A few weeks ago, Dr. Sanithia Williams was working when her group text, made up of friends active in reproductive rights, lit up with news. Under a federal court ruling, the Alabama OB-GYN read, patients would temporarily be allowed to obtain medication for abortion through the mail after a virtual consultation with a doctor, instead of traveling in person to a clinic.
“I was elated,” Williams recalled. “This is something that people have been working on for a really long time ― opening up telehealth for abortion care.”
About 40% of abortions in the U.S. are done using medication. Eligible patients who are less than 10 weeks pregnant ingest two drugs, mifepristone and misoprostol, which essentially induce a miscarriage.
While the pills are typically taken at home, Food and Drug Administration restrictions have long mandated that one of the drugs, mifepristone, be dispensed in a medical setting. In practice, that means patients must travel to an abortion clinic ― often many miles away ― to pick up a drug that could just as easily be mailed. Leading medical groups oppose the FDA requirement, saying it is especially harmful to poor and rural women.
The American Civil Liberties Union challenged the rule during the pandemic, arguing that unnecessary travel puts patients at risk of contracting the coronavirus. On July 13, a federal judge issued an injunction ordering the FDA to temporarily suspend the in-person dispensing requirements, allowing health care providers to send mifepristone to eligible patients.
But Williams’ excitement soon faded once she realized her patients would not be able to take advantage of the federal ruling. Alabama, like many other states, has existing laws on the books that ban the use of telemedicine for abortion. “As of right now, it has not benefited our patients at all,” she said.
The Promise Of Abortion By Mail
Abortion clinics across the country are carefully examining whether it is possible to utilize the ruling to expand access to medication abortion, said Lorie Chaiten, one of the ACLU attorneys representing the plaintiffs in the lawsuit against the FDA. “Not only was this particular restriction completely medically unnecessary, but it added a very serious risk of viral exposure during the pandemic.”
Chaiten said that she heard from one physician who began delivering mifepristone to her patients last week. The doctor gave each of the eligible patients a choice as to whether they wanted to come in to pick up their medication or would prefer to have it brought to their door by a courier service. All opted to have the medication delivered. One patient reported that she was worried about making an in-person appointment because she didn’t have child care; the injunction allowed her to get the drugs sent to her the following day.
Daniel Grossman, a professor of obstetrics, gynecology and reproductive sciences at the University of California, San Francisco, said it was impossible to know how many clinicians providing medication abortion have started mailing mifepristone or how many patients are eligible. Allowing patients to skip coming into the clinic and providing the service through telemedicine is the safest model of care right now during the COVID-19 pandemic, he added.
“The same barriers that existed before the pandemic — the small number of clinics in some states and laws requiring multiple visits to the clinic — have only been exacerbated during the pandemic,” Grossman said.
It can be hard for patients to make arrangements to visit a distant clinic if they are caring for children at home or have to get time off from work. In addition, many clinics are currently limiting appointments in order to maintain social distancing.
“All of these barriers may make it difficult for patients to get into a clinic before the 10-week gestational age limit for medication abortion,” Grossman said.
Planned Parenthood, where an estimated 37% of individuals seeking abortions go for care, declined to provide details on how it was implementing the change in FDA rules.
Alice Mark, medical director of the National Abortion Federation, a professional association of abortion clinics, said her organization has been helping clinics set up telemedicine systems so they can begin mailing medications.
“One of the things that we did early on during the pandemic was to talk about how we can provide abortion care that is very patient-centered and less clinically centered,” Mark said.
Even before the injunction was in place, she said, many abortion clinics adopted new protocols using telehealth. Clinicians were performing as much of the appointment as possible over the phone to minimize the length of the in-person visit.
“The less time a patient is in the office, the safer it is for the patient and the staff,” Mark said. “There’s no reason that these pills need to be handed out in the clinic.”
A Complicated Web Of Laws
Medication abortion is not just subject to FDA rules. While a safe procedure with rare complications, it is highly regulated in many states through a dense web of laws and health department rules.
In 18 states, clinicians must be physically present when medication abortion is administered to patients, barring the use of telemedicine. Those states include ones where COVID-19 is on the rise, such as Oklahoma, Missouri and Nebraska. Even with the federal injunction, patients in those states must still go to a clinic to get the pills. In other states where telemedicine is not explicitly banned for abortion, clinics are treading carefully to ensure they are complying with all the rules.
“There are more than a thousand laws against abortion that have been put on the books in the states since Roe v. Wade,” said Andrea Miller, president of the private National Institute for Reproductive Health. “Abortion care has high punishments and high penalties. Many providers are operating under very challenging circumstances.”
Still, many working on reproductive rights are cautiously optimistic about the impact of the federal injunction. If people learn that medication abortion can be safely provided in the privacy of patients’ homes, there may be public demand to maintain that option after the pandemic.
“There is in fact widespread hope that we will get to a point where the federal government will stop imposing this medically unnecessary restriction,” said Chaiten, the ACLU lawyer. “We’re so excited that this opportunity is here and that patients can control where and how they do this and their practitioners can use their clinical judgment for what is best and safest for them without these unnecessary restrictions.”