For continuing coverage of how COVID-19 is affecting reproductive health, check out our Special Report.

As a physician, I have seen firsthand the widespread and expansive effects of the COVID-19 pandemic on our entire health-care system. This crisis has exposed and exacerbated existing inequities in our systems and structures of care.

Delivery of abortion care is no exception. Abortion is one of the safest health-care procedures in the United States. It also is one of the most common, with nearly 1 in 4 women having an abortion by age 45. Although the rapidly decreasing access to abortion will have a profound impact on many people, some communities will bear the brunt of these inequities. Communities of color and those with low incomes have greater rates of abortion and, as a result, will be disproportionately affected.

These same communities have been heavily affected by COVID-19 infection and death. This is not coincidental. Centuries of institutional inequity, structural racism, and de facto segregation of care have laid the groundwork for our current circumstances.

As it currently exists, the health-care system does not center abortion care access for those most marginalized by these systemic and structural barriers. As we work to protect and expand abortion care in the context of COVID-19, we must actively and explicitly combat these inequities. If we don’t, we run the risk of perpetuating systems of oppression that run along racial, gender, and economic lines. Understanding and prioritizing this is essential to addressing these inequities in any meaningful and sustainable way.

Barriers abound

While the right to abortion was codified into law by the U.S. Supreme Court in its 1973 Roe v. Wade decision, the ability to actualize this right is far from equitable. People seeking abortions face numerous barriers, including legislative restrictions, financial obstacles, and social stigma. Barriers to accessing abortion care are even steeper for people of color, young people, undocumented people, and other marginalized communities. These barriers are compounded when delays in care occur because the pregnancy continues to advance.

Many people pay out of pocket for their care. This is particularly true for people with low incomes who have Medicaid and those with federally sponsored health insurance. Most are unable to use their insurance to cover their abortion due to the Hyde Amendment. For others, abortion may or may not be covered by their insurance plan. As they work to raise money for the abortion, delays often result. Importantly, because abortions later in pregnancy typically cost more than those performed at earlier gestational ages, delays are likely to create huge obstacles in obtaining any care at all for those with limited financial resources.

For many people, logistics present additional challenges. Child care for the children they have, the need to travel from long distances to find an abortion provider, and navigating any number of systemic barriers like lost wages from time off work and the need for accommodations results in more significant delays. From gestational age bans, total abortion bans, waiting periods, and admitting privileges laws, those with the greatest need are affected most.

In the case of access to abortion, those with inequitable access are more likely to be communities who have been historically marginalized from care. People of color and those who have low incomes or live in poverty are less likely to have access to quality, culturally responsive, comprehensive reproductive health care, including access to contraception if they need or want it. These communities are more likely to experience bias and discrimination when seeking health-care services, and more likely to have experienced reproductive rights abuses at an individual or community level in the past, and as a result often report distrust in health-care providers or the health-care system more broadly. This affects an individual’s ability or desire to access reproductive health-care services. Compounding these issues is a decimated social safety net that inhibits an individual’s ability to parent the children they have in safe and healthy environments.

When we look at the inequities in access to abortion care in the context of COVID-19, the intersections of these inequities become magnified.

Disparate impact, COVID-19 edition

Since the first positive U.S. COVID-19 case confirmed by the Centers for Disease Control and Prevention (CDC) in January, to the now close to 650,000 confirmed cases, a lack of a coordinated response, inadequate testing, and poor surveillance of disease has allowed this pandemic to flourish. And although we are all at risk, there are certainly some communities that are experiencing a disparate exacerbation of risk, exposure, infection, and death.

In the early months of this pandemic, few states or jurisdictions reported COVID-19 infections and deaths by race. The CDC finally released data only after increased pressure from advocates and activists.

The stark inequities in care inherent in our health system are glaring. Thirty-three percent of individuals hospitalized with COVID-19 were Black. By contrast, Black people make up an estimated 13 percent of the U.S. population. These results were consistent with what many in the Black community already knew and was reflective of early data coming out of cities like Milwaukee, where 81 percent of deaths related to COVID-19 in the county are among Black people (only 26 percent of the population) and Chicago, where almost 71 percent of COVID-19-related deaths are Black people (29 percent of the population).

While some public health experts and providers have offered explanations for these inequalities, their explanations have been anemic and incomplete. By far, the most repeated explanation for differences in rates of death for people of color infected with and dying from COVID-19 related causes has been racial disparities in chronic conditions—that is to say that Black people have higher rates of chronic diseases like high blood pressure and diabetes, which puts them at higher risk for contracting and dying from the virus. While it is true that Black people are more likely to develop chronic conditions at earlier ages and are more likely to die younger, this is only part of the story.

An analysis of inequities in infection and death from COVID-19 must include an understanding of interlocking oppressions, such as environmental injustice, economic inequity, and racism, which predispose some communities to higher rates of disease than others. Recognizing this context is not just critical for understanding and explaining the inequities but also, most importantly, for seeking solutions to eliminating them.

Seeking solutions at the intersection of inequity

Most solutions for addressing limited access to abortion care in the midst of this pandemic have been grounded in addressing immediate needs: ensuring that clinics remain open, and ensuring our patients and communities can get care in a timely fashion while protecting staff and patients from increased risks of exposure. These concerns are critical to protected clinic-based care, but we must also prioritize equity in planning, programs, and policies to ensure that the needs of the hardest-hit populations are central.

Approaching this work through an equity lens demands that we continue to seek solutions that move past the immediate needs and toward defining long-term, sustainable solutions that prioritize those most affected by these inequities. In other words, we need to ask not just how we can keep clinics open but also what abortion care should look like for those who can’t or won’t make it into a clinic to get their care. We must ask how we can institute changes in our health-care delivery systems to protect access while also examining policies and procedures that reproduce and perpetuate past and current inequities.

Reproductive health-care providers and the clinics and facilities where we work continue to be committed to protecting the health of our communities. Where care continues, there have been changes instituted to keep patients and staff safe and healthy during this crisis. Many providers are trying to limit the need for travel by conducting consultations, health screenings, and follow-up via telephone when possible. There has been an increase in the use of telemedicine and online services as well. Providers are limiting the number of support persons arriving with patients at their appointments and eliminating nonurgent care. But even as the care model changes, the inequity remains.

Reliance on telemedicine without regard for or consideration of the digital divide has the potential to worsen hierarchies in clinical care. Use of the telephone can put people who need to access reproductive health care in secret from their partners or parents at risk of violence or harm. And for many, policies that limit the ability of a friend, partner, or other support person to accompany them to their appointment in order to abide by physical distancing recommendations, worsen the stigma and shame around abortion care.

We have been here before. Those with means and resources will be able to access care. Those without resources will not.

When evaluating strategies for improving or maintaining access to care, it’s crucial to recognize the ways that structural and systemic barriers create stratified systems of care and result in disparate health outcomes for communities. Organizing and prioritizing the delivery of abortion care for those on the margins ensures that if we can protect access to care for those folks, everyone else will benefit as well.

Meaningfully exercising the right to abortion care must occur in a context that supports reproductive health and, more importantly, reproductive justice. As we grapple with ways to provide abortion care in the context of COVID-19, this is an opportunity to begin that conversation.