Clinician Perspectives on Ethics and COVID ‐19: Minding the Gap in Sexual and Reproductive Health

Abstract

In the United States, policies and practices enacted in response to the COVID-19 pandemic-such as social dis-tancing, sheltering in place, shifting to telemedicine and limiting care to "essential" procedures-are widening gaps in sexual and reproductive health (SRH) outcomes and access to services. As obstetrician-gynecologists, pediatri-cians and adolescent medicine specialists who are front-line providers of SRH services, we are seeing firsthand the documented decreases in access to SRH education, abortion and contraceptives (particularly long-acting reversible contraceptives, or LARCs), as well as increases in reports of gender-based violence. 1-4 These trends have disproportionately affected minoritized and marginalized groups, including adolescents, people of color, those living in poverty, immigrants and undocumented individuals, and residents of rural areas. 5,6 In this viewpoint, we provide a clinician' s perspective on the gaps in services and outcomes between these and more privileged groups, and make recommendations to narrow these gaps, both now and in the future. In some cases, the gaps in access to SRH services have been an unintended effect of COVID-19-related policies. For example, access to SRH services at federally qualified health centers and community-based clinics has been limited because of budgetary constraints, shortages of personal protective equipment and staff, and the facil-ities' need to care for sicker populations. This loss of access disproportionately affects youth and marginalized populations , who rely on these centers for health care. While the rapid expansion of telehealth has provided access to SRH providers for many individuals with established sources of care or insurance, the increased reliance on this technology has seriously reduced the initiation of LARC methods, which requires an in-person visit with a health care provider. For adolescents, in particular, reduced opportunities for in-person visits threaten to undo the gains made over the past 10 years in offering clients a wider range of contraceptive options, primarily through expanded access to LARCs. 7-9 Moreover, telehealth requires access to adequate and reliable Internet service, which is not available in some rural areas, 10 and many individuals who do not have Internet service at home (because of cost or geography) and had relied on public access points such as libraries or coffee shops no longer have these options available because of pandemic closures and social distancing. 11 Although newer approaches for improving access to contraceptives, such as provision of hormonal methods through pharmacies, apps or telehealth, 12 have the potential to maintain access to contraceptives, these approaches are frequently not available to all, and may worsen disparities in SRH access among specific groups. For example, laws that regulate telehealth, authorize pharmacists to prescribe contraceptives, or permit minors to provide consent and obtain confidential services vary from state to state. In many states, these laws do not specifically allow adolescents to access contraceptives through telehealth, apps or pharmacies. 12,13 For women in rural areas, pharmacy access can be limited even in states with supportive laws. 14 Further gaps in access to SRH services have resulted from the postponement or cancellation of well-woman and well-child visits; in the absence of such visits, many women are not being screened for asymptomatic STIs, abuse, gender-based violence and contraceptive needs. At the same time, shelter-in-place requirements and quarantine restrictions have led to increases in gender-based violence, as individuals in violent or abusive relationships may be unable to leave unsafe homes. 1 The impact of these pandemic-related barriers and outcomes has been exacerbated by the enactment of targeted policies designed to limit women' s ability to obtain SRH services. Abortion, in particular, has been targeted with additional restrictions, creating, for all women, a gap between the services they need and their ability to obtain them. The designation of abortion as an "elective" procedure allowed states that actively restrict abortion to immediately cut off access to this time-sensitive procedure. 15 Our challenge as health care providers is to identify gaps in access that affect-intentionally or not-the SRH care that our patients need, and to advocate for changing policies that exacerbate gaps in access and outcomes. Cataloging (identifying and tracking) gaps will allow us to address barriers in access and worsening disparities in outcomes , as restrictions loosen. During the current pandemic, policymakers, providers and health care system administrators have had to make difficult decisions and confront challenging ethical questions. What is essential care? When are restrictions too restrictive? Which restrictions can be relaxed safely, and when? In making decisions about individual patients, cli-nicians frequently employ a broad, principle-based medical ethics approach to balance autonomy, beneficence and justice. However, in a public health crisis, these principles often conflict with each other, and clear resolution may not exist. As SRH providers, we advocate for a public health ethics approach that combines an underlying respect for