Rethinking "Elective" Procedures for Women's Reproduction during Covid-19.

Common hospital and surgical center responses to the Covid-19 pandemic included curtailing "elective" procedures, which are typically determined based on implications for physical health and survival. However, in the focus solely on physical health and survival, procedures whose main benefits advance components of well-being beyond health, including self-determination, personal security, economic stability, equal respect, and creation of meaningful social relationships, have been disproportionately deprioritized. We describe how female reproduction-related procedures, including abortion, surgical sterilization, reversible contraception devices and in vitro fertilization, have been broadly categorized as "elective," a designation that fails to capture the value of these procedures or their impact on women's overall well-being. We argue that corresponding restrictions and delays of these procedures are problematically reflective of underlying structural views that marginalize women's rights and interests and therefore threaten to propagate gender injustice during the pandemic and beyond. Finally, we propose a framework for triaging reproduction-related procedures during Covid-19 that is more individualized, accounts for their significance for comprehensive well-being, and can be used to inform resumption of operations as well as subsequent restriction phases.

Essay

In mid‐March 2020, the U.S. Centers for Medicare & Medicaid Services called for curtailing “non‐essential adult elective medical and surgical procedures” to conserve resources and support “flattening the curve” of Covid‐19 infections. State‐and‐hospital‐specific policies followed, ranging from recommendations to outright mandates that elective procedures be canceled or postponed. Although the term “elective” is open to multiple interpretations, decisions about how to adjust the provision of procedural services during the pandemic have largely turned on implications for physical health and survival.

Reproduction‐related surgical procedures such as abortion, surgical sterilization, and in vitro fertilization (IVF) have implications for physical health, but they also advance other important aspects of well‐being, including self‐determination, personal security, economic stability, equal respect, and the creation of meaningful social relationships. Because Covid‐19 surgical cancelation policies have relied so heavily on the single criterion of physical health impact, they deprioritize reproduction‐related procedures. Many reproduction‐related procedures have been designated as elective, resulting in restriction of at least some abortions, surgical sterilizations, and assisted reproductive procedures during the pandemic.

Categorizing procedures as necessary or as elective exclusively in terms of how they promote physical health fails to capture the value of these procedures and may propagate gender injustice. A new framework based in a broader understanding of well‐being would be fairer and more respectful of women in the near term, provide conceptual basis for the prioritization of reproduction‐related procedures in recent guidance for resuming procedures, and perhaps promote women's rights and interests in the post‐Covid era.

The Right to Not Reproduce

Procedures instrumental to the right not to reproduce have been affected by the public health need during Covid‐19 to delay or cancel elective medical care, including abortions and tubal ligations. Calling abortions “elective” is not new to the period of this pandemic, however. The designation has been used to marginalize and delegitimize abortion as a mere matter of optional, personal preference (“choosing” to have an abortion), in contrast to a profoundly consequential decision informed by major life‐affecting considerations. This label has its roots in the days before abortion was legal in the United States, when hospital committees had to adjudicate between “therapeutic” abortions that could be performed legally and “elective” abortions that could not.

There are some cases in which abortion is performed for the immediate physical health of a person. Many abortions, though, are indicated for reasons that less directly affect physical health yet have a foundational impact on a person's overall well‐being. Timely access to abortion is critical to a woman's exercise of self‐determination over the course of her life and to her closely connected interest in controlling if, when, and how she has children. For some women, economic stability for themselves and existing children as well as mental well‐being hang in the balance. Access to abortion, already compromised in many states by restrictive state laws, has been further destabilized by inconsistencies in Covid‐19 responses across health systems and states.

For example, at least eight states in which abortion is particularly politically fraught have capitalized on the proscription of elective surgeries to issue legal injunctions specifically restricting abortions, threatening potential criminal charges and fines for those who continue services. Meanwhile, medical professional societies have taken a stand against the cancelation of abortion services during Covid‐19, asserting that the procedures are “essential and time‐sensitive.” The defense of access to abortion during the pandemic by the American College of Obstetricians and Gynecologists and others reveals an explicit appreciation for the impact of abortion on well‐being beyond health. Abortion providers are working to expand telemedicine use for medical abortions, an option that is theoretically ideal in the pandemic setting yet logistically challenging due to existing policy. Several organizations have mounted legal counterclaims to block the statewide bans. As legal battles have been playing out in court, however, women's well‐being has suffered. Abrupt changes in services have caused some to miss a critical window for getting an early abortion—or even to lose a chance to get one at all—and have imposed the burden of traveling perhaps hundreds of miles to seek care out of state at a time when travel risks are increased.

Like abortion, access to surgical sterilization (such as tubal ligation) or reversible contraceptive devices has great bearing on women's interests in exercising control over their lives and bodies. Unlike abortion, however, these procedures have not been defended by national organizations as essential and nonelective during Covid‐19. Instead, delays of sterilizations or contraceptive device placements have been justified by the availability of alternative contraception methods.

The general rule that surgeries should be deferred when medical alternatives with acceptable outcomes are available is reasonable. When it comes to contraception, however, the existence of alternatives does not ensure that comparable outcomes are likely. For some women, surgical sterilization is the only form of contraception appropriate for their values or life circumstances; for others, nonsurgical contraception is not appropriate for them medically due to health contraindications to those methods.

At baseline, there are racial and socioeconomic disparities in access to surgical sterilization as a result of issues ranging from Medicaid restrictions to age‐and‐parity‐related “relative contraindications.” Delays and cancelations are often tantamount to effective denials of desired sterilizations. Stay‐at‐home orders and social distancing practices have increased intimate‐partner violence and other obstacles to reliably accessing alternative contraceptive methods, such as supply chain shortages and transportation barriers, and these factors are likely to increase the numbers of undesired pregnancies. For women who disproportionately experience these risk factors for undesired pregnancy, cancelation or delay of desired sterilization or device placement creates significant challenges to their well‐being, particularly as cumulative pregnancy risk increases over time.

The Right to Reproduce

Procedures facilitating reproduction include assisted reproductive treatments, like IVF, and a range of gynecologic procedures treating anatomic conditions that compromise the ability to get and stay pregnant, like myomectomies (surgical removals of uterine fibroids). These reproduction‐promoting surgical procedures, too, are valuable more for their contribution to other components of well‐being than for physical health. These components include many of the interests that are at stake in the right not to reproduce in addition to the interest of creating valuable relationships through family building.

However, some protocols for triaging procedures during Covid‐19 place IVF in the same category as cosmetic surgery, wherein the “elective” designation suggests that reproduction‐promoting procedures are discretionary. This perspective devalues the extent to which becoming a parent is a deeply important aspiration for many people. The inability to have a child may be experienced as a deep personal loss, an emotional toll that may be heightened under social isolation in which building meaningful connections has become even more precious. Further, even among women who recognize their value or understand their life plans to be independent of fertility, the inability to become pregnant may impose interpersonal strife, humiliation, and shame.

There are profound racial and socioeconomic disparities in access to IVF at baseline. Patients who are closer to the end of their fertility window or whose ability to afford treatment is compromised by Covid will be those most severely disadvantaged by pandemic‐related restrictions. Women who require fertility treatment to build their family have experienced these cancelations as unfair, especially by comparison to the lack of a recommendation against pregnancy for those who do not require medical assistance. This perspective is consistent with updated guidance for reopening and further periods of restriction wherein embryo transfer and other surgical treatments for infertility are included as priority procedures, in contrast with their deprioritization in the initial phase of the pandemic. However, this approach is inconsistent with current guidance affecting another category of women who cannot get pregnant without medical assistance, as recommendations propose deferral of long‐acting contraceptive device removal where possible.

A Triage Framework Informed by Well‐Being

The pandemic calls for urgent reconsideration of health care practices, with some inherent tensions between individual rights and public health. Health care systems’ resource‐allocation calculus prioritizes health metrics, such as morbidity and mortality. Yet health utility alone does not account for the critical importance of reproduction‐related procedures to values other than health, including self‐determination, personal security, equal respect, and family building. Furthermore, systematic restriction of reproduction‐related procedures during the crisis is particularly harmful given both historic, gendered control over women's reproduction and women's dependence on these procedures for reproductive autonomy and other components of well‐being. In light of these concerns, the threshold for restricting reproduction‐related procedures during the health crisis should be raised, and perhaps raising it will support efforts after the pandemic to address inequities in access to these critical procedures.

To think about the provision of reproduction‐related procedures during a pandemic, when triage becomes necessary, physicians and health care systems need a framework that features multiple dimensions of well‐being, nonphysical as well as physical. Such a framework will inform the ranking of reproduction‐related procedures within broader surgical categories and also of individual cases within procedure types. Here is an example of such a framework:

1) Abortion would never be delayed. Methods and policies that minimize the number of required visits should be used whenever possible, and procedures should be performed in outpatient settings wherever possible.

2) Surgical sterilization and reversible contraceptive implant placement would never be denied when there is either no medically appropriate alternative or no personally acceptable one. Clinical visits for these procedures should take priority over other routine outpatient visits within modifications to social‐distancing practices. If delays are necessary due to clinical capacity, indefinite delays should be avoided. We recommend automatically rescheduling the procedure within four weeks, with reassessment as needed.

3) Long‐acting contraceptive device removal and assisted reproductive procedures should not be denied to women on the outer edge of their fertility window or for whom future access may be jeopardized by the pandemic's impact. IVF should not be halted mid‐cycle, and for egg retrieval, priority should be given to patients whose fertility is most limited and those who intend to proceed with IVF the soonest.

4) Individuals’ dependence on clinical visits for exercising reproductive autonomy should be minimized by, for example, increasing the use of telemedicine, making oral contraceptives available over the counter, and supporting at‐home artificial insemination.

5) Decisions should be transparent, fair, and consistent across state lines, reflecting reproduction's sociopolitical significance for self‐determination and personal security. Providers should collaborate with patients in informed, shared decision‐making.

6) The reversal of restrictions should prioritize cases based on principles of harm reduction in view of the cumulative effect of given procedures on patients’ well‐being. For example, the first cases to be rescheduled should be for women at greatest risk for unplanned pregnancy and those most vulnerable to financial or insurance‐status changes that may limit access in the future.

7) Both during the reintroduction of procedures and in future phases of restriction, triage should account for the impact of procedures on overall well‐being, the use of outpatient settings should be prioritized, and clinical redundancies or ancillary personnel, such as clinical students, should still be eliminated.

Ultimately, a more individualized, well‐being‐centered approach to triage of reproduction‐related procedures that is sensitive to social‐structural contexts and the diversity of community values related to reproduction may yield a more just outcome and mitigate pandemic‐related exacerbation of inequities. Concerns to address include the burdens on clinicians, potentially misaligned incentives to provide or further restrict services (such as claims of exceptionalism and financial motives), dexterity in matching restrictions to an evolving health threat, the need for ongoing ethical oversight and evidence‐based assessment, and residual risk of systematic disenfranchisement of the most disadvantaged and at‐risk patients. Reproductive rights are not “elective,” not even during a pandemic.