July 27, 2011 -- 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.
Medical Abortion Happens at Home
"Generally, during the actual expulsion, it's like a miscarriage," said Grossman. "It can be painful, but it can be easily controlled with oral pain medications. Women come back for a follow-up a week or two later to have an ultrasound to confirm that the abortion is complete."
About 1 percent of the women had a complication related to the medical abortion -- but adverse events were not more prevalent in in one group more than the other.
"The most important thing the study demonstrated was how safe this provision model can be," he said. "There is no indication that this puts women at medical risk."
But the national anti-abortion group, Operation Rescue calls this procedure "push-button" abortion that "kills babies and endangers the lives of women." So far, five states -- Arizona, Kansas, North Dakota, Nebraska and Tennessee -- have passed laws limiting telemedicine abortions, according to the Guttmacher Institute.
The group filed several complaints against Planned Parenthood in 2009, but the Iowa Board of Medicine voted to close the file without any disciplinary action, according to Planned Parenthood of the Heartland spokeswoman Shelby Cloke. "We've always been confident we are offering safe and legal services for Iowa women and this ruling validates that," she said.
Operation Rescue President Troy Newman said telemedicine "reduces health care to something like a Skype connection."
"I can't go got my doctor to get headache relief without going through a quick exam," he said. "They weigh me and take my blood pressure and my temperature. The doctor-patient relationship is removed from this part of health care. It boils down to a pre-measured dose of abortion medicine that is pre-packaged and set in a drawer.
"Every woman, whether she is 80 pounds or 200 pounds, gets the same dose from the doctor, who pushes a button and out pops a pill. Women deserve better."
Newman is quick not to dismiss telemedicine in circumstances where doctors cannot get to patients, as in the Chile mine disaster last year or when astronauts are in space. "When all else fails, you do the best to administer medicine over whatever communication you have," he said.
"But it's like the McDonald's drive-through window of abortion service," he said. "What could be worse than to go home and take a pill or eat a hamburger and get sick. Women who live 100 miles away can have cramping and bleeding and having complications where they are forced to go to the emergency room."
But Todd Buchacker, a nurse and regional director of Planned Parenthood of the Heartland's health services, said telemedicine is widely and safely used throughout the medical world.
"If doctors can provide knee surgery with a physician sitting in his office across the street from the hospital doing it on the computer with robotics -- if they can do that -- why can't we somehow provide this mifepristone pill to women long distance?" he said.
Women choose medical abortions, not because of cost, but because of the privacy it provides in their own home, according to Buchacker.
"I never begin to guess what a woman goes through when making this decision, but I believe a lot of women choose a medical abortion because it's early in pregnancy and seems like an option that is less invasive," he said. "It may be more time-consuming over the course of a few days, as opposed to a 10-minute clinical procedure, but it is more personal and private and some women -- I hate to say this -- say it feels it is more natural."
Buchacker said making it easier for women seeking an abortion doesn't result in more abortions.
The number of abortions in Iowa has fallen from an all-time high of 10,022 in 1997 to 5,829 in 2009, according to statistics from the Centers for Disease Control and Prevention and state health departments, and it has continued to drop each year by about 10 percent.
As part of the Iowa Initiative, a program to reduce unintended pregnancies, Planned Parenthood of the Heartland has implanted 7,000 intrauterine devices (IUDs) and other long-acting reversible contraception in women.
"We won't know the numbers for several years, but I do think that certainly could be part of the reason we are seeing fewer abortions," Buchacker said. "History tells us that when the economy is bad, women tend to have more abortions, and that has not held true in Iowa."
This story has been amended to include more recent abortion statistics in paragraph 8.