US abortion pill boom raises legal and ethical questions

The Supreme Court ruling that overturned legal protection for abortion is transforming the provision of reproductive healthcare in the US, as telehealth start-ups fill gaps in treatment caused by restrictions and bans.

Hey Jane and Choix, which post abortion pills to women following online consultations, have raised millions of dollars in venture capital funding to expand their services, as demand surges following the closure of abortion clinics in several Republican-controlled states.

At least a dozen not-for-profit telehealth providers, including Just The Pill and Aid Access, are also increasing operations. In some cases, the groups provide access to emergency contraception pills and other reproductive and sexual healthcare services via online platforms.

Providers say the Supreme Court ruling overturning Roe vs Wade has increased public awareness of abortion pills — a safe method of terminating a pregnancy that was developed in the 1980s. Most commercial operators do not post pills directly to states that outlaw abortion, but women can use friends’ addresses in states where abortion is legal or travel to receive the drugs.

The Biden administration and women’s rights campaigners have welcomed the telehealth boom. They argue it can help maintain abortion access and relieve the financial and emotional stress women face with unwanted pregnancies.

But it is raising complex questions about the legality of services provided to women in states where abortion is banned, and whether this new generation of abortion providers can offer equitable access to their technology platforms and adequate standards of care, while protecting users’ privacy.

“Everyone has to learn how to use the new technologies and what its limitations are. Patients and clinicians can be overwhelmed by new responsibilities and new ways of doing things,” said Bonnie Kaplan, a medical informatics and bioethics expert at Yale University.

She said ethical issues had become more salient now that telehealth is one of the few remaining ways to access abortion services in some US states. Better data protection and privacy rules are needed along with updated ethical guidelines, Kaplan said.

Demand for medication abortion, which involves consuming two drugs, mifepristone and misoprostol, to terminate a pregnancy within the first 10 weeks, was growing prior to the Supreme Court ruling and now accounts for more than half of all terminations in the US.

But demand has been supercharged by the Roe vs Wade ruling last month and a decision by federal regulators to authorise telehealth providers to post pills to women’s homes with no need to visit a doctor or pharmacist in person because of Covid-19.

“On the day of the ruling we saw a 600 per cent increase in visits to our website and since then we’ve seen about a 50 per cent increase in the number of patients being served by us,” said Cindy Adam, co-founder and chief executive of Choix, a San Francisco-based telehealth provider.

Just The Pill, a not-for-profit provider, said it had 437 appointment requests in the four weeks prior to the Supreme Court ruling and 801 requests in the four weeks afterwards — an 83 per cent increase in demand.

Choix charges women $289 for an online consultation and to mail abortion pills to addresses in California, Colorado, Illinois and New Mexico — all of which are states where abortion and telehealth services are legal.

Adam forecasts demand will continue to grow as more Republican-controlled states ban abortion and appointments at in-person clinics in states where the procedure is legal become harder to secure because of high demand as more women are forced to travel for treatment.

The shifting political climate against abortion was a key reason Adam, a former nurse, and several other healthcare professionals founded Choix in 2020.

Last month Choix raised $1mn in seed funding from Elevate Capital, a US venture capital fund, to accelerate its roll out, and is trying to raise an extra $2mn. It wants to expand its telehealth services — which include abortion, emergency contraception and treatments for genital herpes and other conditions — to 10 states where abortion is legal by the end of 2022.

Choix does not plan to post pills to states that ban telehealth abortion but is considering launching a service to assist women, in tandem with other aid groups, who need to travel from these states to receive abortion pills in neighbouring jurisdictions where abortion is legal.

“These [state] laws are designed to make abortion or healthcare providers afraid but we feel we are very much in the right to offer co-ordination of care for our patients,” said Adam, who is hopeful Congress will pass laws providing legal protection for telehealth providers.

The legal threat is real with at last 19 states requiring a clinician prescribing abortion pills to be present when they are taken, effectively prohibiting telehealth services. Some states enforce abortion laws through “bounty hunter” clauses, which allow private citizens to sue anyone who “aids or abets” an abortion, including pharmacists or doctors.

President Joe Biden signed an executive order this month to protect access to abortion but a lack of clarity surrounding conflicting federal and state laws remains a concern for providers. The American Pharmacists Association on Monday warned the confusion is “compromising patient care”.

Kiki Freedman, a former Uber executive and co-founder of Hey Jane, which has raised $3.6mn and provides telehealth abortion in six states, said the company would comply with state laws to reduce the legal risk to patients and providers.

“Working at Uber I definitely got a lot of exposure to navigating regulatory complexity within a hypergrowth business,” said Freedman, who got the idea for Hey Jane in 2019 when the last abortion clinic in Missouri faced closure.

But in an example of the complexities in operating in such a sensitive sector Hey Jane was recently forced to delete some material from its website to protect users’ privacy. This followed an investigation by The Markup, a news organisation, which raised concerns over the potential disclosure of personal information contained in user reviews on its website and the use of software that tracks the online movement of visitors and facilitates advertisements on social media platforms.

“We’ve found the best way to reach people seeking out safe abortion care is via the channels they’re already on,” Freedman said. “That said, as the regulatory environment has become increasingly hostile, we have chosen to remove the Meta Pixel (the tracking software which allows it to advertise on Facebook and Instagram).”

Healthcare experts say the incident shows why data protection and privacy need to be strengthened, given that women seeking abortions or clinicians providing services could face prosecution in some states.

Kaplan of Yale said: “We’ve already seen people searching for abortion services being tracked and data about them sold by various websites. That’s happening with social media, and it’s happening with abortion telehealth services themselves.”

“That certainly puts people at risk,” she said.