ST. LOUIS — A recent court ruling temporarily easing restrictions on medication abortions during the pandemic has some Missouri women traveling to Illinois, where they can take advantage of the state’s laws that allow telemedicine for abortion care.
Right now, that means a Missouri woman can, if she wants, cross the state border, find a place to park and have a virtual visit with an Illinois doctor via her smartphone. If approved, she can pick up the package of abortion pills a couple of days later at a designated address in Illinois — perhaps at a friend’s or acquaintance’s home or a post office box she has rented.
While the number of women crossing state lines to access the option is believed to be small, one abortion provider with a telehealth program outside of Chicago says more women are learning about the court ruling and differing state laws on the use of telemedicine for abortion.
“If you have a small child, and you don’t want to sit in a health center, with a physician that you may not know, concerned about a pandemic, concerned about the amount of time you’re going to be away from home, it might suddenly become more attractive to do a 15-minute consult in your car and then drive back to pick up your medicine and be done,” said Melissa Grant, chief operating officer of Carafem, which operates four clinics in three states and D.C., including one in Skokie, Illinois.
A better scenario during a pandemic, say abortion advocates, would be for patients to consult with a health care provider through a virtual visit from their home and receive the medications at their own home — a process some call “teleabortion.”
A federal judge in Maryland in July ordered a temporary halt to a U.S. Food and Drug Administration requirement that abortion medications be given in person, allowing state-licensed providers to mail the drugs within their state. An appellate court upheld the ruling in August; on Thursday, the U.S. Supreme Court declined a Trump administration request to immediately reinstate the FDA requirement.
But while the FDA rule remains suspended, restrictions imposed by some states on using telemedicine for abortion care are not. Eighteen states — including Missouri — require in-person consultation, meaning women still have to travel to see a provider.
Over the past two years in Missouri, medication abortions have become nearly nonexistent. Women must travel to the state’s only abortion clinic in St. Louis, have a consultation, wait three days and then return to get the medication. And when they return, they must undergo a pelvic exam.
Missouri’s Republican lawmakers argue the requirements are designed to ensure patient safety, yet professional guidelines for obstetrics say waiting periods and pelvic exams are unnecessary.
The requirements, along with recent state legislative attempts to ban abortions after eight weeks of pregnancy, have most patients traveling out-of-state for medication abortions.
Last year, of the 2,120 medication abortions by Missouri residents, only 15 were provided within the state, Missouri health department data shows. The number of medication abortions sought out-of-state is likely even higher, said department spokeswoman Lisa Cox, as not all states share their data.
It’s still a choice many Missouri women prefer — 46% of all reported abortions by residents last year were medication abortions.
The pandemic, however, has made traveling more difficult, as patients are concerned about contact with others or have lost jobs, transportation or access to day care. Some data suggests the need for abortion has also increased as women have lost access to contraception, fear increased health risks of pregnancy and are struggling financially.
In a written statement, Dr. Colleen McNicholas, chief medical officer of Planned Parenthood of the St. Louis Region and Southwest Missouri, applauded the court ruling allowing abortion medications to be mailed within a state, but she lamented the unequal access to medication abortion.
“Unfortunately for far too many, access to safe, dignified care when they need it and where they want it is not a reality largely due to an overly burdensome and medically unnecessary web of state regulations,” McNicholas said. “We continue to strive to make all safe legal options for ending a pregnancy available to patients, and that includes medication abortion by telemedicine in Illinois.”
Planned Parenthood in October 2019 opened a clinic just across the border in Fairview Heights, so it could expand abortion services.
The pill mifepristone, taken along with the drug misoprostol, causes bleeding and cramping to empty the uterus, much like a miscarriage. It can be used up to 10 weeks into pregnancy.
Research shows the regimen terminates a pregnancy in about 95% of patients, while 5% may need to also have a surgical abortion.
About 3.7 million patients in the U.S. have used the abortion pill with a safe track record. Serious complications such as blood transfusions and severe infections are rare. Common side effects include nausea, vomiting, diarrhea and mild fever.
Over the past decade, the number of medication abortions has increased 73%, according to the Guttmacher Institute. In 2017, medication abortion accounted for 39% of all abortions in the United States and 60% of all abortions before 10 weeks’ gestation.
The FDA, however, has a unique rule for dispensing the pill: Patients must pick it up in person at the prescribing hospital, clinic or medical office.
When the pandemic hit in the United States, a coalition of medical experts and reproductive advocates asked the FDA to suspend the rule as it seemed burdensome and risky, especially for those having to travel far distances.
Grant said in states that allowed telehealth visits for abortion care, clinics were providing curbside drop-offs of the pills in order to reduce contact while still meeting the FDA requirement.
“What value is there of seeing the provider in person if all they’re doing is coming out to your car and handing you medicine like going through the drive-thru at your pharmacy?” Grant said.
With no response from the FDA, the coalition filed a federal lawsuit. The case was brought by the American Civil Liberties Union on behalf of the American College of Obstetricians and Gynecologists, the Council of University Chairs of Obstetrics and Gynecology, New York State Academy of Family Physicians, SisterSong Women of Color Reproductive Justice Collective and an individual family medicine physician.
In July, a federal district court in Maryland found the requirement presents “a serious burden” by forcing patients “to decide between forgoing or substantially delaying abortion care, or risking exposure to COVID-19 for themselves, their children, and family members.”
The ruling prohibited the FDA from enforcing the in-person delivery requirement until at least 30 days after the end of the federal government’s declared public health emergency.
A federal appellate court in August upheld the injunction, but the FDA last month took the case to the Supreme Court, asking the justices to reverse the order and arguing that the rule isn’t a substantial obstacle to abortion access. Thursday’s decision by the high court to hold the Trump administration’s appeal in abeyance means the issue likely won’t be resolved until after the Nov. 3 election.
A group of 20 Republican senators also sent a letter last month to the FDA, calling the court decisions “rogue judicial activism” and asking the agency to ban use of the abortion pill entirely.
“Indeed, by demedicalizing and deregulating the abortion pill, women will be left to engage in a form of ‘DIY’ chemical abortion, as the abortion industry collects payments, and as prescribers evade all legal risk and FDA oversight,” the letter stated. “This is unconscionable.”
The letter also questioned prescribers’ abilities to diagnose ectopic pregnancies and determine the gestation of pregnancies that would make medication abortion dangerous.
Grant said all medication abortions are approved by a physician. During virtual consultations, health care providers take patients’ medical history and provide consent forms. If a patient is at risk of an ectopic pregnancy or unsure if less than 10 weeks pregnant, the provider arranges blood work or an ultrasound with the patient’s primary care doctor or nearby imagining center.
Carafem has been providing teleabortions in Illinois since April, before the court ruling, through a study launched in 2016 by Gynuity Health Projects. In an agreement with the FDA, the study allows patients to make virtual doctor visits and receive the pills in the mail.
The study has grown to include providers in 13 states, including Carafem clinics in Illinois and Maryland, which were added during the pandemic.
Carafem has provided teleabortions at its Georgia clinic for nearly two years as part of the study, Grant said.
After hearing of struggles the pandemic was placing on their clients in other states, she said, “We looked again at the telemedicine model and thought, certainly if there were any time to make this available to more clients who were having a trouble traveling, it was then.”
Grant said so far their patients report little difference between virtual and in-person doctor visits. And the safety and outcomes of receiving the pills in the mail mirror that of picking them up.
“We believe collecting that data is really, really important so that we can show that there’s not a medical reason that this isn’t an option,” she said, “and hopefully that helps to balance some of the political reasons for why people might restrict this medicine.”
Erin Matson, the co-director of Reproaction, an organization that advocates for removing restrictions on abortion pills, said Missouri residents should not have to cross state lines or risk exposure to COVID-19 through repeat visits mandated by the state to get a medication abortion.
The organization also informs women about self-managed abortion, where women obtain abortion pills through websites such as Aid Access.
Whatever a state’s regulations or potential threat to Roe v. Wade posed by a Supreme Court seat vacancy, Matson said, women will find a way to get the pills.
“No matter what happens to these laws, there’s no way they can put abortion pills back in the bottle,” she said.
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