Misoprostol in the era of COVID-19: A love letter to the original medical abortion pill

Introduction: Timely and equitable access to safe, high-quality abortion is a core component of ensuring reproductive autonomy and upholding the tenets of reproductive justice. The coronavirus 2019 (COVID-19) pandemic, coupled with increased demands on national public health systems and restrictions on travel and movement, are exacerbating existing inequities in abortion access. Nonsurgical abortion methods – which can be performed by a wider cadre of providers than surgical abortion methods, require fewer resources, and can be utilised in a range of settings, including one’s home – are key to safeguarding access to safe abortion during and after the pandemic. Now, more than ever, it is imperative to harness the potential for medical abortion, particularly misoprostol, a safe, World Health Organization (WHO) recommended medication for pregnancy termination, to expand access to abortion care for everyone, when and where they need it. While the discovery of medical abortion methods revolutionised safe abortion access for many, systemic inequities in access persist. The consequences of inequitable abortion access include loss of bodily autonomy, forced childbearing, increased morbidity and mortality from use of unsafe methods, and long-term economic, social, and emotional impacts. Long histories of racism, gender inequality, homophobia, and numerous other systems of oppression have resulted in these consequences being disproportionately experienced by communities that have been systematically marginalised. For example, people living in countries that have experienced centuries of colonialism (where the majority of unsafe abortions occur), transgender and gender nonbinary people (who often face discrimination or outright refusals of care), Black, Indigenous, and other people of colour in the United States (who are disproportionately impacted by community disinvestment, abortion restrictions, and federal funding restrictions), and those living in poverty (who face numerous barriers often related to cost and inaccessibility of local services), are more likely to be negatively impacted. Major societal disruptions, such as economic recessions, conflict, and the current pandemic, further amplify inequities in access to care. Disruptions in global contraception supply chains, resource shortages and diversion of sexual and reproductive health facilities to providing COVID-19 care, as well as the impact of severe economic distress on individuals’ livelihoods, compound already existing inequities in access to preferred and reliable methods of contraception and clinic-based abortion care. As this pandemic continues, these inequities will worsen. Previous evidence suggests that during humanitarian crises, sexual and reproductive health care needs rise. It is likely the current pandemic will increase the number of people in need of safe abortion services, as disruptions in contraception access, changes in family structure and dynamics, increased prevalence of sexual violence, and economic insecurity may limit people’s reproductive autonomy and ability to prevent pregnancy.