Abstract
Objective
To understand the barriers to abortion in Shanghai during the COVID‐19 pandemic, and to compare pre‐abortion mental health status before and during the crisis.
Methods
In this case–control study, two groups of women seeking abortion (age ≥18 years, pregnancy duration <98 days) were recruited from March to September, 2021 (n = 1070) and from February to April 2022 (n = 625). The evaluation included COVID‐19‐related abortion stress questions, the Symptom Checklist‐90 Revised questionnaire, the Pittsburgh Sleep Quality Index (PSQI), and the Family Environment Scale Chinese version. The researchers conducted interviews and collected questionnaires.
Results
The median pregnancy duration at abortion among women during the pandemic was 65 days, compared with 51 days in the pre‐pandemic group ( P < 0.001). Anxiety and depression symptoms increased during the crisis (P < 0.001). Sleep disturbances were more common. Higher PSQI scores were related to increased anxiety and depression symptoms. A more negative family climate was described during the pandemic.
Conclusion
During the COVID‐19 pandemic, abortion access was delayed and pre‐abortion mental disorders increased. More attention should be paid to the mental health of women seeking abortions, and innovations should be promoted to ensure abortion services without delay.
Keywords: abortion, coronavirus disease 2019, family environment, mental health, sleep disorder
Synopsis
Abortion access was delayed and risk of pre‐abortion mental disorders among women with unintended pregnancies was increased during the COVID‐19 pandemic in Shanghai.
1. INTRODUCTION
Coronavirus disease (COVID‐19) poses an unprecedented health and social crisis, visibly affecting people's lives and inevitably impacting healthcare delivery. Though the omicron strain is less likely to cause severe disease than previous variants, 1 it is still distressing because of the strained healthcare systems, economic uncertainty, and disrupted social connections. There is considerable evidence that uncertainty and isolation during a pandemic can increase anxiety and depression.
In many cases, abortion is a stressful life event that occurs in the context of an unwanted pregnancy, affecting a woman's mental health over a period of time. Most studies have been designed to address post‐abortion mental health issues, and less attention has been paid to the psychological states of women before abortion. When seeking an abortion, psychosocial burden may increase and lead to adverse psychological consequences. 2 A cross‐sectional study conducted in a tertiary hospital in Beijing showed that the magnitude of perceived stress and depression was high among Chinese women seeking abortion. 3 The COVID‐19 pandemic has exacerbated barriers to abortion access in many countries. 4 China's “zero‐tolerance” fight against the virus has effectively restrained the spread of the virus until February 2022, when the extra‐contagious version of omicron shocked Shanghai. There are 12 million women in Shanghai and the pandemic is challenging the city's reproductive healthcare system. As a result, women are likely to experience stress when seeking abortion during the COVID‐19 crisis. However, to the best of our knowledge, there have been no reports on the psychological state of women seeking abortions in the context of the COVID‐19 pandemic. In the present study, we sought to explore whether access to abortion is impeded by restrictive lockdown policies and requirements that are not medically justified after the COVID‐19 outbreak in Shanghai, and to evaluate the COVID‐19‐related mental symptoms of women seeking abortion after the virus pandemic.
Accumulating evidence suggests that sleep deprivation is significantly associated with a higher risk of anxiety and depressive symptoms. 5 , 6 People with poor family environment and low self‐efficacy are more likely to show symptoms of mental illness. 7 , 8 Therefore, comparisons were also made in order to better understand changes in sleep disturbances and family circumstances before and after the crisis for women seeking abortions.
2. MATERIALS AND METHODS
2.1. Participants and procedure
This is a case–control study. Women aged 18 years or older who wanted a surgical or medical abortion because of an unintended pregnancy were registered. One group of women was recruited from March 2021 to September 2021 before the COVID‐19 pandemic in Shanghai. During that period, there were almost no community cases of COVID‐19 in Shanghai, and people's daily life and medical care were largely unaffected. Another subset of participants was collected during the pandemic from February 2022 to April 2022. Upon checking‐in for their abortion counseling, clinic staff asked all women if they wanted to participate in a study on their mental health before abortion. After obtaining informed consent, they were asked to fill out a survey booklet. Sociodemographic characteristics were also obtained, including participants' age, marital status, education, residence, employment status, and income. The gestational age at which the pregnancy was terminated was recorded directly in the abortion registry of our hospital or in a telephone interview (for abortions performed in other hospitals). Eligible participants were: (1) 18 years of age or older; (2) able to read and write Chinese; (3) seeking abortion with confirmed intrauterine pregnancy less than 14 gestational weeks (98 days); (4) making the decision of abortion of their own free will. Individuals who had been infected by COVID‐19 or had a history of mental illness were excluded. In both specific periods, all women who met the criteria and agreed to participate were included in the study. Ethical approval was obtained from the Ethics Committee of the authors' hospital before participants were approached.
2.2. Scales and measurement
Impact of the COVID‐19 pandemic on access to abortion care, specific barriers to abortion care, self‐reported wait to access abortion, and stresses experienced while waiting for abortion were investigated using a questionnaire among women during the COVID‐19 pandemic. Individuals in both cohorts completed the Symptom Checklist‐90‐Revised (SCL‐90‐R), the Pittsburgh Sleep Quality Index (PSQI), and the Family Environment Scale‐Chinese Version (FES‐CV).
The Symptom Checklist‐90 Scale (SCL‐90) is composed of 90 questions and each item has five answer choices using five levels (0–4). 9 A scale score of 2 or more indicates the presence of underlying psychological problems. In the present study, the SCL‐90‐R subscale scores of somatization, interpersonal sensitivity, obsessive–compulsive disorder, hostility, anxiety, depression, and foraging status were investigated.
PSQI measures sleep quality, identifies “good” or “poor” sleepers, and detects the presence of significant sleep disorders. 10 PSQI questions were scored on a scale of 0 (no difficulty) to 3 (severe difficulty), resulting in a score corresponding to the scale area. Scores range from 0 to 21 and the authors suggest that a score above 5 should be considered as a significant sleep disturbance.
The family climate of the pregnant women was measured using the short‐form of FES‐CV, including subscales of cohesion, expressiveness, and conflict, which were closely related to mental symptoms investigated in previous studies. 7 , 11 The scores of conflict were negatively correlated with family environment, whereas the scores of the other two subscales were positively correlated with family environment.
2.3. Statistics
Survey data were manually checked for accuracy and consistency before being exported toSPSS Statistics Server Version 24.0 (IBM) for analysis. Descriptive statistics were used to summarize participant characteristics and survey responses. χ 2 tests were conducted to examine differences in background variables between the groups. Scores of mental health symptoms were counted as continuous variables. Independent t test was used to evaluate the statistical difference between the two groups. Pearson correlation coefficient was used to measure the strength of the linear association between variables. The level for statistical significance was chosen as P values less than 0.05.
3. RESULTS
3.1. Sociodemographic characteristics
A total of 1695 eligible participants who completed the survey were finally included in the present study. Patient demographics are listed in Table 1. The non‐COVID‐19 cohort contained 1070 women aged 18–47 years (median 27 years) and the COVID‐19 group included 625 individuals aged 18–48 years (median 26 years), both with a predominant age group of 20–30 years (66.4% and 63.4%, respectively). The number of married and unmarried individuals was similar in both cohorts. About two‐thirds of the population lived in urban areas (69.63% and 69.12%, respectively) and few women were unemployed (8.22% and 10.40%, respectively) in the two groups. There was no difference between groups in most baseline variables, including age, marital status, residence, education, employment status, and household income. Women from the non‐COVID‐19 group had a median pregnancy duration of 51 days at the time of abortion (range 35–78 days), compared with a median of 65 days (range 45–95 days) for individuals after the COVID‐19 outbreak in Shanghai (P < 0.001). In the non‐COVID‐19 group, 687 (64.20%) participants were less than 50 days pregnant at the time of abortion, and only 138 (12.90%) had a pregnancy duration greater than 70 days. In the COVID‐19 group, 236 (37.76%) women had a pregnancy duration less than 50 days whereas 165 (26.40%) women had a pregnancy duration longer than 70 days.
TABLE 1.
Demographic characteristics of the participants a
| Variables | Before pandemic (n = 1070) | During pandemic (n = 625) | χ 2 | P value |
|---|---|---|---|---|
| Age, years | 27 (18–47) | 26 (18–48) | 4.297 | 0.117 |
| <20 | 56 (5.23%) | 25 (4.00%) | ||
| 20–30 | 711 (66.45%) | 396 (63.36%) | ||
| >30 | 303 (28.32%) | 204 (32.64%) | ||
| Gestational age, days | 51 (35–78) | 65 (45–95) | 114.799 | <0.001 |
| <50 | 687 (64.20%) | 236 (37.76%) | ||
| 50–70 | 245 (22.90%) | 224 (35.84%) | ||
| >70 | 138 (12.90%) | 165 (26.40%) | ||
| Marital status | 0.250 | 0.617 | ||
| Married | 563 (52.62%) | 321 (51.36%) | ||
| Unmarried | 507 (47.38%) | 304 (48.64%) | ||
| Residence | 0.048 | 0.827 | ||
| Urban | 745 (69.63%) | 432 (69.12%) | ||
| Rural | 325 (30.37%) | 193 (30.88%) | ||
| Education | 3.310 | 0.191 | ||
| Primary school | 47 (4.39%) | 18 (2.88%) | ||
| Secondary school | 680 (63.55%) | 517 (82.72%) | ||
| Graduate and above | 343 (32.06%) | 90 (14.40%) | ||
| Employment status | 3.117 | 0.210 | ||
| Employed | 710 (66.36%) | 417 (66.72%) | ||
| Unemployed | 88 (8.22%) | 65 (10.40%) | ||
| Other inactive | 272 (43.52%) | 143 (22.88%) | ||
| Equivalized household income quintiles | 7.177 | 0.127 | ||
| Lowest | 21 (1.96%) | 23 (3.68%) | ||
| Second | 344 (32.15%) | 175 (50.87%) | ||
| Third | 435 (40.65%) | 260 (41.60%) | ||
| Fourth | 219 (20.47%) | 134 (21.44%) | ||
| Highest | 51 (4.77%) | 33 (5.28%) |
Data are presented as median (range) or as number (percentage).
As shown in Tables 2, 476 (76.25%) patients reported that the pandemic made it more difficult to have an abortion because of the lockdown restrictions (26.45%), strained medical resources (35.20%), extra complicated appointment process (32.48%), economic hardship (5.60%), and fear of infection leading to COVID‐19 (32.04%). One hundred and three (16.50%) participants worried about missing out on a medical abortion, 364 women (58.24%) were concerned that the delay to abortion care may give rise to increased heath harm, and 325 (52.00%) of them feared inadequate post‐abortion care.
TABLE 2.
Survey reports about impact of COVID‐19 pandemic on abortion care acquisition a
| Survey question | |
|---|---|
| Has the COVID‐19 outbreak made it more difficult for you to seek an abortion? | |
| Yes | 476 (76.25%) |
| No | 149 (23.75%) |
| Do you think you waited for an abortion care for a longer time than normal because of COVID‐19 pandemic? | |
| Yes | 521 (83.4%) |
| No | 104 (16.6%) |
| What makes abortion more difficult to get in the COVID‐19 pandemic | |
| Cannot go the hospital because of the lockdown restrictions in the community | 165 (26.45%) |
| Hospital closures or fewer appointments | 220 (35.20%) |
| The procedure for abortion appointment is more complicated than it used to be | 203 (32.48%) |
| Do not have enough money to pay because of lost or decreased income | 35 (5.60%) |
| Fear of coming to the hospital and being infected | 136 (21.76%) |
| Fear of taking public transport and exposure to the virus | 64 (10.24%) |
| Ways in which COVID‐19 pandemic has made you worry when waiting for abortion | |
| Miss the right time for medication abortion | 103 (16.50%) |
| Delay of abortion which may lead to increased injuries | 364 (58.24%) |
| Lack of access to post‐abortion care | 325 (52.00%) |
Data are presented as number (percentage).
3.2. Psychiatric symptoms assessment
Compared with women before the COVID‐19 pandemic, individuals during the pandemic exhibited a significant increase in depression (P < 0.001), anxiety (P < 0.001), and foraging status (state of diet) (P = 0.013) when seeking abortion. No significant differences were found in somatization, obsessive‐compulsion, interpersonal sensitivity, and hostility between the women before and during the COVID‐19 pandemic (Table 3). The average SCL‐90‐R depression score was 1.533 ± 0.650 with the overall rate of depression (score ≥2) being 20.96% in the COVID‐19‐related group, compared with 7.48% in the non‐COVID‐19 group. The incidence of anxiety symptoms in women seeking an abortion after the disease outbreak was 17.80% with a mean score of 1.368 ± 0.496, compared with 7.10% in the population before the pandemic.
TABLE 3.
Comparison of mental health symptoms and sleep quality in samples before and during the COVID‐19 pandemic a
| SCL‐90‐R and PSQI scores | Before pandemic (n = 1070) | During pandemic (n = 625) | Difference test t | P value |
|---|---|---|---|---|
| Somatization | 1.442 ± 0.324 | 1.426 ± 0.354 | 0.973 | 0.331 |
| Obsessive‐compulsion | 1.425 ± 0.374 | 1.436 ± 0.399 | −0.573 | 0.567 |
| Interpersonal Sensitivity | 1.312 ± 0.386 | 1.327 ± 0.408 | −0.750 | 0.454 |
| Anxiety | 1.248 ± 0.356 | 1.368 ± 0.496 | −5.744 | <0.001 |
| Depression | 1.331 ± 0.378 | 1.533 ± 0.650 | −8.088 | <0.001 |
| Hostility | 1.318 ± 0.434 | 1.338 ± 0.485 | −0.888 | 0.374 |
| Foraging status | 1.424 ± 0.395 | 1.475 ± 0.444 | −2.479 | 0.013 |
| Sleep disorder | 5.910 ± 2.595 | 6.594 ± 2.796 | −5.089 | <0.001 |
Abbreviations: PSQI, Pittsburgh Sleep Quality Index; SCL‐90‐R, Symptom Checklist‐90 Revised questionnaire.
Data are presented as mean ± standard deviation.
3.3. Sleep problems evaluation
As shown in Table 3, the average PSQI score of women seeking abortion during the pandemic (6.594 ± 2.796) was significantly higher than that before the pandemic (5.910 ± 2.595) (P < 0.001). Compared with the pre‐COVID‐19 group, the percentage of participants with a PSQI score of greater than 5 was significantly higher in the post‐COVID‐19 group (61.60% vs. 53.8%; P < 0.001), indicating that the COVID‐19 pandemic disturbed the sleep of women seeking abortions. Higher PSQI scores were related to increased anxiety and depression symptoms (r = 0.289, P < 0.001; r = 0.265, P < 0.001) (Table 5).
TABLE 5.
Relationship between symptoms of mental disorders and family environment and sleep disorders a
| Symptom | Cohesion | Conflict | Sleep disorder | |||
|---|---|---|---|---|---|---|
| r a | P value | r a | P value | r a | P value | |
| Anxiety | −0.324 | <0.001 | 0.250 | <0.001 | 0.289 | <0.001 |
| Depression | −0.309 | <0.001 | 0.255 | <0.001 | 0.265 | <0.001 |
R is Pearson's correlation coefficient.
3.4. Family environment examination
The results showed that there were significant differences in FES‐CV scores between groups before and during the COVID‐19 pandemic in Shanghai (Table 4). During the pandemic, families with pregnant women seeking abortion had higher cohesion scores (P = 0.005) and lower conflict scores (P = 0.013). The symptoms of anxiety and depression were negatively correlated with cohesion dimension (r = −0.324, P < 0.001; r = −0.309, P < 0.001), and positively correlated with the dimensions of conflict in the FES‐CV scale (r = 0.250, P < 0.001; r = 0.255, P < 0.001) (Table 5).
TABLE 4.
Comparison of family environment patterns in the samples before and during the COVID‐19 pandemic a
| FES scores | Before pandemic (n = 1070) | During pandemic (n = 625) | Difference test t | P value |
|---|---|---|---|---|
| Cohesion | 7.640 ± 1.929 | 7.346 ± 2.280 | 2.834 | 0.005 |
| Expressiveness | 5.900 ± 2.027 | 5.770 ± 2.098 | 1.261 | 0.207 |
| Conflict | 1.877 ± 1.654 | 2.093 ± 1.830 | −2.495 | 0.013 |
Abbreviation: FES, Family Environment Scale Chinese version.
Data are presented as mean ± standard deviation.
4. DISCUSSION
At present, less attention has been paid to the psychological state of women before induced abortion. Challenges have been brought by the COVID‐19 pandemic in terms of access to abortion, so the risk of mental illness in women with unintended pregnancies may increase. The current study is the first to report the impact of the COVID‐19 pandemic on abortion access in Shanghai, and to focus on the mental health of pregnant women seeking abortions during the COVID‐19 pandemic. Psychopathological symptoms were compared between two groups of women seeking abortions before and during the COVID‐19 pandemic.
A large proportion of women reported having difficulty accessing abortion services and waiting longer than normal for abortion care because of the COVID‐19 pandemic. Not surprisingly, women during the COVID‐19 pandemic in Shanghai had significantly higher gestational ages at the time of abortion than before, suggesting a delay due to the pandemic. The coronavirus lockdown rules strained the medical infrastructure with fewer abortion providers, extra complicated appointment processes, and the fear of infection acting as the greatest barriers to abortion access. Financial hardship is not the main concern, because most people in Shanghai have healthcare insurance, which covers abortion expenses.
Abortion care is a highly time‐sensitive procedure and patients need timely access. The frequency and severity of abortion complications depend on gestational age at the time of abortion and the method of abortion. The risk of complications for the woman increases with advancing gestational age. 12 , 13 A delay of service may increase the risks and result in long‐term negative consequences for women and families. In China, it is not permitted to take tablets (mifepristone and misoprostol) once your pregnancy has passed 49 days. Therefore, if access to medical abortion is delayed, a large number of women who plan to undergo it will lose the opportunity.
Abortion is an essential health service that should continue uninterrupted during the pandemic. As the pandemic continues to challenge health systems' capacity for delivering essential services, the government and providers need to adapt quickly to sustain abortion services. Countries with no policy or protocol changes to facilitate access also reported difficulties in abortion access during the COVID‐19 crisis. 4 , 14
According to the survey report, the fear of missing the appropriate time for a medical abortion or increasing health harm due to delayed abortion has placed a psychological burden on women during the pandemic. In addition, concerns about inadequate post‐abortion care during the pandemic have added to women's psychological distress. In the present study, women who sought abortion during the COVID‐19 pandemic presented more psychopathological symptoms than the group of women who accessed abortion care before the start of the pandemic. Specifically, the pandemic was responsible for a sharp increase in anxiety and depression symptoms among women before abortion. The incidence rate of anxiety and depressive symptoms increased 2.5‐fold and 2.8‐fold, respectively.
A number of previous studies have demonstrated that the COVID‐19 pandemic can impact the mental health of different populations. 15 , 16 Mental health disorders such as anxiety, depression, loneliness, and post‐traumatic stress symptoms are highly prevalent. 16 , 17 , 18 , 19 Research has shown that women have higher prevalence of anxiety, depression, and stress than men during the COVID‐19 pandemic. 20 , 21
Sleep disorders have been linked to depression, anxiety, bipolar disorder and other psychiatric disorders. 22 , 23 During the COVID‐19 pandemic, the frequency of sleep disorders has risen among women requiring abortions. Our data also revealed a significant relationship between sleep disturbances and anxiety/depression symptoms. These results confirm the impact of the COVID‐19 pandemic on pre‐abortion mental health from another perspective.
Abortion is a traumatic event in a woman's life. Family support is an important protective factor for women with unwanted pregnancies and can prevent adverse psychological outcomes in this population. The quality of family relationships, including social support and stress, can affect a woman's mental health. 24 The three subscales of FES‐CV applied in the present study refer to family relationships. However, the COVID‐19 pandemic and the associated societal changes have resulted in lifestyle changes and reduced resources, so increasing the perceived stress of most families and affecting family relationships. In our study, family cohesion decreased and family conflict increased during the pandemic, suggesting a compromised family environment, which was associated with increased anxiety and depressive symptoms among women seeking abortions during the crisis.
There is a limitation to the present study, as it included only women who made it to hospitals and finally obtained abortions. Women who were temporarily unable to get an appointment may be experiencing even more serious emotional disturbance. Nevertheless, the present study drew on first‐hand experience as well as scholarly research to shed light on how COVID‐19 has impacted an abortion care service in Shanghai, and paid close attention to the mental health state of women with unintended pregnancies when seeking for abortion during the crisis.
The findings underscore that women who have unintended pregnancies and their families need more support and assistance today, during the COVID‐19 pandemic, than ever before. The COVID‐19 pandemic has exacerbated barriers to access, thereby preventing many women from terminating unwanted pregnancies. Some providers have innovated to promote telemedicine and self‐managed abortion solutions, even extending the gestational age limit for home medical abortion from 7 to 9 weeks. During the pandemic, pharmacy access to prescribed mifepristone and misoprostol was permitted and drugs could be delivered by mail in some countries/regions. 20 Furthermore, there is an urgent need to for a quick response to provide reliable information and emotional support to help women with unintended pregnancies to cope with the high levels of anxiety and distress caused by uncertainty and stress during the COVID‐19 pandemic.
AUTHOR CONTRIBUTIONS
The study was conceived and designed by YL and LS; data were acquired by ZZ, XW, and JZ; data were analyzed and interpreted by ZZ, WW, JZ, and YL; writing, review, and/or revision of the manuscript were performed by ZZ, YL, and LS.
CONFLICT OF INTEREST
The authors have no conflicts of interest to declare.
ACKNOWLEDGMENTS
The present study was supported by the National Natural Science Foundation of China (Grant no. 82072868).
Zhang Z, Wang X, Wang W, Zhang J, Shan L, Li Y. The impact of the coronavirus disease 2019 pandemic on abortion access and pre‐abortion mental health in Shanghai. Int J Gynecol Obstet. 2022;00:1‐7. doi: 10.1002/ijgo.14516
Zhifang Zhang and Xiaoyun Wang contributed equally to the present study.
Liyun Shan and Yanli Li are also equal contributors to this study.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
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Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.