Every restriction on access to abortion draws the metaphoric walls closer. On who can dispense drugs, on what clinical tests are required first, on how far along the pregnancy can be—the rules are all designed to delay, deter, and delegitimize. It’s a Death Star Trash Compactor. The box around abortion gets smaller and smaller.
That’s policymaking; technology, meanwhile, tends to see boxes as something to think outside of. A long-awaited study published this week in the journal Contraception offers a way around tightening regulations: telemedicine. Abortion medication provided by mail, administered by a practitioner working via videoconference, could safely enlarge the geographic footprint of clinics and providers. “Many clinics already use telemedicine for other services,” says Elizabeth Raymond, a researcher at Gynuity Health Projects who leads the project. “Our study validates that this is a feasible, safe, and effective approach.”
A few US states, most recently Louisiana and Georgia, have passed so-called heartbeat bills that outlaw abortion after about six weeks of pregnancy. But thanks to legal and other challenges, none have gone into effect. Still, those laws are just the most recent iterations of restrictions that have made clinics that provide abortions vanishingly rare. In 27 US cities with populations greater than 50,000 people, there’s no abortion clinic within 100 miles. And one of the drugs used in medication abortions is so regulated by the Food and Drug Administration that pharmacies can’t even dispense it; you have to get it in a clinic, from a provider.
As a consequence, one of the main barriers to abortion is straight-up access. “Clinics are often overscheduled. Women wait a long time to get an appointment, or the clinic’s schedule is not convenient for their work or their life,” Raymond says. “At many clinics there are protesters, and walking through those—having done it myself, as a physician and researcher—is intimidating.”
So Raymond’s study, called TelAbortion, removes IRL from the middle of the equation. A phone call with a clinic starts the process, and depending on the state, women still have to get an ultrasound or pelvic test, nominally to confirm the gestational age of the pregnancy. Some states require further tests. (“It’s much easier to get an ultrasound or lab tests in this country than an abortion,” Raymond says.) Those test results go to a provider licensed in the woman’s state—but not necessarily located there.
Then a provider and patient talk to each other via privacy-rule-compliant videoconferencing software on a computer or phone. If she qualifies and meets the standard of care for a medication abortion, the provider mails her the pills (200 mg of mifepristone and eight tablets of misoprostol at 200 mcg each—you take four and, if you don’t have any bleeding within 24 hours, you take the other four).
The mailing part is a little tricky, not because of medical outcomes—this procedure’s so safe that some folks argue it should be over-the-counter—but because of regulations. The drugs have to be mailed to an address in the state where the provider is licensed. TelAbortion is covered by an Investigational New Drug application, so participants can get mifepristone outside the walls of a clinic. Also, some states explicitly say abortion can’t be administered via telemedicine, and the study has to abide by each state’s laws.
That said, you can imagine that it might be a lot easier for a woman in Idaho to get across the Washington state line and get abortion medications mailed from a provider who lives in Oregon than it would be for that woman to shlep to Portland. “We have six clinics providing the service in eight states, and one of them is Georgia. The provider is not in Georgia, like, ever. The study coordinator is not in Georgia. But the clinic is in Georgia and the provider is licensed in Georgia,” Raymond says. “Our clinic in Maine, which is in this paper, is also providing the service in New York.”
In other words, telemedicine can expand the provision of safe abortions—maybe helping stave off the kind of public-health catastrophe that has followed abortion restrictions in the past. “It’s a really revolutionary idea, and this is a groundbreaking study,” says Ushma Upadhyay, a public health researcher and ob-gyn at UC San Francisco. Telemedicine as part of abortion isn’t itself the new idea; prior studies have looked at that. Going directly to the patient in her home, though—that’s new.
And its success could do more than just hold the line against new regulation—it could push back. As of 2019, 19 states ban the use of telemedicine in abortion. “They carve out abortion for no evidence-based or medical reason,” Upadhyay says. “And these also tend to be the most rural states with the fewest abortion providers.” Raymond’s TelAbortion work helps show that telemedicine is safe, and could provide support in lawsuits against that restriction.
Further research might even challenge the rules requiring ultrasound verification of gestation time. Upadhyay hopes to compare the success rates of TelAbortion’s approach with and without an ultrasound or exam. (It turns out that when women say they’re certain of when they got pregnant, they’re right 98 percent of the time.) Ultimately the TelAbortion results could even induce the FDA to clarify or change its prescribing rules for mifepristone, too.
Or the results could spark an arms race, with new regulations emerging from anti-abortion politicians, requiring new answers from science, and so on. Boxes beget boxes—or at least they will until the Supreme Court takes these new restrictions as an impetus to reconsider the decision that made abortion legal in the US in the first place.