After Roe, women need primary care doctors on the front line of abortion access

This op-ed was originally published in The San Francisco Chronicle.

Ready or not, the post-Roe v. Wade era has begun. The ability to end an unwanted pregnancy is no longer a right guaranteed to all Americans. It is a privilege afforded to some — that is, women who reside in, or have the means to travel to, the 20 states protecting abortion access.

This new reality demands that we reimagine how we deliver women’s health care in this country. Essential reproductive health care — including abortion, but also contraception, miscarriage and maternity support — can no longer be siloed to women’s health specialists, who are already out of reach for the millions of American women living in “gynecological deserts.” And it will only grow harder to access as many women’s health clinics lose funding.

If we are to protect access to vital reproductive health care services, it is the primary care provider — the linchpin of our health care delivery system — who must pick up the gauntlet.

When abortion is treated as a political issue instead of a medical one, an important fact gets lost: Early pregnancy termination is a standard part of a woman’s reproductive life. In the U.S., nearly 1 in 4 women will have an abortion by the age of 45. Roughly 90% of those abortions occur before 12 weeks of gestation, making first-trimester abortion one of the most common procedures that reproductive-aged women get. Moreover, up to half of all pregnancies end in miscarriage — again, most of them in the first trimester — which requires the same treatments used for abortion.

Despite how frequently patients need early pregnancy termination care, primary care providers do not typically offer these services, instead referring women to women’s health clinics or specialists like an obstetrician and gynecologist. This made sense a few decades ago, when abortion was exclusively a medical procedure performed by physicians trained in surgical abortion.

It does not make sense today. In 2000, medication abortion came onto the U.S. market, enabling women to safely terminate a pregnancy up to 11 weeks with two pills, mifepristone and misoprostol. This simple and noninvasive method — which now accounts for more than half of the abortions in the U.S. — should have pushed early-stage abortion squarely into the realm of primary care, along with contraceptive support. Yet, only 1% of abortions are done in primary care settings today.

This baffling slow uptake of medication abortion in primary care is partially explained by the unnecessary and cumbersome restrictions imposed on it — from in-person visit and ultrasound requirements to limiting its availability to specialty pharmacies. Many restrictions stemmed from misperceptions about medication abortion’s safety — for example, that it can only be safely administered in person, not via telehealth, and only by physicians, not by advanced practice providers such as nurse practitioners or physician’s assistants. But a rapidly growing body of research has debunked most of these myths — finding that medical abortion is not only over 95% effective, but safer than Tylenol, and produces identical patient outcomes whether administered online or in person.

Here, the universe has thrown those grieving Roe a bone. While the pro-choice spotlight focused on the battle in the Supreme Court, a side door emerged outside the realm of politics. Two critical advancements — one technological, the other regulatory — have together unlocked the potential of medication abortion as a powerful tool to bolster access in a post-Roe America.

One is the widespread adoption of telehealth, which was cemented into the infrastructure of our health care delivery system during the pandemic and is now here to stay. The second is the Food and Drug Administration’s removal of the in-person requirement for medication abortion in December 2021, which now allows it to be prescribed via telehealth providers and delivered by mail. Properly harnessed, these advancements can have an outsize impact in the post-Roe era.

The newfound availability of medication abortion via telehealth makes the treatment exponentially more accessible in states where it remains legal — as women are no longer required to travel to the rare brick-and-mortar abortion clinic, but can instead get a prescription via phone or virtual consult from anywhere within state lines. This clearly reduces the logistical burden for in-state women, who can now get an abortion consult from home — but also for women traveling from restrictive states, who can now conceivably get a consult from a car just over the border.

Telehealth makes the patient experience of abortion more private, too, empowering women to complete an abortion from the privacy and comfort of their homes. This will no doubt increase the adoption of medication abortion, which could address up to 90% of abortions. Today, that figure sits at 54% — indicating an untapped opportunity for primary care providers to start offering this service as part of comprehensive primary care for women.

Integrating abortion services into primary care is also a powerful mechanism to address the post-Roe abortion supply gap as progressive states like California and New York brace themselves to absorb a sharp increase in patients from out of state. Abortion providers in these so-called reproductive safe havens are already straining to meet this influx of demand, creating weeks-long waiting lists for both out-of-state and in-state patients. This makes it urgent that we meaningfully and quickly increase appointment supply where abortion remains legal. With minimal training, primary care providers — whether a physician, nurse practitioner or physician’s assistant — can safely administer medication abortion and create thousands of new virtual and in-person access points in reproductive safe havens, thereby increasing access for women from blue and red states alike.

To size the potential impact: If all primary care providers in California started offering medication abortion services, they could plausibly cover the needs of all 34 million women at risk of losing access to abortion.

While shifting efforts from the courts to the exam room is fastest force multiplier to expand abortion access, the success of this approach requires action from other stakeholders, too. Policymakers will need to pass legislation protecting patients traveling across state lines and the providers who care for them and health insurers will need to expand coverage for abortion. Employers and nonprofits can subsidize the cost of out-of-state travel.

Reproduction and family planning are core elements of women’s lives and should be integrated into any modern concept of whole-person primary care for women. Siloing a woman’s basic reproductive care from her general health care is a proven contributor to multiple public health crises in the U.S., where women today are more likely to die from pregnancy-related causes than their mothers, suffer from depression at twice the rate of men, and where female-specific conditions like endometriosis take a decade to get properly diagnosed. In other words, integrating a woman’s reproductive health care into her primary care will not only protect patient access to these services, it is simply good medicine.

As we rue the loss of Roe, it’s tempting to focus our efforts on resurrecting federal protection for abortion. But we must also find creative solutions, inside and outside the political sphere, to advance women’s health causes within the confines of a post-Roe America. Expanding the role of primary care providers in delivering reproductive health care to women would be a meaningful first step.

Carolyn Witte is the co-founder and CEO of the women’s health platform Tia, which provides comprehensive primary care, including medication abortion, through its virtual and in-person clinics in partnership with leading health systems, including UCSF Health.