The abortion pill used early in pregnancy should, in theory, be a lot more accessible than a later-stage surgical abortion. If you’re a woman in Texas, Ohio, or North Dakota, though, you might be surprised. In those states, the process could take up to four visits to the clinic: an initial consult, a visit to swallow the first pill, another visit for the second pill, and finally a follow-up exam. Now imagine the clinic is a three-hour drive away or you can’t take four days off from work. No wonder use of the abortion pill has fallen off in states with those restrictive laws.
This week, the Food and Drug Administration posted new rules for the abortion pill Mifeprex that could transform access for women in those states. The new rules nix the post-treatment exam, make the drug available to women later in pregnancy, and reduce cost by decreasing the dosage of the first pill by two-thirds. “This was wonderful news,” says Elizabeth Nash, a policy analyst at the Guttmacher Institute, a reproductive health nonprofit.
The FDA’s new label may be welcome news for women’s health advocates, but it is hardly revolutionary. In fact, doctors in states other than Texas, Ohio, or North Dakota have already been following the new rules when giving women Mifeprex---based on clinical trial data that have come out since the drug’s approval in 2000. “The label was way way out of date,” says Elizabeth Raymond, senior medical associate at Gynuity Health Projects, which conducts research for reproductive health policy. The FDA was merely playing catchup.
But another policy could truly revolutionize access to Mifeprex: making the abortion pill accessible via telemedicine. Some states are already experimenting with a telemedicine model, and an upcoming clinical trial plans to test making the abortion pill available directly to patients.
In 2008, a Planned Parenthood clinic in Iowa began the country’s first telemedicine abortion program. Mifeprex is distinct from emergency contraception like Plan B, so it’s not available in pharmacies. Instead, the only way to get it is to go to a clinic that stocks the drug. In Iowa, women still had to go to a clinic with Mifeprex in stock---but a doctor didn’t have to physically present. Instead, doctor from another clinic could teleconference in to talk to the woman and authorize the Mifeprex.
The program has been and safe and successful, according to followup studies. And it expanded access to abortion for women in the state: In the first year, the number of clinics in Iowa offering abortion rose from 6 to 17.
But the Iowa model had its legal hiccups. The Iowa Board of Medicine banned prescribing Mifeprex via telemedicine in 2013, claiming it endangered women. Two years later, the Iowa Supreme Court unanimously ruled that the ban was unconstitutional; the programs continued.
When it comes to telemedicine abortion programs, “Iowa is the leading example,” says Nash. Clinics in other states like Maine and Alaska have since adopted the model. At the same time, though, eighteen other states have explicitly banned telemedicine abortion by requiring a clinician be present when a woman takes her abortion pill. Nationally, the immediate outlook is for telemedicine abortion programs is more bleak than not.
Outside of the United States, programs in Canada and Australia are already offering direct-to-patient access of abortion pills by mail or by prescription. With the Tabbot Foundation in Australia, for example, women call in and get referred to a local provider for ultrasound and blood tests before getting their abortion pills. Since the program launched last September, over 300 women have used its services.
In the US, FDA rules do not allow this direct-to-patient access to the abortion pill. “That model has not been tested, has not been used in the United States,” says Raymond. But the organization she works for, Gynuity, filed an application for a clinical trial to test providing direct-to-patient telemedicine abortion services this year. The study aims to gather data on the safety, acceptability, and feasibility of the method. It’s the first step to knocking down barriers at the FDA.
But even if the FDA gives the okay to direct-to-patient telemedicine abortion services, state laws can still restrict access---just as they have with the Iowa model of telemedicine abortion. And the political winds are currently blowing that way. “With state legislatures, the composition is not lending itself to expanding access to abortion,” says Nash.
In Texas and Louisiana, for example, Republican-controlled state governments have passed laws requiring abortion clinics to be outfitted like surgical centers. Those requirements ostensibly protect women, but they're so expensive to fulfill that the majority of abortion clinics in the two states will have to close. The laws are now before the Supreme Court, where a 4-4 split would affirm lower court decisions upholding the laws.
States have a precedent for restricting similar telemedicine services. Some have banned prescribing drugs like benzodiazepines via telepsychiatry, says Nathaniel Lacktman, a healthcare lawyer at Foley and Lardner. But that’s because those drugs contain controlled substances, and legislators believe they could jeopardize public health. Interestingly, the states that have banned telemedicine for controlled substances and those for the abortion pill? They don’t overlap that much.
