Twenty years ago this month, the Food and Drug Administration approved a medication destined to become known as the abortion pill. Mifepristone, then called RU486, was going to change everything about abortion — it would expand access and remove the stigma.
I remember devouring the news because this little pill was going to give women reproductive autonomy and let them control if and when they have children. At the time, I was just starting my Ph.D. in public health. The news inspired and exhilarated me, and I knew that the abortion pill is what I wanted to focus my career on.
Medication abortion is a safe, effective alternative to a procedural abortion. It involves taking two prescribed medications, mifepristone followed by misoprostol, to end a pregnancy that is no further than 11 weeks along.
Fast forward to today. Many of the barriers to abortion that existed in September 2000 still exist today. Nearly 90% of U.S. counties have no abortion provider, and my research has found that 27 major cities are “abortion deserts” where residents must travel 100 miles or more to reach an abortion provider.
The introduction of the abortion pill didn’t have the effect I was hoping for, partly because the FDA placed a strict set of rules known as a risk evaluation and mitigation strategy (REMS) on mifepristone. Among these restrictions is the requirement that mifepristone be dispensed in a clinic, doctor’s office, or hospital, effectively prohibiting clinicians from prescribing it during a telehealth visit. In addition to these FDA restrictions, 19 states specifically ban provision of the abortion pill via telehealth for purely political reasons.
As a public health scientist and an expert in abortion safety, I know that these restrictions are outdated and medically unnecessary. Over the past 20 years, almost 4 million pregnant people in the U.S. have used these two medications to end their pregnancies. In a study my colleagues and I did among more than 11,000 individuals who had a medication abortion, the safety rate was more than 99%.
Regardless of where patients obtain the pills, they will almost certainly take them at home. In other words, receiving a prescribed pill in person from a doctor at a clinic versus getting it at a pharmacy or by mail makes it no more or less likely a patient will need emergency care.
Medication abortion is easily administered via telehealth. In the context of Covid-19, social distancing and increasingly scarce medical services make it essential that state and federal governments put politics aside to allow patients access to abortion care via telehealth, instead of trying to further restrict abortion care.
Abortion restrictions that were in place before Covid-19 mean that some states have only a single abortion provider and if that provider — or the staff at clinics — must self-quarantine, patients have even fewer options. For many patients, postponing an abortion could mean not getting one at all. Amid a pandemic, these restrictions put lives at risk because patients still must travel long distances to get to a clinic.
In July, a federal judge ruled that the in-person requirements for medication abortion pose a substantial obstacle during the pandemic and are unconstitutional. In states where the practice is not specifically prohibited, a clinician can now prescribe the abortion pill via telehealth and the medications can be delivered by mail — but only temporarily.
This is a move in the right direction, but it is time to permanently lift the medically unwarranted risk evaluation and mitigation strategy. Clinic-to-clinic telehealth programs exist in some states, but even so they require patients to come to a clinic for tests and to get the pills. The only at-home telehealth program for abortion is a study currently operating in 11 states with approval from the FDA.
But even with this program, in which patients have a telehealth consultation and can then receive abortion pills by mail, this model still requires them to obtain an ultrasound from a clinic to confirm that the pregnancy is within the gestational time limit, which may be difficult under present conditions and is not required for abortion care. Evidence has shown that calculating gestation based on a patient’s known date of last menstrual period is highly accurate for dating pregnancies.
Telehealth for abortion expands access in underserved areas, including in rural areas where there are no providers. Telehealth can contribute to patient-centered care by offering an additional choice that meets patients’ needs for convenience and privacy. If telehealth makes it possible to have abortions sooner, it may make abortion safer by moving all medication abortions to earlier in pregnancy.
Ensuring that people can get abortions as early as possible may not seem urgent in light of the Covid-19 pandemic. But delayed abortion care can prevent people from having wanted abortions, dramatically altering their life trajectories.
It is more urgent than ever that policymakers at both federal and state levels stop blocking telehealth access to mifepristone and start prioritizing science and public safety over politics.
Ushma D. Upadhyay is an associate professor at the Advancing New Standards in Reproductive Health program in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, and director of research at the University of California Global Health Institute’s Center of Expertise on Women’s Health, Gender, and Empowerment.