The Choices Memphis Center for Reproductive Health, a small clinic in Tennessee, had two doctors providing abortion care until a few days ago. The center, which draws patients from all over the region, sees anywhere between 20 and 40 patients a week, according to its assistant director Katy Leopard: They come from Mississippi, where there is only one clinic providing this kind of care, and from Arkansas, where abortions can be hard to come by, and sometimes from even as far as Kentucky.
In the United States, an estimated 11.3 million women live more than an hour’s drive from an abortion provider, and often doctors will split their time between clinics to provide more geographically comprehensive care. Last year, the Los Angeles Times shadowed a provider who performed 50 abortions in 60 hours when she “commuted” from California to Texas, a feat that now given a roiling pandemic and orders from state governments to “just stay home” seems difficult, if not impossible, to imagine. But clinic workers and reproductive health advocates are trying to manage, considering that even in moments of global crisis, unwanted pregnancies don’t stop.
In Tennessee, a person considering terminating a pregnancy must wait 48 hours after stating their intent at a clinic. At Choices, a 70-year-old retired physician was doing that intake work while another, younger doctor performed surgical abortions a few times a week. Confirmed coronavirus cases are up to nearly 200 in Tennessee, and in Memphis, many businesses closed last week. Choices’ elderly doctor was working “in our conference room with a plexiglass shield in front of him,” says Leopard. But by mid-week his family asked him, as someone at high risk should he be infected with the virus, to stop seeing patients. He did.
The clinic’s other doctor is picking up a few more days, though he’s “experiencing a great deal of anxiety,” and worried he’ll get sick, Leopard says. But “we can’t do without him.” If he fell ill or stopped working, Leopard says the clinic would be forced to close: “I don’t know that we could find another doctor licensed in Tennessee.”
The center’s negotiations mirror those of other abortion providers, who in addition to addressing issues that have hobbled many businesses during the pandemic, do vital work that requires close contact between patients and doctors. And given the constraints of state and federal law, clinic workers and clients have historically been forced to travel long distances to facilitate care.
In interviews, three clinic managers from different parts of the country expressed anxiety about future staffing issues and safety measures given the lack of masks and gloves. Many had rescheduled or pushed off visits like pap smears and breast exams; some were encouraging telemedicine visits for transgender and abortion care follow-ups. Given the relatively small number of doctors who perform abortions in the Midwest and the South, there is a deep concern that the pandemic will further impact patient access as demand remains the same. “You know, abortion and birth is not optional,” says Leopard. “It’s very time-sensitive.”
“Even in the pandemic we’re experiencing,” says Julie Burkhart, “your pregnancy doesn’t stop.”
Burkhart is the founder of Trust Women, an organization that currently operates two clinics—one in Wichita, Kansas, the other in Oklahoma City. When I reached her on Friday she was scrambling to find a way to keep her doctors safe while they traveled. Given the shortage of doctors trained to perform abortions in the Midwest, Trust Women relies on a network of physicians from all corners of the country to fly in; Burkhart estimates that there are currently 13 contracting with her clinics in various capacities, based “in every region of the United States.” So far, Burkhart says, those doctors have all decided that they can continue to fly safely, but she fears potential commercial airline restrictions, as well as more personal calculations of risk as the crisis goes on.
The potential for covid-19 exposure “has very much been on [the doctors’] minds,” she says: “What if I’m infected on the plane? What if I can’t get back on that commercial flight?” She worries too, about doctors being pulled back to their communities indefinitely to care for patients on a local scale. Burkhart has been investigating extended lines of credit in order to book private flights for her doctors to continue to work, but it’s barely, if at all, financially feasible without significantly more support.
At the Trust Women clinics themselves, Burkhart says patients and doctors are practicing “social distancing” the best they can—they’ve taken chairs out of the waiting rooms, and are asking friends and loved ones who travel to support women during their abortions to sit on benches outside or stay in the car. Providers are screening patients for symptoms of the novel coronavirus, and taking everyone’s temperatures at the doors. Staffing concerns are at the forefront of her mind: “God forbid anyone gets sick,” she says. And her clinics, like nearly every environment on the planet right now, will soon run out of the supplies that help providers stay healthy and able to continue their work. Right now the Trust Women clinics are keeping medical masks on patients as a safety precaution. They placed an order for more masks recently but recently found that it had been canceled without explanation.
Burkhart’s clinics draw patients from all over the country. People are still driving from Texas and Kansas, making long trips to get the care they need. Melissa Grant, the chief operations officer of Carafem, a network of four clinics in Maryland, Illinois, Tennessee, and Georgia, is concerned that patient travel may be more difficult as the economy stalls. She, like the other providers I spoke to, said most patients are calling right now just to make sure the offices are still open; there haven’t been many cancellations from patients who may fear travel during a particularly terrifying time to be moving around. But Grant says many of her clients are low-income, and many don’t have insurance. “Now our clients, potentially, are starting to lose their jobs,” she says, making paying for travel and lodging even more of a hurdle.
Some of Carafem’s clinics participate in a study that allows them to prescribe medicated abortions through the mail: A research organization called Gynuity Health Projects allows participating clinics to counsel patients remotely and send them mifepristone and misoprostol to take in their homes. But the program is only available to qualifying clinics in 11 states, and even as the federal government has restricted limitations on telemedicine during the outbreak, it has refused to extend similar provisions for what public health advocates argue is essentially an over-the-counter drug.
All of which concerns Grant, considering it appears travel will become much more difficult, if not impossible, for women who need care: “Abortion care has an urgency that some other medical care doesn’t,” she says, “because the further that a pregnancy progresses, the more complicated it can be to receive that care.” She’s hoping to enroll her Maryland clinic in the Gynuity study as early as this week. In Ohio and Texas, state governments have moved swiftly to classify the majority of abortion care as a “non-essential” health service during the pandemic, functionally criminalizing the practice in those states and shrinking the number of clinics who are already struggling in unprecedented times to provide appropriate care.
“It’s a very, very unsettling moment,” says Burkhart. “It’s frightening for me to think about someone essentially being forced to carry a pregnancy because of our public health situation right now.”