Telehealth model increases access to abortion services

Providing abortion services through telehealth was feasible for family medicine physicians and may help increase access to medication abortion, according to two studies published in Contraception.

“Despite family medicine’s commitment to continuity of care, less than 5% offer early abortion services in their primary care practices,” Emily M. Godfrey, MD, MPH, an associate professor in the departments of family medicine and obstetrics and gynecology division of family planning at the University of Washington, and colleagues wrote in the first study.

The researchers wrote that this figure is due to both “onerous regulations imposed by the FDA through its mifepristone Risk Evaluation and Mitigation Strategy (REMS) program that requires special certification of medication abortion providers and physical dispensing of the medications from clinics, rather than from regular retail pharmacies.” In April, the FDA said it will waive mifepristone’s in-person dispensing requirement, but only during the COVID-19 public health emergency.

“Other barriers include state-specific laws and restrictions on federal funding, religious or other policies prohibiting abortion within particular health systems, lack of mentorship, stigma of being an abortion provider, geographic location, and lack of providers’ prioritization of abortion provision,” the researchers wrote.

Online platform increases access to medication abortion

Godfrey and colleagues analyzed data from patients who received abortion care from a family medicine physician based in New Jersey, New York or Washington state through Aid Access — an asynchronous, online consultation platform — from April 23, 2020, through November 30, 2020.

According to the researchers, patients can use the platform to request medication for an abortion at up to 10 weeks gestation during an online consultation. The patients are asked about their age, number of children, gestational age at the time of consultation, whether the gestational age was determined by ultrasound, circumstances of pregnancy and reason for choosing online services. They are not required to answer questions that are not related to medical eligibility. Family medicine physicians from the patient’s state review the consultations within 24 hours and either ship medications directly to eligible patients or to an online pharmacy, the researchers wrote.

During the study period, three family medicine physicians provided abortion care to 534 patients (8.6% aged younger than 20 years; 20% aged 20 to 24 years; 27.7% aged 25 to 29 years; 21% aged 30 to 34 years; 15.5% aged 35 to 39 years; 6.2% aged 40 to 44 years; 0.9% aged 45 years or older). Among these patients, 71% lived in urban areas, 24% lived in high Social Vulnerability Index (SVI) counties, 33% lived in median-high SVI counties and 26% lived in median-low SVI counties. Eighty-five percent of the patients were less than 7 weeks gestation.

Patients reported seeking abortion care online due to the COVID-19 pandemic (53%), cost (42%) and the need to keep the abortion a secret (36%), according to the researchers. Stigma was also a factor in patients’ decisions: 33% of patients who lived in Washington reported using online abortion services due to stigma vs. 20% in New Jersey and 22% in New York (P = .041).

“Regardless of state, family physicians successfully provided online medication abortion care to a range of early pregnant persons, most of whom were less than 7 weeks gestation at the time they requested care,” the researchers wrote. “The ability to serve patients over a wide geography is important, especially since abortion access in the U.S. has historically been limited, in part, by the scarcity of abortion providers and their geographic distribution.”

Components of effective telehealth delivery of abortion services

In the second study, Godfrey and colleagues evaluated factors associated with successful implementation of telehealth abortion services in different practice settings.

“Despite the growing body of evidence around how various factors influence successful implementation, few studies have evaluated the introduction of novel abortion services in different health care practice settings,” Godfrey and colleagues wrote. “This is important because innovations related to abortion care remain challenging given the political spotlight under which they operate.”

The authors added that “unlike other clinical services, abortion services are forced to adapt to ever-changing state and federal laws and respond to extreme stigma.”

The researchers used the Consolidated Framework for Implementation Research to identify themes from 21 semi-structured interviews with health care providers and clinic administrators who worked at practices that provided abortion services via telehealth. Among 15 clinical sites, six were independent primary care practices, three were online clinics, four were specialty family planning clinics and two were primary care clinics within multispecialty health systems.

According to the researchers, factors that contributed to the successful implementation of a telehealth model for abortion services included:

• access to inter-organizational networks for information, such as professional organizations or mentorship from innovators in the field;
• availability of clinic resources, such as functional electronic health records and options for intuitive virtual patient-provider interactions; and
• motivated and effective clinic champions.

“We observed that clinician-supported telehealth abortion provision under non-research conditions could feasibly be offered within four different clinic practice settings,” the researchers wrote.

Still, they noted that health care providers encountered obstacles in providing telehealth abortion services. Those who were based in states that do not permit telehealth abortion services did not qualify for the study. Even those who were able to initiate telehealth had to meet federal, state and organizational requirements, according to the researchers.

“On the federal level, it included the FDA REMS provider registration and clinic dispensing requirement, and on the state level, clinics had difficulty seeking reimbursement from state Medicaid programs,” they wrote. “At the organizational level, providers and staff also had to contend with garnering support from leaders and other staff, find systems that allowed them to do telehealth and obtain Patient Agreement Form signatures electronically. Those providers who were adding telehealth as a new service needed to determine if professional liability insurance would cover such services.”

The researchers also wrote that the FDA’s REMS program may be the most taxing barrier to telehealth abortion services because it “has essentially set the tone for widespread misperceptions about the complexity and safety of medication abortion.”

“The FDA REMS program, which was intended to reduce harm, is unnecessary, given mifepristone’s proven safety record of more than 20 years, with complications occurring in fewer than 1% of women who have used the drug,” the researchers wrote. “The FDA’s decision to maintain the mifepristone REMS program even during the U.S. public health emergency is especially distressing, since mifepristone has proven to be safer than many other medications routinely prescribed and managed by primary care providers, such as anticoagulants, antibiotics, antihypertensive agents and drugs for the treatment of erectile dysfunction.”

The authors concluded that “the removal of REMS would allow for telehealth abortion expansion in a number of states across the U.S., significantly reduce geographic barriers and help to address racial/ethnic disparities in access to high quality, comprehensive reproductive health services.”

References:

• Godfrey EM, et al. Contraception. 2021;doi:10.1016/j.contraception.2021.04.026.
• Godfrey EM, et al. Contraception. 2021;doi: 10.1016/j.contraception.2021.04.021.