Abortion and the COVID-19 pandemic: insights for Latin America Aborto e a pandemia da COVID-19: lições para América Latina Aborto y pandemia de COVID-19: reflexiones para Latinoamérica

The COVID-19 pandemic may accentuate existing problems, hindering access to legal abortion, with a consequent increase in unsafe abortions. This scenario may be even worse in lowand middle-income countries, especially in Latin America, where abortion laws are already restrictive and access to services is already hampered. Our objective was to understand how different countries, with an emphasis on Latin Americans, have dealt with legal abortion services in the context of the COVID-19. Thus, we conducted a narrative review on abortion and COVID-19. The 75 articles included, plus other relevant references, indicate that the pandemic affects sexual and reproductive health services by amplifying existing problems and restricting access to reproductive rights, such as legal abortion. This impact may be even stronger in lowand middle-income countries, especially in Latin America, where access to legal abortion is normally restricted. The revision of sources in this article underlines the urgent need to maintain legal abortion services, both from women’s perspective, in support of their reproductive rights, but also from that of the international commitment to achieving the Millennium Development Goals. Thereby, Latin American countries must place reproductive rights as a priority on their agendas and adapt legislation to accommodate alternative models of abortion care. Furthermore, our results underscore the need for clear information on the functioning of sexual and reproductive health services as essential for understanding the impact of the pandemic on legal abortion and to identify the groups most affected by the changes. Abortion; COVID-19; Legal Abortion; Reproductive Rights Correspondence F. B. Pilecco Universidade Federal de Minas Gerais. Av. Prof. Alfredo Balena 190, sala 803, Belo Horizonte, MG 30130-100, Brasil. flaviapilecco@yahoo.com.br 1 Universidade Federal de Minas Gerais, Belo Horizonte, Brasil. 2 Rede CoVida – Ciência, Informação e Solidariedade, Salvador, Brasil. 3 Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brasil. 4 Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brasil. 5 Escola de Nutrição, Universidade Federal da Bahia, Salvador, Brasil. This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited.


Introduction
Cad. Saúde Pública 2021; 37(6):e00322320 trafficking networks 27 . Acquisition from such illicit sources is not always accompanied by correct information on the use of misoprostol. Therefore, the substitution of invasive methods is not equal for all women, thus reproducing existing inequalities of class and race in access to the medicine and to the information necessary for its proper use 28 .
Given the above, our goal in preparing this article was to understand how different countries, with an emphasis on Latin America, have dealt with legal abortion services in the context of the COVID-19 pandemic.
The review focused on countries in Latin America; however, it adopted a broader and comparative approach, to contemplate what has been done in other countries regarding the abortion services during COVID-19 times. We limited the search to studies published from 2020 until March 10 th 2021. Original and review articles, comments, letters to the editor, and opinion articles were included.
All articles relevant to the topic were read in full and included in this review. Due to the scarcity of studies on abortion services in Latin America, another survey of articles was conducted on Google Scholar (https://scholar.google.com), which included the names of Latin American countries, abortion (in each country's official language) and COVID-19. Finally, documents from the gray literature and from the websites of multilateral organizations working on the theme of abortion, such as WHO, UNFPA, Ministries of Health of Latin American countries, the Guttmacher Institute, and other nongovernmental organizations (NGOs) aimed at to sexual and reproductive health, were included.

Results and discussion
The final search resulted in 668 studies (LitCovid -128; GIM -15; BVS -422; JSTOR -103), of which 111 were excluded because of duplicates. Of the remaining 557, seven articles were excluded due to linguistic reasons (four were written in Chinese, one in Dutch, one in German and one in Russian), eleven because they were studies conducted in animals (wrong population), and nine because they were a wrong publication type (appendices, annexes, notes, references). Of the 530 remaining, 248 were on the effects of COVID-19 on health, on health services and the treatments used to fight the disease, and 20 were on testing for COVID-19. In total, 54 papers focused on COVID-19 and pregnancy or the risk of transmission of the disease through abortion, 11 on the effects of the disease on the fetus/child, and eight on other issues on sexual and reproductive health. Twenty-one studies were excluded because they focus on spontaneous abortion and seven because they focused on the history of abortion/abortion before the pandemic/men's role in abortion/post-abortion infections. Other 82 articles were excluded because they thematized issues unrelated to abortion in the days of COVID-19. Finally, 77 articles were read in full, from which 75 were included in this review (exclusions were due to the articles being clinical reports of abortion during the pandemic, not addressing health services) ( Figure 1).
Although it is a narrative review of the literature, this article has the merit of the breadth of the search process, which included, besides the strategy presented here, complementary searches on Google Scholar, gray literature and on multilateral organizations websites.
In what follows, we present an overview of what has been produced about the effect of the pandemic on abortion services, in general, and, more specifically, in Latin America.

The COVID-19 pandemic and legal abortion services worldwide
The COVID-19 pandemic has exposed the vulnerability of abortion services worldwide. Although threats to reverse legalization and thereby to restrict access to safe abortion are neither new nor limited to the context of the pandemic, they are of greater concern under the current circumstances, in which women are even more exposed to unintended pregnancy.
Supporters of the closure of legal abortion services base their argument on the scarcity of human and financial resources caused by the pandemic. They argue that abortion is an elective procedure and that equipment and resources may be better allocated. However, these points are fallacious. Regarding the allocation of resources, surgical abortion requires minimal equipment and, in most cases, it does not require hospitalization, since it may be performed in extra-hospital settings, such as in health clinics. Moreover, medical abortion may take place at home (not requiring, in general, the use of personal protective equipment (PPE) 14,29,30 . The maintenance of pregnancy, in turn, implies a broad use of these resources during prenatal, delivery, and puerperium care 14,29 .
The understanding that, when not practiced therapeutically, abortion is an elective procedure, contradicts guidelines and the positions expoused by experts, and public health organizations 32,33 . The term "elective", in general, is used for health procedures that can be scheduled, planned and, if necessary, postponed, but never canceled. In the context of the COVID-19 pandemic, it makes sense for elective procedures to be postponed and performed when there is greater security. In many Latin American countries, elective procedures are performed in hospitals, in a scheduled and planned way; however, this is not the case of abortion, which, together with prenatal, childbirth and puerperium care, is time-dependent. As reproductive rights, these procedures must be guaranteed. In the specific case of abortion, postponement implies the following: (i) increased procedural complexity; (ii) greater risks associated with women's physical and mental health; (iii) higher costs for the health system; and (iv) making it unfeasible, due to legal and ethical impediments, depending on the state or country 14,32,34 .
Lawmakers in countries and states with more conservative views on abortion have used pandemic containment measures to restrict access to these services. Some countries did this through legal loopholes such as in several US states 14,16,30,35,36,37,38 . Others, such as Italy 39,40 and India 41 , restricted access by reducing the supply of services and diverting professionals to assist patients with COVID-19. Malta, for example, with one of the most restrictive abortion laws in Europe, made it even more difficult by banning flights, thus preventing women from seeking abortion in other countries or Cad. Saúde Pública 2021; 37(6):e00322320 receiving abortion pills in the country 42 . And other countries, like Poland 42 , tried unsuccessfully to pass laws banning abortion in the country.
The consequences of interrupting the provision of abortion services will be disastrous in both the short and long terms. It will be even worse to the most vulnerable women -black, indigenous, Latin, immigrants, especially those without documents, minors, people with some type of disability, women in rural contexts, and victims of intimate partner violence 43,44 -who will suffer the consequences of this curtailing of services. Finding access to the procedure impeded, they will experience an increase in cost and risk, or even need to resort to unsafe abortion 30,35,45,46 . These barriers to access can also compel many women to continue with a pregnancy that, for various reasons, they had decided to terminate. Studies found that women that carry on with unintended pregnancies report worse levels of physical and mental health, greater economic restrictions, and more violence committed by the intimate partner than women who access abortion 47,48,49 .  Despite the setbacks, some proposals to enable the continuity of abortion care have been made and adopted. For pregnancies up to 12 weeks, self-managed medical abortion is indicated, with the use of mifepristone and misoprostol, without prior testing, with guidance and advice provided via telehealth (through telephone or internet) 31,5,51,52,53,54,55 . A recent systematic review published in Cochrane indicated that self-administration of drugs, if well targeted, is as effective for the completion of abortion as the surgical procedure performed by a professional 56 .
Moreover, some authors argue that the use of self-managed medical abortion challenges hierarchies of power and truth constituted in medicine, since it centers abortion on women and, therefore, consists of an innovative form of care 53,54 . There is also the proposal of protocols that do not require ultrasound and pre-abortion blood tests. These protocols are based on evidence that clinical outcomes are not improved by performing these tests 57 . The use of these new protocols for self-managed medical abortion is indicated in the absence of risk of ectopic pregnancy, if the woman is reasonably sure of the date of her last menstruation, is not using hormonal contraception, has regular menstrual cycles, and has no other contraindications. Otherwise, the use of ultrasound is still recommended 34 . However, there is no proposed protocol for pregnancies that are over 12 weeks. When surgical abortion is the only option (either due to advanced gestational age, a lack of privacy at home, or the threat of domestic violence), unnecessary contact in health services should be avoided, with the provision of pre-and post-procedural counseling via telehealth, pre-procedure symptom tracking, restriction of the number of people present in the procedure room, adequate use of PPE, and decontamination of the post-procedure site. In such cases, the use of general anesthesia is best avoided, thus reducing the need for mechanical ventilation (eliminating the generation of aerosols), requiring fewer professionals, and allowing greater distance in the procedure room 11,34,43 .
Some countries, such as the United Kingdom 58,59,60 , acting on the basis of the understanding that it is important to maintain access to abortion services and ensure that the procedure is performed at the right time, encouraged the use of remote consultations during the pandemic. Others, such as Finland and Scotland, extended the period in which medical abortion is permitted 61 . France not only maintained access but encouraged remote consultations and extended the period for abortion 61,62 . In addition to establishing new modalities of access to abortion as part of the response to the pandemic, the process of providing legal abortion services has been accelerated in other countries, for example in Northern Ireland (excluded from the United Kingdom Abortion Act until 2019). Thus, women do not need to travel to England in search of this service, as they did previously, reducing the risk of contagion by COVID-19. Besides, in March 2020, the New Zealand parliament decriminalized abortion after decades of campaigns 63 .

Legal abortion and COVID-19: Latin American specificities
Few articles on Latin America address the changes and continuities in abortion services due to the COVID-19 pandemic. Most of the information available comes either from feminist activists and NGO working with sexual and reproductive health or from the governments of the countries themselves. In the region, the pandemic poses an additional obstacle to the already difficult task of obtaining legal and safe abortion 64 . The Brazilian NGO Gênero e Número pointed out that, while governments in Argentina, Mexico, and Colombia aligned themselves with the WHO, which declared that sexual and reproductive health services are essential during the pandemic, Chile and Brazil did not position themselves 5 .
In Argentina, in addition to legal abortion being treated as an essential service in times of a pandemic, a free telephone service was available to answer questions from users and receive complaints about provinces that have not maintained it. In the Mexican capital, where abortion is legalized in any situation until the 12th gestational week, access to teleconsultations was expanded and the use of medical abortion was privileged, to reduce invasive and face-to-face procedures. In Colombia, the government guaranteed the continuity of voluntary abortion services 5 , and the NGO "Oriéntame" created a consultation service via telephone and WhatsApp to guide women on performing a self-managed medical abortion, within the situations permitted by law. In these cases, medication is sent by mail 65 .
However, the media and feminist organizations have reported that women are experiencing difficulties in accessing sexual and reproductive health services, especially for legal abortion. Contracep-Cad. Saúde Pública 2021; 37(6):e00322320 tion acquisition has been hampered by distance measures in Honduras and shortages in Guatemala and especially in Chile, in which the access to misoprostol has also been hindered 66 . In Mexico City, conservative organizations have been collecting signatures requesting the closure of abortion clinics during the pandemic. In Argentina, access to legal abortion also appears to be suffering from the effects of the health crisis 67 . Nevertheless, this situation may change with the recent decriminalization and legalization of abortion, approved by the Chamber of Deputies and the Senate 68 . In Colombia, activists fear that restrictions on displacement will further hamper access to legal abortion, which, even before the pandemic, was already limited 5 . This difficulty in carrying out a legal abortion provided by the state is reflected in the increased demand for feminist organizations. Moreover, these restrictions tend to be even greater among Venezuelan migrants living in Colombian territory. In Bolivia, legal terminations of pregnancy and post-abortion medical care decreased due to quarantine 5 . However, according to the NGO Ipas -Health. Access. Rights., in this country, searches for information on medical abortion, though not allowed by law, have increased 13 . In Ecuador, feminists reported that, even under normal conditions, access to legal abortion had been hampered and that this situation worsened after the onset of the pandemic 5 .
In Brazil, the Ministry of Health was slow to take an official position on sexual and reproductive health. In Technical Notes, care for women during the COVID-19 pandemic was to be reduced to the pregnancy-puerperal cycle, excluding contraception and abortion. On May 1 st 2020, the Ministry of Health issued another Technical Note recognizing sexual and reproductive health services, including legal abortion, as essential. This document reinforced guidelines in the Policy of Comprehensive Care for Women's Health and reiterated the importance of continuing the services already provided 69 . However, three days later, after an intervention by higher echelons of the federal government, the Brazilian Ministry of Health removed the Note. This episode culminated in the dismissal of the Ministry's coordinators of Women's and Men's Health. Thus the Brazilian government, which staunchly opposes women's reproductive rights, reaffirmed its conservative position. In response, several civil society organizations have lobbied against the dismissals and the withdrawal of the Note, and reinforced the importance of maintaining sexual and reproductive health services.
The Pérola Byington Hospital, a reference institution for legal abortion in Brazil's most populous megalopolis, São Paulo, suspended the procedures from March 26 th to 30 th , 2020, to redirect efforts to confront COVID-19. Assistance was resumed after intervention by the State Public Prosecutor's Office and the Public Defender's Office of the State of São Paulo. However, a survey conducted by the NGO ARTIGO 19, the Az Mina magazine, and the Gênero e Número webpage pointed out that this was not an isolated situation. Abortion services in the country were admittedly scarce even before the pandemic, concentrated in large centers, and had functional problems 18 ; of the 76 hospitals that actually reported providing abortions in 2019, only 55% were in operation during the pandemic 70 . Recently, the country experienced an emblematic situation, when a ten-year-old child, who had been repeatedly raped since the age of six, had to go to court to obtain access to the abortion that was her legal right. Her case fits into two situations in which abortion is allowed by law since 1940: in the case of rape, and of risk of life to the pregnant woman. In addition to this unnecessary recourse to an injunction, the child had to travel more than 2,000 kilometers to obtain the procedure, since the nearest legal abortion service refused to perform the procedure, alleging technical restrictions. In a further breach of her rights, her private data was exposed on social networks and, as a result, her access to the health service where she would obtain the procedure was hampered by religious extremists, who picketed the hospital 71 .
This case exposes the difficulties faced by Brazilian and Latin American girls and women seeking access to reproductive health. Notwithstanding legal guarantees, abortion is far from accessible to women, who are often forced to carry on with an unintended pregnancy, even when it is a result of violence. The State, by failing to ensure access to a constitutional right, engenders institutional violence against girls and women. Moreover, although constitutionally Latin American countries proclaim themselves secular, religious influence on state actions is clearly present. In response to the huge public outcry over the case of the pregnant ten-year-old rape victim and on the eve of the Supreme Federal Court's judgement of the Allegation of Breach of Fundamental Precept (ADPF) 442, which could allow abortion at the request of the woman until the 12th gestation period, the Brazilian Ministry of Health issued Ordinances n. 2,282/2020 72  sures to hinder women's access to sexual and reproductive health services, aiming to discourage them from having abortions. Ordinance n. 2,282/2020 intended to force health professionals to notify the police authority of cases of rape, contrary to the Brazilian Ministry of Health's own previous technical standard, as well as to inform women of any risks related to abortion and to offer them the possibility of visualizing the fetus or embryo through ultrasound. Ordinance n. 2,561/2020, however, revoked the obligation to offer fetus visualization, but maintained the other instructions.
The strategies adopted to facilitate access to abortion in cases provided for by law in high income countries and countries in Latin America encounter other legal and operational barriers. In Brazil, for example, attention to abortion in the public system occurs in maternity hospitals, where it is difficult to alter entrenched models of abortion care. Another difficulty is the ban on the marketing of mifepristone 74 and the restriction of misoprostol to hospital use 75 , which prevents self-induced medical abortion at home. There is evidence of the lack of this medication, the use of which is not restricted to abortion, in the public network of the country even before the pandemic 76 . Finally, unequal access to digital technologies limits the offer of distance care, making those belonging to more vulnerable groups and especially poorer women need to expose themselves to the risk of contracting COVID-19 in the search for face-to-face assistance. In this context, partnerships with local health promoters, peer educators, hotlines, and, in the case of Brazil, with community health agents, could be useful to support medical abortion in the community 7 .

Conclusions
In the pandemic scenario of COVID-19, women are seeing their reproductive rights threatened by the action of States, with a reduction in services and supplies related to reproductive health, especially legal abortion. Despite being signatories to the final declarations of World Conferences on Women and despite having adopted the Human Rights framework in the formulation of their women's health policies, several Latin American countries do not use the guidance these documents provide to shape the daily practices of their health institutions.
In Latin America, the adaptations to face restrictions imposed by COVID-19 adopted in other countries have encountered additional obstacles, since Latin American countries, in general, have a more conservative and restrictive position regarding to abortion. In times of a pandemic, these restrictions are even more pronounced. In the region, the scenario has been marked by most government's lack of positioning about the importance of maintaining these services. The restrictions imposed on abortion therefore imply an increase in social and racial inequality as a result of the way governments face the pandemic 30 . Black women in a situation of social vulnerability, notably the young and low-income, who are already excluded from so many other constitutional rights, will seek unsafe alternatives alone and unsupported and often pay with their own lives.
At the time of the writing, the data available on legal abortion services in Latin America was insufficient to provide a picture of the effect of the pandemic on reproductive outcomes. Investigations should monitor this effect in the long term, especially given the possibility of the occurrence of several waves of COVID-19. Besides, these investigations should not only indicate the magnitude of the reduction in access to legal abortion but also uncover which groups are most affected.
Adapting to the new demands on sexual and reproductive health resulting from the pandemic is urgent. Countries must revise their legislation to reduce legal and access barriers, such as the requirement for a prescription for the purchase of abortion pills; eradicate censorship of abortion information available online; promote interventions to reduce stigma regarding abortion; and increase access to and the quality of abortion and post-abortion services 54 . Otherwise, women that have the right to access legal abortion services will be left unattended, searching for unsafe abortion as their only recourse. In this context, if service care for women in situations of abortion is not maintained and reinforced, maternal mortality is likely to increase significantly, in addition to the increase in deaths due to COVID-19, which makes the achievement of the Sustainable Development Goals even more difficult.
Cad. Saúde Pública 2021; 37(6):e00322320 Contributors F. B. Pilecco and G. M. S. Menezes contributed in the study conception and design and analysis or interpretation of data, drafted the manuscript, approved its final version, and agreed to be accountable for all aspects of the article, ensuring that questions related to the accuracy or integrity of any part of the paper were investigated and resolved. C. A. McCallum contributed in the analysis or interpretation of data, reviewed the manuscript critically, approved its final version, and agreed to be accountable for all aspects of the article, ensuring that questions related to the accuracy or integrity of any part of the paper were appropriately investigated and resolved. M. C. C. Almeida, F. J. O. Alves, A. S. Rocha, N. Ortelan and L. Gabrielli contributed in the study conception and design, reviewed the manuscript critically, approved its final version, and agreed to be accountable for all aspects of the article, ensuring that questions related to the accuracy or integrity of any part of the paper were appropriately investigated and resolved.