Medical Examiner

How the Pandemic Is Changing Abortion Care in Vulnerable Countries

A woman wearing a mask, scrubs, and gloves sits in an ambulance.
Rosemary Koech, a Doctors Without Borders EMT working in Kenya, prepares for her 16-hour night shift.
Photo illustration by Slate. Photo by Paul Odongo/MSF.

Coronavirus Diaries is a series of dispatches exploring how the coronavirus is affecting people’s lives. For the latest public health information, please refer to the Centers for Disease Control and Prevention’s website. For Slate’s coronavirus coverage, click here.

This as-told-to essay from Dr. Manisha Kumar has been edited and condensed for clarity from an interview with Rachelle Hampton.

I am currently the head of Médecins Sans Frontières’ task force for safe abortion care. It’s a relatively new initiative that started in 2016 to increase provision of contraception and safe abortion care in MSF projects. Before this role, I worked for MSF in many different capacities. I was both a field staff doctor in the Democratic Republic of Congo and a medical coordinator in DRC and Bangladesh. Just like many people, I’m working from home now, in Amsterdam. I’ve never spent this much time in my apartment, behind my computer, on Zoom meetings and calls. So much of MSF and who we are is based in the field.

Our biggest priority is supporting our field staff who are encountering barriers or challenges to providing reproductive health services, namely contraception and safe abortion care. It’s hard not to be able to be there to support them in person. Our field visits are so important because that’s when you get to talk with our front-line staff and hospital patients and really listen to them. It’s through listening and engagement with communities that we move forward on a lot of these sensitive topics. When it comes to a topic like abortion, one of the biggest barriers is stigma. Abortion is considered a taboo subject that’s not talked about openly the way that other health topics like malaria or antenatal care are discussed. It can lead to a lot of myths and misperceptions. Even a lot of medical providers aren’t aware of basic facts, like that 1 out of 4 pregnancies ends in abortion, or that an abortion can be safely and effectively provided with pills.

When the COVID-19 epidemic first started, we were immediately concerned about its impact where we work, which is in mostly poor and crisis settings. Epidemics have a way of magnifying preexisting disparities and inequities. Our teams on the ground were already working with the bare minimum of needed resources. We know from past epidemics, especially in low- and middle-income countries, that the indirect mortality from the shutdown of routine services can be higher than the direct mortality from the epidemic itself. One example is the Ebola outbreak in 2014 and 2015 in West Africa. As part of the response to Ebola, a lot of facilities shut down or stopped routine services like maternity care, safe deliveries, newborn care, routine vaccinations. Contraception, safe abortion care, or treatment for things like malaria became exceedingly more difficult.

We knew from the beginning that maintaining these routine services would be key to preventing unnecessary death and suffering. The additional challenge for services like contraception and safe abortion care is that historically they have not been regarded as essential or lifesaving services. I feel sometimes that they’re considered minority services, but women are not a minority. A recent analysis by the Guttmacher Institute estimated that even a 10 percent decline of sexual and reproductive health services in low- and middle-income countries due to COVID-19 would mean an additional 15.4 million unintended pregnancies, more than 3.3 million unsafe abortions, and 28,000 maternal deaths. Front-line reproductive health providers are already reporting thousands of clinic closures and predict reductions as high as 80 percent of health services, so imagine eight times those figures. The thing that’s important to keep in mind is that the true impact of these disruptions will be really hard to measure as women and girls denied care also suffer at home, hidden within communities.

So many of my planned field visits have been postponed. We had been planning on organizing this big safe abortion care implementation training for 25 of our field staff from countries all around the world, but, of course, now all face-to-face trainings have been postponed due to travel restrictions. It’s been really challenging to get staff into the country, and it’s also been really challenging to get staff who are finishing their assignments out. So what we see is a very overstretched, undersourced team. In the Democratic Republic of Congo, we have had to limit some of our reproductive health activities due to supply shortages. Globally, there are concerns about a shortage of contraceptive supplies because a lot of the components or ingredients of contraceptives were manufactured in China and those factories were not working for quite some time.

In some contexts, such as Bangladesh, for example, we are exploring ways that we can support what’s referred to as more self-managed abortion. It’s the past and it’s the future. Self-managed abortion refers to a person who manages their own abortion without interaction with the formal health system. In the past, that referred to a wide range of unsafe and safe methods. But more recently it’s come to mean people take abortion medications themselves at home with the support of maybe a telephone hotline or a website that provides information. Self-managed abortion has gained increasing acceptance by the formal health sector as safe and appropriate because, once again, abortion pills are just that safe and effective.

The biggest concern with COVID-19 is that people are going to be less able to access our clinics because of movement restrictions and government officials locking down areas once community transmission starts. During epidemics, people also fear going to health facilities because of the stigma associated, and they’re afraid of acquiring the virus. We have to be innovative, and part of that innovation is going to be developing more of these self-care community-based models, distributing condoms or emergency contraception pills that, in the U.S., people call Plan B. There are also now self-injectable contraceptives. That will help to see us through this pandemic, but hopefully will also impact the way that we envision health care or these services even beyond it.