Demand for Self-Managed Online Telemedicine Abortion in Eight European Countries During the COVID-19 Pandemic: A Regression Discontinuity Analysis

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In most European countries, patients seeking medication abortion during the 30 COVID-19 pandemic are still expected to attend healthcare settings in person despite lockdown 31 measures and infection risk. We assessed whether demand for self-managed medication abortion 32 provided by a fully remote online telemedicine service increased following the emergence of 33 COVID-19. 34 Design: We used regression discontinuity to compare the number of requests to online 35 telemedicine service Women on Web in eight European countries before and after they 36 implemented lockdown measures to slow COVID-19 transmission. We examined the number 37 deaths due to COVID-19, the degree of government-provided economic support, the severity of 38 lockdown travel restrictions, and the medication abortion service provision model in countries 39 with and without significant changes in requests. 40 Setting: Eight European countries served by Women on Web. 41 Participants: 3,915 people who made requests for self-managed abortion to Women on Web 42 between January 1st, 2019 and June 1st, 2020. 43 Main Outcome Measures: Percent change in requests to Women on Web before and after the 44 emergence of COVID-19 and associated lockdown measures. 45

Five countries showed significant increases in requests, ranging from 28% in Northern 46 Ireland (p=0.001) to 139% in Portugal (p<0.001). Two countries showed no significant change 47 in requests, and one country, Great Britain, showed an 88% decrease in requests (p<0.001). 48 Countries with significant increases in requests were either countries where abortion services are 49 mainly provided in hospitals or where no abortion services are available and international travel 50 was prohibited during lockdown. By contrast, Great Britain authorized teleconsultation for 51 medication abortion and provision of medications by mail during the pandemic. 52

These marked changes in requests for self-managed medication abortion during 53 COVID-19 demonstrate demand for fully remote models of abortion care and an urgent need 54 for policymakers to expand access to medication abortion by telemedicine. 55 56 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 4

57 58 The first wave of the COVID-19 pandemic posed challenges for the provision of abortion care 59 in Europe. Reallocation of resources, redeployment of staff, and social distancing requirements 60 all introduced new barriers to in-person clinic visits.1,2 61 62 Countries differed in their policy responses to these new challenges. Great Britain expanded 63 remote access to medication abortion, allowing teleconsultation with providers, and mifepristone 64 and misoprostol to be provided by mail.3-5 France extended the ability to take abortion 65 medications at home following an in-person visit with a healthcare professional from 7 weeks to 66 9 weeks of gestation.6 Germany allowed mandatory pre-abortion counselling to take place by 67 phone or video teleconsult instead of in person.7 Most other countries, however, made few 68 changes to medication abortion service models and continued to require fully in-person 69 provision, despite calls from human rights groups to prioritize patient safety and expand remote 70 access.7,8 71 72 At the same time, the economic downtown and rising unemployment across Europe in the wake 73 of the pandemic may increase demand for abortion care at a time when it is most difficult to 74 access in the clinic setting. This situation raises the possibility of an increase in abortions taking 75 place outside the formal healthcare setting. Marie Stopes International estimates that an 76 additional 2.7 million unsafe abortions will take place globally as a result of health service 77 disruptions caused by the pandemic.9 78 79 However, not all abortions that take place outside the formal healthcare settings are unsafe. 80 Medication abortion provided through online telemedicine services has been shown to be a safe 81 and effective option.10,11 Using data from one such service, we assessed whether demand for 82 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 5 online telemedicine abortion changed in eight European countries after stay-at-home restrictions 83 to slow the spread of COVID-19 were introduced. 84 85

86 87 We obtained fully de-identified data from Women on Web (WoW), a non-profit organisation 88 that provides telemedicine medication abortion services up to 10 weeks of gestation.12 The 89 service is accessed via an online form, which directly populates the database from which our data 90 were obtained. Submitted forms are screened by a doctor, and if clinical eligibility criteria are 91 met, mifepristone and misoprostol are sent by mail. In some countries, referrals are also made to 92 local in-clinic services. A donation of 70-90 Euros is requested to support the service, but may 93 be waived or reduced in cases of financial hardship. Information and support are provided via 94 email in a variety of languages by a trained helpdesk team. People accessing the service consent 95 to the fully anonymized use of their data for research purposes at the time of submitting the 96 online consultation form. 97 98 Our analytic sample includes eight countries: Germany, Hungary, Italy, Malta, The Netherlands, 99 Northern Ireland, Portugal, and Great Britain. WoW does not accept consultations from all 100 countries in Europe, because abortion is legal and normally relatively accessible in most places. 101 Among those countries that WoW does serve, some have only a few consultations requests over 102 the course of a year. We excluded countries that had too few requests to reliable detect 103 differences in request numbers between the ‘before’ and ‘after’ periods (i.e. fewer than 10 104 expected requests in the ‘after’ period). We also excluded Spain, because the Spanish 105 Government censored the WoW website during the study period and so no requests could be 106 made,13 and Poland because the number of requests made to WoW has been unstable since the 107 beginning of 2020. 108 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 6 109 We obtained the daily number of requests made to WoW from the eight countries in our sample 110 between 1st January 2019 and 1st June 2020 (the last day that lockdown measures were lifted in a 111 country included in the analysis). We excluded duplicate requests, which were identified as >1 112 request with the same information and location made within 12 hours. The number of requests 113 from each country was analysed using a regression-discontinuity design.14 We designated a 114 ‘before’ period, which began on 1st January 2019 and ended on the date that each individual 115 country’s government issued their first ‘stay-at-home’ directive. The one exception was 116 Germany, where the ‘before’ period begins on 1st January 2020, due to the fact that WoW did 117 not accept consultations from Germany in until late 2019. The ‘after’ period began the first day 118 after the ‘stay-at-home’ directive was issued for each country, and ended on the first day that the 119 directives were eased in each country. ‘Stay-at-home’ directives were chosen as the threshold date 120 defining the “pre” and “post” periods, because the majority of European countries issued such a 121 directive, which posed definitive limitations on population movement and activities. Of the 122 countries included in our analytic sample, only Malta did not issue a population-wide directive, 123 and we instead used the date that the Maltese government issued a directive to close public 124 places as the discontinuity point.15 125 126 We fit a generalised linear model (GLM) for each country’s daily requests between 1st January 127 2019 ( 1st January 2020, for Germany) and the date of easing ‘stay-at-home’ restrictions. The 128 model incorporated a dummy variable for the ‘before’ v. ‘after’ period, representing a possible 129 discontinuity at the day of the ‘stay-at-home’ directive. The significance of the discontinuity for 130 each country was assessed using a likelihood ratio test to compare with a null model that did not 131 include a dummy variable for the ‘before’ v. ‘after’ period. The null model was also used to 132 generate Monte Carlo simulations for each country, which create a probability distribution of the 133 expected requests in the ‘after’ period with no discontinuity. The observed requests line would 134 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 7 be highly likely to lie within this probability distribution if there was no difference in requests 135 between the ‘before’ and ‘after’ periods. We also calculated the percentage difference between 136 observed and expected requests in the ‘after’ period. For Northern Ireland, both the null and 137 discontinuity models also included a dummy variable indicating the period after 10th April 2020, 138 because abortion services became available for the first time in Northern Ireland on this date.16 139 140 We also compiled information for each country included in the analysis on several metrics we 141 hypothesised could be related to demand for online abortion: stringency of ‘stay-at-home’ 142 requirements; deaths due to COVID-19; economic assistance provided by governments in 143 response to the pandemic; 17 and abortion service provision before and during the pandemic.7,18-20 144 We examined each of these metrics across each country included in the analysis to assess their 145 relationship to changes in requests to WoW. 146 147 Data analyses were conducted using the R statistical package version 3.6.2.21 Findings were 148 considered statistically significant at an alpha level of 0.05. The study was reviewed by the 149 University of Texas at Austin Institutional Review Board and considered exempt on the basis 150 that the study is an analysis of pre-collected, fully de-identified data. 151 152 Patient involvement 153 Patients were not involved in the design or conduct of the study. However, the follow-up that 154 WoW provides is designed to address the priorities and experiences of people who access the 155 service. Thus, although this study is an analysis of secondary, de-identified data, with no direct 156 participant involvement, the research questions were informed by the needs of people who rely 157 on WoW to access abortion. 158 159 160 All rights reserved. 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161 During the data collection period, Women on Web received 3,915 requests for abortion 162 medications from the eight countries included in the analysis. Among these, we observed a 163 statistically significant increase in requests during the ‘after’ period in five countries: Hungary, 164 Italy, Malta, Portugal, and Northern Ireland (Figure 1). The magnitude of the observed increases 165 ranged from 139% above expected in Portugal to 28% above expected in Northern Ireland 166 (Table 1). In two countries (Germany, the Netherlands) there was no statistically significant 167 difference in observed compared to expected numbers of requests in the ‘after’ period (Figure 1 168 and Table 1). In one country (Great Britain), there was a statistically significant decrease in 169 requests in the ‘after’ period (Figure 1 and Table 1). 170 171 Countries that had higher numbers of COVID-19 related deaths or which provided less 172 government economic support during the pandemic did not appear to have higher numbers of 173 requests to WoW (Table 2). We did however, observe a relationship between higher numbers of 174 requests and both the location of abortion service provision, and the severity of domestic and 175 international travel restrictions (Table 2). In Italy, Portugal, and Hungary, all of which showed 176 significant increases in requests to WoW, abortion is provided mostly in the hospital setting and 177 all enacted stringent stay-at-home requirements. In Northern Ireland and Malta, where 178 significant increases in requests were also observed, in-clinic abortion services are only available 179 by traveling outside of the country, and international travel was restricted during the study 180 periods. In Germany and the Netherlands, we observed no increases in requests, abortion 181 services remained available in clinic settings, and no country-wide domestic travel restrictions 182 were enacted. In Great Britain, abortion services were made available by fully remote 183 telemedicine shortly after lockdown began and we observed a significant decrease in requests. 184 185 186 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 9

187 188 During the first wave of the COVID-19 pandemic in Europe, we observed changes in requests 189 to the WoW online telemedicine abortion service among five out of eight countries in our 190 analysis. Among countries where abortion is legally available within the formal healthcare setting, 191 we observed increased requests to the WoW online telemedicine service in those countries that 192 had more stringent stay-at-home requirements––including country-wide domestic travel 193 restrictions––and where abortion is mostly available only in the hospital setting. Among the two 194 countries where abortion was not legally available within the formal healthcare setting during the 195 study period, and where travel outside the country was restricted, we also observed an increase in 196 requests. Among countries where abortion is legally available but which enacted less stringent 197 stay-at-home policies (including no country-wide domestic travel restrictions) and where 198 abortions are provided outside the hospital setting, we observed no increases in requests. In the 199 sole country where abortion services were made available by fully remote telemedicine during the 200 study period, we observed a significant decrease in requests. 201 202 Our data provide a unique window into requests for self-managed medication abortion using 203 online telemedicine during COVID-19. Key strengths include the ability to measure changes in 204 demand for self-managed abortion from a reliable source that does not rely on self-reporting, 205 and the ability to compare data from before and after the emergence of COVID-19. An 206 important limitation, however, is that there are of course other pathways to abortion outside the 207 formal healthcare setting in Europe, including alternative sources of mifepristone and 208 misoprostol, and non-medication methods. Thus, we cannot measure all demand for self-209 managed abortion during the pandemic. We also lack nuanced insight into the exact reasons 210 underlying changes in requests to WoW for any particular country. It is important to note that in 211 the two countries where we observed no increases in requests, people likely still encountered 212 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 10 challenges to accessing abortion services.22 Future qualitative work could address this important 213 knowledge gap. 214 215 Our results may reflect two distinct phenomena. First, in some countries, more people may be 216 seeking abortion through all channels during the pandemic. The decision to end a pregnancy 217 could be due to the perception of risk posed by COVID-19, reduced access to pre-natal care, 218 and limited social support during lockdowns.23 Additionally, decision-making could be influenced 219 by the economic downturn COVID-19 has precipitated, with many people facing unemployment 220 or financial losses.24 It has also been suggested that social distancing policies may increase rates 221 of unintended pregnancy due to increased time spent at home with a partner or reduced access 222 to contraception.25 223 224 Second, the observed increases in requests may represent a shift in demand from in-clinic 225 abortion to self-managed abortion using online telemedicine. In countries where abortion 226 services are provided predominantly or solely in hospital settings, people may have feared 227 entering a hospital due to perceived or real risk of infection. Even where limited alternatives are 228 available in the community setting––for example in Portugal, where a few private clinics offer 229 abortion services––accessing these services may still have been extremely challenging due to the 230 infection risk associated with public transport, inability to escape surveillance from a controlling 231 partner, or difficulty finding childcare while daycares and schools were closed. Moreover, in 232 countries with no abortion services, the inability to travel outside of the country to seek abortion 233 care due to travel restrictions may have led more people to seek an alternative in online 234 telemedicine. Indeed, our findings from Northern Ireland show a steep increase in requests to 235 WoW following the introduction of lockdown measures, followed by a levelling off shortly after 236 the introduction of within-country abortion services. 237 238 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 11 These challenges to accessing medication abortion during COVID-19, coupled with the 239 increases we observed in requests for online telemedicine are reflected in the fact that people in 240 countries where the challenges are greatest found their own solutions outside the clinic setting. 241 However, while medication abortion provided via online telemedicine is a safe and effective 242 option,10,11 it is not without legal risks.26 Its safety also depends on access to the formal healthcare 243 system when necessary, which is not guaranteed during a pandemic. Additionally, while some 244 people may prefer self-managed medication abortion, others may experience it as fraught and 245 isolating due to stigma or the threat of criminalization, or may have preferred in-clinic care.27 246 Despite the fact that the WHO recommends the use of telemedicine abortion provision models 247 during COVID-19,28 only one country in the analysis, Great Britain, responded to pandemic by 248 purposefully changing their medication abortion service to circumvent the difficulties of in-249 person care. Following the introduction of a fully remote telemedicine service for medication 250 abortion up to 10 week’s gestation, where consultations with healthcare professionals are done 251 by phone or video, and medications are mailed or made available for pick-up from a clinic front-252 desk, requests to WoW decreased to a single consultation. This dramatic decrease points not 253 only to the removal of access barriers posed by COVID-19, but also of pre-existing barriers. 254 Evidence from other settings suggests that similar telemedicine models for medication abortion 255 are safe, effective, and acceptable to patients.29 256 257

258 Our findings provide evidence in support of the need for service model changes to make 259 medication abortion more accessible during and beyond the COVID-19 pandemic.30 Fully 260 remote provision of early medication abortion negates the need to visit a hospital or healthcare 261 facility, thus preserving personal protective equipment, and reducing infection risks for both 262 patients and healthcare providers. Follow-up care can be provided in the clinic if necessary, and 263 patients have clear continuity of care in the rare instances that adverse events occur. Authorizing 264 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 12 and implementing telemedicine models within the formal healthcare setting in line with the 265 WHO recommendations would help to meet the demand we observed for remote provision and 266 would ensure truly patient-centered care. 267 268 269 Contributors 270 ARAA and CEA conceived of the original research question. ARAA, CEA, JGS, and JES 271 contributed to the study design. RG provided the de-identified data. JES conducted the statistical 272 analyses and prepared the tables and figures. ARAA and CEA did the initial data interpretation. 273 ARAA wrote the first draft of the manuscript. All authors contributed to final data 274 interpretation, revised first and subsequent drafts critically for intellectual content, and approved 275 the final manuscript. All authors agree to be accountable for all aspects of the work. ARAA is 276 the manuscripts guarantor. The corresponding author attests that all listed authors meet 277 authorship criteria and that no others meeting the criteria have been omitted. 278 279 280 Competing Interests 281 All authors have completed the ICMJE uniform disclosure form 282 at www.icmje.org/coi_disclosure.pdf and declare: ARAA and JES have received grant support 283 from the Society of Family Planning and infrastructure support from the National Institutes of 284 Health. The authors declare no financial relationships with any organisations that might have an 285 interest in the submitted work in the previous three years. RG is Founder and Director of 286 Women on Web. The authors declare no other relationships or activities that could appear to 287 have influenced the submitted work. 288 289 290 Copyright 291 The Corresponding Author has the right to grant on behalf of all authors and does grant on be-292 half of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all 293 forms, formats and media (whether known now or created in the future), to i) publish, repro-294 duce, distribute, display and store the Contribution, ii) translate the Contribution into other lan-295 guages, create adaptations, reprints, include within collections and create summaries, extracts 296 and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Con-297 tribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic 298 links from the Contribution to third party material where-ever it may be located; and, vi) licence 299 any third party to do any or all of the above. 300 301 Data Sharing 302 No additional data are available. 303 All authors, external and internal, had full access to all of the data (including statistical reports 304 and tables) in the study and can take responsibility for the integrity of the data and the accuracy 305 of the data analysis. 306 307 Ethics Approval 308 The University of Texas at Austin Institutional Review Board reviewed the study protocol and 309 declared the use of pre-collected, fully de-identified data exempt from the need for approval. 310 311 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 13 312 313 Transparency 314 ARAA affirms that the manuscript is an honest, accurate, and transparent account of the study 315 being reported; that no important aspects of the study have been omitted; and that any 316 discrepancies from the study as planned (and, if relevant, registered) have been explained 317 318 Role of the Funding Source 319 This study was supported in part by the Eunice Kennedy Shriver National Institute of Child 320 Health & Human Development of the NIH through Center Grant P2CHD042849, awarded to 321 the Population Research Center at the University of Texas at Austin. The funder played no role 322 in the study design; in the collection, analysis, and interpretation of data; in the writing of the 323 report; or in the decision to submit the article for publication. The authors are completely 324 independent from the funding sources. The content of this article is solely the responsibility of 325 the authors and does not necessarily represent the official views of the National Institutes of 326 Health. 327 328 Dissemination Declaration 329 We plan to disseminate the results to people who have made requests to the WoW service by 330 having a link to the published paper included in the ‘Research’ section of the WoW website. 331 332 All rights reserved. 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June 1st 2020. 452 https://apps.who.int/iris/handle/10665/332240 (Accessed September 4th 2020). 453 454 29. Kohn JE, Snow JL, Simons HR, Seymour JW, Thompson TA, Grossman D. Medication 455 abortion provided through telemedicine in four US states. Obstetrics & Gynecology. 456 2019:134(2);343-50. 457 458 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 19 30. Assis MP, Larrea S. Why self-managed abortion is so much more than a provisional solution 459 for times of pandemic. Sexual and Reproductive Health Matters. 2020 Jan 1;28(1):1779633. 460 461 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 20 Table 1: Actual versus expected numbers of self-managed abortion requests in the 462 “after” period for each country included in the study 463 464 Country Actual Requests Expected Requests Percent Change Over Baseline Trend (95% CI) P Value Portugal 34 14.2 139.0 (54.5, 385.7) < 0.001 Italy 53 31.6 67.9 (23.3, 152.4) < 0.001 Hungary 113 83.2 35.8 (11.9, 71.2) < 0.001 Malta 69 52.3 31.9 (3.0, 76.9) < 0.001 Northern Ireland (UK) 97 75.8 28.0 (4.3, 64.4) 0.001 Germany 465 467.1 -0.5 (-9.0, 9.2) 0.798 Netherlands 47 50.9 -7.7 (-28.8, 27.0) 0.458 Great Britain 1 8.1 -87.6 (-92.9, -66.7) < 0.001 465 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 21 466 Table 2: Financial and health parameters during the COVID-19 pandemic for all 467 countries included in the analysis 468 469 Country Date stay-at- home requirements began Date stay-at- home requirements ended Number of Deaths due to COVID-19 when stay-at-home requirement ended Stringency of stay-at-home requirements (Country-wide domestic travel restriction) Government economic support index Location and scope of abortion service provision Portugal 19/03/20 14/04/20 535 87.96 (Yes) 75 Abortion available on request through 10 weeks gestation with a 3-day waiting period and provided mostly in hospitals. Northern Ireland 23/03/20 10/04/20 476 75.93 (Yes, including to the rest of the UK) 100 No abortion services available until new legislation brought into effect on April 10th 2020. Hungary 12/03/20 04/05/20 351 76.85 (Yes) 75 Abortion available in certain circumstances through 12 weeks gestation and provided in hospitals. No medication abortion available. Malta 17/03/20† 01/06/20 9 NA (No, but no travel outside the country) NA No abortion services available. Italy 23/03/20 10/04/20 18,281 93.52 (Yes) 50 Abortion available on request through 90 days gestation with a 7-day waiting period, and provided mostly in hospitals. Germany 09/03/20 04/05/20 6,692 73.15 (No, only a few specific districts) 88 Abortions provided on request through 14 weeks with a 3- day waiting period, and mostly provided in doctor’s offices and clinics. Netherlands 06/03/20 11/05/20 5,440 80 (No) 63 Abortions provided on request up until viability with a 5-day waiting period, and mostly provided in doctor’s offices and clinics. Great Britain 23/03/20 13/05/20 32,692 76 (Yes) 100 Medication abortion provision changed from in—person to fully remote service model, including phone consultation and pills provided by mail or pick-up at a clinic † Malta did not issue a population-wide directive, so that date that the Maltese government issued 470 a directive to close public places is used in lieu. 471 472 473 474 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint 22 Figure 1: Observed versus expected requests to Women on Web for all countries 475 included in the analysis 476 Cumulative requests in the “before” versus “after” periods are in black and orange, respectively. 477 Vertical dashed lines show the dates when stay-at-home orders were announced. The blue line 478 shows the model without any discontinuities (the null model), and the green line shows the 479 model fit with a discontinuity. for the stay-at-home order. The pink lines are the 250 Monte 480 Carlo simulations from the null model, which support the likelihood ratio test’s finding that the 481 model with discontinuities is a significantly better fit than the null model. 482 All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint Women on Web requests since 01−01−2019 Countries with significant increase in requests 250 300 350 Mar 01 Mar 15 Apr 01 Apr 15 Ma y 01 Hungary 580 600 620 640 660 Mar 09 Mar 16 Mar 23 Mar 30 Apr 06 Italy 160 180 200 220 Mar Apr Ma y Jun Malta 960 1000 1040 1080 Mar 15 Apr 01 Apr 15 Ma y 01 Ma y 15 Northern Ireland (UK) 10 20 30 40 Mar 15 Apr 01 Apr 15 Portugal Countries without significant change in requests 600 800 1000 Mar 01 Mar 15 Apr 01 Apr 15 Ma y 01 Germany 300 325 350 375 Mar Apr Ma y Netherlands Countries with significant decrease in requests 55 60 65 70 75 80 Mar 15 Apr 01 Apr 15 Ma y 01 Ma y 15 Great Britain Data (no restrictions) Data (restrictions) Fit without discontinuity Fit with discontinuity All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for thisthis version posted September 18, 2020. ; https://doi.org/10.1101/2020.09.15.20195222doi: medRxiv preprint