Abortion rights advocates are exploring how technology might preserve or even expand women’s access to abortion if the Supreme Court scales back Roe v. Wade.
A nonprofit group is testing whether it’s safe to let women take abortion pills in their own homes after taking screening tests and consulting with a doctor on their phones or computers. Because the study is part of an FDA clinical trial, the group isn’t bound by current rules requiring the drugs be administered in a doctor’s office or clinic.
The group, called Gynuity Health Projects, is carrying out the trial in five states that already allow virtual doctors to oversee administration of the abortion pill, and may expand to others. If the trial proves that allowing women to take the pill at home is safe — under a virtual doctor’s supervision — the group hopes the FDA could eventually loosen restrictions to allow women to take pills mailed to them after the consult.
If FDA took that step, it could even help women in states with restrictive abortion laws get around them, potentially blurring the strict boundaries between abortion laws in different states if — as is likely — the Senate confirms a high court justice who is open to further limits on Roe.
Telemedicine “will become much more of a flashpoint because medication abortion is a method so many patients [are] looking to use,” said Elizabeth Nash of the Guttmacher Institute, a research group that supports abortion rights.
Right now, even in states that allow a licensed provider to administer the abortion pill by video hookup, the provider must watch, in person or by video, as a woman takes the first medication in a clinic or other health care setting. The drugs abort the fetus without surgery but are safe and effective only in the first 10 weeks of pregnancy. If the group’s study shows it’s safe for women to administer the drug themselves after an online consultation with a health care provider, it will petition the FDA to lift the requirement.
If that were to occur — a big “if” under a Republican administration — states with more permissive abortion laws could expand access to the procedure to clinics served by video hookups, effectively reducing the long distances many women often travel to find a provider.
But it could also potentially boost access for women living in states with more restrictive laws as they might have an easier time obtaining prescriptions by mail, besides having a greater number of telemedicine clinics to go to if they were able and willing to travel across state lines.
“We know even now that some women are accessing these medications online — it may not be strictly legal, but people are doing that,” said Daniel Grossman, a University of California, San Francisco researcher who has studied the safety of telemedicine abortions. “It would be a hard thing to crack down on.”
Grossman notes that women in other countries that prohibit abortion have used the internet to buy abortion pills by mail and get around restrictions.
Not everyone is convinced, however.
“It could open some doors,” Nash said. “Still, people [in restricted states] would have to jump through hoops.”
For example, restrictions on waiting periods and a counseling requirement would apply, and doctors who prescribe the pills would still have to be licensed in the state where the patient resides — though patients don’t usually face penalties for failing to comply with state abortion laws.
“All of the burden falls to the provider,” she said. “But if the state wanted to, there’s potential for women to be charged in some way.”
Anti-abortion lawmakers in Texas wouldn’t speculate on whether they might change state law to impose penalties on patients if the FDA loosened regulations on telemedicine abortion, but they believe existing restrictions in the state’s telemedicine law, which are being challenged in court, would prevent women from obtaining the medicines remotely.
Gynuity, which is currently enrolling patients in Maine, Hawaii, Oregon, New York and Washington state, plans to expand the telehealth-abortion study to women in other states where telemedicine for abortion has not been outlawed.
Roe shift could limit medication abortion in many states
In 2008, a Planned Parenthood affiliate in Iowa became the first to offer medication abortions through telemedicine to rural residents in that state. A patient comes to one of the group’s clinics throughout the state and receives a checkup before she is connected remotely to a doctor at another clinic who looks through her records to determine whether she’s suitable for a medication abortion.
If the patient is deemed suitable for the procedure, the doctor directs on-site staff to hand the patient the first dose of pills.
Medication abortions accounted for about a third of all non-hospital abortions nationwide in 2014, according to Guttmacher. FDA studies show that complications are rare but usually include hemorrhage or failure to end the pregnancy.
“It’s so critical for women who are three to four hours away [from an abortion provider] to get access to this care,” said Evelyn Kieltyka, senior vice president at Maine Family Planning, which is participating in the Gynuity study. About 4 percent of the clinic’s patients opt for the program, which the clinic calls “Meds by Mail,“ said Leah Coplon, director of abortion services.
In 2014, 1 in 5 women needed to travel at least 43 miles to reach an abortion clinic, according to Guttmacher. The number of clinics has declined dramatically since then.
If the Supreme Court were to overturn the constitutional protection of abortion, regulation would likely revert to the states. And in states that ban abortion, telemedicine abortion would also be banned.
Nineteen states already ban doctors from providing abortion pills through telemedicine, according to Guttmacher: Alabama, Arizona, Arkansas, Indiana, Kansas, Louisiana, Michigan, Mississippi, Missouri, Nebraska, North Carolina, North Dakota, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, West Virginia and Wisconsin.
In the event the high court allows states to restrict the procedure further, however, the availability of telemedicine abortion could make it easier to secure access for women willing and able to travel to California, Connecticut, Delaware, Hawaii, Maine, Maryland, Nevada and Washington.
And if research shows it is safe to induce miscarriage at home, internet providers and abortion rights groups could also foster greater access to the drugs needed to carry out a medication abortion through the mail — something that is already happening now. This access troubles abortion foes who already fear that technology is moving faster than state abortion laws.
Existing internet apps such as Nurx — created by a company that recently added Chelsea Clinton to its board — allow women in 18 states to order various forms of contraception from their phones or computer and have the medications delivered by mail.
That is “worrisome,” said Rebecca Parma, an associate at the anti-abortion group Texas Right to Life, which considers emergency contraception such as Plan B — known as the “morning-after pill”— a form of abortion. “I don’t know how much is in place to make sure such apps are compliant with state law.”
Telemedicine abortion has already survived legal challenges in Iowa, Oklahoma and Idaho, where courts have rejected arguments from anti-abortion groups that claim it is too dangerous to provide women with abortion pills outside of a physician’s direct care.
Bans on the procedure face fresh court challenges in other states including Indiana and Texas, where sweeping new lawsuits against abortion restrictions have been brought.
While awaiting a more conservative high court, many states are adding hurdles to clinics that seek to offer medication abortions via telemedicine. These include mandatory waiting periods, which could make it hard or impossible for some women to get a medication abortion in the first 10 weeks of pregnancy. Iowa’s Supreme Court recently struck down a law mandating a 72-hour waiting period between a counseling session and an abortion procedure. Still, more than two dozen states require women to wait some period of time — usually 24 hours — between the two appointments. An appeals court struck down Indiana’s 18-hour waiting period law, signed by then-Gov. Mike Pence, last week.
Other states are trying to push bans on abortion earlier in pregnancy. For instance, the Iowa Supreme Court also struck down the state’s telemedicine abortion ban in 2015, but the state recently prohibited abortions after about six weeks. The six-week law has been blocked from taking effect until a legal challenge to it is decided.
Data might support expansion of telemedicine abortions
In a related effort to expand telemedicine abortions, one of the Gynuity participants, Maine Family Planning, is also challenging a state requirement that a physician oversee the administration of abortion pills, arguing in a federal lawsuit that nurse practitioners and midwives should be allowed to provide abortions including via telemedicine.
The study may provide evidence relevant to this and other court cases.
“It’s super important to continue to make sure the data” is part of the discussion, said Kelly Blanchard, president of research group Ibis Reproductive Health.
Ibis recently collaborated on a study with Grossman, the University of California, San Francisco researcher, that analyzed the outcomes of 19,000 medication abortions in Iowa over seven years, about half of which were administered via telemedicine. They found that medication abortions provided through telemedicine were just as safe as those administered in person.
In a 2012 study, Grossman showed that patients preferred to get abortion pills prescribed through telemedicine doctors rather than in person, because of decreased travel times and the greater availability of appointments.
Self-managed abortion is different than it was in the era of women using coat hangers or poisons to induce miscarriage, Grossman said. “These medications are safe and effective enough that they meet the criteria for being available over the counter.”
Continued data on the safety and effectiveness of telemedicine can “debunk myths and ensure legislators’ discussions reflect what is really true about the success of these approaches,” Blanchard said.