In the Age of Virtual Clinics, An Invitation to do Better.

Research can be a powerful tool in helping to inform policy and bring positive change in communities. Unfortunately more often than not traditional research methodologies lack a social justice framework, missing the mark on how we work alongside and inform communities most affected by our work. So it’s been really important for us to get involved in work that tries to be better and make sure the collaborations we work on center on Reproductive Justice (RJ) values. Which is why we were excited to team up with researchers from UCSF who understand the importance of incorporating an RJ lens in research.

In 2021 CLRJ finished our first 6 months of collaborative research on The California Home Abortion by Telehealth (CHAT) Study. The CHAT Study is a collaboration with researchers at UCSF, focusing on how best to provide accessible and normalized telehealth options to abortion care. While the study started in California it is now a national study.

At CLRJ we believe all people should have access to the abortion care they feel most comfortable with, without shame or stigma. We hoped that by collaborating on this important study we could shed light on the challenges our communities face when it comes to receiving the abortion care they need. Unfortunately, we experienced a number of setbacks, some even before launching the study. By sharing this experience as the CLRJ Research program, we hope to begin a conversation that highlights the kinds of best practices researchers need to implement and how we can move forward.

About CHAT:

The CHAT study was ready to begin in 2018, but federal restrictions prevented the mailing of medication abortion – a key element in this study.

With the rise of COVID-19 and the declaration of a global health emergency, this ironically opened the door to FDA lifting the restriction on mailing medication. The FDA approval of medication by mail including mifepristone, which is one of the two different medications used in medication abortion, enabled abortion providers to dispense the medications through telehealth and mail.

When restrictions were suspended, virtual clinics for medication abortion started popping up with the hope that they could expand access and services to people who often face barriers to care, including: lack of transportation, long distance to the nearest provider, securing care for dependants, lack of access to insurance, lack of sick leave or ability to take time off of work, financial barriers or even harassment from anti abortion protestors.

The CHAT Study quickly expanded to include people’s experiences accessing these virtual clinics and online medication abortion services.

From the beginning, UCSF and CLRJ researchers were interested in studying how these virtual clinics could address some of the myriad of abortion care barriers faced by so many people in our communities. Yet somewhere along the way, like so many other times, we witnessed the subtle and not so subtle ways systemic racism filtered into who has access and who continues to be left out from accessing the health care services they need.

Initially, one of the telehealth providers we partnered with took an “equity blindness” approach. In other words, in an effort to remove bias and not wanting to bog down patients with too many questions, no demographic data (racial, ethnic, or income data) was collected from people seeking services. While we know that data is often used against systematically oppressed communities, in this specific instance, not capturing this information made it hard to identify inequities in an online health care setting.

Omitting this data makes it impossible to accurately assess if systematically oppressed communities are indeed accessing care in these settings. Guided by our reproductive justice values, we worked together with the UCSF research team to advocate for the collection of data that could ultimately help identify gaps. Failing to collect demographic data can result in health providers continuing to perpetuate the very inequities they hope to address. Fortunately, our telehealth clinic partners were receptive to our request and immediately ameliorated the problem.

Through conversations with the provider, it became clear the lack of data collection was not ill intentioned – however – failing to collect key demographics such as race and ethnicity can have serious repercussions in our communities. Let’s be honest, our society was designed to be inequitable for certain groups of people and operating under the assumption that all people seeking health services online are the same – perpetuates racial, ethnic, economic and other inequities that are deep seeded. Our objections to the lack of data collection opened up a dialogue with the provider, something we know does not always happen. But what happens when a provider is not open to dialogue? Or when the research team is not guided by reproductive justice values to raise concerns?

In our experience thus far, we see there is still so much work to be done and so many more inequities that the pandemic has exposed. When it comes to telemedicine and the virtual clinics’ ability to close the service and accessibility gap, our communities continue to suffer. For one, currently none of the online providers we worked with offer services in other languages besides English, making them completely inaccessible to so many people in our communities. This is especially a miss for those clinics providing services in California – the most linguistically diverse state in the nation, where at least 220 languages are spoken and nearly half of its residents speak a language other than English at home. Cultural competency is a distance away when language is a barrier.

And the gap widens. How truly accessible are virtual clinics that do not account for the lack of accessibility to credit cards or bank accounts by young people, the poor, and our undocumented communities, to pay for their services? Fees for services are out of reach for many and most do not accept Medicaid or other insurance. By using a reproductive justice lens it becomes glaringly clear that while virtual clinics might seem accessible, many BIPOC, people with disabilities, young people, poor people, people who live in rural communities, undocumented people, and folks left behind by technological barriers – just to name a few – will be unable to access the services they need through these virtual clinics.

And while we know virtual clinics have limitations as new start ups, we have seen time and time again that having good intentions is never enough when it comes to those who are continuously left behind. It’s time we do better. It’s time actions match intentions. As access to abortion services across the country continues to dwindle, and fake abortion clinics – also called Crisis Pregnancy Centers (CPC’s) – continue to fuel misinformation, our communities can no longer wait until we get it right. We call on all folks seeking to improve access to use a reproductive justice lens: do the research, invest in justice and equity, before – not after the fact.

Now more than ever, it is imperative that we approach this work from the perspective of those folks who have been invisibilized and systematically oppressed. That we ask who is being left behind? Who is not being served? An RJ approach can help us begin to dismantle systemic oppression and ultimately, dismantle healthcare practices embedded in white supremacy.