Joanna Mishtal, Silvia De Zordo, Irene Capelli, Anastasia Martino, Laura Rahm and Giulia Zanini
Abortion under COVID-19
Abortion access is central to gender equality, human rights, and social justice, and it is fundamental in primary healthcare provision. The COVID-19 pandemic has severely disrupted health systems around the globe, including in Europe, where most countries have strong public health services. Its impact on sexual and reproductive health has been serious. Mobility restrictions and the foreclosure or reduction of services have negatively affected the provision of contraception and abortion care. In many countries, the classification of abortion care as essential healthcare is at the center of intense political debates. Abortion providers and reproductive rights advocates are demanding that access to medical abortion (oral use of mifepristone–misoprostol) in the first trimester be simplified by reducing the number of in-person visits and/or by allowing medical abortion via telemedicine. In some countries, governments and medical authorities have quickly responded to these demands. Unfortunately, in others, like Italy, a political battle is still ongoing, and no changes have been made.
In this commentary, we examine the impact of the COVID-19 pandemic on abortion governance in an already fragmented European political landscape where access to care varies dramatically between countries (De Zordo et al. 2016). Even in “normal” times, pregnant people face numerous barriers before they can secure an abortion, including legal, procedural, and social obstacles and delays. We bring attention to those countries that may escape our scrutiny because abortion is legal on women’s request or on broad grounds. Specifically, we analyze the situation in France and Italy, based on our ongoing ERC (European Research Council)-funded study on barriers to access and abortion travel in Europe, and the authors’ participation in the current debates on abortion provision.
Since COVID-19 lockdowns escalated in March 2020, political responses to ensuring abortion access varied. The Republic of Ireland, the last European country where abortion was legalized in 2018, was the first country to enact emergency measures permitting remote (rather than in-person) consultations with GPs during the pandemic to ease access to abortions. Following the Irish model, the UK and France enacted telemedicine measures, while Italy has refused to take action.
Focusing on our current research in France (Paris) and Italy (Rome and Milan) we show how these two countries are responding to the COVID-19 emergency differently, and consider the implications of these political (in)actions.
In France, a large network of prominent healthcare and abortion providers, Planning Familial association, perinatal networks, and regional health agencies mobilized early on to ensure access to abortion care during COVID-19. On the second day of lockdown, the Parisian Regional Health Agency (ARS) issued the first medical recommendations on the adaptation of abortion services. The French government promptly responded by introducing a number of exceptions, including the extension of medical abortion at home from seven to nine weeks amenorrhea, in combination with newly available telemedicine consultation. Furthermore, the planning of surgical abortion in the hospital sector has been adapted to promote local over general anesthesia, allowing women to have shorter visits carried out in an ambulatory setting, and for health institutions to save anesthesia resources and limit operating room use. Women can still choose their preferred procedure, but abortion providers now perform all the necessary examinations and consultations on one day, whereas before COVID-19 women were usually given multiple appointments over several days. Lastly, governmental guidelines stress that second trimester abortions for psychosocial reasons are still available. This is important because access to abortions after 12 weeks of pregnancy in “normal” times is difficult in France, and thousands of French-resident women have to travel abroad every year to access second trimester services (De Zordo et al. 2020).
Despite all these changes, the hospitals where we conduct research in Paris note a drastic decline in the number of women seeking abortions, which matches reports from other regions. The hospital staff is concerned over a potential increase in the number of women coming close to the gestational age limit, and there are political efforts to extend this limit from 12 to 14 weeks. Also, abortion providers note that due to lockdown, fewer women travel for abortion care, and women who do access services are additionally distressed over the potential contagion with COVID-19. Thus, despite a prompt response by health professionals and the government, psychological barriers to services, and general physical immobility during lockdown still pose barriers for pregnant people.
Our research team’s experience in Italy tells a different story. Italy instituted COVID-19-related lockdown measures on March 9, 2020. Initially, no specific policy guidelines on abortion care were issued. Due to the high rates of contagion in certain areas, along with the large number of infected healthcare workers, some abortion services were transferred to other facilities or closed altogether. On March 30, the Ministry of Health listed abortion among the services that could not be postponed during the COVID-19 emergency, but it did not change existing guidelines requiring multiple in-person hospital visits for each step of the treatment.
Since March, numerous actors have mobilized to petition the Italian government to ease access to abortion. In particular, the Italian Pro-Choice Network for Contraception and Abortion has formally demanded that the Ministry of Health consider emergency measures. The four requested changes focused on medical abortion: (1) expanding treatment from 7 to 9 weeks of pregnancy, (2) eliminating the requirement for hospitalization, and (3) allowing women to proceed with the treatment at home after a single in-hospital assessment, and (4) introducing medical abortion via telemedicine. This petition is in line with evidence from a systematic review of research published by the World Health Organization in 2011 showing that medical abortion is equally safe and effective as a home-based or clinic-based treatment. Effort to launch the petition also constitutes one of the largest abortion rights mobilizations in Italy since the 1978 legalization of abortion, sparking synergies between actors ranging from the medical sector to civil society and feminist movements. The national Scientific Society of Obstetrics and Gynecology released a press statement publicly supporting the petition. To date, however, the Italian government has failed to respond, despite a thriving public debate on this issue. Multiple factors account for the difficulties in affirming abortion rights in Italy. The strong political influence historically exerted by Catholic-inspired groups and the Vatican’s representatives in the domain of sexual and reproductive matters has long been the basis of Italian governments’ reluctance to facilitate abortion provision. The present government’s inaction is likely another manifestation of this lack of political will to pass new regulations in this contentious domain.
Towards Responsive and Harmonized Political Action in Europe
COVID-19 and other emerging and re-emerging infectious outbreaks like Ebola and Zika are relatively recent global crises, but such events may only become harsher and more frequent. This is particularly due to the continued damage to healthcare systems exacted by neoliberal policies that under-fund facilities, providers, and primary care, in addition to growing racial, ethnic, socioeconomic class, and citizenship status-based disparities in access to care.
Despite inevitable challenges, in this commentary we have shown that responsive political action is indeed possible when governments take seriously women’s rights, health rights, and evidence of what is needed. In the area of sexual and reproductive healthcare, we argue that governments must listen and respond to key actors with on-the-ground knowledge of women’s health needs, from healthcare providers to NGO advocates. While abortion rights advocacy movements exist in both France and Italy and were active prior to the pandemic, key differences are instructive.
The Italian case shows how—in a country where the government has no political interest in engaging in abortion talks and where the Vatican has long exerted political influence—the public and organized calls from numerous actors, including NGOs and the medical community, remain unanswered. It is difficult to estimate at this time the toll that this inaction will bring on women’s health and lives in Italy.
The contrasting scenario from France demonstrates that swift and decisive actions in favor of reproductive health during a time of crisis are possible when a government can effectively resist conservative political and religious forces. The French state, prompted in part by abortion rights activists, adapted to safeguard women’s right to access this essential service by easing abortion protocols and reducing social contact to maximize safety, yet even with positive legislative action, the lockdown’s measures seem to be preventing some women from accessing abortion care.
As the Council of Europe recently stated, in these times of crisis every EU member state should commit not only to safeguarding public health but also to improving gender equality and protecting women and pregnant people from risks by providing easily accessible sexual and reproductive healthcare, including abortion. Each state should shape its positive action-based response following the model of countries like Ireland or France during this pandemic as well as in the “normal” times that will follow.
Joanna Mishtal, PhD is a social anthropologist, Associate Professor at the University of Central Florida, and a Senior Researcher for the European Research Council (ERC) project. Her research focuses on reproductive rights and policies in the European Union (including Ireland and Poland), as well as gender and governance more broadly. University of Central Florida, Department of Anthropology, 4297 Andromeda Loop N, Orlando, FL 32816, USA; Tel. +1 407 8233797; firstname.lastname@example.org
Silvia De Zordo, PhD is a social anthropologist, ERC Stg PI and Ramón y Cajal at the University of Barcelona, and has pioneered research on abortion and conscientious objection in Europe. She is the Principal Investigator for the European Research Council (ERC) project BAR2LEGAB (680004). University of Barcelona, Department of Anthropology, c. Montalegre 6, 08001, Barcelona, Spain; Tel. +34 934037957; email@example.com
Irene Capelli, PhD is a social anthropologist and a Research Assistant in Italy for the European Research Council (ERC) project. Her research focuses on sexual and reproductive health and rights (Italy and Morocco) and on health and migration (Italy). University of Barcelona, Department of Social Anthropology, c. Montalegre 6-8, 08001 Barcelona, Spain; Tel. +34 934037957; firstname.lastname@example.org
Anastasia Martino, PhD is a social anthropologist, currently she works as Research Assistant in Italy in the European Research Council (ERC) project. Her research focuses on reproduction and sexuality (abortion, family planning policies, public health) in Italy and Mexico. University of Barcelona, Department of Social Anthropology, c. Montalegre 6-8, 08001 Barcelona, Spain; Tel. +34 934037957; email@example.com
Laura Rahm, PhD is a political sociologist and a Post-Doctoral Researcher in France for the European Research Council (ERC) project. Her research focuses on gender, reproductive health and abortion policies in Europe, the Caucasus and Asia. University of Barcelona, Department of Social Anthropology, c. Montalegre 6-8, 08001 Barcelona, Spain; Tel. +33 787131581; firstname.lastname@example.org
Giulia Zanini, PhD is a social anthropologist, currently a Post-Doctoral Research Assistant at Queen Mary University in London (UK). She has worked as a Post-Doctoral Researcher in the European Research Council (ERC) project. Her research focuses on reproduction (infertility, ARTs, and abortion) and reproductive governance in Italy and the UK. Queen Mary University of London, London, Department of People and Organisations, Queen Mary University of London, Mile End Road, London E1 4NS, The UK; Tel: +44 (0) 20 7882 5555; email@example.com
De Zordo S., Mishtal J., Anton L. (Eds.) 2016. A Fragmented Landscape: Abortion Governance and Protest Logics in Europe. Berghahn Books: Oxford and New York.
De Zordo S., Zanini G., Mishtal J., Ziegler A.K., Garnsey C., Gerdts. C. 2020. “Gestational age limits for abortion and cross-border reproductive care in Europe: a mixed-methods study.” BJOG – An International Journal of Obstetrics and Gynecology. In post-R&R review.