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In March, Stella* made an appointment to get a medication abortion at a health clinic near her home in Texas. Then, the day before her procedure, a federal appeals court upheld Texas Gov. Greg Abbott’s executive order declaring all abortion procedures nonessential during the coronavirus pandemic. With her appointment canceled, Stella turned to Google and found a telehealth abortion program offered by Planned Parenthood of the Rocky Mountains. To get care, she’d have to travel to New Mexico to do a video consultation with a doctor and pick up the necessary medications.
The next day, with a family member who requires 24-hour care in tow, Stella drove 10 hours. Snowstorms made for treacherous driving conditions at times, and Stella’s out-of-state license plates could have gotten her pulled over due to pandemic travel restrictions. But her health needs outweighed the risks of making the trip.
Once Stella reached New Mexico, she pulled over and video chatted with Dr. Kristina Tocce, medical director of PPRM, which has clinics in Colorado, New Mexico, southern Nevada and Wyoming. Tocce relayed Stella’s story to me, concealing identifying details to protect her patient’s privacy. After making sure Stella was a good candidate for a medication abortion, Tocce mailed her the prescriptions she’d need to take. Federal rules prohibited Tocce from shipping Stella’s prescriptions across state lines, so Stella had to arrange to receive them in New Mexico.
Once the coronavirus hit, telehealth became the only way for many women in the US to exercise their reproductive rights. During a time when most states were urging residents to stay home to help flatten the curve, Tocce says PPRM became “overwhelmed” by patients traveling long distances for virtual abortion care. “Some weeks, we served as many people as we did in more than a month,” says Tocce.
Still, due to federal laws, only women with access to specific clinics in 13 states can get a medication abortion without stepping foot in a clinic. And even though “nonessential” procedures have started ramping back up, proposed federal and state laws continue to threaten access to abortion. On the other hand, if access to medication abortion is expanded — particularly the telehealth model that Stella used, where the medication was mailed to her — more women will be able to obtain care easily and safely when they need it.
“Research evidence is clear that [telemedicine for abortion] is just as safe, just as effective, and patients are just as satisfied — if not more so — with this care as compared to in-person service,” says Daniel Grossman, professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco. “Telemedicine is used in just about every area of medicine; there’s no reason to restrict this.”
How telemedicine abortions work
According to the Guttmacher Institute, 89 percent of US counties don’t have any abortion providers. Getting an abortion can be expensive, time-consuming and emotionally draining even when there’s a clinic nearby. Long-distance travel only compounds existing hurdles and makes safe, affordable abortions less accessible for more women.
One legal hurdle specifically targets medication abortions, which are FDA-approved for pregnancies up to 10 weeks: As of 2016, the FDA requires the first pill taken during a medication abortion to be dispensed by a certified provider at a clinic, medical office or hospital. The stated reason for this rule is that the medication is “dangerous,” even though its safety is well-supported. For patients, this means the only way to get a medication abortion is to visit a healthcare facility in person.
“Many countries, including Canada, already provide abortions with fewer barriers and without in-person visits.”
Telemedicine abortions, as a practice, first emerged in Iowa in 2008, when select abortion clinics in the state began using what’s known as a “site-to-site” model. Here’s how it works: A patient goes to a health center or abortion clinic, where a trained staff member reviews their options, including adoption and different types of abortion. If the patient decides to have a medication abortion, the staff member takes their medical history and vitals and performs an ultrasound. This information is uploaded to a secure electronic platform and reviewed by a physician, who then does a video call with the patient to ensure that they want an abortion and that medication abortion is appropriate for them. Then the doctor remotely dispenses pre-dosed medications to the patient via a lockbox, or a clinic assistant hands the patient their medications.
The actual abortion procedure consists of taking two medications, both pills, within a one- to two-day period. The first pill, mifepristone, ends the pregnancy by blocking the production of progesterone. The second medication, misoprostol, empties the uterus, which causes cramping. Some states require patients to take the first pill at a health center, while other states allow patients to take it at home. In all states, patients take the second medication at home. A week or two later, to ensure the abortion is complete, the patient either goes back to the facility for an ultrasound or blood test or they take a urine pregnancy test at home. “People know their bodies well, and most can reliably know if the medication worked or not based on their symptoms,” adds Kristyn Brandi, chair of Physicians for Reproductive Health and assistant professor of obstetrics and gynecology at Rutgers University.
New options on the rise
Since 2016, a research organization called Gynuity has provided “direct-to-patient” telehealth abortions through a program called TelAbortion. This option lets patients get medication abortions without doing any in-person visits. TelAbortion, which is now available in 13 states, isn’t hamstrung by FDA regulations because it’s technically a study, not a consumer healthcare service.
“When you think about it, once the patient gets the drugs in the mail, there’s no difference between our study and any other type of medication abortion,” says Gynuity senior medical associate Elizabeth Raymond. “You talk to the same kind of doctors, and it’s the same medicine. The only difference with TelAbortion is how you get the medication.”
TelAbortion has a strong safety record. In a 2019 study involving 190 people who took medications sent through the TelAbortion program, 93 percent had successful, complication-free abortions. Interest in TelAbortion has risen since COVID hit: Since mid-March, the average number of packages shipped per week has been more than twice the average weekly shipment volume earlier in the year, Raymond reports.
Telemedicine is one of the few studied interventions shown to decrease the incidence of second-trimester abortions.
The coronavirus outbreak has also led to a new abortion option: a “no-test” medication abortion, which is so far only offered at a limited number of US clinics. What distinguishes the “no-test” model is that it doesn’t require patients to get ultrasounds, or any other tests, before having abortions. Leah Coplon, a program director at Maine Family Planning, the state’s largest reproductive health organization, explained the process to me. As long as a patient has no contraindications, after an intake visit with a staff member, they videoconference with a provider, who prescribes mifepristone and misoprostol. The patient can then drive to any one of Maine Family Planning’s 18 clinics to pick up the drugs, along with ibuprofen, condoms, a birth control method if desired and ordered by the provider, clear instructions, a 24/7 after-hours number, and two pregnancy tests. Afterward, the patient receives at least one follow-up phone call from a staff member.
“The main reasons we screen with an ultrasound or pelvic exam are to assess the gestational age so it’s not too far along to be reasonably safe, and to make sure the patient doesn’t have an ectopic pregnancy,” Raymond explains. (Medication abortion is only known to work if a pregnancy is in the uterus; an ectopic pregnancy occurs outside the uterus.) “By asking about the last menstrual period and other risk factors and symptoms, we can select out those patients for whom this treatment would be safe without ultrasound,” she adds. The American College of Obstetricians and Gynecologists supports the no-test approach, and research shows it’s safe and effective. “Many countries, including Canada, already provide abortions in a similar way with fewer barriers and without in-person visits with providers,” Coplon adds.
Safely expanding access
In the US, 18 states still prohibit the use of any telemedicine for abortion. Since healthcare providers are licensed to practice by states, they can only furnish care to patients who are physically in that state. Generally speaking, telehealth services became much more accessible to patients after the pandemic hit. But relaxed rules regarding telehealth use don’t apply to abortion. That’s why Stella had to drive from Texas to New Mexico for a video visit, and then have her medications mailed to a New Mexico address. “Crossing states lines is true of a lot of patients who need an abortion and go to a clinic in-person too,” Raymond points out.
Ultimately, telemedicine can play a role in making safe, affordable abortions readily available to all patients. “There are real public health benefits to this,” Grossman says. Telemedicine is one of the few studied interventions shown to decrease the incidence of second-trimester abortions, the leading explanation being that telemedicine increases access to first-trimester abortions. Additionally, although second-trimester abortions have proven to be very safe, they carry a higher risk of complications because the uterus is larger.
There’s also a mental health benefit to telemedicine abortion: “If someone is sure they want to end a pregnancy, they want to do it as soon as possible,” Brandi says. “It’s better for their well-being.” Research shows that patients who use telemedicine abortion are just as satisfied with the experience as those who see a doctor face-to-face. Patients choose to go the virtual route for a variety of reasons. Some, Raymond says, just prefer “the privacy of being at home.”
Additionally, studies show the two procedures are equally safe. “The reality is, even when someone has an in-person visit for medication abortion, they take the medications at home,” Grossman says. “There’s nothing happening in terms of the abortion process in the clinic; that happens at home.” With safety in mind, providers give patients information on what to expect, signs of potential complications that indicate they need to seek care, and a phone number to call if they have any questions.
Lastly, the cost of using telemedicine for abortion is often the same as the cost for in-clinic abortions. However, telemedicine may save patients money, since they don’t have to come into the clinic twice (for the initial consultation and then the procedure) or, in some instances, travel as far if they do come into the clinic. And although not all health insurance covers abortions, some cover ultrasounds as long as they are not performed at abortion clinics.
“This is a model that is used in other countries with great success,” Coplon says. “People face monumental hurdles in seeking abortion care, including child care, distance to a clinic, time off work and expense. As awareness increases that safe, effective, high-quality abortion care can be delivered in this way, more people may seek out clinics who provide those services.”
* Not their real name