Federal protections around abortion will leap back half a century if the Supreme Court repeals Roe v. Wade, as a leaked draft opinion suggests it will. The reality of how people access abortions, though, has evolved in those 50 years. The majority of U.S. abortions are now induced with medication instead of done surgically, and telemedicine providers of these pills will play a crucial role in serving patients who live in states that sharply limit or ban abortions.
It was only in December that the Food and Drug Administration made permanent a rule change allowing patients to receive abortion pills by mail instead of having to visit specially certified providers in person. Now telemedicine abortion providers will have to grapple with how to serve patients across the country as more states are expected to restrict and criminalize abortions.
“I’m fully aware that my days in certain places may be limited,” said Melissa Grant, chief operations officer of Carafem, which provides both telemedicine and in-person abortion in several states.
Telehealth services are expected to help ease the surge in demand in-person clinics will likely face in states where abortion remains legal. But forcing patients to cross state lines to access this health care will inevitably limit access. And many people are still unaware that telemedicine abortion is a possible treatment, meaning providers are also working to educate patients about their options.
Although mainstream telehealth companies focused on women’s sexual freedom have opted not to provide abortion pills, several nonprofits and organizations focused explicitly on this treatment have been offering telemedicine abortion in the U.S. since the start of the Covid-19 pandemic. Currently, 19 states prohibit abortion provided via telemedicine visits and a two-pill combination (mifepristone and misoprostol) sent through the mail — a procedure that is considered safe and effective in the first 10 weeks of pregnancy.
An additional five to 10 states are expected to limit access to telemedicine abortion if Roe v. Wade is overturned, said Cindy Adam, nurse practitioner and chief executive at Choix, which provides telemedicine abortion services in California, Colorado, and Illinois.
Meanwhile, other areas of the country are expected to see huge surges in demand as people travel to get abortions prohibited in their home states. “That will have an impact on the entire country as people try to travel from areas where they cannot receive service and surge into areas where they can,” said Grant. “It’s already happening as restrictions across the states have made abortion clinics few and far between.”
Telemedicine abortion will be the most accessible option for most of the country, Hey Jane co-founder and chief executive Kiki Freedman said in a statement emailed to STAT. Some patients are already traveling across state lines to access telemedicine abortion and then return home. Others are finding ways to “self source” abortion pills, by getting friends to send the medication from out of state or using the nonprofit Aid Access, which was founded by a physician in the Netherlands and sends the treatment regardless of state law.
After Texas banned abortion after six weeks of pregnancy in September, Aid Access received more than 137 requests per day from the state, according to data from a researcher at the University of Texas at Austin reported in the Texas Tribune. “As we’ve learned in the past 20 years of people using these drugs, they’re not that difficult to use,” said Grant.
But the risk of criminal prosecution will deter some patients, who also could be afraid to seek medical care if they experience an adverse reaction, such as excessively heavy bleeding, which is rare but possible. One study of 1,390 abortions performed by telemedicine and medication found there were 10 serious adverse events, a rate of less than 1%.
Choix is looking into providing support for women and trans and nonbinary people who need to travel out of state, said Adam, but is waiting to see if state laws will penalize people for doing so. A woman in Texas was arrested and charged with murder last month for self-induced abortion, though there was no legal basis for the charges, which were later dropped.
Texas’ new abortion law does invite private citizens to sue anyone who “aids and abets” an abortion, which could potentially include anyone from Uber drivers unknowingly taking a patient to clinic to people sharing information about abortion providers. “When you look at a state like Texas, where they talk about ‘aiding and abetting,’ the language is so general, it really makes it challenging for patients and providers to feel safe providing care this way,” said Adam.
Freedman, from Hey Jane, called on states that will continue to provide abortion to pass legislation that will protect providers and patients from criminal threats.
Hey Jane, Carafem, and Choix leaders said they are prepared to meet the increased demand — “One of the beauties of telehealth is it is such a nimble model,” said Adam — and telemedicine abortion will have to ramp up to help ease the pressure in brick and mortar clinics.
Traditional abortion facilities are struggling to cope with the demand as people travel to seek care, and telemedicine can help ensure that in-person services are reserved for those who need them, the officials said. “I’m hoping telemedicine provides a safety valve,” said Grant, adding that long wait times can have devastating consequences for patients who need an abortion.
While telemedicine could significantly expand access, there are still expected to be barriers for some patients. The pills cause cramping and bleeding for several hours. “If you’re trying to maintain more privacy in your life, if you’re not sharing the decision, it may not be the best option,” said Grant. For some patients, in-person abortion procedures may be a more private alternative.
Traveling, whether to receive telemedicine or in-person abortion care, is also a challenge. “Over 50% of our clients have small children, oftentimes [are] low-income, missing work or school is very challenging in those circumstances,” said Grant. “And these people are oftentimes already marginalized, poor or rural.”
More education is also needed, so that people understand the legalities and what’s available to them. “People hearing that Roe v. Wade is overturned, a lot of people will think abortion is illegal in this country,” said Adam. The possibility of telemedicine abortion is already surprising to patients who are used to this care being stigmatized. “We get calls every day asking, ‘Are the services real?’” added Adam.
Even as telemedicine provides an option unavailable before Roe v. Wade, it is inevitably hardest to reach those who already have less access to health care, said Grant — namely people of color, those who are LGBTQ+, and those who live in rural and lower-income communities. “In the United States we owe to the people we have in this country to take care of them,” she said. “It’s frightening that we’re potentially leaving great portions of our population behind.”