Telemedicine, Medication Abortion, and Access After Roe v. Wade

For a half-century, pregnant people in the United States have had the legal right to decide their pregnancies and reproductive health. The Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization eliminated that right for millions of people in 26 states. Legislatures in 13 states have passed “trigger” laws that ban abortion if the Roe v. Wade decision is overturned, and 13 have bans that have become enforceable in the absence of Roe. In this environment, public health must continue to seek approaches to improve access to abortion services.

In this issue of AJPH, Seymour et al. (p. 1202) estimate how telemedicine could increase access to medication abortion. Medication abortion—a two-medication regimen of mifepristone and misoprostol—is a safe and effective method to end a pregnancy when used within 70 days’ gestation.¹ First approved in the United States in 2000, medication abortions have increased in the intervening years, and in 2020, they constituted the majority (54%) of abortions.² This growth reflects increasing acceptance by patients and providers, changes in medicine driven by the COVID-19 pandemic, and the erosion of access caused by federal- and state-level restrictions.

FEDERAL RESTRICTIONS ON MEDICATION ABORTION

Delivery of mifepristone for the medical termination of uterine pregnancy is subject to a Risk Evaluation and Mitigation Strategy (REMS) established by the US Food and Drug Administration (FDA). The purpose of the REMS is to ensure that the benefits of mifepristone outweigh its risks through the imposition of these requirements: (1) clinician certification, (2) patient signature on an FDA-approved agreement form, and (3) a requirement that mifepristone is administered under the direct supervision of a certified medical provider (also called the “in-person dispensing requirement”). The American College of Obstetricians and Gynecologists opposes REMS for mifepristone, citing safety data from two decades of use, lack of benefit for patients, barriers they create for underserved and rural communities,³ and barriers for providers and clinics that decrease the number of clinicians providing this care.⁴ In December 2021, the FDA removed the in-person dispensing requirement and added a requirement for pharmacy certification. These modifications expand the reach of telemedicine for medication abortion (TMAB) because they eliminate the need for patients to travel to participating clinics.

STATE RESTRICTIONS ON MEDICATION ABORTION

Currently, 34 states have bans or restrictions on the provision of medication abortion. Thirty-two limit its provision to physicians, ignoring evidence that physician assistants and advanced practice nurses can safely provide medication abortion. Nineteen states have in-person dispensing requirements that supplant the in-person dispensing requirement that the FDA removed in 2021. Two states have active partial bans based on gestational age, and three additional states have passed complete or partial bans on medication abortion that are blocked by court order. Furthermore, three states banned mailing abortion pills, and three other states have mail bans blocked by the courts. New restrictions are being considered every month; between January and May 2022, 16 states introduced bills to ban or restrict medication abortion, seven sought to ban it entirely, five sought to ban mailing pills, and eight sought to ban TMAB.

TELEMEDICINE FOR MEDICATION ABORTION

The combined effects of state-level bans and restrictions have resulted in a dramatic decrease in the number of abortion providers. In their study, Seymour et al. included 925 providers identified via the Advancing New Standards in Reproductive Health abortion provider database in 2018. Just two years later, the number of abortion-providing facilities in Advancing New Standards in Reproductive Health had decreased dramatically, with approximately 750 facilities listed in 2020.

Seymour et al. examined TMAB access where patients presented to a participating clinic, consulted a remote physician, and received their medication. The hope is that expansion of access to TMAB could increase access for women in states with abortion restrictions, because the distance from an abortion provider is a leading barrier. For example, a study by Thompson et al.⁵ found a dose–response relationship between travel distance and abortion rate—women living 120 miles or more from a provider had abortion rates one fifth of those among women living within five miles of a provider. Furthermore, shorter travel distances are associated with significant reductions in times to appointments.⁶ Finally, data from a cohort study representing 85% of medication abortions performed between April and June 2020 indicated that a hybrid TMAB at-home model had a four-day shorter waiting time and an increased proportion of medication abortions provided at six weeks’ gestation or earlier.⁷

In their study, Seymour et al. identified 1091 abortion providers and Planned Parenthood clinics in the United States, geocoded all facility locations, and calculated the proportion of women of reproductive age in every census tract who live within a 30-, 60-, or 90-minute drive to a participating clinic. In 2018, 65.3% of persons of reproductive age lived within 30 minutes of a clinic, 80.5% were within 60 minutes, and 88.9% were within 90 minutes.

Seymour et al. also examined the potential effect on abortion access of two policy changes. In the first, TMAB was expanded to 241 non–abortion-providing Planned Parenthood clinics in states without a TMAB ban. This policy change would increase access with 68.3%, 82.6%, and 90.1% of women of reproductive age within a 30-, 60-, or 90-minute drive to a clinic, respectively. The second policy change evaluated was the removal of existing TMAB bans from 19 states. Abortion access was expanded to 70.9%, 84.7%, and 91.7% of women of reproductive age. Expansion of TMAB to all Planned Parenthood clinics in non–TMAB ban states would mean an additional 781 556 women of reproductive age would live within 90 minutes of a clinic. Elimination of existing state TMAB bans would result in 1.75 million more women living within 90 minutes of a TMAB provider.

TELEMEDICINE MEDICATION ABORTION AFTER ROE

As we face a post-Roe world, telemedicine and medication abortion are leading options for preserving and expanding access to abortion services. Yet, as we increase our focus on these services, we must be mindful of the “digital divide.” In the United States, the populations with the greatest barriers to abortion access are disproportionately impacted by barriers to telemedicine. More specifically, vulnerable populations have greater economic and social disparities in the access to, use of, or impact of information and communication technologies. A recent AJPH editorial added urgency to prior calls to define broadband Internet access (BIA) as a social determinant of health because it affects access to health care, economic stability, education, food, community and social context, and neighborhood and physical environment.⁸ Notably, most people of reproductive age reported having BIA.⁹ But access varies by age, race/ethnicity, rural residence, and other demographic characteristics. Adults aged 18 to 29 years had lower BIA (70%) than those aged 30 to 49 years (86%). White adults had higher rates of BIA (80%) than Black (71%) and Hispanic (65%) adults. Urban and suburban residents had higher rates of BIA than those living in rural areas (77%–79% vs 72%). Households with incomes of $100 000 or more had higher rates of BIA (93%) than households with incomes less than $30 000 (57%).

Although telemedicine breaks down barriers to abortion access, the lack of BIA in many homes puts vulnerable women at a disadvantage when identifying and contacting abortion providers and participating in telemedicine visits. As the women’s reproductive health community moves forward in this fight to preserve abortion access, we must also push for an information infrastructure that will ensure equitable access to that care.