Abortion pills offered via telehealth as safe as in-person medication abortions, study finds

With the Supreme Court just a month away from hearing arguments over access to the abortion medication mifepristone, a new study published on Wednesday in Nature Medicine offers additional evidence that abortion pills are safe to prescribe — even remotely.

Researchers looked at the records of more than 6,000 patients who received medication abortion — a combination of mifepristone and misoprostol — through pills delivered via mail after a telehealth consultation conducted in 28% of cases through video calls and in 72% of cases through text messages.

The authors found that 97.7% of patients had complete abortions, while in 2.3% of cases the initial course of abortion pills was insufficient and patients needed further doses of medication or evacuation procedures that were not considered emergencies. The researchers also tracked all hospitalizations due to an abortion and found that patients had severe adverse events in 0.25% of cases. The authors noted that both the success and adverse event rates from this study are comparable with those reported by studies of in-person prescriptions. Researchers also found no significant difference in the safety and effectiveness of telehealth abortion based on how patient consultation was conducted.

The findings are in line with previous research on the safety of abortion, including a very large study of more than 52,000 abortions conducted in the U.K. But these U.S.-based results may impact the conversation around telehealth abortion in a way foreign studies rarely do, said Ushma Upadhyay, a professor of public health at the University of California, San Francisco, and the study’s lead author.

“It’s American exceptionalism,” she said. “The FDA and many others don’t believe a study until they see it proven among U.S. populations.”

Upadhyay went on to add that the study adds to a solid body of evidence showing that abortion medications are safe and effective, even as these drugs are now being challenged in court.

“There’s a case at the Supreme Court looking at whether the most recent approvals by the FDA were based in science — and they absolutely were,” she said. “And the study affirms the FDA decisions to make this medication more broadly available.”

The study, named California Home Abortion by Telehealth (CHAT), started taking shape in 2018 and was originally meant to take place only in California. “We wanted to do a telehealth study, assess the safety and effectiveness, because even before the Dobbs decision, there were so many barriers to abortion, and we thought telehealth would be an incredible solution in making medications available,” said Upadhyay.

At first, the researchers weren’t able to get authorization from the Food and Drug Administration, even just for research purposes, because of the in-person requirements for the prescription of mifepristone and misoprostol. But then Covid-19 happened and the FDA removed the in-person requirements, and several startups began providing telehealth abortion far beyond California. Upadhyay and her team collaborated with three virtual abortion clinics: Choix, which opened in October 2020; Hey Jane, opened in January 2021; and Abortion on Demand, opened in April 2021. The three clinics expanded operations to 20 states and were chosen because they were among the earlier ones to open and operate in states with large populations.

A crucial difference between in-person and remote prescriptions is the frequency of ultrasound used to determine the gestational age of a pregnancy. When it came to prescriptions delivered via mail, gestational age was self-reported 92% of the time, and in only 8% of cases was it necessary to refer pregnant people to have a dating ultrasound. By comparison, said Upadhyay, nearly all in-person medication abortions are prescribed following an ultrasound, which makes the process more expensive and more involved and time-consuming for both patient and health care provider. Upadhyay has recently submitted a study for peer review comparing the cost of medication abortion obtained through virtual and in-person clinics, and she says the costs are much lower in the former.

“These results show that an ultrasound isn’t necessary if the patient already knows how far along they are,” said Upadhyay, even in those instances when a patient prefers an in-person visit. “Some people just want to make a quick stop. They have to get back to work, they’re coming to the Planned Parenthood on their lunch break,” she said, “and [the study] just shows that we really don’t need to overmedicalize this type of care.”

Currently, about 10% of abortion pills are prescribed via telehealth. Julia Rollison, a senior policy researcher at policy nonprofit RAND, said that lawmakers need to be sure they clearly communicate the availability of such services and their safety based on the most recent evidence.

“Adding another study to the evidence base regarding the safety of medication abortion prescribed via telehealth is welcome from a policy perspective for groups seeking to make medication abortion more accessible,” said Rollison, who was not involved in the study, in an email. This is especially important, she added, for those who may have trouble accessing in-person care based on their location or personal circumstances.

The findings follow the retraction of two studies pointing to supposed dangers associated with abortion pills. “Although the retracted study did not speak to telehealth medication abortion specifically, this contributed to misinformation that can lead to confusion or misconceptions around not only what is legal, but what safety outcomes can be expected which can impact people’s medical decision-making considerations,” said Rollison.