The impact of the COVID-19 pandemic on abortion care utilization and disparities by age

Abstract

Background: A variety of state-level restrictions were placed on abortion care in response to the COVID-19 pandemic, leading to drops in utilization and delays in time to abortion. Other pandemic-related factors also may have impacted 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 because there was no wide-scale abortion policy change in response to the pandemic.

Objective: This study aimed to evaluate the impact of the COVID-19 pandemic on abortion care utilization and disparities in utilization by patient age in Massachusetts.

Study design: Using the electronic medical records from all abortions that occurred at the 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 the number of abortions from the 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 less abortions than expected, corresponding to a 20% drop, from March 2020 to December 2020 (95% prediction interval, -2025 to -1394) with 888 less (20% reduction) abortions among adults, 792 (20% reduction) less among young adults, and 45 (27% reduction) among minors. Adults and young adults experienced significant reductions in the number of abortions beginning in March 2020, whereas decreases among minors did not begin until July 2020. The rate of abortions occurring ≥12 weeks gestational age was unchanged during the COVID-19 pandemic among minors (adjusted rate ratio, 0.92; 95% confidence interval, 0.55-1.51) and among adults (adjusted rate ratio, 0.92; 95% confidence interval, 0.78-1.09). Young adults had a lower rate of second trimester abortion during the pandemic (adjusted rate ratio, 0.79; 95% confidence interval, 0.66-0.95).

Conclusion: 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 abortions 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.

Keywords: COVID-19; abortion access; abortion care; health disparities; health service utilization.

Figure 1

Weekly number of abortions from May 1, 2017 to December 31, 2020 Fulcher et al. Abortion care utilization during COVID-19. Am J Obstet Gynecol 2022.

Figure 2

Monthly deviation in number of abortions with 95% prediction intervals Percentage change from expected in red text (March 1, 2020 to December 31, 2020). Fulcher et al. Abortion care utilization during COVID-19. Am J Obstet Gynecol 2022.

Figure 3

Gestational age at abortion by time epoch and age group (March 15–December 31) Light gray indicates data for 2018, dark gray indicates data for 2019, and red indicates data for 2020. Fulcher et al. Abortion care utilization during COVID-19. Am J Obstet Gynecol 2022.

Supplemental Figure 1

Scatterplot of residuals for each age group model Fulcher et al. Abortion care utilization during COVID-19. Am J Obstet Gynecol 2022.

Supplemental Figure 2

Autocorrelation function plot for each age group model Fulcher et al. Abortion care utilization during COVID-19. Am J Obstet Gynecol 2022.

Supplemental Figure 3

Annual number of births in Massachusetts from 1990 to 2020 Fulcher et al. Abortion care utilization during COVID-19. Am J Obstet Gynecol 2022.

Supplemental Figure 4

Annual percentage change in number of births in Massachusetts from 1990 to 2020 All data can be found in Massachusetts state-level birth reports for 1990 to 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). Fulcher et al. Abortion care utilization during COVID-19. Am J Obstet Gynecol 2022.