Legal threats to telehealth abortion are also a climate issue

Legal threats to the provision of mifepristone via telemedicine, mail delivery, and pharmacy dispensing have the potential to greatly reduce access to abortion for many communities in the U.S. by requiring in-person care at clinics and medical offices. Those facing the potential for road closures and power outages as hurricane and wildfire seasons close in this summer could have an even harder time obtaining abortion care if remote access options are restricted by the courts.

Delays brought on by extreme weather events "can push people further into pregnancy, narrowing or eliminating the window in which medication abortion is available and increasing the cost and complexity of care," Serra Sippel of The Brigid Alliance, which provides logistical and practical support to people seeking abortions, told CG. In some cases, the option of prescribing abortion medications in a virtual appointment and mailing the medications directly to patients can help to address these delays.

But a May 1 ruling from the 5th U.S. Circuit Court ‌of Appeals in the case Louisiana v. U.S. Food and Drug Administration re-imposed a previous federal requirement that the provision of mifepristone — one of the drugs that can be used to end a pregnancy — be conducted in person. Days later, and after mifepristone manufacturers highlighted the "confusion," "upheaval," and "regulatory chaos" whipped up by the lower court's sudden restrictions, the U.S. Supreme Court temporarily stayed the Circuit Court's ruling. 

That administrative stay reinstated telehealth, mail, and pharmacy provision of the drug — where it is otherwise legal — through at least May 11. But legal actions following the stay could remove access to these more remote options.

Back in 2000, the FDA approved mifepristone for the medical termination of a pregnancy through seven weeks of gestation but at that time required in-person dispensing at a clinic or doctor's office. In 2016, the agency approved its use through the 10th week of pregnancy. During the COVID-19 pandemic, the FDA expanded access to include telemedicine prescriptions, mail delivery of medications, and pharmacy dispensing in 2021. 

In many cases, this meant patients could be prescribed mifepristone without having to secure an appointment at a sometimes faraway clinic, take time off of work for that appointment, arrange costly child care — or drive through a major storm to get there. Mifepristone could then be delivered by mail or dispensed at a pharmacy to the patient. 

Telehealth abortion care has also been widely regarded as a stopgap for preserving some legal access to abortion in states where the health care is now banned or heavily restricted following the overturn of Roe v. Wade in 2022. According to the New York Times, "Eight states have [enacted] telemedicine shield laws, which aim to protect doctors and others who prescribe and send abortion pills in the mail to patients located in states with bans."

"That is really why the number of abortions that people have in the U.S. has not declined since the U.S. Supreme Court overturned Roe," Molly Rivera, Communications Director at Planned Parenthood South Atlantic, told CG in an interview. "It is because of telehealth access, largely."

Rivera understands the impact of protecting multiple pathways to abortion care. In her South Atlantic service area, the telehealth option is already limited in North Carolina and already banned in South Carolina. In South Carolina, abortion is also banned after six weeks of gestation. In West Virginia, there is a total abortion ban.

At the state level, abortion care — including the telehealth option — has already been banned or heavily restricted in numerous states. Now, more federal limits are on the table, as the case Louisiana v. FDA threatens the agency's 2021 approval for telehealth care. 

"Restricting access to telehealth, like for any other health service, would restrict access to that service," Rivera said. "And the challenge with abortion care is that it is time-sensitive care. It's not something that can be scheduled out six months in advance. So when people need it, they need it right now."

That factor of time sensitivity can play a role for anyone seeking abortion care, and it can mean unscheduled obstacles — such as sudden storms or wildfires — can pose serious challenges to access.

Sippel is the Executive Director at The Brigid Alliance, which, she says, mostly supports clients who "are later in gestation and require in-clinic care" — medication abortion isn't recommended past a certain point in pregnancy. Meanwhile, she told CG, "For abortion seekers who are looking to access medication abortion, extreme weather can have a profound impact." 

"Storms, flooding, wildfires, and other disasters can delay travel, close roads, cancel flights, interrupt child care, destabilize housing, and make it harder for people to gather the funds and documents they need to get care," she said. 

"After Hurricane Helene, people seeking abortion care in the South faced additional barriers on top of an already strained access landscape," Sippel continued, pointing to the impacts of the major 2024 storm that devastated numerous Southeastern states and parts of the Caribbean.

Telemedicine options that make it possible for abortion drugs to reach patients where they are — instead of forcing patients to reach brick-and-mortar health facilities — can help to alleviate some of this strain. Although, as Jenna Hudson, Senior Counsel of U.S. Litigation at the Center for Reproductive Rights, pointed out, extreme weather can delay mail delivery of medications too.

"Damaged clinics may be forced to close. Impassable roads can prevent abortion pills in the mail from getting in and patients from getting out," Hudson told CG. "These communities already live with unpredictability when it comes to the weather — their care and safety shouldn’t feel the same."

Even though telemedicine and mail delivery aren't silver bullets for ensuring abortion access — given not only storm-snarled mail delays but also an ever-evolving maze of state laws and the fact that some patients will need or prefer in-person care — reproductive rights advocates agree it's important to protect the telehealth option.

The significance of this option won't be of any surprise to the global health experts who have long touted self-care as a climate adaptation to sustain medical access — to everything from blood pressure monitoring to HPV testing and contraception — that might otherwise be compromised when flooded roadways or drought-strained infrastructure make in-person care difficult or impossible.

And advocates in the U.S. stress that another type of medication abortion should still be accessible via telehealth even in the event of a ruling against the virtual prescription and mail delivery of mifepristone.

The medication misoprostol is another drug that can be used to end a pregnancy. While it's often used in combination with mifepristone, the misoprostol-only regimen for abortion can be safe and effective, and it's recommended by the World Health Organization. According to the reproductive rights organization Ipas, "A misoprostol-only regimen has success rates of 84-93%."

Rivera described how the misoprostol-only approach has already been leveraged in her service area to maintain abortion access where the telehealth option is otherwise legal.  

"On [May 1], when the 5th Circuit ruled, we had health centers open [the next day, before the ruling was stayed], and we were able to maintain telehealth access to abortion care using misoprostol," Rivera said.

Unsurprisingly, however, there are concerns that the telehealth prescription and mail delivery of misoprostol could face legal battles similar to those already raised against mifepristone. 

"We've already seen it at the state level," Rivera explained. "Nothing has passed as of yet, but the state of South Carolina right now is advancing a bill that would classify not only mifepristone but also misoprostol as a controlled substance, and that would make it harder to get."

Rivera and others have emphasized that such a move could compromise access to other types of essential health care as well. That's because misoprostol can also be used to manage miscarriages, induce labor, treat postpartum hemorrhage, treat fibroids, insert intrauterine devices, treat ulcers, and address arthritis.

So what are reproductive rights advocates doing while the public awaits word from the Supreme Court — and as hurricane and wildfire seasons inch closer for many parts of the country this summer?

"In the face of extreme weather and ongoing legal threats, our goal is to reduce as many barriers as possible so that people can get to the abortion care they need when they need it," Sippel told CG. "That means responding to urgent logistical challenges, helping cover rising costs, and strengthening the practical support infrastructure that patients rely on when care is pushed farther out of reach."

Hudson suggests that those who want to help protect abortion access call their elected officials, donate to abortion funds that help make costly care possible for patients, and consider supporting organizations like hers as they continue fighting in the courts. 

"The anti-abortion movement claims that cutting off access to a trusted, proven-safe medication is about 'protecting women,' but there is nothing safe about forcing patients to drive through winter storms or snowy mountain passes to pick up a pill that's just as safe for them to get in the mail and that, either way, they'll take at home," Hudson said. 

"Being able to mail abortion pills to patients can make the difference between getting care or not — and that's exactly why the anti-abortion movement is set on reducing access to them."

Kirsten Krueger contributed to the editing of this article.