Abortion By Mail Delivers Promise For Better Access But Political Questions Remain

by Phil Galewitz, Kaiser Health News, November 14, 2016

When the abortion pills arrived in her mailbox this summer, she felt anxious but also in control, knowing she could end her pregnancy entirely in the privacy of her own home.

“I was happy that I was going to be able to do it myself and I did not have a nurse there or doctors there staring at me and judging me,” she said, asking to be identified only by her middle name, Marie, because she did not want people outside her immediate family to know about her abortion.

Marie is part of a small but closely watched research effort to determine whether medical abortions — those induced by medicine instead of surgery — can be done safely through an online consultation with a doctor and drugs mailed to a woman’s home.

At a time when access to abortion is being restricted on many fronts, advocates say being able to terminate a pregnancy through telemedicine and mail-order drugs would provide a welcome new option for women. Opponents of abortion find the concept dangerous and deeply disturbing.

The idea builds on a trend that is helping women obtain birth control more easily. A growing number of smartphone apps and websites now make it possible to get prescription contraceptives without visiting a doctor’s office first. The pills Marie and the other women received through the study are not allowed for sale in pharmacies and are usually available only at hospitals and abortion clinics.

Australia and the Canadian province of British Columbia allow women to get abortion pills by mail after consulting with a physician or other health care provider via phone or the internet. Several international organizations offer mail service in countries where abortion is otherwise unavailable or severely restricted. The oldest group, Women on Web, based in the Netherlands, has provided abortion medications to about 50,000 women in 130 countries since 2006. The service is not available in the United States, and the Food and Drug Administration warns against buying the drugs over the internet.

Having the pills delivered to her home in Hawaii meant that Marie could avoid the cost and time of traveling by plane to the nearest abortion clinic, over 100 miles away in Honolulu or Maui. Once she received them, she set the package aside for a week in her bedroom, waiting until she could schedule time off from her job at McDonald’s.

The first pill, as expected, had little effect. The next morning, with her mother at her home to watch her toddler, she took the second. Almost immediately, the bleeding and cramping began. Within three hours, her eight-week pregnancy was over. She described the pain as a five on a 10-point scale. That night she cooked dinner for her family, and the next day she went back to work.

The study Marie participated in is being conducted in four states — Hawaii, New York, Oregon and Washington. It is being funded and organized by Gynuity Health Projects, a nonprofit research group focused on reproductive health services that seeks to improve women’s access to medical abortions. The FDA has allowed the experiment. Women learn about it when contacting the abortion clinics in the study and other health providers who are aware of the trial and the website telabortion.org.

Danco Laboratories, the company that makes the pills, has no plans to seek wider distribution of the medication either through mail-order pharmacies or physical pharmacies, a spokeswoman said. It would have to seek the FDA’s permission to do so; the agency can also ask companies to change how their drugs are distributed.

“Abortion is a politically charged issue in this country, and there is an extra degree of caution,” said the spokeswoman, Abby Long, explaining that research would be needed to support changing the drug’s distribution.

Of the first 12 women who participated in the study, all in Hawaii, 11 reported they had no complications and one did not take the pills, researchers said. Ten who completed surveys afterward said they were satisfied with the service and would recommend it to a friend, according to the researchers.

“It’s absolutely an important step forward to expanding access to abortion that is safe and effective and creating options for women,” said Susan Wood, director of the Jacobs Institute of Women’s Health at George Washington University, in Washington, D.C. She was not involved in the study.

Anti-abortion groups are outraged by the experiment.

“We have grave concerns about handing out dangerous, life-ending drugs without medical supervision because women face great risks for chemical abortions,” said Kristi Hamrick, spokeswoman for Americans United for Life.

Carol Tobias, president of the National Right to Life Committee, also raised safety concerns.

“If pills are sent through the mail, who are they supposed to call if they have a problem?” she said.

“There are serious downsides from the pills,” she said, adding, “and just talking to someone over a computer and sending pills in the mail, to me, that is just reckless.”

The process does not allow women to avoid the doctor’s office entirely. Using a video hookup on a home computer, a woman first consults with a doctor (or other clinician such as a nurse practitioner) at one of three participating abortion clinics who evaluates her medical history and explains how to take abortion pills and what to expect afterward. She must then get medical tests including ultrasound and bloodwork.

If the tests show she is eligible for the study, the clinic sends her a package with pills and instructions via overnight mail. After taking them, she has some additional tests, such as an ultrasound to verify that the abortion is complete and also a phone consultation to review the results.

Access to abortion has been declining steadily in the United States as dozens of clinics have been forced to close under new state restrictions. In Texas, the number of clinics fell to 18 in 2015 from 41 in 2012. Five states have just one clinic that offers abortions.

Medical abortions require women to take two drugs that together induce a miscarriage. The first, mifepristone (marketed as Mifeprex), is typically taken in a doctor’s office or clinic while the second, misoprostol, is given to the woman to take at home the next day.

In the United States, the FDA has approved medical abortion pills for use only in the first 10 weeks of pregnancy, while surgical abortions can be done later than that.

Medical abortions make up a quarter of all abortions in the country. About 2.8 million women in the United States have used mifepristone to terminate a pregnancy since the drug’s approval in 2000, according to Danco Laboratories, its manufacturer.

The American abortion study using overnight mail comes nearly a decade after Iowa became the first state to offer medical abortion counseling via telemedicine from a physician. But in Iowa and the three states that followed — Alaska, Maine and Minnesota — women must still go to a clinic that stocks mifepristone to receive the pills.

If the study shows the telemedicine and mail approach works, that could encourage the FDA to stop restrictions on mifepristone, Gynuity’s principal investigator, Dr. Elizabeth Raymond, said.

“All kinds of dangerous drugs are prescribed and available at pharmacies, including drugs for heart disease and Viagra,” she said. “There is no justification for why this safe drug should not be in pharmacies now.”

But even if the FDA were to lift its restriction on where abortion pills are dispensed, 19 states ban the use of telemedicine for abortion and require a physician to be physically present when consulting a woman, according to the Guttmacher Institute, a reproductive rights research group.

“While this has the potential for being the future of abortion delivery for a good segment of the population, that vision might not be fulfilled due to the politics around the issue and restrictions in many states,” said Jessica Arons, president and chief executive of the Reproductive Health Technologies Project in Washington, an advocacy group.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.