After the draft opinion overturning Roe v. Wade leaked this week from the Supreme Court, I called up Dr. Mai Fleming, who’s a family medicine physician at the Univeristy of California, San Francisco. She also works for a telehealth company called Hey Jane and is a fellow with Physicians for Reproductive Health. In some ways Fleming was expecting this, but it didn’t make it easier to hear. “It still was very upsetting to see the words that were written by Justice Alito,” Fleming said. “While folks who have been working in reproductive health and access have been talking about this for a long time, I’m hoping that the shock of this for not just us, but for everybody, really brings this issue into the mainstream.”
On Friday’s episode of What Next: TBD, I spoke with Fleming, a doctor who helps facilitate abortion via the internet. The pandemic changed the way abortion care could be provided online. So what happens now? Our conversation has been condensed and edited for clarity.
Lizzie O’Leary: Before the pandemic, if you wanted a medication abortion, where a pregnancy up to 10 weeks’ gestation is terminated using a two-pill regimen, you generally needed to get the first pill from a hospital or a clinic. With the exception of a small telehealth research program, FDA rules meant that a patient who wanted a medication abortion had to see a provider face to face. COVID changed that. First, when a judge briefly lifted the FDA restrictions in 2020, and then in April of last year, when the agency itself temporarily allowed patients to get the drugs by mail. That meant a huge opportunity for telehealth.
Mai Fleming: A lot of the care that we’ve been providing in person can be carried out just as well and just as safely over the phone or through virtual video visits. Abortion care was one of those things. In the middle of the COVID-19 pandemic, there was a huge study that came out of England, and the National Health Service there, that demonstrated over tens of thousands of people who obtained medication abortion via telehealth in Great Britain were able to do so very, very safely and actually with fewer complications than the previously published numbers on safety for medication abortion. So we were able to replicate a lot of those studies here in the United States, reconfirming and redemonstrating just how safe and effective medication abortion over the phone is.
I was really struck looking at that study. It compared groups of women who’d had in-person appointments for a medication abortion, and they’d gotten a traditional appointment with a sonogram, and then groups who had gotten it via telehealth. And essentially the rates of complications were pretty much the same.
Right. I do want to quickly emphasize and stress that it is not only women who obtain abortion care. People of all genders who have a uterus and have the capability of becoming pregnant do seek and obtain abortion care, so I think it’s important to be inclusive in the language that we use.
But whether a person is prescribed medications from an in-person clinic or a telehealth clinic, or whether they order their own medications online, these medications in the abortion process are the exact same across the board and proven to be very, very safe.
Based on studies like this and data from its own temporary rule change, the FDA decided to permanently allow patients to get abortion medication in the mail at the end of last year. That means platforms like Hey Jane, where Mai Fleming works, are able to provide virtual services in states where telehealth abortion is legal. With a platform like Hey Jane, do you have conversations with people who are on the fence, or do most of the patients who you are talking with, do they know what they want?
Like any medical care, there is no one size fits all for a patient encounter in any field. Some people know exactly what they need and what they want, and we are happy to help facilitate that in a safe way. There are people who may not feel 100 percent certain at the time that they start engaging with us whether this is something that they want to proceed with, and we talk with folks through that.
Do you have a typical patient? I know that’s a tough question. There’s a New York Times thing that they have resurfaced in the past day saying a typical patient already has children, is probably in their late 20s. I wonder if you have seen commonalities among your patients, particularly the ones who are doing this online.
Generally, I see a whole range of people coming from all different experiences and backgrounds. Some people are already parents, absolutely, and are making a decision that best fits what they need for their current families. Some folks are not parents and have never been parents. Some people have never had an abortion. Some people have had abortions before. There is not one abortion patient. There is not a typical abortion patient. A common statistic that folks reference is that 1 in 4 people of reproductive potential may need at least one abortion in their lifetime. So most people know somebody who’s had an abortion regardless of who you are or what your circumstances are.
Where do your patients typically live? Obviously you’re physically based in California, but you’re licensed in a number of states, and I’m wondering, are they in a rural part of the state and they can’t physically get to a clinic because there isn’t one near them?
Yeah, so that also ranges. I’ve had patients from very remote areas where the nearest abortion provider might be three or more hours away, and patients who live in a big city where abortion might be accessible, but the wait times are weeks long.
I wonder if you could talk a little bit from your perspective as a provider of what it’s been like to have the internet as another tool in your practice. You’ve been doing this work for a while, and I wonder if having the expanded reach of the internet has made you think about being able to reach people who you couldn’t reach before. What has that been like?
For folks that have ready access to internet and phone, the ability to be able to provide care in the safety and comfort of a person’s own home really means a lot to some people. And particularly when we talked about very stigmatized care, where a person doesn’t have to travel for sometimes hours, sometimes days to access care. They may not have to get child care. They may not have to travel through angry protesters to try to reach their doctor or their health care provider in order to access this care. It has been a really important avenue.
Of course the digital divide means that people who don’t have reliable internet access have a harder time getting telehealth abortion care.
Outside of the internet access piece, not everybody has access to a safe space in their own home or in their own situation in order to access care. Whether folks are victims of interpersonal or domestic violence, folks have been victims of trafficking, or don’t feel safe disclosing the type of medical care that they need with their family or other people who live in their household—it is for those reasons, telehealth is not the answer. It doesn’t actually address the root issue, which is the overall lack of accessibility in the first place, and is only accessible largely in the states with permissive abortion laws. We already know that many states already have, and if they don’t already have, they’re working on it, legislation to restrict and eliminate abortion access via telehealth and for some just medication abortion in general.
Despite the FDA rules, 19 states restrict the use of telemedicine for abortion care. That can either mean an outright ban or requiring that a clinician is present when the pills used for medication abortion are administered, which in effect means telemedicine can’t be used.
For the people who are in the states where they are not able to use telemedicine for medication abortion, if abortion is still accessible in those states, they may be traveling very far distances to obtain care. If not, they may be traveling to distant states in order to access care. Some people may be ordering their own pills online.
I think the biggest risk with folks self-managing their abortions at home is not the medical piece. We’ve already well-established how safe these medications are for people, but it’s really the potential legal repercussions. We’ve seen criminalization of folks who have self-managed their abortion, and even by extension, we’ve seen criminalization of people who are actually suffering a miscarriage, where a person who they have reached out to for help and for medical care have reported them for suspicion for self-managed abortion or self-induced abortion, when in fact it’s really a miscarriage.
So it’s not surprising that the folks who are most at risk of being criminalized are the same folks that are at highest risk of being criminalized in our country in general—folks of color, folks who are undocumented, gender-diverse folks, folks who are in lower-income communities. And I worry about the state of increasing restrictive and punitive climate on the ways in which people on the ground may end up translating those restrictions and laws into criminalizing patients who are seeking medical care.
The internet has made meds easier to get, even if you are not talking to a board-certified doctor like yourself. I wonder if we are contemplating this post-Roe future, will those informal networks get bigger? Will the internet play an even larger role here?
We have a lot of experience of what a post-Roe world will look like in the state of Texas. There was a study that looked at how the demand and request for medications through aid access changed in Texas after the implementation of S.B. 8, and the number of requests, honestly, not only in Texas, but actually across the country, increased by a very significant degree, by multiple magnitudes. If that’s any indication, I wouldn’t be surprised if that would happen
Can you imagine a future where you are helping people in those states get medication over the internet?
Regardless of what the law is in any given state, there are always going to be people whose goal and mission is to help folks access safe care, whether that be through logistical means of helping folks travel across state lines if they’re able to, providing monetary and logistical support to do so, or helping get folks the information that they need to safely manage their own care where they are.