One night in 2007, Jill June, CEO of Planned Parenthood of the Heartland, couldn't sleep. She was grappling with a problem that vexes rural pro-choice advocates everywhere: the lack of access to abortion. At the time, Planned Parenthood of the Heartland, which performs most of the abortions in Iowa, had 17 clinics in its network but only three with an on-site physician. Doctors would travel, sometimes as far as 200 miles, to three other clinics in the state to perform intermittent care. The remaining 11 clinics did not offer abortion services. In all, 91 percent of Iowa's counties, the more sparsely populated regions that are home to more than half the state's women, lacked an abortion provider.
For June, providing access to medical abortion-the termination of an early pregnancy using a pill, rather than a surgical procedure-was especially challenging. In a few states, nurse practitioners or other midlevel medical staffers are allowed to dispense medical abortion pills, widening the number of clinics that can provide the procedure and reducing wait times for an appointment. But Iowa, like 39 other states, stipulates that only a physician can perform an abortion. Elizabeth Nash, state issues director for the Guttmacher Institute, a nonprofit organization that works to advance sexual and reproductive health and rights, says these laws date from the 1970s, when medical abortions, which were not approved for use until 2000, were not yet in the picture.
That night, as June lay awake, channel-surfing, she happened upon a news program where a woman was relaying the details of her recent heart-valve replacement. A doctor in another wing of the hospital had performed the procedure using a robotic arm as part of a new innovation called telemedicine. "I just thought to myself," June recalls, "they're using telemedicine for open-heart surgery. Why can't we hand someone a pill?"
By mid-2008, June had turned her late-night brain wave into the first large-scale telemedicine abortion program in the country, with medical abortion offered at 15 clinics in Iowa. The use of telemedicine for abortion immediately became controversial, although only a handful of telemedicine abortion programs were implemented nationwide. Twelve states-including Nebraska, where Planned Parenthood of the Heartland also has clinics-have passed legislation directly outlawing telemedicine abortion. Other states have indirectly prohibited the practice by forbidding or limiting the use of medical abortion drugs. Most of these bans were preemptive, but a few were not; a law that took effect in Texas in 2012 shut down a nascent telemedicine program operated by Whole Woman's Health, a for-profit abortion provider with five sites in the state. Planned Parenthood is currently operating one other telemedicine abortion program on a small scale in Minnesota; it narrowly escaped closure earlier this year when Governor Mark Dayton vetoed a telemedicine ban.
Proponents of the bans, which include anti-abortion organizations like Americans United for Life and Operation Rescue, argue that what they call "Web cam" or "push button" abortion endangers women by denying them a physical examination from a physician and a face-to-face conversation about the procedure. "When you're going to hand out life-threatening, life-ending drugs, it seems appropriate to give the best care," says Kristi Hamrick, a spokesperson for Americans United for Life, an anti-abortion legal advocacy organization. "It's not a risk we should be taking."
Reproductive health experts say that telemedicine abortions are perfectly safe. In Planned Parenthood of the Heartland's procedure, women at a satellite clinic receive an ultrasound from a clinic staffer and talk to a counselor. They then speak with a doctor using a live two-way video conference. To dispense the medication, the doctor presses a button to remotely open a secure drawer at the satellite clinic, which contains the abortion pills. The woman takes the first pill, which induces the abortion, under the doctor's supervision, and the second pill, which evacuates the uterus, at home. The woman returns to the clinic after two weeks to ensure that the abortion, which happens over the course of several days, has gone smoothly.
Planned Parenthood of the Heartland remains the largest telemedicine abortion provider in the country. But now the program is in danger. Late last month, the Iowa Board of Medicine voted 8-2 to move forward a petition filed by 14 medical professionals that would require physicians to give a physical examination and dispense abortion pills in-person, effectively prohibiting telemedicine abortion. The board dismissed a similar petition filed in 2010, but since then, its composition has changed. Governor Terry Branstad, an anti-choice Republican who publicly supports the new rule, assumed office in early 2011 and appointed a new set of members to the board. These appointees include a Catholic priest and a former state legislator who, in his brief tenure in the Iowa Statehouse, sponsored a bill that required physicians to offer women seeking abortions materials to encourage adoption.
The board is still at the beginning of a several-month process to approve the rule; it will hold a public hearing on August 28. But given the board's overwhelming support for the petition, the rule could go into effect as soon as October. The governor has the power to veto the rule, but it's hard to imagine Branstad would do so. The legislature can also file an objection, which would delay the effective date of the rule and aid the rule's opponents if they sue, but it's unclear whether lawmakers will take action.
While states are curbing the use of telemedicine for abortion, demand for other forms of telemedicine-whether it's for surgery, radiology, dentistry, or more-is exploding. Telemedicine systems are both convenient and cost-effective, and the federal government is one of their strongest proponents; for example, the Affordable Care Act encourages hospitals to lower readmission rates by providing virtual consultations for Medicare patients who make frequent trips to see doctors. "Telemedicine is used by about 10 million to 12 million Americans every year," says Jon Linkous, CEO of the American Telemedicine Association, a resource and advocacy organization. "That's probably triple what it was five years ago."
Although one might expect that women would prefer a face-to-face encounter with an abortion provider, a study of Iowa's telemedicine system shows that many women are happier with telemedicine. An evaluation conducted by Ibis Reproductive Health, a nonprofit research organization that prioritizes access to safe abortion, found that women who received a telemedicine abortion were significantly more likely to say they were satisfied with their experience than women who had an in-person procedure.
Dan Grossman, a medical doctor and one of the study's co-authors, notes that only about one-quarter of the study participants said they would have preferred an in-person procedure. But even these women were still happy with their telemedicine experience, largely because a face-to-face encounter was only possible at a clinic far from their home or after a long wait. "In an ideal world, if they could have had an in-person visit with a physician closer to their home or as early as they were able to schedule it, they would have chosen that," Grossman says, "but the next best thing was telemedicine, and they were fine with it."
The study also dispelled anti-abortion advocates' two main fears: that widening the availability of abortion would cause more women to seek the procedure, and that the use of telemedicine for abortion endangers women's health. Iowa's abortion rates, which have been decreasing for the past decade, continued to decline after the telemedicine program was implemented. A small number (3 percent to 5 percent) of medical abortions need to be followed up with a surgical procedure, but the study showed that these outcomes were no more common among the telemedicine patients than the women who saw doctors in person. The number of complications that required emergency room visits or trips to other clinics was not statistically different between telemedicine procedures and face-to-face visits.
Whatever happens in Iowa, the ultimate legality of telemedicine abortion will likely be decided in court. Based on recent state-level decisions, it's hard to know which way the pendulum will swing. On July 15, a state judge struck down a North Dakota law that effectively barred telemedicine abortion by outlawing one of the two drugs used in medical abortion, declaring such bans to be "contextual and contrived." However, an Ohio court upheld most of a similar law in 2012, ruling that restrictions on the use of medical abortion-including requiring the physician to dispense the medication in person-are acceptable, although some exceptions for a woman's health may be permitted. If the telemedicine ban is implemented in Iowa, there will almost certainly be another legal contest over the validity of such restrictions.
The recent wave of abortion laws enacted across the country gives pro-choice advocates a reason to keep fighting for telemedicine. The problem that was keeping Jill June up at night in 2007 has only grown more severe. As states with large rural populations, like Texas, pass laws and regulations that shutter abortion clinics and increase wait times, telemedicine-however fragile its future-remains the most practical way to ensure that rural women can receive safe abortions. In this contentious context, a court battle over Iowa's telemedicine abortion program could have momentous national consequences.
