in the Shadow
The Women Who Got Lost in the Health System
E. is 22 years old. A. is not even 17. M. postponed her wedding. All three women found themselves with unwanted pregnancies in the middle of the corona crisis. They, like many other women, were left to "solve the problem by themselves" when the Ministry of Health ordered a stop to all "non־emergency" procedures in hospitals in March and April. The ministry shirked its responsibilities, leaving the hospitals to act as they saw fit and the distressed women and teenage girls to fend for themselves.
May 5, 2020
The height of the corona crisis caught E. in the sixth week of an unwanted pregnancy. Most of her attempts to fix an appointment with a pregnancy termination committee at the various hospitals went unanswered, and those who did reply told her that she would have to wait at least another two weeks. This response caused her great emotional turmoil. 22־year־old E. suddenly realized that all her plans to terminate her unplanned pregnancy using non־invasive medication would very shortly stop being relevant. From the eighth week of pregnancy, she would have to undergo a D&C surgical procedure in hospital – this was her worst fear.
At this point, E. did not yet know that she wasn’t alone in this confusion. According to estimates, during March and April, dozens of women did not pursue the process of terminating their pregnancies. And while they were struggling with their fears, the state chose to make it even more difficult for them (see below for more on this). In the coming months, the personal price for the peak months of the corona crisis will become clearer.
Dr. Matan Elami־Suzin, a senior physician at Hadassah Ein Kerem hospital and a volunteer at Open Door, the leading organization for the promotion of healthy sexuality in Israel, divides his time at Hadassah between the delivery rooms and the clinic for adolescent girls that he heads. Most of his patients at the clinic are teenagers with unwanted pregnancies or who are under medical supervision in order to prevent them from becoming pregnant.
According to Elami־Suzin, something strange happened from the middle of March to the end of April: "The teenagers simply stopped coming. My clinic was almost empty. In contrast to the normally fully clinic, we suddenly had only one or two girls a day. From my knowledge about teenage girls in distress, I don’t think we suddenly found ourselves in a situation where there weren’t any unwanted pregnancies. If there is a reduction, it means that the girls are not coming for help, and we will find out about them at a later stage or that they will try and take all kinds of inefficient, even dangerous, steps to terminate their pregnancies. In any case, they will pay a price. It is always the weaker sectors of society that pay the price."
Dr. Elami־Suzin: "Based on my knowledge of at־risk teenage girls, I don’t think we suddenly found ourselves in a situation where there aren’t any unwanted pregnancies. If there is a reduction, it means that the girls are not coming for help and we will find out about them at a later stage or that they will try and take all kinds of inefficient, even dangerous, steps to terminate their pregnancies."
They didn’t come because of corona?
"Some of them didn’t come because they were afraid of getting infected by the coronavirus, but there is more to it. The support centers that girls with unwanted pregnancies would usually contact were closed because of the pandemic. They don’t have the option being in touch with an older woman who could support them emotionally and with the bureaucratic tangle of getting an appointment with the pregnancy termination committee and during the actual process. For some of these girls, it’s their first time encountering the medical system and in a very embarrassing situation which they feel uncomfortable sharing with their parents."
Were there any other reasons why the girls didn’t leave their homes?
"Yes. The services provided by the state were, in addition, severely curtailed at the height of the crisis. Although the hospitals won’t admit it and the Ministry of Health didn’t issue an official statement on the matter, as soon as ministry officials told healthcare providers to divert resources elsewhere and not to carry out elective (non־urgent) procedures, the message was clear."
"Abortion is not exactly an elective procedure, but one that should ideally be done within a certain timeframe. If you miss this ‘window of opportunity,’ there are ramifications. We will certainly see ramifications of some kind from March and April. It’s not like in Europe where abortions can be performed until the 12th week without any kind of committee. There, a woman is responsible for her body and she decides what will happen at this stage of the pregnancy. Why does Israel force women to go through a committee at any week of their pregnancy? I don’t have a good answer."
Let’s go back to the girls. How have you experienced their increased distress over the past month?
"Many more girls contacted me via WhatsApp, email, and Facebook. Somehow or other my personal phone number became known to all kinds of patients, including female IDF soldiers for whom I hold a clinic as part of my military reserve duty. It’s almost impossible to answer all the phone calls and not everything can be dealt with online. However, it’s important to tell them that it is safe to come to the hospital, since corona patients are completely separated from all other sections of the hospital, and that they mustn’t delay coming because of corona."
A senior official at TLV Medical that operates the Doctors’ Home in Tel Aviv confirms this: "It’s possible that later on we will see the birth of a generation of corona children, because at present women are simply not coming. To be honest, I was expecting an increase in the number of women contacting us, but so far this has not happened. They usually contact us at the very early stages of pregnancy, at 5–6 weeks as soon as they find out. Now it seems that women are holding out until the last possible date, sometimes even until the 10th week. Maybe they are waiting till the last moment and we will see a large number of women contacting us in a week or two."
The Ministry of Health is shirking its responsibility
Before we continue this report, some background information is necessary. At the height of the corona crisis, when the heads of the health system and the prime minister went on primetime TV predicting thousands of ventilated patients and fatalities in Israel, the Ministry of Health halted almost all elective procedures in public hospitals.
On March 19, Dr. Vered Ezra, director of the Ministry of Health’s medical division, sent a letter to hospital directors instructing them to cease all elective procedures from March 22 with the exception of 12 types of surgery and procedures, among them IVF treatments (which were also later stopped). Abortion was not included in the list of exceptions. As soon as this was noticed by women’s groups, they sent an urgent letter to Moshe Bar Siman Tov, director־general of the Ministry of Health, warning that this could "cause women to act out of despair in ways that could endanger their lives."
In his response, Bar Siman Tov referred the women’s groups to the final paragraph of Dr. Ezra’s letter which stated that exceptions committees will be set up in each hospital, headed by the hospital director (or a representative), the head of nursing (or a representative), and a representative of the department heads. Bar Siman Tov stressed that until further notice, these exceptions committees would decide on of all abortions in all of the hospitals. This is a complete reversal of the normal regulations according to which pregnancy termination committees meet several times a month and approve over 99% of the applications they review.
What this means in practice is that the director־general was sanctioning a unique form of chaos in Israel with hospitals permitted to act as they saw fit and to allocate resources to the procedures they considered important.
On April 21, almost one month after Dr. Ezra’s letter, Bar Siman Tov sent his own letter to the heads of the public hospitals in which he reiterated the directives about elective procedures and the exceptions committees. He went even further and wrote: "a breach of these directives will be viewed as a breach of the law with all that this implies." In other words, this was an actual threat to punish them with sanctions.
Dina Shalev: "Women’s rights are usually harmed in times of emergency. In the current political climate, the Ministry of Health cannot officially declare that abortions are an essential medical procedure. This has much more to do with politics than with medicine; it is an attempt not to wake sleeping dogs and not to lean toward a political statement that is too extreme."
By the following day, Channel 12’s health reporter, Yoav Even, already reported that Bar Siman Tov had apologized for his words and clarified that he had not intended to threaten hospital directors in the midst of an unprecedented health crisis.
According to Shomrim’s investigation, the large public hospitals did indeed act as they saw fit for a wide variety of procedures (details at the end of this report). For example, although the hospitals Sheba־Tel Hashomer, Wolfson, Kaplan, Rambam, Hadassah Mount Scopus, and others made a point of continuing their abortion clinics as usual, other hospitals, such as Barzilay and Beilinson, halted this service temporarily. In contrast, Ichilov and Asaf HaRofe seem to have chosen to obey the ministry’s directives and significantly reduced the number of elective procedures including abortions.
Did some hospitals take the liberty of interpreting the directives in accordance with a certain agenda? This is difficult to prove, however, when we contacted the committee’s hotline at Jerusalem’s Shaare Zedek Hospital, the receptionist chose to argue with us about when a fetus becomes viable. When we called Assuta kalaniot Hospital in Ashdod, an attempt – albeit subtle and gradual – was made to direct us to a private clinic where the procedure costs thousands of shekels.
The following is a transcript of our telephone call to Assuta kalaniot Ashdod on April 26.
S (Shomrim): Hello, is the pregnancy termination committee?
A (Assuta): You have reached Assuta Kalaniot. We have had no committee meetings for the past two months.
S. What am I supposed to do if I am pregnant?
A. You can contact a hospital. You can try Assuta in Ramat Hachayal.
S. Why is this? Is it because of corona?
A. There are no committees.
S. What if I go to a committee somewhere else and then come back to you?
A. What HMO (health fund) do you belong to?
A. You can’t do that if you belong to Clalit.
S. I understand that the waiting list is really long because this is an elective procedure and no exceptions have been made for abortions because people think it is not important…
A. It is important. If you have authorization from the committee and your health fund will cover the cost, that is one matter. If your health fund won’t cover the cost, you can do the procedure here privately, which will cost you NIS 2,765.
Next, we investigated the situation at the nearby Barzilay Hospital in Ashkelon. Since this hospital is critically important for southern Israel and for many peripheral communities, we would have expected abortions to have continued as normal. However, the committee at Barzilay stopped meeting at the very height of the corona crisis on March 22 and, no abortions have been carried out since.
According to information that has reached Shomrim, the committee did not meet for almost two weeks, until April 5. Barzilay Hospital denies this allegation, referring instead to a "specific problem with the committee’s office." Eventually, thanks to women’s groups that pressurized the Ministry of Health, the southern hospital began performing abortions again, but there are still long waiting lines. The following is a transcript of a conversation with the receptionist of the pregnancy termination committee at Barzilay Hospital on April 22.
Shomrim’s representative introduced herself as a resident living in the south who wanted to make an appointment with the pregnancy termination committee.
S (Shomrim): I was told that it will take some time to make an appointment for the committee at Barzilay.
B (Barzilay): You are correct. Our next committee is only meeting in two weeks’ time, in May.
S. Only in May? And then the process is straightforward from there?
B. The committee decides.
S. Why is it only meeting in May? Because of corona?
B. There are many applicants and the days have filled up. It’s just that there is a cap on the number of women who can be seen.
Violence, Fear, and Budget Freezes
As if the situation were not complicated enough and there was no shortage of problems, funding for the organizations that provide support for women and teenage girls in distress, as with many other organizations, was frozen and almost entirely halted at the height of the corona crisis; some funding was completely halted. These organizations serve as a beacon of support for women, including those with unwanted pregnancies.
M. asked for help during the corona crisis because of an unplanned pregnancy. She was in a delicate situation: she was engaged to be married but the wedding had been postponed because of the pandemic. The delay caught her unprepared. The couple had had unprotected sex previously, and she had already had to have one abortion. Her main fear was that her family would find out, because they had not managed to find an alternative date for the wedding. For two weeks she sensed that she was pregnant but could not bring herself to do a pregnancy test, fearing that a positive result would send her on a complicated and torturous journey with no deadline in sight.
After speaking to Open Door volunteers four times, M. finally felt able to go to her health clinic for a pregnancy test that confirmed what she felt, and she could begin the process of terminating the pregnancy. She had lost precious time because of her fears and hesitation and now found herself in a race against the clock, hoping to have a medically־induced abortion before the 8th week of pregnancy and thus avoid having a D&C. Having waited until it was almost too late, everything fell into place. She says that she was lucky.
MK Merav Michaeli: "What happened with abortions during the corona crisis came about because of the health minister, because of Litzman’s agenda. It is somewhat reminiscent of his battles at the beginning of the crisis to keep synagogues and ritual baths open….Moreover, this shows that our democracy is flawed. A democracy that does not give full equal rights to half the population is a flawed one."
A. was not so lucky. From the time she became sexually active, she has always been afraid of getting pregnant. Yet, even in her worst nightmares, she did not imagine it would happen before she was 17 and during a pandemic. At first, she made online contact with Open Door, and then phoned its nighttime helpline. She explained that she could not talk freely because she was stuck at home in a small apartment with her parents and brother in a peripheral area of the country. Later in the conversation, she reported having been sexually assaulted a few months earlier by a boy in her neighborhood. She was in very deep distress because she did not know how to leave her house, where to go to be examined, and when and how she could have an abortion. She feared that the hospitals were all hotbeds of corona. Above all, she was frightened what would happen if her parents found out.
The Open Door volunteer spoke to her at length, explaining to her that her parents care about her and would support her under any circumstances. A few days later, she contacted Open Door again; she was much calmer. She still did not know what would happen to her, but she had told her mother about her predicament and gained her support. Her mother took her for a pregnancy test, which A. had been too frightened to do due to the corona crisis. This was just the start of her journey. She then tried to make an appointment for the pregnancy termination committee nearest to where she lived. She called and got a recorded message. Only after trying to get help and seeing how difficult it was to proceed, did she realize what a mistake she had made by waiting.
Sharon Cherkasky, executive director of Open Door, confirms that "at the height of the crisis the number of women who turned to us for help went down. Open Door is the largest non־profit in its field in Israel, promoting the right to healthy sexuality and reliable sexual education. At the start of the crisis, there was a sense of chaos in the hospitals and this filtered outside. Let me make it quite clear: if a teenage girl in an at־risk family in which there is domestic violence gets pregnant and cannot terminate it discretely, as Israeli law allows her to do, tshe is in a life־threatening situation."
Open Door operates a 24־hour helpline. Cherkasky explains: "We are in contact with the social workers in all of the hospitals – to helpfind solutions. In normal times, a pregnant teenager could have left her home to go and buy a pregnancy testing kit and then come to our counseling center for discrete counseling and advice. However, at the height of the corona crisis, there was a sense of chaos because of the state of the health system and also because people were spending much more time at home, which led to more tension and more instances of domestic violence."
During the crisis, some local authorities froze funding for Open Door and sent the social workers on unpaid leave. Cherkasky adds: "Some of the local authorities we work with informed us that they were freezing the project with immediate effect. All the national programs for at־risk youth were also frozen. At the peak of the crisis, many teenage girls, who even under normal circumstances have difficulties contacting us, now were wondering how they could leave their front doors and whether they could do anything other than continue their pregnancies. To me, this is terrible."
The streets are on fire: "It’s a question of life or death"
Nitzan Hacohen, Open Door’s director of counseling, manages 150 male and female volunteers who provide support for women and teenage girls who contact the organization for help: "Abortions are not an elective procedure that can be temporarily postponed. A woman or teenager who accidently becomes pregnant is in great emotional distress. Abandoning her in a situation where she has no choice but to continue the pregnancy is inconceivable, both for her and for me. It means taking a person who is anyhow under great stress and making matters even worse for her. Once the right to terminate their pregnancy is taken away from them, women could reach a situation where they self־harm. This is a question of life or death."
According to the Central Bureau of Statistics, 17,869 abortion applications were made in 2018 (99% of which were approved). When asked how many women have applied so far in 2020, the Ministry of Health’s data division replied: "We don’t yet have data about abortions for the months of March־April. This information will only be available at the end of the year."
Dina Shalev, executive director of Lada’at – Choose Well, who spearheaded the women’s groups’ appeal to the Ministry of Health: "Women’s rights are usually harmed in times of emergency. We received a quick response saying that responsibility is now being transferred to the exceptions committee in each hospital. However, as far as we are concerned, this is not a good answer, because it is impossible to know what will be decided in these committees. We demanded that abortions be included in the list of exceptions to postponed elective procedures, but this did not happen."
Although the hospitals Sheba־Tel Hashomer, Wolfson, Kaplan, Hadassah Mount Scopus, and others made a point of continuing their abortion clinics as usual, other hospitals, such as Barzilay and Beilinson, halted this service temporarily. Ichilov and Asaf HaRofe significantly reduced the number of elective procedures, which included abortions.
Do you have any idea why not?
"I believe it is mainly because of political considerations. In the political climate that we are now living in, the Ministry of Health cannot officially declare that abortions are an essential medical procedure. This has much more to do with politics than with medicine, it is an attempt not to wake sleeping dogs and not to lean toward a political statement that is too extreme."
In your opinion, did the current situation, in which every decision about abortions had to be considered by the exceptions committee in each hospital, give rise to regional problems?
"Based on an investigation we did during the corona crisis, there seems to have been a problem in the Sharon region because the pregnancy termination committees in two hospitals in this region, Meir Hospital in Kfar Saba and Beilinson Hospital in Petah Tikva, did not function as normal, which caused problems for women living between Tel Aviv and Hadera. There is pressure because there were less appointments available and also because of the Passover holiday, which always means a longer wait."
"I see the nationwide distribution of hospitals as vital. Even if one hospital in Tel Aviv is not doing any abortions at present because it is fully devoted to treating corona patients, there are always three other local options available. However, a woman living in Kiryat Gat, Beer Sheva, or Ashkelon does not have such alternatives because there is usually only one hospital nearby. Therefore, we objected vehemently when abortions were stopped at Barzilay Hospital. Even in normal times, there is a low accessibility to this service in the south of the country; there is no way that the entire region can rely on only Soroka Hospital in Beer Sheva and Assuta in Ashdod. What about a 16־year- old girl who has no car or a woman in a perilous financial situation? These are precisely the populations that suffer."
On April 22, in the middle of the corona crisis, exactly one month after Dr. Vered Ezra from the Ministry of Health sent her letter, women’s groups – including Open Door and Lada’at – Choose Well – chalked up an important victory: the health ministry authorized medically־induced abortions at home (during the first weeks of pregnancy) and then also in community health clinics.
In her letter to hospital directors and the heads of pregnancy termination committees, Dr. Ezra wrote that the decision was made "as a result of requests we received from the public." This implies that the Ministry of Health realized that its decision not to make abortions an exception had caused a lot of pressure and harmed many women.
"The Ministry of Health speaks with two voices"
Permission to perform elective procedures in hospitals was given on April 26, more than one month after the decision to halt them. This time, Dr. Ezra wrote to the hospital directors that "limiting the number of elective procedures has medical influences on public health and on both short- and long־term quality of life."
Are we seeing the dawn of a new era of understanding? Not really, according to MK Merav Michaeli who has been watching the situation closely and is not impressed. "What happened with abortions during the corona crisis came about because of the health minister, because of Litzman’s agenda. It is somewhat reminiscent of his battles at the beginning of the crisis to keep synagogues and ritual baths open. The very fact that 100 years after being given the right to vote, women still do not have the right to decide about their bodies and the right to an abortion is proof that we are still far from full equality. Moreover, this shows that our democracy is flawed. A democracy that does not give fully equal rights to half the population is a flawed one."
A., who is not yet 17, became pregnant. Talking to Open Door (the Israeli branch of the International Planned Parenthood Federation) she first explained that she couldn’t talk openly because she was stuck at home in a small apartment with her parents and brother in a peripheral area of the country. Later in the conversation, she reported having been sexually assaulted a few months earlier by a boy in her neighborhood.
Should we simply accept the situation?
"No. absolutely not. The Ministry of Health speaks with two voices on this issue. When the news came out that two ultra־Orthodox hospitals do not allow abortions, I contacted Litzman and his reply focused on procedural matters – the kind of answer that is difficult to relate to. When they tell you that this one is in charge of one thing and that one is in charge of another and so on and so forth, it is much harder to deal with the issue than if they were to just give a frank reply: ‘Correct, we do not perform abortions.’"
"This time around, we supported the appeal by Lada’at – Choose Well to the Ministry of Health and asked them to let us know if there were still problems. We haven’t heard anything from them, so I am assuming that everything is ok. However, I will look into the matter again."
What do you think of the refusal to officially acknowledge abortion as an urgent procedure?
"The declarative aspect of all things concerning abortions is very, very important, but it is even more important to make sure that women can have an abortion. I want to avoid, at all costs, getting into a battle in which we have to ‘prove’ abortion is an urgent procedure – and certainly not in the middle of the current sensitive situation. For me, the most important issue is that women are able to terminate their pregnancies with no health־related or other fears. We don’t, God forbid, want to get to a situation like the United States where there is a black market for abortions."
But what about the principle? Is there any chance of reform?
"I have proposed a bill (that was originally proposed by Zahava Galon) to alter definitions so that abortions are no longer dependent on medical committees."
Michaeli’s bill has been on the Knesset’s agenda since 2017. It calls for a woman to have the right to decide whether to terminate her pregnancy since she has sole responsibility for her body.
The bill states that the current legal situation "places inherent limitations on women’s autonomy of their bodies. This arrangement prevents a pregnant woman having control and responsibility for her body and her fertility and does not give any weight to the woman’s wish to terminate her pregnancy. This legal situation harms women’s rights to equality, liberty, dignity, and health and is not in accordance with the legal situation in most developed countries. A woman’s right to terminate her pregnancy is a constitutional right deriving from the right to freedom and is linked inextricably to the right to equality and human dignity."
Due to the distress women have experienced during the corona crisis and thanks to Shomrim’s investigative report, MK Michaeli has announced that she intends to propose an updated version of her bill which she says will "anchor the right of a woman to control over her body and to access to abortion services that will not be influenced by any future crisis from an acknowledgment that they are vital emergency services."
Eyal Basson, Health Ministry spokesman refused to comment on the questions, offering an extremely strange statement that Shomrim is a non־profit organization.
Barzilay: "Pregnancy termination was not halted. At the beginning of the crisis, there was a specific problem with the Pregnancy Termination Committee secretary and the issue was dealt with immediately."
Shamir Hospital (Assaf Harofe): In March, we performed 26 pregnancy terminations, and in April – 19. This is half the number of terminations, as compared with the same months last year."
Icholov: "In principle, all elective procedures were reduced in number, in accordance with Ministry of Health directives."
Wolfson: "We did not see any major changes."
Beilinson: "In accordance with Ministry of Health directives, we did not perform ambulatory procedures. Therefore, the Pregnancy Termination Committee only met when there was a medical reason to terminate a pregnancy."
Sheba Tel Hashomer: "The Pregnancy Termination Committees have been operating as normal since the beginning of the year. The committee met eight times in February, twice a week, and reviewed 53 termination applications. In March, the committee met eight times and reviewed 54 applications. In April, which included the Passover holiday, the committee met six times and reviewed 46 applications."
Hadassah Mount Scopus: "We are proud to state that whereas other surrounding hospitals reported a reduction in the number of pregnancy terminations during the corona crisis, the Pregnancy Termination Committee in our hospital did not even stop working for a single day. These are procedures that are important for both mind and body."
Kaplan: "We worked as normal."
Hillel Yaffe: "Pregnancy termination is not considered an elective procedure, but an emergency one. Therefore, when the need arose, and in accordance with the regulations, we worked as normal.”
Soroka and Poriya hospital did not make any comments.