Last year, over concerns of exposure to Covid-19, a federal judge ended the US Food and Drug Administration’s requirement that mifepristone, a medication necessary to terminate an early pregnancy, must be obtained directly from a hospital or provider’s office.
On January 12, the Supreme Court reinstated that requirement, over the objection of medical organisations. The ruling put us right back where we were: Among the 20,000 medications regulated by the FDA, mifepristone is the only one that requires an in-person pickup.
The decision was heart-breaking to us, and felt unfair. Patients taking objectively more dangerous drugs are not forced to appear in person during a raging pandemic.
But despite this setback, abortion care has transformed – in a good way – during Covid-19. To keep patients safe, some providers have stripped away many in-person requirements to obtain an abortion – and shown in the process that these requirements are often medically unnecessary and pose unfair burdens on patients.
All of that progress is at risk: The Supreme Court’s decision to reinstate one of those in-person requirements makes that crystal clear. Let’s not lose any more.
Typically, a person seeking an abortion makes an appointment at a clinic, where they may undergo a physical exam and or ultrasound to make sure the pregnancy is less than 10 weeks along (mifepristone is currently approved only up to 70 days). If eligible, they get the medication and take it at home.
The pandemic suddenly made every step in that process risky, particularly for low-income, Black and Latinx patients, who are being hit hardest by Covid-19.
At Maine Family Planning (MFP), almost all of the abortions before Covid included at least one clinic visit for an ultrasound and to obtain pills. But starting spring 2020, MFP began offering abortions entirely by telehealth: Over a video call, patients report the date of their last menstrual period, which enables providers to estimate the length of their pregnancy.
Staff give information on how to use the pills, follow-up care and a 24/7 number to reach on-call staff. If eligible, patients are prescribed mifepristone. Before the Supreme Court reversed the federal judge’s ruling, people in many states could get their medication by mail – making it an entirely remote abortion. Since Covid hit, 71 per cent of MFP’s abortions have proceeded without an ultrasound, and there has not been any increase in adverse events.
Most US clinics still require ultrasounds or in-person visits, but some doctors and nurse practitioners will skip these steps when prescribing mifepristone. And there’s evidence to show this is safe: A 2018 study of more than 400 women in three countries, including the US, found that 95 per cent who received medications for an abortion without an ultrasound or pelvic exam had safe abortions without the need for extra interventions, and 90 percent were comfortable forgoing the exams.
With the recent ruling, even if US patients can get a prescription for mifepristone without a clinic visit, they would need to pick it up in person. Other countries have continued to suspend that requirement during Covid-19.
In the UK, after a telephone call with a nurse or midwife, people seeking abortions can receive mifepristone by mail within a couple of days. Data released in May 2020 from the Pills by Post programme reported that more than 8,300 patients received remote abortions over a six-week period during the pandemic, and 97 per cent said they were “satisfied” or “very satisfied” with the experience.
What’s more, 60 per cent said that without the programme, they would have had trouble accessing help for their abortions during the Covid crisis. The British Pregnancy Advisory Service, the UK’s leading abortion-care service, says it plans to continue Pills by Post.
Since Covid hit, 71 per cent of abortions at Maine Family Planning have proceeded without an ultrasound, and there has not been any increase in adverse events.
Although the Supreme Court has decided US patients must continue to pick up their medications in person (a requirement which continues to be challenged in the courts), we should keep offering to forgo in-person exams or ultrasounds during the pandemic – and beyond.
Some people will always need and prefer in-person abortion care, but there are many reasons also to provide the option of telehealth: The majority of people who have abortions are already parents and at a lower socioeconomic level, so it’s hard to spend time at a clinic when you have to consider arranging child care, taking time off work or paying for gas (especially in rural areas).
What’s more, people who want abortions but aren’t able to get them are more likely to live below the federal poverty level, experience complications and stay with abusive partners.
We could use more data, of course. If more abortion providers try telemedicine – and they should, given the positive evidence thus far, not to mention Covid – then we can better document the quality-of-care patients receive.
We also need to expand remote offerings such as Aid Access and others offered in New York and other states such as Minnesota, and ensure that language or technological issues don’t further perpetuate unequal access to abortion care.
Of course, sometimes data are not enough. If they were, we wouldn’t be here, forcing patients to take unnecessary risks in a pandemic. We also need policymakers who are willing to look at the facts and figures, and rely on them to shape the policies that affect our everyday lives.
When they do, we suspect they will see what we know: In-person requirements for medication abortions place unnecessary burdens that are rooted in politics, not science.
- A Knowable Magazine opinion/ Leah Coplon and Claire Brindis