Telehealth Abortion After Dobbs

For someone has spent decades navigating the jagged regulatory and medical landscape of abortion in the United States, Beverly Winikoff, M.D., M.P.H., finds herself uncomfortably unsure about the future.

“It’s not something you can ask me to enlighten you about because I don’t know which way it’ll go,” she told Managed Healthcare Executive® in a phone interview just days following the U.S. Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization.

The 5-4 decision that the Constitution does not confer a right to abortion overturned Roe v. Wade and returned authority to regulate abortion to the states. The ruling had the effect of enacting so-called “trigger laws” in some states that made abortion illegal contingent upon the court’s rulings. Other states moved to take swift legislative action, either to protect the right to an abortion or to restrict it.

All of which puts Winikoff in an odd position. She is president of Gynuity Health Projects, which since 2003 has made it its business to expand access to abortion by researching ways to make the procedure safer and more efficient. In a post-Dobbs world, Winikoff says the push to make abortion care more efficient has become even more urgent. She believes telemedicine could be a key part of the solution, even if patients have to travel across state lines to access it.

TelAbortion study

Winikoff has good reason for being a proponent of telemedicine abortion. One of Gynuity’s landmark accomplishments was the TelAbortion study, which showed that abortions using video consultations and medication abortion (most commonly mifepristone and misoprostol) were a safe, effective way to expand access to early abortions. The study was launched in 2016. Back then, “telemedicine” typically meant going to a clinic and then connecting with a doctor at another one. It was cumbersome and contrived, Winikoff says

“Why do you have to get them to go to a clinic, which has no doctor and a lockbox that’s going to pop open, and they’re allowed to take pills?” she asks. “It doesn’t make any sense.”

In results published in March 2021 in Contraception, the study’s investigators revealed that 95% of patients who received mifepristone and misoprostol by mail did not require further procedures and that 99% of patients who completed a questionnaire said they were satisfied by their experience. The findings were partially responsible for the FDA permanently lifting a requirement that abortion pills be dispensed in a clinic. Before that, the pills could only be mailed to patients within the context of the clinical trial. The percentage of abortions in the US performed via medication crossed 50% for the first time when the COVID-19 pandemic hit, according to the Guttmacher Institute.

Abortion by telemedicine might have become mainstream like telemedicine for primary care has become. The Dobbs decision has complicated matters, to put it mildly, because it means many patients might not be able to access abortion via telemedicine — at least not legally.

The Irish experience

Perhaps the closest one can come to predicting the role of telemedicine abortion in a post-Dobbs world is to look at the experiences of women in Ireland and Northern Ireland, where abortion was illegal until 2019.

A 2017 study published in BMJ examined the self-reported outcomes of 1,000 women in Ireland and Northern Ireland who sought abortion medications through Women on Web, an online telemedicine service that provides abortion medication to women in areas where abortion access is restricted. Like the TelAbortion study, this study — which included patients who used the Women on Web telemedicine service between 2010 and 2012 — had a 94.7% success rate of ending the patient’s pregnancy without the need for surgical intervention.

The study results showed that users of self-sourced abortion pills tended to be older, possibly because they were more likely than their younger counterparts to recognize their pregnancies early enough to use medication abortion. The findings also suggested that women with adequate economic means were more likely to travel to other jurisdictions for abortions. However, the results showed some patients preferred telemedicine because it was perceived as more private or because they feared prosecution.

“Women who have had a self-sourced abortion and those who have had an early pregnancy loss are clinically indistinguishable, but these events raise the concerning possibility of a chilling effect, whereby women might be reluctant to seek care for fear of being reported,” wrote the study’s corresponding author, Rebecca Gomperts, M.D., M.P.P., Ph.D., who founded Women on Web.

Post-Dobbs

In the U.S., people seeking abortions who live in states where abortion is illegal will face difficult decisions. A February 2022 report by the Guttmacher Institute showed six states already had laws in force or tied up in courts that banned the mailing of abortion pills to patients. However, Winikoff says it is unclear how a state would go about enforcing such a ban.

“Honestly, if people can’t get services in a reliable U.S.-based way, they’re going to order it from the internet,” she says “And, I mean, there’s too much mail. Nobody’s going to be able to figure out what’s in the packages.”

Aid Access, an organization founded by Gomperts, has said it will provide abortion pills to women in all 50 states. In 20 states, abortion drugs can be prescribed by U.S. doctors and delivered within a few days. Women outside those 20 states who use the service will have their prescription ordered by a doctor in Europe, and delivery of the medications can take one to three weeks.

Short of circumventing local laws, women in states with tight abortion prohibitions might have to travel out of state to receive care. Even if they do, telemedicine might still play an important role.

Winikoff notes that one problem clinics in legal-abortion states are having is a backlog of patients seeking appointments as clinics in prohibition states shut down and force patients to drive across state lines for care.

“People are waiting a week — two weeks sometimes — to get an appointment,” she says “Even for telemedicine, sometimes there’s a delay.”

Winikoff says converting more in-person meetings to telemedicine would help unburden the system because it would eliminate some of the waiting time and lead to faster visits.

Still, Winikoff has her eye on an even faster model of care: asynchronous delivery. “In other words, the person who wants the service goes online and fills out a form that is read later by a medical provider,” she says “And if that person is cleared by the answers on the form, then the drugs are sent without actually any face-to-face (conversation).”

Such a system would be faster, in part, because there would be no need to find appointment times that worked for both patient and provider. Asynchronous abortion telemedicine is already happening. Winikoff says. Gynuity is providing the service to collect data and prove it is safe and effective. Meanwhile, a California-based telehealth startup called Choix is offering asynchronous abortion-pill services in four states. The service is based on a questionnaire that is presented as taking only five minutes to fill out and costs $289. The company recently closed a $1 million round of seed funding.

Although Winikoff says she does not know where the regulatory framework around abortion is heading, she believes the future of abortion needs to be both safe and streamlined.

“I think we have to be cognizant of the frustrations of the consumers,” she says. “When you want an abortion, you want it as fast as you can get it.”

Jared Kaltwasser is a healthcare writer in Iowa and a regular contributor to Managed Healthcare Executive®.