Here we are, just after the 1-year anniversary of the U.S. Supreme Court’s Dobbs decision. A patchwork of abortion policies have emerged across the country, meaning that where you live dictates the medical care you can receive. Fifteen states have banned abortion completely or at 6 weeks of pregnancy, before many people even know they’re pregnant. An additional five states have enacted bans at 12 to 18 weeks of pregnancy, and bans in other states are working their way through the courts or scheduled to go into effect soon. As a doctor in California, I know there is more I could do to help patients across the country who need care if only our legal system allowed me to do so.
Laws banning abortion are having a real impact on women and others with the capacity for pregnancy — both for people seeking abortion care and those experiencing complications during pregnancy. A recent report, which I wrote with colleagues from the University of California San Francisco and the University of Texas at Austin, documented 50 cases of poor-quality medical care due to these bans. These cases described care that was delayed or denied, resulting in serious harm to pregnant women. For example, there were 11 cases of women whose water broke in the second trimester, long before their babies could survive. Instead of being offered the option of an abortion, considered the national standard of care, these women were sent home and told to come back when they were in labor or had signs of infection. Many of them developed a serious infection requiring treatment in the intensive care unit.
With medical care so compromised in a growing number of states — potentially half our nation — clinicians in states where abortion remains legal are anxious to help patients living in places where care is restricted. We are welcoming the patients who can travel to our states and obtain care with us, and some of us are traveling to the states nearest those with bans, such as Illinois and Kansas, to provide in-person care.
But telemedicine could also be part of the solution. A great deal of evidence has proven that telemedicine for medication abortion is safe and effective. Patients seeking abortion care can be evaluated for eligibility using video, telephone, or online screening, and those who are eligible receive the pills by mail. The FDA has recognized telemedicine provision of medication abortion as standard medical care.
Unfortunately, our country’s medical and legal systems limit the potential of this telemedicine solution. Medical practice is largely regulated at the state level, and telemedicine is viewed as occurring in the state where the patient is located. To provide abortion care to a patient in another state, I must be licensed in the state where the patient is and comply with that state’s laws. Under this scenario, I couldn’t do this in a state that has banned abortion.
Last year, Massachusetts became the first state to enact a “shield” law to protect clinicians there who provide reproductive healthcare, including abortion and gender-affirming care, regardless of where the patient is located. On its face, the law provides protections against incarceration by preventing extradition, as well as protecting the provider’s license and limiting the enforcement of civil judgments. Several other states, including Colorado, Vermont, and Washington, have passed similar bills, and another, SB 345 introduced by state senator Nancy Skinner (D-Calif.), was just passed by the California Senate. Most recently, New York took action last week to protect providers who prescribe medication abortion for patients in states that have banned abortion.
These laws cannot provide complete protection. If a clinician providing cross-state telemedicine medication abortion were accused of a crime in Texas, for example, and ever traveled there — or to any other state that might agree to extradition — there is a risk they could be arrested. In addition, these laws have not yet been tested in the courts, and it remains to be seen how much protection they will actually afford.
The stories from our report of doctors who had to watch their patients bleed or develop an infection because of abortion bans are hard to read. They are not too far from how I feel, comfortably caring for patients in California, knowing that I could safely provide medication abortion by telemedicine if only the law would allow. I cannot sit by idly as patients in other states desperately seek out options for an unintended or medically complicated pregnancy. I hope California and every state where abortion remains legal passes a shield law protecting the provision of care across state lines.
Daniel Grossman, MD, is a professor of obstetrics, gynecology, and reproductive sciences at the University of California San Francisco, and director of Advancing New Standards in Reproductive Health.
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