The Challenges of Innovating Access to Abortion

The New Yorker (Mar. 6, 2019): The Challenges of Innovating Access to Abortion, by Sue Halpern:

As states across the country continue to enact burdensome and medically unnecessary restrictions on safe and legal abortion care, last week the New Yorker examined the landscpe for access to abortion care via telemedicine.

Hawaii has one of the least restrictive abortion policies in the country, and yet services are still hard to come by due to geographic challenges. In 2018, only two of the Hawaiian islands had abortion providers: Maui and Oahu. As a result, medication abortion via telemedicine is a vital service to Hawaiian women seeking care.

Telemedicine—obtaining medical services over the phone or through the Internet—is not a new phenomenon. In the U.S., it began to take off in the late nineteen-fifties, and a 2016 federal grant to increase access to health care in rural areas has made it more mainstream.

TelAbortion, a service provided by the reproductive-health initiative Gynuity, enables a woman to terminate a pregnancy in the privacy of her own home, but with medical oversight. The service is available in Hawaii, Maine, New York, Oregon, and Washington as a five-state trial launched by Gynuity in response to the ever-diminishing availability of abortion services in the United States.

Although the five states in the TelAbortion trial have some of the most accommodating abortion laws in the country, Gynuity is only able to run the trial with a waiver from the F.D.A., which has put onerous restrictions on the distribution of abortifacients. Mifepristone is one of only seventy-five F.D.A.-approved medications controlled through its Risk Evaluation and Mitigation Strategy (REMS), and only one of fifty with its most stringent restrictions. According to the F.D.A., REMS, which regulates such drugs as Thalidomide, which is known to cause birth defects, is a drug-safety program for “medications with serious safety concerns to help ensure the benefits of the medication outweigh its risks.” The REMS mandates that mifepristone only be dispensed to a patient in a clinic, medical office, or hospital. A doctor can’t send a patient to their local pharmacy with a prescription for the medication, because pharmacies are not allowed to carry the drug. This limits the ability of physicians to administer the medication and of patients to obtain it, despite nearly twenty years of evidence demonstrating its safety and efficacy. The American Congress of Obstetricians and Gynecologists has recommended eliminating the REMS altogether. An F.D.A. panel of experts recommended eliminating one aspect of the REMS in 2016 when the mifepristone REMS came up for review. It was overruled by the F.D.A. commissioner, an Obama appointee.

Medication abortion should make access to care easier, but some of the more recent restrictions passed by state legislatures also make getting medication abortion, which is already constrained by the REMS, more difficult. Seventeen states require that a clinician be physically present when mifepristone is taken. Thirty-four states require those clinicians to be licensed physicians. Women who obtain and self-administer medication abortion outside the traditional medical establishment, typically from an Internet pharmacy, may be subject to arrest and imprisonment. In 2013, a woman in Pennsylvania who had ordered them online for her daughter was sentenced to a nine-to-eighteen-month jail term for “providing abortion without a medical license, dispensing drugs without being a pharmacist, assault and endangering the welfare of a child.”

It is now possible to order these medications through AidAccess, a program overseen by a doctor in the Netherlands. While no one has been arrested, the promulgation of fetal-homicide laws—thirty-eight states now have them—and aggressive prosecutors puts women at risk of arrest if they obtain them in this manner.

According to the Guttmacher Institute, “these laws are even being used to pursue women who are merely suspected of having self-induced an abortion but in fact had suffered miscarriages.”