In September 2020, Kelsey drove nearly 750 miles round-trip to have an abortion. She was living in a state where there was very little abortion care, and she was concerned about the COVID-19 protocols of the clinic closest to her, 160 miles away. So, she went for the next-best option: a clinic in Colorado. Despite staying with a friend to avoid hotel costs, she said she spent over $700 on travel and the procedure itself.
“It wasn’t the abortion itself that was awful,” she said. “The abortion was very necessary, and I’m very glad that I was able to have it. It was all of the hurdles that were traumatic.”
In late 2022, Kelsey, whose name has been changed to protect her privacy, learned that she was pregnant again. By this time, she was living in New Mexico, where abortion remains legal, and there were two providers within 40 minutes of her home. Both clinics, however, like all eight of New Mexico’s in-person abortion providers, were overstretched because of increased demand from neighboring states like Texas and Oklahoma, where abortion has been banned. (The increased demand is affecting more than abortion care; it’s also delaying other appointments, such as for birth control.) The earliest available appointment was more than a month out.
So Kelsey turned to the website of Aid Access, a European nonprofit that enables doctors to provide virtual consultations and abortion pills by mail around the world. She was connected with a clinic in Las Cruces that prescribed the medication, and an online pharmacy sent it to her.
As more states enact abortion bans following the Supreme Court’s June 2022 decision to overturn Roe v. Wade, researchers expect the distance many patients have to travel will triple. By choosing telemedicine and self-management, Kelsey joined the increasing number of Westerners able to avoid long-distance travel to clinics. These at-home alternatives, which studies show are as safe as clinical abortions, can improve abortion access in the health-care deserts of the rural West while reducing the cost, travel and environmental impacts of seeking care far away.
IT TOOK JUST SIX DAYS for Kelsey’s pills to arrive. Researchers say this is one of the main reasons patients utilize telehealth for abortions: It’s often much faster than waiting for in-person appointments. Virtual care also significantly decreases the distances patients need to travel — which, in the West, regularly involve mountains, snow and long drives. On top of that, not everyone has access to a car.
Kelsey said she thought about this when she traveled to have an abortion in 2020. In the relatively poor and rural area where she lived, transportation was difficult for some. Her neighbors often asked for rides on Facebook. “If you can’t get a ride 30 minutes to town to make it to your court date, then how would you possibly round up a vehicle and enough money to drive yourself to another state to have an abortion?”
“How would you possibly round up a vehicle and enough money to drive yourself to another state to have an abortion?”
That travel burden also has an environmental cost. In a new study, researchers at the University of California, San Francisco surveyed telehealth abortion patients about their experiences — and calculated the travel they avoided. Across more than 6,000 patients in 24 states, 56% of whom were in the West, the researchers found that telehealth saved patients a total of nearly 163,000 miles of driving, or nearly 4,200 hours.
More detailed surveys of a subset of those patients showed that Westerners saved an average of nine miles of driving by using telehealth. But 90% of those patients were in urban areas. For the 10% in rural areas, the difference was far bigger — they saved an average of 83 miles. That mileage adds up. According to the EPA’s carbon footprint calculator, this kept an estimated 63 to 66 metric tons of carbon dioxide out of the atmosphere.
The researchers also asked the patients in the study whether an abortion would have been easily accessible to them without telehealth. Most patients of color, younger patients, rural patients and those who would have had to drive over 100 miles for an appointment said no. “Thinking about the folks who were really living at the margins and are already facing many forms of structural oppression, lifting this travel burden feels really tied up in climate justice to me,” said Leah Koenig, a Ph.D. student in epidemiology at UCSF and the lead author of the paper.
In July 2020, a district court in Maryland ruled that during the COVID-19 pandemic, it should be possible to mail mifepristone, which is one of the two pills taken in conjunction to terminate a pregnancy. (At the time, it required in-person pick-up.) The Food and Drug Administration made that decision permanent in December 2021, though it is under scrutiny again. A Texas judge is currently hearing a legal challenge to it; his ruling could affect providers’ ability to mail mifepristone.
The authorization cleared the way for a slew of virtual abortion-care startups, including Abortion on Demand, Just the Pill, Choix, Hey Jane and Abortion Telemedicine. Patients schedule video or text-message consultations with a licensed health-care provider in the company’s network, the provider prescribes the pills, and the company arranges for the pills to be shipped to the patient’s address. (If the Texas judge suspends the authorization to mail mifepristone, telemedicine startups say that people seeking abortions will likely continue using modified dosages of the other medication, misoprostol, a method that lacks FDA approval but has been deemed safe by the World Health Organization.)
The startups, some nonprofit and some for-profit, don’t take insurance, but they’re often cheaper than getting a clinical abortion.
Though they can only operate in states where abortion is legal, they are able to serve people who aren’t from those states, with one caveat: In order to have a consultation and receive a prescription, the patient needs to physically be in a state where abortion is legal. The travel this requires involves the same equity issues that clinical abortions do, but going to a hotel or friend’s home for a telehealth appointment can be easier and faster than waiting for a clinical appointment.
Aid Access, which Kelsey contacted, operates slightly differently than the startups. In states where telehealth abortion is legal, it functions the same way they do, partnering with local clinics to prescribe pills and offer consultations. But in states with bans, it works around the U.S. legal and health systems: A doctor in Europe, where U.S. laws have no jurisdiction, prescribes the pills, and a pharmacy in India mails them. This enables even people who live in states that have criminalized abortion to obtain pills by mail, though they still lack access to a consultation. The approach relies on a legal loophole. Although in most cases, it’s illegal to import medicines, the FDA seldom enforces that rule for prescription drugs that are imported for a person’s own use.
Abortions like this are considered “self-managed,” a term doctors and researchers use to refer to abortions that take place outside the health system. Such abortions were once associated with back-alley procedures, but now the use of medications is far more common. Before May 2022, when the Supreme Court’s plans to overturn Roe v. Wade leaked out, Aid Access received an average of 83 requests a day from the U.S. for pills for self-managed abortions; after the draft decision was announced, the requests jumped to more than 200 a day.
“For various parts of the country, including rural regions in the West, telehealth clinics are filling health-care deserts while also reducing the travel, costs, logistics, and environ-mental impacts of having an abortion.”
Kelsey knew about telehealth and self-managed options when she traveled to Colorado in 2020. “I thought really hard about it,” she said, wanting to avoid the trip. But in the end, she said, she got spooked: “I had never had this happen to me before, so I didn’t know what it was going to be like, and I kind of wanted a doctor.” This time, she said, “I didn’t feel like waiting a month, and I’d had a medication abortion before with no complications. So, I was just kind of like, fuck it, let’s go with this.”
Doctors and researchers emphasize that the pills are safe. In over half of all abortions in the U.S. — including many clinical abortions, such as Kelsey’s first — physicians use medication. According to another UCSF study, adverse reactions that require blood transfusion, surgery or hospital admission occur in less than half a percent of medication abortions. Even when pills are prescribed in person, they’re often taken at home.
Still, like other aspects of reproductive care in the U.S., the legal landscape of medication abortions is in flux. In addition to the litigation over mailing mifepristone, some states have sought to prosecute self-managed abortions, either banning them outright or using indirect laws, like those governing the disposal of human remains. In at least one instance in Ohio, a criminal case involving mail-order abortion pills resulted in a conviction. And in January, the attorney general of Alabama announced that individuals who had medication abortions in the state could be prosecuted under a law aimed at protecting children from chemicals in homes.
For Kelsey and many others, telehealth offers convenience and efficiency. But for some patients in the West, telehealth provides more than comfort — it’s the only feasible choice. “For various parts of the country, including rural regions in the West, telehealth clinics are filling health-care deserts while also reducing the travel, costs, logistics, and environmental impacts of having an abortion,” Andréa Becker, one of the other researchers on the UCSF study, wrote in an email. “It’s critical to give people the option to choose the abortion process that works for them, whether that’s in a clinic or from their couch.”
Caroline Tracey is the climate justice fellow at High Country News. Email her at caroline.tracey@hcn.org or submit a letter to the editor. See our letters to the editor policy.
This article appeared in the print edition of the magazine with the headline Navigating the new health-care deserts.
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