Editor’s Note: This story was first published on New Hampshire Bulletin.

A recent federal rule change will expand access to abortion care by allowing pharmacies, no longer just clinics, to dispense abortion pills, which can be used to terminate a pregnancy up to 11 weeks. But it’s local providers who may give even greater access with the introduction of telehealth appointments.

Last summer, Planned Parenthood of Northern New England began offering patients seeking to terminate a pregnancy with medication, rather than a surgical procedure, the option of consulting with a provider via telehealth. If a provider deems medication abortion safe for the patient, the clinic will send the medication by mail. Previously, patients had to physically visit a clinic to get it.

The Equality Health Center in Concord hopes to roll out a similar program early this year.

Until recently, federal and state regulations made telehealth abortions and mail-order medication in New Hampshire impossible, said Kayla Montgomery, vice president for public affairs at Planned Parenthood of Northern New England.

The state’s 24-week abortion ban required an ultrasound, which must be done in a clinic, until lawmakers removed it last year. And prior to the pandemic, Medicaid reimbursed for telehealth visits at much lower rates than it did for in-person care, making telemedicine a financial challenge. Legislation passed in 2020 now disallows that discrepancy in reimbursement rates.

And in 2021, the Food and Drug Administration said it would permanently drop a prohibition on mailing abortion pills; it initially made that rule change during the pandemic, but only as a temporary measure.

Montgomery said among Planned Parenthood of Northern New England’s patients, about 60% choose a medication abortion over a surgical procedure. But currently, most are still coming to the clinic for medication abortions; just 10% to 15% are using the new telehealth option, she said.

Montgomery said she suspects that’s due in part to the option being new but also because telehealth is not possible or preferred by everyone. For example, medication abortion is not an option after 11 weeks of pregnancy or for patients with risk factors or who require an ultrasound.

“People really find that, if you’re early on in pregnancy, if you don’t have a lot of risk factors, a lot are choosing medication abortion because they can have their abortion in the comfort of their home,” she said.

But it may not be the right choice for someone without a safe place to have an abortion outside the clinic. And medication abortion can take longer, one or two days, versus an hour for a surgical abortion and recovery.

“It’s really all about patient choice,” Montgomery said. “It’s all about whatever works best for each individual patient. We want to work with all of our patients to make sure that they have the choices that they need and that works best for them.”

What is a medication abortion?

Medication abortions are on the rise in the United States, from 39% of terminations in 2017 to 54% in 2020, according to a 2022 report from Guttmacher Institute.

The process requires two medications, mifepristone followed by misoprostol. Unlike the “morning-after pill,” which prevents pregnancy, mifepristone and misoprostol terminate a pregnancy by blocking the progesterone needed for a pregnancy to continue.

A patient can expect cramping and bleeding. Planned Parenthood likens the experience to having a really heavy, crampy period and describes it as similar to a miscarriage.

Who is eligible for a telehealth medication abortion?

Planned Parenthood of Northern New England and the Equality Health Center offer pill abortions up to 11 weeks after the first day of a patient’s last period. Equality Health Center will shorten the time frame for telehealth medication terminations to eight weeks.

After 11 weeks, surgical abortions are the only option for ending a pregnancy.

Patients must not require lab work or an ultrasound, and they have to have a stable, safe place to go through the process, which may take several hours but can take longer. Providers can treat only patients in a state where they are licensed to practice medicine.

For Planned Parenthood of Northern New England, whose providers are licensed only in New Hampshire, Maine or Vermont, a person must live in one of those states or they must travel here for an in-clinic abortion, including medication termination.

Montgomery said their providers cannot mail abortion pills to people outside those three, such as those living in states that have significantly restricted access to abortion.

How do telehealth medication abortions and mail-order pills work?

In many ways, a telehealth appointment is similar to a clinic visit, providers said. A clinician reviews a patient’s medical history and talks through termination options and the specifics of a medication abortion. If a provider determines a medication abortion is safe for a patient, the person can pick up the medication in the clinic or request it be sent by mail.

The January rule change by the Food and Drug Administration now allows pharmacists for the first time to dispense mifepristone, the first drug required for a medication abortion, to someone with a prescription from a health care provider. The second drug, misoprostol, was already available at pharmacies.

The New York Times reported Thursday that CVS and Walgreens have said they will offer mifepristone where abortion remains legal, which includes New Hampshire up to 24 weeks. After that, an abortion can be performed only if a fetus has a fetal anomaly.

Abortion will be back before lawmakers

Of the more than 800 bills the Legislature is expected to take up this session, none so far target telehealth medication abortion or the mailing of abortion pills. But there are several that target the state’s abortion law and access to abortion and reproductive health.

One bill would ban abortions after a fetal heartbeat is detected, which can be as early as about six weeks. The same legislation failed in 2020 and 2022. Another would require a patient to give “informed consent” prior to terminating a pregnancy, which can include showing patients images or illustrations of a fetus at their state of pregnancy. Similar legislation has failed multiple times since 1992.

One bill is not explicitly linked to abortion but could come into play in some abortions. Under the legislation, the text of which has not been released, medical providers would have to give any baby born alive life-saving medical treatment.

This would impact parents whose baby is born alive during or after an abortion but will not live long. Lawmakers heard from parents last session who chose abortion because their fetus had a fatal anomaly but wanted to hold the baby until it died. Similar legislation has failed at least four times since 2016.

Other bills would expand or protect access to abortion.

Democrats have introduced legislation that would repeal the 24-week abortion ban, a bill that would prohibit further restrictions on abortion and a proposed constitutional amendment establishing a right to make personal reproductive decisions.

Gov. Chris Sununu has said he would not support further limits on abortion, and House Majority Leader Jason Osborne, an Auburn Republican, has said he doesn’t believe House Republicans will pass legislation that would attempt to do so.

Montgomery said Planned Parenthood of Northern New England is not relying on those statements.

“It was Governor Sununu who in 2020 said that there wasn’t going to be any abortion restrictions, and he signed an abortion ban,” she said. “We’re never going to stop fighting, we’re never going to back down. We need to protect access, we need to expand access. No, no matter who says what, no matter what comes from politicians, we know we’re going to have a fight on our hands every year.”

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