128 Collective

We have seen wave upon wave of attacks on abortion rights in the US as conservative-led courts and state governments enacted a record number of anti-abortion laws and regulations in recent years. At the end of 2021, The Guttmacher Institute reported (accessed 1/20/22) that 108 abortion restrictions had been enacted in 19 states, the highest total in any year since Roe vs. Wade was affirmed in 1973. As we commemorated its 49th anniversary this past week, Roe vs. Wade has been all but hollowed out even before we hear the Supreme Court’s decision on the pending Dobbs v. Jackson Women's Health Organization (accessed 1/20/22) case.

128 Collective recognizes the urgency of supporting access to abortion, and we see increasing opportunities through the harnessing of technology. To support this thesis, 128 Collective has championed University of California, San Francisco’s (UCSF’s) Bixby Center and its ANSIRH research team. They recently published groundbreaking research in this article in the Journal of American Medical Association on the safety of abortions pills remotely administered through telehealth.

Below is our conversation with the two leaders of the California Home Abortion by Telehealth (CHAT) study, Dr. Ushma D. Upadhyay, PhD, MPH, Department of Obstetrics, Gynecology, and Reproductive Sciences (UDU); and Jennifer Ko, MLIS, Project Director, ANSIRH (JK) at UCSF, to hear more about the impact of the study and what’s next.

Tell us what motivated you to be researchers in this area?

JK: One of the reasons I’ve tended to gravitate towards research in public health, and why working with Dr. Upadhyay has been so easy, is our shared interest in patient-centered care and demedicalizing medication abortion care, specifically. At the heart of our research group is this idea that we want our research to be able to help give people autonomy and empowerment over their own bodies and reproductive options.

There is too much power taken away from the person seeking an abortion versus those who can provide it. Abortion care can actually be quite simple - the patient already 1) knows what their health problem is (they’re pregnant and do not want to be), 2) typically will know their related health history (last menstrual period), and 3) the treatment is pretty universal and proven safe and effective than other over-the-counter medications like Tylenol. So why is it so difficult to put the medication into the hands of the patient?

UDU: Much of my previous research has been done on state-level abortion restrictions and their impact on people’s lives. These restrictions often create insurmountable barriers to obtaining an abortion. We identified 27 abortion deserts in the U.S. – major cities where residents have to travel 100 miles or more to reach an abortion provider. It was horrifying to imagine what lengths people must go through to obtain this essential health care service. While not a panacea, medication abortion has the potential to bring abortion within reach for thousands of people living in states where access is limited.

I am strongly motivated by the idea that we need to support people to become parents only when they want, under the circumstances they want. We know that the majority of women who seek out abortion are already moms and often choose abortion to better care for the children they already have.

What are the key objectives and findings of the CHAT study?

ANSIRH: This 3-year study has 3 overall aims:

1. to evaluate the provision of clinically-supported medication abortion care through online telehealth platforms, i.e., “virtual clinics”;
2. to determine the factors that contribute to people’s decisions to use a virtual clinic and their experience obtaining abortion care through this model; and
3. to measure time to abortion care, as well as safety and efficacy outcomes.

Currently 19 states in the U.S. ban telehealth for abortion care. In the CHAT Study, we are building a strong evidence base to demonstrate, not only is telehealth for abortion safe and effective, but people really like this model of care.

Further, we are partnering with California Latinas for Reproductive Justic (CLRJ) to address how telehealth could potentially address other barriers to care, particularly among those in which abortion care is especially challenging, such as undocumented and monolingual immigrant communities, rural people, and people living on low incomes. In particular, we are looking into how telehealth care impacts trust between patients and providers, privacy, experiences of racism – and how does this impact, if any, influence their choice.

There has been a steady erosion of abortion rights in the US--how is medication abortion going to help and who will be left behind?

ANSIRH: We are deeply concerned about the major dichotomy between protected and restricted access states. Our previous research shows that among people who are considering abortion, those who live in restricted access states are less likely to find timely care, thus carrying their pregnancies to term, than those in protected access states. We also found that among people who said they were considering an abortion, those living in states that ban Medicaid coverage for abortions are twice as likely to still be trying to get an abortion 4 weeks later. State-level abortion restrictions perpetuate economic and racial divides.

Medication abortion though telehealth can help close these divides by being able to reach people who cannot travel to get an abortion, and by lowering the financial costs. Developing an evidence base and standard of care in protected access states can impact and change expectations in restricted access states. This evidence can be used in litigation when challenging laws that ban telehealth for abortion care. Residents of restricted access states can point to models of care that they should have access to. In fact, it is only when the FDA saw that models for abortion care were changing in the U.K. and Canada that they began to seriously consider lifting restrictions here in the U.S.

Tell us about the recent FDA decision and what more the government could be doing to advance reproductive justice in this country?

ANSIRH: On December 16, 2021, the FDA announced that it will permanently lift the in-person requirement for dispensing mifepristone, the first pill in a medication abortion. This is amazing, it’s wonderful news. We hope that this means both brick-and-mortar and mail-order pharmacies will be able to dispense these medications; we will know in the coming months. But the FDA restrictions on mifepristone still unnecessarily require prescribers to be certified with mifepristone’s distributor, which is an arduous process and clinicians must identify as an “abortion provider” and submit documentation. There is no medical justification for this requirement, and it actually prevents many primary care providers from writing a prescription for the medications if they don’t want to be on a list of “abortion providers.” Abortion care is healthcare, and any physician should be able to prescribe these very safe medications for their patients.

Thank you to the ANSIRH team for sharing your work, and we can’t wait to share the rest of the results of the CHAT study with the world. If you’d like to hear about the latest findings as they come out, sign up to join the CHAT Study mailing list or follow Dr. Upadhyay on Twitter @UshmaU.