As much of the country prepares to return to some form of post-pandemic normalcy, reproductive health care providers and advocates hope we continue one vital pandemic tradition: telemedicine options for receiving and providing reproductive care from home.
Some researchers and providers have found offering medication abortion care via telehealth is crucial to bridging gaps in abortion access. Abortion medication care is safe and effective up to 10 weeks into one's pregnancy, and providers say that having a telehealth component to abortion care may even help establish greater medical trust and comfort for patients from marginalized communities seeking care.
"I thought there could be this feeling that telehealth is less than, or substandard," Leah Coplon, nurse midwife and clinic director at Maine Family Planning, told Salon. "I feel like there is a risk for folks who already feel marginalized by the medical community to feel like, 'Wait, I have to meet someone over video? That doesn't seem right.'"
But Coplon and other providers and leaders in the reproductive health space say they've found telemedicine abortion has been widely embraced by patients, including patients who have traditionally faced more barriers to get health care, or come from communities with mistrust toward the medical system.
"The relief I hear in patients' voice when I say, 'Oh no, you don't need to come into an office, we can do this over the phone, we can mail your pills' — it's a huge relief to folks," Coplon said. "In the past, having an abortion meant taking a day off work, sitting in a waiting room, finding child care, all that."
In many states, abortion providers can offer medication abortion through a telehealth call, discussing eligiblity and concerns with the patient over the phone. Providers then can mail the abortion pills to the patient's home or local pharmacy. Medication abortion involves two pills: mifepristone, which induces a miscarriage, and misoprostol, which induces labor to remove the fetal tissue. In April, the FDA temporarily lifted a policy that has required abortion providers to dispense abortion pills to their patients in-person at the clinic, allowing the medication to be offered via telehealth and mail during the pandemic.
America's history of eugenics and targeting people of color for medical experimentation has fostered greater distrust of the medical system in some communities. Throughout history, people of color, people with disabilities, immigrants, and other marginalized groups have been subjected to forced sterilizations and ongoing reproductive coercion. Today, those same marginalized groups generally face higher-risk pregnancies and birth-related complications, often as a result of medical bias.
Researchers and providers say telemedicine abortion access builds trust and comfort for marginalized patients
According to experts, telemedicine reproductive health options have helped patients marginalized by the medical system feel more comfortable and at ease getting care. In some cases, it can even protect them from harm.
"It might be safer for undocumented or immigrant populations to be able to stay at home and access these services and not have to make an in-person visit," Dr. Upadhyay, a researcher at Advancing New Standards in Reproductive Health, told Salon, of her joint research with California Latinas for Reproductive Justice around undocumented patients seeking medication abortion care with telehealth.
Many undocumented people or folks with undocumented family members fear seeking health care of any kind if it could expose their immigration status, and often mistrust providers. Telehealth options to get abortion care from the safety of their home could be crucial, even beyond the pandemic.
It's not just immigrant and undocumented patients who might feel safer and more comfortable seeking abortion care from the comfort of their homes. "For some patients, telehealth might even equalize the power dynamics between a patient and physician — when a patient is at their home, they may feel more relaxed, or may be able to hold a partner's hand," Upadhyay said. "Patients might feel more empowered if they're in a place they feel most comfortable having this interaction with their physician."
Katie Quinoñez, executive director of Women's Health Center of West Virginia, provides reproductive care in West Virginia, a state that is hostile to abortion and bans telemedicine provision of it. According to Quinoñez, not only could telemedicine abortion care help patients feel more comfortable, but it could also make them safer — specifically, from the anti-abortion protesters who routinely camp outside her clinic, which is the sole abortion-providing clinic in her state.
"Whenever there's the ability to provide medication abortion via telehealth, that eliminates the visit for the patient, and possible interactions with anti-abortion protesters to harass the patient and try to limit their options and choices," she said to Salon. "To people who are marginalized, they don't necessarily feel safe to come to the clinical setting."
Dr. Lynda Gilliam, an OB-GYN based in Pensacola, Florida, who remotely provides birth control to patients via the telemedicine birth control platform Nurx, offered similar observations to Salon. "When a patient walks in the OB-GYN office, that can already be an intimidating place," she said. "A lot of times, you're just like, 'Let me get my pills and get out of here, I don't really want to be here.' I've found I can have a better conversation with patients, often times online, because that intimidation is gone."
Gilliam also says telemedicine options for reproductive care can help patients who face racial or other identity-based bias in the medical system feel more secure, when they're not immediately perceived or judged by their identity. "Telehealth gives you the opportunity to allow people to have a conversation, not necessarily making any kind of biases or pre-judgments based on how someone looks or acts or what their preferences are," she said. "Some people in the LGBTQ community may be uncomfortable going into a building, or talking to someone — for example, a trans person trying to get care with an OB-GYN. Platforms like Nurx can let them in, in an open, non-judgmental fashion, which really opens doors for people."
Providers may benefit from telehealth options, too. "We've been hearing from providers that they feel like they get to know patients a bit better because they're seeing them in their own homes, and in the context of their lives," Dr. Upadhyay said. "Providers see patients at home with their children, or their pets, or they'll get a better sense of the barriers that they might face." She said one provider participating in her study recalled serving a patient who was a driver for Amazon, and was sitting in her truck during the telehealth visit to seek medication abortion.
But ultimately, according to Dr. Jamie Phifer, an abortion provider and the founder of Abortion on Demand (AOD), not all patients seeking telemedicine abortion care necessarily want a "relationship" with their provider — and that's fine.
"AOD's model is built to de-emphasize the clinician in the process as medication abortion is medically uncomplicated," Phifer said in an email to Salon. AOD is the first large-scale telehealth abortion service run by a U.S.-based provider, and offers telemedicine abortion care to patients across the country in more than 20 states via its website.
"Compared to my experience in brick and mortar practices, patients seem more at ease in their own space and seeking care on their own terms," she added. "AOD's patients are seeing us for a single concern that is relatively brief. Relationship-building is less of a priority in most cases, which may be part of why patients seem at ease."
Will telemedicine options for reproductive care remain necessary post-pandemic?
Researchers and providers of reproductive health emphasize that before and during the pandemic, telehealth options have allowed providers to build relationships or help people who might otherwise not be able to get abortion or birth control at all.
"Telehealth bridges geographic disparities," Upadhyay said. "There are 27 abortion deserts throughout the US, so it might enhance access, especially for rural communities."
The term "abortion deserts" refer to cities in which people have to travel 100 miles or more to reach an abortion provider. Twenty-seven exist across the country, in every region except the Northeast. Notably, 90% of US counties lacks an abortion provider, and seven states are down to just one.
Travel across state lines to get an abortion at a clinic, and all of the costs associated with the procedure and trip, can be highly costly — especially for patients of color. Black, Latinx and Indigenous women are among the most likely to be uninsured, have shouldered the brunt of pandemic-related job loss, and are also more likely to be in poverty.
"It can be difficult for people to travel three, four hours away from their hometown to access care," Quinoñez said. "That predominantly impacts low-income people, rural people, people of color." Even if a patient could otherwise afford their abortion, it's the myriad other costs and hurdles to get to a clinic that might make getting it impossible. "They can't always afford to find child care, they can't always afford transportation to get to the clinic, they can't afford to miss an entire or multiple hours of work and missed wages to get to the clinic," she added.
If struggles to access essential health care weaken patients' trust in the medical system, innovative approaches to address these struggles are essential to the patient-provider relationship.
"[Telemedicine abortion] would really strengthen a lot of that trust in that relationship, because we're meeting the patient where they are, we're trusting them to know what they need, trusting them to ask for that care, and they're trusting for us to be able to provide it to them," Quinoñez said.
"Telehealth for abortion care was ALWAYS necessary; the pandemic rather demonstrated the urgency more clearly," Phifer said in an email to Salon. "Abortion by telehealth will remain vital post-pandemic for all the obvious reasons: lower costs, quicker access, less strain on patient resources, and frankly safety — depending on how far a patient is from the closest in person provider, it may be safer to have a telehealth abortion than to be on the interstate."
Telemedicine reproductive care is popular — but faces challenges
Use of medication abortion care instead of in-clinic surgical care has been on the rise in recent years, with about a third of abortions in the first trimester being completed through the medication. Some reproductive care providers have reported significant increases in requests for medication abortion over surgical abortion during the pandemic.
"We're still finding a good 40 to 50% of patients are choosing [telemedicine abortion], even as COVID numbers are low and vaccine rates are high in Maine," Coplon said. "All those burdens that people face trying to get an abortion — child care, time off from work, travel, gas, money, maybe even just snowstorms — they're really taking to this model."
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Despite how medication abortion care has been approved by the FDA since 2000 and has a proven record of safety and efficacy, it has remained subject to Risk Evaluation and Mitigation Strategy (REMS), which requires patients to retrieve it from a clinic or hospital, rather than by mail or at a retail pharmacy. A lawsuit earlier in the pandemic led to REMS being lifted, only for the Supreme Court to reverse this in January.
Within months of the Supreme Court ruling, the Biden administration announced it would temporarily allow telemedicine abortions during the pandemic. But with many parts of life steadily returning to normal, it's unclear whether this will continue. And despite the temporary halt on these FDA requirements, 19 states require the clinician providing a medication abortion to be physically present when the medication is administered, prohibiting telemedicine.
Recently, several state legislatures have passed or introduced bills to ban telemedicine options for abortion care. Other states have passed anti-abortion legislation requiring providers to give patients information about medically unproven options to "reverse" their medication abortion. "It absolutely demeans the patient-provider relationship, because we're being required by law to read basically lies to our patients," Quinoñez said of these policies.
And while medication abortion care is medically safe, historically, self-managed abortion through pills has sometimes led to concerning legal risks, as a result of anti-abortion politics and stigma. Because medication abortions happen through inducing a miscarriage, even natural loss of pregnancy could be criminalized if Roe v. Wade were reversed. The targeting and surveillance of disproportionately women of color for pregnancy loss, or self-induced abortions with medication, is already happening, even with Roe v. Wade intact.
In recent years, there have been several high-profile cases in which women have been jailed or criminally charged for pregnancy loss, including Purvi Patel, an Indian-American woman, who became the first person to be sent to prison for inducing an abortion in the post-Roe era, contradictorily charged with feticide and child abuse for using medication abortion in 2013. Amber Abreu, a Latina teenager and young mother, faced felony charges for "procuring a miscarriage" for using abortion pills in 2007.
While providers who spoke to Salon acknowledge the ongoing threat of abortion and pregnancy criminalization, they currently only provide telemedicine abortion care to patients where this option is legal.
"AOD provides only early medication abortion services in full regulatory compliance in the states we serve," Phifer said. "We refer patients to a resources page to find other fully legal providers if they do not qualify for our service due to medical, age or location restrictions."
Upadhyay says patients participating in her research live in states where telemedicine abortion is entirely legal. But she notes that, for those who self-manage their abortions and have concerns, "there is a hotline for legal help." As of this month, there is also a legal defense fund.
Ultimately, Coplon says she's careful to make it clear to her patients that she's not trying to phase out in-person abortion care, or in-person care in general.
"We're very careful to lay out all the options for everybody. We don't promote one or the other," she said. "In different communities [telemedicine] is going to mean different things. The most important thing is we give everyone the choice to have what kind of abortion they want, where they want it, and support them."