Almost five years ago, Amy Hagstrom Miller, the founder of Whole Woman's Health, became one of the first U.S. abortion providers to use video technology allowing doctors to prescribe drugs to end unwanted pregnancies.
Doctors at Miller's clinic in Austin, Texas, could consult and prescribe the pills to women in McAllen, about 300 miles away on the Mexican border, via phone and video conference. The so-called telemedicine eliminated drive time for physicians and doubled to 24 the number of days per month the service was offered.
It didn't last long. A law that took effect last year requires doctors to show and describe ultrasound images of the fetus to women seeking an abortion. Because the provider must be in the same room as the patient, Miller's business ground to a halt.
"We still do it in our Maryland clinic and plan to start it up in our Minnesota clinic, but our five Texas sites are very limited now," Miller said.
States approved a record 135 abortion restrictions over the past 24 months. Telemedicine bans are the latest weapon in a broader fight over abortion-inducing drugs, which, since their advent over a decade ago, have transformed the procedure. Instead of an invasive surgery sought in clinics, which can be blockaded and tightly regulated, now a woman early in her pregnancy can start one at her physician's office with a pill and finish the process at home.
To abortion opponents, the drugs are seen as vehicles for the procedure to become more widely available.
This year, legislation introduced in at least five states would effectively ban telemedicine abortions by requiring that doctors be physically present to examine patients before prescribing abortion-inducing drugs.
All but one law are based on model legislation written by Americans United for Life, the legal arm of the anti-abortion movement, which calls medication abortion "the new profit-boosting frontier" for providers.
Charmaine Yoest, president of the Washington, D.C.,-based group, calls a telemedicine ban one of her favorite strategies. Abortion-rights advocates have long emphasized the sanctity of the patient-doctor relationship when claiming that anti-abortion laws violate privacy rights, she said.
Telemedicine abortions belie that argument, she said. "Now, it's between a woman and her Skype program."
Telemedicine was first used in the 1960s to check on astronauts in outer space and has since revolutionized how people in rural and under-served areas receive a range of health services, according to the American Telemedicine Association. The technology's reach has quadrupled in the past five years to 10 million Americans, aided by millions of dollars in public and private investment.
It's now used to help treat everything from pediatric head injuries in Montana to infectious disease on Alaska's Aleutian Islands in the Bering Sea.
Abortion is the only area in which lawmakers have curbed telemedicine or prevented its use from expanding, said Jon Linkous, chief executive officer of the Washington-based association.
The groundwork for tele-medicine abortions was laid in 2000 when the U.S. Food and Drug Administration approved a French drug that induced miscarriage. The drugs accounted for 17 percent of nonhospital abortions in 2008, the latest year for which data are available, according to the Guttmacher Institute, a New York-based reproductive health research group.
Women up to nine weeks pregnant typically take the first dose at a health provider, the second at home 48 hours later, and follow up with a doctor two weeks after that. Physicians now prescribe the drugs after consulting with patients via phone and video link at Planned Parenthood clinics in Iowa and Minnesota, and at Whole Woman's Health in Maryland.
This year, Republican lawmakers in Iowa, Alabama, Indiana, Missouri and Mississippi have introduced telemedicine abortion bans, while a proposal in Texas would build upon what's already passed.
Iowa, the sole state that would ban a practice already in place, is home to 16 clinics offering telemedicine abortions. There, researchers conducted a study published in 2011 in the journal Obstetrics & Gynecology that compared the provision of abortion-inducing drugs via telemedicine to those done face to face. It found the complication rate, at 1.3 percent, to be no different.