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Abortion Care in a Pandemic De Kort et al. Archives of Public Health (2021) 79:140 https://doi.org/10.1186/s13690-021-00665-6 RESEARCH Open Access Abortion care in a pandemic: an analysis of the number and social profile of people requesting and receiving abortion care during the first COVID-19 lockdown (March 16 to June 14, 2020) in Flanders, Belgium Leen De Kort* , Jonas Wood, Edwin Wouters and Sarah Van de Velde Abstract Background: The COVID-19 pandemic and the national COVID-19 measures might have increased potential barriers to abortion care and created new ones, especially for vulnerable groups. This study documents the impact of the pandemic and the lockdown measures on the profile of people going through the abortion process. Methods: Using anonymized patient records from a Belgian abortion centre, we first compared the number of abortion requests and procedures during the first COVID-19 lockdown with the same months in the five preceding years. Next, we analysed the social profile of people requesting an abortion in those two time periods and looked at the number of long-acting reversible contraceptive devices (LARC) placed after curettage. Results: The abortion centre saw a drop in the number of abortion requests during the lockdown. This difference was more pronounced for people in paid employment and people using (modern) contraception. People were also more likely to request an abortion earlier in their pregnancy. The drop in abortion procedures and LARC’s placed after curettage was proportionate to the drop in abortion requests and did not differ according to clients’ characteristics. Conclusion: Questions arose concerning the potential selectivity with which COVID-19 influenced the need for abortion care and accessibility to services. Although there was a general drop in abortion requests and procedures during the first COVID-19 lockdown in the studied abortion centre, our results suggest that the profile of people requesting and receiving an abortion did only slightly change during the lockdown, and did not affect vulnerable groups visibly harder. Keywords: COVID-19, Abortion, Belgium, Reproductive health, Healthcare services Background non-essential shops were closed, teleworking was man- For Belgium, governmental COVID-19 measures were dated for “non-essential” occupations, and people were most stringent during the first lockdown, which started only permitted to leave the house for essential activities on the 14th of March 2020. Schools, restaurants, and or limited outdoor exercise with close family members or one friend. The country also closed its borders. Mea- * Correspondence: [email protected] sures were relaxed from the 10th of May on, and borders Centre for Population, Family and Health, Department of Sociology, opened from the 15th of June. These measures University of Antwerp, Sint-Jacobstraat 2-4, 2000 Antwerp, Belgium © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. De Kort et al. Archives of Public Health (2021) 79:140 Page 2 of 8 significantly impacted the organization of Belgian pri- date, empirical research on this topic is scarce. Available mary health care (PHC) services, where quick adapta- research shows that people encountered more difficulties tions in practice management and consultation in obtaining timely sexual and reproductive health strategies were necessary to guarantee safe practices [1– (SRH) care services [17], and that in countries with strict 3]. COVID-19 regulations, the demand for self-managed Concerning abortion care, possible pre-existing diffi- abortion increased [18]. Other research shows that solu- culties such as arranging childcare, taking time off from tions, including self-managed abortions through tele- work, and transport to the abortion centre [4–9] may medicine, were well received by clients [19–21]. In have potentially been increased by both the pandemic it- Belgium, previous research found that the staff of the self and the protective measures installed by the Belgian abortion centre was worried about the level of psycho- government. Additionally, the COVID-19 pandemic may logical support they were able to offer to vulnerable have resulted in new barriers due to, for example, con- groups during the lockdown [3]. flicting media messages concerning the availability of With the current study, we contribute to this body of PHC-services, fear of infection with COVID-19 when empirical research by examining one of the bigger Flem- using public transport or visiting PHC-services, and fear ish abortion centres and studying (1) whether COVID- of being sanctioned for traveling outside the house. Al- 19 had an impact on the number of people progressing though Belgian abortion centres are located very central, through the various steps of the abortion service (abor- the practical side of arranging abortion care might have tion request, abortion procedure, and placing LARC), as been compromised by the COVID-19 measures; schools well as (2) whether certain groups of people were af- were closed, telework was mandated, and people were fected more severely. discouraged from making use of grandparents to look after children. In addition, secrecy might have been Context compromised by continually having family members In 1990, Belgium partially depenalised abortion by mak- around, and additionally, one was not able to use cul- ing abortion on demand legal in the first 12 weeks of a tural/social activities as an alibi. Furthermore, telephone pregnancy (after this period, abortion is possible only consultations (aimed at minimizing the number of con- when the life of the mother is in danger or if serious ab- tact moments between clients and staff) might have re- normalities are found in the foetus). A report from an sulted in more communication difficulties [3]. By opinion poll conducted in 2017 showed that 75,4% of Belgian law, curettages require two visits to the abortion the participants agreed with bills proposing to also re- centre, while medical abortions require three visits to move abortion from the criminal code [22], and in Octo- the abortion centre (see the ‘context’ section). Because ber 2018, this change of the law officially completed the of this additional in-person visit, some centres also depenalisation of abortion in Belgium. stopped offering medical abortions during the lockdown, When a client contacts one of the abortion centres, an thus reducing the options for people in need of abortion appointment at the abortion centre will be offered care (see [3] for more information on this change in pro- within 10 days. During this first appointment a consult- cedure in the abortion centre which is the focus of this ation with a social worker or psychologist, and a medical study). Since abortion care could not be offered to check-up take place. The second appointment in which people with COVID-19 symptoms, this may also have the abortion will be performed, can be scheduled after a created additional barriers. six-day waiting period. If the unwanted pregnancy is Additionally, the question arises whether the COVID- younger than 7 weeks, the client can choose between a 19 pandemic and lockdown measures affected all groups curettage or a medical abortion (unless there are medical equally in terms of their progress through the various reasons to prefer one method over the other). After 7 steps of the abortion service (abortion request, abortion weeks of conception, only a curettage is possible. The procedure, and placing long-acting contraceptive devices procedures take place in the abortion centre. This is also (LARC)). Under normal circumstances, socioeconomi- the case for the medical abortion, where both the inges- cally vulnerable people and people with a migration tion of mifepristone (during the second appointment) background were already more likely to experience bar- and the ingestion of misoprostol (during an additional riers in accessing abortion care [10–13]. This risk may third appointment) need to happen under the supervi- have been elevated due to higher COVID-19 infection sion of an abortion centre staff member. risk in people living in urban and deprived areas [14, All people residing in Belgium have government- 15], and sudden income loss caused by lockdown mea- sponsored health insurance, which covers most costs of sures [16]. abortions (clients only pay 3.68 euro). For non- Although there are many reasons to suspect that regularized migrants, abortion is seen as urgent medical COVID-19 affected people in need of abortion care, to help, which means that a refugee centre or the public De Kort et al. Archives of Public Health (2021) 79:140 Page 3 of 8 social welfare office (‘openbaar centrum voor maatschap- when interpreting the results related to this variable. pelijk welzijn’, or in short ‘OCMW’) can interfere in the When referring to types of contraception, permanent costs. methods such as sterilisation, long-acting reversible contraception, hormonal contraception, barrier methods, Methods and emergency contraception were seen as modern The current study was built on a collaboration with the methods, whereas coïtus interruptus and natural family network of Dutch speaking non-hospital-based abortion planning methods were not.
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