Co-authored by If/When/How, Lawyering for Reproductive Justice, National Network of Abortion Funds, and the National Partnership for Women & Families.

Introduction

Everyone needs time to access health care without threatening their economic stability. Paid sick days allow a person to recover from short-term illnesses, access preventive care, undergo a basic medical procedure, or care for a sick child or family member. Yet more than 26 million people—nearly one in four private sector workersU.S. Bureau of Labor Statistics, National Compensation Survey: Employee Benefits in the United States, March 2021 (Table 33 and Appendix Table 2), accessed September 29, 2021, https://www.bls.gov/ncs/ebs/benefits/2021/employee-benefits-in-the-united-states-march-2021.pdf.—do not have a single paid sick day. Just 33 percent of the lowest-paid workers—those least likely to be able to afford unpaid time away from work—have access to paid sick days.U.S. Bureau of Labor Statistics, National Compensation Survey: Employee Benefits in the United States, March 2021 (Table 33 and Appendix Table 2), accessed September 29, 2021, https://www.bls.gov/ncs/ebs/benefits/2021/employee-benefits-in-the-united-states-march-2021.pdf. Moreover, Hispanics, American Indian or Alaska Native, and Black people are less likely to have access to paid sick days, due in significant part to the fact that they are disproportionately concentrated in low-wage jobs.Institute for Women’s Policy Research, Paid Sick Days Access and Usage Rates Vary by Race/Ethnicity, Occupation, and Earnings, accessed March 14, 2022, https://iwpr.org/wp-content/uploads/2020/08/B356-paid-sick-days.pdf. For far too many people, then, taking time off from work to attend to their health means putting their jobs and finances at risk.

Paid sick days give people seeking abortion care the time they need to travel to a clinic, receive care, and recover. The benefits of this paid time away from work are especially apparent for people who obtain an abortion via an in-clinic procedure, which more closely resembles other kinds of in-person or outpatient medical care for which people commonly use paid sick days. Medication abortion care, however, often looks different, as it commonly involves fewer trips to a provider’s office and is a process that takes place mostly in one’s own home. For many people, it is less intuitive that paid sick days are applicable to this form of care — but they are. The availability of paid sick days for medication abortion is an essential component of ensuring that people can access care that best suits their needs and preferences, and do so in ways that protect both their health and economic security.

Not having access to paid sick days is especially problematic for pregnant people seeking abortion care.In this brief, we use gender neutral language in recognition of the fact that not all those who can get pregnant or who seek abortions are cisgender women. However, when citing studies or works, we use language congruent to the terms used in those studies. Myriad restrictive abortion laws require people to pay out of pocket for abortion care, travel long distances, take multiple days off work, make multiple medically unnecessary visits to an abortion provider, and spend hundreds or thousands of dollars on travel and procedure-related expenses. When a person lacks paid sick days, getting the care they need may mean not only facing common, persistent challenges like bans on abortion coverage and other harmful abortion restrictions, but also lost wages and possibly job loss. The financial burden, as well as the potential struggles of navigating inflexible work schedules and policies, may delay or even entirely prevent a person’s ability to obtain care. The combination of barriers to abortion care and a lack of paid sick days disproportionately affects people with low incomes, people of color, and those living in medically underserved areas, including rural communities.

Paid Sick Days Cover Time Off for Medication Abortion Care

In 14 states and 22 other cities and counties, paid sick days laws ensure workers can earn a baseline amount of paid sick days to seek treatment for and recover from their own illness, access preventive care, or cover for a family member’s care.National Partnership for Women & Families, Paid Sick Days Statutes, last modified July 2021, /wp-content/uploads/2023/02/paid-sick-days-statutes.pdf. This leave is usually short in duration, and laws typically allow it to be used in increments from as small as the couple of hours someone may need to go to an appointment with a provider to the few days someone may be sick with a minor illness. In most cases, if a person’s absence from work is for three days in a row or less, they do not need to provide documentation to their employer.

For a worker not protected by a paid sick days law, access depends on whether their employer opts to provide paid sick days, and their employer may restrict use of leave. About one in five workers with access to some paid time off say they would not be able to use it to care for a family member.U.S. Bureau of Labor Statistics, Access to and Use of Leave — 2017-2018: Data from the American Time Use Survey (Table 3), August 29, 2019, https://www.bls.gov/news.release/pdf/leave.pdf. Some employers discourage workers from taking needed leave through punitive “no fault” attendance policiesDina Bakst, Elizabeth Gedmark, and Christine Dinan, A Better Balance, Misled & Misinformed: How Some U.S. Employers Use “No Fault” Attendance Policies to Trample on Workers’ Rights (And Get Away With It), June 2020, https://www.abetterbalance.org/wp-content/uploads/2020/06/Misled_and_Misinformed_A_Better_Balance-1-1.pdf., or require a worker to find a replacement in order to take leave. Workers of color are especially likely to face barriers to taking leave; for example in fall 2020, 28 percent of Black workers reported having requests for leave denied compared to 9 percent of white workers.Jessica Mason and Paula Molina Acosta, National Partnership for Women & Families, Called to Care: A Racially Just Recovery Demands Paid Family and Medical Leave, March 2021, https://nationalpartnership.org/report/called-to-care-a-racially-just-demands-paid-family-and-medical-leave/.

One of the reasons people are increasingly opting for medication abortion care is because it can feel less “medicalized”, given that it often involves fewer (or in some cases, no) in-person trips to a health care provider’s office, and the process occurs mostly in the comfort of one’s home. However, the fact that this method of abortion largely occurs at home might mean that people are less likely to realize that their available paid sick days may be used to access medication abortion care — but they can. First, a person with paid sick time can take it for any appointments they have with a provider — whether in-person or via telehealth — including any consultation prior to obtaining abortion care, a visit to pick up or take the medication itself, and for any follow-up care. Under post paid sick leave laws, employees do not have to disclose detailed medical reasons for requesting leave.Drew Lewis, New Federal Paid Sick Leave Rights (2022): The Ultimate Guide for Employees, last modified February 9, 2022, https://drewlewis.law/federal-paid-sick-leave-rights-for-employees/. Second, a person with paid sick days typically may use the time they have earned to stay home as their body goes through the process of terminating the pregnancy, as well as any associated recovery time. This is true even though abortion care is not an “illness” or preventive care (as commonly understood to be covered by paid sick days laws) and even though the side effects from medication abortion are generally very minimal and manageable with common over-the-counter medications like ibuprofen. Using paid sick days in this way can both promote people’s health and well-being while they seek essential reproductive care and simultaneously mitigate some of the risks to their financial stability while doing so.

At the same time — because far too many people still do not have the benefit of such worker protections and live in places with myriad abortion restrcitions — policymakers must work urgently to expand and strengthen workers’ access to paid sick days and their access to comprehensive reproductive health care, including medication abortion.

Medication Abortion Care Is a Safe, Effective, and Essential Option

Medication abortion is an FDA-approved option for ending a pregnancy up to 10 weeks of gestation with a prescription from a provider.Kaiser Family Foundation, The Availability and Use of Medication Abortion Care, last modified October 21, 2021, https://www.kff.org/infographic/the-availability-and-use-of-medication-abortion-care/. It generally involves the use of two separate medications, taken in pill form: mifepristone, available under the brand name Mifeprex, and misoprostol.U.S. Food & Drug Administration, Mifeprex (Mifepristone) Information, last modified December 16, 2021, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/mifeprex-mifepristone-information. The mifepristone is taken first to block progesterone, a hormone essential to the development of a pregnancy. Between 24 and 48 hours later, the misoprostol is taken to trigger a process similar to a menstrual period in which the uterus cramps and sheds its lining so that the pregnancy leaves the person’s body. People can also use mifepristone and/or misoprostol to safely and effectively complete a miscarriage. Some states require a person to take the first pill in a clinic or provider’s office, and then they can take the second pill at home or wherever they are most comfortable.Guttmacher Institute, Evidence You Can Use: Medication Abortion, last modified February 2021, https://www.guttmacher.org/evidence-you-can-use/medication-abortion; Guttmacher Institute, State Laws and Policies: Medication Abortion, last modified March 1, 2022, https://www.guttmacher.org/state-policy/explore/medication-abortion. Other states allow a person to take both pills at home after an in-person or virtual visit, while some states allow for a telehealth visit followed by pills being mailed to the person. All states require people who are seeking a prescription for abortion pills to consult with a health care provider. In addition, follow-up with the provider is done seven to 14 days laterU.S. Food and Drug Administration. “Mifeprex (Mifepristone) Information,” February 5, 2018, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/mifeprex-mifepristone-information., and may take place over the phone.U.S. Food & Drug Administration, Summary Review, Center for Drug Evaluation and Research, accessed March 14, 2022, https://www.accessdata.fda.gov/drugsatfda_docs/nda/2016/020687Orig1s020SumR.pdf; Rachel K. Jones and Heather Boonstra, “The Public Health Implications of the FDA’s Update to the Medication Abortion Label,” Health Affairs (June 30, 2016), 10.1377/forefront.20160630.055639.

Evidence shows that medication abortion is extremely safe and effective. A 2018 National Academies of Science, Engineering, and Medicine review of medication abortion care found an overall effectiveness rate of 96.7 percent for gestations up to nine weeks.National Academies of Sciences, Engineering, and Medicine, The Safety and Quality of Abortion Care in the United States, accessed March 14, 2022, https://www.nap.edu/read/24950/chapter/1; Melissa J. Chen and Mitchell D. Creinin, Mifepristone with Buccal Misoprostol for Medical Abortion: A Systematic Review, Obstetrics and Gynecology, 126, no. 1 (July 2015), 12-21, Pubmed ID: 26241251, https://escholarship.org/uc/item/0v4749ss. Other research shows that serious complications requiring hospitalization or transfusion occur in less than 0.4 percent of patients.Elizabeth G. Raymond, Caitlin Shannon, Mark A. Weaver, and Beverly Winikoff, First-Trimester Medical Abortion with Mifepristone 200 mg and Misoprostol: A Systematic Review, Contraception 87, no. 1 (January 2013): 26-37, doi: 10.1016/j.contraception.2012.06.011. A 2019 systematic review of telemedicine use for medication abortion also supports the practice: outcomes were similar to in-person care, with high rates of completed abortions, very low rates of complications, and high acceptability on the part of both patients and providers.17. M. Endler, A. Lavelanet, A. Cleeve, B. Ganatra, R. Gomperts, and K Gemzell-Danielsson, Telemedicine for Medical Abortion: A Systematic Review, BJOG: An International Journal of Obstetrics and Gynaecology 126, no. 9 (August 2019): 1094-1102, doi: 10.1111/1471-0528.15684. In addition to its proven safety, medication abortion care may better fit a person’s individual circumstances, needs and preferences, for example by offering more control and privacy in the process, or allowing someone to be with loved ones for support during the process.Stephen L. Fielding, Emme Edmunds, and Eric A. Schaff, Having an Abortion Using Mifepristone and Home Misoprostol: A Qualitative Analysis of Women’s Experiences, Perspectives on Sexual and Reproductive Health 34, no. 1 (January-February 2002): 34-40, https://doi.org/10.2307/3030230. Furthermore, telehealth can reduce barriers to abortion care, including travel, child care, long wait times fozr an appointment and the costs that result from these obstacles to care.

Despite Persistent Restrictions, Use of Medication Abortion Is Growing

Because of the numerous benefits that medication abortion can offer, more and more people are opting for this form of care. Medication abortion accounted for more than one-third of all abortions in the United States in 2017 (the most recent year for which this data is available), which is a 25% increase from 2014.Rachel K. Jones, Elizabeth Witwer, and Jenna Jerman, Abortion Incidence and Service Availability in the United States, 2017, last modified September 2019, https://www.guttmacher.org/report/abortion-incidence-service-availability-us-2017. Medication abortion also accounted for an estimated 60% of all abortion care prior to 10 weeks.Rachel K. Jones, Elizabeth Witwer, and Jenna Jerman, Abortion Incidence and Service Availability in the United States, 2017, last modified September 2019, https://www.guttmacher.org/report/abortion-incidence-service-availability-us-2017.

The COVID-19 pandemic has only accelerated usage of medication abortion, as people sought to maximize their ability to stay at home, as several states moved to deny abortion as essential health care, and as many states and providers offered rapid changes in how care was provided, including via telehealth.Abigail R.A. Aiken, Jennifer E. Starling, Rebecca Gomperts, Mauricio Tec, James G. Scott, and Catherine E. Aiken, Demand for Self Managed Online Telemedicine Abortion in the United States During the Coronavirus Disease 2019 (COVID-19) Pandemic, Obstetrics & Gynecology 136, no. 4 (October 2020), http://doi.org/10.1097/AOG.0000000000004081. For example, TelAbortion, a pilot study in the U.S. that allows people seeking an abortion to have video consultations with certified providers and then receive the medication abortion pills by mail, found about twice as many people had abortions through the program in March and April 2020 compared to January and February.Pam Belluck, “Abortion by Telemedicine: A Growing Option as Access to Clinics Wanes,” The New York Times, April 28, 2020, https://www.nytimes.com/2020/04/28/health/telabortion-abortion-telemedicine.html. Moreover, in a span of three weeks from late March into April 2020, more than 3,300 people in the United States requested help from Aid Access, a European organization that helps pregnant people access mifepristone and misoprostol by mail, increasing by more than a quarter from pre-COVID levels.Abigail R.A. Aiken, Jennifer E. Starling, Rebecca Gomperts, Mauricio Tec, James G. Scott, and Catherine E. Aiken, Demand for Self Managed Online Telemedicine Abortion in the United States During the Coronavirus Disease 2019 (COVID-19) Pandemic, Obstetrics & Gynecology 136, no. 4 (October 2020), http://doi.org/10.1097/AOG.0000000000004081.

A growing body of research demonstrates that the protocol used to provide medication abortion care during the pandemic is equally as safe as in-person care, and that people are highly satisfied with the care they have received.Erica Chong, Tara Shochet, Elizabeth Raymond, Ingrida Platais, Holly A. Anger, Shandhini Raidoo, Reni Soon, Melissa S. Grant, Susan Haskell, Kristina Tocce, Maureen K. Baldwin, Christy M. Boraas, Paula H. Bednarek, Joey Banks, Leah Coplon, Francine Thompson, Esther Priegue, and Beverly Winikoff, Expansion of a Direct-to-Patient Telemedicine Abortion Service in the United States and Experience During the COVID-19 Pandemic, Contraception 104, no. 1 (July 2021): 43-48, doi: 10.1016/j.contraception.2021.03.019. In March 2022, the World Health Organization published new guidelines that, for the first time, provided recommendations for the use of telemedicine for abortion care and cited it as a successful intervention that improves quality access to reproductive health care.World Health Organization, WHO issues new guidelines on abortion to help countries deliver lifesaving care, last modified March 9, 2022, https://www.who.int/news/item/09-03-2022-access-to-safe-abortion-critical-for-health-of-women-and-girls.

Even though medication abortion has proven to be a safe, effective, and essential form of care, restrictions on its availability and use continue to persist. At the federal level, in 2011, the Food and Drug Administration (FDA) issued a restriction on medication abortion, placing mifepristone under the Risk Evaluation and Mitigation Strategy (REMS). Mifepristone’s REMS required, among other things, that individual prescribing providers be certified and that the pill be distributed only in person, in a health care facility by or under the supervision of a certified prescriber.U.S. Food and Drug Administration, Risk Evaluation and Mitigation Strategy (REMS) Single Shared System for Mifepristone 200mg, accessed March 15, 2022, https://www.accessdata.fda.gov/drugsatfda_docs/rems/Mifepristone_2019_04_11_REMS_Full.pdf. In April 2021, as a response to the extenuating circumstances and risks involved in the coronavirus pandemic, the FDA announced it was suspending the in-person dispensing requirement for the duration of the public health emergency.U.S. Food and Drug Administration, letter to American College of Obstetricians and Gynecologists, April 12, 2021, https://www.aclu.org/letter/fda-response-acog-april-2021. Then, in December 2021, the FDA announced that, after reviewing the science and evidence on the safety and efficacy of medication abortion, it would permanently lift this in-person requirement, enabling people to get mifepristone by mail from certified prescribers or pharmacies.U.S. Food and Drug Administration, Questions and Answers on Mifeprex, last modified December 16, 2021, https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifeprex. This change is a significant step forward that will improve medication abortion access for many people.

At the same time, the impact of this change is severely blunted by the fact that, as of March 2022, 19 states have laws that nevertheless require the clinician providing a medication abortion to be physically present when the medication is administered, thereby prohibiting the use of telemedicine to prescribe medication for abortion or mail to deliver it.Guttmacher Institute, State Laws and Policies: Medication Abortion, last modified March 1, 2022, https://www.guttmacher.org/state-policy/explore/medication-abortion. Additional state laws aimed at undermining the availability of medication abortion are also proliferating; for example, Texas has prohibited medication abortion after seven weeks of pregnancy, despite FDA approval for use up to 10 weeks.Kevin Reynolds, “Texas Law Restricting Access to Abortion Medications Goes Into Effect Dec. 2 After Governor Signs Bill,” Texas Tribune, September 24, 2021, https://www.texastribune.org/2021/09/24/texas-abortion-medication-law-abbott/. Since the start of the 2022 state legislative sessions, legislators in at least 20 states have proposed laws that would ban or restrict access to medication abortion.Christine Vestal, Pew Charitable Trusts, As Abortion Pills Take Off, Some States Move to Curb Them, last modified March 16, 2022, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2022/03/16/as-abortion-pills-take-off-some-states-move-to-curb-them.

Recommendations for Policymakers

Access to both paid sick days and to medication abortion are critical to people’s health, well-being, economic security, and ability to thrive. Consequently, policymakers at the federal level must enact:

• The Healthy Families Act, which would establish a national paid sick and safe days standard and allow workers to earn up to seven paid, job-protected sick days each year;
• The Equal Access to Abortion Coverage in Health Insurance (EACH) Act, which would ensure abortion coverage to pregnant people who receive health care or insurance through the federal government; and
• The Woman’s Health Protection Act (WHPA), which protects the right to access abortion free from medically unnecessary restrictions and bans on abortion.

Additionally, policymakers at the municipal and state level must enact:

• Paid sick and safe days laws that allow all workers to earn job-protected paid sick days;
• Laws that would enhance abortion access by requiring insurance coverage for abortion care, including ensuring that state funds are used to provide abortion care for Medicaid enrollees;
• Laws like the Whole Woman’s Health Act that build upon the precedent set by the U.S. Supreme Court in Whole Woman’s Health v. Hellerstedt and help protect pregnant people and abortion providers from medically unnecessary regulations;
• Laws repealing antiquated criminal abortion offenses; and
• Laws to protect people who self-manage their own abortions — and those who help them — from criminalization.

Not everyone who needs access to abortion care may be aware of paid sick days laws in their city, county or state. We partnered with the National Network of Abortion Funds (NNAF) to create Know Your Rights documents for five localities:

• Arizona
• Duluth, Minn.
• Minneapolis
• Rhode Island
• St. Paul, Minn.

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