Demand for telemedicine abortion is increasing in the face of abortion restrictions and a potential Roe v. Wade overturn. Researchers say that the service is safer and more effective than ever.
As states across the U.S. continue to restrict abortion access, people in states that ban telemedicine abortion are increasingly turning to European doctors to access abortion pills. New research published in The Lancet definitively shows that people served by Austria-based telemedicine abortion provider Aid Access have had highly positive experiences with the service, with very low rates of complications reported.
“This study is the first evidence from the U.S. context that self-managed medication abortion provided using this online telemedicine model is safe, effective and acceptable to users,” says the study’s lead author, Dr. Abigail R. A. Aiken, associate professor at the University of Texas at Austin’s LBJ School of Public Affairs. Aid Access services are physician supervised but considered self-managed because they are outside of the formal U.S. healthcare system.
Dutch physician Rebecca Gomperts founded Aid Access in Austria in 2018 to provide online, telemedicine abortion to people in all 50 U.S. states, including the 19 states that currently prohibit telemedicine abortion. The service requires an online consultation to determine eligibility for using abortion pills, and provides information about how to use abortion pills. Patients in states allowing telemedicine abortion receive care from U.S.-based caregiver who ships medications from Honeybee Health.
For patients in states that block U.S. providers from offering this service, Dr. Gomperts sends a prescription to a pharmacist in India, who ships the medications directly to them. Patients receive the medications in 2-3 weeks. Dr. Gomperts charges a sliding scale fee up to $110. She has served over 30,000 people in the U.S. since she began Aid Access four years ago.
Aiken’s research found that between March 2018 and March 2019, Aid Access mailed abortion medications to 4,584 people. Of the 2,797 people who used the medications and responded to a follow-up survey, 96.4 percent reported successfully ending their pregnancy without surgical intervention and only one percent reported any treatment for a serious adverse event, a rate only slightly higher than in clinical settings. No deaths were reported to the service by family, friends, the authorities or the media. Aid Access telemedicine abortion is much safer than carrying a pregnancy to term, says Aiken.
One area of concern is that medication abortion outside of the formal US health care system might delay a diagnosis of an ectopic pregnancy—a dangerous conditions where a fertilized egg implants and grow outside of the uterus. But Aiken says that they saw the opposite in the study. “We saw that people actually were diagnosed at the time of contacting Aid Access, which is a really good thing,” she says. No ectopic pregnancies were reported after using the medications.
The research also showed that patients’ reports of last menstrual period is an accurate method for determining gestation duration in early pregnancy, meaning ultrasounds aren’t necessary.
Respondents reported positively about their experiences of using abortion medication through Aid Access: 98.4 percent were satisfied with their abortion experience; 95.5 percent said it was the right choice; 98.1 percent felt they had enough information on how to use the medications; and 93.4 percent felt they had enough information on what to expect from the process.
The research also provided evidence that medication abortion after 10 weeks is effective and safe, although slightly less so than before ten weeks. Of the patients taking abortion pills before 10 weeks of pregnancy, 97 percent successfully ended their pregnancies. The success rate for people taking the pills after 10 weeks was 92 percent. While only .08 percent of patients with pregnancies up to 10 weeks had complications, 2.3 percent after 10 weeks did. “It’s of course higher, but it’s not alarmingly high,” says Aiken, noting that the World Health Organization has approved the use of abortion pills up to 13 weeks of pregnancy.
Aiken says that the research is important, both for the clinical community and abortion providers, but also for policymakers who are figuring out how to regulate self-managed abortion. “I think self-managed telemedicine abortion will become seen as more legitimate and more of a real part of good quality, safe, effective care as we see more of these results and see more about how it’s operating and working,” she says. “I think it’s a very legitimate option and so important because of its affordability.” Over 61 percent of the respondents reported they had difficulty affording the full $110 fee.
Dr. Aiken says that this research supports making medication abortion pills over the counter where pharmacists could screen patients for contraindications and gestation limit.
“This is a pretty similar model. People can take the pills and instructions home and follow them. In the rare case of a serious adverse event, they could seek help. I think we showed that in the study,” she says.
People are self-managing abortion in a variety of ways, including herbs and botanicals, manual vacuum aspiration and pills.
“Medication abortion provided through Aid Access is among the safest and most effective ways we have to self-manage abortion in this country,” says Aiken, but she noted there may be other ways that are safe and effective.
“Folks in indigenous communities have been doing self-managed abortions since there were people here in North America. I don’t want to be quick to dismiss the idea that those abortions work or that they’re effective. We don’t know because we don’t have that data. For other methods, such as herbal or botanical abortion, there’s not a lot of really good data to back up the safety and effectiveness of those options.”
But with any self-managed abortion, legal issues are a concern. There have been 24 unjust legal prosecutions for alleged self-managed abortion since 2000, says Aiken, and many are targeted at low-income and racially minoritized people.
“No matter whether you’re using herbs, or menstrual extraction or pills, if you’re outside of a formal U.S. healthcare setting, your picture looks very different when it comes to potential legal risk,” says Aiken.
Currently, just five states have explicit criminal prohibitions of self-managed abortions: Arizona, Delaware, Nevada, Oklahoma and South Carolina. But prosecutors in other states have tried to use a range of laws against pregnant women, including laws against feticide, child neglect, practicing medicine without a license and possession of a dangerous substance. However, there have been no successful prosecutions of women who self-managed an abortion using pills in early pregnancy
Gomperts herself serves patients in states where telemedicine abortion is not available (see gray states in the map below), but she works with nine U.S.-based health care professionals, such as Dr. Robin Tucker and Christie Pitney, to provide services to people in the other states. U.S.-based Aid Access providers charge a sliding scale fee of $150 and the medications arrive within 1-4 days. The services provided are otherwise very similar.
Aiken’s research comes just as requests for abortion pills are increasing in response to increasing abortion restrictions across the country. In another recent study, Aiken found that requests for pills to Aid Access jumped 1,180 percent after the Texas abortion ban went into effect on September 1, 2021, and remained high during the three months afterwards.
“Requests for the service have been going up over time, especially because of the big bump that Senate Bill 8 caused in Texas,” says Aiken, who estimates Aid Access has received around 90,000 requests for abortion pills since opening in 2018.
As the Supreme Court appears poised to overturn Roe v. Wade and states are passing abortion restrictions in unprecedented numbers, Aiken is hopeful that self-managed medication abortion by telemedicine can help people without access to abortion health care.
“Just because you declare abortion to be illegal, the need for abortion is still there. People still need to find ways of accessing the care they need,” she says. “It’s reassuring to think that we have a safe, effective and acceptable way for people to go ahead and access that care and preserve their reproductive autonomy.”
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