A typical patient who walks into Planned Parenthood of the Heartland in Iowa isn't typical at all. She may older or younger, married or single, but she is usually confident in her decision to terminate a pregnancy.
Neither is her preferred method these days -- a medical abortion without a doctor physically present.
As states increasingly enact laws that restrict women's access to legal abortion and a dwindling number of doctors choose to perform them, women who live in rural states like Iowa have found it more difficult to terminate their pregnancies. But now, women who might otherwise travel hundreds of miles to see a physician have another option: telemedicine.
A woman seeking an abortion via telemedicine has an ultrasound performed by a trained technician, receives information about medical abortion and signs a standard informed consent for the abortion.
Once that is complete, a physician steps in via teleconference. The doctor reviews the woman's medical history and ultrasound images, and once it is determined that she is eligible -- up to nine weeks pregnant and not an ectopic pregnancy -- she has time to ask questions.
Then, the doctor enters a computer passcode to remotely open a drawer at the clinic containing two pills. She then swallows the mifepristone, under the doctor's supervision, and then is instructed to take four additional tablets of misoprostol within the next 24 to 48 hours. The actual abortion happens at home.
Iowa is one of the many states that require a doctor to perform a medical abortion. But telemedicine fits within the guidelines of that law.
After many years of declines, the number of abortions edged up 1 percent to 1.21 million in the United States in 2008, the last year statistics are available, compared with 2005, making it a one of the most common procedures undergone by women.
In Iowa, about 60 percent of women seeking abortion choose a medical one, rather than a surgical procedure -- and many of them choose telemedicine.
"Most of our patients are not young teens," said Julie Bosier, central manager in charge of patient education at the Cedar Rapids Planned Parenthood clinic. "We get a wide variety of women from all walks of life and at a difficult point in their life. It's not an easy decision, but they do what's best for them at that time.
"We first ask them how confident they are and talk about options," she said. "We can size up how a patient is feeling, and most say, 'Yup,' we know what we want to do. But sometimes we have a patient who is not confident and could use more time or needs to slow down a bit. One of the nice things about the telemedicine program is if a patient is not 100 percent sure, we can reschedule them and give them more time."
By the time the patient actually gets to see the doctor on the monitor, "she's feeling real comfortable," said Bosier. "I sit and process with her -- 99 percent of the time, they don't have any questions. We dispense the pill and off the patient goes."
When mifepristone is administered, nothing happens for about two days until she takes misoprostol at home and bleeding and cramping start. Women's reactions vary from reporting a heavy period to significant pain. Fewer than 5 percent of all women require a surgical procedure to complete the abortion.
Planned Parenthood of the Heartland offers telemedicine abortions at 16 of its 25 centers throughout the state, but not at its three clinics in neighboring Nebraska, where it is against the law.
Telemedicine abortions have been performed in Iowa since 2008, but for the first time, a study by Ibis Reproductive Health, a non-profit abortion rights research organization based in Oakland, Calif., shows that they are as safe and successful as medical abortions with a doctor physically present.
"Part of it has to do with the convenience for women," said Ibis senior researcher Daniel Grossman, who is a gynecologist and an obstetrician. "They are able to get it closer to home and done sooner. It just adds another option for women that fits better into their lives."
"Before this was set up, women had to travel as much as 200 miles to where a physician was, or the physician had to travel," he said. "Since there is such a shortage of abortion providers, there are real work force issues. It's hard for the provider to travel so much, and it's not the best use of her time. Telemedicine extends the reach of the physician and at the same time provides a high quality service."
Researchers followed 450 women between 2008 and 2009 who obtained medical abortions at six Planned Parenthood of the Heartland clinics in Iowa. Half of the women in the study accessed the services through an in-person physician visit and half through a telemedicine visit where the woman spoke to the doctor using video teleconference equipment on a secure dedicated data connection.