This post was written by our summer 2022 MPH Intern, Abigail O'Keefe

On May 26, 2022, North Carolina legislators introduced and filed the Reproductive Freedom Act (HB1119)¹. The legislation aimed to protect the right to an abortion in North Carolina,  as well as make it easier to access abortion care by removing some state-level abortion restrictions¹. One of the restrictions that would be lifted if this bill were to be enacted is the restriction on using telemedicine to receive medication abortion¹. This bill was introduced, but not given a hearing nor voted on. However, this piece of legislation would not only protect abortion access in North Carolina but also specifically legalize the use of telemedicine for prescribing medication abortion and should have been passed into state law because of the impact it would have on ensuring equitable access to abortion care and on promoting the reproductive health of all North Carolinians. 

To start, medication abortion is a method of abortion in which medications are taken by a patient to terminate a pregnancy². The most common practice for a medication abortion is the use of the medications mifepristone and misoprostol, a regimine approved as a proecdure to terminate a pregnancy in 2000³. Medication abortion is considered to be very safe with the chance of complications being very small⁵, and the World Health Organization (WHO) has endorsed this type of abortion procedure for over 20 years now^4,5. Since the approval of medication abortion, the percentage of abortions in the United States that have used this method has steadily increased, to the point where more than 50% of abortions in 2020 were medication abortions³. The increase in the use of medication abortions as the method to end a pregnancy is not just observed at the national level, but also at the state level. In North Carolina, the percentage of abortions that were medication abortions has increased since 2010, with 45.7% of abortions in 2019 being medication abortions⁶. While there is still a higher percentage of abortions that are completed via the surgical procedure, that percentage in the state has been decreasing since 2010⁶, showing that more North Carolinians are favoring medication abortions for their type of abortion procedure.

Currently the law in North Carolina is that telemedicine can not be used to provide medication for an abortion, as all patients are required by the state to be in person in the same space as the health care professional who will be conducting the procedure when they are given the medication⁷. In reality, using telemedicine to prescribe and provide medication for abortion has been endorsed by many entities, such as the American College Obstetricians and Gynecologists⁸, and the use of telemedicine for providing medication for abortion has been proven to be just as successful and safe as if someone had received the medication in a clinic⁹. With the ban in place on telemedicine, however, this means that patients in North Carolina have to visit a clinic to receive the medication for an abortion. There are only 14 abortion clinics in North Carolina, which leaves more than half of the women in the state living in a county that does not have an abortion clinic¹⁰. This means that many individuals in North Carolina may have to travel long distances in order to have an abortion, and travel can heavily burden those who do not have the financial resources for it - transportation, childcare, and time off of work - and for those who live in rural areas far away from any clinic¹¹. The distance that one may have to travel in order to receive abortion care can ultimately lead to some individuals not being able to receive timely abortion care or not being able to receive abortion care at all¹¹. Telemedicine has been proven to be faster in providing medication to patients and decreasing the amount of time patients have to wait after an initial consultation with a provider⁹. By advancing this bill and removing the ban on medication abortion, this would remove a barrier to abortion care that many individuals in North Carolina face, and would increase access to essential healthcare that many people in North Carolina need and use each year. 

The ban on telemedicine for providing medication abortion should also be removed because many patients in North Carolina may fear violence and harassment from protestors at abortion clinics.  In 2021, violence and harassment at abortion clinics increased significantly from 2020, with there being increases in the reports of vandalism, blockades, hoax/suspcious devices, and assault at abortion clinics¹². Patients who have gone to abortion clinics and experienced anti-abortion protests have stated feeling scared about what the protestors might do, avoiding some clinics in order to not encounter protestors, and being made to feel very shameful about the decision they made¹³. While the Governor of North Carolina recently signed an executive order on abortion accesss in the state which included actions for combating clinic violence¹⁴, removing the ban on telemedicine would be an additional way to protect the health, privacy, and safety of patients by allowing them to choose where they would like to receive their medication and not burdening them with having to be harassed by protesters for accessing care that they have decided they need. 

The removal of the ban on telemedicine for providing abortion also has the potential to positively impact patients who are traveling to North Carolina to receive treatments. With the recent overturn of Roe vs. Wade, many states surrounding North Carolina have taken action to restrict or ban abortion services, which will increase the distance that patients have to travel if they are not able to receive an abortion in their state¹⁵. This also has the potential to increase the number of out-of-state patients that visit abortion clinics in states where abortion is still legal¹⁶. Specifically in North Carolina, a clinic in Charlotte reported seeing an increase in out-of-state patients that were coming to their facility for abortion services, and more than half of the appointments in one week were for out-of-state patients¹⁷. Providing medication abortion via telemedicine has been proven to shorten the amount of time it takes for a patient to receive the medication⁹ and would increase the time that abortion clinics have to serve patients¹⁸; therefore, removing the ban on providing medication abortion via telemedicine has the potential to increase availability and access to aborton services for both residents of North Carolina and residents of other states. 

Preserving the basic right to have an abortion in North Carolina is a very important policy action that should be taken, but in recognizing the impact that these restrictions on abortion in North Carolina have on the people who want and need this medical service, legislative action also needs to be taken to remove these medically unnecessary hurdles to basic reproductive healthcare. Removing the restriction on telemedicine for prescribing medication abortion is an important step that North Carolina legislators should take given how access to abortion services would be increased, patient’s safety and well-being would be protected, and it would help abortion clinics in the state serve both in-state and out-of-state patients.  Everyone deserves the right to freely access the medical care that they want, and by passing the Reproductive Freedom Act, North Carolina would have taken a stance to ensure it's a place where everyone’s reproductive freedoms are valued and protected.

References

1. Pro-Choice North Carolina. BREAKING: Bills to Codify Roe Filed in the North Carolina Legislature!. Pro-Choice North Carolina. May 26, 2022. Accessed July 15, 2022. Breaking! Bills to Codify Roe Filed in the NC Legislature! (prochoicenc.org)
2. Mayo Clinic. Medical Abortion. Mayo Clinic. Accessed July 15, 2022. Medical abortion - Mayo Clinic
3. Jones RK, Nash E, Cross L, Philbin J, Kirstein M. Medication Abortion Now Accounts for More Than Half of All US Abortions. Guttmacher Institute. February 24, 2022. Accessed July 15, 2022. Medication Abortion Now Accounts for More Than Half of All US Abortions | Guttmacher Institute
4. Ngo TD, Park MH, Shakur H, Free C. Comparative effectiveness, safety and acceptability of medical abortion at home and in a clinic: a systematic review. Bull World Health Organ. 2011;89(5):360-370. doi:10.2471/BLT.10.084046
5. Kapp N, Lohr PA. Modern methods to induce abortion: Safety, efficacy and choice. Best Pract Res Clin Obstet Gynaecol. 2020;63:37-44. doi:10.1016/j.bpobgyn.2019.11.008
6. N.C. Department of Health and Human Services. State Center for Health Statistics. NC RESIDENT ABORTIONS: CHARACTERISTICS OF WOMEN RECEIVING ABORTIONS NORTH CAROLINA RESIDENTS, 2010 - 2019. N.C. Department of Health and Human Services; 2020. Accessed July 15, 2022. Version 9.4 SAS System Output (ncdhhs.gov)
7. N.C. Gen. Stat. Ann. § 90-21.82 (Enacted 2011; Amended 2015).
8. The American College of Obstetricians and Gynecologists. ACOG Statement Regarding Telemedicine Abortion. The American College of Obstetricians and Gynecologists. June 19, 2015. Accessed July 15, 2022. https://www.acog.org/en/news/news-releases/2015/06/acog-statement-regarding-telemedicine-abortion
9. Aiken A, Lohr PA, Lord J, Ghosh N, Starling J. Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study. BJOG. 2021;128(9):1464-1474. doi:10.1111/1471-0528.16668
10. Guttmacher Institute. State Facts About Abortion: North Carolina. Guttmacher Institute. Accessed July 15, 2022. State Facts About Abortion: North Carolina | Guttmacher Institute 
11. Bearak JM, Burke KL, Jones RK. Disparities and change over time in distance women would need to travel to have an abortion in the USA: a spatial analysis. Lancet Public Health. 2017;2(11):e493-e500. doi:10.1016/S2468-2667(17)30158-5
12. National Abortion Federation. 2021 Violence & Disruption Statistics. National Abortion Federation; 2022. Accessed July 15, 2022. Provider Security - National Abortion Federation (prochoice.org)
13. Kimport K, Cockrill K, Weitz TA. Analyzing the impacts of abortion clinic structures and processes: a qualitative analysis of women's negative experience of abortion clinics. Contraception. 2012;85(2):204-210. doi:10.1016/j.contraception.2011.05.020
14. Sherman L. NC governor moves to further protect abortion access, AXIOS Raleigh. July 6, 2022. Accessed July 15, 2022. NC Gov. Roy Cooper moves to protect abortion access - Axios Raleigh
15.  Guttmacher Institute. If Roe v. Wade Is Overturned: New Interactive Map Shows How Far People Seeking Abortion in the 26 States Certain or Likely to Ban the Procedure Will Need to Travel to Get the Care They Need. Guttmacher Institute. Published October 28, 2021. Accessed July 15, 2022. If Roe v. Wade Is Overturned: New Interactive Map Shows How Far People Seeking Abortion in the 26 States Certain or Likely to Ban the Procedure Will Need to Travel to Get the Care They Need | Guttmacher Institute
16. Maddow-Zimet I, Kost K. Even Before Roe Was Overturned, Nearly One in 10 People Obtaining an Abortion Traveled Across State Lines for Care. Guttmacher Institute. July 21, 2022. Accessed July 27, 2022. Even Before Roe Was Overturned, Nearly One in 10 People Obtaining an Abortion Traveled Across State Lines for Care | Guttmacher Institute
17. Douglas B, Contino G. Charlotte, NC abortion clinics seeing increased demand post-Roe reversal. The News & Observer. July 17, 2022. Accessed July 19, 2022. NC abortion clinics see increased demand from out of state | Raleigh News & Observer (newsobserver.com)
18. Raymond EG, Grossman D, Wiebe E, Winikoff B. Reaching women where they are: eliminating the initial in-person medical abortion visit. Contraception. 2015;92(3):190-193. doi:10.1016/j.contraception.2015.06.020