Author: Nicole Anthony, MD
Editor: Alec Feuerbach, MD
A few years ago, I had a patient, a young woman, who had just immigrated to New York from Libya. She had left her family behind, and her only contact in New York City was the family friend with whom she was staying. When I told her, awkwardly and with the help of a phone interpreter, that the nausea and vomiting which had brought her to the ED was from early pregnancy, she screamed. The sound was shocking in a crowded ED–public in its location, private in its agony. From the interpreter phone, I heard the repetitive, “They will kill me, they will kill me, they will kill me” over and over again as the interpreter attempted to keep up in real time.
It took her a few minutes for her to remember I was there. When she finally did, it was difficult to get any further information from her, other than 1) no one could know she was pregnant and 2) she needed an abortion as soon as possible. The family friend especially, she insisted, could not know. I printed out the information for our women’s health center and hoped that it would all somehow work out. I drew a map on her discharge paperwork, circled phone numbers and addresses, and placed exclamation points next to the most important parts of the discharge instructions.
This interaction occurred shortly before the Food and Drug Administration (FDA) lifted the restriction on obtaining abortion pills online and restrictions on prescribing misoprostol, leaving my uninsured and undocumented patient with very few attainable options. But as the COVID-19 pandemic ramped up and most nonessential clinics shut their doors, the FDA approved the dispensation of mifepristone and misoprostol by telehealth. In the state of New York, we are finally able to offer our patients expanded access to abortions.
Although the following abortion access information will touch on general federal regulations, some information will be New York State-specific due to the wide state-by-state variability in legislation.
Gestation Regulations
Gestational limits vary greatly state by state. In states where abortion is legal, the gestational age limit typically spans anywhere from 6 to 24 weeks, with the majority of states lying somewhere in the middle. Seven states, including New Jersey, allow abortion at any gestational age for any reason. Find your state-specific gestation restrictions.
Figure 1. State-specific late-term abortion legislation.[1]
New York allows abortion up until “fetal viability” as defined by current federal regulation–i.e. 23 to 24 weeks at this time.
Types of Abortion
Simplified, there are two types of abortion–those that use pills (medical abortion) and those that involve a procedure (commonly referred to as in-clinic or surgical abortion). The type of abortion available to the patient is based on both gestational age and state-specific laws.
Medical abortions (approved for up to 11 weeks gestation) use medications to induce the passage of uterine contents. There are two regimens commonly available– Mifepristone/Misoprostol and Misoprostol alone. Mifepristone is a progesterone receptor antagonist which causes menstrual bleeding, shedding of the uterine lining, and softening of the cervix. Misoprostol is a uterotonic that generates uterine contractions.
Although the combined mifepristone/misoprostol regimen has a high rate of effectiveness as compared to misoprostol alone (95% vs 78%), there are prescriber restrictions on mifepristone that make the misoprostol-only option more accessible.[2–4] Only a prescriber who is certified by a manufacturer of mifepristone is able to prescribe it. Misoprostol, on the other hand, has no such restrictions.
Table 1. Medication abortion regimens. Source – Kaiser Family Foundation
In-clinic abortion (any gestational age, only limited by state law): Although medical abortion is preferred in the first trimester due to ease and relative non-invasiveness, surgical abortion is the only option available past 11 weeks gestation. In-clinic abortion, also called aspiration curettage, dilation and curettage, dilation and evacuation, or surgical abortion, all entail roughly the same thing – a procedure during which the uterine contents are evacuated. Depending on the gestational age, this may be performedd as a one-day or two-day procedure.
State-specific abortion restrictions
Telehealth: Many states allow a telehealth consultation instead of an in-person visit when prescribing abortion medication. The telehealth consultation can entail as little as filling out an online form and does not require a virtual consultation with a physician. The cost for the combined telehealth consultation and mailed medication can be as low as $100 in New York.
– 25 states allow telehealth abortion without restrictions
– 27 states have a mandatory waiting period
– 14 states require 2 in-person clinic visits
– 27 states mandate an ultrasound
– 6 states require the provider to show and describe the ultrasound image
– 12 states require the patient to receive a handout on fetal pain
Minors: Most states require parental consent or parental notification in order for minors to receive abortions (although many have exceptions in the case of a medical emergency or in the case of rape or sexual abuse). In New York, minors can access abortion without parental consent as long as the minor is deemed capable of giving consent.
Figure 2 – Source: Kaiser Family Foundation
Opinion: Prescribing mifepristone and misoprostol should be within our scope-of-practice
In a time when abortion pills can be obtained by filling out an online form, there is no reasonable argument that can be made against an emergency physician’s capabilities in providing medical abortions.
Although there is convincing data that the telemedicine-hybrid model (in-person or telehealth visit without an ultrasound) has the same rate of ectopic pregnancy as the traditional in-person with ultrasound model, this isn’t generalizable to a model that foregoes all face-to-face evaluation in lieu of filling out an online medical form.[5] Are we that confident that an unstandardized medical form will pick up on the features of a person’s history that might mark them as high risk for an ectopic pregnancy? Even if the form asks all the right questions, can we guarantee that the patient understands those questions and is answering appropriately? How many times has a patient described a past ectopic pregnancy in vague terms such as a “tube burst” or “my ovary popped,” phrases that might only make sense with several follow-up questions.
If patients were reliably able to obtain abortion medication in the ED, we could do them the justice of providing a responsible medical screening exam and, after identifying a subset of patients at high risk for ectopic pregnancy, providing an ultrasound and screening beta-hcg when appropriate. Furthermore, patients would have access to high-quality counseling on return precautions, STI screening, birth control, and close follow-up. The Royal College of Obstetrics and Gynaecologists have published an excellent bulletin on best practices in providing telemedicine abortion care for those interested in providing abortion care.
For those physicians who would like to prescribe abortion medication from the ED, logistics will be the main challenge. Although misoprostol does not have any prescriber restrictions, physicians prescribing mifepristone must be Risk Evaluation and Mitigation Strategies (REMS) certified which must then be filled by a REMS certified pharmacy–none of which are in the state of New York. REMS certification is obtained through the FDA.
The one workaround would be to order the single dose of mifepristone to be given in the ED, followed by an outpatient prescription for misoprostol. Many hospitals have protocols about which providers are able to order mifepristone, so this may end up being a larger conversation between pharmacy, administration, ED, and Obstetrics Department. For instance, at Kings County Hospital, only the Obstetrics and Gynecology physicians are permitted to order mifepristone and typically only in the event of medical emergency (eg. a qualifying ectopic or missed abortion). In order to offer abortion care from the ED, a protocol will need to be developed in which emergency physicians are permitted to either order a dose of mifepristone from the ED or consult Obstetrics and Gynecology to order the mifepristone instead. There can be built-in checks and balances such that a physician is unable to order mifepristone for a patient without a scheduled follow-up within the next 2 days.
In the meantime, you can brush up on your knowledge with these free evidence-based online CME training modules for healthcare workers interested in providing medical abortion care developed jointly by UC Davis and Brown University.
Final thoughts
When I consider all the challenges my patient would have had to overcome, a large part of me believes that she probably never got that abortion. I wonder whether she was completely cut off from her family as a result and how she is managing now. Although few cases are so black and white in how they can detrimentally affect a person’s life, there are probably more cases than we care to admit. I think about how easy it is for us in 2023 NYC to provide good abortion care to our patients (especially as compared to other states and parts of the world) and hope we can pave the way for emergency physicians everywhere.
Additional patient resources
Policies
Abortion Policies Tracker
Guttmacher Institute
Finding an abortion
Planned Parenthood Abortion Clinics Near You
The Plan C Guide to Abortion Pills
National Abortion Hotline
NYC Health Abortion Access Hub
Funding
Does Medicaid cover abortion in my state?
National Network of Abortion Funds
New York Abortion Fund
References
1. What States Allow Late Term Abortion 2023. Accessed March 2, 2023. https://worldpopulationreview.com/state-rankings/what-states-allow-late-term-abortion
2. Raymond EG, Harrison MS, Weaver MA. Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review. Obstet Gynecol. 2019;133(1):137-147. doi:10.1097/AOG.0000000000003017
3. Ferguson I, Scott H. Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries. J Obstet Gynaecol Can. 2020;42(12):1532-1542.e2. doi:10.1016/j.jogc.2020.04.006
4. MacNaughton H, Nothnagle M, Early J. Mifepristone and Misoprostol for Early Pregnancy Loss and Medication Abortion. Am Fam Physician. 2021;103(8):473-480.
5. Aiken A, Lohr P, 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 Int J Obstet Gynaecol. 2021;128(9):1464-1474. doi:10.1111/1471-0528.16668
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