Published: June 8, 2010

The New York Times


DES MOINES — The situation has played out hundreds of times. From his office here, a doctor asks a woman on the computer screen before him one final question: Are you ready to take your pill?

Then, with a click of his mouse, a modified cash register drawer pops open in front of the woman seated next to a nurse in a clinic — perhaps 100 miles from this city — with mifepristone, the medicine formerly known as RU-486, that is meant to end her pregnancy.

Efforts to provide medical services by videoconference, a notion known as telemedicine, are expanding into all sorts of realms, but these clinics in Iowa are the first in the nation, and so far the only ones, experts say, to provide abortions this way.

Advocates say the idea offers an answer to an essential struggle that has long troubled those who favor abortion rights: How to make abortions available in far-flung, rural places and communities where abortion providers are unable or unwilling to travel. So far onlyPlanned Parenthood clinics in Iowa use this method, but around the country, abortion providers have begun asking how they might replicate the concept.

For some, however, the program tests the already complicated bounds of telemedicine. Abortion opponents say they are alarmed, fearful for the safety of women who undergo abortions after consulting with doctors who have never actually been in the same room with them. Opponents filed a complaint this spring with the Iowa Board of Medicine, arguing that a doctor’s remote clicking of a mouse hardly meets the state’s law requiring licensed physicians to perform abortions, and more objections are coming.

“This is a prescription for disaster,” said Troy Newman, who leads Operation Rescue, which opposes abortion and, in May, took part in protests over the telemedicine matter in Cedar Rapids. “You are removing the doctor-patient relationship from this process. And think about it: With this scheme, one abortionist sitting in his pajamas at home could literally do thousands of abortions a week. This is about expanding their abortion base.”

Abortion rights leaders dismiss the objections, and say this method has proved largely safe, effective and — to the surprise of some — perfectly acceptable with most patients.

“They are not really protesting the new technology,” Dr. Vanessa Cullins, the vice president for medical affairs at Planned Parenthood Federation of America, said of the critics. “They are protesting abortion in general.”

Though the efforts drew little attention until recently, Planned Parenthood of the Heartland (which recently combined affiliate operations in Nebraska with those in Iowa) has dispensed abortion medication using teleconferencing equipment at 16 Iowa clinics since June 2008; 1,500 such abortions have been performed in this state.

Federal authorities approved the use of abortion pills in the United States in 2000. Since then, more than a million women have taken mifepristone, followed a day or two later by a second drug, misoprostol. The option is provided to women only early in pregnancy, up to nine weeks.

The total number of abortions nationally has declined in recent years, but the percentage of women opting for abortions by medication — as opposed to the more common surgical alternative — is growing.

Abortion providers say the pills are safe and mostly effective (successfully ending about 97 in 100 pregnancies, according to Planned Parenthood). In rare cases, such abortions have appeared related to sometimes fatal infections caused by a bacterium, though federal authorities have found no definitive link.

Some people, including Jill June, president and chief executive of Planned Parenthood of the Heartland, have long seen the potential of abortion medication as making it feasible for women in remote places, far from surgical clinics and surgical abortion providers, to have access to abortions in their own local doctors’ offices. But that promise, Ms. June said, has largely gone unfulfilled (many doctors have not offered the pills), and that — as well as a television show she saw one night in which a doctor carried out elaborate surgery via a robotic device — led her to dream up Iowa’s program.

“If they can do some of these complicated surgeries from miles and miles away from an operating room, why can’t I hand someone a pill across the state?” Ms. June remembered thinking.

In the Planned Parenthood offices here, a demonstration of the abortion procedure by teleconferencing reveals a process that feels not unlike any ordinary doctor’s office visit, but for the doctor appearing on a computer screen on the desk and the unexpected sight of a cash register drawer eventually flinging open with the needed drugs.

Before the videoconference begins, a patient in a distant clinic meets (in person) with a nurse. There, blood tests, a medical history, an exam, an ultrasound and counseling on matters like what to expect from the procedure and plans for a follow-up exam are completed. The results are shared (by computer) with a doctor miles away, and the doctor and the patient (at all times accompanied by the nurse, who sits beside her) meet by videoconference over a private network.

“I don’t feel like something is lost or missing,” Dr. Tom Ross, one of Planned Parenthood’s doctors, said.

Dr. Ross said he talked to patients — asking his questions and answering any of theirs — as if he were speaking to them in person. In most cases, he then clicks on a button that releases the drawer in front of the woman. Inside are two bottles — one for the mifepristone she will take immediately, while still sitting in the clinic, and the other for the misoprostol she will take later.

No serious complications have occurred in Iowa involving these videoconference patients. And the patients, mainly, seem fine with the procedure. They have a choice: when they call to seek an abortion, women who live far from city clinics can either take abortion medication in a distant office with the doctor on teleconference, or travel to the doctor.

It is uncertain how long it will take the State Board of Medicine to investigate Operation Rescue’s complaint that this method does not meet the state requirement that licensed physicians — not nurses or others — perform abortions.

“One way or another, we’re going to shut this scheme down,” Mr. Newman of Operation Rescue said. “Health care just isn’t a one-size-fits-all package of pills. And yet there it is — prearranged, prepackaged, out pops that package of pills — pop!”

About a dozen states allow medical personnel with training less than that of licensed doctors to perform abortions. In those places, mimicking Iowa’s system might have little purpose. But elsewhere, said Vicki Saporta, president of the National Abortion Federation, which represents abortion providers, such providers are watching Iowa with keen interest.