ABSTRACT
The disruption caused by the COVID-19 pandemic on health services around the world boosted interest over telehealth models of care. In Brazil, where abortion is heavily restricted, abortion seekers have long relied on international telehealth services to access abortion pills. We conducted a cross-sectional multilevel study to assess the effect of individual and contextual social factors on utilization of one such service. For the individual-level, we analyzed data from the records of abortion seekers contacting this feminist international telehealth organization during 2019 (n = 25,920). Individual-level variables were age, race, education level and pregnancy length. Contextual-level units were states, for which we used data from the national Demographic Census and Household Surveys. Contextual-level variables were household income per capita, adjusted net school attendance rate, percentage of racialized women and income Gini Index. We fitted five multilevel Poisson Mixed-effects models with robust variance to estimate prevalence ratios (PR) of service utilization, which was defined as receiving abortion pills through the service. We found that only 8.2% of requesters got abortion pills through the service. Utilization was higher among women who were older, white, more educated and 5-8-weeks pregnant. Independently of this, service utilization was higher in states with higher income and education access, with lower proportions of racialized women, and located in the South, Southeast and Central-West regions. We concluded that while feminist telehealth abortion initiatives provide a life-saving service for some abortion seekers, they are not fully equipped to overcome entrenched social inequalities in their utilization, both at individual and contextual levels.
ABSTRACT
Working mothers, unable to juggle work, children, and household chores, have left their jobs to respond to the increased need for care work at home.2 Underfunded healthcare systems have collapsed in the face of an unprecedented demand.3 Frontline and low-wage essential care workers, particularly those in the gig economy, endure overexploitation and burnout even in the cases where they are able to keep their jobs.4 These are just a few examples of how the current public health crisis further exposes the contradictions of care and capital. Worldwide, sex workers face barriers to access financial relief for immediate needs, to benefit from recovery plans, or to enjoy temporary forms of labor protection devised to respond to the socioeconomic consequences of the pandemic.5 Particularly those living in the so-called red light areas not only are incapable of following social distancing and other public health orders, but they are also targeted with greater stigmatization and other forms of discrimination.6 Stigmatization of sex work through its association with the spread of infectious disease is not a new phenomenon, but it finds renewed severity in studies that purportedly seek to investigate the potential impact of closing red light areas in response to COVID-19.7 Marginalized, stigmatized, and often denied their full citizenship status, street sex workers develop their own informal networks of care and self-care, which prove essential for their survival. Because of the care work they do in "normal" times, sex workers have also proved crucial in responding to health crises, as the history of the hiv/aids epidemic tells us. Organized in networks initially formed to fight against police violence - starting with state and international ngo funding, and later, with their own resources - sex workers engaged in large nationwide information campaigns about hiv/aids, distributing condoms, teaching people how to use them, and reporting cases of sexual exploitation.15 Since then, sex workers have become responsible for ensuring their own health through peer education, spreading messages that also contribute to their own self-esteem.16 Through the collective learning of the last thirty years, they have developed and expanded the meaning of health, demanding access to integrated care beyond std prevention and learning to care for themselves.17 The knowledge acquired in building those informal structures of care and self-care has proved critical during the current pandemic.