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Three years ago, Dr. Reni Soon joined a group of Hawaii doctors offering abortions to women over the internet.
Connecting with her patients through a video conferencing app that most women can access on their cell phone, Soon said the use of telemedicine in her practice is helping to normalize abortion as part of meeting women’s health care needs. More importantly, it’s eliminating the need for some women to travel by airplane to reach an abortion clinic.
It works like this: A woman who wishes to terminate her pregnancy uses a cell phone, tablet or computer to participate in a video evaluation with an abortion provider. The woman then travels to a local medical facility for an ultrasound and other pre-abortion tests, which are evaluated remotely by the abortion provider.
The woman next receives medications commonly known as “the abortion pill” in the mail, along with instructions. After the woman ingests the pills, the results are reviewed in a series of follow-up tests and a second video consultation.
“We’re video conferencing with a woman who’s sitting in the backyard and her kids are running around behind her,” Soon said of the TelAbortion trial. “It says, ‘It’s OK that this is happening.’ I think it really takes the stigma away from the abortion process.”
Piggybacking on a popular model of using telemedicine to boost health care access in rural, medically under-served areas, Hawaii is one of seven states participating in a TelAbortion pilot study offered by Gynuity Health Projects in cooperation with the Food and Drug Administration. The study aims to test the viability of sending abortion pills to patients by mail — something the FDA otherwise prohibits.
A wave of mostly Southern states have passed historically strict abortion restrictions recently, including a near-complete abortion ban in Alabama and a new law in Georgia prohibiting abortions at a stage that occurs when many women don’t yet know they are pregnant.
By contrast, Hawaii retains some of the nation’s most vigorous laws protecting a woman’s right to terminate her pregnancy. There’s no sign of any significant legislative effort to soften them.
But even with these legal protections, Hawaii’s island geography poses an increasing threat to a woman’s ability to access an abortion provider as abortion clinics close and consolidate on Oahu.
When state lawmakers codified a woman’s right to an abortion in 1970, there were 10 hospitals performing abortions across Hawaii. Nearly a half-century later, the number of abortion clinics in Hawaii has dwindled to three — two on Oahu and one on Maui, where abortions are available only two days per month, said Soon.
On the Big Island, women have access to an abortion provider just one day per month. But three or four weeks is too long for some women to wait, according to Soon, whose colleagues travel to Hilo to provide the island’s monthly abortion services.
“It can be very anxiety-provoking for a woman to have to wait once she makes that decision,” Soon said. “So what ends up happening is they end up flying to Oahu to get the procedure quicker.”
As the distribution of abortion clinics in Hawaii narrows, women on four of the eight main Hawaiian islands must travel by airplane to obtain an abortion. Only Oahu offers steady and frequent abortion services.
“Particularly for patients on neighbor islands, you can’t just get in the car and drive to your appointment if there’s no abortion provider on your island,” said Soon, who performs and teaches surgical and medication abortion procedures as a faculty member of the University of Hawaii John A. Burns School of Medicine.
Soon notes that it’s possible some Hawaii doctors who don’t advertise abortion services are quietly performing them — but only for their existing patients.
Hawaii became the first state in the nation to grant women the right to choose an abortion in March 1970 — three years before Roe v. Wade solidified a woman’s constitutional right to terminate her pregnancy.
Hawaii law enshrines abortion rights, protecting them even if the Supreme Court were to overturn Roe v. Wade. That means the surge in legal crackdowns elsewhere on abortions is unlikely to affect women in Hawaii.
But as clinics become more scarce, a growing number of women are separated from an abortion provider by a hundred miles of water or more.
Although health insurance will pay for the procedure and airplane ticket, there are hidden financial costs and logistical hurdles when air travel becomes a necessary part of the abortion process. The cost of ground transportation typically falls to the patient. Lost wages factor in when a woman is forced to take a day off from work. And keeping an abortion confidential from employers, neighbors and friends can become more difficult when air travel is involved.
More than a nuisance, some local abortion providers say air travel can be an insurmountable barrier, especially for women who are homeless, poor, in their teenage years, fearful of an abusive partner, unable to speak English, suffering from substance abuse or mental illness or living in a religiously conservative family or community.
As abortion access wanes in rural Hawaii — Planned Parenthood shuttered its Big Island and Kauai clinics in 2014, although the Kauai clinic did not offer abortion services in the years leading up to its closure — Hawaii’s TelAbortion trial offers a temporary means of assisting those in remote locations.
All told, 382 women — 186 of them from Hawaii — have received an abortion through the TelAbortion pilot program since it began in 2016. Of the Hawaii participants, 70 percent of the women lived on neighbor islands.
“There are still a lot of barriers that patients have to get through because they do need to have an ultrasound and they need to get labs, but doing the conferencing consultation over the internet is pretty amazing,” Soon said.
Linking women who want an abortion to an abortion provider via a remote video conferencing app, the TelAbortion pilot is able to function with approval from the Federal Drug Administration. The FDA is allowing participants to temporarily sidestep FDA rules that require doctors to physically hand off abortion medication to their patients in person.
Women seeking a non-surgical medication abortion have always been permitted to take the pills at home. But the FDA enforces a strict rule that women must obtain the medication in person from a doctor at a medical facility, even though doctors qualified to administer a medication abortion are geographically out of reach from many rural women.
The study is set to expire after it enrolls 1,000 women across the eight participating states. It’s unclear whether abortion telemedicine has a future in Hawaii once the pilot study terminates.
Since 2009, Dr. Graham Chelius has delivered about a thousand babies at Kauai Veterans Memorial Hospital in the small town of Waimea.
Mothers of some of the babies born into his hands on the island’s rural west side had voiced a desire to have an abortion, Chelius said. But there are no abortion providers on Kauai.
“There have been patients of mine who have communicated a desire to get an abortion and they end up carrying a baby to term, apparently against their will, because they just can’t do the appointment,” Chelius said.
Chelius said he would like to perform medication abortions for his patients, but the Food and Drug Administration won’t allow him to write a prescription for what’s known as the abortion pill unless the hospital that employs him agrees to stock the drug and he registers with the drug maker.
That’s unlikely to happen. Kauai Veterans Memorial Hospital prohibits its physicians from terminating a pregnancy.
“The reality is that I’ve had staff members tell me they do not like being involved in the process of abortion even on the paperwork level,” Chelius said. “With the current FDA regulations, it involves too many people, from the physician to the nurse to the person who stocks the medication — five or six people need to be involved to make it happen.”
In 2017, Chelius waged a legal battle against the FDA rule that prohibits women from filling a prescription for the medication Mifeprex, commonly known as “the abortion pill,” at her local retail or mail-order pharmacy.
The American Civil Liberties Union is representing him in his complaint, in which Chelius argues that the rule disadvantages Hawaii women on neighbor islands who must travel by airplane to seek the medical supervision required to obtain the abortion pill, especially since these women are permitted and often choose to ingest the pill privately at home.
“This case is about where a woman must be standing when she receives the pill her health care provider has prescribed for her,” the complaint reads.
Chelius said if his legal challenge prevails, it will open up new opportunities for Hawaii women to receive an abortion closer to home. He argues there is no medical benefit to the FDA restrictions, which he believes makes health care less safe and more costly for rural women.
ACLU of Hawaii Legal Director Mateo Caballero said he is seeking a summary judgment in the case, which could have national implications.
“If the case is decided in our favor,” Caballero said, “then the FDA regulations would not apply anywhere in the United States. So any woman would be able to get a prescription for the medication from her doctor and more importantly any doctor would be able to write that prescription.”
It’s more than a matter of geography. In Hawaii, abortion access is hampered by state law that gives not only individual physicians but also entire hospitals the right to refuse to participate in abortions, which Chelius said is the case at Kauai Veterans Memorial Hospital where he is employed.
There are also federal limitations. A ban on federal spending for abortions means that women with federal health plans in Hawaii do not have abortion coverage. Out-of-pocket costs for an abortion range from about $600 to $2,000, according to Soon, depending on how far along a woman is in her pregnancy.
“A number of our patients that have military insurance that we see are 18 or 19 weeks pregnant and just got diagnosed with a fetal anomaly,” said Soon. “And it could be a very wanted pregnancy, but they are making a very difficult choice to end that pregnancy and they have to come up with thousands of dollars in order to do that.”
And although it removes major barriers, such as airplane travel, Chelius said the TelAbortion pilot study — which is only temporary — poses its own set of difficulties for women who don’t own a computer or cell phone.
Some women, he said, do not have sufficient cellular data plans to support the video conferencing app that participants are required to use to consult remotely with a prescribing physician.
On numerous occasions, Chelius said he has invited frantic women who can’t activate the app on their own device to drive to his office and use his own personal cell phone — even after work hours.
“It becomes like an emergency,” Chelius said. “That’s why it would be best if it were me, my prescription pad and the patient — that’s it.”
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