Safe care at home: The untapped potential of telemedicine abortion during the COVID-19 pandemic and beyond
Isabel R. Fulcher & Elizabeth Janiak
The word “essential” has wielded special power during the COVID-19 pandemic. It determines if you will be able to work in-person or remotely, visit local businesses or order online, and receive certain healthcare services or delay them. Early in the pandemic, leading clinical organizations in obstetrics and gynecology affirmed that abortion care is an “essential component of comprehensive health care” and that, accordingly, abortion services cannot be curtailed due to the pandemic.1 Any delay in abortion care has profound consequences, as it may restrict the type of care someone is able to receive or, worse, make the service inaccessible.2
Fortunately, abortion care can be delivered both through low-morbidity, low-cost in-person procedures, and through pills patients can safely take at home through telemedicine.3 Yet, a recent survey found that only 4% of abortion clinics had mailed abortion pills (mifepristone followed by misoprostol) to patients as of May 2020.4 Despite clear public health benefits and continuing patient need, the potential of telemedicine abortion remains untapped due to ongoing political attacks on abortion access.
The pandemic worsens an existing access crisis
Attacks on abortion care in the United States are not new. Over the past twenty-five years, access to this essential health service has declined due to rapidly proliferating state-level abortion restrictions.5 These laws target both abortion providers and their patients by imposing burdensome and medically unnecessary restrictions, such as mandatory waiting periods (25 states), in-person counseling laws (14 states), and needlessly stringent structural requirements for abortion facilities (12 states).6 In addition, certain laws worsen access to care for young people whose parents are unsupportive of abortion; minors are delayed an average of a week or more by state laws requiring parental consent for abortion.7,8 At the federal level, the Hyde Amendment, an annually renewed congressional budget rider, prohibits federal Medicaid dollars from being used for most abortion care. As a result, low-income people in 34 states have severely limited access to abortion through public insurance.9 It is in this context of burdensome laws and regulations that the Food and Drug Administration’s Risk Evaluation and Mitigation Strategy (FDA REMS) for mifepristone worsens access further by mandating that the medication be given to the patient directly in a clinic or hospital under the supervision of the prescriber.10 This means that patients cannot receive mifepristone as they would other drugs via a prescription to a retail pharmacy.
Similar to the word “essential,” these restrictions take on a new importance in the wake of the COVID-19 pandemic. Specifically, in-person counseling visit laws, mandatory ultrasound laws, and mandates that the prescribing physician be present during mifepristone administration result in medically unnecessary clinic visits that increase the risk of COVID-19 exposure for both patients and providers. Based on state-level abortion data from prior years, our recent work found that over 30,000 in-person visits would be averted per month across the United States if these policies were repealed.11 This also meant that from March 2020 to July 2020, over 120,000 such medically unnecessary clinic visits occurred.
The effects of the pandemic, when combined with such legislative provisions, not only pose additional direct threats to the health of patients, but they may also worsen the impact of existing barriers to abortion care. Due to the Hyde Amendment and state restrictions on insurance coverage of abortion, over half of patients pay for abortion care out of pocket.12 Consequently, financial barriers are the greatest cause of delay among people seeking abortion.13,14 As the COVID-19 pandemic drives record unemployment numbers, needing to self-pay for abortion may create more hurdles than ever. Furthermore, traveling to receive care – especially in states with mandatory abortion waiting periods or separate counseling visits – may be near impossible for people experiencing financial hardships or full-time childcare responsibilities due to the pandemic. Fear of COVID-19 exposure at the clinic or during transport compounds these challenges, and may deter pregnant individuals from seeking care in a timely manner—or at all. Recognizing these burdens, a federal judge suspended the in-person requirement for dispensing mifepristone in July 2020, thereby allowing medication abortion to be mailed or delivered to patients.15 On January 12, 2021, the US Supreme Court reversed this decision, ruling that the in-person dispensing requirement for mifepristone should be reinstated. It remains to be seen whether the FDA will voluntarily revise the REMS under the Biden Administration, based on the robust safety data that has accrued over the 20 years since the drug’s initial approval in the United States. Notably, mifepristone was approved more than a decade earlier in Europe16, and the major complication rate for medical abortion is very low, less than 0.5%.17
Is change on the horizon?
Across many areas of medicine, telemedicine has readily replaced in-person visits to reduce risk of COVID-19 exposure during healthcare delivery. Indeed, some researchers have stated that telehealth innovations during this time will become an integral part of care after the pandemic.18-20 Can the same be said for telemedicine abortion services?
The short answer is no, not without substantial policy change. Even if the federal in-person dispensing requirement for mifepristone were permanently repealed—as safety data suggest it should be—existing state-level abortion restrictions that require in-person care would remain in place until repealed by state legislatures or overturned by the courts. In particular, 24 states would effectively be able to prohibit telemedicine abortion via a mixture of restrictions: state-level dispensing laws (19 states21), ultrasound requirements (11 states), and in-person abortion counseling visits (14 states).11
Nevertheless, the temporary injunction presented a unique opportunity to investigate how telemedicine abortion could become an integral part of care. Examining data on how mifepristone was dispensed during the 6 months when telemedicine abortion was permitted by federal law will allow researchers to estimate reductions in delays in time to abortion, as well as address any lingering safety concerns. Beyond this, qualitative data can be collected among patients who sought abortion care during this period to better understand their experience with telemedicine abortion.
However, addressing the unique abortion care needs of specific patient populations is another imperative area of research, as telemedicine abortion may not be the preferred type of care for all patients, such as persons with chronic disease, with disability, or those experiencing intimate partner violence. Given the varied needs of populations seeking abortion care, the availability of telemedicine abortion does not diminish the necessity of ensuring access to procedural abortion, which currently accounts for about 61% of abortions in the United States.22
The delivery of abortion care should be guided by scientific evidence and patient needs, not through state or federal mandates that contradict medical guidelines. Permanently removing the FDA REMS in-person dispensing requirement and repealing state laws that mandate medically unnecessary visits is critical to allow clinicians to practice evidence-based abortion care, both during and after the COVID-19 pandemic.
About the Authors
Isabel R. Fulcher, PhD
Postdoctoral Fellow, Department of Global Health and Social Medicine, Harvard Medical School; Postdoctoral Fellow, Harvard Data Science Initiative
Isabel Fulcher is a Harvard Data Science Initiative Fellow specializing in integrating causal inference methods into implementation science to evaluate the impact of programs and policies on health outcomes. Dr. Fulcher uses innovative data science tools to improve the delivery of sexual and reproductive healthcare globally.
Elizabeth Janiak, ScD
Assistant Professor, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women’s Hopsital and Harvard Medical School; Director of Social Science Research, Planned Parenthood
Elizabeth Janiak is an interdisciplinary public health researcher with expertise in sociology, epidemiology, and health systems research. Dr. Janiak’s research focuses on how public policy, health systems, and provider-level factors affect the availability, timeliness, and quality of contraceptive and abortion care in the United States.
References
American College of Obstetricians and Gynecologists (2020). COVID-19 FAQs for Obstetrician–Gynecologists, Gynecology. https://www.acog.org/en/clinical-information/physician-faqs/COVID19-FAQs-for-Ob-Gyns-Gynecology [Accessed 12 December 2020].
Upadhyay, U. D., Weitz, T. A., Jones, R. K., Barar, R. E., & Foster, D. G. (2014). Denial of abortion because of provider gestational age limits in the United States. American journal of public health, 104(9), 1687-1694.
National Academies of Sciences, Engineering, and Medicine. (2018). The safety and quality of abortion care in the United States. National Academies Press.
Upadhyay, U., Schroeder, R., & Roberts, S. C. (2020). Adoption of no-test and telehealth medication abortion care among independent abortion providers in response to COVID-19. Contraception: X, 100049.
Nash, E., Dreweke, J. (2019). The U.S. Abortion Rate Continues to Drop: Once Again, State Abortion Restrictions Are Not the Main Driver. Guttmacher Institute. https://www.guttmacher.org/gpr/2019/09/us-abortion-rate-continues-drop-once-again-state-abortion-restrictions-are-not-main#figure1 [Accessed 12 December 2020].
The Policy Surveillance Program (2018). State Abortion Laws. https://www.lawatlas.org/datasets/abortion-laws [Accessed 14 December 2020].
Ralph, L. J., King, E., Belusa, E., Foster, D. G., Brindis, C. D., & Biggs, M. A. (2018). The impact of a parental notification requirement on Illinois minors' access to and decision-making around abortion. Journal of Adolescent Health, 62(3), 281-287.
Janiak, E., Fulcher, I. R., Cottrill, A. A., Tantoco, N., Mason, A. H., Fortin, J., ... & Goldberg, A. B. (2019). Massachusetts' parental consent law and procedural timing among adolescents undergoing abortion. Obstetrics and gynecology, 133(5), 978.
Kaiser Family Foundation. The Hyde Amendment and Coverage for Abortion Services (2020) https://www.kff.org/womens-health-policy/issue-brief/the-hyde-amendment-and-coverage-for-abortion-services/ [Accessed 14 February 2021].
U.S. Federal Drug Administration. Approved Risk Evaluation and Mitigation Strategies. (2019) https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390 [Accessed 14 December 2020].
Fulcher, I. R., Neill, S., Bharadwa, S., Goldberg, A. B., & Janiak, E. (2020). State and federal abortion restrictions increase risk of COVID-19 exposure by mandating unnecessary clinic visits. Contraception.
Jerman, J., Jones, R.K., & Onda, T. Characteristics of U.S. Abortion Patients in 2014 and Changes Since 2008. (2016) https://www.guttmacher.org/report/characteristics-us-abortion-patients-2014 [Accessed 18 December 2020].
Janiak, E., Kawachi, I., Goldberg, A., & Gottlieb, B. (2014). Abortion barriers and perceptions of gestational age among women seeking abortion care in the latter half of the second trimester. Contraception, 89(4), 322-327.
Drey, E. A., Foster, D. G., Jackson, R. A., Lee, S. J., Cardenas, L. H., & Darney, P. D. (2006). Risk factors associated with presenting for abortion in the second trimester. Obstetrics & Gynecology, 107(1), 128-135.
Kunzelman, M. (2020) Federal judge rules women can get abortion pill without doctor visits. PBS. https://www.pbs.org/newshour/health/federal-judge-rules-women-can-get-abortion-pill-without-doctor-visits [Accessed 14 December 2020].
Henney, J. E., & Gayle, H. D. (2019). Time to reevaluate US mifepristone restrictions. New England Journal of Medicine, 381(7), 597-598. https://www.nejm.org/doi/full/10.1056/NEJMp1908305
Upadhyay, U. D., Desai, S., Zlidar, V., Weitz, T. A., Grossman, D., Anderson, P., & Taylor, D. (2015). Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology, 125(1), 175-183.
Barney A, Buckelew S, Mesheriakova V, Raymond-Flesch M. (2020) The COVID-19 pandemic and rapid implementation of adolescent and young adult telemedicine: challenges and opportunities for innovation. Journal of Adolescent Health. doi:10.1016/j.jadohealth.2020.05.006.
Gadzinski, AJ, Ellimoottil, C. (2020) Telehealth in urology after the COVID-19 pandemic. Nature Reviews Urology; 17, 363–364. doi:10.1038/s41585-020-0336-6.
Shachar C, Engel J, Elwyn G. (2020) Implications for Telehealth in a Postpandemic Future: Regulatory and Privacy Issues. JAMA; 323(23):2375–2376. doi:10.1001/jama.2020.7943.
Guttmacher Institute. Medication Abortion (2021). https://www.guttmacher.org/state-policy/explore/medication-abortion. [Accessed 14 February 2021].
Jones RK, Witwer E, Jerman J. (2019) Abortion Incidence and Service Availability in the United States, 2017. Guttmacher Institute. https://www.guttmacher.org/report/abortion-incidence-service-availability-us-2017. [Accessed 14 December 2020].