Coronavirus disease 2019 impact on abortion care at a Northern California tertiary family planning program

Objective

This study aimed to assess surgical abortion procedures at a Northern California tertiary referral center during the early outbreak (February 2020), the initial surge (March to April 2020), and decline (May 2020) of the coronavirus disease 2019 (COVID-19) pandemic.

Study Design

We accessed a deidentified database that contained patient referral information to extract data by month for February to May in the years 2017 to 2020. We evaluated referring provider or self-referral, procedure indication, gestational age on the procedure day, and COVID test results, when available. We used R (R Core Team, 2020, Vienna, Austria) to calculate Poisson prediction intervals for each month, based on values from 2017 to 2019, to assess whether the monthly 2020 values were significantly different from expected (ie, outside the 95% prediction interval) based on source, referral indication, and gestational age (at 15- and 20-week cutoffs). No institutional abortion access- or provision-related changes occurred during the years evaluated. Our institution did not suggest routine COVID-19 testing for preoperative patients until April 2, 2020, and required testing as of April 13, 2020. The University of California, Davis Institutional Review Board determined this evaluation as exempt.

Results

For the months of February to May, our service received 355, 434, 507, and 555 surgical abortion referrals in the years 2017, 2018, 2019, and 2020, respectively. During these years, we performed 163 (46% of referrals), 203 (47%), 169 (33%), and 235 procedures (42%). The number of referrals and procedures performed fluctuated from month to month and year to year, with an increase in referrals in February and March 2020 compared with previous years, correlating with an increase in the number of procedures in March and April 2020 of 35% to 52% compared with the previous 3 years (Table ). Based on Poisson prediction intervals, the number of procedures in February and May was within the expected range, but March and April represented a significant increase. Most of the procedures we performed were referred from community clinics, and these clinics accounted primarily for the increase in the number of procedures. We identified no significant increase in procedures for any month of 2020 compared with previous years based on referral source. We identified significant increases in March by indication (patient choice only [40 vs mean 25 for 2017–2019] and not for pregnancy loss or anomaly). Procedure volume increased significantly in gestations of 15 weeks or more in March and April 2020 (mean 60 in 2017–2019 vs 97 in 2020; 61% increase), mainly from procedures at 20 weeks or more (mean 26 compared with 63, respectively; 145% increase). Of 105 patients (all in April and May) who had COVID-19 testing, none had a positive result.

Table.

Surgical abortion referrals and procedures in February to May 2020 compared with previous years at a Northern California tertiary referral center

	2017	2018	2019	2020	Poisson prediction intervals
					Mean (2017–2019)	Variance (2017–2019)	Boundsa
Surgical referrals
February	68	118	117	163	101.0	187.0	79, 125
March	93	100	111	157	101.3	82.3	79, 126
April	83	110	137	124	110.0	729.0	87, 135
May	111	106	142	111	119.67	380.3	65, 146
Total	355	434	507	555
Surgical procedures
February	39	49	40	51	42.7	30.3	28, 59
March	46	49	39	62	44.7	26.3	30, 61
April	39	49	49	65	45.7	33.3	31, 63
May	39	56	41	57	45.3	86.3	30, 62
Total	163	203	169	235
Procedures as percentage of referrals	45.9%	46.8%	33.3%	42.3%

Creinin. Coronavirus disease 2019 impact on abortion care at a Northern California. Am J Obstet Gynecol 2021.

^aA value in 2020 outside the bounds indicates statistical significance (unexpected value).

Conclusion

During the initial COVID-19 surge, our Northern California tertiary reproductive health referral center experienced a significant increase in abortion referrals in February and March 2020, correlating with a significant overall increase in procedures during March and April 2020, the initial peak months of COVID-19 cases in the United States. These data come from a region with relatively low COVID-19 infection rates during the months analyzed; it is possible that service availability in areas with higher infection burden was affected differently. The increase in referrals and procedures during the initial surge of this pandemic may just be an extreme of the normal variations we experience from month to month and year to year; we will not be able to discern this limitation until we have data for another 1 to 2 years. At a minimum, for now, we can conclude that the need for tertiary-level abortion care does not decline during the pandemic. Legislation aimed at restricting abortion access during the pandemic are contrary to patient need.