Clare Wenham and colleagues draw parallels with the Ebola and Zika outbreaks.

“Women were less likely than men to have power in decision making around the outbreak, and their needs were largely unmet,” they say. “For example, [during the Ebola epidemic in Sierra Leone], resources for reproductive and sexual health were diverted to the emergency response, contributing to a rise in maternal mortality in a region with one of the highest rates in the world.”

“During the Zika virus outbreak, differences in power between men and women meant that women did not have autonomy over their sexual and reproductive lives, which was compounded by their inadequate access to healthcare and insufficient financial resources to travel to hospitals for checkups for their children, despite women doing most of the community vector control activities.”

– Clare Wenham et al.

A similar outcome could happen now as a result of COVID-19. A report from the Guttmacher Institute warns of the “catastrophic” consequences that overlooking sexual and reproductive needs during these times might have.

Starting from the assumption that essential services would be reduced by 10%, the report foresees a huge spike in maternal and newborn deaths in low- and middle-income countries:

  • “A 10% proportional decline in short- and long-term reversible contraceptive use would result in an additional 49 million women with an unmet need for modern contraception […]. In turn, this would lead to more unsafe abortions and other negative outcomes.
  • ​A 10% decline in the provision of pregnancy-related and newborn healthcare [would lead to] an additional 1.7 million women who give birth and an additional 2.6 million newborns would experience major complications and not receive the care they need. This would result in an additional 28,000 maternal deaths and 168,000 newborn deaths.
  • ​Additionally, if countrywide lockdowns force abortion clinics to close or countries treat abortion as nonessential, that would lead to a reduction in safe abortion procedures. Under the assumption that 10% of safe abortions become unsafe, we would see an additional 3 million unsafe abortions and an additional 1,000 maternal deaths due to unsafe abortions.”

Limited access to healthcare in richer countries such as the U.S. could lead to similar figures. Self-managed abortions rates were already high in states that were more hostile to the procedure.

For example, a study from early this year estimated that the rate of women who attempt to perform an abortion on their own in Texas is already more than three times that of the national average (6.9% versus 2.2%).

Healthcare governance needs more women

What previous epidemics have taught us is that in order to meet women’s needs, a more equal distribution of the decision making power in healthcare is necessary.

As some have noted, “Other than a handful of high profile women leading global institutions, women are conspicuously invisible in global health governance: [P]eople working in global health are aware of and see women in care roles that underpin health systems, yet they are invisible in global health strategy, policy, or practice.”

The COVID-19 response so far indicates a trend of repeating past mistakes: a lack of female representation in the COVID-19 task force, the unavailability of sex-disaggregated data on the impact of this new virus, and the attempts to encroach on women’s autonomy over their own reproductive health.

A more balanced gender representation in governing health bodies and a full and equal participation in decision making processes would ensure that women are no longer “invisible,” that their sexual health and reproductive needs are met, and that potentially disastrous consequences such as increased maternal and newborn mortality rates do not come to fruition.

In the words of experts at the Guttmacher Institute, “Outbreaks are inevitable, but catastrophic losses for sexual and reproductive health are not.”

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