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Telemedicine Will Change How Underground Abortions Work

But it’s hardly a solution to legislation against reproductive rights

Photo: Phil Walter/Getty

TThe past few weeks have been a terrifying time for the American reproductive rights movement, as state after state has passed legislation banning all but the earliest possible abortions — and, in the case of Alabama, banning the procedure outright. Although none of the bans have gone into effect yet, and there’s a good chance at least a few if not all will be overturned or enjoined by the courts, the wave of anti-abortion legislation nevertheless feels like a terrifying omen of things to come.

To many in the abortion-rights camp, it’s clear that it’s only a matter of time until a significant portion of the country is thrust back to the pre-Roe v. Wade era, one where people in need of abortions are forced to go underground. And no matter what happens in the courts and the legislatures, recent technological advancements in medicine have made it unlikely that the underground abortion scene will bear any resemblance to the back alleys of decades past.

The most significant change is the development of mifepristone and misoprostol, two medications that work together to safely and effectively terminate a pregnancy — even when a person takes the pills on their own, without the supervision of a doctor. (Misoprostol, which is more widely available than mifepristone, can also be used alone, though it’s less effective than the two medications in combination.) In combination with telemedicine, these pills offer a fallback plan, one where an illegal abortion can be safely administered in the privacy of one’s home with medication ordered off the internet. Although the FDA has only approved mifepristone for use up to 10 weeks of pregnancy, self-managed abortion advocates argue that misoprostol pills can be used to safely terminate pregnancy up to 12, and potentially even 20 weeks in.

There are already sites that provide access to abortion pills, as well as detailed instructions on how to safely induce an abortion at home. Advocacy and education site Plan C maintains a report card that rates the available options on price, product quality, and speed of delivery (a key factor for people looking to induce an abortion). Plan C’s top pick, the Europe-based Aid Access, is ignoring an order from the FDA and is continuing to ship abortion pills to the U.S., even to states with restrictive abortion laws, or where self-managed abortion is outlawed.

As the U.S. moves toward a patchwork collection of conflicting stances and state policies regulating abortion, some advocates see a path for telemedicine to provide relief to patients.

While physically safe, self-managed abortion does come with potential legal risks. As Jill E. Adams, executive director of If/When/How: Lawyering for Reproductive Justice, tells me, there are six states that ban self-managed abortion, 10 states with fetal harm laws that do not make an exception for the pregnant person, and 14 states with antiquated laws that could be misapplied to criminalize people who end or lose a pregnancy. Even when there are no laws on the books that specifically criminalize self-managed abortion, a sufficiently motivated prosecutor can find a way to make a criminal case.

“The law is secondary,” says Adams. “They will use whatever part of the criminal code they can get their hands on to try to punish someone, even when those laws were never intended to be used against a person who ends their own pregnancy.”

But as the United States moves toward a patchwork of conflicting stances and state policies regulating abortion, some advocates see a path for telemedicine to provide relief to patients living in anti-abortion states — without having to turn to a potentially sketchy website, or seek aid from outside the country. Even as states like Alabama move towards outlawing abortions, a significant portion of the country — including states like New York, California, Maine, Nevada, and Illinois — are taking steps to make abortion legally protected and more accessible. These abortion-rights oases could play a key role in providing pharmaceutical abortion access throughout the United States.

At present, there is one physician-backed, U.S.-based abortion telemedicine site, the FDA-reviewed research project TelAbortion. Sponsored by the non-profit reproductive health organization Gynuity Health Projects, TelAbortion currently provides online abortion access to residents of eight different states: Hawaii, Washington, Oregon, Colorado, New Mexico, New York, Maine, and, perhaps surprisingly given its recent move to severely restrict abortion rights, Georgia.

In order to make use of TelAbortion’s services, one has to be able to conduct an online consultation and receive mail within the borders of one of its approved states — simpler and less stressful traveling to an abortion clinic in another state, especially when pills alone are often significantly cheaper than a surgical abortion.

Additionally, online abortion services offer scheduling flexibility rarely afforded by clinics, where abortions may only be available one day a week when providers happen to be on site. “The nice thing about the TelAbortion project is that women are able to obtain the service at a time that’s convenient to them,” says Inga Platais, a program associate for Gynuity.

Easy access to self-managed abortion in some states is hardly a panacea for regressive abortion laws in others.

But even as telemedicine has the potential to radically change our understanding of abortion access, the promise of projects like TelAbortion is currently stymied by FDA regulations. Since its debut on the U.S. market in 2000, mifepristone has been governed by an additional set of restrictions known as Risk Evaluation and Management Strategies (often referred to as the REMS), which severely curtail when, how, and under what circumstances the drug can be dispensed.

Most notably, the REMS requires mifepristone to be dispensed at a clinic, hospital, or medical office — a restriction that makes distribution by mail potentially in violation of FDA policy. As a research project, TelAbortion is given some leeway with regards to the REMS, but until the REMS is overturned, it’s unlikely that we’ll see other U.S.-based telemedicine abortion projects following in its footsteps. Even if it is, it’s possible that states may decide to curtail the expansion of telemedicine abortion, through restrictions that discourage pregnant people from self-managing their procedures at home.

And while the combination of telemedicine and self-managed abortion has the potential to provide an appealing alternative to unsafe back-alley abortions or lengthy trips to the lone abortion clinic in a neighboring state, it’s still far from a perfect solution for people living in anti-abortion states. Easy access to self-managed abortion in some states is hardly a panacea for regressive abortion laws in others.

“Every state should be held on the hook for making abortion more accessible within its own borders,” says Erin Matson, co-founder and co-director of the reproductive justice advocacy organization ReproAction. “It’s not acceptable to point to other states as a solution.”

At a time when a rapid expansion has made it nearly effortless to gain access to erectile dysfunction medications, anti-balding drugs, and even dubious libido pills, it’s frustrating to see the promise of radically transformed abortion access stymied by politics and regressive attitudes towards reproductive rights. But that reality points to a larger truth: Tech may make it easier for people to navigate punitive abortion restriction, but it’s no replacement for sensible laws that recognize abortion as the necessary and essential medical procedure that it is.

OneZero columnist, Peabody-nominated producer, and the author of Faking It: The Lies Women Tell About Sex — And the Truths They Reveal.

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