Re: Testimony in Support of LB 276
Dear Chairperson Lathrop and members of the Judiciary Committee,
My name is Meg Mikolajczyk, and I am the Deputy Director and Legal Counsel at Planned Parenthood North Central States (PPNCS) in Nebraska. PPNCS, including our medical practice Planned Parenthood of the Heartland (“PPH”), provides, promotes, and protects sexual and reproductive health and rights through high-quality care, education, and advocacy in Nebraska, North Dakota, South Dakota, Iowa and Minnesota.
PPNCS serves more than 8000 patients in two Nebraska-based health centers with services including but not limited to STI testing and treatment, well-woman exams, contraception, abortion, gender-affirming hormone therapy, and adoption counseling and placement. I am here today on behalf of Planned Parenthood to offer strong support for LB 276 and answer any questions the committee may have regarding telehealth abortion care delivery.
Planned Parenthood believes abortion must always be a matter of personal choice and that a patient, in consultation with a physician, has the right to obtain an abortion under safe, legal and dignified conditions, and at reasonable cost. We also recognize and accept our responsibility to guard against coercion or denial regarding a patient’s decision about continuing a pregnancy. I am not a medical doctor, but am including the expert opinion of Dr. Sarah Traxler, our Chief Medical Officer as an attachment to my written testimony. She was unable to be here today, as she is primarily based in Minneapolis/St. Paul, Minnesota.
Planned Parenthood is an innovator in health care delivery, including providing telehealth medication abortions in Iowa since 2008. When this service is offered through telehealth, our physician uses a synchronous, HIPAA-compliant platform to connect into the health center room where the patient is present with a support staff member. The physician consults with the patient as they would if they were physically present in the room.
The physician also confirms patient identity, discusses the medication abortion process with the patient, screens for coercion and provides options counseling, and once assured the patient is acting of their own free will and has given informed consent, the physician dispenses the two medications that comprise a medication abortion via a remote-controlled locked box in the patient exam room. The care is essentially identical to the care offered if the physician were physically present in the room.
Medication abortion is safe and delivering it via telehealth does not increase any health risk. The medical community at large supports telemedicine abortion, including the American College of Obstetrics and Gynecologists. The process consists of a two-dose regimen—first, the patient ingests mifepristone while they are at the health center and visible to the physician via the virtual platform connection. Mifepristone acts to block progesterone, the pregnancy hormone, and ends the pregnancy. The patient takes the second medication, misoprostol, home with them to be ingested between 24 and 48 hours after mifepristone, to make sure the contents of the uterus are emptied.
Briefly, in 2011, the Iowa State Board of Medicine attempted to ban telehealth abortion care delivery. Planned Parenthood sued, took the case to the Iowa Supreme Court, and won. The language the Nebraska Legislature enacted during this time—the subject of this repeal bill—was very similar to that of the Iowa Board of Medicine’s and the intent was identical: to ban only one type of medical care through telehealth for political or religious, but not medical, reasons. That court decision is also attached as part of my testimony.
Medication abortion is the most common method of abortion in Nebraska and is available to patients up to ten weeks of pregnancy (measured from the person’s last missed period). In 2019, nearly 61 percent of all patients seeking abortion in Nebraska received their care via medication.1 It is the only medical service that could be delivered via telehealth in Nebraska but is barred by state statute to my knowledge.
As mentioned, the risks of medication abortion are exceptionally low and include cramping, bleeding, and potentially nausea and dizziness. Antibiotics are also prescribed preemptively, regardless of whether the care occurs in person or through telehealth, to prevent infection. And, as NE DHHS has noted in their annual Abortion Report, there have been virtually no complications for any Nebraska patient seeking any type of abortion in Nebraska, with a no complication rate of 99.9% since 2014 (which recorded a no complication rate of 100%).2
My point—this type of health care is exceptionally safe. And, Planned Parenthood also sends patients home with complete information for aftercare, in the rare occurrence that follow up care is needed. None of these medical processes change under this bill.
This policy has become exceptionally more important and timelier because of the ongoing global pandemic our country continues to battle. The state of Nebraska is over 400 miles east to west, but there are only abortion providers on the eastern part of the state. Rural Nebraska has a shortage of all types of health care providers, including sexual and reproductive health care providers; being able to leverage telehealth during this pandemic the way other medical specialties have would ensure more equitable access to care for Nebraskans.
I want to express immense gratitude to Senator Hunt, as well as her co-sponsor Senator J. Cavanaugh, for supporting this legislation and access to health care for all Nebraskans, particularly when health care delivery via telehealth has never been more important. We urge this committee to support LB 276 and advance it to General File.
Deputy Director - NE
Expert Opinion in Support of LB 276
My name is Sarah Traxler, MD. I am the Chief Medical Officer and the Director of Abortion Services at Planned Parenthood North Central States, which includes Nebraska, Iowa, Minnesota, North Dakota and South Dakota. I have taught obstetrics and gynecology residents, conducted sexual and reproductive health research, and provided abortion services for the past decade. I received my medical degree from Oregon Health & Science University, completed an OB/GYN residency at the University of Minnesota and a family planning fellowship at the Hospital of the University of Pennsylvania, and hold a Master of Science in Health Policy from the University of Pennsylvania.
I regret being unable to testify in person today because of the ongoing pandemic and medical responsibilities I have in Minnesota but am proud to offer my medical expertise and support for LB 276 on behalf of my patients, myself, and PPNCS, particularly since our medical practice was the first in the country to deliver abortion services via telehealth over a decade ago.
First, I want to reiterate that, in my medical judgment, through my years of experience, and with reinforcement from evidence-based research and professional medical societies,3 medication abortion is very safe for patients and has been since inception nearly 20 years ago. This remains true regardless of whether the physician dispensing the medication is in the room or interacts with the patient via synchronous telehealth.
Prior to dispensing or administering either medication, the physician performs a medical history, laboratory, and ultrasound imaging review via the electronic health record. After the review, the physician consults with the patient via video conference call, allowing an opportunity for clarifying questions and instructions for both the physician and patient. Once clinical criteria are met, the medications are dispensed through a remotely controlled lock box, and the patient takes the first pill in the regimen (mifepristone) during the video visit.
Mifepristone and misoprostol, the two-drug medication abortion regimen approved by the FDA, are extremely effective in ending an early pregnancy, working approximately 98 percent of the time. No medications or health services come without risk of complication, but abortion is one of the safest medical procedures in this country. Studies indicate that complications for in-person versus telemedicine abortion are comparable and rare (risk of major complications related to telemedicine abortion are less than 0.3%, comparable to over-the-counter medications). We always discuss risks and alternatives to abortion with each patient regardless of whether a patient receives in-person or telemedicine abortion care. And patients’ follow up care options are the same for in-person and telemedicine abortion.
When a Nebraska patient presents to a Planned Parenthood health center for a medication abortion, the patient receives the following information and services ahead of their abortion: pregnancy options counseling (including abortion, adoption and parenting); an ultrasound to assess gestational age and appropriateness for medication abortion (along with an hour waiting period post-ultrasound, as required by Nebraska law); a thorough medical history and current medical problem assessment; necessary laboratory evaluations (hemoglobin and Rh status); an assessment to rule out coercion; education about medication abortion, including its effectiveness, safety, risks, and alternatives; informed consent; follow up care options; and after hours contact information for any issues that may arise after the health center closes.
LB 276 does not change this process—our patients would still visit a health center, receive the same information, counseling, and health services that are best practice in obstetrics and gynecology or are required by law. The only difference between in-person and telemedicine abortion care is the patient and the physician are in different locations.
The patient, with a support staff person in the room with them, consults with a physician, who is in another location, via a secure, HIPAA-compliant telecommunication platform. The physician verifies patient identifying information, discusses the medication abortion with the patient, verifies the patient is sure in their decision and there is no coercion, and then dispense both the mifepristone and the misoprostol through a lock box that is remotely controlled by the physician.
The patient then takes the mifepristone on-camera, in front of the physician. Patients then take the misoprostol pills home with them to take 24–48 hours after ingesting mifepristone. The misoprostol is the medication that causes uterine contractions, dilates the cervix, and aids in expulsion of the products of conception. Additionally, every patient receives verbal and printed home care instructions, reminders of the follow up plan, and information on our 24-hour call line where an on-call nurse can answer any questions they have.
The importance of being able to deliver health care, including abortion, via telehealth has become more apparent during the past year as we have all grappled with safe and timely health care delivery in the context of a global pandemic. Through telemedicine abortion, more patients can access health care closer to home. This means less travel and less contact with people outside of their own communities, thus removing barriers to health care and balancing other demands patients face related to the pandemic—childcare, on-line school, potential wage loss, and travel time. For our health care workers, seeing patients via telemedicine allows us to care for patients while minimizing person-to-person contact.
As stated earlier, our medical practice has been offering telehealth abortion in Iowa since 2008. Some data demonstrated that when telehealth abortion services were available to patients, people were able to obtain care earlier in their pregnancies, travel shorter distances to receive care, and access care more equitably regardless of their zip code or geography.4
Studies also show that when patients can seek this care earlier in their pregnancies through telehealth, the barriers to obtaining care—such as taking days off of work, finding childcare, traveling long distances—are lessened.5 Overall, induced abortion is one of the safest and most common medical procedures performed in the United States and providing abortion via telemedicine does not increase health risks.
It is crucial that patients have access to telemedicine abortion as a safe and effective option to end a pregnancy that also eliminates key barriers to care. Thank you to Senator Hunt for introducing this legislation and working for equitable access to health care for all Nebraskans, particularly when health care delivery via telehealth has never been more important. We urge this committee to support LB 276 and advance it to general file.
Sarah Traxler, MD, MSHP, FACOG
Chief Medical Officer - Planned Parenthood North Central States
1 Miller, Mark. “Nebraska 2019 Statistical Report of Abortions”, Department of Health and Human Services, June 2020. https://dhhs.ne.gov/Abortion%20Reports/2019%20Statistical%20Report%20of%20Abortions.pdf
2 Id; Also: Miller, Mark. “Nebraska 2018 Statistical Report of Abortions”, Department of Health and Human Services, May 2019; Miller, Mark. “Nebraska 2017 Statistical Report of Abortions”, Department of Health and Human Services, April 2018; Miller, Mark. “Nebraska 2016 Statistical Report of Abortions”, Department of Health and Human Services, May 2017; Miller, Mark. “Nebraska 2015 Statistical Report of Abortions”, Department of Health and Human Services, June 2016; Miller, Mark. “Nebraska 2014 Statistical Report of Abortions”, Department of Health and Human Services, May 2015.
3 Grossman 2011 and 2017 studies; National Academies Abortion document (spec pages 57-59). Recent Endler systematic review and Gynuity direct to consumer article (all attached). Also support from ACOG, SFP, AMA.
4 Grossman, Daniel A., et al, “Changes in Service Delivery Patterns After Introduction of Telemedicine Provision of Medical Abortion in Iowa”, American Journal of Public Health, Jan 2013; 103(1): 73-78; https://ajph.aphapublications.org/doi/10.2105/AJPH.2012.301097