News & Resources
Abortion by Telemedicine: A Growing Option as Access to Clinics Wanes
The coronavirus has created a surge in demand for telemedicine of all types – including for a quietly expanding program for terminating pregnancies.
Ashley Dale was grateful she could end her pregnancy at home.
As her 3-year-old daughter played nearby, she spoke by video from her living room in Hawaii with Dr. Bliss Kaneshiro, an obstetrician-gynecologist, who was a 200-mile plane ride away in Honolulu. The doctor explained that two medicines that would be mailed to Ms. Dale would halt her pregnancy and cause a miscarriage.
“Does it sound like what you want to do in terms of terminating the pregnancy?” Dr. Kaneshiro asked gently. Ms. Dale, who said she would love to have another baby, had wrestled with the decision, but circumstances involving an estranged boyfriend had made the choice clear: “It does,” she replied.
Abortion through telemedicine is a quietly growing phenomenon, driven in part by restrictions from conservative states and the Trump administration that have limited access and increased the distance many women must travel to abortion clinics.
Now, the coronavirus pandemic is catapulting demand for telemedicine abortion to a new level, with much of the nation under strict stay-at-home advisories and as several states, including Arkansas, Oklahoma and Texas, have sought to suspend access to surgical abortions during the crisis.
The telemedicine program that Ms. Dale participated in has been allowed to operate as a research study for several years under a special arrangement with the Food and Drug Administration. It allows women seeking abortions to have video consultations with certified doctors and then receive abortion pills by mail to take on their own.
Over the past year, the program, called TelAbortion, has expanded from serving five states to serving 13, adding two of those — Illinois and Maryland — as the coronavirus crisis exploded. Not including those new states, about twice as many women had abortions through the program in March and April as in January and February.
To accommodate women during the pandemic, TelAbortion is “working to expand to new states as fast as possible,” said Dr. Elizabeth Raymond, senior medical associate at Gynuity Health Projects, which runs the program. It is also hearing from more women in neighboring states seeking to cross state lines so TelAbortion can serve them.
As of April 22, TelAbortion had mailed a total of 841 packages containing abortion pills and confirmed 611 completed abortions, Dr. Raymond said. Another 216 participants were either still in the follow-up process or have not been in contact to confirm their results. The program’s growth is significant enough that Republican senators recently introduced a bill to ban telemedicine abortion.
The F.D.A., which has allowed TelAbortion to continue operating during the Trump administration, declined to answer questions from The New York Times about the program.
Abortion through medication, first approved by the F.D.A. in 2000, is increasingly becoming women’s preferred method. Recent research estimated that about 60 percent of abortion patients early enough in pregnancy to be eligible — 10 weeks pregnant or less — chose medication abortion over suction or surgery.
But the F.D.A. requires that the first drug in the two-medication regimen, mifepristone, be dispensed in clinics or hospitals by specially certified doctors or other medical providers.
The F.D.A. rules, however, do not specify that providers must see patients in person, so some clinics have begun allowing women to come in for video consultations with certified doctors based elsewhere. TelAbortion goes further, offering telemedicine consultations to women at home (or anywhere), mailing them pills and following up after women take them.
In interviews, seven women who terminated pregnancies through TelAbortion described the conflicting emotions and intricate logistics that can accompany a decision to have an abortion, and their reasons for choosing to do it through telemedicine.
Ms. Dale, a single mother, was about to start a job at a storage center when she became pregnant last year. She would have had to fly to Honolulu, incurring expenses for travel and child care.
The alternative would be to wait for a doctor to come to my island in three weeks,” Ms. Dale, 35, told Dr. Kaneshiro during her consultation, which she allowed a Times reporter to observe. By then, she would be too pregnant for a medication abortion.
But many TelAbortion patients live near clinics. Shiloh Kirby, 24, of Denver, who said she had become pregnant after being raped at a party, chose TelAbortion for convenience and privacy. She conducted her video consultation while sitting in her car in the parking lot of the hardware store where she worked.
Dawn, 30, a divorced mother of two who asked to be identified only by her first name, was terrified that the debilitating postpartum depression she experienced after her children’s births would return if she continued her pregnancy. And she worried protesters at her local Planned Parenthood in Salem, Ore., might recognize her.
“I just don’t want to deal with that ridicule,” she said.
Expanding across the country
Based on state laws governing telemedicine and abortion, Dr. Raymond estimated TelAbortion might be legal in slightly over half of the states, including some conservative ones. It now serves Colorado, Georgia, Hawaii, Illinois, Iowa, Maine, Maryland, Minnesota, Montana, New Mexico, New York, Oregon and Washington.
The doctors (and nurses or midwives in some states) who do TelAbortion’s video consultations must be licensed in states where medication is mailed, but do not have to practice there. Likewise, patients do not have to live in the states that TelAbortion serves; they just have to be in one of them during the videoconference and provide an address there — that of a friend, relative, even a motel or post office — to which pills can be shipped.
“We have had patients who cross state lines in order to receive TelAbortions,” Dr. Raymond said. More are expected to do so during the pandemic. This month, a woman from Texas drove 10 hours in snowy weather to New Mexico, where she stayed in a motel for her videoconference and to receive the pills.
The organization that provides TelAbortion services in Georgia, carafem, has expanded recently to Maryland and Illinois, and it is running digital ads that are expected to reach women in some nearby states like Missouri and Ohio, which have more abortion restrictions, said Melissa Grant, carafem’s chief operations officer.
In May, shortly after Georgia’s governor signed one of the country’s strictest abortion laws (which is now being challenged in court), Lee, 37, who lives near Atlanta, discovered she was seven weeks pregnant.
Lee, who asked to be identified only by a shortened version of her first name, said the pregnancy had shocked her because she took birth control pills regularly. She decided to terminate the pregnancy because she had recently cut ties with her boyfriend after he was arrested on drug charges, she said.
She kept her decision from her family members, who she said were strongly against abortion. And she feared protesters would castigate her if she visited an abortion clinic.
“No one goes through life saying, ‘I’m going to grow up and get an abortion,’” Lee said. “So you’re already struggling with that and then to have someone tell you that you’re going to hell or that you’re killing babies, it’s horrible.”
She found carafem, and videoconferenced in her office at lunchtime with a doctor in another state.
During such consultations, doctors explain that most women do not experience discomfort from mifepristone, which blocks a hormone necessary for pregnancy to develop. Cramping and bleeding, resembling a heavy period, occur after the expulsion of fetal tissue caused by the second drug, misoprostol, which is taken up to 48 hours later. After several hours, bleeding dwindles but might continue for two weeks. In rare cases, women can develop fevers, infections or extensive bleeding requiring medical attention.
Lee received a package marked only with her name and address; it contained the pills, tea bags, peppermints, maxipads, prescription ibuprofen and nausea medication.
“Just everything you could need,” she said. “It was so comforting.”
TelAbortion reports that of the 611 completed abortions documented through April 22, most were accomplished with only the pills and without complications. In 26 cases, aspiration was performed to finish the termination.
Dr. Raymond said 46 women went to emergency rooms or urgent care centers with issues that appear just as likely to have occurred if the women had followed the common practice of visiting abortion clinics for consultations, taking the first medication there and the second at home. Two women went before receiving the pills and two before taking them, either because of morning sickness or because they thought they were miscarrying. Fifteen ended up needing no medical treatment. Some were given medicine for pain or nausea.
Three were hospitalized, all successfully treated: two women had excessive bleeding, and another had a seizure after an aspiration, Dr. Raymond said.
Dr. Kristina Tocce, medical director of Planned Parenthood of the Rocky Mountains, who consulted with Ms. Kirby. Credit: Rachel Woolf for the New York Times.
Eleven women decided not to have abortions and did not take the pills they were sent. Another woman continued her pregnancy after the medication failed, as did another after vomiting the mifepristone. Sixteen women have undergone two telabortions, Dr. Raymond said.
Of the women The Times interviewed, only Dawn, who said she has anxiety, called the 24-hour TelAbortion line for emotional support.
“It was after I took the pills,” Dawn said. “I felt like my body, my hormones essentially crashed. And because I suffer from mental health issues, just everything was just kind of out of whack and I started really panicking bad. I called the nurse and she just sat on the phone with me.”
TelAbortion typically charges $200 to $375 for consultations and pills. Women must also pay for an ultrasound and lab tests, obtained from any provider. During the coronavirus pandemic, TelAbortion may waive its requirement for an ultrasound to gauge the gestational age of the pregnancy if women are unable to visit a doctor to obtain one, Dr. Raymond said.
In some states, some or all of the costs are covered by private insurance or Medicaid. For women facing financial hardship, like Ms. Kirby in Denver, the program taps abortion grant networks.
Some patients said the teleconsultations helped them navigate the complex feelings that abortion can evoke.
Leigh, a 28-year-old construction inspector in Denver, who asked to be identified only by her middle name, said she considered herself “totally pro-life.”
But, she said, she also has depression, which became so severe after she had a baby two years ago that she sometimes felt suicidal. Doctors, she said, “didn’t trust me alone with my baby.”
Last March, after discovering she was pregnant and consulting her fiancé, she called Planned Parenthood. “I said, ‘I don’t want to be this person, but I need to abort this pregnancy,’” Leigh said.
She chose the TelAbortion option. After taking the first medication, she attended a previously scheduled photo shoot for engagement pictures with her fiancé, then took the second medication that evening.
Conducting her follow-up call from a field on a job site, Leigh told the doctor, Kristina Tocce, medical director of Planned Parenthood of the Rocky Mountains, that she felt compelled to abort “no matter how much I hate myself.”
When she sees a baby now, she says she still sometimes wonders, “‘Did I make the wrong choice?’”
“I wanted to keep my baby, but I just couldn’t,” she said.
A quiet consultation
Credit: Michelle Mishina-Kunz for The New York Times
During Ms. Dale’s videoconference in Hawaii, Dr. Kaneshiro spoke calmly.
“It is pretty normal to pass some blood clots that maybe are even the size of a quarter,” she said.
“I’m prepared because I actually had a miscarriage last year at four months along,” Ms. Dale replied.
“This will not be that bad — I mean, at this stage of pregnancy, the actual embryo is smaller than the size of a grain of rice,” Dr. Kaneshiro said. “It’s very unlikely to see anything that’s recognizable as a pregnancy.”
“OK, that’s good,” said Ms. Dale, then eight and a half weeks pregnant.
“It doesn’t affect future pregnancies, so it doesn’t have any long-term effects,” Dr. Kaneshiro said.
“OK, that was one of my questions, thank you,” Ms. Dale said.
“Mommy, mommy!” called her daughter, Sophia, bouncing into the living room from a bedroom filled with Legos and a pop-up castle.
“She’s beautiful,” Dr. Kaneshiro said.
Ms. Dale’s consultation and lab tests were covered by Hawaii public assistance. The pills, which cost her $135, arrived by certified mail. She placed them on a table near two pregnancy ultrasound photos.
“OK, this is happening,” Ms. Dale said she told herself. “I’m doing this.”
Her reasons partly involved disagreements with her estranged boyfriend, the father of Sophia, now 4. Their strained relationship made Ms. Dale believe she would have to raise their second child alone.
“I’ve got a beautiful daughter and I’d really love to have another one,” she said. “But it’s just not feasible for my sanity, and I feel like I’d basically be guaranteeing us to live in poverty.”
On the back of an ultrasound picture, she wrote: “Never forget why you had to make the hard decision to let this baby go.” She swallowed the pill.
She had Sophia stay at her mother’s house and took the other tablets, which she said felt like chalk in her mouth. To distract from seven hours of cramping and heavy bleeding, she watched back-to-back “Matrix” movies.
“It’s not like it was easy,” she reflected later, “but at the same time it’s pretty clearly the right choice.”
Michelle Mishina-Kunz for The New York Times
Pam Belluck is a health and science writer. She was one of seven Times staffers awarded the 2015 Pulitzer Prize for International Reporting for coverage of the Ebola epidemic. She is the author of “Island Practice,” about a colorful and contrarian doctor on Nantucket. @PamBelluck