Telehealth Abortions Are Changing The Culture Of Medicine : Short Wave Recent rule changes have increased access to abortion pills through the mail, using telehealth services. As many U.S. states gear up to restrict abortion access in anticipation of the Supreme Court possibly overturning Roe v. Wade, the medical professionals behind these services are preparing for an even bigger surge in demand. Groups that provide abortion pills are also preparing to face significant new obstacles, as anti-abortion states push back against expanded online access. Both patients and clinicians are testing the boundaries of this service that is fully legal in many states — but operates in a legal gray area in others.

Telehealth Abortions Are Changing The Culture Of Medicine

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EMILY KWONG, HOST:

You're listening to SHORT WAVE...

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KWONG: ...From NPR.

Hey, SHORT WAVErs, Emily Kwong here with a SHORT WAVE favorite - NPR science desk reporter Pien Huang, who's joined by NPR contributor Dr. Mara Gordon.

PIEN HUANG, BYLINE: Hey, Emily.

MARA GORDON, BYLINE: Hey, Emily.

KWONG: Hi. So, Pien, I hear you've got a story to start us off with.

HUANG: Yes. So a few weeks ago, the Supreme Court's draft ruling on abortion rights was leaked, and that set off alarm bells that nationwide abortion rights could soon be ending.

KWONG: I remember this day.

HUANG: Well, on that day, a woman named Nora (ph) was on the couch in her apartment getting through a medical abortion, which is done by taking pills.

NORA: And I was bleeding through a pad about every 40 minutes. And I would take panty liners - I made, like, these caterpillar pads just to cover all the bases. They lasted maybe 40 minutes.

HUANG: We're just using Nora's first name for her personal safety, and she's a baker in upstate New York.

NORA: And I've always wanted kids, but I'm 22, and I am poor. And I just can't even wrap my head around, like, just going to the doctor, getting an ultrasound - all of these things are very expensive - over a baby that you could be forced to have.

HUANG: While deciding to end her pregnancy was hard, getting the FDA-approved pills was not.

KWONG: Where did Nora get the pills?

HUANG: She got them online through this medical provider called Aid Access, and it's one of a handful of online telehealth abortion providers that have been springing up in recent years.

GORDON: So this is Mara. The companies - they're named things like Hey Jane and Abortion On Demand, and they benefited from some rule changes during the pandemic that have allowed abortion pills to be sent through the mail and taken at home. The FDA made these rule changes permanent last year. Now, as more abortion restrictions loom over parts of the country, Robin Tucker, a nurse practitioner and midwife who works with Aid Access, says these telehealth services are seeing a surge in demand.

ROBIN TUCKER: The future of abortion access is going to be getting pills out there and getting pills in the hands of people. That's, like, one of the interventions that can provide the most autonomy in this kind of environment where people are going to lose reproductive rights.

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KWONG: Today on the show - how the boom in telehealth startups that mail abortion pills is clashing with the legal landscape and the culture of medicine. I'm your host, Emily Kwong.

HUANG: I'm Pien Huang.

GORDON: And I'm Mara Gordon.

KWONG: And you're listening to SHORT WAVE, the daily science podcast from NPR.

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KWONG: All right, Mara, we're going to start with you. Can you talk about how abortion has undergone a change - from being solely a surgical procedure to one that can be done through the mail?

GORDON: Yeah. So for years, patients usually had to go to freestanding clinics that offer abortion. In a lot of places, you couldn't just go to your regular doctor's office or your regular gynecologist's office to get an abortion because there were just so many rules and regulations about abortions. They're called TRAP laws, or targeted regulation of abortion providers. So as a result, people often had to travel pretty far to get an abortion. There was one study published in The Lancet a few years ago that found that 1 in 5 women would have to go more than 40 miles to get to a clinic that provides abortions.

KWONG: Wow. Yeah, I can see that taking a lot of work in and of itself, right? Like, you're arranging childcare, taking time off work, securing gas money, bus fare, maybe even finding a place to stay.

GORDON: Yeah. And patients also faced harassment from anti-abortion protesters because they often targeted those clinics that specifically provided abortions. So now, with telehealth abortions, patients can access pill abortions privately from home with a credit card and just a few taps on a smartphone. That's what Jamie Phifer has been seeing. She's the founder of Abortion On Demand, a company that provides telehealth abortions in 21 states.

JAMIE PHIFER: Most of my patients are sitting in their parked cars. They're doing a 15-minute video on their lunch break at work. They are waiting to head home after traffic clears. Some of them are sitting on the couch breastfeeding their infants. They're waiting to pick up their kids from day care.

KWONG: That's interesting. So Pien, what has changed with regulations in the U.S. that allows these services to be available so widely now?

HUANG: Well, it's two main things, and they're both really recent - they happened during the pandemic. So first, there was a boom in telehealth across all kinds of medicine. You know, people started getting routine medical visits, physical therapy, their rashes checked out through telehealth. And also, insurance companies started paying up for it. And the second thing that happened was that there was a specific change to abortions. So during the pandemic, the FDA relaxed the rules for one of the pills, mifepristone. And pre-pandemic, it required an in-person provider visit. But then, the FDA started allowing it to be sent through the mail, so that actually made it possible for these internet-based services to start providing fully remote abortions. You do an online telehealth appointment, you get the pills in the mail, and you take them at home.

KWONG: OK. But we've also been hearing a lot about states that restrict abortion or will soon, as Roe is overturned. What does that mean for people from these states getting these pills?

HUANG: Well, even now, when abortions are still legal in every state, telehealth abortions are not. So in states like Texas, Louisiana, Arkansas, telehealth abortions are straight-up banned, and other states have some in-person requirements.

GORDON: And Alina Salganicoff, director of women's health policy at the Kaiser Family Foundation, says that this leaves many grey areas. For example, can you see a doctor in a different state? Can friends and family send you pills across state lines?

ALINA SALGANICOFF: So we really are moving into a new zone. I think it's going to be challenging for providers, I think it's going to be challenging for patients, and I think we're going to see a lot of litigation as these cases move forward.

KWONG: Wow. So much gray area. And she's saying that the tensions are already stewing.

GORDON: Yeah, both in terms of what will people actually do and how will any of this get enforced.

KWONG: Yeah.

HUANG: Now, most telehealth abortion providers are only operating in states where it's fully legal.

KWONG: Uh huh.

HUANG: But in states where it's not, some of these providers have a workaround.

KWONG: Like what?

HUANG: Well, take Aid Access, for instance. They have a doctor based in Europe who sends abortion pills from India. But the FDA is, quote, "very concerned" about these drugs' safety, and one doctor with Aid Access told me it can delay an abortion by several weeks. She asked us not to identify her by name to protect her family, and she says providers would prefer to send FDA-approved pills to other states, but they would need legal protection.

UNIDENTIFIED PHYSICIAN: We're really trying to lobby the state to pass those assurances that my license will not be at jeopardy, my malpractice will not be at jeopardy, and that I will not be extradited to another state and prosecuted - because these are criminal and civil penalties that we're looking at.

KWONG: Wow. These providers have some pretty serious issues to grapple with.

HUANG: Yeah. And some states, like Connecticut, Washington, California, have passed or are thinking of passing laws like this that would protect their clinicians.

KWONG: Got it.

Mara, going back to you - as a medical professional, can you just explain how these pills work?

GORDON: Generally, medication abortions in the U.S. are a combination of two drugs, mifepristone and misoprostol. Together, the pills block a hormone that is needed to continue an early pregnancy, and then they get the uterus to expel the pregnancy. The pills are safe. They're effective. They work for any pregnancies up to 10 to 12 weeks.

KWONG: And mifepristone's been around for a minute.

GORDON: Yeah, it's not new. The FDA approved it in 2000, and its use has been growing. So about 10 years ago, it was used in about a quarter of all U.S. abortions, and now it's used in about half.

KWONG: And you said these drugs are safe, they're effective. But in the past, patients have needed to see practitioners. How are doctors doing that now, through telehealth?

GORDON: Yeah, this is a huge change. So in medical school, I learned that doctors always need to do an ultrasound and blood tests before an abortion. That's to figure out how far along someone is in their pregnancy. It's to make sure it's not an ectopic pregnancy, check for risk factors like anemia - things like that. But rather than doing these tests, telehealth providers have a checklist that they go through with their patients. They'll ask about when their last period was, medications that they're taking, any pain that they're feeling - that's to figure out how at risk the patients are for complications.

KWONG: But what happens when someone's not a good candidate for this?

GORDON: So if they're pretty far along in their pregnancy, or if they're at risk for a lot of bleeding, the providers will refer them to in-person care, or they'll ask them to get an ultrasound before mailing the pills.

HUANG: There's a paper from March 2022 that showed that major adverse events were very rare. Less than 1% of abortions performed without this kind of testing needed follow-up care, like blood transfusions or surgery, and patients were really satisfied with their care.

KWONG: So given how many people are using abortion pills - a lot sent through the mail - what does this change mean for doctors and how they view abortion?

GORDON: Yeah, medicine is a field that can be really slow to change. I remember, at the beginning of the pandemic, my colleagues and I - we were not ready to move to telehealth. There were so many logistical challenges. But I think, more importantly, telehealth challenges the power balance in the doctor-patient relationship. You know, instead of me making my patients wait in an exam room, when I do telehealth, my patients - they make me wait. You know, oh, Dr. Gordon, wait one second while I get the video chat set up.

KWONG: Yeah.

GORDON: And I think that this is really highlighted in telehealth abortion. The providers have to trust what their patients are telling them about their health rather than using tests to confirm it, and that is a huge cultural shift from the way that we're taught to practice medicine when we're in school.

So abortion is an area of medicine that's also under a lot of legal scrutiny. I've talked to a lot of doctors who provide abortions, who are really staunch abortion rights advocates, and they're still pretty nervous about the idea of doing an abortion without an ultrasound, even with the research that shows that it's safe.

KWONG: I want to end with a broad question to both of you. So the possible overturning of Roe means there will be no federal protection to the right to an abortion in this country. States will come up with their own laws. As both of you continue your work reporting - and in your case, Dr. Gordon, providing care - what questions do you have?

HUANG: Well, we're in a gray area right now with a lot of these issues, and we have a lot of big questions to answer about what will and won't be legal, what the medical regulations are going to be, and how all of these changes are going to play out in real time. One of the things that stayed with me is the idea that, even if Roe vs. Wade gets overturned, there are safer options now than there were before Roe, like these pills. So hopefully women won't have to revert to using dangerous methods like coat hangers to end abortions, which is a popular symbol for pro-abortion-rights advocates. But still, if Roe v. Wade is overturned, a lot of women and others that want to end their pregnancies will have super limited access to abortions. Even in haven states, it'll increase the wait times for abortions. And the longer you wait to get an abortion, the riskier it is.

GORDON: Yeah. One thing that really interested me in our reporting, Pien, was the clinicians who said that they'd be willing to provide telehealth abortions across state lines. I think there's going to be a lot of changes coming, you know, about how far anti-abortion states can go to prosecute a doctor in another state, and how far a state can go to protect their own doctors, too.

KWONG: Right, because clinicians are licensed state by state.

GORDON: Yeah. But we live in a world where people travel, and the internet is breaking down all those geographic barriers. You know, for example, I live in Pennsylvania. I practice medicine in New Jersey. If one of my patients is traveling, say, to Nebraska, they forget their blood pressure pills, I will electronically prescribe those pills to a pharmacy there. When it's for medical care other than abortion, nobody bats an eye. And another thing I'm really curious about is something that's called advanced provision. It's when people who aren't even pregnant get abortion medications to keep on hand just in case they need them or a friend needs them.

HUANG: Yeah, and that's a real gray area, too. It's an off-label use for the pills, and it really just opens up this whole new front on abortions that are self-managed, which is to say without the guidance of a medical professional at all.

GORDON: Yeah. But as a doctor, I really worry about a world where patients feel like they might have to lie to the people who are taking care of them. But if abortions get further restricted, it may be where things are headed.

KWONG: It's a world that we've never really known, and certainly not in my lifetime, so thank you for getting answers to some of these questions.

HUANG: Thanks, Emily.

GORDON: Thank you.

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KWONG: This episode was produced by Rebecca Ramirez and edited by Gisele Grayson, who is our senior supervising editor. Margaret Cirino checked the facts. Robert Rodriguez was our audio engineer. Andrea Kissack runs the science desk. Edith Chapin is vice president and executive editor-at-large. Terence Samuel is vice president and executive editor, and Nancy Barnes is our senior vice president of news. I'm Emily Kwong. Thank you so much for listening to SHORT WAVE, the daily science podcast from NPR.

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