Katie realized she was pregnant during the first week of April 2020. She decided pretty quickly that she wanted to terminate the pregnancy. She already had two kids, and she’d just been diagnosed with high blood pressure. The condition was still uncontrolled, which made her pregnancy high-risk. But it was just weeks into the COVID-19 pandemic in the U.S. She was in full lockdown, and she wasn’t sure if she could get an abortion.
"I was Googling abortions," she tells Refinery29. "My biggest thing was not wanting to actually go to a place." Besides being afraid of catching the virus, the nearest clinic to Katie was six hours away from her home in New Mexico, and she wasn’t sure how she’d find the time to get there.
Her internet research led her to the website for the TelAbortion Study. If she participated, she’d be able to receive the pills necessary for a medication abortion — a procedure that uses medication to end a pregnancy — through the mail, and have consultations with her doctors via the phone. Besides an ultrasound, which she could obtain at a nearby facility, she’d never have to leave her house.
Less than three weeks later, in late April, she began her abortion by taking mifepristone, a drug that blocks progesterone, a hormone needed for pregnancy to continue. The following day, a Friday, she took misoprostol, which induced uterine contractions to help her body expel the tissue. And that was it. "I laid in bed and [the medication] kind of just took its course. I cramped a little bit," she says. She had taken that Friday off work, and her children (ages 3 and 7) were at their father’s house for the weekend. "I liked the fact that it was in the comfort of my own home," she says. "I was able to do it on my own time."
Over 1 In 3 Abortions Use This Pill. Why Is It So Heavily Restricted?
In 2017, medication abortions accounted for 39% of all abortions in the U.S., according to the Guttmacher Institute. When used during the early stages of gestation (up until around 11 weeks), the drugs are safe and effective. A patient is given an ultrasound or blood test to confirm they’re eligible before being prescribed the drugs — mifepristone and misoprostol — along with a pain medication like ibuprofen and an anti-nausea medication, explains Kristina Tocce, MD, MPH, vice president and medical director of the Planned Parenthood of the Rocky Mountains, a TelAbortion provider. The provider may offer birth control counseling or prescriptions, as well. One to two weeks after the abortion, the patient has a follow-up appointment.
Unfortunately, like all abortion care in the U.S., medication abortion is subject to restrictions that limit people’s ability to access the treatment.
In 2011, the FDA imposed a Risk Evaluation and Mitigation Strategy on Mifeprex, the brand name for mifepristone. (The other abortion drug, misoprostol, is prescription-only, but not regulated by a REMS.) As a result, the medication must be dispensed by a certified provider in a clinic, hospital, or medical office. That means patients generally can’t be prescribed via telemedicine, or receive the drug via the mail — or even at a retail pharmacy. What’s more, in order to carry the drugs, physicians are required to be included on a list of certified abortion providers. Many are reluctant to do so, fearing backlash, according to an article published in the New England Journal of Medicine.
All this can make the medication difficult to get. "It is needlessly stressful to have to establish care with a new medical provider for such a private, yet simple medical service," says Melissa Grant, COO of Carafem, a network of healthcare providers working with TelAbortion.
The REMS seems restrictive for a drug that’s largely seen as safe. "To date, 19 deaths have been reported to the FDA among the more than 3 million women in the United States who have used Mifeprex," write the authors of the NEJM article. "In contrast, the background risk of pregnancy-related death among pregnant women in the United States who do not have abortions and instead proceed to live birth is... 14 times higher." A study of 8,765 telemedicine and 10,405 in-person medical abortions found "a very low prevalence of clinically significant adverse events among patients undergoing medical abortion," reports the journal Obstetrics & Gynecology.
The TelAbortion Study can get around the REMS because it’s a clinical study, and therefore granted an exemption, says Inga Platais, a senior program associate at Gynuity Health Projects, the non-profit organization sponsoring the TelAbortion Study. Since 2016, the project has been allowed by the FDA to provide abortion medication via mail to patients in Colorado, Georgia, Hawaii, Illinois, Iowa, Maine, Maryland, Minnesota, Montana, New Mexico, New York, Oregon, Washington, and the District of Columbia. "We are currently exploring expansion into additional states," Platais says. They've been able to work with residents who live in other states but are able to travel to a participating state on a case-by-case basis.
Dr. Tocce recalls treating a patient from Texas, where abortions were deemed "non-essential" during the pandemic by Governor Greg Abbott. "They traveled 10 hours by car through difficult weather conditions. They had a disabled family member and their caregiver in the car with them, and they stayed in a hotel in New Mexico [to receive treatment]." Dr. Tocce says that while it was frustrating that their option required the patient to travel, she was glad that they were able to travel the smallest distance possible. "The patient was so appreciative," she says. "We were so thankful that we could help this person."
How Activists Are Using COVID-19 To Push For Change
Reproductive rights advocates have long pushed for lower restrictions around abortion medication, given its safety and efficacy. Now, pressure created by the COVID-19 pandemic has opened the door to legislative change.
In late May, the American Civil Liberties Union filed a lawsuit on behalf of a coalition of medical experts led by the American College of Obstetricians and Gynecologists meant to challenge the FDA’s restrictions on mifepristone, which can also be used to manage miscarriages. The ACLU claimed that not allowing patients to be prescribed the medicine via telehealth and to fill the prescription by mail during the pandemic subjects them to unnecessary risk. (The organization filed a similar suit against the FDA — minus the COVID-19 concerns — in 2017. It is still pending.)
The most recent lawsuit stated that: "Plaintiffs have submitted evidence that 75% of women obtaining abortion care are poor or low-income and 60% are people of color, and that these populations face a significantly higher health risk from COVID-19 and in turn face particularly significant transportation, childcare, and economic challenges during the pandemic that make accessing in-person care particularly difficult and dangerous."
Federal U.S. District Judge Theodore Chuang ruled in favor of the ACLU, finding that the in-person requirements for those seeking medication abortions impose a "substantial obstacle," and are likely unconstitutional under the circumstances of the pandemic. Until the public health emergency is over (it was renewed for 90 days on October 2), the FDA will not enforce its REMS regarding the abortion pill. Chuang says, however, that states could still oversee abortion medication “above and beyond” the FDA’s rules, The Hill reports.
While ACOG called the ruling "a victory" in a statement, Marjorie Dannenfelser, the president of an anti-abortion organization, Susan B. Anthony List, expressed disappointment in her own statement, calling the original FDA regulations "reasonable and necessary to protect women from serious and potentially life-threatening complications of abortion drugs, including intense pain, heavy bleeding, infection, and even death."
Grant tells Refinery29 that she’s seen a "significant" uptick in clients since the pandemic hit, and has added two additional locations from Carafem into the study. "We've seen an increase in the number of clients asking for this, from maybe a couple a week to three times that right away. And now it’s gone up even more," she says.
Grant says that the pandemic simply magnified an existing issue around access. "People who are pregnant that are low income, who live in a place that might be cut off from medical providers, who are of color, or who don't have reliable transportation, find it much more difficult to access an abortion," she says. Already, she says that 30% of the network’s Georgia- and Illinois-based patients have to drive over 100 miles to reach the states’ health centers, because they don't have any other choice.
"Now [during the pandemic], people have lost their jobs, people have lost their access to reliable childcare," Grant notes. "Oftentimes kids are not in school or maybe their daycare situation has changed. So they're trying to juggle that." Telemedicine abortion care could be a life-changer.
While research studies like the TelAbortion project and emergency rulings like the FDA’s response to the ACLU lawsuit earlier this year are a positive sign, Grant hopes that access isn’t rolled back again once the pandemic passes. "This has potentially allowed greater access to more people," Grant explains of the ruling. "We're hopeful that that will be an option that people can continue to access."
Opponents Don’t Care About Science. They Just Want To Take Away Access
There is, of course, opposition to allowing medication abortion to take place via telemedicine — or really, to take place at all. "Pregnancy is not a life-threatening illness, and the abortion pill does not cure or prevent any disease. Make no mistake, Mifeprex [the brand name of mifepristone] is a dangerous pill. That’s why 20 of my Republican colleagues and I are urging @US_FDA to classify it as such," Senator Ted Cruz tweeted in September. Attached to the Tweet is a letter from Cruz and 20 Republican senators to FDA commissioner Stephen Hahn, MD, asking the FDA to remove the drug from the U.S. market entirely. They say that Mifeprex is a "significant threat of danger."
The data suggests that Cruz and his like-minded colleagues are wrong. "It is incredibly frustrating to try to be regulated by individuals that don't have a medical background," Dr. Tocce says. "It’s exceptionally frustrating because the safety of medication abortion has been shown so thoroughly in so many studies, and this is literally a barrier for barrier’s sake."
"We've shown so far that it's equally effective to receive your medication at home through the mail," Grant adds. In 2011, a systematic review conducted by the World Health Organization found that, "There is no evidence that home-based medical abortion is less effective, safe or acceptable than clinic-based medical abortion."
The TelAbortion Study has been collecting data to further demonstrate that medication abortion is safe, and can be safely carried out via telemedicine, since 2016. "Four years," Platais says. "How much longer are we going to have to do this to show that it’s safe?"
Dr. Tocce says that speaking with the TelAbortion Study patient has been a heartwarming experience. "I've seen people sitting on their couch, hugging their cat and being with their children and not having to worry about, 'How am I going to coordinate and pay for childcare while I have this visit?'" she says. "I’ve seen people in their cars during a break from work. It just really works for the patients. This is truly the definition of meeting patients where they are."
Katie would recommend TelAbortion to anyone considering a medical abortion. She says her providers were warm and kind, which she appreciated. And while she was a little worried about using the medications correctly, ultimately she found the process simple, and she says the abortion wasn’t painful.
"It’s nice to be in the comfort of your own home, and I guess… Not that people judge you over it, but…" Katie pauses, searching for the right word. "It felt safer. That’s the word I was looking for: safer."