A teenager whose mother had trouble getting her to an abortion clinic during normal business hours.
A busy professional who couldn't leave work until 4 p.m.
A mother with young children, no child care and no car.
All of these Maine women recently had abortions in the privacy of their own homes, without having to step foot in an abortion clinic. Using pills that arrived by mail as part of a study by the research and technical assistance organization Gynuity, the women legally induced their own miscarriages before 10 weeks of pregnancy. And in doing so, they became soldiers on the front lines of the biggest abortion battle you've never heard of.
Hailed in the 1990s as "the pill that changes everything," the abortion pill mifepristone (also known as RU-486 and Mifeprex) got off to a slow start after Food and Drug Administration approval in 2000.
But now, the pill is at a crossroads, with 31 percent of American abortion patients choosing pill-induced abortion over surgery, and bold new initiatives dangling the prospect of dramatically increased access. The Gynuity study is allowing women in Maine, Hawaii, Washington, and Oregon to confer with a doctor from home via video chat, and then get the pills delivered to their homes by mail. In California, women may soon be offered an even more streamlined medication-by-mail option. In Hawaii, the American Civil Liberties Union recently filed a lawsuit that could open the door to ordinary doctors nationwide prescribing the pill, and women picking it up at their local pharmacies.
"I feel optimistic," said Francine Coeytaux, co-director of Plan C, an abortion-rights project that hopes to offer pills by mail in California soon via a demonstration study, and then expand to other states as well. Plan C offers a website with information about pill-based abortion and anticipates that established international telemedicine-abortion initiatives, such as Women on Web, will find a way to ship pills to women in the U.S.
"It's not about what we're doing. It's a fact. It's happening. It has so much potential, and there are so many ways in which it's beginning to happen, that nobody's going to be able to stop this," Coeytaux said.
Anti-abortion forces are concerned, and they hold the upper hand politically. With a Republican president and Congress and control of 31 state legislatures, they see multiple ways to block the pill, including a U.S. Supreme Court reversal of Roe v. Wade.
The pill is a "big priority," according to Carol Tobias, president of the National Right to Life Committee. Since 2011, 20 states have banned the use of telemedicine for pill-based abortion. In Iowa, the state Supreme Court later struck down the ban.
Anti-abortion advocates also are embracing abortion pill reversal, a controversial medical approach in which a woman who has changed her mind after taking the first pill in a medication abortion is given the hormone progesterone to reverse the pill's effects.
"We've been working with our state affiliates to stop (pill-based abortion), prevent this, protect the babies and mothers any way we can, whether it is preventing telemedicine from being used for chemical (pill-based) abortions or making sure that women can reverse the abortion if they act quickly enough," said Tobias.
"Certainly that's been something we've been focusing on, and we will continue to do so."
Abortion via telemedicine has been available in the U.S. since 2008, when the first formal program began in Iowa. A patient in one clinic confers, via video conference, with a doctor in another clinic and then receives abortion pills. This satisfies a federal requirement that the doctor "dispense" mifepristone to the patient in a clinic, office or hospital. The patient takes a mifepristone pill, which blocks the hormone progesterone, either at the clinic or at home. She then takes several misoprostol pills at home, causing uterine contractions and miscarriage.
But clinic-to-clinic telemedicine has limitations. The woman still has to get to a clinic, and the median distance to an abortion clinic is 180 miles or more in three states (North Dakota, South Dakota and Wyoming), as well as in large portions of states such as Texas, Alaska, Kansas and Nebraska, according to a 2017 study in The Lancet Public Health, which found the number of abortion clinics declined 6 percent from 2011 to 2014.
Gynuity Senior Medical Associate Dr. Elizabeth Raymond points to the dramatic example of Hawaii, where only two of the five most populous islands have abortion clinics.
Until recently, that meant that if a woman on another island wanted an abortion, she had to fly to Maui or Oahu, said Raymond.
But under the Gynuity study, a woman living on another island can get an ultrasound and bloodwork close to home, then video chat with a doctor on Oahu. The pills arrive by mail, no plane flight required.
"We do think it's a big deal to be able to do this, and it should be available, just as a regular, routine practice," Raymond said.
Maine Family Planning, where the Gynuity study has been operating since September, reports that a handful of patients there have received abortions at home via telemedicine, including a pregnant teenager.
"It seemed like there was a lot of stuff going on with her family that made it very challenging for them to have the organization to get into a clinic at a certain time," said Director of Abortion Services Leah Coplon.
With the help of her mother, the girl had already obtained the necessary ultrasound and bloodwork, and the clinic was able to review those records. The mother gave her consent, in keeping with Maine law.
"I set up a video conference with (the teen) on a day she didn't have school," Coplon said. "I went over everything with her. She was able to sign documents right from her computer. We connected her with a doctor the following Thursday."
The doctor video-conferenced with the teen, making sure she didn't have any questions. The girl got the pills in the mail the next day.
Patients in the study take one mifepristone pill first and then take four tablets of misoprostol six to 48 hours later. Bleeding and cramping start after the misoprostol, and cramping can be severe. Raymond said many patients compare the discomfort to a bad period.
None of the patients in the Gynuity study agreed to speak to a reporter, but the National Network of Abortion Funds connected the Chicago Tribune with a woman willing to describe her experience with medication abortion.
Kelsea McLain, 32, of Durham, N.C., has had two clinic-based medication abortions, the first in 2011. She had recently graduated from college, and she and her then-boyfriend (now husband) had trouble scraping together the money for the procedure. Due to financial issues and a mandatory waiting period, she was about eight weeks pregnant when she was able to obtain the medication. After taking the second medication at home, she experienced intense cramping and heavy bleeding, as well as nausea and body aches, she said.
Still, the pain was manageable - not much worse than her worst period, she said. Her second medication abortion was earlier in pregnancy and physically much easier, she said.
"I got exactly what I wanted out of it. I wanted the experience to happen at home. I wanted the first time (to) have my mom there rubbing my back and the second time my partner rubbing my feet. I wanted to definitely experience it more and be more hands-on with what my body was going through. I don't want my body to be a mystery to me."
Abortion opponents say pill-induced abortion has been associated with complications and deaths, but studies have shown the risk is low.
A 2012 article in Obstetrics and Gynecology, co-authored by Raymond, found that the risk of death associated with childbirth (8.8 deaths per 100,000 live births) was approximately 14 times higher than the risk of death associated with abortion (0.6 deaths per 100,000 live births). The authors didn't do a detailed analysis of the risk of pill-based vs. surgical abortion, but noted that mifepristone's U.S. distributor had identified 11 pregnancy-related deaths among the 1.6 million U.S. women who had used the drug since 2000. That would translate to 0.7 deaths per 100,000 abortion-pill users.
Foes are looking to the work of Dr. George Delgado, a San Diego-area family physician and abortion pill reversal pioneer. Pill reversal has led to the births of more than 350 babies, and about 100 to 150 women are currently pregnant after pill reversal, according to Delgado.
The number of women using pill reversal is small relative to the approximately 270,000 women per year who get pill-based abortions, and a 2015 article in the journal Contraception called abortion pill reversal an "unproven therapy."
The authors of the article found that many pregnancies continue after a woman takes mifepristone alone, even without abortion pill reversal: anywhere from 8 percent to 46 percent. That compares to 57 percent to 67 percent of women (in a single study of "poor quality") who were able to continue their pregnancies after abortion pill reversal.
But for anti-abortion advocates, the power of the approach goes beyond the numbers. Delgado was a keynote speaker at the National Right to Life Convention in 2015, and his approach has led to news coverage, including a recent Sacramento Bee article accompanied by an online video titled "Woman says abortion reversal procedure saved her baby."
Gynuity hopes to expand its medication-by-mail study to more states this year, and Coeytaux is working on a Plan C study that would allow California women to get abortion medication by mail without blood tests or an ultrasound.
The battle is playing out on fields large and small, from state legislatures to abortion clinics in snowy stretches of rural Maine.
Coplon, the Maine Family Planning abortion director, sees potential for pill-based telemedicine in a new generation of abortion patients who are at home with internet access. She also sees the passion of the opposition. Like many abortion providers, she encounters protesters outside her clinic. Among the signs they plant in the ground these days is one advertising abortion pill reversal.
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