In September 2020 Kelsey traveled almost 750 miles round trip to have an abortion. She lived in a state with very little abortion care and was concerned about the COVID-19 protocols of the clinic closest to her, 100 miles away. So she chose the next best option: a clinic in Colorado. Although she stayed with a friend to avoid hotel costs, she said she spent more than $700 on travel and the procedure itself.
“It wasn’t the abortion itself that was horrible,” she said. “The abortion was very necessary and I am very glad that I was able to do it. All the obstacles were traumatic.”
In late 2022, Kelsey, whose name has been changed to protect her privacy, learned she was pregnant again. At the time, she lived in New Mexico, where abortion remains legal, and there were two providers within 40 minutes of her home. However, both clinics, as well as all eight in-person abortion providers in New Mexico, were overwhelmed by increased demand from neighboring states such as Texas and Oklahoma, where abortion is prohibited. (Increased demand affects more than abortion care; it also delays other appointments, such as for birth control.) The earliest available appointment was more than a month away.
So Kelsey turned to the website of Aid Access, a European non-profit organization that allows doctors to provide virtual consultations and abortion pills by mail worldwide. She was connected to a clinic in Las Cruces that prescribed the drug, and an online pharmacy sent it to her.
As more states enact abortion bans after Supreme Court’s June 2022 decision to overturn Roe v. Wade, researchers expect the distance many patients must travel will triple. By choosing telemedicine and self-monitoring, Kelsey joined the growing number of Westerners able to avoid traveling long distances to clinics. These home alternatives, which studies show are as safe as clinical abortions, could improve access to abortion in the health care deserts of the rural West while reducing the cost, travel, and environmental impact of seeking care away.
IT ONLY TAKES SIX DAYS for Kelsey’s pills to arrive. Researchers say that’s one of the main reasons patients use telehealth for abortions: It’s often much faster than waiting for in-person appointments. Virtual care also greatly reduces the distances patients have to travel – which in the West usually involves mountains, snow and long journeys. Also, not everyone has access to a car.
Kelsey said she thought about that when she traveled to get an abortion in 2020. In the relatively poor and rural area where she lived, transportation was difficult for some. Her neighbors often asked for rides on Facebook. “If you can’t get a ride 30 minutes into town to get to your court date, then how could you possibly round up a vehicle and enough money to go to another state to get an abortion?”
“How could you find a car and enough money to drive to another state to get an abortion?”
This travel burden also has an environmental cost. In a new study, researchers at the University of California, San Francisco surveyed telehealth abortion patients about their experiences and calculated the trips they avoided. In more than 6,000 patients in 24 states, 56% of them in the West, researchers found that telehealth saved patients a total of nearly 163,000 miles of driving, or nearly 4,200 hours.
More detailed studies of a subset of these patients showed that Westerners saved an average of nine miles of driving by using telehealth. But 90% of these patients were in urban areas. For the 10% in rural areas, the difference is much greater – they save an average of 83 miles. This mileage is cumulative. According to the EPA’s carbon footprint calculator, this kept about 63 to 66 metric tons of carbon dioxide out of the atmosphere.
The researchers also asked patients in the study whether abortion would be readily available to them without telehealth. Most patients of color, younger patients, rural patients and those who would have to drive more than 100 miles for an appointment said no. “Thinking about the people who have really lived on the edge and are already facing many forms of structural oppression, removing that travel burden seems really tied to climate justice to me,” said Leah Koenig, Ph.D. student in epidemiology at UCSF and lead author of the paper.
In July 2020, a district court in Maryland ruled that during the COVID-19 pandemic, it should be possible to mail mifepristone, one of two pills taken together to terminate a pregnancy. (At the time, it required in-person pickup.) The Food and Drug Administration made that decision permanent in December 2021, though it’s back under review. A Texas judge is currently hearing a legal challenge against him; his decision could affect providers’ ability to mail mifepristone.
The clearance cleared the way for a host of virtual abortion startups, including Abortion on Demand, Just the Pill, Choix, Hey Jane and Abortion Telemedicine. Patients schedule video or text consultations with a licensed healthcare provider in the company’s network, the provider prescribes the pills, and the company arranges for the pills to be shipped to the patient’s address. (If a Texas judge blocks the mail-order authorization of mifepristone, telemedicine startups say abortion-seekers will likely continue to use modified doses of the other drug, misoprostol, a method that is not FDA-approved but is considered safe by the World Health Organization.)
Startups, some for-profit and some for-profit, don’t take insurance, but it’s often cheaper than getting a clinical abortion.
Although they can only work in states where abortion is legal, they are able to serve people outside of those states, with one caveat: in order to have a consultation and get a prescription, the patient must physically be in a state where abortion is legal. The travel this requires involves the same equity issues as clinic abortions, but going to a hotel or a friend’s home for a telehealth appointment can be easier and faster than waiting for a clinic appointment.
Aid Access, which Kelsey contacted, works a little differently than startups. In states where telehealth abortions are legal, they operate the same way, partnering with local clinics to prescribe pills and offer counseling. But in states with bans, it works around the U.S. legal and health systems: A doctor in Europe, where U.S. law has no jurisdiction, prescribes the pills, and a pharmacy in India mails them. This allows even people who live in states that have criminalized abortion to get pills in the mail, even though they don’t yet have access to counseling. The approach relies on a legal loophole. Although it is illegal to import drugs in most cases, the FDA rarely enforces this rule for prescription drugs that are imported for personal use.
Abortions like this are considered “self-administered,” a term doctors and researchers use to refer to abortions that are performed outside of the health care system. Such abortions were once associated with posterior procedures, but now the use of drugs is much more common. Before May 2022, when the High Court plans to overturn Roe v. Wade expired, Aid Access receives an average of 83 requests per day from the US for self-administered abortion pills; after the draft decision was announced, applications jumped to over 200 per day.
“For parts of the country, including the rural West, telehealth clinics are filling health care deserts while reducing the travel, cost, logistics and environmental impact of obtaining an abortion.”
Kelsey knew about telehealth and self-care options when she traveled to Colorado in 2020. “I thought about it a lot,” she said, wanting to avoid the trip. But in the end, she said, she freaked out: “I’ve never had this happen to me before, so I didn’t know what it was going to be like, and I kind of wanted a doctor.” This time, she said, “I didn’t feel like waiting a whole month, but before I had a medical abortion without complications. So I just thought, fuck it, go with it.”
Doctors and researchers emphasize that the pills are safe. In more than half of all abortions in the U.S.—including many clinical abortions like Kelsey’s first—doctors use medication. According to another UCSF study, adverse reactions that require a blood transfusion, surgery or hospital admission occur in less than half a percent of medication abortions. Even when pills are prescribed in person, they are often taken at home.
Still, like other aspects of U.S. reproductive care, the legal landscape of medication abortion is in flux. In addition to mifepristone mail-order litigation, some states have tried to prosecute self-administered abortions by banning them outright or using indirect laws, such as those governing the disposal of human remains. In at least one case in Ohio, a criminal case involving the delivery of abortion pills by mail resulted in a conviction. And in January, Alabama’s attorney general announced that people who had medical abortions in the state could be prosecuted under a law aimed at protecting children from chemicals in the home.
For Kelsey and many others, telehealth offers convenience and efficiency. But for some patients in the West, telehealth provides more than comfort—it’s the only possible choice. “For parts of the country, including the rural West, telehealth clinics are filling health care deserts while reducing the travel, cost, logistics and environmental impact of abortion,” Andrea Becker, one of the other researchers on the UCSF study , he wrote in an email. “It’s extremely important to empower people to choose the abortion process that works for them, whether it’s in a clinic or from their couch.”
Caroline Tracey is a Climate Fellow at High Country News. Email her at [email protected] or submit a letter to the editor. Check out ours letters to the editor policy.