Mail-Order Medication Abortion Effective and Acceptable to Patients

Mail-order pharmacy dispensing of mifepristone (Mifeprex) for medication abortion was effective and acceptable to patients, a prospective cohort study showed.

Of 510 medication abortions, complete abortion was achieved in 97.8%, and 91.2% reported satisfaction with medication abortion, which was comparable to studies of medication abortion with in-person dispensing, reported Daniel Grossman, MD, of the University of California San Francisco, and colleagues.

In addition, 90.4% of the participants who completed two surveys on their experience said they would use mail-order dispensing again for abortion care, the researchers reported in JAMA Internal Medicine.

There were 24 adverse events (4.7%) for which additional care was sought. Only three patients experienced serious adverse events requiring hospitalization (one with blood transfusion). However, none of the adverse events were associated with mail-order dispensing.

“All of the evidence continues to show that these simplified models of providing medication abortion are safe and effective,” Grossman told MedPage Today, adding that research like this study is necessary for the FDA to change its policies.

Medication abortions have become increasingly popular. From 2020 to 2023, the proportion of non-hospital abortions that were medication abortions rose from 53% to 63%, likely tied to both the COVID-19 pandemic and the overturning of Roe v. Wade. During the pandemic, the FDA suspended and then removed mifepristone’s in-person dispensing requirement, which opened up prescribing in telehealth sessions.

The prospective CHAT study published earlier this year also showed that medication abortions obtained via telemedicine were safe and effective.

“The FDA really did the right thing when it reviewed the evidence back in 2021, and made the decision to eliminate the in-person dispensing requirement,” Grossman said, noting that the requirement didn’t “make sense from a medical perspective” and limited access to care.

Melissa Simon, MD, MPH, of Northwestern University Feinberg School of Medicine in Chicago, told MedPage Today that this study was especially critical for rural America and for states with restricted access to abortion.

“This research was really important because it basically delineates that care, especially reproductive healthcare and care for abortion, can absolutely be delivered safely via mail, telehealth, and other approaches rather than forcing a person who is pregnant to come into a clinic in person,” said Simon, who was not involved in the study. “And this is especially important in times of disasters or emergencies such as COVID.”

She noted that this type of research is relevant in the context of unacceptably high maternal mortality rates and closures of abortion clinics and maternity wards in large swaths of the country.

Grossman said that while there has been interest from primary care physicians to provide medication abortions, there’s been a lot of barriers; dispensing by mail would remove one of those barriers.

In an accompanying viewpoint, Emily Godfrey, MD, MPH, of the University of Washington School of Medicine in Seattle, and co-authors noted that “primary care clinicians are a critical, untapped resource poised to take on the U.S.’ abortion care crisis by offering medication abortion to patients in their clinics,” particularly in rural areas, where telehealth is “especially important.”

“By recognizing that half of all pregnancies occurring in the U.S. are unplanned, that abortion is common, and that providing first-trimester abortion services using prescription medicines is within the scope of primary care, these primary care clinicians who offer abortion services can dramatically increase patient access earlier in the pregnancy, which is a critical part of reducing the U.S.’ comparatively poor record of pregnancy-related complications and death,” they wrote.

Grossman said future research may depend on how upcoming Supreme Court decisions go, including the Alliance for Hippocratic Medicine’s challenge to mifepristone.

This study was conducted from January 2020 through May 2022 (with a pause from March to June 2020 because of the COVID pandemic) across 11 clinics in seven states: California, Colorado, Delaware, Georgia, New York, Pennsylvania, and Rhode Island. Of the 11 clinics, five were abortion clinics and six were primary care sites, four of which had not provided abortion before.

Participants were seeking medication abortion for a pregnancy ≤63 days’ gestation. They had to be willing to take misoprostol buccally.

They were assessed for eligibility for medication abortion in-person but mifepristone and misoprostol were prescribed via mail-order pharmacy. Patients received standard follow-up care at the clinic, and those who consented participated in online surveys about their experiences at days 3 and 14 after enrollment.

Of the 540 patients enrolled, 506 had 510 abortions and 477 completed both surveys and had clinical information available.

Median patient age was 27, 38.3% were Black, 17.4% were Hispanic, 27.9% were white, and 8.9% were multiracial or other.

The authors noted that because their study was not randomized, generalizability may be limited. Clinical sites with a motivated clinician and supportive administrators tended to be in states with fewer abortion restrictions. In addition, patients had to consent to mail-order dispensing, which may not be an option for all patients. The study was not powered to precisely estimate safety outcomes, and satisfaction with services may have been overestimated due to social desirability bias.

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