If adopted, proposed “No-Test” protocol would move dangerous DIY Chemical Abortion ever closer to reality

By Randall K. O’Bannon, Ph.D. NRL Director of Education & Research

If you thought that Planned Parenthood’s webcam and Gynuity’s TelAbortion programs represented the limits as to how far the abortion industry would go in efforts to move chemical abortions out of the clinic, a recent journal article by some of the industry’s top researchers and will be a troubling eye-opener.

If adopted and allowed, this new protocol would move the country ever closer to abortion advocates’ dream scenario – the do-it-yourself (DIY) abortion that a woman performs on herself with pills bought from an on-line pharmacy. These “self-managed” abortions are extremely dangerous to the woman, but you would never know it by proponents.

In an article appearing in the June 2020 issue of Contraception (www.contraceptionjournal.org/article/S0010-7824 (20)30108-6/pdf) well-known abortionists Daniel Grossman, Elizabeth Raymond, Mitchell Creinin, and others, published a “sample protocol” for “No-test medication [chemical] abortion.” They maintain that expensive tests and those requiring direct clinical evaluation, such as ultrasound, pelvic examination, blood tests and Rh typing could be dispensed with. This would pave the way for even further reduced contact between the patient and any medical professional, which is, of course, the objective, but at the expense of greater risk for women. 

The authors claim that the coronavirus pandemic prompted the need for a new protocol with reduced clinical contact. But the headline unapologetically tells us their real objective: 

“No-test medication abortion: A sample protocol for increasing access during a pandemic and beyond.”

As they write, “[W]e anticipate that this approach to providing the service will continue to be beneficial for both patients and abortion providers even after the current epidemic resolves.”

How we got here. Use of “Telemedicine” for Abortion

To see how much things have already drastically changed, consider this. When mifepristone (one of the two-drugs that make up the “RU-486” abortion technique) was first approved for sale in September of 2000, the U.S. Food and Drug Administration (FDA) instructed doctors who met the certification requirements to follow a process whereby women would have three visits to the clinic. 

The first visit, to screen and counsel the woman before she took mifepristone there in the office, the second, two days later, for her to come in and receive misoprostol, the second drug. The first pills shut down the baby’s life support system, the second stimulate powerful uterine contractions to expel the child’s tiny corpse. A third visit at two weeks confirmed whether or not the abortion was complete.

The FDA modified the protocol in 2016. The woman now need only come in for the first visit to be screened, counseled, and given both the mifepristone pills, which she took there, and the misoprostol, which she could take at home.  Some sort of follow-up with the abortionist was to occur a week or two later where the completion of the abortion could be confirmed, but the FDA did not specify that this be an in person return visit to the clinic.

In 2008, though, Planned Parenthood’s Iowa affiliate began offering webcam or “telemedicine” abortions. Here, a woman would visit a small storefront Planned Parenthood office, chat over a computer connection with  the abortionist back in Des Moines who looked at her ultrasound. He would ask her a few pertinent medical questions, explain the process, and click a mouse at his location triggering the release of a locked drawer containing the pills at her location.  She took the first set of pills while the abortionist watched and took the rest home.  She had a hotline number to call if she had problems.

The woman came back to the storefront clinic for an ultrasound to confirm the completion of her abortion. Unless significant problems arose, she was never actually physically examined by or in physical presence of the doctor who oversaw her abortion. 

Gynuity, an abortion research group founded by Beverly Winikoff, who helped the Population Council bring mifepristone to the United States in the 1990s, began its own “TelAbortion” program in 2016 as part of a four state study. (New York, Hawaii, Oregon, and Washington, now expanded to nine additional states.) 

Gynuity also screened and counseled women over a webcam. But Gynuity allowed women to get necessary testing (e.g., ultrasound to determine gestational age) at a doctor’s office of their own choosing. Once the woman’s test results were passed along to Gynuity, abortion pills were shipped by overnight mail to her home, along with instructions. Someone at Gynuity was available for a phone consult if questions or problems arose, and women were directed to appropriate help if a medical emergency arose.

While eliminating a trip to the abortion clinic, both of these telemedical models still involved some trip to a medical office of some sort where the pregnancy could be confirmed and dated (important because the pills are less “effective” the farther along the pregnancy; the FDA has limited use to ten weeks–70 days–after a woman’s last menstrual period) and the woman could be screened for possible ectopic pregnancy. (Mifepristone and misoprostol are not effective in the case of tubal pregnancies.)

This usually involved ultrasound to ascertain the gestational age (trained and experienced ob-gyns may be able to do this by physical examination) and to confirm the presence of the embryo in the uterus (rather than in the fallopian tube or elsewhere where growth could eventually cause a dangerous rupture). Testing for Rh antibodies is also usually performed at this time to ensure that the mother’s blood doesn’t carry a factor that will prove deadly to children conceived in the future.

Ultrasound or additional testing may also be used in subsequent visits to determine whether the abortion was complete — no parts of the baby or any residual placental tissue remained.

The new “no-test” abortion model

The “no-test” model proposed by Grossman, Raymond, Creinin, et al., would eliminate all those critical tests. This would pave the way for “new venues and by new categories of providers” and “new service delivery models, such as synchronous or asynchronous telehealth, stationary or mobile ‘mini-clinics,’ pill pickup arrangements, or dispensing via lockboxes or, potentially, by mail.” 

In essence, this means that women would be their own doctors and lab techs. They not only would perform and manage their own abortions, but also confirm their pregnancies, do their own estimations of the baby’s gestational age, assess their own risk of ectopic pregnancy, and determine whether their abortion was complete.

It is situation fraught with peril for the woman.

If a woman underestimates her gestational age, it increases her risk of complications and failures. Even the ordinary, uncomplicated” chemical abortion can be a bloody, painful, and terrifying affair. The rupture of an undetected ectopic pregnancy could kill her. She could also die if her abortion is incomplete and infection arises from some tissue that was left over. Her future childbearing could be at risk.

Concerns about possible gestational misdating by patients trying to use what they believe to be their last menstrual date are dismissed. Though the authors admit that this “will inevitably result in treatment of some fraction of patients whose true GAs [gestational ages] exceed 77 days,” they reassure readers (citing their own studies) that these medications will work at later gestations than those approved by the government and that serious “adverse events” will be “rare.”

Grossman and pals have decided that “requiring Rh testing and anti-D immunoglobulin as part of abortion care is becoming a barrier” to chemical abortion expansion, particularly telemedicine and DIY “self-managed medication abortion.” They may be jettisoned, because “Rh testing is not a requirement for abortion in any setting.”

A failure to identify and treat a woman with an Rh-negative blood type can mean the death of children in subsequent pregnancies. Nonetheless, the authors say that such testing is “unnecessary for patients who can report a Rh-positive blood type or who are certain that they want no future children after the planned abortion.” 

This presumes a great deal about a woman’s knowledge and her plans, which may change with better circumstances. 

That a very serious harm could easily be averted with a simple blood test and an immunoglobulin injection takes a back seat to easing the abortionist’s burden and expanding marketing for their deadly pills.

About 1-2% of pregnancies in the U.S. are ectopic, that is, where the unborn child implants outside the womb. If not identified and addressed, they can grow and rupture, placing the mother’s life at risk. Mifepristone and misoprostol do not work in the case of ectopic pregnancy, though the symptoms of a rupture – uterine pain, cramping, bleeding – are, at least initially, difficult to distinguish from the normal side effects of a chemical abortion.

Given the conditions, it is not surprising to find that Mifepristone patients have died when their ectopic pregnancies went undetected.

Advocates of the “no-test” chemical abortion know of the abortion pill’s lack of effectiveness in such situations and the risk it poses. But they blithely advise that ectopic pregnancies missed by their self-screening methods miss “can be detected and managed afterwards.”

These advocates are suggesting that these “no-test” chemical abortions can performed at gestations up to 11 weeks, or more. Given that the rupture of ectopic pregnancies can occur anywhere between the 6th and 16th week of pregnancy (Antonette T. Dulay, “Ectopic Pregnancy,” Merck Manual Consumer Version, August 2019, accessed 6/11/20) and produce symptoms disturbingly similar to chemical abortion side effects, this lack of caution seems irresponsibly optimistic.

The authors acknowledge that the pills do not always work and that with that come the possibility of additional medication, testing, or even surgery (“aspiration”). Essentially, this allows them to sell “no-test” no-clinic visit abortions to abortion pill prescribers and patients even while admitting that a certain percentage of them have to have clinical tests or surgical procedures anyway. 

Of course, no one knows for sure in advance who the unlucky women will be, though risks are higher for later gestations. Either all women must still be prepared to make those additional medical visits (undercutting the sales point), or advocates are prepared to write off a certain number of casualties for the sake of the “no-test” abortion cause.

Disregarding the Danger

In the end, these advocates admit that their “no-test” model comes with risk of misdating, and with that, the possibility of increased failure and more severe side effects. They argue that complications are rare and can generally be managed remotely if the women will only call the abortionist before heading to the hospital. Note that that would reduce reporting, but not necessarily risk.

They also grant that missed ectopic pregnancy is a real possibility, but suggest that women can play the odds and address that later if need be.

The bottom line is that abortion pill advocates are so anxious to get rid of any obstacle that stands in the way of DIY abortions that they are willing to abandon even the most basic diagnostic tests and safety screens in order to push their agenda.

To expose women to unnecessary risk in the name of convenience is not only a violation of the first principle of medical ethics – “first of all, do no harm” – but something that looks an awful lot like something approaching gross medical malpractice.