Medication Abortion Shouldn't Require an In-Person Visit (Especially During a Pandemic!)

Medication abortion provides safe, effective, and time-sensitive medical care to patients that require an abortion. Unfortunately, medication abortion faces multiple restrictions in the U.S., with the Supreme Court recently ruling that reinstates an FDA requirement that patients must access the medication in-person. Especially in the midst of the coronavirus pandemic, these restrictions are not only unnecessary, but blatantly dangerous. Dr. Jamila Perritt, a board-certified OBGYN and family planning specialist, and President and CEO of Physicians for Reproductive Health, talks to us about these restrictions and how they are impacting people’s access to basic abortion care, in and outside of the context of the pandemic.  

Medication abortion is a safe and effective abortion option for those who are seeking abortion in early pregnancy. Medication uses two medicines—mifepristone and misoprostol—to stop the progression of the pregnancy and cause cramps for the purpose of passing the pregnancy. Despite medication abortion being extremely safe and easy to use, there are many restrictions that patients have to face in order to access this type of care. These restrictions vary based on where you live—some states will require that patients need to visit clinics twice in order to receive a medication abortion, some states mandate the patient must sit through state-mandated counseling that is intentionally designed to convince patients to not follow through with an abortion, and some states have a ban on accessing medication abortion through telehealth.

Restrictions on medication abortion largely come from an F.D.A. rule called REMS, which stands for risk evaluation and mitigation strategies. REMS is a drug safety program that is designed to balance the risk and benefit of a medication and to support safe use. Only a few medications have REMS attached. Mifepristone is restricted as if it were an unsafe medication, meaning there are additional consent processes, follow-up, and medical visits to receive it, even though it is extremely safe to use.

During the coronavirus pandemic, many clinics and health providers have tried to rearrange services to provide access to abortion care, specifically though telemedicine services. The F.D.A lifted the requirement for in-person administration of mifepristone during the coronavirus pandemic, but the Supreme Court reversed this decision on January 12, 2021. Logistically, this means that patients are put at risk for contracting COVID-19 because they are forced to make an in-person visit to a doctor’s office to receive a medication abortion. Historically marginalized communities, like young people, LGBTQ+ people, people of color, low-income people, are disproportionately burdened by these restrictions.

The Biden-Harris administration has the ability to expand access to telemedicine abortion and repeal the in-person dispensing mandate, which is exceedingly important during the ongoing coronavirus pandemic. There can also be an issue to review the F.D.A.’s current restrictions on mifepristone, which would base access on medical fact rather than politics. This includes elimination of REMS from mifepristone beyond the pandemic. Organizers and organizations in individual states also have the ability to push back on and fight state-based abortion restrictions.

Links from this episode

Physicians for Reproductive Health on Twitter
Physicians for Reproductive Health on Facebook
rePROs Fight Back podcast episode on Self-Managed Abortion

Transcript

Jennie: Welcome to RePROs Fight Back, a podcast where we explore all things reproductive health, rights and justice. I'm your host, Jennie Wetter, and I'll be helping you stay informed around issues like birth control, abortion, sex education and LGBTQ issues and much, much more-- giving you the tools you need to take action and fight back. Okay, let's dive in.

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Jennie: Welcome to this week's episode of RePROs Fight Back. I'm your host, Jennie Wetter, and my preferred pronouns are she/her.

Jennie: Hi rePROs. Welcome to our first episode and the Biden Harrison administration. So y'all, I'm recording this on the Friday after the inauguration, also known as the anniversary of Roe V. Wade, which I guess I can't let that pass without Mark remarking on it. You know, it's so important that we fight to keep Roe in place to make sure that abortion stays legal, but it is definitely not enough. Right? Right now, as we have talked about many times over this podcast, it's clear that Roe V. Wade is not a lived reality on the ground for so many people who need access to abortion. So Roe is important and we need to fight to keep it, but it is not enough. It is definitely the floor, but we need to make sure that everyone who wants an abortion is able to get one where regardless of where they live, whether they can afford it, it's basic health care. We need to keep fighting for that. Right? That's one of the things I'm thinking about today, you know, there's been so much going on, right? With the Biden-Harris administration, so many tears that day. I don't know about y'all, but it really hit me in all the feels. Watching the first woman, Vice President gets sworn in, the first Black, South Asian Vice-President get sworn in. It just felt so good. So I can't wait to see what comes out of the Biden-Harris administration. You know, I know we're going to have to push them to get all we want, but it's going to be so much better already than what we had from the previous administration. So I can't wait to have more positive episodes to talk about good things that are happening then instead of having to focus on all of the horrible things all the time. So I think that's going to be a great relief for, I'm sure all of you. Let's see what else. Oh, so this past weekend, I decided to start tackling my new year's resolution, which was to try to bake pastry and y'all, I made pain au chocolat and they turned out amazing. I was terrified. I just, you know, the idea of having to laminate the dough and make, uh, get all the layers of the croissant. Like it just seemed really scary and really intimidating. And there was no way this was going to go well, but you know what? I was going to do it anyway, because you know what, it was still going to taste good, even if it failed, but you all, it turned out so gorgeous. I'll make sure we share a picture or a video or something on our social. So you can see it because one, I'm so freaking proud of myself, but two, I, you know, telling y'all that, that's what I was going to do this year, O made sure that I actually did it. So it's really nice to have this like accountability check on myself. So, you know, I'd mentioned that pastry was going to be my new year's resolution. I was really excited to already have one checked off. I don't know what's next. So if anybody has any suggestions, let me know and we'll figure out what to tackle next.

Jennie: Also, our next episode is our hundredth episode. Y'all I cannot believe that is true. It feels like we had just started doing this podcast slash we've been doing it for so long. It's a combination of both. So our next episode was going to be episode 100. So we decided to do something fun and we are going to be doing an ask me anything episode. So if you have questions, Rachel has been posting on social media for you to submit your questions there.

Jennie: So you can find it on rePROs Fight Back on Facebook and Twitter, or reprosfb on Instagram. She'll keep asking for questions for the next week or so, you know, up until we record the episode, also feel free to email me your questions, jennie@reprosfightback.com and we will make sure to answer your questions for that episode. It should be a lot of fun and, um, it should be fun to see what you all want to hear about. So I'm really excited to share with you all this week's episode with Dr. Jamila Perritt with Physicians for Reproductive Health, we have a wonderful conversation talking all about medication abortion, the ways it has been restricted, and why it's more important now than ever to ensure that we get rid of these in-person requirements for obtaining medication abortion during a pandemic, there is no reason for you to be going in person and putting your life at risk to access basic healthcare. So we have a long conversation about medication abortion and what the Biden administration can do to make it easier to access. So with that, I'm going to take you to my interview.

Jennie: Hi Dr. Perritt, thank you so much for being here today.

Dr. Perritt: Hello. Thank you so much for having me.

Jennie: So before we get started, do you want to take a quick second and introduce yourself and include your pronouns?

Dr. Perritt: Sure. My name is Dr. Jamila Perritt. I use she her pronouns. I am a board-certified OBGYN and family planning specialist and the President and CEO of Physicians for Reproductive Health, which is a physician-led advocacy organization that advocates for the use of medicine and science to shape policies and procedures around access to comprehensive reproductive healthcare for all people.

Jennie: Well, I am so excited to have you here today to talk about medication abortion. It has been in the news a lot lately with SCOTUS and some other things, um, but it seemed like a really good time to kind of do a deep dive into what it is and what are the restrictions we face around it. And then what do we want to see from the Biden administration? So I guess we'll start at the very beginning. And what is medication abortion?

Dr. Perritt: Medication abortion is an extremely safe and effective option. First of all, for people that are seeking abortion in early pregnancy. And so, um, there are two types of abortion: in clinic or “suction abortion” as it is sometimes called, and an abortion with medication. So medication abortion uses two medicines, mifepristone and misoprostol to end the pregnancy. The first medication, mifepristone, actually stops the pregnancy from growing or progressing. And the second medication, misoprostol, causes period-like cramps to help you pass the pregnancy.

Jennie: Great. So it seems, you know, it's very safe, very easy to use, but there are a lot of restrictions and kind of a path you have to navigate to be able to access medication abortion. Do you want to talk a little bit about what patients face when they're trying to access this care?

Dr. Perritt: Absolutely. You know, I want to start by saying that, uh, abortion care in the United States is highly restricted period. So whether we're talking about abortion with medication or clinic-based abortion, there are a lot of unnecessary restrictions that are placed on accessing that care just at baseline. And when we really think about it, it's such a critically important, uh, and uh, timely procedure, right? Abortion care cannot be delayed because the pregnancy continues. And so these medically unnecessary restrictions on access to care really make it more complicated and more expensive for people that are seeking abortion services. So when we're thinking about abortion with medication more specifically, then, you know, a lot of it is going to be, uh, to some extent on where you live and how easily you can access a clinic in general, depending on the state you live in, you might be required to hear a state mandated counseling. Um, that's really intentionally designed to try to convince you not to have an abortion. And that's true for in-clinic surgical abortion or medication abortion. Some states require that you visit a clinic twice; once to receive counseling and then again, to receive and take the medication or to have the abortion that you've chosen. And some states even have a ban on accessing the services for abortion care, using medication through tele-health, which we've really seen grown a lot and during the COVID pandemic. And so when we're thinking though about really the restrictions on medication abortion, specifically, one of the largest restrictions we see come as a result of something called the REMS. And it's an FDA rule it's called REM, which stands for r”isk evaluation and mitigation strategies”. And this is essentially just a drug safety program that's put in place and carried out through the food and drug administration, the FDA, and it's designed to balance the risk and benefit of a medication and to support safe use. It's important to understand though, only a few medications have these REMS attached and they're typically really dangerous medications that need to be regulated. Medication abortion, the mifepristone specifically, that first medication is in the group that is restricted as if it were a highly unsafe medication. And so from a patient standpoint, that means you have to have visits in the health center to get this medication that's safe enough, honestly, to be obtained over the counter, you have to sign additional consent forms to get it. You have to have additional follow-up. And so it's a really highly ready regulated medication, even though all of the medicine and science says very clearly that it's safe and it's effective. So there are lots of barriers to be able to go in and obtain medication abortion from your healthcare provider, even though medication abortion is really safe.

Jennie: Yeah. I think it's also worth pointing out all of these restrictions kind of interact with each other, right? So if you have a waiting period, it might push you past the ability to use medication abortion, or you have to make two trips. And all of a sudden you can't afford, you know, to take this time off. And all of these restrictions are just such huge barriers, um, for some people.

Dr. Perritt: Absolutely. So when we are talking about medication abortion specifically, it's approved for use up to 11 weeks of pregnancy in the United States. So thinking about what that actually means, most people don't even realize that they've missed their period until they're at least seven or eight weeks out during their pregnancy. And then you need to find a provider that actually can prescribe medication abortion. If you're a doctor like me that provides abortion services, including medication abortion, you have to be registered with a drug company. You have to have the medication in your office, in your clinic or in your health center in advance. You have to have all of the administrative supports to be able to have these additional consents, these barriers that are put in place to limit access to this medication. And so for some people that means calling around to even find out whether or not there's a provider in their city or even their state that provides this care. Then you also have to figure out a way to get there. If it's not in the, in the city or state where you live or work, then that means travel for a lot of people that need time off work. Most people who have abortions already have at least one child. So then that means trying to find someone to take care of your kids in order to be able to get in. When you lay all of these barriers on top of a public health crisis, the COVID pandemic, then we know that that's even more of a chance that by the time you're actually able to jump through all of these hoops, you're out of the window for being able to get the medication abortion in the first place.

Jennie: Yeah. I mean, that's a great point. Like, so how has this changed during the pandemic? Because now you're talking about risking exposure to COVID by having to go to a clinic.

Dr. Perritt: Absolutely. So lots of clinics and health providers have really tried to rearrange their services to support access, to care for folks who need abortions. During this time during this pandemic, we realized that the need for abortion care doesn't stop because we're in the midst of a COVID pandemic. Um, but we're healthcare providers. So we want to make sure that patients are able to remain safe and accessing these services. So for some healthcare providers, that meant really a shifting, uh, to be able to provide this through telehealth or telemedicine services, for example. And so we were really relieved to see the FDA lift the requirement of medication, abortion administration during the pandemic that required in-person administration of the first medication for medication abortion. And that's also the reason why the Supreme Court decision reversing this process is really so harmful because it ignores evidence. It ignores science and the safety of our communities requiring people to leave their homes to travel. When we know that that absolutely puts them at greater risk of contracting COVID-19 and becoming sick because of it trying to access the safe and essential medical service.

Jennie: Yeah. I just remember it being such a relief when there was the first, um, decision to expand and allow people to access medication abortion via telehealth. And it's just such, it's so frustrating to see the Supreme Court go back on that to again, make patients put their lives at risk to go and access basic healthcare.

Dr. Perritt: Exactly. And it's, and it's not just frustrating. I mean, it's, it's dangerous, absolutely dangerous, right? And so we know that it doesn't require in-person administration. You don't need to come in and travel to my office for me to hand you a pill for you to be able to take them and pass the pregnancy at home. There's nothing essential about coming in and having a face-to-face visit with a provider to be able to get this pill. A lot of these services and the support that goes along with them can be provided through telehealth services, keeping people safe and protected and allowing them to shelter in place in the midst of this pandemic. So the mandate that people then had to travel from their homes sometimes into another state to be able to get care really is a safety issue in the midst of a medical crisis.

Jennie: And again, this goes back to like, what will this mean for patients? Because again, you're talking about so many of these states also have waiting periods, so you're not having to do it once, you're having to do it twice.

Dr. Perritt: Exactly. What we know is that states that pass abortion bans or restrictions on abortion care, including those states, for example, that specifically carve out or exclude telemedicine use for abortion services, tend to have not just one of those laws on the books, but multiple laws. So the states that have restrictions on tele-health often have waiting periods and, and mandating all kinds of what we call TRAP laws--targeted restriction of abortion provider laws. So all kinds of laws that are just designed to not keep our patients safe, but specifically to eliminate access to abortion care period.

Jennie: So, you know, this is like the ongoing conversation right now of who's going to be the most impacted because we always see it's the same people who are suffering the heaviest burdens from laws like these.

Dr. Perritt: Absolutely. And so, uh, it's not, it, isn't hard to tell who's going to bear the brunt of these medically unnecessary and, you know, medically unsafe restrictions on access to care. So that's going to be folks in communities that are already historically marginalized from care and have difficulty accessing healthcare more broadly and reproductive healthcare specifically. So we're talking about young people, for example, what does it mean to be a young person who needs to access reproductive health care or abortion care and are trying to obtain access to abortion, to need to travel, to be able to get that care? What does it mean for folks who have low incomes? And so these are folks that are often not qualified through these, these current mandates don't fall underneath the sort of the umbrella of, of folks that can work from home, for example. So having to take time off work, having to raise the money for travel, in addition to funding money to cover this needed care. So folks with low incomes are going to be disproportionately impacted by these mandates and then also communities of color. We know that communities of color are more likely to need access to abortion services are less likely to have access to insurance coverage. For example, that covers abortion services. And so finances, again, are going to be disproportionately impacted for communities of color and trying to be able to get this care just really adds on additional burdens to an already, uh, an equitable healthcare system.

Jennie: And I think this just makes me think so we're having this conversation on January 22nd, which is the anniversary of Roe v. Wade, and the promise that Roe offered to people to be able to access safe, legal abortion in the US and how that was never been the reality for so many people. And I feel like that disparity has only gotten worse due to all of these restrictions.

Dr. Perritt: I agree. I agree, you know, Roe is of critical importance in making sure that we protect and uphold the legal right to access abortion is important. And it's also important that we understand that that is simply the floor-- legal access has never been enough to ensure care for those who need it most in our, who, who are least likely to be able to get it. And so just because abortion is legal in Mississippi, for example, doesn't mean folks who are in rural communities who have difficulty traveling and accessing the one abortion clinic that's there are going to be able to access that care. So when we're talking about the anniversary of Roe and the importance of Roe, it's really important to me as an abortion provider, that we repeat that that is the floor-- legality has never been enough to, um, to ensure care for those who need it. We know that folks with means will always and have always had access to abortion services prior to legalization in this country. These were folks who were able to travel. They were able to pay for it out of pocket. They were able to get this care without threat of prosecution or persecution, whether it was legal or not. And so for folks who have, um, who don't have the same resources, then that inequity remained and we see it magnified just as you pointed out, uh, in this current moment in time.

Jennie: Yeah. It's, it's a lot to think about and mentioning Mississippi, that just makes me think that SCOTUS is conferencing supposedly again today on the Mississippi restrictions, that would be a direct attack on Roe. And it's hope we might know. We will know whether they pick it up or not…

Dr. Perritt: Yes, and Mississippi, isn't the only play. Right? You know, we don't want to, we don't want to give the illusion that Mississippi, uh, stands alone. Uh, they are one of many states in a race to the bottom here. And so places like Arizona, Texas, Ohio, Pennsylvania, Virginia, where I'm licensed has, has, uh, thankfully started and started to loosen, uh, some of these restrictions. But again, we have to understand that this is part of a strategic effort, um, nationwide to eliminate access to abortion care. It's not specific to one governor or one place. This is part of a larger movement to eliminate and prevent folks who need access to abortion from getting it writ large.

Jennie: Yeah. We're hopefully going to be turning a corner with the administration, being able to make some changes, but so many of the fights need to happen at the state level and will be happening at the state level that it's still a long road to go, especially with the new makeup of the court system.

Dr. Perritt: Exactly. And, and, you know, and the, the, I, I'm so glad that you brought that up in, in terms of the, the Biden-Harris administration, because there are a number of things that they can and should immediately do, um, that will help us push back the harm that's been caused. Um, and this can be done, some of these things can really be done through administrative action. And so there is an opportunity for sure at the federal level to really, uh, enforce, um, the, the laws and the legislation we know will help support access to care. And there's a lot of work to be done at the state level. So when we're thinking about access to this critical service, then we have to think about it as a both, and what can be done to push back and roll back the harms that have been caused by the previous administration and accessing, um, comprehensive reproductive health care. And what can we continuously do at the state level to address these inequities as well.

Jennie: That's a perfect turn to what can the Biden-Harris administration do?

Dr. Perritt: You know, I think, you know, it's been wonderful to see the, the president like Biden and this new administration to repeatedly say that they will address, um, COVID 19 by following evidence and science. Um, and so they really can, can start on day one by allowing folks who are eligible to receive the medication from medication abortion by mail, uh, during the public health emergency, uh, to do so. Right? And so issuing, um, this executive order that suspends the in-person mandate is one really way to start. And this will ensure that patients are no longer forced to, to risk needless exposure to COVID-19 as a condition of accessing this care. Um, the other thing that we really need to push this administration to do is to initiate a comprehensive FDA review of current restrictions on mifepristone, so that a person's access to care is based on the latest science and medical evidence and not on policy and politics of the way that it's currently been framed. Um, even after the public health emergency ends, we have, um, an enormous amount of data in science that supports the safety and efficacy and effectiveness of mifepristone and misoprostol.... And so, um, pushing the FDA to, to use the science and medical evidence to make their recommendations around restrictions, it’s really critical that we do that. And that includes, um, elimination of the REMS. We know that this medication is safe and does not need to be regulated in, in this way.

Jennie: Yeah. It makes, takes me back to thinking of the fights over Plan-B and moving it to like being over the counter and having to really push the FDA to make those changes.

Dr. Perritt: Absolutely. Absolutely. And that's, that's critical.

Jennie: Yeah, you're right. Like, I think that that is such a huge change that the Biden administration could easily make and to do it during the pandemic to make sure that no one is putting their lives at risk to access basic healthcare. Um, but to, to make sure that in the future, we don't go back to having it restricted.

Dr. Perritt: Absolutely because even long before the pandemic leading medical authorities, including the American College of OBGYNs and the American Medical Association had been clear that the FDA's restrictions on medication abortion have no medical basis whatsoever, all they do is create barriers to time-sensitive essential health care. And so it's really critical that we take this time to listen to medical experts who were very clear, uh, and, and supporting the science and saying that this is government mandated harm. That's really the beginning and end of it. The negative impact of the FDA's restrictions on mifepristone has always fallen hardest on communities that are already being disproportionately impacted by inequities in care. Um, and so we know that these now during the pandemic, as you mentioned, these restrictions are, are even more burdensome in exposing, um, the people that we care for to these needless visits to hospitals and health centers, to be able to get this care when it can be obtained safely, um, through a mail order and through telemedicine services.

Jennie: So you also mentioned that there are things states can do, do you want to touch on what states can do?

Dr. Perritt:Sure. I mean, you know, we have wonderful, um, organizations, community-based organizations and organizers on the ground who have really been pushing back on these abortion bans and these restrictions at state levels, you know, even looking at, um, the initial lawsuit that was, um, led by the, the ACLU and supportive organizations like SisterSong. And, um, that came out and, and really were very clear about the disproportionate impact on communities at a state level. And so organizers who are out there really are reaching out to legislators and saying, this is what, this is the harm that these restrictions are causing in our own community. And we demand that we have equitable access to the care, um, that we legally deserve, uh, and have a right to, so organizing at the state level to push back on the narrative that, um, abortion is unsafe or should be restricted. We know that that is simply not true at all. So states like Georgia who have, who really defeated, uh, that six week ban, for example, that was done because of a lot of organizers on the ground led by primarily Black women who, who really came out and push the state, um, to, to honor Roe in this way and not eliminate access to care.

Jennie: So we always like to end by focusing on what can the audience do. So what steps can the audience take right now to make this a reality?

Dr. Perritt: I think that there's a ton of, there's a lot of work that can be done as an individual and as part of your organization, certainly at the federal level, we should all be pushing and encouraging the Biden-Harris administration to take immediate administrative action, to reverse the decision to, um, mandate in-person, uh, dispensing of medication abortion. And so that's critical. We also need to demand, uh, in, into this, the discriminatory policies that eliminate access and coverage for insurance coverage of abortion, specifically for some communities. And I'm thinking specifically about bands through the insurance exchange and also, um, the Hyde Amendment, which eliminates access to abortion care for those who are reliant on governmental insurance. Uh, and so pushing us, pushing at the federal level is a, is an important place to start. And then we also need to make demands, as we mentioned at the state level, and to say, you know, “we are your constituents. We live here and we demand access to these services.” And then, we often forget that legislators work for us. They're supposed to be representing us as their constituents and as, as people who live in the communities. And so we must make voices heard and say that we disagree with these policies and we demand equal access to this care. And so those are, are really some important ways to lift it up. And then I would suggest that we, you know, folks also partner with, uh, reproductive health organizations in their own communities that are already doing this work. And so there are many organized efforts across the country to, to make sure that folks who needed had access to abortion more broadly, and of course, medication abortion specifically

Jennie: Dr. Perritt, thank you so much for being here.

Dr. Perritt: It was a real pleasure to talk to you. It's always my pleasure to talk with you all as well. Uh, and thank you so much for having me.

Jennie: Thanks for listening everyone. And we'll see you on our next episode of RePROS Fight Back. For more information, including show notes from this episode and previous episodes, please visit our website at reprosfightback.com. You can also find us on Facebook and Twitter at RePROS Fight Back, or on Instagram at reprosfb. If you like our show, please help others find it by sharing it with your friends and subscribing, rating and reviewing us on iTunes. Thanks for listening.

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