Reproductive healthcare access in during the COVID-19 pandemic

During the COVID-19 state of emergency, Ohio limited healthcare procedures to allow for only essential care. is essential healthcare.

Among U.S. states, Ohio took early and decisive action to minimize the spread of COVID-19. With the support of Governor Mike DeWine, Ohio Department of Health (ODH) Director Amy Acton ordered that all non-essential surgeries in Ohio cease, effective March 18, 2020 at 5:00 PM;1 this order remained in effect until healthcare access was expanded on May 1, 2020.2 One day prior to the initial ODH order, multiple medical societies – including the American College of Obstetricians (ACOG) and the Society for Maternal-Fetal Medicine – published a joint statement clarifying that abortion, while often performed in an outpatient setting, was “an essential component of comprehensive healthcare.”3 Letters from Attorney General David Yost and comments from Governor DeWine disputed the status of abortion as essential health care in the week that followed.4,5 In response, the state’s surgical abortion clinics requested protection of their services within the ongoing case challenging Ohio’s six-week abortion ban, and United States District Court Judge Michael Barrett allowed surgical to continue.

As indicated by ACOG, abortions are both essential and time-sensitive, and “the consequences of being unable to obtain an abortion profoundly impact a person’s life, health, and well-being.”3 In this fact sheet, we highlight abortion and contraceptive access in our state during the COVID-19 crisis. Within the rapidly changing circumstances of a Abortion access in Ohio during pandemic, we aim to provide a context for the importance AN emergency order of reproductive healthcare that will be needed during this uncertain time. We describe the benefits of timely abortion All nine abortion clinics in Ohio (some of which provide only care and access to telemedicine, as well as how complications medication abortion, and some of which provide medication caused by restrictive Ohio abortion policies are made worse and surgical abortion) remain open, and people are allowed during COVID-19. Additionally, we examine how interactions to travel to seek healthcare.6 In accordance with ODH’s between reproductive healthcare and COVID-19 restrictions emergency order, patients had to use medication abortion, differentially impact rural people and people of color. as opposed to surgical abortion, whenever possible and if eligible. Patients were eligible for medication abortion if they had a pregnancy that was ten weeks’ gestation or less Nine abortion clinics in Ohio and if the medications were not contraindicated for them. remain open and people are Surgical abortions were scheduled to ensure that clinics had sufficient personal protective equipment (PPE) and allowed to travel to seek supplies, to give time for care providers to make case-by- healthcare. case assessments about whether the surgery was essential, and to allow for social distancing in the clinics.

1 Contraceptive Access in Ohio to access timely and robust reproductive care, including during an emergency order abortion, which remains safer than carrying a pregnancy 24 to term. Increased restrictions on access to reproductive Ohio’s COVID-19 restrictions have likely resulted in reduced healthcare thus exacerbate racial disparities in maternal access to contraceptive service provision. The physical and infant health. distancing orders are particularly impactful for patients using the injectable method (Depo-Provera) or long- Ohio’s rural and urban acting reversible contraceptives (e.g. Nexplanon, Mirena, disparities in reproductive Skyla, ParaGard, etc.) as these require ongoing contact healthcare utilization with medical professionals. Shorter-acting methods (e.g. birth control pills) can be prescribed through telemedicine. In the United States, geographic disparities have led to Commercial providers of birth control pills and hormonal the unequal distribution of reproductive health outcomes, patches via internet ordering exist and may be used by especially between urban and rural locales. Family planning Ohio residents who have Medicaid coverage. Surgical services are often less accessible in rural areas than in sterilization procedures – such as vasectomy and tubal urban ones.25 This includes Ohio’s Appalachian regions, ligation – were largely delayed under ODH’s emergency which are overwhelmingly rural with above-average levels order. of poverty.26

Uninsured people, and people with limited internet access or unstable housing, may face additional barriers to accessing these methods than they normally would. Because access to safe healthcare Contraceptive safety net organizations – such as Federally is compromised by racial and Qualified Health Centers (FQHCs) and Title X Grantees – are largely ill-equipped to meet the demand for virtual ethnic disparities, the impact of services. Many publicly-funded institutions have suffered COVID-related restrictions on from historical disinvestment and have not yet integrated reproductive healthcare may fall the technology and training requisite for a seamless switch to telemedical service delivery. hardest on people of color.

Racial disparities in access to Policy changes in the last ten years have coincided with the reproductive healthcare closures of several abortion facilities in the state. Residents living in rural areas, where the closure of a clinic results in The risks of illness and death from COVID-19, and patients needing to travel across the state for care, have the consequences of reduced access to reproductive been hit particularly hard.27 From 2010-2018, the abortion healthcare, are meaningful for all people in Ohio during ratio (abortions per 1,000 live births) in rural Ohio dropped a pandemic. But communities of color are at greater risk at a faster rate than that in urban Ohio. Travel difficulties of mortality due to COVID-19,7 reflecting a larger pattern during COVID-19 – when patients may have less income of health inequity. Because access to safe healthcare is (due to job loss) and less childcare (due to closures of compromised by racial and ethnic disparities, the impact of daycare centers, pre-schools, and schools) – further limit COVID-related restrictions on reproductive healthcare may patient access to abortion and contraceptive care, and fall hardest on people of color,8–10 who face intersecting those living in rural areas will likely face greater barriers to sources of disempowerment.11 While information regarding accessing this necessary care. COVID-related risks in pregnancy is limited,12 we expect that the structural conditions13 that lead to racial disparities Ohio’s requirements for waiting in infant and maternal mortality in Ohio are compounded by period and in-person visits the pandemic. Ohio has a 24-hour waiting period for abortions, In particular, people of color are simultaneously less able to necessitating at least two in-person visits to the clinic.28 At 14,15 access necessary reproductive care and more at risk of the first visit, the physician counsels the patient based on reproductive oppression (including forced sterilizations and several state requirements that are designed to discourage 16–18 IUD insertions). Black and indigenous people are more people from having an abortion28 (these include, for example, 19 likely to die from pregnancy-related complications, and mandatory ultrasound and the provision of information to in Ohio, Black infants die at three times the rate of White the patient on the likelihood of fetal survival if the patient 20 infants. Simultaneously, reduced access to abortion care did not have an abortion).29 Evidence shows that waiting 21 is associated with higher infant mortality rates. Doulas and periods and counseling requirements are unnecessary and lactation consultants, essential care providers whose work unjustified.30–32 The primary impact of these regulations is has demonstrably positive impacts on maternal and infant to increase the number of visits and to increase the time 22 health, have been limited from being with birthing patients patients have to wait to obtain an abortion – in some cases 23 because of COVID-related medical restrictions. These for more than two weeks, such as when patients must wait disparities highlight the importance of patients’ abilities for their next day off work or arrange childcare.31,32 2 Benefits of timely abortion care

State restrictions on medical care and surgeries allow Access to timely abortion care exceptions for healthcare that is time sensitive.1,33 This is associated with a range of includes abortion care,3 a procedure for which timely care provides considerable benefits. While second-trimester benefits, including a lower risk abortions are safe, abortion procedures become more of intimate partner violence, complicated later in pregnancy34 and can sometimes better socioeconomic conditions, require two-day procedures. Compared to earlier abortion and better overall health. procedures, later procedures are more costly35 and are less accessible, as fewer facilities offer second trimester abortions. Access to timely abortion care is associated delivery and quality of care because it offers “convenience with a range of additional benefits, including a lower and confidentiality” and can improve “safety, patient- 53 risk of intimate partner violence,36 better socioeconomic centeredness, timeliness and geographic equity” in care. conditions,37 and better overall health.38 Patients also report Under COVID-19 guidelines, Ohio’s telemedicine abortion a desire for earlier access to abortion care.39 care is a necessary means of administering healthcare while limiting patient and practitioner exposure, as well If patients are forced to delay their abortion, many as PPE use. Ohio places two unnecessary limitations on procedures will be pushed into the second trimester. For telemedicine for abortion; first, the patient must have an example, in 2018, 30 percent of abortions were obtained initial medication abortion visit in-person and second, the during the last weeks of the first trimester (9-12 weeks patient must be at a clinic again for their medication abortion 54 gestational age).40 Thus, a four-week delay in care would video conference. Evidence, however, suggests that all dramatically increase the number of abortions that occur medication abortion care can be “no-test” using the full after 12 weeks. Pre-existing state abortion policies, such capacity of telemedicine: all visits (including all counseling as mandatory waiting periods, mean that patients in Ohio visits) performed via teleconference from a patient’s home 55 already receive abortion care later in comparison to the rest and medications provided by mail. Ohio’s recent efforts to 54 of the U.S.;27 if abortion care is delayed due to COVID-19 ban telemedicine for abortion do not reflect the advice of 56,57 restrictions, it may become unavailable due to cost,31,41,42 professional medical societies. distance,43 or state gestational age limits.44 Within the national context Patients whose pregnancy terminations are delayed past the state’s gestational limit will be required to travel out-of- Like Ohio, ten other states have taken action to try to limit state to receive their needed care. This travel will increase access to abortion care under COVID-19 restrictions. the risk of COVID-19 transmission if the travel requires that Litigation is ongoing in Arkansas, where appeals courts’ the patient interact with more people getting to and from decisions have severely restricted access to abortion their appointment(s) and/or spending the night out-of-state. care and forced patients to travel out of state.58 Texas’ Overall, ensuring timely access to care would help slow the initial total ban on abortions, which would have made spread of COVID-19 by reducing patient-provider exposure abortion geographically inaccessible to most Texans,59 has and would save PPE by having fewer in-person visits. recently expired so that access to surgical and medication Prompt access to care becomes all the more important abortions is now restored. Providers in Alabama, Iowa, when recognizing the racial and regional disparities in Louisiana, Oklahoma, Tennessee, and West Virginia faced accessing timely abortion care. similar legal challenges as those in Ohio, while governors in Mississippi and Alaska claimed that abortion was non- Benefits of telemedicine essential, but have not taken legal action.

Telemedicine uses communication technologies to deliver In comparison, a number of other states have taken healthcare services and information remotely, and is proactive steps to ensure continued access to abortion 60 especially advantageous for rural communities (about half and contraception care during the pandemic. At least of Ohio women live in a county with no abortion provider).45 eight states have issued executive orders specifying The use of telemedicine in abortion care is currently that abortion and contraception are essential healthcare. allowed in Ohio in limited ways.46 Telemedicine is already California Attorney General Xavier Becerra joined with 20 being used across the state for primary care provision, other attorneys general to request that the Food and Drug mental healthcare, and specialty consulting, as healthcare Administration modify the Risk Evaluation and Mitigation providers work to implement social distancing policies into Strategy designation for Mifepristone, which is used in their practices. medication abortion; such a move would increase access to medication abortion.61 These varying approaches Medication abortion via telemedicine is safe, effective, highlight the complex differences between states’ highly acceptable to both patients and providers,47–52 and legislative environments, even as access to abortion and may lower the gestational age at which patients obtain contraception is needed in all parts of the country. their abortion.53 Because telemedicine abortion is so safe and cost-effective, it has the potential to improve service 3 Reproductive health access is REFERENCES limited in Ohio, and COVID-19 1. Acton A. Director’s Order for the Management of Non-essential makes things harder Surgeries and Procedures throughout Ohio. March 2020. https:// content.govdelivery.com/attachments/OHOOD/2020/03/17/ file_attachments/1403950/Director%27s%20Order%20non- Ohio was an early national leader in its response to essential%20surgery%203-17-2020.pdf COVID-19. 62 State leaders could do more to proactively 2. Acton A. Director’s Stay Safe Ohio Order; 2020. https://coronavirus. ohio.gov/static/publicorders/Directors-Stay-Safe-Ohio-Order.pdf. address the reproductive healthcare needs of people of 3. The American College of Obstetricians and Gynecologists. Joint our state during this pandemic. Abortion remains available Statement on Abortion Access During the COVID-19 Outbreak. to Ohioans under current healthcare regulations, as does https://www.acog.org/en/News/News Releases/2020/03/Joint Statement on Abortion Access During the COVID 19 Outbreak. access to contraceptive care. Existing state restrictions Published March 18, 2020. on abortion already make abortion procedures, as well as 4. Da Silva C. Ohio attorney general faces backlash over “non- other forms of reproductive healthcare, difficult to access; essential” abortion ban amid coronavirus outbreak. Newsweek. https://www.newsweek.com/ohio-attorney-general-abortion-ban- any further limitations under COVID-19 orders would be coronavirus-covid-19-outbreak-1493635. Published March 22, detrimental to Ohioans’ health and wellbeing. 2020. 5. Ohio Could See Up To 8,000 COVID-19 Cases Per Day At Peak; Coronavirus Update, March 26, 2020. ideastream. https://www. ideastream.org/ohio-could-see-up-to-8000-covid-19-cases-per- day-at-peak-coronavirus-update-march-26-2020. Published March Existing state restrictions on 26, 2020. abortion already make abortion 6. Acton A. Director’s Stay at Home Order, Amended. Ohio Department of Health; 2020. https://coronavirus.ohio.gov/static/ procedures difficult to access; any publicorders/Directors-Stay-At-Home-Order-Amended-04-02-20. pdf. Accessed April 10, 2020. further limitations under COVID-19 7. Cineas F. Covid-19 is disproportionately taking black lives. Vox. https://www.vox.com/identities/2020/4/7/21211849/coronavirus- orders would be detrimental to black-americans. Published April 7, 2020. Accessed April 10, Ohioans’ health and wellbeing. 2020. 8. Ross L, Solinger R. Reproductive Justice. University of California Press; 2017. https://www.ucpress.edu/book. php?isbn=9780520288201. Furthermore, these risks are not equally distributed among 9. Goldberg M. The Means of Reproduction: Sex, Power, and the Ohioans, such that patients who are made vulnerable Future of the World. Penguin; 2009. – by racism, poverty, and disinvestment in rural health 10. Luna Z, Luker K. Reproductive Justice. Annu Rev Law Soc Sci. 2013;9(1):327-352. doi:10.1146/annurev-lawsocsci-102612-134037 infrastructure – will be disproportionately impacted by a 11. Loder CM, Minadeo L, Jimenez L, et al. Bridging the Expertise lack of access to safe reproductive healthcare. Overall, we of Advocates and Academics to Identify Reproductive Justice urge Ohio’s decisionmakers to take actions that provide Learning Outcomes. Teach Learn Med. 2020;32(1):11-22. doi:10.10 80/10401334.2019.1631168 the best access to reproductive healthcare during the 12. Association of Women’s Health, Obstetric and Neonatal Nurses. COVID-19 pandemic, with special attention to the needs of Novel Coronavirus (COVID-19). AWHONN. https://awhonn.org/ those whose access is already impeded. novel-coronavirus-covid-19/. 13. Phelan JC, Link BG. Is Racism a Fundamental Cause of Inequalities in Health? Annu Rev Sociol. 2015;41(1):311-330. To Cite This Fact Sheet: doi:10.1146/annurev-soc-073014-112305 14. Center for Reproductive Rights. Report on the United States’ Ohio Policy Evaluation Network. Reproductive Healthcare Compliance with Its Human Rights Obligations In the Area of Women’s Reproductive and Sexual Health. Center for Reproductive Access in Ohio During the COVID-19 Pandemic. Fact Rights; 2011. https://www.reproductiverights.org/document/report- Sheet. May 2020. on-the-united-states-compliance-with-human-rights-obligations- womens-health. 15. Joffe C, Parker WJ. Race, reproductive politics and reproductive healthcare in the contemporary United States. Contraception. 2012;86(1):1-3. doi:10.1016/j.contraception.2012.03.009 16. Roberts D. Killing the Black Body: Race, Reproduction, and the Meaning of Liberty. Knopf Doubleday Publishing Group; 2014. 17. King L, Meyer MH. The Politics of Reproductive Benefits: U.S. Insurance Coverage of Contraceptive and Infertility Treatments. Gend Soc. 1997;11(1):8-30. 18. Greil AL, McQuillan J, Shreffler KM, Johnson KM, Slauson-Blevins KS. Race-Ethnicity and Medical Services for Infertility: Stratified Reproduction in a Population-based Sample of U.S. Women. J Health Soc Behav. 2011;52(4):493-509. 19. Petersen EE. Racial/Ethnic Disparities in Pregnancy-Related Deaths — United States, 2007–2016. MMWR Morb Mortal Wkly Rep. 2019;68. doi:10.15585/mmwr.mm6835a3 20. Ohio Department of Health. 2017 Ohio Infant Mortality Data: General Findings; 2019. https://odh.ohio.gov/wps/wcm/connect/ gov/5b43b42b-0733-42cd-8a01-063f831ec53f/2017+Ohio +Infant+Mortality+Report.pdf?MOD=AJPERES&CONVERT_ TO=url&CACHEID=ROOTWORKSPACE.Z18_ M1HGGIK0N0JO00QO9DDDDM3000-5b43b42b-0733-42cd- 8a01-063f831ec53f-mLmEAnU.

4 21. Krieger N, Gruskin S, Singh N, et al. Reproductive justice & 43. Bearak J, Jones RK, Nash E, Donovan MK. COVID-19 Abortion preventable deaths: State funding, family planning, abortion, and Bans Would Greatly Increase Driving Distances for Those Seeking infant mortality, US 1980–2010. SSM - Popul Health. 2016;2:277- Care. Guttmacher Institute; 2020. https://www.guttmacher.org/ 293. doi:10.1016/j.ssmph.2016.03.007 article/2020/04/covid-19-abortion-bans-would-greatly-increase- driving-distances-those-seeking-care. 22. Sauls DJ. Effects of Labor Support on Mothers, Babies, and Birth Outcomes. J Obstet Gynecol Neonatal Nurs. 2002;31(6):733-741. 44. Upadhyay UD, Weitz TA, Jones RK, Barar RE, Foster DG. Denial of doi:10.1177/0884217502239209 Abortion Because of Provider Gestational Age Limits in the United States. Am J Public Health. 2013;104(9):1687-1694. doi:10.2105/ 23. Association of Women’s Health, Obstetric and Neonatal Nurses. AJPH.2013.301378 COVID-19 Archived Updates. COVID-19 Arch Updat. March 2020. https://awhonn.org/covid-19-archived-updates/. 45. Jones RK, Witwer E, Jerman J. Abortion Incidence and Service Availability in the United States, 2017. Guttmacher Institute; 2019. 24. Raymond EG, Grimes DA. The Comparative Safety of doi:10.1363/2019.30760 Legal Induced Abortion and Childbirth in the United States. Obstet Gynecol. 2012;119(2):215–219. doi:10.1097/ 46. Jones RK, Jerman J. Abortion Incidence and Service Availability AOG.0b013e31823fe923 In the United States, 2014. Perspect Sex Reprod Health. 2017;49(1):17-27. doi:10.1363/psrh.12015 25. Martins SL, Starr KA, Hellerstedt WL, Gilliam ML. Differences in Family Planning Services by Rural–urban Geography: Survey of 47. Endler M, Lavelanet A, Cleeve A, Ganatra B, Gomperts R, Title X–Supported Clinics In Great Plains and Midwestern States. Gemzell‐Danielsson K. Telemedicine for medical abortion: a Perspect Sex Reprod Health. 2016;48(1):9-16. doi:10.1363/48e7116 systematic review. BJOG Int J Obstet Gynaecol. 2019;126(9):1094- 1102. doi:10.1111/1471- 0528.15684 26. Appalachian Regional Commission. The Appalachian Region. https://www.arc.gov/appalachian_region/TheAppalachianRegion. 48. Grossman D, Grindlay K. Safety of Medical Abortion Provided asp. Through Telemedicine Compared With In Person. Obstet Gynecol. 2017;130(4):778-782. doi:10.1097/AOG.0000000000002212 27. Norris AH, Chakraborty P, Lang K, et al. Abortion access in Ohio’s changing legislative context. Forthcoming. 49. Grossman D, Grindlay K, Buchacker T, Lane K, Blanchard K. Effectiveness and acceptability of medical abortion provided 28. Guttmacher Institute. State Facts About Abortion Ohio. 2020:2. through telemedicine. Obstet Gynecol. 2011;118(2 Pt 1):296-303. 29. NARAL Pro-Choice Ohio. “Abortion in Ohio: What Are the Current doi:10.1097/AOG.0b013e318224d110 Laws?” http://womenspublicpolicynetwork.org/wp-content/ 50. Grindlay K, Lane K, Grossman D. Women’s and providers’ uploads/2017/05/Ohio-abortion-laws.pdf. experiences with medical abortion provided through telemedicine: 30. Morse JE, Charm S, Bryant A, Ramesh S, Krashin J, Stuart GS. a qualitative study. Women’s Health Issues Off Publ Jacobs The Impact of a 72-hour Waiting Period on Women’s Access to Inst Womens Health. 2013;23(2):e117-122. doi:10.1016/j. Abortion Care at a Hospital-Based Clinic in North Carolina. N C whi.2012.12.002 Med J. 2018;79(4):205-209. doi:10.18043/ncm.79.4.205 51. Grindlay K, Grossman D. Telemedicine provision of medical 31. Jones RK, Jerman J. Time to Appointment and Delays in : Through the provider’s lens. J Telemed Accessing Care Among U.S. Abortion Patients. New York: Telecare. 2017;23(7):680-685. doi:10.1177/1357633X16659166 Guttmacher Institute; 2016:22. 52. Kohn J, Snow J, Simons H, Seymour J, Thompson T-A, Grossman 32. Karasek D, Roberts SCM, Weitz TA. Abortion Patients’ Experience D. Medication Abortion Provided Through Telemedicine in Four and Perceptions of Waiting Periods: Survey Evidence before U.S. States. Obstet Gynecol. 2019;134(2):343-350. doi:10.1097/ Arizona’s Two-visit 24-hour Mandatory Waiting Period Law. AOG.0000000000003357 Women’s Health Issues. 2016;26(1):60-66. doi:10.1016/j. 53. Grossman DA, Grindlay K, Buchacker T, Potter JE, Schmertmann whi.2015.10.004 CP. Changes in Service Delivery Patterns After Introduction of 33. Ohio Department of Health. Essential Versus Non-Essential Telemedicine Provision of Medical . Am J Public Surgeries COVID-19 Checklist. https://coronavirus.ohio.gov/wps/ Health. 2012;103(1):73-78. doi:10.2105/AJPH.2012.301097 portal/gov/covid-19/checklists/english-checklists/essential-versus- 54. Hancock L. votes to ban medication abortions non-essential-surgeries-covid-19-checklist. Published April 8, administered through telemedicine. cleveland. https://www. 2020. cleveland.com/open/2020/03/ohio-senate-votes-to-ban- 34. Zane S, Creanga AA, Berg CJ, et al. Abortion-Related Mortality in medication-abortions-administered-through-telemedicine.html. the United States 1998–2010. Obstet Gynecol. 2015;126(2):258- Published March 4, 2020. 265. doi:10.1097/AOG.0000000000000945 55. Raymond E, Grossman D, Mark A, et al. Medication Abortion: A 35. Jerman J, Jones RK. Secondary Measures of Access to Abortion Sample Protocol for Increasing Access During a Pandemic and Services in the United States, 2011 and 2012: Gestational Beyond. April 2020. https://escholarship.org/uc/item/02v2t0n9. Age Limits, Cost, and Harassment. Women’s Health Issues. 56. NFPRHA. Initiating Telehealth in Response to COVID-19: Initial 2014;24(4):e419-e424. doi:10.1016/j.whi.2014.05.002 Considerations and Resources. National Family Planning 36. Roberts SC, Biggs MA, Chibber KS, Gould H, Rocca CH, Foster & Reproductive Health Association; 2020. https://www. DG. Risk of violence from the man involved in the pregnancy after nationalfamilyplanning.org/file/NFPRHA-Resource_Telehealth- receiving or being denied an abortion. BMC Med. 2014;12(1):144. COVID-19-Response-3.30.2020.pdf. doi:10.1186/s12916-014-0144-z 57. Fok WK, Mark A. Abortion through telemedicine: Curr 37. Foster DG, Biggs MA, Ralph L, Gerdts C, Roberts S, Glymour Opin Obstet Gynecol. 2018;30(6):394-399. doi:10.1097/ MM. Socioeconomic Outcomes of Women Who Receive and GCO.0000000000000498 Women Who Are Denied Wanted Abortions in the United 58. Ramaswamy A, Frederiksen B, 2020. State Action to Limit Abortion States. Am J Public Health. 2018;108(3):407-413. doi:10.2105/ Access During the COVID-19 Pandemic. Henry J Kais Fam Found. AJPH.2017.304247 April 2020. https://www.kff.org/womens-health-policy/issue- 38. Gerdts C, Dobkin L, Foster DG, Schwarz EB. Side Effects, Physical brief/state-action-to-limit-abortion-access-during-the-covid-19- Health Consequences, and Mortality Associated with Abortion pandemic/. and Birth after an Unwanted Pregnancy. Women’s Health Issues. 59. White K, Sierra G, Vizcarra E, et al. The Potential Impacts of Texas’ 2016;26(1):55-59. doi:10.1016/j.whi.2015.10.001 Executive Order on Patients’ Access to Abortion Care. 2019:4. 39. Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Timing 60. Sobel L, Ramaswamy A, Frederiksen B, Salganicoff A. State Action of steps and reasons for delays in obtaining abortions in the to Limit Abortion Access During the COVID-19 Pandemic. Henry J United States. Contraception. 2006;74(4):334-344. doi:10.1016/j. Kais Fam Found. April 2020. https://www.kff.org/womens-health- contraception.2006.04.010 policy/issue-brief/state-action-to-limit-abortion-access-during-the- 40. Paulson J, Smith DL. Induced Abortions in Ohio, 2018. Ohio covid-19-pandemic/. Department of Health; 2018:46. 61. Attorney General Becerra Leads Coalition of 21 Attorneys General 41. Finer LB, Frohwirth LF, Dauphinee LA, Singh S, Moore AM. Timing Asking FDA to Increase Access to Reproductive Telehealth Care of steps and reasons for delays in obtaining abortions in the During COVID-19 Pandemic. State of California - Department of United States. Contraception. 2006;74(4):334-344. doi:10.1016/j. Justice - Office of the Attorney General. https://oag.ca.gov/news/ contraception.2006.04.010 press-releases/attorney-general-becerra-leads-coalition-21- attorneys-general-asking-fda. Published March 30, 2020. 42. Foster DG, Kimport K. Who Seeks Abortions at or After 20 Weeks? Perspect Sex Reprod Health. 2013;45(4):210-218. 62. “Every day counts so much” Gov. DeWine and Gov. Pritzker outline doi:10.1363/4521013 state responses. NBC News. https://www.nbcnews.com/meet-the- press/video/-every-day-counts-so-much-gov-dewine-and-gov- pritzker-outline-state-responses-80682053636. Published May 15, 2020. 5