By Kelly Burch

Granite State News Collaborative

The coronavirus pandemic has changed how sexual and reproductive healthcare is delivered in New Hampshire. Some services, including abortions, are now delivered partially via telehealth, while other services, including sexually-transmitted disease (STD) testing and PrEP, a regiment to prevent HIV transmissions, have seen a significant decrease in demand.  

“We’ve kept services the same, and, where appropriate, we’ve put into place things that we can do in a touch-less manner,” said Dalia Vidunas, executive director of Equality Health Center in Concord.

On April 21, Planned Parenthood of Northern New England (PPNNE), which covers New Hampshire, Vermont and Maine, announced an expanded telehealth program to keep healthcare accessible even during the pandemic and shutdown. The organization began using video chat and phone services to cut down or eliminate the time that people needed to spend in the office. 

“During a pandemic, sexual and reproductive health care can’t wait, and in these uncertain times, we're committed to caring for our patients — no matter what,” Meagan Gallagher, president and CEO of PPNNE, said in a press release. 

A clinic-by-clinic decision 

While many sexual and reproductive health services require some in-person interaction, telehealth has allowed preliminary, counseling and follow-up appointments to happen virtually during the pandemic. For medical abortion — in which pregnancy is terminated by taking a pill — everything can be done virtually for people who are very confident in the date of their last period. Since medical abortion can only be used up to 10-11 weeks gestation, people who aren’t sure when they got pregnant still need an ultrasound to date the pregnancy. 

In New Hampshire clinics, a woman is still required, at minimum, to walk into a clinic to pick up the medical abortion pill directly from the prescriber. Surgical abortions are being delivered as normal, clinics say, except that most patients are not allowed to bring a support person into the clinic with them. 

Equality Health Center regularly serves people from the far north country who drive hours for care, Vidunas said. Even if those people are still required to come into a clinic to pick up their medication, telehealth could provide them important counseling ahead of time.

“I really really think the more information that people can get the better,” she said. “To be able to do a telehealth [appointment], it’s in the comfort of their own home, and they may be comfortable asking more questions.”

Equality Health Center uses telehealth to counsel patients about their pregnancy options, types of abortions and birth control options. This cuts down on time spent in the clinic and allows providers to deliver “touchless” medical abortions, but patients are still required to come in for a visit to obtain medication. 

“We feel, for us, this is our best practice,” Vidunas said. 

Lovering Health Center, in Greenland, has also started using telehealth appointments before and after an abortion, but requires a woman to come in for an appointment and ultrasound before receiving the pills that induce an abortion, according to Executive Director Lisa Leach. Unlike Equality Health Center, Lovering Health Center requires patients to have an ultrasound, largely to rule out ectopic pregnancy, a condition where an embryo implants in the fallopian tube, rather than the uterus. Out of an abundance of caution around ectopic pregnancies, which are dangerous and often require surgery, the clinic is “not quite there yet” on delivering touchless abortion services, Leach said. 

“That’s what's right for us,” Leach said. “Something else might be right for other clinics.”

Expanding abortion access via telehealth

There is a push nationally to use telehealth services to expand abortion access. The national TelAbortion research project offers medical abortion in 13 states and Washington D.C. done entirely via telehealth. A person seeking an abortion has a digital consultation with a provider, and any necessary lab work is done at a nearby facility. The abortion medication is then mailed to the patient. The only New England state participating in the project is Maine. 

Telehealth services could improve abortion access in New Hampshire, providers say, especially if the legislature adopts SB555, which would make it easier for telehealth services to be reimbursed by insurance providers. Reimbursement for telehealth services was first expanded in the state via emergency order 8, issued by Governor Chris Sununu on March 18. SB555 would make those changes permanent. 

However, at least one provider worried that easier access to abortion in the state could lead to more attempts to restrict access. In general, New Hampshire has few restrictions on abortion access. As of 2017, there were 12 clinics in the state providing abortion care, according to the Guttmacher Institute; 30% of New Hampshire women lived in counties with no abortion services, compared to 38% of women nationally. However, there has been a sustained push to further restrict access to abortion nationally and in The Granite State, including the introduction of a so-called “heartbeat bill,” which would prohibit abortion after roughly six weeks gestation, earlier this year in the New Hampshire legislature. 

Decreased demand for abortion, STD testing

Since the pandemic and accompanying stay-at-home order, clinics across New Hampshire have seen decreased demand for abortions and STD testing. Leach speculated that’s because people were less sexually active during the lockdown. 

“They’re not engaging,” she said. 

However, Vidunas believes the explanation might be more complicated than that. 

“Even though we’ve been in a shutdown, that doesn’t necessarily mean people have stopped having sex,” she said. She worries that people are avoiding seeking care. The steep drop-off in demand for STD testing and for PrEP, a medical regiment that can reduce the risk of contracting HIV, is particularly concerning, she said. 

“That really worries us. Those numbers should be increasing,” as more people take advantage of the programs, she said. Vidunas worries about losing the progress that’s been made in access to reproductive and sexual health services in the state, especially if public health funds are funneled toward pandemic response at the expense of other public health spending. So far, however, that hasn’t happened and public awareness campaigns around STD testing and PrEP have continued, she said. Still, she’s concerned about the drop off of people utilizing the services. 

“I’m afraid of that slide back. What’s it going to look like and how bad is it going to be?” she said. “You’re hoping that people are being safe, but if people are prone to risky behavior, they’re prone with COVID or without COVID.”

These articles are being shared by partners in The Granite State News Collaborative. For more information visit collaborativenh.org.