Abortion has unfortunately become a controversial topic particularly in the recent years, due to ongoing pressure from different groups and ultimately due to the overturn of Roe v. Wade by the Supreme Court. Owing to both legislative pressures as well as the SARS-CoV-2 pandemic telemedicine has emerged as a popular method for accessing abortion services, particularly in regions where access to in-person care is limited. However, the safety and legality of telemedicine abortion have been the subject of much debate, with opponents arguing that it is unsafe and should be prohibited.
In this article, we will explore the safety of telemedicine abortion, taking into account the latest legislative developments in the United States.
What is telemedicine abortion?
Telemedicine abortion is a method of accessing abortion services remotely, using video conferencing, phone consultations, and online prescribing. The process involves a patient communicating with a healthcare provider who is located remotely, often in a different state, to receive an abortion consultation, medication, or both.
In telemedicine abortion, a woman seeking abortion services contacts a healthcare provider who evaluates her medical history and performs an evaluation remotely. Telemedicine abortion is termed a history-based abortion as the provider does not rely on an ultrasound, physical examination nor a laboratory assessment. As such the eligible patient is one with a known last menstrual period, as well as no/low risk factors for ectopic pregnancy. The provider then prescribes medication abortion, typically mifepristone and misoprostol that can be dispensed either in person at a local pharmacy or via mail, which the patient can take at home to induce an abortion.
The use of telemedicine abortion has increased in recent years, particularly in rural areas where access to in-person abortion care is limited. Several studies have demonstrated that the effectiveness of telemedicine in abortion is higher than in person visits, with over 95% patient satisfaction. Furthermore, in a large study of almost 4000 patients adverse event rate of telemedicine abortion was comparable to in person medicine abortion with an ultrasound and physical examination at 0.5% as well as with a similar effectiveness of about 95%.
Legal developments on telemedicine abortion in the US
The legality of telemedicine abortion varies by state in the United States. 5 States currently completely ban the use of telehealth for abortion (Indiana, West Virginia, Arkansas, Arizona, Louisiana, Texas), and a further 14 require physical presence of the prescribing clinician.
The legality of telemedicine abortion is on the junction of Federal and State level jurisprudence. As of January 2023, the U.S. Food and Drug Administration (FDA) expanded access to mifepristone by allowing a prescription from a prescriber to be filled from any mifepristone registered pharmacy. Such restrictions were never been shown to be effective to lower the already extremely rare adverse events nor abortion rates with FDA reported success rates of nearly 99.6% and a mortality rate of 0.00064% (meaning 6 deaths per million when compared to the US maternal mortality rate of 238 maternal deaths per million live births).
From an ongoing legality perspective, the governor of South Dakota issued an executive order in late 2021 in response to the changes to prescription by the FDA decreeing that the South Dakota Health Department ban telehealth for medication abortion and the drugs for medication abortion only to be made available in person at a licensed abortion facility, and requiring a follow up visit. No such requirements were ever established by the FDA, and ultimately a federal district judge blocked the decree while the litigation is ongoing. Since then, numerous states passed laws, and numerous lawsuits ensued. With the main arguments being FDA authority preempting state law and asking the enforcement of state laws to be blocked. Currently (as of March 2023) litigants include drug manufacturers of mifepristone challenging West Virginia’s total abortion ban, as well as a physician suing North Carolina’s restrictions have both cases pending in US District Courts.
Furthermore, some states have established laws that go against the established scientific evidence. E.g., Utah requires counseling that mifepristone is not always effective, although the data indicates it is effective almost 100% of the time and Nebraska requires counseling that medication abortion can be reversed, although the available data from randomized controlled trials does not demonstrate this.
Safety of telemedicine abortion
The safety of telemedicine abortion as well as medical abortion has been researched countless times and contrary to arguments of “pro-lifers” that it is unsafe and puts women’s health at risk, it’s been demonstrated by study after study to be safe and effective with no long-term risks or effects such as negative psychological impacts or effects on future pregnancies. Although opponents may also try to coopt state laws and regulations to make up risks or require counseling against the scientific findings the scientific data is crystal clear. Telemedicine abortion is as safe and effective as in-person abortion.
Conclusion
Telemedicine abortion has emerged as a popular method for accessing abortion services, particularly in regions where access to in-person care is limited. The use of telemedicine abortion has been shown to be safe and effective in numerous studies, with high levels of patient satisfaction. However, its legality varies by state in the United States, and its use has been limited by recent legal developments.
Ultimately, the decision to use telemedicine for abortion care should be left to the patient and her healthcare provider, based on her individual circumstances and preferences. Women should have the right to access safe and effective abortion care, regardless of their location or circumstances.
Reference:
Upadhyay UD, Raymond EG, Koenig LR, et al. Outcomes and safety of history-based screening for medication abortion: a retrospective multicenter cohort study. JAMA Intern Med. 2022;182(5):482-491.
Grossman D, Grindlay K, Buchacker T, Lane K, Blanchard K. Effectiveness and acceptability of medical abortion provided through telemedicine. Obstet Gynecol. 2011;118(2 Pt 1):296-303.
Upadhyay UD, Koenig LR, Meckstroth KR. Safety and efficacy of telehealth medication abortions in the us during the covid-19 pandemic. JAMA Netw Open. 2021;4(8):e2122320.
Grossman D, Raifman S, Morris N, et al. Mail-order pharmacy dispensing of mifepristone for medication abortion after in-person clinical assessment. Contraception. 2022;107:36-41.
Emma, erson, Dec 02 LSP, 2021. State restrictions on telehealth abortion. KFF. (https://www.kff.org/womens-health-policy/slide/state-restrictions-on-telehealth-abortion/)
https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation (Accessed on Mar 01, 2023).
Mifepristone Adverse Event summary table december 31 2018 | FDA (https://www.fda.gov/media/112118/download)
South Dakota Executive Order 2021-12 (https://sdsos.gov/general-information/executive-actions/executive-orders/assets/2021-12.PDF)
Creinin MD, Hou MY, Dalton L, Steward R, Chen MJ. Mifepristone antagonization with progesterone to prevent medical abortion: a randomized controlled trial. Obstetrics & Gynecology. 2020;135(1):158