In this Sept. 22, 2010 photo, a doctor, foreground, in Des Moines, Iowa, and a nurse in a clinic in another city, demonstrate a telemedicine program with which Planned Parenthood of the Heartland clinic doctors can remotely prescribe the abortion-inducing drug RU-486.
The House of Representatives’ approval last week of a bill to ban abortions after 20 weeks brings into sharp focus the issue of early access to abortion. Abortion rights supporters say more than a dozen states have banned one option that could improve early access: telemedicine.
Iowa and Minnesota are the only states that offer so-called “telemed” abortions. Women who choose this option confer with a doctor through an Internet video connection and can then be prescribed two drugs, mifepristone and misoprostol, which when taken in sequence induce an abortion. Women who opt for a medication abortion can be no more than nine weeks into their pregnancy.
Supporters of telemed abortions say it increases the odds that a woman will be able to get an abortion earlier in her pregnancy, when the procedure is safer and cheaper, and in areas where providers are stretched thin. In 2011, 89 percent of counties nationwide had no clinics that provided abortion services, according to the Guttmacher Institute, and more than a third of women of childbearing age lived in those counties.
“We believe it’s too dangerous for women,” says Cheryl Sullenger, a senior policy adviser at Operation Rescue, a group that opposes abortion. “There’s no physical exam ahead of time, and there are a lot of cues a doctor gets from a medical exam.”
Planned Parenthood of the Heartland provides surgical and medication abortion at two of its 13 sites in Iowa and telemed medication abortions at six sites. The organization began offering telemed services in 2008.
If a woman opts for a medication abortion through that group, she’ll go to the clinic and meet with a member of the staff who will explain the procedure and answer questions, get her informed consent, check her blood type and take a brief medical history. She’ll have an ultrasound to ensure she’s not more than nine weeks pregnant. Then the staff member will connect her via videoconference with the doctor, who will review the ultrasound and any other relevant medical information, and talk with the patient to ensure she’s comfortable with her decision.
At that point, the doctor will use a computer to unlock a drawer in the clinic that contains the pills. While the doctor and staff member observe, the patient will take the first pill, then bring the second pill home to take 24 to 48 hours later. A follow-up visit is scheduled two weeks later to make sure the abortion was successful.
Penny Dickey, chief clinical officer at Planned Parenthood of the Heartland, says patients get exactly the same care in person or in the telemedicine appointments.
The overall rate of abortion has decreased in Iowa, as it has nationally since 1981. Medication abortions, whether provided telemedically or face to face, accounted for nearly a quarter of abortions in 2011, up from 17 percent in 2008.
Meanwhile, a study comparing the two-year periods before and after telemed abortions were introduced found that the proportion of medication abortions increased from 46 percent to 54 percent at the Iowa Planned Parenthood clinics. The study published in the American Journal of Public Health in 2012 also found that women were 46 percent more likely to have an abortion during their first trimester after telemed abortions were introduced.
“From a public health perspective, even though there was a relatively small decline in second trimester abortions, it’s significant,” says Daniel Grossman, lead author of the study and vice president for research at Ibis Reproductive Health, an organization focused on women’s reproductive health. “Second trimester abortions have higher complications and are more expensive for women.”
Cost is an issue, since only about 12 percent of abortions are paid for by private insurance, a study by the Guttmacher Institute found.
The median cost of a first-trimester abortion, whether surgical or medication, was approximately $500 in 2012, compared with a median cost of $1,350 for a surgical abortion at 20 weeks, according to Guttmacher.
The Iowa telemed operation may be on borrowed time, however. In 2013, the state Board of Medicine adopted a new rule that requires a physician to be physically present for a medication abortion. Planned Parenthood of the Heartland sued, and the group is awaiting a decision by the state’s Supreme Court, expected “anytime,” according to Mike Falkstrom, the group’s general counsel.
After an emotionally charged hearing, the board chairman said his group acted because of concerns that women’s health was not being protected in the telemed abortions. Greg Hoversten, an Iowa City physician, said at the hearing that complications could be serious, according to quotes in the Des Moines Register. “The woman essentially goes home and labors and delivers a fetus. It’s very bloody. It’s painful,” he said when explaining why he thought a physician should be close by.
The Iowa rule is similar to actions in 16 other states that require physicians to be in the room to provide medication abortions.
Supporters of telemed abortions argue that the procedure is safe and having a doctor physically present is unnecessary.
In a 2011 study published in Obstetrics & Gynecology, Grossman compared the results for patients who received medication abortions telemedically in Iowa versus those who were in the room with the doctor. The results were almost identical: 99 percent of telemedicine patients had a successful abortion compared with 97 percent of those who were face-to-face with the doctor.
“Adverse events are no higher with telemedicine,” says Grossman. “We have looked at this and we have some data that shows it’s just as safe as medication abortions provided in person.”
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