If you live in Hawaii and need to get an abortion, you might literally have to cross the ocean.
Only two of the archipelago's seven populated islands have abortion clinics—meaning women without access to one must fly or take a ferry to either Oʻahu or Maui. A flight from Big Island—which closed its last clinic in 2014—to Oʻahu costs about $200 and takes at least 40 minutes.
The problem isn't unique to Hawaii, either. When it comes to abortion access, geographic barriers like these are now standard for a rapidly growing number of American women—and have been for a long time. As far back as 2008, one study found that nearly a third of patients needed to travel at least 25 miles to find a clinic. Last year, the New York Times reported that Texas had just 17 abortion clinics in the entire state, located an average of 111 miles away from the next nearest county. The dearth of accessible clinics, not surprisingly, also appears to coincide with a surging interest in unsafe, DIY methods of treatment. In 2015, there were 700,000 Google searches in the US alone that contained phrases like "how to self-abort" and "how to have a miscarriage." And with the Trump administration vowing to punish doctors who give abortions, these problems show no signs of letting up.
A new, ongoing study, however, offers a sliver of hope. Earlier this year, Hawaii became the first state to begin distributing mifepristone and misoprostol—the two most common abortion medications—through the mail. Upon receiving the medications, patients are required to conduct a remote video chat session with an experienced physician, who guides them through the process of taking the pills.
"Ideally, this wouldn't be a study," says Elizabeth Raymond, senior medical associate at Gynuity Health Projects, the research group that sponsored the program. "It would just be a service." Since March, Raymond says, 11 women in Hawaii have opted into the program's "direct to patient" treatment model. "We've had no complications," she says, "and the women have all been satisfied with the process." Raymond hopes to attract at least 50 patients in each of the participating states, which will also include Oregon and Washington State.
The process involves taking two rounds of medication. The first, mifepristone, halts the production of the hormone progesterone and breaks down the lining of the uterus. Two days later, the patients take misoprostol, which empties the uterus. Complications from treatments are rare—a 2015 study of over 13,000 women found that hospitalization due to infection and heavy bleeding, for instance, occurred in less than 0.03 percent of women. Nearly 43 percent of abortions are now performed with medication rather than through surgical procedures, a 2014 Reuters report concluded.
These facts, however, have done little to assuage the fears of lawmakers; 19 states have already placed a ban on telemedicine abortions, requiring clinicians to be physically present when women take the medication. Raymond stresses that patients in the study receive the same level of care in the direct-to-patient model as they would in a clinic. Before a patient receives the pills, for instance, the doctor reviews her medical history, evaluates test results, and rules out any significant health risks. "They go through the same steps," Raymond says, "but just do them near their home or wherever they happen to be."
While Hawaii is the first state to test this model, Iowa's Planned Parenthood of the Heartland has also been quietly providing abortion medication to patients since 2008 using a slightly modified "clinic to clinic" approach. The key difference: Patients still must go to an abortion clinic to take the medication and conduct the video chat with a provider. This setup enables a single provider to counsel patients at multiple locations in a single day—which is crucial when nearly 90 percent of counties in the US lack providers, according to the Guttmacher Institute.
Maine, Minnesota, and Alaska have also adopted similar models. Lawmakers, however, have also opposed this method of abortion. In October of 2013, Iowa regulators approved a ruling from the Iowa Board of Medicine that requires physicians to be present when dispensing abortion medication. But Planned Parenthood filed an appeal and challenged the ruling in 2015, prompting the Supreme Court to rule the measure unconstitutional.
For millions of women living without access to an abortion clinic, telemedicine services like these may be the only answer to a severe shortage of abortion providers. One 19-year-old Iowa woman who spoke anonymously to researchers from Ibis Reproductive Health in the journal Women's Health Issues put it, "Traveling, that'd be a full tank of gas for me there and back and I don't have money like that." She adds that the process made it easier to keep her abortion private.
Other participants told researchers that the video chat experience actually helped them open up more with their doctor—something that can be tough for many women given the social stigma associated with abortion. "When you're going to do something like that, it's a little embarrassing," says one 21-year-old quoted in the Ibis study. "Over the computer, it's easier to just have a [conversation]."
Alaska began offering clinic-to-clinic treatments in 2011, and while experts have noted improved abortion access, some feel the state would benefit even more from adopting Gynuity's model. Until 2011, ending an unwanted pregnancy could have meant braving subzero temperatures to get to the nearest clinic—if an appointment with an abortion provider was even available.
"Before telemedicine was introduced, a woman might have to wait weeks for a physician to travel to her nearest clinic," explains Kate Grindlay, program director of Ibis Reproductive Health, who has studied telemedicine abortions in Alaska. "This wait time could put her outside the window of eligibility for medication abortion, including into the second trimester where services can have more risks to women and be more expensive." Under the telemedicine model, Grindlay says, a woman "can be scheduled in a matter of days, or even the same day she calls—and this in turn allows her to be seen at earlier gestational ages."
Despite the progress being made, there are still major hurdles ahead for the program to be more widely adopted. "The [FDA] registration of mifepristone in the US still requires that it be dispensed in a hospital or clinic," Grindlay says, "so a direct-to-patient model is not possible [outside of FDA-approved studies]." That means the drug can't be sold in pharmacies or over the Internet. "[The FDA] inhibits what you can do," Raymond says. "They don't allow a lot of leeway." This is especially problematic since the policy doesn't directly address telemedicine programs, Raymond says. "It's not clear what the restriction actually prohibits—we just assume that [it includes] what we're doing."
Combined with a slew of legislative roadblocks, these restrictions severely limit the potential of the program to expand beyond small research studies.
"Poor women and rural women," Grindlay says, "are left to bear the brunt of this access gap."