“This is a very safe early option. You can have a telemedicine appointment with a doctor in the comfort of your home and you get something mailed to your home. … To have that ability to be able to take care of yourself at home, I think that’s just an amazing service. And it should continue to be an option.”
Updated Dec. 15 at 1:15 p.m. PT.
Telemedicine abortion startups are springing up across the country after a federal court in July temporarily suspended FDA restrictions on distribution of the abortion pill during the pandemic. This decision was reinforced last week, after a federal court upheld the suspension on in-person requirements for those seeking a medication abortion.
These new virtual clinics screen patients by video conference, telephone or text, using the new no-test, no-touch medical protocol that is now the standard of care for medication abortion (which uses pills to end a pregnancy). They then mail the medication to their patients at home, often using new online pharmacies. In total, people in 19 states and Washington D.C. now have legal access to telemedicine abortion from a doctor within their state.
These startups are revolutionizing abortion care by offering quick, private, safe, convenient and affordable services.
Approved by the FDA for use during the first 10 weeks of gestation, medication abortion uses two types of pills:
- mifepristone, which interrupts the flow of the hormone progesterone that sustains the pregnancy; and
- misoprostol, which causes contractions.
This combination of pills is 95 percent effective and is an extremely safe way to end a pregnancy. Many people choose telemedicine abortion because it is less invasive, more private and more convenient than in-clinic medication abortion or procedural abortion by aspiration. According to the Guttmacher Institute, medication abortion accounts for 60 percent of abortions performed up to 10 weeks gestation in 2017, having increased significantly in the last few years.
New Telemedicine Abortion Startups
The non-profit Just The Pill opened for business on October 12, offering telemedicine abortion care to people in Minnesota. Choix opened on October 28, offering abortion care to people aged sixteen and over in California.
Just the Pill and Choix are fully virtual abortion clinics. The non-profit carafem, which had previously offered in-person abortion care, now offers telemedicine abortion care to people living in Georgia, Illinois, Maryland, Washington, D.C. and Virginia. A new digital abortion provider, Hey Jane, will launch soon in California, New York and Washington.
At Just the Pill, patients fill out an online form and then have a follow-up phone call with a patient educator and a doctor, who then mails the pills to eligible patients. There are follow-up phone calls at seven days and four weeks. Just the Pill has a feminist fee structure, with a sliding scale from $0-$350 (they don’t take insurance). The difference is made up by the Minnesota abortion fund, Our Justice.
According to Medical Director Dr. Julie Amaon, Just the Pill formed to serve people in rural Minnesota who live far from the state’s five abortion clinics, which are concentrated in urban areas. Dr. Amaon told Ms. they have seen about thirty patients so far.
“Most of our patients live more than 100 miles from the nearest clinic,” says Dr. Amaon. “Ninety-seven percent of counties in Minnesota do not have an abortion provider. In our research, people are having to sometimes drive three or four hours for services. That’s tough when you have kids at home and you’re trying to look for childcare.”
“This is a very safe early option—that you can have a telemedicine appointment with a doctor in the comfort of your home and you get something mailed to your home. You don’t have to leave the house,” Dr. Amaon told Ms. “Women know how to take care of their bodies. This is just inducing a miscarriage. This is very safe. People have been doing this for centuries on their own. To have that ability to be able to take care of yourself at home, I think that’s just an amazing service. And it should continue to be an option for women.”
Just the Pill offers translation services and is now working to expand their services into Montana.
At Choix, patient care is conducted asynchronously by HIPPA compliant, encrypted texting. Patients fill out an online form and medical professionals consult with them by text, or telephone if desired, then mail the abortion pills if they are eligible. There are follow up check-ins 72 hours and one month after the abortion. Choix charges $199 (compared to $500 for in-clinic medication abortion in California). They do not take insurance at this point, but they work with the digital mutual-aid abortion fund, ReproCare, which supports a sliding scale payment mechanism right on the Choix website that ensures equity of access for all.
The co-founders of Choix, Cindy Adam and Lauren Dubey, told Ms. they had both worked as clinicians in a primary care practice, but they wanted to be able to provide a different type of care.
“We wanted to expand access to folks who have limited access,” said Adam, who is CEO at Choix. “We really wanted to help revolutionize abortion care. We are both really passionate about sexual reproductive health care.”
Normalizing Abortion Care
“The big push in the abortion world is to normalize abortion. Abortion is part of normal reproductive health,” says Dr. Aisha Wagner, the collaborating physician at Choix. “This is something that I think we need to shout from the rooftops.”
“Abortion is a totally normal part of your reproductive health care. Having a pregnancy that you no longer want to continue is for some people, a very huge grave decision and for other people it’s not a big deal,” says Dubey, who is the Chief Nursing Officer at Choix. “People coming to our platform can come with pride or with shame—whatever their own feelings are, we will treat everybody with dignity and respect. We want people to feel like we’re their partners in their reproductive future. We’re not here to judge them.”
Accessible, Quick and Convenient
Telemedicine makes abortion accessible for people in rural areas, but it also makes abortion access faster and more convenient for people living in urban areas.
“In rural parts of California and urban parts of California, the desire is there,” says Dubey. “Whether it’s an access issue or whether it’s because the appointments are all booked up in urban areas.”
Clinic-based medication abortion care is often time-consuming and costly, says Dr. Wagner. Clinics are crowded, appointments can take several hours, and providers often insist on an in-person follow-up appointment. Many clinics conduct ultrasounds and blood tests, which is no longer the standard of care and makes abortion care more expensive.
“Some people may not have the time and money to go to a clinic and pay the higher cost associated with a medicalized abortion and take the hours of time,” says Dr. Wagner. “You need to find childcare, you need to take time off of work.”
Telemedicine care, on the other hand, can be scheduled quickly and happen wherever you are, on your phone or computer. And virtual abortion clinics can provide eligible patients care right away, even in early pregnancy, unlike traditional abortion clinics.
“You usually can’t proceed until there’s a pregnancy seen on ultrasound. If you’re only four weeks pregnant, you’re not going to see anything on the ultrasound and therefore you’re going to be turned away. For our platform, if you realize your period is two days late, you take a pregnancy test and your pregnancy test is positive, you can zoom online right away and we can get this taken care of.”
Privacy
Online abortion care also allows women seeking abortion care to avoid protesters at clinics and maintain more privacy than in-clinic care at traditional abortion clinics.
“Even though you know you’re going somewhere that’s supportive, you’re still meeting a lot of people, you’re telling your story to a lot of people,” says Dr. Wagner. “Even if you’re not required to, I think people feel obligated to explain why they’re there. It’s just emotionally easier to do this at home on your own time.”
carafem
carafem has run health centers offering in-person abortion care in several states since 2015. They are now also offering telemedicine abortion care to approximately fifty clients a week in Georgia, Illinois, Maryland, Washington, D.C. and Virginia combined, says Melissa Grant, chief operating officer of FemHealth USA, which owns carafem. According to Grant, carafem “seeks to normalize, ‘de-medicalize’ and remove the social stigma from the provision of birth control and early abortion care.”
“We as a country in many places have decreased the availability to receive abortion care easily,” Grant told Ms. “If a woman wants to receive abortion care, it’s not unusual for her to have to find a way to travel hundreds of miles to a physician that she may have never seen before and will never see again. That’s a huge barrier to care. For a medical procedure that is this simple and easy to provide, it’s wrong.”
carafem offers online, video visits for medication abortion, which take about 30 minutes. They provide a secure text messaging platform with a virtual assistant, named cara, who can connect patients with staff if needed 24×7. The cost is between $325 and $375, depending on the medication selected, and includes a follow-up check-in within 48 hours and confirmation of a negative pregnancy test at 30 days. carafem takes insurance, including Medicaid in Illinois and Maryland.
Funding
“The potential for democratizing abortion access through these platforms is promising,” says Morgan Love, co-founder of the new digital mutual-aid abortion fund, Reprocare. “But it is imperative that this not become an ‘elite’ option, available only for those who can afford to pay out of pocket or have a strong personal network of support from which to draw.”
“Reprocare offers a robust financial support platform designed to shift how abortion funding is achieved and perceived,” says Morgan, a software engineer.
The platform provides a sliding scale payment mechanism that ensures equity of access for all. They are currently working with Choix, and plan to offer their services soon through Hey Jane (slated to begin offering services in January).
“We were really excited to learn about the prospect of having medication abortion be accessible via the telehealth platforms,” Reprocare co-founder Phoebe Abramowitz told Ms. “But we knew that for it to be truly accessible, it would need to be financially accessible. So we were really glad to be able to partner with these different organizations to support a sliding scale, wherever possible, and be sure that remotely accessible medication abortion isn’t like a boutique early option and actually does expand to the people who need it the most.”
Emotional Support
Reprocare also offers peer-based support for people during a medication abortion through their Healthline.
“We provide emotional support and medical information for people planning abortion with pills at home,” Love told Ms. “We support the abortion-at-home model and make sure that folks who are having an abortion have peer-based support.”
“We offer culturally congruent care because folks have the right to be supported by people who have a lived experience that resembles theirs,” says Love.
Reprocare supports all callers, without asking for personally identifiable health information.
Legal Status of Virtual Abortion Care
All of this was made possible by a federal court decision last July. Because of the pandemic, U.S. District Court Judge Theodore Chuang in Maryland temporarily suspended an FDA restriction on the distribution of the abortion pill. Many doctors had interpreted the FDA restriction to require an in-person visit for patients to receive abortion pills. Judge Chuang’s order allowed patients to receive mifepristone from their doctors through the mail during the pandemic after a telemedicine appointment. It also allowed certified providers to contract with mail order pharmacies to dispense the abortion pill.
As a result, in September, for the first time, a U.S.-based pharmacy—Honeybee Health—began distributing abortion pills directly to patients within the country by mail. Honeybee is a California-based, accredited, online pharmacy that sells generic medications at steep discounts, without the need for insurance. Shortly after, the American Mail Order Pharmacy (AMOP) began mailing abortion pills to patients, offering overnight delivery and taking most insurance plans.
Spreading the Word and Expanding Care
The organization Plan C, which advocates for expanded access to medication abortion, has just rolled out a comprehensive new website with information for medical professionals and patients.
The website includes all the new avenues for pill access that now exist in the US, including telemedicine services, online pharmacies, and reliable websites selling the abortion pill. Searchable by state, the website offers patients information about all of their options wherever they live, as well as information about financial support, legality, and legal resources. Plan C also offers a tool kit for medical professionals with a step-by-step guide on how to become a medication abortion provider.
In addition to the new start-ups, other avenues to access abortion pills include the TelAbortion research study and the overseas organization Aid Access.
Since 2016, Gynuity Health Projects has operated TelAbortion, which allows clinicians participating in the study to provide medication abortion care by videoconference and mail the abortion pill without an in-person visit to a clinic. The study is currently running in 13 states and DC: Colorado; Georgia; Hawaii; Illinois; Iowa; Maine; Maryland; Washington, D.C.; Minnesota; Montana; New Mexico; New York; Oregon and Washington.
From outside of the United States, the organization Aid Access has U.S.-based physicians providing telemedicine abortion service in New York, New Jersey, Washington, Nevada, Idaho and Alaska.
In states that do not yet have telemedicine abortion services, evidence indicates that people are obtaining the abortion pill by other means.
Aid Access serves people in all 50 states, offering online consultations and shipping of the abortion pill from abroad for a sliding scale fee as low as $95.
Others are ordering the abortion pill from websites and self-managing their abortions. Plan C has researched the quality and cost of the abortion pill sold on various websites, including the reliability, shipping time, and payment options for these websites. This information is available on the Plan C website, along with information about safe use of the abortion pill (also provided by SASS). The Reprocare Healthline offers medical information about the abortion pill and peer-based, trauma-informed emotional support seven days a week. Repro Legal Helpline answers questions about legal rights and self-managed abortion.
Finally, Wells says that research indicates that some people are using mail forwarding services such as iPostal1.com or Anytime Mailbox to rent an “address” in state that have legal online abortion services, then doing an online consultation at a digital abortion clinic and listing the forwarding service address as the shipping address.
According to the Plan C website,
“If asked, they confirm they are in that state at the time of the consultation (since the services are only allowed to serve people in those states)… When the mail forwarding service tells them that a package has arrived at their ‘address,’ they ask for it to be forwarded to them at their home address.”
The problem with this option is that it may jeopardize the health providers, who are only allowed to serve people within the states in which they are licensed.
The Fight to Lift FDA Restrictions on the Abortion Pill
While the court decision that made these developments possible is only temporary—just for the duration of the pandemic (or until a current Trump administration challenge to the decision prevails)—advocates, lawmakers and medical professionals have been pressing the FDA to remove its restrictions on the abortion pill.
Kirsten Moore, director of the Expanding Medication Abortion Access (EMAA) Project, told Ms. that her organization plans to make a “first day ask” of the Biden administration requesting that the FDA review their abortion pill restrictions.
The FDA approved mifepristone in 2000, after a long fight by abortion rights activists to have the drug approved for the U.S. market. But despite clear evidence of its safety and efficacy, nevertheless, the FDA placed the drug under a regulatory restriction called Subpart H, later called the Risk Evaluation and Mitigation Strategy (REMS) drug safety program. Under the REMS restriction, the FDA prohibited retail pharmacies from stocking and distributing mifepristone, instead requiring mifepristone to be dispensed in a doctor’s office, clinic or hospital registered with the drug manufacturer. Many interpret the REMS to block the use of telemedicine for medication abortion using mifepristone.
There is some disagreement, however, about whether the FDA restrictions on the abortion pill in fact require medical professionals to dispense the medication in-person and some clinicians were already mailing pills before the judge’s injunction. The FDA wording says pills must be “dispensed in a clinic…” but do not explicitly say that the medication must be handed to the patient in person.
Co-founder of Plan C Elisa Wells believes the language is open to interpretation and that the new telemedicine abortion services will challenge the restriction if the injunction expires. Moore believes that the FDA requires that certified providers dispense the pills to patients in person so she is fighting to have this restriction removed.
“These restrictions place more of a burden than a benefit on providers and their patients,” says Moore, citing the FDA standard for imposing the REMS restriction.
“Based on opinion research we conducted last year, people like the idea that women have access to an option for ending an early pregnancy,” says Moore. “And they like the idea that it’s an FDA-approved drug that’s been around for twenty years. We think it’s time to revisit these restrictions and move forward.”
Reproductive health advocates argue that the REMS restriction is based on politics, not medical evidence. Whereas REMS is meant to restrict dangerous drugs, mifepristone is an extremely safe drug. In fact, mifepristone is six times safer than Viagra—which the FDA does not restrict under the REMS program.
Advocates, health care providers and policymakers are challenging the REMS restriction in court and lobbying the FDA to remove the restriction.
On March 30, twenty-one state attorneys general sent a letter to the FDA Commissioner Stephen Hahn, demanding the FDA remove the REMS restriction.
On April 14, Senators Patty Murray (D-Wash.), Elizabeth Warren (D-Mass.) and Tammy Baldwin (D-Wisc.) sent their own letter asking the FDA to lift the restriction during the pandemic.
On June 16, a group of 109 lawmakers, led by U.S. Reps. Diana DeGette (D-Colo.), Barbara Lee (D-Calif.), Ayanna Pressley (D-Mass.), and Jan Schakowsky (D-Ill.) sent a letter urging the FDA to permanently ease the dispensing restrictions on mifepristone.
The National Women’s Health Network (NWHN) coordinated 80 women’s health organizations to write a letter to Hahn demanding that the FDA remove the REMS restriction on mifepristone and requesting a meeting with Hahn. The NWHN also has a social media campaign called “Get the Pill Where You Take It—At Home!” with the hashtag #FreeTheAbortionPill, a video, a petition and digital billboards in New York state.
Going Forward
Telemedicine abortion care is revolutionizing abortion health care by significantly expanding abortion access in the United States. The pandemic has opened a door that will hard to close back up. Once people realize how safe, easy, and accessible medication abortion can be, they are unlikely to go quietly back to the old days of cumbersome, over-medicalized, time-consuming and expensive abortion health care.
People creating new telemedicine startups repeatedly emphasize the need to increase access to abortion health care, especially for people living in rural areas or in places without abortion clinics.
“We’ve been trying to fight for a long time to say abortion should remain legal,” says Grant of carafem. “But it’s equally important in the places where it’s legal to make sure it’s accessible. Because if you can’t get to the care, whether it’s legal or not doesn’t really matter. So if you’re in a small town, and don’t have a car, and don’t have a job, and are stuck without anyone that’s going to be supportive of your decision, then you effectively still have no choice even though it is legal in your state.”
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