In late March, the state of Texas outlawed abortions with the Texas Attorney General Ken Paxton stating abortions are “elective surgery” and medical supplies used at the abortion clinics were needed to fight COVID-19. Five other states including Ohio, Arkansas, Alabama, Tennessee, and Oklahoma made similar moves. Abortion supporters filed suit and the procedure became a ping pong ball going back and forth as one court made a decision and the next reversed it. AG Paxton made a unilateral decision affecting women across that state. Interestingly, he did not order primary care physicians or specialists providing “elective” care to close and/or send their masks and gloves to the hospitals, only the abortion clinics. This begs the question, why are abortion clinics the only ones told to close in order to save PPE (Personal Protection Equipment)? AG Paxton’s reasoning is based on an outdated narrative in which women’s healthcare is separate from all other forms of healthcare and can therefore be denied or considered optional.
The historical narrative identifies women’s healthcare as separate and different from all other types of healthcare. It has been segregated and considered its own standalone medical item while frequently overlooked. For example, when the Affordable Care Act (Obamacare) debate was reignited after President Trump’s election, there were male legislators who opposed covering prenatal care because they personally do not need it, instead wanting women to have to pick up the tab. Feminine hygiene items are frequently left out of emergency preparedness lists and kits by government agencies and nonprofits. Tampons and pads are subject to sales tax because they are not considered an essential item in many states. Any item that has to do with women’s reproductive health is considered optional or an afterthought. Instead, women’s healthcare must become an integral part of any modern healthcare system.
When considering women’s healthcare through this old lens, it is easy to start to pick apart different elements and consider them expendable. In reality, abortion is part of comprehensive women’s healthcare and must be considered as such. Additionally, it has legal protections that other procedures do not. Some would argue abortion is “elective” surgery; it is not. The term elective surgery means the procedure is non-emergent and can wait without the situation getting worse for the patient. For example, knee surgery can wait because you can still get around, but sooner or later, you will need the surgery. Abortion clearly cannot wait as it is a time sensitive condition becoming a more complicated procedure as time goes by. Regardless of your personal opinion about abortion, it is a legal medical procedure. In North Carolina, DHHS Secretary Mandy Cohen defined elective surgery as “…any procedure or surgery that if not done within the next 4 weeks would cause harm to the patient.” Clearly, continuing a pregnancy for an additional four weeks could cause more difficulty for the woman having the abortion, or make it move past the legal point for having the procedure altogether. Additionally, many abortion clinics, including Planned Parenthood, provide comprehensive women’s healthcare including prenatal care and birth control. When the clinic is forced to close, then women who depend on the clinic no longer have access to these vital services.
As of this date, there have been no bills presented in the North Carolina General Assembly regarding closing abortion clinics. But as the pandemic continues and particularly if another spike in illness causes more drastic measures at hospitals, the community needs to be thinking about how to continue services. One possibility would be to roll back the NCGA statute from 2013 that outlawed medication abortions via telemedicine. While the FDA currently does not allow mifepristone to be prescribed via telemedicine, twenty-one Attorneys General (including our own Josh Stein) wrote to DHHS Secretary Alex Azar to encourage the agency to approve the drug for telemedicine use. They write “In fact, Mifepristone is four times safer than Viagra and fourteen times safer than carrying a pregnancy to term. The FDA itself has stated ‘the safety profile of Mifepristone is well-characterized and its risks well-understood after more than 15 years of marketing. Serious adverse events are rare and the safety profile of Mifepristone has not substantially changed.’” Medication abortions are available to women until 13 weeks of pregnancy, a period during which the vast majority of abortions occur. Particularly during this pandemic, telemedicine abortions would be safer than a visit to the clinic where a patient is faced with protesters and staff members who are all possible vectors of disease.
Other areas of women’s reproductive healthcare are also impacted by the pandemic. Over thirty million unemployment claims have been filed since mid-March. For those women who have lost their health insurance, it also means they lost their birth control coverage. Birth control pills without insurance coverage can cost $600-$800/year. We know from research compiled by the Guttmacher Institute that the abortion rate is closely tied to the number of unplanned pregnancies. And of course, unplanned pregnancies are related to regular access to birth control. The pandemic is making many question the uniquely American practice of tying healthcare to your employment status. Oral contraception is not something you can go on and off of as you obtain employment or get laid off. It is a hormonal treatment which requires taking regular doses on a daily basis. If you go off oral contraceptives, then you have to wait a month once you are back on them before they are effective. In talking to Tara Romano, Executive Director of NC NARAL, about this topic, she mentioned, “There has been a movement over the years for getting oral contraceptives available over the counter. You would be working with your pharmacist, who is a healthcare professional. Because they (oral contraceptives) have been around a long time, health professionals know a lot about oral contraceptives.” Another solution would be to enact the Medicaid expansion to provide birth control for women who have lost their jobs.
As the country moves through this pandemic period of undetermined length, it is important to keep track of the myriad ways it affects people at every stage of life. As women are 51% of the population of this country, the full spectrum of women’s reproductive healthcare must become an integral part of all healthcare discussions. And with one in four American women having had an abortion before the age of 45, abortion is clearly an important part of comprehensive women’s healthcare.