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Impact of the COVID-19 pandemic on induced abortions in France in 2020

  • Annick Vilain
    Affiliations
    Population Health Office, Directorate of Research, Studies, Evaluation and Statistics (DREES), French Ministry of Health and Solidarity, Paris, France
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  • Sylvie Rey
    Affiliations
    Population Health Office, Directorate of Research, Studies, Evaluation and Statistics (DREES), French Ministry of Health and Solidarity, Paris, France
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  • Camille Le Ray
    Affiliations
    Obstetrical, Perinatal and Paediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and Statistics, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Université de Paris, Paris, France
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  • Catherine Quantin
    Affiliations
    Biostatistics and Bioinformatics (DIM), Dijon University Hospital, Dijon, France
    Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Center 1432, Dijon, France
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  • Jennifer Zeitlin
    Affiliations
    Obstetrical, Perinatal and Paediatric Epidemiology Research Team (EPOPé), Centre of Research in Epidemiology and Statistics, Institut National de la Santé et de la Recherche Médicale, Institut National de la Recherche Agronomique, Université de Paris, Paris, France
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  • Jeanne Fresson
    Affiliations
    Population Health Office, Directorate of Research, Studies, Evaluation and Statistics (DREES), French Ministry of Health and Solidarity, 14, Ave. Duquesne, 75007 Paris Cedex, Paris
    Department of Medical Information (DIM), University Hospital, Nancy, France
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Published:January 05, 2022DOI:https://doi.org/10.1016/j.ajog.2021.12.265

      Objective

      A major concern during the COVID-19 lockdowns was reduced access to time-sensitive reproductive healthcare, in particular, healthcare related to abortions.
      • Robinson E.F.
      • Moulder J.K.
      • Zerden M.L.
      • Miller A.M.
      • Zite N.B.
      Preserving and advocating for essential care for women during the coronavirus disease 2019 pandemic.
      France’s first lockdown from March 17 to May 10, 2020, consisted of strict stay-at-home orders that dramatically limited population movement.
      • Pullano G.
      • Valdano E.
      • Scarpa N.
      • Rubrichi S.
      • Colizza V.
      Evaluating the effect of demographic factors, socioeconomic factors, and risk aversion on mobility during the COVID-19 epidemic in France under lockdown: a population-based study.
      Medical care was exempted from these restrictions, but pandemic-related health service reorganization and fears of infection created potential obstacles to abortion services. In France, abortions are permitted without restriction until 14 weeks of gestation (until 7 weeks’ gestation in an ambulatory setting). After 14 weeks of gestation, only abortions for severe anomalies or maternal health risks can be performed after authorization by a medical committee. To maintain access to abortion services, the government modified management of medical abortions by extending the gestational limit to 9 weeks in an ambulatory setting, authorizing telemedicine visits, and allowing direct pickup from pharmacies of call-in orders for mifepristone and misoprostol.
      • Moreau C.
      • Shankar M.
      • Glasier A.
      • Cameron S.
      • Gemzell-Danielsson K.
      Abortion regulation in Europe in the era of COVID-19: a spectrum of policy responses.
      ,
      • Bojovic N.
      • Stanisljevic J.
      • Giunti G.
      The impact of COVID-19 on abortion access: insights from the European Union and the United Kingdom.
      This study aimed to investigate changes in the use of abortion services during and after this first very restrictive COVID-19 lockdown in France.

      Study Design

      We used data on the number of monthly abortions from 2016 to 2020 in France (N=1,104,408). Data on all procedural and medical abortions in hospitals and clinics are recorded in hospital discharge data, whereas medical abortions prescribed in doctors’ or midwives’ offices can be obtained from insurance claims data. We modeled the time series from 2016 to February 2020 to forecast the expected monthly values with their confidence intervals for March 2020 onward using an autoregressive integrated moving average model. Potential increases in delayed care were assessed by the percentage of abortions within 2 weeks of the legal limit. Live birth conceptions were estimated from birth registration data by subtracting 9 months from the date of birth, and monthly conceptions in 2020 were compared with those in 2018 and 2019.

      Results

      In 2020, the number of monthly abortions deviated from the predicted data in May and June, but the first 2 months of the lockdown in March and April were in line with expectations (Figure; full time series results in Supplemental Figure). Decreases in the number of abortions occurred in hospitals and clinics. The proportion of abortions at 13 to 14 weeks were similar in 2020 (2.3%) and 2019 (2.7%). In 2020, the estimated number of conceptions ending in a live birth was 123,271 in January and February, 112,335 in March and April, 113,521 in May and June, and 379,006 from July to December or −3.5%, −10.3%, −3.3%, and +1.4% respectively, of the conceptions that occurred during the same periods in 2019 and −5.1%, −11.1%, −1.2%, and −1.5% of those in 2018.
      Figure thumbnail gr1
      FigureNumber of monthly abortions by setting in 2020
      Number of monthly abortions by setting in 2020 and its comparison with the predicted values from the ARIMA model. The full ARIMA model from 2016 to 2020 is provided in the .
      ARIMA, autoregressive integrated moving average.
      Vilain. Impact of the COVID-19 pandemic on induced abortions in France in 2020. Am J Obstet Gynecol 2022.

      Conclusion

      We observed a reduction in the abortions during France’s strict COVID-19 lockdown, but the delayed time pattern, the stability of late abortions, and concurrent changes in live birth conceptions suggest that it was caused principally by declines in conceptions. This reduction occurred primarily among induced abortions in hospitals and clinics, and the number of these abortions continued to be lower than expected throughout 2020. However, the total number of abortions was in line with the expectations from July through December 2020 despite the second pandemic wave in September and October and a less restrictive lockdown in November.
      National- and state-level approaches to abortion care have been heterogeneous during the pandemic.
      • Moreau C.
      • Shankar M.
      • Glasier A.
      • Cameron S.
      • Gemzell-Danielsson K.
      Abortion regulation in Europe in the era of COVID-19: a spectrum of policy responses.
      • Bojovic N.
      • Stanisljevic J.
      • Giunti G.
      The impact of COVID-19 on abortion access: insights from the European Union and the United Kingdom.
      • Mello K.
      • Smith M.H.
      • Hill B.J.
      • et al.
      Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic.
      There are some reports of restricted access to services,
      • Mello K.
      • Smith M.H.
      • Hill B.J.
      • et al.
      Federal, state, and institutional barriers to the expansion of medication and telemedicine abortion services in Ohio, Kentucky, and West Virginia during the COVID-19 pandemic.
      ,
      • Roberts S.C.M.
      • Berglas N.F.
      • Schroeder R.
      • Lingwall M.
      • Grossman D.
      • White K.
      Disruptions to abortion care in Louisiana during early months of the COVID-19 pandemic.
      but data are scarce. Our nationwide study contributes important evidence that broadening the window for medical abortions and permitting telemedicine visits preserved access in France. Our results also highlight the need to account for pandemic-related changes in conceptions when evaluating abortion policies.

      Appendix

      Figure thumbnail fx1
      Supplemental FigureNumber of monthly abortions by setting from 2016 to 2020
      Number of monthly abortions by setting from 2016 to 2020 and a comparison with the predicted values obtained from the autoregressive integrated moving average model. Note that the first 12 months are used to model the time series.
      Vilain. Impact of the COVID-19 pandemic on induced abortions in France in 2020. Am J Obstet Gynecol 2022.

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