As we await the fate of Roe v. Wade, Ms.’s “Online Abortion Provider” series will spotlight the wide range of new telemedicine abortion providers springing up across the country in response to the recent removal of longstanding FDA restrictions on the abortion pill mifepristone.
Cindy Adam and Lauren Dubey are nurse practitioners and owners of Choix, a virtual clinic offering asynchronous telemedicine abortion services to people in California, Colorado and Illinois. They serve patients regardless of insurance or documentation status. They also provide birth control, emergency contraception, STI testing and urinary tract infection care.
Ms. spoke to Adam and Dubey about how and why they began offering telemedicine abortion.
Carrie Baker: Can you tell me about your medical background and your practice?
Lauren Dubey: Cindy and myself are both nurse practitioners. We actually met in nursing school in San Francisco. We both had a keen interest in sexual and reproductive health throughout the course of our studies. I wound up at a Planned Parenthood doing almost exclusively reproductive health and that launched my career in abortion care.
Cindy Adam: I started off in primary care, doing full scope primary care and community health. And then I specialized further in sexual reproductive health, and women’s health, pregnancy and prenatal care. I wasn’t able to become an abortion provider until we founded Choix.
Baker: Can you tell me about Choix and how you founded it?
Adam: Lauren and I founded Choix along with Dr. Aisha Wagner and my husband, Mark. We wanted to be able to offer a sexual and reproductive health platform and we wanted to do abortion care as part of that. The FDA ruling came down just as we were ready to open our services. We opened up mailing mifepristone through Honeybee Health pharmacy. We also received a grant from Plan C to help develop the Access Delivered provider guide to offering telemedicine abortion.
Dubey: We are certified as a NAF [National Abortion Federation] member clinic. We developed our own clinical protocols that meet our patient needs in the places where we’re serving them, while also providing high-quality, evidence-based medicine.
Baker: How do you provide medical telemedicine abortion care?
Adam: We’re a completely asynchronous telehealth platform. We use a messaging platform where patients can do regular text messaging or encrypted text messaging. All of our care is done via medical questionnaires and over text.
Patients first sign up on our website and fill out an initial questionnaire, then we review their history and follow up via text with any questions. Once patients are approved to proceed, they’re able to complete the consent online. We send our video and educational handouts electronically and make them available via our patient portal. We’re always accessible via phone for patients.
Right now we’re in states that allow for asynchronous care, and so that’s our primary method of offering care. In the future, we will expand to audio and video visits, depending on what the telehealth regulations are in those states. But we have done patient surveys and of those who have responded, I think it’s close to 90 percent of patients prefer messaging by text, which is really interesting. I found that to be very encouraging.
Baker: Can you tell me about your educational video?
Dubey: We send patients pretty lengthy written educational materials that have visual aids in them. But it can be a little bit confusing and overwhelming, especially with the heightened feelings of urgency surrounding having an abortion. So we wanted to create something for more visual learners that was a summary of all of the patient education materials that they receive, with the main points like how to take your medication, what order to take your medications, what the package is going to look like, if it’s discrete, how much bleeding to expect and how to insert medication in your mouth or in your vagina depending on the route that you choose to take misoprostol, which is the second medication.
The video provides a quick visual reassurance of the process. It’s narrated by a provider so it feels a little bit more intimate, like you’re getting face-to-face counseling, but you can do it on your own time.
Baker: How long does it take between when a patient registers on your website and when they’re approved for medication abortion?
Dubey: We commit to reviewing all patient inquiries within one business day. So if you submitted by 3 p.m. on Tuesday, you will hear from us by 3 p.m. on Wednesday. The majority of the time we get to people before that. One benefit of asynchronous care is we’re able to see more people in a given day, which means that we’re increasing access because people don’t have to wait very long to hear from us.
We’re a completely asynchronous telehealth platform: All of our care is done via medical questionnaires and over text. One benefit is we’re able to see more people in a given day—which means that we’re increasing access because people don’t have to wait very long to hear from us.
Baker: How long does it take for the pills to reach a patient once you’ve prescribed them?
Adam: Honeybee Health pharmacy ships to California in one to two business days, to Colorado in one to three days, and to Illinois in one to four days. We also offer expedited shipping so people can get next day air.
Baker: What percentage of your patients are you able to serve fully remotely?
Dubey: The majority of people. There’s a small subset, who need an ultrasound before proceeding with care with us and an even smaller subset who are just ineligible based on being too far along in pregnancy or having some sort of medical condition that precludes them from safely accessing care with us.
Baker: Do most people know when their last period was?
Adam: Yes, they do.
Dubey: People are so creative. They check their text messages or they check credit card charge on their phone for the day when they went to buy tampons or pads.
Baker: What kind of follow-up care do you provide after the patients get their pills?
Adam: First we’ll do an initial medication check-in visit. Then we set up a 72-hour follow up from the date that they take the misoprostol.
Baker: And that’s by text?
Adam: Yes, it’s all by text with links to the patient portal. When they log back in, it will prompt the next questionnaire depending on where they’re at in the process. For example, during a 72-hour follow up, it will ask them whether or not they have ongoing symptoms of pregnancy, if they think they passed the pregnancy or not and if the bleeding has improved since they took the misoprostol. Those questions are really helpful for us to assess whether or not the medication abortion is complete.
Baker: How many telemedicine abortion patients have you seen so far since you opened?
Adam: We’ve served over 2,200 patients since we opened in October 2020.
Baker: How have your patients responded to your telemedicine abortion services?
Dubey: People express such gratitude for being able to access care in this way. Some are kind of afraid of it or skeptical of it at first, and then having every question answered, getting to do this in the comfort of their own home, feeling supported by the educational materials they receive, even just a warm text from someone that they don’t have to talk to is sometimes all that people really want and need.
Baker: Can you talk about who your patients are?
Dubey: We see people of all income levels. We see people who live in the most expensive neighborhoods of Los Angeles and people who live in the most rural parts of Colorado and Illinois. The median age of our patients is 26. People who identify as different genders access our care too.
We see people who live in the most expensive neighborhoods of Los Angeles and people who live in the most rural parts of Colorado and Illinois.
Baker: Why do your patients use telemedicine, as opposed to going to a local Planned Parenthood?
Adam: They’re really excited to be able to get this care in a confidential way at home, and in most cases without an ultrasound. They know that Choix is discrete, private and often much faster than getting an in-person appointment.
Sometimes people have a history of trauma, in the healthcare setting, with a prior abortion, or otherwise, and doing their abortion at home helps them own the process and make the process more theirs. Some people don’t want to see their ultrasound—that in and of itself can be traumatic for some people. And right now during the pandemic, not having to leave the house is just really reassuring to people.
We had a patient who had two children with special needs and did the medication abortion process at night while her kids were sleeping. It was really hard for her to get childcare to leave the home. She had very little support, but was able to do it on her time.
Another issue is cost. This is really one of the most cost-effective options for them.
Dubey: Even if they could get to their nearest abortion clinic, we have had patients who have compromised immune systems or kids who have health problems. We’re hearing that a lot, especially pre-vaccine, that this was the safest option for them and their family.
Another reason patients use our services is that in light of S.B. 8 and Texas patients traveling to Colorado for care, patients there can’t get appointments for two, three weeks because the clinics are so overwhelmed. We are their soonest option. We’re able to help them in a more timely fashion, especially given that medication abortion does have a time limit on it.
Baker: What do you charge?
Adam: Right now, we charge $289. There’s an initial consult fee of $20, which goes towards the $289 total. Patients only complete the full payment once they’ve been approved to proceed. We really excited to announce that we’re going to be offering Medicaid coverage next year in California.
Baker: Do you take other forms of insurance now?
Adam: We currently operate with a fee for service model and work with abortion funds in some states There’s also an option to receive a $50 electronic gift card for folks who are interested in participating in a University of California, San Francisco research study.
We’re constantly working on ways that we can reduce our price or offer financial assistance to those who need it. We have done our own fundraising through our partnership with Reprocare. In the past, we’ve had partnerships with NAF [the National Abortion Federation].
Baker: How easy is it to navigate your platform?
Adam: The majority of the time people have a really good, user-friendly experience.
Baker: Do you offer missed period pills?
Adam: That is something we’re really excited to be looking into and potentially offering next year.
Baker: Do you offer advance provision abortion pills?
Adam: We do not.
Baker: What are your motivations for offering telemedicine abortion? Why is this so important and important now?
Dubey: Access to abortion health care in California is extremely high compared to other places in the country. And still, it doesn’t seem like enough. There are rules and protocols that are rooted more in provider comfort or fear of liability than evidence-based medicine. One of my most heartbreaking things I ever had to do when I was working at Planned Parenthood was someone would come in and they’d be 10 weeks and two days in their ultrasound and I would have to turn them away for medication abortion. And they would say, “Well, if I could have just gotten in here two weeks ago when I made the appointment, when I took the pregnancy test…” But my hands were tied. When you do this via telehealth, there’s no waiting for an appointment for two weeks. So for me, with telehealth, we can offer people more options for care.
Baker: I see you have a supervising physician. What does she do?
Adam: Our chief medical officer is Dr. Aisha Wagner. She provides consultation services for the nurse practitioners as well as clinical protocol development and review. She provides in-person care as a family practice physician and also works for Planned Parenthood doing aspiration abortions.
Baker: Have any of your patients mentioned not wanting to cross picket lines in front of clinics as one of their reasons for using telemedicine abortion?
Dubey: Yes. On our feedback surveys, there are a few instances where people say, “I live in a small town, the closest abortion clinic always has a picket line and horrible posters out front. I’m confident in my choice, but that makes me feel really disgusted and sad. I’m so glad I didn’t have to do that.”
Baker: How does it feel to be able to help people in this way?
Dubey: It feels really cool that I can do this on a day-to-day basis. Cindy and I are at the forefront of telemedicine abortion, teaching other people how to do it, helping more people to do it and exposing the world to this new type of care. It is incredibly fulfilling, not just being an abortion provider and not just doing it via telehealth, but being at the forefront of abortion care in a new way. We are part of networks and teams of people that are so forward thinking. We’re figuring out how to help more people in new ways.
Adam: With everything going on with the Supreme Court and Dobbs and Texas, it feels really good to be a part of the movement to expand access to medication abortions. We hope to be able to continue to innovate and find ways to support patients who are in states with restrictive laws.
Baker: If someone were a clinician thinking about offering telemedicine abortion, what’s the first step?
Adam: The Access Delivered toolkit is a great place to start. They cover all the things you need to consider.
Dubey: The National Abortion Federation is building a platform to support providers doing telehealth abortions. They are trying to eliminate barriers to providing this type of care.
Baker: Any final words?
Adam: We’re really excited about the future of abortion care. We’ve had such a wonderful experience.
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