Wednesday, August 8, 2018
Aug. 7, 2018 (WIRED): Telemedicine Could Help Fill the Gaps in America's Abortion Care, by Garnet Henderson:
If a woman in Lubbock, Texas wants an abortion, the nearest clinic is 308 miles away in Fort Worth, forcing her to take time off from work, pay for travel, and likely arrange childcare to get there. If that same woman is less than ten weeks along, she’s a candidate for medication abortion—which could, theoretically, be completed in the privacy of her home. Texas, however, requires that the outdated FDA protocol for medication abortion be followed to the letter, and so the woman will have to return to the clinic within one to two weeks for a follow-up visit, despite evidence that an in-person follow-up is unnecessary.
So what if she could video chat with a doctor, pick up a prescription from her regular pharmacy, and manage her own abortion with on-call medical support— otherwise known as a telemedicine abortion?
As it turns out, similar services are already available in a handful of states, though they still involve physical visits to an office. A growing body of research suggests that medication abortion could be offered without any in-person interaction at all. It’s a possibility that is already the subject of an intense political debate that is likely to intensify with a Supreme Court more hostile toward abortion rights.
The first U.S. telemedicine abortion program began in Iowa ten years ago. Between 2008 and 2015, four Planned Parenthood clinics in Iowa performed 8,765 abortions via telemedicine. Each clinic followed the same basic protocol: a patient would come into the clinic for an intake appointment, including an ultrasound, and a doctor would review her images and medical history remotely. After talking to the patient via videoconference, the doctor would enter a password to unlock a drawer in front of the patient. Inside, there were two pills. The first pill, mifepristone, the patient took with the doctor still watching. The second pill, misoprostol, she took at home. Within two weeks, the patient returned to the clinic for a follow-up to ensure the abortion was complete.
A study of the Iowa program, which included the records of about 20,000 patients, showed that telemedicine abortion is just as safe and effective as meeting with a doctor face to face. Patients in Iowa were also more likely to have their abortions earlier in their pregnancies after telehealth was introduced.
Planned Parenthood affiliates in ten states currently offer telemedicine abortion. Telehealth services are also offered at a Whole Woman’s Health clinic in Illinois and in Maine at Maine Family Planning. The Iowa program was interrupted after the state passed a law banning telemedicine abortion in 2013, but was reinstated in 2015 when the Iowa Supreme Court ruled that law unconstitutional. Idaho was forced to repeal two laws banning the telemedicine abortion in order to settle a lawsuit with Planned Parenthood in 2017.
Despite these successful legal challenges, nineteen states currently ban telemedicine abortion. Both Oklahoma and Arkansas have tried to ban medication abortion altogether, including remote practices, but Oklahoma’s law was overturned, and a federal judge placed the Arkansas law on hold pending trial.
The Lilith Fund is one of numerous plaintiffs, led by Whole Woman’s Health Alliance, that recently announced a challenge to dozens of abortion restrictions in Texas, including the state’s telehealth abortion ban. Whole Woman’s Health Alliance is leading similar lawsuits in Virginia and Indiana.
Access to telemedicine abortions would be especially beneficial to patients in rural and other underserved areas. That doesn’t mean it will fix all problems of abortion access, of course. Medication abortion is only FDA-approved up to ten weeks of gestation, and some candidates for the procedure still prefer an in-clinic abortion. Medication abortion is a slightly longer process that still requires a follow-up visit.
The procedure—especially with some changes that make it more fully remote—has the potential to dramatically improve access. With special permission from the FDA, Gynuity Health Projects is conducting a study in Hawaii, Oregon, Washington, New York, and Maine that allows patients to receive pills by mail, eliminating the need for doctors to stock them. Mifepristone, pill number one, is regulated under the FDA’s Risk Evaluation and Mitigation Strategies, which means the medication has to be dispensed by a certified prescriber, not a regular pharmacist. While patients in that study still have to get an ultrasound and medical exam, scientific evidence suggests the process could be even simpler, foregoing the ultrasound altogether. Doing so would make the process even more self-determined.