Reproductive rights experts point to evidence showing medication abortions prescribed via telehealth have increased during the pandemic and have been as safe and effective as those prescribed in person, yet FDA’s permanent lifting of the in-person dispensing requirement for one of the drugs in the two-step medication abortion regimen has been overridden by requirements in 19 states and additional states are looking at limiting abortion access.
More states are moving to ramp up abortion care restrictions while they await the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization, which centers on a Mississippi law that bans abortion after 15 weeks. Experts have predicted that in June, SCOTUS will rule in favor of the Mississippi law and overturn Roe v. Wade in the process, which would allow states to impose even more restrictions on abortion across the board, including medication abortion, or ban it altogether.
Two pills are used to induce early abortions or treat early miscarriages: mifepristone and misoprostol. Both drugs can be taken at home. Mifepristone is subject to FDA restrictions under a Risk Evaluation and Mitigation Strategy (REMS); misoprostol is not. FDA relaxed its mifepristone in-person prescribing REMS restrictions during the pandemic to make the pill more accessible via telehealth, and, in December, the agency made those changes permanent. But FDA’s initial strict REMS requirements had already paved the way for a number of states to put in place even stronger restrictions.
Kaori Sueyoshi, director of innovation at Planned Parenthood Federation of America, said the FDA’s removal of in-person requirements was a significant step in expanding abortion access during the pandemic.
“The fact that medication abortion accounted for more than half of all U.S. abortions in 2020 makes it clear that when people have access to the health care they need, then they can indeed get the health care they need,” Sueyoshi said.
Yet despite the increased flexibilities, some states still have in-person requirements for medication abortion, which impose “medically unnecessary restrictions,” according to Jaclyn Dean, congressional relations consultant on reproductive justice for the National Partnership for Women & Families, and states are increasingly taking strips to outlaw abortion in general.
Currently, 19 states prohibit telehealth for medication abortion and there is a potential for that number to increase, according to experts.
Sueyoshi said during this legislative season alone, there are more than 40 bills introduced across 24 states that aim to limit medication abortion. The bills range from total bans on medication abortion to bands on telehealth or at-home delivery.
“For example, just this week, the governor of South Dakota signed a law that would mandate three … in-person visits for patients seeking a medication abortion. South Dakota only has one abortion provider and already has a 72-hour waiting period,” Sueyoshi said. “Over in Kentucky, lawmakers are one step away from passing a bill that would add a myriad of restrictions to medication abortion. And in Ohio, this week lawmakers held a hearing on legislation to ban telehealth for medication abortion and require that patients have an in-person visit 24 hours before receiving their medication."
On the other hand, Kimberley Lufkin, senior U.S. communications manager at the Guttmacher Institute, said there are cases in Montana and Ohio challenging telehealth bans for medication abortions and in both states the restrictions cannot be enforced due to court action.
“Medically unnecessary restrictions on abortion like mandatory ultrasounds and waiting periods often force patients to make multiple trips to a health center, sometimes traveling very far distances, which can push patients further into pregnancy before they can ultimately access abortion,” Dean said
Although medication abortion via telehealth has been a topic of discussion in the larger push for expanded telehealth access since the beginning of the pandemic, Lufkin said some states also are preventing access to abortion through telemedicine entirely.
“A substantial majority of states with the harshest restrictions also have laws that it difficult or nearly impossible or illegal to provide medication abortion without some type of in-person visit,” Lufkin said. “So most telehealth providers offering medication abortion are not, and will not be, able to do so in these states.”
Dean said anti-abortion medication legislation also is gaining traction among some some federal lawmakers because they recognize the growing importance of telehealth to abortion access.
“At least one bill in the Senate seeks to restrict the use of telehealth for so-called ‘chemical abortions,’ and legislators have also attempted to attach similar amendments to larger legislation,” Dean said. “For example, several sought to attach restrictions on reproductive health care via telehealth in a recent bill to support and provide more resources for the United States Postal Service.”
But several states are also going In the opposite direction, seeking to bolster abortion rights. States including Colorado, New Jersey, Vermont and Michigan have passed legislation that will add protections to the right to abortion in state laws through statute or constitutional amendment, according to Sueyoshi. California Gov. Gavin Newsom (D) signed the Abortion Accessibility Act into law this week, which makes abortions more affordable for patients with private insurance plans.
Federal lawmakers supportive of a women’s right to choose also have sought the support of the administration, Dean notes. Reps. Carolyn Maloney (D-NY), chair of the House Oversight Committee, and Oversight members Ayanna Pressley (D-MA) and Cori Bush (D-MO) recently sent a letter to HHS Secretary Xavier Becerra urging the administration’s new Reproductive Health Care Task Force to protect and expand access to medication abortion.
On Jan. 21, HHS launched a department-wide task force charged with bolstering access to reproductive health care amid an onslaught of state and court efforts to cut off such access. HHS pointed to an “unprecedented number” of state laws, regulations and policies aimed at undermining access to sexual and reproductive health care and noted the Supreme Court was making decisions that could impact the right to abortion and have a chilling effect on the availability of other reproductive health care services.
Sueyoshi and other reproductive rights advocates said the current and proposed state restrictions on medication abortion via telehealth or in person are not rooted in science.
They point to a growing body of research demonstrates that the protocol used to provide medication abortion care during the pandemic is as safe and effective as in person care.
Sueyoshi said there is little difference between the in-person versus telemedicine medication abortion because either way the process is completed at home or in any setting where the patient feels comfortable. Medication abortion has a safety record of over 99%, according to Sueyoshi, and is safest and most effective earlier on in pregnancy.
Dean said in March 2022 the World Health Organization published new guidelines providing recommendations for the use of telemedicine for abortion care and cited such services as an effective and successful intervention that improves quality access to reproductive care.
“A pilot study called TelAbortion at the start of the pandemic provided access to video consultations and mailed medication abortion pills to their clients, and they found that about twice as many people had abortions in March and April 2020 compared to January and February 2020,” Dean said. “Another organization, that helps people obtain medication abortion pills by mail, Aid Access, also saw a large influx of requests between March and April 2020."
Experts also say that abortion medication via telehealth helps improve health equity. It eliminates some of the barriers that formerly prevented people from getting care and that disproportionately impacted people of color, people in lower socioeconomic classes and those who live in rural or medically underserved areas.
Sueyoshi said having telemedicine as an option allows women to receive essential health care services in a way that fits their lives.
“Providing care via telemedicine gives patients the freedom and comfort of having an abortion at home without driving long distances, finding child care or finding transportation,” Sueyoshi said. “It has also been especially critical during the ongoing pandemic in efforts to keep patients and health center staff as safe as possible.”
Sometimes, attending an in-person abortion clinic for a consultation with a provider can be uncomfortable for patients, Dean noted.
“Medication abortion eliminates many of these barriers and more--for many, it means that they can take medication abortion with the guidance and consultation of a provider, but in the comfort of their own home under their terms, with loved ones to care for them and without the harassment or stigma they may face from anti-abortion protesters at a physical clinic,” Dean said. -- Cara Smith (csmith@iwpnews.com), Beth Wang (bwang@iwpnews.com)
