Using Telehealth to Boost Abortion Access in a Post-Roe World

On June 24, reproductive healthcare in the US was dealt a significant blow when the Supreme Court overturned the landmark Roe v. Wade decision. In the emerging landscape, rife with restrictions to care access, medication abortions through telehealth have become a lifeline for many nationwide.  

Since Roe was overturned, 13 states have banned abortion, and five have enforced gestational limits ranging from six to 20 weeks, according to data gathered by The New York Times. Judges have temporarily blocked abortion bans in eight states, while abortion is legal but limited in another 10.  

"We are at a crisis point for abortion access in the US, which makes it critical to secure and expand access to abortion in innovative ways wherever possible to combat this national healthcare crisis," said Sarah Diemert, director of medical standards integration and evaluation at Planned Parenthood Federation of America, in an email.

With the federal government throwing its weight behind medication abortion access in various ways — including by warning retail pharmacies that they are obligated to provide prescribed medications under federal civil rights laws — telehealth has become an increasingly popular modality to access these types of abortions.  

TELEHEALTH USE FOR REPRODUCTIVE HEALTHCARE IS ON THE RISE

Amid the COVID-19 pandemic, as telehealth usage shot up, reproductive healthcare also went digital.

At Planned Parenthood, affiliates across the country conducted over 425,000 appointments via telehealth from March to October 2020, Diemert said.

"Telehealth has played a significant role in helping Planned Parenthood reach people with the high-quality care and information they need to stay safe and healthy in timely and personal ways, including abortion care," she added.

In addition to abortion services, Planned Parenthood patients gain access to Roo, a sexual health chatbot, and Chat/Text and Chatea/Textea programs to get information about reproductive health in real time from sexual health educators.

Carafem, a provider of reproductive healthcare, has also experienced a rising interest in digital care services among its patient population. According to Melissa Grant, chief operating officer of carafem, there was a 200 percent increase in telehealth abortions provided by carafem health centers in the last year. To meet this rising patient demand, the organization went from offering telehealth-enabled care in five states to 15.

Then, Roe v Wade was overturned. In the months since, as restrictions on abortion access grew, reproductive healthcare providers have seen a further jump in demand for services.

Carafem saw an approximately 225 percent increase in clients receiving abortion care in August compared to the same period last year. That figure includes both in-person and virtual abortion services and represents centers in states where abortion is legal.

"Now our southern states, like I said, [we] have stopped," Grant said in a phone interview. "We don't see patients for abortion. It's illegal now in Tennessee, so we can't. And our Georgia site was cut back to up to six weeks only, just before many people know they're pregnant. So that particular site is down about 25 percent. If you think about it — the 100 percent of clients that were in Tennessee and the 25 percent [that until] at least last month we were generally seeing in Georgia have to go someplace else."

Though Planned Parenthood declined to provide specific data, the organization has seen a significant surge in patients traveling to seek abortion care in states with fewer or no abortion restrictions.

"Planned Parenthood affiliates are working together in a regional model to ensure patients are getting the care they need as soon as possible," Diemert said.

As patient volumes rise in states allowing abortion, reproductive healthcare providers increasingly lean on virtual care options to extend care. This is largely because telehealth provides several benefits, as demonstrated by the increase in use even before Roe was overturned.

"Using telehealth to provide medication abortion reduces the number of required health center visits and other logistical hurdles for patients accessing care — such as securing child care, coordinating transportation, or taking longer periods of time off work," Diemert said. "This can be especially helpful for those living in remote, rural, or medically underserved communities."

Grant echoed Diemert, adding that telehealth enables reproductive health providers to add more staff to serve the rising patient volumes, thereby avoiding the confines of brick-and-mortar locations.

Another advantage is cost. Since they did not have to incur expenses to add brick-and-mortar health centers, carafem has decreased the price of its telehealth services, passing along those savings to patients, Grant noted.  

In addition to accessibility, cost, and other benefits, telehealth enables confidentiality and a reprieve from anti-abortion groups that tend to protest outside centers providing abortion care.

"Instead, to be able to sit down on the couch in your living room or in your best friend's apartment, or sometimes even in a private room at a library in order to get good computer access," Grant said. "We've seen all kinds of different ways that people choose to do it, but they can pick the best time and the best place to be with the greatest discretion, and sometimes that's very important for our clients."

WHAT IS A TELEHEALTH-ENABLED MEDICATION ABORTION?

Medication abortions involve taking two pregnancy termination drugs, Mifepristone and Misoprostol, in the first 10 weeks of pregnancy. 

At carafem, the medication abortion process begins with patients deciding whether they would like to come into a brick-and-mortar location or participate in a telehealth visit. If they select the telehealth option, the patient must then schedule a video visit.

"Currently, we do meet with each of our clients with a video visit," said Grant. "We're looking at whether that's necessary in every state, but we've elected at the beginning to start that way in order to build rapport with our clients."

Before the video-based appointment, carafem collects the patient's health history to ensure they are an appropriate candidate for a medication abortion. The organization also sends relevant information to the patient via email, including instructions for performing a medication abortion and financial assistance options.

During the visit, which patients can access through a private link, a client care coordinator goes over the instructions to ensure patients know how to take the medications correctly. Mifepristone is taken orally, followed by Misoprostol 24 to 48 hours later, which is placed in the cheek or taken vaginally.

"We go through how that works, what to expect or the side effects of the medication, what any risks of using the medication are, and then how to know afterward whether your abortion was complete, whether everything went the way that we expect," Grant said. "And [we] provide information about how to talk to us should you have any concerns along the way."

After speaking with the client care coordinator, the patient is connected with a physician, who reviews the patient's health history again and ensures that any unresolved questions are answered. The physician then sends an e-prescription to an online pharmacy that ships the medications to the patient within two to three days.

Following the video visit, the patient is connected to an SMS-based virtual assistant named Cara.

"Cara [is] our virtual online assistant who helps the client track the medication all the way to when [they] pick it up and then walks [them] through the process of using it, making sure it worked well all the way through to the end when a client might use a pregnancy test at home about four weeks afterward," Grant said.

Many Planned Parenthood health centers also offer medication abortions via telehealth. These services are currently available in 21 states. It is important to note that as of Sept. 1, two states have banned the use of medication abortion beyond a specific point in pregnancy, and 19 states require the clinician prescribing the medication to be physically present when the drug is administered.

"Medication abortion is extremely safe — with a safety record of over 99 percent — and is a highly effective way to end an early pregnancy," said Diemert. "There is very little difference between the in-person medication abortion process and medication abortion via telehealth, and there is published research that supports this."

CHALLENGES OF PROVIDING TELEHEALTH ABORTIONS

Though telehealth is undoubtedly beneficial in extending reproductive health services, particularly abortion care, there are several hurdles providers face.

These include several overarching barriers to virtual care, like low digital health literacy and limited internet access.

"[These] create unnecessary barriers to care that mostly affect Black, Indigenous, and Latino communities, rural communities, and people with low income," Diemert said.

Additionally, building a rapport with people seeking abortions through a screen can be challenging.

According to Grant, one can glean physical cues more efficiently in face-to-face patient encounters through body language.

"It can be a challenge, particularly for people who may not be native English speakers and may have deficits in hearing or other issues that make it more difficult," she said.

But, with practice, carafem's virtual abortion care providers have identified strategies that can help overcome this issue. These include leaving time for questions and ensuring the physician is in a quiet place and can be seen clearly through the screen, Grant said.

Also, thinking through ways to make information-sharing easier for the patient can help improve the virtual visit experience.

"…now what we're doing is [providing] connecting links in addition to a visit so that they can receive this written information right away and then receive written information again when we mail medications," Grant said.

But there are barriers to virtual reproductive health services outside of individual providers' control. One is that the overturning of Roe triggered various state laws, which has resulted in confusion over what types of care are legal under certain abortion restrictions.

"While telehealth makes it possible for more people who need an abortion to access one, it isn’t a solution for all of the legislative attacks we've seen across the country," Diemert said.

Another is the lack of reimbursement for medication abortions, specifically through telehealth, Grant added.

In light of these challenges and the enduring preference for in-person care among certain patients, the key to ensuring access to abortion lies in providing both in-person and virtual care modalities.

"Every pregnancy and body is unique, and every person is different," Diemert said. "What works best in one situation or for one person might not be ideal in another situation or for another person. This is why it is so important for patients to have as many options to access abortion as possible."