Terminating Pregnancy During a Pandemic – The Case for Telemedicine

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By: Emily Gerson, Undergraduate Student at George Washington University and Research Assistant at the Maternal Health Task Force

The COVID-19 pandemic has required health care facilities to reimagine the provision of healthcare services, forcing them to make tough decisions about what constitutes an “essential” procedure. In many countries, including Austria, Romania, Croatia, Poland, Slovakia, and Brazil, along with many conservative-minded states within the United States, the decision to label abortion care as “elective” and “non-essential” all but banned the procedure during periods of lockdown.

Abortion is a uniquely politicized medical procedure, and a few weeks of postponement can completely alter its legality. Even if restrictive policies are temporary, gestational age limits pose a small window of opportunity to terminate a pregnancy. Further, limited staffing and resources make appointments nearly impossible to book in time. In Texas, abortion is not permitted after gestational age of 20 weeks, regardless of pandemic-based restrictions. If a fetus ages out during the temporary ban, the choice is taken away. Travel restrictions set in place to limit disease spread only exacerbate this issue. For instance, abortion is illegal in Poland, and closed borders inhibited the ability to travel to England to obtain one between March and June.

Classifying abortion as an elective, non-essential procedure can hold grave consequences. Abortion provider Marie Stopes International estimates that disruption to its services due to the coronavirus could lead to an additional 3 million unintended pregnancies, 2.7 million unsafe abortions, and 11,000 pregnancy-related deaths. Shockingly, over 5,000 clinics providing reproductive healthcare services have closed worldwide since the beginning of the pandemic.

If the severe consequences of being denied a wanted abortion are unclear, one can consult the Turnaway Study, the largest study examining experiences with unwanted pregnancy and abortion in the U.S., conducted over five years through interviews with about 1,000 women. The study found that women denied an abortion had four times greater odds of living below the federal poverty level and three times greater odds of being unemployed. Furthermore, their older children showed worse developmental outcomes than those of women who received a wanted abortion. For more details on the Turnaway Study, check out The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having—or Being Denied—an Abortion, a recently published book by Diana Greene Foster.

Fears of contracting coronavirus at a clinic are not unfounded. However, there is a safe and easy alternative—medication abortions administered via telemedicine. Abortions induced by medication involve taking two pills, mifepristone and misoprostol, and expelling the fetus in a manner similar to a heavy period. The global pandemic has caused an uptake in what is referred to as the “no-test” abortion protocol, which removes the need for in-person pregnancy testing, pelvic examination, ultrasounds, or labs. This method consists of four steps:

  1. Patient consults with clinician via phone or video. Pregnancy confirmed with home pregnancy test and date of last menstrual period.
  2. If eligible, the patient picks up medications from the clinic.
  3. Patient takes medications at home.
  4. Follow up via phone or video.

While anti-abortion groups insist abortion is a risky and invasive procedure that they conclude cannot be conducted remotely, research has found very low prevalence of clinically significant adverse events and no significantly higher prevalence of adverse events compared with in-person procedures. The procedure is effective over 95% of the time, and the vast majority of women who have received telemedicine abortions would recommend the method, with a systematic review finding only 0.2 to 2.3% of women reporting dissatisfaction. 

Several organizations have dedicated themselves to telemedicine abortion access. TelAbortion partners with clinics in the U.S. to provide this service in states where it is legal, although patients residing in other states may obtain services if they video conference from a legal state and provide a shipping address there. TelAbortion also has a 24-hour telephone line for emotional support. U.S. provider Carafem sends discreetly marked packages, which contain abortion pills, tea bags, peppermints, maxipads, prescription ibuprofen, and nausea medication, which were described by a patient as “Just everything you could need. It was so comforting.” Socorristas en Red, an Argentine activist group, helps citizens navigate access to abortion in a nation where the procedure is only meant to be conducted in cases of rape or life endangerment. The socorristas, literally translating to “lifeguards,” have been video chatting with Argentine women and directing them to doctors who will prescribe misoprostol and otherwise help with the process.

Despite the apparent advantages of permitting telemedicine medical abortions, legal requirements limit providers’ abilities to administer the medication remotely, both within the U.S. and globally. Fourteen U.S. states require patients to receive an ultrasound before an abortion, and 13 require in-person counseling, leaving only 23 states in which the “no-test” model can be used. The Risk Evaluation and Mitigation Strategy (REMS) placed on mifepristone by the FDA makes the medication unavailable in pharmacies or by mail. Colombia began to permit virtual abortion care in March, although individuals hoping to receive the medications must meet the requirements under Colombia’s laws, including being no more than nine weeks pregnant and not having any preexisting conditions. England led the way in the United Kingdom by permitting both pills to be taken at home, although they have stated that this measure is temporary and will be retracted when the pandemic is over. Telemedicine abortions are available in Argentina, however cities including Córdoba have been reporting shortages of misoprostol since early March. Other countries, such as Mexico and India, have been experiencing medication shortages as well, due to the derailing of supply chains and distraction of physicians who have been redirected to coronavirus patients.

With the availability of virtual counseling, the minimal safety concerns, and the heightened anxiety around making in-person clinic visits, telemedicine abortions provide a concrete alternative to “surgical” abortions. Coronavirus has already lead to massive job, housing, and food insecurity, and we cannot afford to plunge vulnerable people further into poverty by putting up huge logistical barriers to abortion care. This procedure is essential, time-sensitive, and high-stakes, and should be treated as such. By excluding abortion from services offered during this pandemic, governments have been denying women agency over their bodies and initiating a wave of adverse social, economic, and health outcomes. Telemedicine abortions permit women to exercise bodily autonomy without further congesting clinics, and the virtual counseling adopted by organizations like Telabortion is key for managing nerves or other emotional distress. Further, the ability to obtain the medication by mail or in a pharmacy would be critical to keeping the procedure as safe as possible.