Telemedicine could expand access to medical abortions

Women in the U.S. without reproductive health services close to home might have an easier time getting medical abortions if they could consult with doctors online instead of scheduling in-person visits, some providers argue.

Although surgical abortions require clinic visits, roughly one quarter of abortions are done with medication and might be provided with telemedicine - using webcams and video chats to diagnose and treat these patients, Dr. Elizabeth Raymond of Gynuity Health Projects in New York and colleagues argue in JAMA Internal Medicine.

"The use of telemedicine is growing," Raymond said by email. "It has tremendous potential to make many essential services more accessible, more convenient and cheaper. Medical abortion is such a service."

For many U.S. women, obtaining an abortion is difficult because they live at least 100 miles away from the nearest clinic, the authors note. Mississippi, Missouri, South Dakota and North Dakota each only have one abortion clinic, and Wyoming has none.

Medical abortions performed before 10 weeks of gestation with two drugs - mifepristone and misoprostol - can be self-administered at home. Healthcare providers can use telemedicine to interview patients and assess potential safety issues by reviewing lab test results and ultrasounds before prescribing medication, the authors note.

In the two-step medical abortion regimen typically used in the U.S., women first take mifepristone. This pill works by blocking the hormone progesterone, which causes the lining of the uterus to break down and makes it impossible for the pregnancy to continue. Then, 24 to 48 hours later, women take misoprostol, which causes the uterus to empty.

Women are usually advised to have a clinic visit within two weeks to confirm the pregnancy was terminated. In rare cases when ultrasound or a blood test shows the medical abortion didn't succeed, women require surgical abortions.

In 2008, a Planned Parenthood affiliate in Iowa initiated the first formal telemedicine abortion program in the U.S. with physicians reviewing labs and imaging then speaking to patients to determine if the clinic should be authorized to dispense medical abortion pills.

In the first year, this program nearly tripled the number of sites in Iowa offering abortion services, from six to 17, the researchers report.

Among 233 women with follow-up, the treatment was successful 99 percent of the time. One patient had a blood transfusion in an emergency department, and there were no other serious adverse events reported.

Direct-to-patient telemedicine programs for medical abortions are available in the Canadian province of British Columbia and in Australia, the authors note.

But in the U.S., regulators require that abortion medications be dispensed to patients in clinics, medical offices and hospitals.

Widespread use of telemedicine for medical abortions in the U.S. is also restricted because some states require in-person exams or have banned telemedicine abortions, the authors note.

"Currently, more than half of rural women don't have access to reproductive health services anywhere in their county," said Katy Kozhimannil, a researcher in health policy at the University of Minnesota School of Public Health in Minneapolis who wasn't involved in the study.

"For these women, telemedicine can make medication abortions more accessible," Kozhimannil added by email.

"Non-clinical factors, including state and federal regulations, influence requirements such as exams and in-person clinician visits," Kozhimannil said. "Many of these decisions are influenced by political factors, and not explicitly made based on medical evidence."

SOURCE: http://bit.ly/22Iat5T JAMA Internal Medicine, online March 28, 2016.