As Clinics Close, Anti-Choicers Target Telemedicine

The current reproductive health-care climate is, to put it mildly, not an encouraging one. In 2014 alone, more than 50 clinics permanently closed, in both red and blue states, due to funding cuts, insurance coverage restrictions, and targeted regulation of abortion provider (TRAP) laws. And those who have been hit the hardest by these shutterings live in rural communities, as they have to travel the farthest to reach providers.

In light of this, reproductive health-care advocates have had to get innovative, with one measure in particular — telemedicine, the remote prescribing of medication abortion — providing valuable services to those in need. Now, a decision in Wisconsin is revealing why telemedicine is more necessary than ever — and how harmful bans on the practice are for the most vulnerable Americans.

A Devastating Closure In Wisconsin

Planned Parenthood of Wisconsin announced last week that they will not be reopening their Appleton North clinic due to the high cost of implementing new security features, leaving the majority of the 65,498-square-mile state without an abortion provider. This is part of a national trend; according to Guttmacher Institute, 38% of women aged 15–44 live in the 89% of U.S. counties with no abortion provider.

The Madison and Milwaukee clinics — located just 80 miles apart in the southeastern corner — will be the only full-spectrum reproductive health-care facilities available to serve the 1.1 million women of reproductive age living in Wisconsin. And while the northwest corner of rural Wisconsin is adjacent to Iowa and Minnesota, the area that includes Appleton is bordered by Canada and Lake Michigan. Residents will be faced with traveling 100 miles or more in each direction — plus a 24-hour waiting period, which means staying overnight or making the trip twice.

The step back comes after the state seemed to be making progress. Reproductive rights supporters in Wisconsin just celebrated the Supreme Court not hearing the state’s appeal to lift an injunction on a law that, like the Texas one overturned by Whole Woman’s v. Hellerstedt, threatened to close full-spectrum health facilities. It seemed like the trend of oppressive laws enacted by the legislature and Governor Scott Walker, as well as the defunding of Planned Parenthood that led to five previous health center closures, had possibly come to an end. Instead, the state has now been left with only three clinics in two cities to provide the approximately 98,000 abortions that happen annually.

The closure is all the more troubling since Wisconsin is a state that requires a prescribing physician to be in the physical presence of a patient — leaving those in need of care, and unable to get to a clinic, without the valuable alternative of getting a prescription remotely. In this way, the closure is shedding light on an oft-overlooked issue in reproductive health: the anti-choicer fight against telemedicine.

Anti-Choicers Take On Telemedicine

Telemedicine is essentially a Skype appointment with a licensed abortion provider that allows a patient to receive a prescription for a medication abortion remotely. Patients make an appointment with a physician in their area and then speak with an abortion provider via computer from their local physician’s office. The practice was designed to help precisely those patients now facing reduced options for accessing abortion care. And medication abortion — now available up to 70 days gestation (i.e., since the last menstrual period) thanks to an FDA protocol update in March — is increasingly popular.

It’s also extremely safe. According to the Association of Reproductive Health Professionals (ARHP), Mifeprex® (the brand name for mifepristone in the U.S.) “is as safe or safer than commonly used medications such as over-the-counter non-steroidal anti-inflammatory drugs and anti-histamines, and is less risky than continuing a pregnancy to term.” Tylenol causes 150 deaths per year and Viagra causes death in 5/100,000 prescriptions; risk of death for mifepristone is 1/100,000 prescriptions written. Pregnancy, on the other hand, is a condition people die of every day in this country — a horrifying reality our legislators seem to have no interest in addressing.

It turns out patients don’t receive instructions differently via video than they do via an in-person prescriber. And prescribing by video is also of particular benefit to low-income Americans, for whom traveling to the closest clinic is cost-prohibitive. Had this been the solution to nearly any other gap in health care, it’s hard to imagine anything but celebration over the innovation.

So it’s troubling, if not surprising, that this popular, effective, far-reaching, and safe method of reproductive care has come under attack in this country. Indeed, anti-choice legislators have cracked down hard on telemedicine during the historic spike in anti-abortion laws over the past few years. A full 15% of the 288 abortion-restricting laws passed from 2011–2015 concerned medication abortion — double the percentage concerning gestation limits, despite the media focus on that category of law.

Recently, the anti-choice movement’s efforts to thwart this increasingly essential procedure came to a head in Iowa. Planned Parenthood of the Heartland pioneered telemedicine abortion, providing the service to 7,200 Iowans since 2008. And as is typical, it was regarded as a resounding success. Via ThinkProgress, which reported on this issue last year:

“Research into Iowa’s telemedicine abortion program has found that there’s no difference between the patients who are prescribed the abortion pill in person versus the patients who consult with a doctor remotely. Surveys among the patients who have used the video technology service report low rates of complications and high levels of satisfaction — reflecting the fact that the best evidence in the field confirms medication abortion is very safe.”

So when Iowa’s anti-choicer-stacked state’s board of health effectively banned telemedicine in 2013 by approving a regulation requiring abortion doctors to be physically present in order to issue prescriptions, Planned Parenthood sued and won. The court ruled unanimously that the restriction was unconstitutional because it creates an undue burden — the precedent cited in Whole Woman’s.

Mark S. DeFrancesco, MD, President of the American College of Obstetricians and Gynecologists (ACOG), said in a statement following the victory last year:

“Telemedicine is widely regarded as an important and promising technology in medical care, and its potential benefit to American patients’ access to care is significant. In fact, the Iowa Board of Medicine has, in the past, stated an intent to reduce regulatory barriers to telemedicine services. Singling out and restricting one particular use of telemedicine care is wrong, and we are pleased that the Iowa Supreme Court has recognized that. Today’s decision will help many women in Iowa get the safe, effective care that is right for them.”

In addition to this recent victory, there have been promising state trends when it comes to medication abortion — like California passing a proactive law two years ago allowing trained non-physician providers like nurse practitioners and physician assistants to provide it.

And yet, despite all this, bans and restrictions on medication abortion are still prevalent around the country.

Thirty-seven states explicitly by law require clinicians who dispense abortion-inducing medications be licensed physicians, and telemedicine-targeted restrictions in 18 states require the clinician providing the medication to be “physically present during the procedure.” (No, there isn’t an actual procedure — they just need to make it sound more involved and potentially dangerous to pass these laws.) Measures introduced in Alaska, Minnesota, Ohio, South Carolina, and Utah could bring that number up to 23 — almost half the states in the country.

Moreover, three states require the primary medication — mifepristone — be provided with an outdated protocol that is threatening the practice.

A Problematic Protocol

The U.S. was excruciatingly slow to approve mifepristone, which has been used in Europe since the ’80s and is currently approved in more than 50 countries. Over time, best medical practices will change as more effective dosages and instructions are developed within the medical community. But while this happens with all kinds of medications, in the case of mifepristone, some states forbid physicians from prescribing “off label” — altering protocol without waiting for the updated label approval from the FDA.

One of these states is Ohio, where, in 2011, the state’s federal court upheld the state’s 2004 law prohibiting the use of medication abortion unless it was prescribed exactly as the FDA recomendations require. As Rewire put it, doctors were essentially told “they can not use their skills or their medical judgment to prescribe an already-approved drug in accordance with the most recent medical and clinical data available.” As reported at The Establishment in March, when the FDA did finally update its protocol, this caused significant hardships for patients seeking to terminate pregnancies in the state.

“In 2011, in an attempt to decrease access to abortion, politicians forced Ohio abortion providers to follow an outdated and less effective FDA protocol, under the guise of protecting women’s health,” Chrisse France, executive director of Cleveland-based reproductive health group Preterm told The Establishment. “In reality, this law simply made medication abortion unnecessarily costly and nearly impossible to access.”

Due to the 24-hour waiting period and law requiring an office visit to administer misoprostol (the second of the two medications in the protocol), patients in Ohio were forced to obtain four separate office visits — an expensive and time-consuming burden that has now been reduced by one visit.

Today, the fears of reproductive justice advocates were validated when researchers from the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco (UCSF), led by Advancing New Standards in Reproductive Health (ANSIRH)’s Ushma Upadhyay, published a study on the effects of Ohio’s law:

“Despite legislators’ claims that this law was aimed at improving women’s health, our findings show the result was the opposite. The protocol required by law ignores the fact that medical practice is constantly improving as a result of clinical research. This type of research ultimately led to a label change for mifepristone just this past March.”

The upside to this research is that it can be used to sway the public as well as on-the-fence legislators. Overturning the laws in North Dakota, Ohio, and Texas requiring the harmful outdated protocol could help millions of people.

“Laws like Ohio’s limit physicians from practicing medicine based on the latest evidence and providing the highest quality of reproductive health care to women,” said study co-author Lisa Keder, Associate Professor of Obstetrics and Gynecology at Ohio State University.

As Upadhyay pointed out in the press release about the study, even having just a handful of states requiring outdated protocol on any medication is risky because the only constant in medicine is change.

“While the FDA has now updated the label for medication abortion, this new protocol will eventually become out-of-date as clinical practice and research evolves,” said Upadhyay. “Legislating the practice of medicine may force doctors to provide care that falls below the standard set by the latest research and evidence.”

Here’s to a day where this logic is applied to all manner of health care — including abortions of all types in all ZIP codes to people of all income levels.


Lead image: flickr/Jonas Tana and Pixabay