key: cord-1054634-1ixspug4
authors: FULCHER, Dr. Isabel R.; ONWUZURIKE, Dr. Chiamaka; GOLDBERG, Dr. Alisa; COTTRILL, Mr. Alischer A.; FORTIN, Ms. Jennifer; JANIAK, Dr. Elizabeth
title: The impact of the COVID-19 pandemic on abortion care utilization and disparities by age
date: 2022-01-31
journal: Am J Obstet Gynecol
DOI: 10.1016/j.ajog.2022.01.025
sha: 0f5bb1ea04ad31a57918c018ee7af2538cb66fb5
doc_id: 1054634
cord_uid: 1ixspug4

Background A variety of state-level restrictions were placed on abortion care in response to the COVID-19 pandemic, resulting in drops in utilization and delays in time to abortion. Other pandemic-related factors may also impact receipt of abortion care, potentially exacerbating existing barriers to care. Massachusetts is an ideal setting to study the impact of these other pandemic-related factors on abortion care utilization as there was no wide-scale abortion policy change in response to the pandemic. Objective To evaluate the impact of the COVID-19 pandemic on abortion care utilization and on disparities in utilization by patient age in Massachusetts. Study design Utilizing electronic medical records on all abortions at Planned Parenthood League of Massachusetts from May 1, 2017 through December 31, 2020 (N=35,411), we performed time series modeling to estimate monthly changes in number of abortions from expected counts during the COVID-19 pandemic. We also assessed if legal minors (<18 years) experienced delays in time to abortion, based on gestational age at procedure, and whether minors were differentially impacted by the pandemic. Results There were 1725 fewer abortions than expected, corresponding to a 20% drop, from March to December 2020 (95% prediction interval: [-2025, -1394]) with 888 (20% fewer) abortions among adults, 792 (20% fewer) among young adults, and 45 (27% fewer) among minors. Adults and young adults experienced significant decreases in the number of abortions beginning in March 2020, while decreases among minors did not begin until July 2020. The rate of abortions occurring at or after 12 weeks gestational age was unchanged during the COVID-19 pandemic among minors (adjusted risk ratio (RR): 0.92; 95% Confidence Interval (CI): [0.55, 1.51]) and among adults (RR: 0.92; 95% CI: [0.78, 1.09]). Young adults had lower risk of second trimester abortion during the pandemic (RR=0.79, 95% CI: [0.66, 0.95]). Conclusions Despite uninterrupted abortion service provision, abortion care utilization decreased markedly in Massachusetts during the pandemic. There was no evidence of an increase in second trimester abortion in any age group. Further research is needed to determine if a decline in the pregnancy rate or other factors, such as financial and travel barriers, fear of infection, or privacy concerns, may have contributed to this decline.

Noting that service disruptions can have life-altering consequences for individuals, leading 96 clinical organizations in the US quickly affirmed that abortion is an essential health service that 97 should continue uninterrupted during the COVID-19 pandemic. 1 In addition to direct restrictions placed on abortion care, other pandemic-related factors may 108 affect access. Stay-at-home orders may complicate travel to a clinic, especially among 109 individuals requiring childcare. 6 The risk of SARS-CoV-2 exposure may discourage some 110 individuals from seeking any medical care, including abortion, especially for individuals whose 111 household members have pre-existing health conditions that increase risk for severe COVID-19 112 disease. 7,8 These factors further compound limitations on abortion access for individuals living in 113 US states that had abortion restrictions in place prior to the pandemic, such as mandatory waiting 114 periods and parental involvement laws, which place substantial burdens on patients at baseline. 9 115

These burdens are not equally distributed, disproportionately affecting individuals who identify 116 as people of color and legal minors in the United States. 10 117 J o u r n a l P r e -p r o o f Thirty-eight states require parental involvement in a minor's decision to have an abortion, and 119 several studies demonstrate these laws cause delay in accessing abortion, though effects vary 120 across states. [11] [12] [13] [14] From 1981 through 2020, Massachusetts' parental consent law required that 121 minors < 18 years of age either obtain parental consent for abortion care or bypass the 122 requirement via a hearing with a Superior Court judge. 15 We collected the following variables for each abortion: patient age, insurance status, patient race 161 and ethnicity (self-reported), date of abortion, and gestational age at abortion by ultrasound. 162

Gestational age is reported categorically as <8 weeks and then in increasing increments of 1 163 J o u r n a l P r e -p r o o f

week. For these patient covariates, we operationalized age categorically with three distinct 164 groups: Minors (<18 years of age), Young Adults (18-26 years of age), and Adults (> 27 years of 165 age). The distinction between Young Adults and Adults reflects potential differences in care 166 seeking due to the Affordable Care Act, which allows individuals to remain covered by their 167 parents' commercial insurance through age 26. Insurance status refers to the insurance type that 168 was used on the date of service, coded as: private, public, self-pay, and private charitable fund. 1, 2020 -December 31, 2020). Note that the COVID-19 period starts on March 1, 2020 as we 188 chose the monthly level to avoid moving holidays that result in multi-day closings in some years 189 and not others. 22 

To flexibly model time trends and seasonality, we fit the model separately for each age group. 194

We report the deviation between expected and observed counts for each month with 95% 195 prediction intervals, calculated using a parametric bootstrap procedure. These statistical methods 196 were employed during the COVID-19 pandemic and described in greater detail to perform 197 syndromic surveillance 23 and estimate excess deaths. 24 Finally, we perform several model 198 checking procedures to assess the validity of modeling assumptions in the age group time series 199 models. 200

To formally compare abortion utilization by age group, we modified the Poisson regression 202 model (Eq. 1) to include the entire time range with additional terms for age group, COVID-19 203 period (pre-vs. during pandemic), and an interaction between age group and COVID-19 period. 204

We also adjusted for the monthly distribution of race/ethnicity and insurance status as these 205 variables are associated with abortion utilization and delay, and may impact who received an 206 abortion during the early COVID-19 pandemic. 25,26 207 208 J o u r n a l P r e -p r o o f

The secondary analysis investigated if the COVID-19 pandemic was associated with delays in 209 time to abortion and if minors were differentially impacted as compared to young adults and 210 adults. We first assessed if the distribution of gestational age at abortion changed during the 211 pandemic among minors using a Kruskal-Wallis test. To assess differential impact among 212 minors, we modeled the monthly number of abortions occurring at or after 12-weeks gestation 213 using the same Poisson regression model described above with the addition of an offset term for 214 the number of monthly abortions. All data cleaning and analyses were conducted in R V3.6.0. (Figure 1 ). Adults and young adults had lower 233 than expected numbers of abortions for all ten months of the COVID-19-period. Among minors, 234 the number of abortions was close to expected during the months of March through June, lower 235 than expected in July through October, and returned to expected by November (Figure 2) . For 236 all age groups, the deviation in number of abortions from expected was largest in August 2020 237 and began to rebound towards expected thereafter. We found no evidence of overdispersion or 238 autocorrelation in these models (see Appendix A for more details). After adjusting for 239 race/ethnicity and insurance status in the Poisson regression model, there were no significant 240 differences in deviations over the COVID-19 period between the age groups ( Table 3) . In the model for abortion delay, we found no change in the risk of having an abortion procedure 250 at or after 12 weeks among adults and minors during the COVID-19 pandemic ( Table 3 ). In Appendix B Table B Notably, the declines in pregnancy and birth rates from these published reports are smaller than 292 what was observed in our study, which could be due to: (1) individuals shifting abortion care-293 seeking from PPLM clinics to other providers, (2) individuals choosing to continue their 294 pregnancies, or (3) individuals being unable to obtain an abortion. However, it is unlikely that 295 people sought care outside of PPLM clinics at a higher rate during the pandemic as the clinics 296 had no interruption in abortion care during the pandemic and did not need to shift any resources 297 to care for patients with COVID-19. 30 There is also no evidence that people chose to continue 298 pregnancies at a higher rate during the pandemic; in fact, a national survey indicated a 299 precipitous drop in the proportion of pregnancy-capable individuals desiring a birth during the 300 pandemic. 31 Of these options, the most likely explanation may be that more individuals were 301 unable to obtain a wanted abortion due to financial barriers, fear of infection, increased life 302 chaos, childcare responsibilities, and increases in intimate partner violence-all phenomena that 303 have been documented worldwide during the pandemic. 32,33 304 305 Researchers hypothesized delays in abortion care would occur during the pandemic, 34 especially 306 among minors as prior studies have shown later gestational ages at abortion compared to 307 adults. 35, 36 Our findings align with these prior studies as minors were more likely to have a 308 second trimester abortion compared to young adults and adults in all time periods. However, we 309 did not find evidence of a delay in time to abortion among minors during the pandemic. 310 311 Clinical Implications. The decrease in abortions during the second trimester observed among 312 minors and young adults, but not adults, could be due to widespread societal closures of 313 workplaces and schools, allowing them to obtain abortion care more quickly precisely because 314 they did not require time off from these other obligations to seek care. Because this finding was 315 coupled with a decline in abortion care utilization, further research is needed to understand 316 whether the change among minors and young adults is due to faster access to abortion care once 317 pregnant, or due to an increase in the frequency of minors and young adults continuing undesired 318 pregnancies. As much of the United States returns to pre-pandemic levels of social interaction, 319 sexual activity may also increase. It is imperative in this context that individuals can access 320 essential sexual and reproductive health care, including contraception for those wishing to 321 prevent pregnancy, and continued access to abortion for individuals in need. This study had several limitations. First, there was more missing race and ethnicity data during 347 the pandemic, likely because this question was assessed during a telehealth visit by a provider 348 (vs. self-reported on a tablet by the patient). It is possible that the missing race determination was 349 not random, thereby classifying some races as missing more often than others. Such 350 misclassification of race would have masked true racial differences in outcomes across time 351 epochs presented in Table 1 J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f All data can be found in Massachusetts state-level birth reports for 1990-2017 at https://www.mass.gov/lists/birth-data. Reports for the remaining years can be found at https://www.cdc.gov/nchs/data/nvsr/nvsr70/nvsr70-02-508.pdf (2019), https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_13-508.pdf (2018), and https://www.cdc.gov/nchs/data/vsrr/vsrr012-508.pdf (2020).

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