Abortion access is a critical component of comprehensive reproductive health care. During the coronavirus disease 2019 (COVID -19) pandemic, telehealth emerged as a promising solution to expand abortion access, which has continued in the wake of significant policy shifts and clinical updates. Several early programs paved the way for broader adoption; however, the pandemic forced existing telehealth abortion programs to alter their models and made way for new virtual clinics dedicated to abortion care as well as the integration of telehealth abortion care into established health systems and brick-and-mortar clinics. Published protocols can be used to expand practice.
Key points
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Medication abortion through telehealth is safe and effective, both within and outside the formal health care system.
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If people have regular periods and a sure last menstrual period, they can accurately predict their gestational age.
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Patients do not need Rh testing or anemia workup before an early abortion.
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The risk of ectopic pregnancy is rare and can often be identified on history before abortion or absence of vaginal bleeding after medication administration.
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Follow-up for medication abortion can occur in many forms and should include a self-administered pregnancy test 4 to 5 weeks after abortion.
| ACOG | American College of Obstetricians and Gynecologists |
| APCs | advanced practice clinicians |
| BIPOC | Black, Indigenous, and People of Color |
| HSPT | high sensitivity pregnancy tests |
| LMP | last menstrual period |
| NAF | National Abortion Federation |
| REMS | risk evaluation and mitigation strategy |
| RhIg | Rh immunoglobulin |
| SMA | Self-managed abortion |
| WHO | World Health Organization |
Background
Abortion access is a critical component of comprehensive reproductive health care; it is vital for maintaining bodily autonomy as well as promoting individual and community health, safety, and well-being. , In the United States, approximately 1 in 4 people with the capacity for pregnancy will seek first trimester abortion care by the age of 45. Both medication and procedural abortions are safe, with complications being rare. Despite this, 89% of US counties do not provide abortion care, and thousands of people face numerous barriers each day to access the care they critically need. These barriers can take the form of restrictive state or federal laws, financial limitations, religious prohibitions within certain health systems, and widespread stigma associated with being an abortion provider. For individuals where abortion access is limited, the costs of travel, childcare, and lodging to receive essential care can be prohibitive, exacerbating the challenges for marginalized populations.
Denying people access to abortion has serious consequences. Individuals who are unable to obtain an abortion experience worse health outcomes and are more likely to live below the Federal poverty level. Moreover, abortion bans disproportionately harm those already facing systemic inequities, particularly people with lower incomes and Black, Indigenous, and People of Color (BIPOC) communities.
In June 2022, the landscape for abortion access changed dramatically; the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade and Planned Parenthood v. Casey , leaving abortion regulation to individual states. Since the ruling, 14 states have enacted total abortion bans, and 27 states have imposed gestational age restrictions on abortion access.
In response to this shifting legal landscape and growing barriers, more individuals are turning to self-managing their abortions or seeking medication through telehealth services. During the COVID-19 pandemic, telehealth emerged as a promising solution to expand abortion access and has grown in the wake of significant clinical and policy shifts. This article will explore the evolution of telehealth medication abortion, examining its protocols, logistical and clinical considerations, and legal frameworks that have shaped its provision since the COVID-19 pandemic.
Overview of Medication Abortion
In the United States, medication abortion is increasingly common, accounting for 63% of abortions in 2023. Medication abortion typically refers to inducing the expulsion of a pregnancy with medication, either a combination of mifepristone and misoprostol, or with misoprostol alone. Medication abortion is safe and effective with risks such as heavy bleeding and infection being exceedingly rare. Only 0.2% of people need some type of intervention in the 24 hours following administration of misoprostol due to heavy bleeding, with less than 0.1% needing blood transfusion. , Infection is rare, occurring in less than 1% of patients after medication abortion. Although regimens vary, National Abortion Federation (NAF) and the American College of Obstetricians and Gynecologists (ACOG) provide evidence-based guidelines, outlined in Table 1 , and contraindications and precautions, outlined in Box 1 . ,
| Mifepristone is a selective progesterone glucocorticoid receptors antagonist. , It causes both decidual necrosis and placental separation while also softening the cervix. Mifepristone also provides sensitization to misoprostol, making the medication more effective. Misoprostol is a prostaglandin (E1), which causes uterine contractility and expulsion of the pregnancy tissue. | ||
| Mifepristone and Misoprostol | <9 wk gestation |
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| 9–11 wk gestation |
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| Misoprostol alone | <12 wk gestation |
|
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Known allergy: people with known allergies to mifepristone or misoprostol should avoid those medications. With allergy to mifepristone patients can opt for misoprostol alone.
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Porphyria: Mifepristone is porphyrinogenic and is contraindicated but misoprostol can be taken.
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Chronic adrenal failure or long-term corticosteroid use
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Mifepristone is a glucocorticoid receptor antagonist and is contraindicated, but misoprostol can be taken.
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Known or suspected ectopic pregnancy
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Known or suspected hydatidiform molar pregnancy
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Current severe anemia
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Current anticoagulation therapy
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If current IUD user, recommended to have removal and ultrasound for assessment of pregnancy location
The Rise of Telemedicine
Telehealth or telemedicine , is defined by the World Health Organization (WHO) as the use of information and communication technologies to deliver health care services over a distance . This encompasses videoconferencing, mobile apps, secure messaging, phone-calls, and online data exchanges between patients and clinicians.
The COVID-19 pandemic accelerated telehealth adoption, with over 60% of medical visits conducted virtually by April 2020, up from less than 1% 2 months earlier. This surge was supported by regulatory and policy changes, including Centers for Medicare & Medicaid Services’ reimbursement parity for virtual visits, suspension of geographic restrictions, and relaxed Health Insurance Portability and Accountability Act requirements. Initially a response to a public health crisis, telehealth continues to transform health care delivery.
Telehealth has long been seen as a way to increase health care access by reducing geographic and logistical barriers, especially for those in rural and underserved areas. Patients using telehealth report higher satisfaction levels and better communication with providers, leading to greater empowerment in managing their health. Studies show improved efficiency in health care delivery, including reduced wait times. , However, the benefits of telehealth are not universal; access depends on technology and internet access, which remains unevenly distributed. This disparity disproportionately affects rural residents, low-income households, and communities of color, worsening existing health care inequities.
Telehealth Medication Abortion
Telemedicine abortion integrates telehealth technologies into abortion care. This approach can take various forms, from remote consultations with patients at home or in health centers, provision of care with or without prior testing, and medication distribution through health centers, pharmacies, or direct mailing to patients’ homes.
An early model of telehealth abortion was Planned Parenthood of the Heartland’s 2008 program, in which they employed remote consultation with abortion providers for patients in health centers not staffed by an abortion provider. The health center staff would counsel the patient and screen for eligibility. If the decision was made to proceed with medication abortion, the remote consultant connected to the patient by videoconferencing, spoke with the patient, reviewed the medical records, and could then authorize the medication remotely. The introduction of this model increased the proportion of abortions done by medication, and patients were able to access abortion care at an earlier gestation. Furthermore, qualitative research demonstrated that remote care for abortion was largely satisfactory for patients. ,
Although telemedicine abortion existed before the COVID-19 pandemic, its reach was severely limited by regulations like the Food and Drug Administration (FDA)’s risk evaluation and mitigation strategy (REMS). Implemented in 2011, REMS required mifepristone to be dispensed in-person by a certified provider in a health care setting. These regulations were not based on scientific evidence and do not make care safer. , ACOG advocates for the removal of the REMS restrictions on mifepristone, recognizing that they are not medically justified and contribute to health inequity.
The REMS restrictions disproportionately burden individuals, whose lives are already shaped by social and structural forces, limiting their ability to access essential health care services like medication abortion. , For those living in rural regions, the in-person requirement often meant hours of travel to reach a clinic, adding costs for transportation, childcare, and time off work. , For low-income individuals, these added costs compounded the already significant financial barriers to abortion care. Meanwhile, BIPOC communities, who face higher rates of health care discrimination and structural barriers, were further marginalized by a policy that did nothing to enhance safety but instead created additional obstacles to care. The requirement for in-person dispensing limited the geographic reach of telemedicine abortion, forcing people to physically visit a facility, thus negating the convenience and accessibility telehealth could otherwise provide.
In 2020, the spread of COVID-19 accelerated the timeline for bringing telehealth abortion care into the mainstream. Reproductive health providers scrambled to modify care to incorporate public health recommendations into their systems and protocols. They quickly adapted their protocols to align with public health guidelines, aiming to offer remote services, promote social distancing, and reduce visits to crowded health care settings. This shift was supported by 3 key regulatory and clinical changes in medication abortion, alongside emerging data confirming the safety and efficacy of telehealth in abortion care.
Changes Driving Expansion of Telehealth Abortion
In the spring of 2020, the FDA had allowed the mailing of many REMS-classified drugs but had not yet lifted this requirement for mifepristone. The American Civil Liberties Union filed a lawsuit to fight the in-person dispensing ruling on behalf of a group of medical experts and reproductive justice advocates. In July 2020, a federal district court issued a preliminary injunction that blocked the FDA from enforcing the in-person dispensing requirement of the REMS in the face of the public health emergency, allowing for dispensing by mail. In January 2023, this FDA modification of the REMS became permanent, removing the in-person dispensing requirement and adding a new pharmacy certification process, allowing mifepristone to be dispensed by a pharmacist who receives a prescription from a certified provider. , , The simplification of protocols and removal of federal requirements allowed licensed clinicians (in states that do not prohibit abortion using telemedicine) to mail medication abortion pills directly to patients or to contract dispensing with mail-order pharmacies.
With these changes came the emergence of several new online services that offered medication abortion entirely remotely using telemedicine and mail. Mail-order pharmacies were quicker than brick-and-mortar pharmacies to make mifepristone available through their services. In early 2024, 2 large national pharmacy chains, CVS and Walgreens, made mifepristone available in stores in select states. For patients, being able to access medication for an abortion in a doctor’s office, at a local pharmacy, or by mail to their home means that they are better able to get care when, where, and how it best meets their needs.
Updates in clinical practice have also played a role in the expansion in access to medication abortion. An important clinical practice change has been the broadening of the eligibility criteria with regards to gestational age. When Mifeprex was approved by the FDA for the first time in 2000, the medication abortion regimen was approved up to 49 days, or 7 weeks, of gestation. An update to the REMS in 2016 increased that gestational age to 70 days, or 10 weeks. However, the data has always been ahead of the regulations, demonstrating efficacy beyond that which the FDA has acknowledged.
Recent research has evaluated the efficacy of the same regimen of mifepristone and misoprostol beyond 70 days. In the years leading up to the COVID-19 pandemic, study findings showed a continuation of the trend of decreasing efficacy with increasing gestational age, and modifications to the regimen were being explored. , The decrease in efficacy was found to be mitigated by adding an additional dose of misoprostol in the regimen, prescribing 2 doses instead of one; see Table 2 for details. With this new regimen, the very high success rate of medication abortion was able to be maintained through 77 days. However, this shift had not been widely adopted in the United States until the COVID-19 pandemic. In 2020, armed with this data and driven to find ways to maintain access to abortion care within the public health constraints of the time, the family planning community moved toward mainstreaming the use of medication abortion up to 77 days.
| Overall efficacy | Ongoing pregnancy | |
|---|---|---|
| 57–63 d gestation | ||
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93.5% | 3.1% |
| 64–70 d gestation | ||
|
92.3% | 3.6% |
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99.6% | 0.4% |
| 71–77 d gestation | ||
|
86.7% | 8.7% |
|
97.6% | 1.6% |
Another significant clinical update has been the reduction in Rh immunoglobulin (RhIg) administration for prevention of Rh alloimmunization. Historically, ACOG and other medical organizations recommended Rh factor testing and RhIg administration for unsensitized Rh-negative people after an abortion or spontaneous pregnancy loss, regardless of gestational age. This was based mainly on expert opinion, extrapolation from the benefits farther along in the pregnancy, and the potential benefit of preventing Rh alloimmunization. , This recommendation meant a need for laboratory testing for people seeking abortion care, in order to determine Rh status.
Recent studies examined more closely the risk of Rh alloimmunization at an early gestational age. The technique of flow cytometry was used to measure circulating fetal red blood cells in maternal circulation, and it was found to be below the threshold for Rh sensitization of 125 fetal red blood cells (RBCs)/5 million total RBCs, which was calculated by the authors from the existing literature. A pilot study of 37 patients was published in 2020, followed by a larger scale cohort study of 506 patients, which had similar findings. , This bench research aligns with population data comparing alloimmunization rates between 2 countries with differing practices on the administration of RhIg in early pregnancy loss and abortion, Netherlands and Canada. This analysis did not find a reduction in perinatal antibodies with the country-wide practice of RhIg administration in Canada, compared with Netherlands. which was not administering RhIg before 7 weeks for induced abortions or before 10 weeks for spontaneous abortions.
With a spotlight on this recent data, expert organizations started to curb their recommendations. The WHO stopped recommending Rh testing and RhIg administration for abortions less than 12 weeks gestation, followed by NAF, Society of Family Planning, and others. , , As this practice shift gained popularity, it facilitated the growth of telehealth medication abortion, removing laboratory testing as a driver for in-person clinical encounters. Of note, many providers in the United States held onto Rh testing and RhIG administration, as ACOG and SMFM continued to recommend this practice. However, with the recent ACOG update to its recommendation in September 2024, the door has been opened for foregoing Rh testing and RhIg administration in the mainstream.
Safety and Efficacy of Telehealth Medication Abortion
Before the COVID-19 pandemic, the vast majority of the approximately 340,000 medication abortions provided annually were obtained in specialized and high-volume abortion clinics. In fact, direct-to-patient telehealth medication abortion was only available in the United States to individuals enrolled in research studies, or via online international organizations. This model was investigated in an incremental fashion with initial research, exemplified in the 2016 Telabortion study, focused on reducing in-person visits while still requiring laboratory tests and ultrasounds. , Concurrently, evidence supporting the eligibility of history-based screening for medication abortion accumulated. This no-test method assessed medical contraindications via patient history, gestational age using menstrual history, and risk of ectopic pregnancy through symptom review and historical risk factors. In 2018, the safety and efficacy of this no-touch method was closely examined through a study conducted in 3 countries, reporting a success rate of 95% and serious adverse outcomes of 1%, both comparable to data from in-person abortion care. ,
In the first 2 years of the COVID-19 pandemic, telehealth for medication abortion expanded rapidly, with countries like Great Britain implementing hybrid models that combined telehealth screening with additional testing only if clinically indicated. A study conducted by Aiken and colleagues comparing outcomes before and after the introduction of this new hybrid model reported a success rate of 98% with no increase in serious adverse outcomes. Success was defined as complete expulsion of the pregnancy without need for surgical intervention. Furthermore, previously cited concerns with foregoing an ultrasound scan, namely erroneous gestational age calculation and risk of undiagnosed ectopic pregnancy, did not prove to pose a risk in this cohort.
In the United States, Upadhyay and colleagues conducted a large-scale retrospective cohort study that analyzed the outcomes for over 3000 patients who received medication abortions without preabortion ultrasounds or pelvic examinations between February 2020 and January 2021. This study encompassed a diverse array of clinical settings, including independent clinics, planned parenthood facilities, academic centers, and online-only services. The success of the regimen—defined as complete expulsion of pregnancy tissue following administration of mifepristone and up to 2 doses of 800mcg misoprostol—was found to be 95%, consistent with existing literature. Notably, rates of ectopic pregnancy and major adverse outcomes were recorded at less than 1%. Follow-up assessments identified 9 patients (0.4%) who exceeded the gestational age limit of 70 days without prior detection by screening protocols. This study concluded that the practice of medication abortion devoid of ultrasounds or physical examinations is both effective and safe, thus providing an alternative model that reduces logistical barriers, aligns with patient-centered care principles, and enhances access for marginalized populations, including individuals in rural settings.
The findings from these extensive studies are corroborated by a growing body of literature, which collectively indicates that efficacy rates for remote medication abortion consistently approximate 95%, with major adverse events occurring in less than 1% of cases.
Discussion
Self-Managed Abortion and Its Intersection with Telehealth Medication Abortion
Self-managed abortion (SMA) refers to any action taken to end a pregnancy outside of formalized health care and includes self-sourcing the same medications used clinically for medication abortion (mifepristone and misoprostol), use of herbs and supplements with or without the assistance of an herbalist, use of toxic substances or drugs or a physical method. , The current spread of abortion restrictions and increased accessibility to medication abortion has led to a surge of self-management with medication. SMA with medication is medically as safe and effective as clinic-based care. , Although there are only 3 states with laws specifically banning SMA, 26 states have attempted to use unrelated laws to prosecute people suspected to have self-managed an abortion.
The threat of criminalization brings one of the greatest risks of harm to people undergoing an SMA. A decriminalization lens is particularly important for health care providers interacting with patients that may have had an SMA and are seeking urgent or emergent medical care. Some patients may seek out in-person medical care after their abortion to confirm effectiveness or for rare complications. Clinicians could inadvertently put patients at legal risk through their actions; understanding local laws, maintaining the confidential provider-patient relationship, and providing compassionate, nonjudgmental care to patients presenting before, during or after an SMA are essential. Management of issues that arise after an SMA is usually the same as management of a miscarriage; hence, clinicians may determine that there is no need to detail in electronic medical records specific information that may lead to incrimination for SMA. , People who are self-managing their abortion may desire clinician or community support through the process (see Table 3 for resources).
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