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When N.H.'s ultrasound mandate fell, so did barriers to telehealth abortion services

Several mailboxes in a suburban neighborhood at sunset
John Watson
Flickr Creative Commons Attribution-NonCommercial 2.0 Generic (CC BY-NC 2.0)
In December 2021, the FDA permanently removed its requirement that patients had to pick up that medication at a hospital or clinic, allowing the drug to be shipped through the mail to states where that option was legal.

Dr. Julie Jenkins lives in Dover and works for a company that provides telemedicine abortion services in a handful of states where it's legal. She's considered getting licensed to do the same in New Hampshire — but until recently, one barrier has stood in the way.

“The reason that I have not pursued licensure in New Hampshire is specifically because of the ultrasound law,” she said.

This was one of the potentially unintended and under-the-radar consequences of a 2021 New Hampshire law that required an ultrasound before any abortion, even in cases where that step wasn’t medically necessary.

While local abortion providers said ultrasounds were routine for many abortion patients seen in person, the law effectively outlawed telehealth access the two-pill medication abortion regimen at a time when this procedure was expanding elsewhere.

But the recent repeal of New Hampshire’s ultrasound mandate, combined with expanded telehealth access to abortion medication by federal regulators, could make it easier for local patients to get an abortion early in pregnancy without ever having to set foot in a clinic. And this expanded access in New Hampshire comes at time when abortion access across the country stands on shakier ground than it has in decades.

How the COVID-19 pandemic changed abortion access via telemedicine

Medication abortions have long been an option for people seeking to end a pregnancy in New Hampshire. But until recently, that medication had to be obtained in person, at a hospital or clinic.

The COVID-19 pandemic changed that. In an effort to prevent the spread of the virus, health providers, courts and regulators took steps to reduce in-person healthcare visits that weren’t medically necessary on all kinds of procedures — including to obtain medication to end a pregnancy. In December 2021, the FDA permanently removed its requirement that patients had to pick up that medication at a hospital or clinic, allowing the drug to be shipped through the mail to states where that option was legal.

Medication abortions, both in and outside of clinics, account for over half of all abortions in the U.S., according to the Guttmacher Institute, a research and policy organization that advocates for expanded abortion access.

Many states have targeted access to this procedure by restricting telehealth appointments or requiring a clinician to be present while abortion medication is administered. While the debate over New Hampshire’s newly repealed ultrasound mandate focused on access to both medical and surgical abortions more broadly, the law had the secondary effect of banning medication abortions via telemedicine.

Renee Johannensen, a Vermont-based OB-GYN who is also licensed in New Hampshire, said the ultrasound mandate might not have been such a big deal if it passed prior to the pandemic — because ultrasounds were routine and telemedicine was less common.

“We'd be like, So what? We're doing [an ultrasound] anyway,” she said. “Who cares if it's mandated?”

But Johannensen said the pandemic pushed reproductive healthcare providers to re-evaluate their protocols and question whether a routine ultrasound was actually medically necessary.

Early in the pandemic, before New Hampshire’s ultrasound mandate took effect, Equality Health Center in Concord stopped performing ultrasounds in cases where it wasn’t medically necessary. Instead, as reported by the New Hampshire Bulletin, the clinic’s providers used other less-invasive methods to determine the age of the fetus, like asking a prospective abortion patient the date of their last period.

Recent studies indicate that providing an abortion via telehealth is safe, effective and improves access to care. One study published Journal of Midwifery & Women’s Health last February found it can also reduce wait times between a referral and treatment, allowing people to get an abortion about four days earlier than when a clinic visit was required.

The U.S. Food and Drug Administration has only approved the abortion pill regimen for use up to 10 weeks in a pregnancy. World Health Organization guidelines state that it can be used for up to 12 weeks at home and after 12 weeks in a medical office.

What this means for N.H. patients and providers

Now that New Hampshire's ultrasound mandate is repealed, licensed telehealth providers based all across the country can legally see local patients and prescribe abortion medication through the mail.

One telehealth clinic, Abortion On Demand, opened virtual appointments to New Hampshire patients at the start of June. Another provider, Aid Access, plans to start accepting New Hampshire patients next week.

Planned Parenthood of Northern New England, which performs abortions at two of its clinics in New Hampshire, is also planning to pilot a new program meant to allow patients to obtain a prescription for medication abortion mailed to their door. (In some cases, patients may first need to undergo certain lab tests.) This option is already available for patients in Vermont and Maine.

Josie Pinto, executive director of theReproductive Freedom Fund of New Hampshire, said the repeal of the state’s ultrasound mandate is a big deal — especially for Granite Staters who live in rural areas. Offering pregnant people a way to get an abortion via telehealth, they said, will make it “a lot easier for folks that struggle to physically get to clinics.”

The Reproductive Freedom Fund offers financial support for people seeking abortion, and Pinto said this policy change has also made it possible for them to work with a small group of trusted providers to help patients access the procedure through telemedicine. They previously held off on offering support for this type of abortion due to concerns about its legality while the ultrasound mandate was still in place.

For patients paying for an abortion out-of-pocket, Pinto said obtaining medication through telehealth can be more affordable than visiting a clinic. An abortion performed at a clinic early in a patient's pregnancy can cost up to $750, according to Planned Parenthood; telehealth clinic Aid Access, for example, offers abortion pills and a virtual appointment for $150.

How this option might fit into a changing abortion landscape

Improving access to abortions through telemedicine has already become a focus for abortion advocates and providers as conservative states impose broad restrictions on abortion access.

Many experts see the fight over medication abortion as thenext frontier in the battle of abortion rights. While many states have already taken action to restrict the procedure, it could become hard to enforce those policies if patients turn to unsanctioned providers or attempt to order the medication from overseas.

In states like New Hampshire, where there are comparatively fewer restrictions on abortion than in some other states, Johannensen said the rise in medication abortion could play another role.

Providers and advocates across New England are preparing to assist an influx of out-of-state patients following the expected overturn of Roe v. Wade. Johannensen said making it easier to access abortion medication through telehealth could help to reduce the number of patients traveling to local clinics — which, in turn, could lower wait times and “open more clinic appointments for people who really need to be in the clinic.”

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