Clinic Project: Definition of Abortion Services as Non-Essential
As the pandemic swept across the country, so did a series of state wide executive orders classifying abortion services as non-essential elective procedures. As a research team, we had trouble deciphering what this classification meant for abortion access. Did it ban all forms of abortion? Did it cancel all existing appointments for abortion services? How long were these orders going to be in effect? Reproductive rights advocates and legal teams responded immediately and fought to reverse these restrictive orders. Unfortunately, these fights are never straight forward, and state-wide recognition of abortion as an “essential” service took weeks in some states.
If we were struggling to understand what this “non-essential” classification meant for abortion access, we could not imagine how confusing and anxiety provoking it had been for individuals in need of abortion services. Through interviews, we hoped to elucidate how the "non-essential" definition affected individual clinics and the populations that they serve.
Each clinic we interviewed was uniquely impacted by the state-wide executive orders during the time they were in place. Clinics in Iowa were able to stay open as they fought the ban on surgical abortions and navigated how to assist their clients in need of those services. However, not all clinics had this capacity. A Tennessee clinic had to shut down the clinic for two weeks as they tried to understand the services they were allowed to provide and how they were allowed to provide them.
Despite these different experiences, clinics in all states reported widespread confusion and anxiety associated with the “non-essential” orders. This was seen through the floods of phone calls received by an Alabama clinic about whether they were still providing abortion services, and an uptick in medication abortion in Iowa due to fears that more aboriton bans due to the pandemic may be put in place. However, clinics also reported that these behaviors amongst their clients were not new. Individuals seeking abortion services in states where they were deemed non-essential already had restrictive and confusing abortion laws pre-pandemic. Clinics were used to receiving floods of phone calls when TRAP laws or other restrictive legislation was passed. Unfortunately, constant confusion and anxiety is a norm for those in living in states where an individual’s right to abortion care and reproductive rights more broadly are still contested.
We believe that all forms of reproductive health care are essential. We also believe that it is a person’s right to know whether abortion services are available and safely accessible in their state. Our action item for this blog post is to check out and support ineedana through a donation or by becoming a volunteer. The ineedana site provides simple, localized, and up-to-date sources of information for people seeking abortions.
Clinic Project: Abortion Restrictions Hitting Clinics Hardest
In our interviews with abortion clinics across the US, we asked them which abortion restrictions had the biggest impact on their service provision during the COVID-19 pandemic. Almost all of the clinics talked about the detrimental effects of waiting periods and telemedicine bans, reflecting the scope and impact of these laws.
Waiting periods and two-trip requirement
Waiting periods for abortion procedures vary from 18 hours to 72 hours state-to-state and often require those seeking abortion services to make two trips to the clinic for an abortion. The majority of the clinics we spoke to indicated that waiting periods placed a significant strain on their clinic’s ability to provide services, and pose a significant barrier to abortion access. At the Alabama Women’s Center clinic, an ultrasound is required before the administration of the abortion pill. Coupled with Alabama’s 48 hour waiting period, staff indicated that abortion services often require three trips to the clinic. Organizing three trips to a clinic prevents people from seeking abortion services. Can they afford to take time off work? Can they organize childcare? Can they afford travel costs, and find adequate lodging? These are all questions that people seeking abortion services have to navigate due to waiting periods. In addition, waiting periods also impact clinics' scheduling and capacity. Due to the COVID-19 pandemic, the number of patients a clinic can see per day has already been reduced - waiting periods only drive this number down.
Telemedicine bans in certain states were also identified by staff as further straining a clinics’ capacity to provide services, especially during a pandemic. The Planned Parenthood of Nebraska and Iowa indicated that due to the telemedicine ban in Nebraska, they saw an increase in patients at an Iowa clinic that offers telemedicine abortions on the Nebraska-Iowa border. The Alabama Women’s Center also talked about their efforts to strike down the statewide requirement for a licensed physician to be present during the provision of an abortion pill which inhibits the use of telemedicine in the state. Especially when trying to limit in-person contact, these laws are huge barriers to abortion services.
That said, when we asked the Knoxville Center for Reproductive Health to name the most damaging restriction for patients and clinics, they claimed that restrictions in any form have been detrimental for access. If you have the means and would like to help mitigate this impact, you can use this map to identify a local clinic and make a donation!
Clinic Project: Timing and Type of Appointments
The COVID-19 pandemic has shifted the types of appointments patients are scheduling and the availability of appointments overall. In our interviews with individual abortion clinics, we asked staff about appointment delays and changes in appointment type.
Delays and cancellations
While the clinics we spoke with described a range of shifted circumstances, many clinic administrators noted similar experiences with appointment delays and cancellations due to the pandemic. Three out of five clinics reported a change in the rate of appointment cancellations. For some, cancellations increased when state executive orders declared surgical abortion procedures “non-essential.” These procedures could not be performed until the executive order was lifted, causing an uptick in the number of patients needing to cancel appointments. On the other hand, one Tennessee clinic actually reported fewer appointment cancellations overall. Due to restrictions in surrounding states, this clinic had an increase in appointments from out of state patients in addition to more patients coming to their appointments early. They also saw a higher rate of patients keeping their first scheduled appointments.
A staff member from this clinic noted that, prior to the pandemic, their show-rate for patients at the first consultation appointment “was normally 50, 60, 70 percent.” Once access was threatened, the clinic was “seeing closer to 80 or 90 percent.”
Clinic administrators suggested that the restrictions caused by the pandemic contributed to patient concerns about appointment and procedure availability. Our interviews highlighted the ways these pandemic restrictions impacted both patient health care seeking behavior and clinic ability to schedule and hold appointments.
Changes in appointment type
Our conversations with clinic staff about shifts in appointment type also revealed notable data and anecdotes. At most clinics, patients can request a few different types of appointments, including both surgical and medical abortion procedures. Procedures can also be scheduled during different trimesters, depending on the health and needs of the patient. Since many states instituted bans on surgical abortions during the pandemic and maintained waiting periods between the first appointment and the procedure, we were interested in understanding how these restrictions may have affected the types of appointments requested during this time. We anticipated that increased wait times and the inability to access some procedures would force many patients to change their planned course of action.
One Iowa clinic reported an increase in non-surgical abortion procedures during the pandemic, with almost twice as many appointments scheduled during the pandemic compared to earlier months. This clinic also reported that the number of second trimester abortion procedures remained relatively stable during this time. Contrastingly, an Alabama clinic reported that they did experience an increase in the number of scheduled second trimester abortions. They attributed this increase to new patients coming from out of state for the procedure, with some patients recorded as coming from as far as Texas for an appointment. These data support our assumption that pandemic restrictions have forced patients to alter their method of care, to travel outside of state lines to receive care, and to experience more barriers to access overall — especially in states already hostile toward abortion.
It is clear the pandemic has highlighted disparities in abortion access that are causing real-life consequences for many people. No one should have to travel across state lines to receive health care.
This is why the work that independent clinics do to support their patients is critical. They have the difficult job of helping their patients understand what care is available to them and what may be under restriction. Many independent clinics have also had to make changes in order to continue operating during the pandemic, like transitioning to telemedicine or operating with fewer staff members. Our action item for this blog post is to find an independent abortion clinic near you and support them in any way you can.
Clinic Project: Geographic Origin of Patients
To understand how the pandemic has impacted individual clinics, it is critical to understand how it has shifted patient population. We assessed this landscape by asking clinic staff about these demographic shifts, including changes in the distance people were traveling to receive reproductive healthcare.
Throughout the pandemic, journalists told stories of patients making hours long journeys out of state to access abortions when states like Texas banned the procedure, forcing providers to refer patients to Kansas and New Mexico. Just last week, a research article published in The Journal of the American Medical Association (JAMA) documented an increase in travel by people seeking abortion services outside of Texas during the month of April (see our Instagram post on this article here). Traveling long distances for care introduces unnecessary burden and exacerbates existing barriers for folks, especially those who do not have access to transportation or are unable to afford accommodations or childcare during travel. We wondered how abortion clinics had experienced these shifts in patient demographics and what they saw as the driving force behind these changes.
All of the clinics we interviewed had either noticed changes in patient geographic origin or identified reasons for a lack of change during the pandemic. One Alabama clinic noted that patients were traveling further distances to seek care; while their usual patient demographic was from Alabama, Louisiana, Mississippi, Tennessee, and Florida, patients had started coming from Texas too, driving upwards of ten hours to seek care. At the same time, some clinics noted they had not seen major shifts in patients’ geographic origin. The clinics we interviewed were all in states or located near states that are hostile to abortion access, and particularly so during the pandemic. As a result, clinics noted that they have always seen patients from all over the region travel for care—even before the pandemic. Ultimately, the pandemic has exacerbated pre-existing access concerns.
One clinic administrator noted that they were already in one of the “most restrictive states anyway,” stating:
“We're almost used to it... it's just more difficult for the patients to try to navigate getting here and finding some place to stay and all of those things that go along with it especially in the midst of a pandemic."
Given that so many sources documented increased out-of-state travel for abortion care during the pandemic, we expected more homogeneity in these responses about patient geographic origin. Instead, the five clinics we interviewed offered varied answers and reflections. Just as the populations they serve vary widely, each clinic has distinctive experiences and distinctive needs. Now more than ever these clinics—and especially independent clinics—need support.
Barriers in geographic access to abortion services have always existed and are only amplified by pandemic restrictions and concerns about contracting COVID-19. Local abortion funds help patients and clinics overcome this barrier by helping patients fund and arrange their travel. Our action item for this blog post is tolook up your local abortion fund using this map, read about their work, and make a donation today!
Introduction: Access Atlas Blog
The pandemic sweeping across America isn’t just a health issue for people who contract COVID-19. It’s also hurting people who need abortions. In May we launched this site, Access Atlas: a set of maps that track abortion availability and access during the COVID-19 pandemic. While this research allowed us to expose the uneven impacts of state-level responses to the COVID-19 crisis on abortion access, our analysis of their implications lacked local narrative.
Today we’re launching a new blog series to highlight some of our findings from a months long research project on the effects of the pandemic on individual abortion clinics. Over the past few months, we have called clinics in the 11 states that classified abortion as non-essential in initial government orders. We conducted five informal interviews with clinics in Alabama, Tennessee, Iowa, and Nebraska, and collected both quantitative and qualitative data on over ten clinic level variables. This blog series will look at the findings from these interviews, exploring areas of commonality and difference in clinic experiences. Our goal is to highlight the unique experiences that clinics and their clients have had to navigate and overcome throughout the COVID-19 crisis and the need to support abortion providers now more than ever.
Over the next few months, we will be posting the findings from our interviews in a series of bi-weekly blog posts. We will look at issues ranging from changes in clinic staff to financial strain on clinics to confusion around COVID-19 executive orders. Stay tuned for our findings in the next posts!