Impact of COVID-19 on termination of pregnancy

Objective

To evaluate the impact of COVID-19 pandemic on termination of pregnancy.

Methods

This was a retrospective study aimed to assess the impact of COVID-19 pandemic on termination of pregnancy in a single center in Italy. Consecutive data on pregnant women who requested induced termination of pregnancy (I-TOP) from February 2018 to December 2021 were included in a dedicated database. The data were divided into two groups according to the COVID-19 outbreak. Women who requested I-TOP from February 2018 to January 2020 were included into the group ‘before COVID-19 pandemic’. Women who requested I-TOP from February 2020 to January 2022 were included into the group ‘during COVID-19 pandemic’. Indications for I-TOP included elective abortion and therapeutic for fetal or maternal indication.

Results

A total of 2578 women were included in the study. Of them, 1637 had I-TOP before COVID-19, and 941 had I-TOP during COVID-19. During the pandemic, the request for elective abortion decreased from 76.2% to 67.7% (p<0.01). Therapeutic abortion were performed in 141/693 cases in the first trimester, and in 552/693 cases in the second trimester. Overall, 91 were for maternal indications and 602 for fetal indications. No differences were noticed between before and during pandemic (p=0.99). Follow-up visits two weeks after abortions were offered to all women. However, only 35.5% women visited for follow-up during pandemic vs. 65.0% before COVID-19 (p<0.01).

Conclusion

The COVID-19 pandemic had impact on access to abortion services, reducing request for elective abortion and post-abortion follow-up visits.

Keywords

COVID-19, induced termination of pregnancy, abortion, miscarriage, curettage.

Introduction

Coronaviruses (CoVs) are the largest group of viruses belonging to the Nidovirales order. They are enveloped, non-segmented positive-sense RNA viruses.[1] The Novel Coronavirus (2019-nCoV), also known as Wuhan coronavirus, causes the 2019-nCoV acute respiratory disease or COVID-19 or SARS-CoV-2.[2]
The COVID-19 outbreak poses significant risk to public health.[3] In obstetrics and gynecology, COVID-19 pandemic is associated with significantly higher risk of maternal and perinatal complications,[4–15] but also challenges and issues about organizing labor and delivery unit,[16–18] training program,[19] and vaccination.[20–23] Family planning services may be also affected by COVID-19 pandemic.[24] A health system response for family planning services during the pandemic, including telemedicine, is important to avoid unwanted pregnancies and prevent additional mortality and morbidity of women.[25,26] Currently, there is no lack of information on the impact of the COVID-19 pandemic on abortion access and indications.
Thus, the aim of this study was to evaluate impact of COVID-19 pandemic on termination of pregnancy.

Methods

Study design

This was a retrospective study aimed to assess the impact of COVID-19 pandemic on termination of pregnancy (abortion) performed at a single center in Italy (University of Naples Federico II, Napoli, Italy). Consecutive data on pregnant women who requested induced termination of pregnancy (I-TOP) from February 2018 to January 2022 were included in a dedicated database. The data were divided into two groups according to the COVID-19 outbreak. Women who requested I-TOP from February 2018 to January 2020 were included into the group ‘before COVID-19 pandemic’. Women who requested I-TOP from February 2020 to January 2022 were included into the group ‘during COVID-19 pandemic’. Inclusion criteria were pregnant women undergoing I-TOP. Women with spontaneous abortion or second trimester loss were excluded from the analysis. Indications for I-TOP included elective abortion and therapeutic abortion for fetal or maternal indication. We also evaluated methods of abortion, either surgical or medical.
Elective abortion, or nontherapeutic abortion, was defined as abortion done because a woman chooses to end the pregnancy.[27–31] In Italy, elective abortion is allowed until 12 weeks and 6 days. In our institution, elective abortion was performed either with medical approach or surgical approach. Surgical approach in the first trimester was performed by dilation and curettage with or without vacuum aspiration. Medical approach in the first trimester was performed using oral mifepristone 600 mg followed by oral misoprostol 400 mcg every 4 hours.[32]
Therapeutic abortion is allowed in Italy until 21 weeks and 6 days.[27–31] In our institution, second trimester abortion was performed using oral mifepristone followed by oral or vaginal misoprostol.

Statistical analysis

The data are shown as mean with standard deviation, or as number (percentage). Descriptive statistics were calculated for sociodemographic characteristics. Univariate comparisons of dichotomous data were performed with the use of the chi-square with continuity correction. Comparisons between groups to test group means with standard deviation were performed with the use of the t-test by assuming equal within-group variances. A 2-sided p-value less than .05 was considered significant. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) v. 19.0 (IBM Inc., Armonk, NY, USA).

Results

A total of 2578 women were included in the study. Of them, 1637 had I-TOP before COVID-19, and 941 had I-TOP during COVID-19.
During the pandemic, the request for elective abortion decreased from 76.2% to 67.7% (p<0.01). Therapeutic abortion was performed in 141/693 cases in the first trimester, and in 552/693 cases in the second trimester. Overall, 91 were for maternal indications and 602 for fetal indications (Table 1). No differences were noticed between before and during pandemic (p=0.99).
Follow-up visits two weeks after abortions were offered to all women. However, only 35.5% women visited for follow-up during pandemic vs. 65.0% before COVID-19 (p<0.01).

Discussion

This study evaluated impact of COVID-19 pandemic on indication for termination of pregnancy. The study showed that COVID-19 reduced request for elective abortion, while did not impact on therapeutic I-TOP. COVID-19 had also a negative impact on follow-up, reducing post-abortion visits.
This study had several limitations. The sample size is small. The single-center study design raises the question of external generalizability. Because of its retrospective nature, it was not possible to separate the importance of the pandemic versus other confounders that may have affected the results.
The COVID-19 pandemic is a public health crisis that generated social, political, economic, and psychological consequences. In pregnant women, COVID-19 is associated with increased risk of maternal and perinatal complications.[7,33–35] Access to abortion care can be restricted by numerous logistical and financial barriers, and the COVID-19 pandemic may intensify many challenges that abortion service face in providing their services.[36] In our setting, abortion unit remained open during the pandemic proving abortion care, counselling, and follow-up visits. The reducing request for elective abortion may be caused by different conditions linked to the pandemic. Access to the hospital was restricted to family members and care givers, and visitors. Women can be afraid to go to general medical visit, with less gynecologic visits, including contraception counselling, and missed pregnancy test before 13 weeks, being the gestational age cut-off allowed in Italy for elective abortion.
Prior studies evaluated the impact of COVID-19 on abortion services.[36–40] Tu et al. showed that the pandemic was associated with increased intention of seeking induced abortion due to social factors.[38] Kaller et al.[39] showed that the COVID-19 pandemic caused several disruptions to abortion service availability in India, including lockdowns. To reduce in-person visit time, some clinics shifted to offering medication abortion (versus procedural) or telehealth. In a cohort analysis of abortion requests made through the telemedicine abortion service Women on Web (WoW), almost half of the women and pregnant people having an abortion through WoW reported experiencing obstacles to abortion care because of COVID-19.[40]

Conclusion

In summary, the COVID-19 pandemic had impact on access to abortion services, reducing request for elective abortion and post-abortion follow-up visits. Policies or protocols improving abortion access are urgently required.

References

1. Fehr AR, Perlman S. Coronaviruses: an overview of their replication and pathogenesis. Methods Mol Biol 2015;1282:1–23. [PubMed] [CrossRef] 


2. Perlman S. Another decade, another coronavirus. N Engl J Med 2020;382:760–2. [PubMed] [CrossRef] 


3. Cheema S, Ameduri M, Abraham A, Doraiswamy S, Mamtani R. The COVID-19 pandemic: the public health reality. Epidemiol Infect 2020;148:e223. [PubMed] [CrossRef] 


4. Carbone L, Raffone A, Travaglino A, Sarno L, Conforti A, Gabrielli O, et al. Obstetric A&E unit admission and hospitalization for obstetrical management during COVID-19 pandemic in a third-level hospital of southern Italy. Arch Gynecol Obstet 2021 Aug 29:1–9. doi:10.1007/s00404-021-06212-6  [PubMed] [CrossRef] 


5. Di Mascio D, Buca D, Berghella V, Khalil A, Rizzo G, Odibo A, et al. Counseling in maternal-fetal medicine: SARS-CoV-2 infection in pregnancy. Ultrasound Obstet Gynecol 2021;57:687–97. [PubMed] [CrossRef] 


6. D’Antonio F, Sen C, Mascio DD, Galindo A, Villalain C, Herraiz I, et al.; On the behalf of the World Association of Perinatal Medicine Working Group on Coronavirus Disease 2019. Maternal and perinatal outcomes in high compared to low risk pregnancies complicated by severe acute respiratory syndrome coronavirus 2 infection (phase 2): the World Association of Perinatal Medicine Working Group on Coronavirus Disease 2019. Am J Obstet Gynecol MFM 2021;3:100329. [PubMed] [CrossRef] 


7. WAPM (The World Association of Perinatal Medicine) working group on COVID-19. Maternal and perinatal outcomes of pregnant women with SARS-COV-2 infection. Ultrasound Obstet Gynecol 2021;57:232–41. [PubMed] [CrossRef] 


8. Carbone L, Esposito R, Raffone A, Verrazzo P, Carbone IF, Saccone G. Proposal for radiologic diagnosis and follow-up of COVID-19 in pregnant women. J Matern Fetal Neonatal Med 2020 Jul 16:1–2. doi:10.1080/14767058.2020.1793325  [PubMed] [CrossRef] 


9. Api O, Sen C, Debska M, Saccone G, D’Antonio F, Volpe N, et al. Clinical management of coronavirus disease 2019 (COVID-19) in pregnancy: recommendations of WAPM-World Association of Perinatal Medicine. J Perinat Med 2020;48:857–66. [PubMed] [CrossRef] 


10. Di Mascio D, Sen C, Saccone G, Galindo A, Grünebaum A, Yoshimatsu J, et al. Risk factors associated with adverse fetal outcomes in pregnancies affected by Coronavirus disease 2019 (COVID-19): a secondary analysis of the WAPM study on COVID-19. J Perinat Med 2020;48:950–5. [PubMed] [CrossRef] 


11. Zullo F, Di Mascio D, Saccone G. COVID-19 Antibody testing in pregnancy. Am J Obstet Gynecol MFM 2020;2:100142. [PubMed] [CrossRef] 


12. Spiniello L, Di Mascio D, Bianco C, Esposito O, Giangiordano I, Muzii L, et al. All we know about COVID-19 in pregnancy: from perinatal to ethical and psychological perspective. Perinat J 2020;28:120–6. [CrossRef] 


13. Saccone G, Carbone FI, Zullo F. The novel coronavirus (2019-nCoV) in pregnancy: what we need to know. Eur J Obstet Gynecol Reprod Biol 2020;249:92–3. [PubMed] [CrossRef] 


14. Di Mascio D, Khalil A, Saccone G, Rizzo G, Buca D, Liberati M, et al. Outcome of coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020;2:100107. [PubMed] [CrossRef] 


15. Saccone G, Florio A, Aiello F, Venturella R, De Angelis MC, Locci M, et al. Psychological impact of coronavirus disease 2019 in pregnant women. Am J Obstet Gynecol 2020;223:293–5. [PubMed] [CrossRef] 


16. Boelig RC, Manuck T, Oliver EA, Di Mascio D, Saccone G, Bellussi F, et al. Labor and delivery guidance for COVID-19. Am J Obstet Gynecol MFM 2020;2:100110. [PubMed] [CrossRef] 


17. Boelig RC, Saccone G, Bellussi F, Berghella V. MFM Guidance for COVID-19. Am J Obstet Gynecol MFM 2020;2:100106. [PubMed] [CrossRef] 


18. Saccone G. Get your obstetric inpatient and outpatient units ready for COVID-19. Minerva Ginecol 2020;72:185–6. [PubMed] [CrossRef] 


19. Bitonti G, Palumbo AR, Gallo C, Rania E, Saccone G, De Vivo V, et al. Being an obstetrics and gynaecology resident during the COVID-19: Impact of the pandemic on the residency training program. Eur J Obstet Gynecol Reprod Biol 2020;253:48–51. [PubMed] [CrossRef] 


20. Carbone L, Mappa I, Sirico A, Di Girolamo R, Saccone G, Di Mascio D, et al. Pregnant women’s perspectives on severe acute respiratory syndrome coronavirus 2 vaccine. Am J Obstet Gynecol MFM 2021;3:100352. [PubMed] [CrossRef] 


21. Carbone L, Raffone A, Sarno L, Travaglino A, Saccone G, Gabrielli O, et al. Invasive prenatal diagnosis during COVID- 19 pandemic. Arch Gynecol Obstet 2022;305:797–80. [PubMed] [CrossRef] 


22. Carbone L, Mappa I, Sirico A, Girolamo RD, Saccone G, Mascio DD, et al. Pregnant women perspectives on SARS-COV-2 vaccine: Condensation: Most of Italian pregnant women would not agree to get the SARS-COV-2 vaccine, irrespective of having features of high risk themselves, or being high-risk pregnancies. Am J Obstet Gynecol MFM 2021;3:100352. [PubMed] [CrossRef] 


23. Saccone G, Zullo F, Di Mascio D. Coronavirus disease 2019 vaccine in pregnant women: not so far! The importance of counselling and the need for evidence-based data. Am J Obstet Gynecol MFM 2021;3:100324. [PubMed] [CrossRef] 


24. Stanton T, Bateson D. Effects of the COVID-19 pandemic on family planning services. Curr Opin Obstet Gynecol 2021;33:425–30. [PubMed] [CrossRef] 


25. Brandell K, Vanbenschoten H, Parachini M, Gomperts R, Gemzell-Danielsson K. Telemedicine as an alternative way to access abortion in Italy and characteristics of requests during the COVID-19 pandemic. BMJ Sex Reprod Health 2021 Oct 25:bmjsrh-2021-201281. doi: 10.1136/bmjsrh-2021-201281  [PubMed] [CrossRef] 


26. Stifani BM, Avila K, Levi EE. Telemedicine for contraceptive counseling: an exploratory survey of US family planning providers following rapid adoption of services during the COVID-19 pandemic. Contraception 2021;103:157–62. [PubMed] [CrossRef] 


27. Morra I, Ferrara C, Sglavo G, Sansone A, Saccone G, Perriera L, Di Carlo C. Incidence of uterine rupture in second-trimester abortion with gemeprost alone compared to mifepristone and gemeprost. Contraception 2019;99:152–4. [PubMed] [CrossRef] 


28. Spinelli A, Grandolfo ME. Induced abortion and contraception in Italy. Plan Parent Eur 1991;20:18–9. [PubMed] 


29. Filicori M, Flamigni C. Epidemiology of voluntary abortion in the region of Emilia Romagna and in Italy. Acta Eur Fertil 1980;11:157–65. [PubMed] 


30. Cioffi A. Perspectives of medical abortion in Italy. Sex Reprod Healthc 2020;26:100550. [PubMed] [CrossRef] 


31. Bettarini SS, D’Andrea SS. Induced abortion in Italy: levels, trends and characteristics. Fam Plann Perspect 1996;28:267–71, 277. [PubMed] 


32. Macnaughton H, Nothnagle M, Early J. Mifepristone and misoprostol for early pregnancy loss and medication abortion. Am Fam Physician 2021;103:473–80. [PubMed] 


33. Gragnano E, Esposito G, Ilardi B, Turco M, Verrazzo P, Saccone G. Letter to the Editor: COVID-19 vaccine during pregnancy: it is time to have a fair inclusion of pregnant women in clinical trials. Perinat J 2021;29:274–5. [CrossRef] 


34. Spiniello L, Di Mascio D, Bianco C, Esposito O, Giangiordano I, Muzii L, et al. All we know about COVID-19 in pregnancy: from perinatal to ethical and psychological perspective. Perinat J 2020;28:120–6. [CrossRef] 


35. D’Antonio F, Şen C, Di Mascio D, Galindo A, Viallalain C, Herraiz I; WAPM Working Group on COVID-19. Maternal and perinatal outcomes in women with advanced maternal age affected by SARS-CoV-2 infection (Phase-2): The WAPM (World Association of Perinatal Medicine) Working Group on COVID-19. Perinat J 2021;29:71–8. [CrossRef] 


36. Bojovic N, Stanisljevic J, Giunti G. The impact of COVID-19 on abortion access: insights from the European Union and the United Kingdom. Health Policy 2021;125:841–58. [PubMed] [CrossRef] 


37. Bateson DJ, Lohr PA, Norman WV, Moreau C, Gemzell-Danielsson K, Blumenthal PD, et al. The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries. BMJ Sex Reprod Health 2020;46:241–3. [PubMed] [CrossRef] 


38. Tu P, Li J, Jiang X, Pei K, Gu Y. Impact of the COVID-19 pandemic on sexual and reproductive health among women with induced abortion. Sci Rep 2021;11:16310. [PubMed] [CrossRef] 


39. Kaller S, Muñoz MGI, Sharma S, Tayel S, Ahlbach C, Cook C, Upadhyay UD. Abortion service availability during the COVID-19 pandemic: results from a national census of abortion facilities in the U.S. Contracept X 2021;3:100067. [PubMed] 


40. van Ooijen LT, Gemzell-Danielsson K, Waltz M, Gomperts R. A trans-national examination of the impact of the COVID-19 pandemic on abortion requests through a telemedicine service. BMJ Sex Reprod Health 2021;bmjsrh-2021-201159. [PubMed] [CrossRef] 

	File/Dsecription
	Table 1. Details of the abortions.