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Many states are implementing new restrictions on abortion, and the U.S. Supreme Court may soon overturn the landmark 1973 Roe v. Wade decision that ensures the right to an abortion before fetal viability.
On Thursday, June 9, SciLine interviewed: Dr. Ushma Upadhyay, an associate professor of obstetrics, gynecology, and reproductive science at the University of California, San Francisco, and public health social scientist. She discussed topics including: research on the safety and efficacy of medication abortion; trends in out-of-pocket costs for patients seeking abortion; the landscape of abortion-providing facilities in the United States; and research on the effects of state-level restrictions on abortion.
USHMA UPADHYAY: My name is Dr. Ushma Upadhyay. I’m an associate professor and a public health social scientist at the Advancing New Standards in Reproductive Health Program at University of California, San Francisco. I primarily study the safety of abortion as well as access to abortion care in the United States. I’m currently leading research on telehealth for medication abortion.
Interview with SciLine
What does the research say about the safety and effectiveness of medication abortion?
USHMA UPADHYAY: First, let me explain what a medication abortion is since many people don’t even know that one can have an abortion with pills. A medication abortion is the use of mifepristone, which blocks the hormone that allows a pregnancy to grow, and misoprostol, which cause the cervix to dilate and the uterus to contract and empty. Medication abortion is currently approved by the FDA up to ten weeks. But now, based on evidence, many providers are offering it to patients up to 11 or 12 weeks of pregnancy.
These medications have been studied for decades, and all of the evidence we have unequivocally finds that medication abortion is extremely safe and effective. About 95 to 97% of people have successful abortions with no need for additional intervention, and well over 99% experience no serious adverse events. One large study that we conducted of over 11,000 people who had medication abortions found a rate of serious complications of less than a third of 1%. Medication abortion is safer than Tylenol, aspirin and Viagra.
What does the evidence say about the safety of telehealth medication abortions?
USHMA UPADHYAY: Since the COVID pandemic, there’s been a growth of telemedicine for medication abortion. This involves a telehealth consultation with a clinician and the pills mailed directly to patients. We’ve amassed strong evidence that providing medication abortion through telehealth is just as safe and effective as in clinic care.
What is the current landscape of abortion-providing facilities in the United States?
USHMA UPADHYAY: Currently, there are 790 publicly advertising abortion facilities in the United States, and we know that this is not nearly enough. There are 27 abortion deserts in this country, which is defined as major cities with populations of 50,000 or more where residents have to travel a hundred miles or more to reach an abortion-providing facility. Six states have only a single abortion-providing facility.
How could access to abortion services change if Roe v. Wade is overturned?
USHMA UPADHYAY: If Roe is overturned, we could see all clinics in up to half of states shutter. This would be the eventual closure of about 200 of the country’s abortion providers. We could see average distance to reach an abortion provider increase to about 279 miles each way.
What is the trend in the landscape of abortion-providing facilities in the United States?
USHMA UPADHYAY: Across the United States since 2017, our data finds that the number of abortion-providing facilities has remained relatively constant. And this is because while in restricted-access states, abortion facilities are being closed due to increasingly restrictive state laws. The other states are compensating by expanding abortion access. So, we’ve seen a huge rise in the number of medication abortion-only facilities, including outlets that offer telehealth for medication abortion.
What types of barriers do state-level abortion restrictions impose on people seeking abortions?
USHMA UPADHYAY: Our research finds that costs and logistics are already a major issue for people needing an abortion. Costs are the single greatest barrier to obtaining a wanted abortion. And this includes all of the costs involved in obtaining an abortion, time off work, arranging for childcare, gas or a bus ticket to another state and the abortion itself. Laws that prohibit low-income pregnant people from using their own health insurance to cover abortion create insurmountable barriers to care. We’ve had patients tell us that they’ve had to sell items like their TVs to raise the funds needed to obtain an abortion. A few of our study participants have reported that by the time they raised funds needed for travel costs and for the abortion itself, they’d call the clinic to make an appointment only to learn that because they’re later in pregnancy, the price has gone up.
When someone who wants an abortion cannot access one, what do they do next, according to your research?
USHMA UPADHYAY: If someone lives in a state where abortion is banned, they have one of three options. One, they can travel out of state. But often, it is just too hard. Many people have never left their state before. Some can’t take that amount of time off from work. And a long trip also means they have to reveal why they are going on such a long trip to more people.
Second, they can self-manage their abortion. And this could take two routes. One, they could order abortion pills online through services such as Aid Access, which are safe and effective, using the same medications that are FDA-approved. However, using these services opens people up to legal risks, risks of criminalization. And people of color are disproportionately at risk because they’re at greater risk of being monitored and targeted for their behavior. And this carries over to abortion. We also know that people attempt to end their own pregnancies using ineffective means, like herbs, as well as harmful means, such as throwing themselves down stairs or taking excessive amounts of prescription medications to induce an abortion. So that is very harmful.
So—and the third pathway is carrying to term. Through UCSF research, we know that denying someone an abortion can cause them economic and physical hardship for years to come. It also impacts their children, who tend to have worse developmental and economic outcomes.
What can you tell us about trends in out-of-pocket costs for patients seeking abortion?
USHMA UPADHYAY: We recently published a paper examining trends in patient costs for abortion. And this is important since most people pay out of pocket for abortion because their insurance doesn’t cover it because of state or federal laws. We found that since 2017, the costs of abortion have been increasing. In 2021, the median self-pay cost for abortion care in the U.S. was $568 for a medication abortion, $625 for a first trimester procedural abortion and over $800 for a second trimester abortion. So many people do not have that kind of money saved up for a rainy day. And it creates an insurmountable barrier for many people.
Which groups of people are most impacted by abortion restrictions? Who would be most impacted if the Supreme Court reverses Roe v. Wade?
USHMA UPADHYAY: It will be people of color and low-income people who will be most affected by abortion bans. Wealthy people and people with strong interstate networks will have an easier time traveling out of state. I’m worried about people of color, undocumented people, as well as incarcerated people, adolescents, people with disabilities, who simply won’t have the option to travel long distances to obtain an abortion.
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