How the FDA’s decision to allow the telemedical prescription of Mifepristone does (and does not) change abortion

Part Two: Abortion without Clinics and Greater Risk

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

Editor’s note In Part One Dr. O’Bannon outlined how the only one these bloody, extremely painful chemical abortions are easier for is the abortionist who only does a cursory interview, prescribes the pills and ships them to the woman’s home. Today we look at how chemical abortion affects the business in two more ways.

It helps to solve the industry’s problems with closed clinics and retiring abortionists.

The stories come every few years or so about all the closing abortion clinics and retiring abortionists. Supposedly this leaves women in large areas of the country (they call them “abortion deserts”) without “access” to this “vital service.”

There is in fact a “shortage” of qualified abortionists in the industry, as most reputable doctors, committed to healing, not killing patients, want nothing to do with it.

There were 2,918 abortion “providers” in the U.S. in 1982, the peak number of abortionists reached less than ten years after Roe. Those numbers began falling back, dropping by more than third to 1,819, by 2001. Despite the industry’s best efforts to train and recruit more abortionists, they have had to go after willing nurses, physician assistants, and midwives to try and expand their ranks.  Still, the number has continued to fall, until a Guttmacher report for 2017 found only 1,587 “abortion providing facilities,” only about half as many as there were in 1982.

Some abortionists who started back in the early days of Roe got old and retired. Others, like West Philadelphia’s Kermit Gosnell, exited in scandal and disgrace and (in his case) a life sentence in prison.  Clinics have closed due to financial mismanagement, corporate reorganization, or just lack of business.  Many clinics simply decided to shut down rather than undertake the expensive repairs needed to bring their facilities up to basic safety codes.

Over time, all these individual retirements and closures, whatever their reason, impacted the larger market. Fewer women bought their “product”– fewer women had abortions. Abortions in the U.S. fell from more than 1.6 million in 1990 to just 862,320 in 2017.

There is no way this escaped the attention of the abortion industry’s abortion pill promoters.  Clearly they saw in mifepristone, and especially in home delivery of abortion pills, a way to sell their deadly product to women in communities where there were no longer any abortionists and no longer enough business to maintain an abortion clinic.

If a woman can contact an abortionist online and have pills sent to her home, it doesn’t matter if the clinic across the street is closed or the nearest abortionist is hundreds of miles away. The abortionist need not fly in from out of state, or drive across the country to be able to see patients.  One abortionist, logging in from his or her home computer, can screen and prescribe abortion pills to dozens of women a day, shipping them all across the country.

No clinic needed.  And one abortionist (who, by the new FDA rules, doesn’t even have to be an MD!) in one central location can now do the work that used to be spread among two, three, or four colleagues flying between multiple cities.

The industry hopes that telemedicine and home delivery of abortion pills have the potential to make closing clinics and retiring abortionists a non-issue. With self-managed abortions, they think they can skip the clinics, bypass the surgeons, and keep the business humming by mailing and delivering abortion pills directly into women’s hands. 

It makes abortion more dangerous.

It’s hardly ever mentioned in the press or in the medical journals, and certainly not featured in the industry’s promotional materials, but chemical abortion with mifepristone and misoprostol has already been shown to be more dangerous than surgical abortion. And home use will only make it more so.

A 2015 study by noted abortion researchers studying emergency department visits found that found that 5.19%, or more than one in every twenty chemical abortions patients, sought treatment in an emergency room. This is more than four times the rate for those having first trimester aspiration abortions and higher even than it was for later surgical procedures.

Making those at-home abortions is only likely to exacerbate the factors that make chemical abortion dangerous.

Women undergoing chemical abortions under the original FDA protocol–which required the dispensing of the abortion pills in person–had the opportunity to be screened in person, often with ultrasound, to ascertain the age of child and confirm the presence of the child safely ensconced in the uterus (versus the fallopian tube, which would lead to a dangerous tubal or ectopic pregnancy).

These are critical factors, as the pill’s effectiveness wanes and the risk of complications increases as the pregnancy progresses and the child gets older. Moreover these drugs do not work in circumstances of ectopic pregnancy, where the child implants outside the womb.

An actual in-person visit with ultrasound can ensure, with greater certainty, that the woman is not past the 10 week deadline and can check to make sure than the child is implanted where he or she belongs in the uterus. 

A physician in a telemedical visit must rely on a woman’s honesty and accuracy in regards to the date of her last menstrual period or LMP (spotting in early pregnancy can sometimes lead women to miscalculate LMP) and must hope that the woman recognizes and shares any signs of ectopic pregnancy.

In addition to its being generally non-responsive to the abortion drugs mifepristone and misoprostol, ectopic pregnancy and the signs of a ruptured fallopian tube are troublingly similar to the expected consequences of chemical abortion – severe cramps, sharp pain, heavy bleeding. If ectopic pregnancy has occurred but has not been identified, it is easy for patients and even their hotline nurses to think that a woman is merely experiencing the pain, the bleeding, the cramps – the normal events that accompany every chemical abortion – rather than recognizing that a full blown tubal rupture is occurring.

The frequency and severity of these events are only expected to be worse with at home self-managed abortion.

It is inconceivable to think that there won’t be more dating errors, more missed ectopic pregnancies without the in-person, in clinic examinations and ultrasounds, and with that, more complications and more incomplete abortions.

This is to say nothing of problems of women who are having telemedical home abortions being too far from emergency help, or women, confused by the complex instructions involved with these drugs, using these incorrectly, or or their being used by persons other than those to whom they were prescribed, what to do with women who might change their minds, etc.

Women having chemical abortions have problems with pain and bleeding; they always do. It’s just that skipping the in person physical exam and relying on subjective interview questions to determine gestational age, implantation location, contraindications/medical eligibility, understanding of and willingness to comply with instructions, etc. make the occurrence of complications or “serious adverse events” with excessive pain, bleeding, infections, etc., more likely and potentially more deadly. 

One more note.

These sorts of complications that we’re talking about are more than simple inconveniences. The most recent report from the FDA shows that at least 26 chemical abortion patients have died and thousands more have suffered serious complications such as hemorrhage, infection, and ruptured ectopic pregnancies that require special treatment, surgery, and put many in the hospital.

On Tuesday, in Part Three, we’ll examine what role chemical abortions play if the Supreme Court allows serious limitations or even overturns Roe v. Wade.