While the uterus is commonly revered as the miraculous womb of life, it comes with inconvenience, costs, and stigma for many women. Some of the challenges are unavoidably physical—monthly cramps and decades-long exposure to pregnancy risk. But many others result from social and political constructs that stigmatize women’s bodies and create barriers to accessing reproductive health care.
No other body part is as highly regulated as the uterus. In 2011, a year after anti-choice candidates swept state elections in the United States, more than 1,100 bills were introduced regarding women’s health and rights. While some ground was regained during the Obama administration—most notably the coverage of contraception under the Affordable Care Act, which resulted in more than 57 million women getting contraception without a co-payment—the Trump administration is systematically eroding this progress. State legislators across the country continue to introduce laws to restrict essential reproductive health services.
In such a political climate, it is critical to find ways of making both contraceptives and abortion more accessible to those who need them. The right to obtain and use contraception and access abortion is part of the fundamental right to privacy guaranteed by the US Constitution. Nearly half of the six million pregnancies that occur each year in the United States are unintended. There is no reason to force women to go without convenient access to these safe and effective options.
Technology may afford a way around the current challenges to reproductive health access. Just as Amazon and Airbnb are using creative delivery and technology solutions to increase access to goods and services, new channels have arisen for accessing health services. Today’s reproductive generation consists of digital natives who are attracted to and demand client-centered design and convenience. Our organizations, Pandia Health and Plan C, answer their need for better options.
The Potential of Technology
About three years ago, coauthor Sophia Yen learned that one of the top three reasons women don’t take their birth control pills is because they don’t have them on hand. Yen and Pandia Health cofounder Perla Ni knew they could solve this problem: just ship the pills to women and keep shipping them (automatic refills) until the women said to stop. They would provide a delightful user-friendly experience instead of the current slow, painful pharmacy experience. However, when Yen and Ni ran ads for “free birth control delivery,” they found that about 60 percent of women didn’t have a prescription. As a doctor, Yen realized she could write the prescriptions. Thus, the idea of their organization was born. (Note: Ni was the founding publisher of Stanford Social Innovation Review.)
Pandia Health currently provides convenient, confidential, and reliable prescription birth control delivery in California, and it is raising funds to serve more states. Pandia Health increases access for women who live hours away from the nearest pharmacy or doctor, and delivers prescription birth control (the birth control pill, patch, or ring) to wherever women have Internet access and a mailbox. By delivering the medications to their mailbox, Pandia Health saves women the time and transportation costs they would have incurred by refilling their prescription at the pharmacy every month. It also spares them the potential embarrassment they may face as their neighbors see them in line or the pharmacist announces aloud, “You’re here for birth control again?”
The potential for technology to deliver convenient reproductive health services to women does not stop with prescription birth control. Coauthors Francine Coeytaux and Elisa Wells recognized that the same technology-based model could be used to expand access to mifepristone and misoprostol, the two medicines that constitute the highly effective abortion pills, also called medication abortion.
For more than 10 years, women around the world have been able to self-diagnose their pregnancies and order highly effective and safe early-abortion pills online or obtain them from a local pharmacy, often without a prescription. Services such as Women on Web, Women Help Women, and, more recently, safe2choose offer online consultations and express delivery of abortion pills directly to women in their homes, all without a physical exam. These sites also offer information and support to women about what to expect during the abortion process. Not surprisingly, research has found that women value the convenience and privacy of online services. Research has also demonstrated that the safety and effectiveness of this model are comparable to those of services delivered through clinics.
Unfortunately, none of the services that supply pills in other countries will ship them to the United States, despite receiving nearly 10,000 requests per month from women here. These pills are the same ones given to women who choose a medication abortion at Planned Parenthood and other abortion clinics. But because abortion is so highly politicized in the United States, access to these pills has been severely restricted since the day that mifepristone (RU-486, also known as the French abortion pill) was approved by the US Food and Drug Administration in 2000. Unlike the vast majority of medications, which clinicians prescribe and patients pick up at a pharmacy, mifepristone can only be shipped to doctors who have specially registered with the manufacturer.
This unusual FDA requirement was not established because mifepristone poses risks or requires special clinical expertise to provide—it is safer than Tylenol. Rather, the politics surrounding abortion and the strength of the US anti-choice lobby successfully restricted this safe, new technology. The hope had been that having an abortion pill could de-medicalize the abortion experience and expand the availability of abortion services beyond surgeons and into the hands of primary care providers. Advocates also envisioned pharmacy or over-the-counter access, which could have greatly diffused the stigma of both providing and seeking abortion and enabled a home-based private abortion experience. Instead, 18 years later, the only approved access in the United States to these easy-to-use and very safe pills is still through registered abortion providers, who are becoming fewer and farther between.
So Coeytaux and Wells created Plan C—an effort to spread the word about safe and effective pills for those who miss a period and do not want to be pregnant. Since early 2016, Plan C has been helping frame the national dialogue around self-managed abortion, publicly sharing information about the safe and effective pills that exist; mobilizing a generation to take action and demand access; and laying the groundwork for putting these pills directly in the hands of those who need them most.
In California, following Pandia Health’s innovative approach, Coeytaux and Wells have rallied researchers to test a new model of care. Ushma Upadhyay, associate professor at the University of California, San Francisco, is launching the California Home Abortion by Telemedicine (CHAT) Study to demonstrate and evaluate a medically supported online service delivery model similar to those used internationally. By harnessing the power of new communication and Web-based technologies and shipping the pills to people’s homes, Upadhyay hopes that women can avoid the arduous steps currently required to obtain an early abortion.
CHAT Study participants will request abortion services using a HIPAA-certified online or mobile platform. After answering relevant medical history questions (including the gestation of their pregnancy), they will have the option of chatting online with a provider to discuss any questions or concerns. If approved for the service, they will receive abortion pills via express delivery to their doorstep and follow-up medical support through the mobile platform and/or telephone communication with a provider, as needed or requested by the user. And like the user-friendly Pandia Health model, the CHAT study user experience will be simple, straightforward, and user-driven. Unlike other telemedicine models, which require a patient to appear in person at a clinic and/or schedule a specific appointment time, both models provide users with home-based services at their convenience.
In Women’s Hands
The Pandia Health model of service delivery has already proved very popular. Indeed, a few similar services have launched and are adding coverage in other states as the excitement and demand grow. Similarly, the CHAT Study, if successful, could radically alter abortion services throughout the United States, providing universal access to abortion care and enabling those who need services to circumvent the barriers and stigma that have plagued abortion services for decades. Together, these Web-based, medically supported models of medication distribution by mail are demonstrating a new means of service delivery for reproductive health care that greatly increases access and puts convenience, confidentiality, and control in users’ hands.
But a coordinated effort is needed to realize their full potential. These startup models need funding, particularly for expanding into more rural areas where the need is acute but the incentive is less compelling for for-profit enterprises. Philanthropists can play a role through social-impact investing or low-interest loans. Similarly, state governments that want to improve public health and decrease costs could fund pilot programs and change legislation that restricts access to this type of telemedicine.
Finally, the public needs to know that taking birth control and abortion pills is neither risky nor complicated. Access to these effective family planning methods is limited because of politics, not health concerns.
We have very safe, very effective methods that medical research and decades of use by millions of women have proven do not need much medical oversight. We also have the technologies to help people access quality reproductive health care—convenient, inexpensive, and ubiquitous mechanisms for ordering, shipping, and delivery. It is time to use these technologies to disrupt the nation’s restrictive reproductive health policies and put reproductive health medication into the hands of those who need it most.