Trendy Health Startups Still Don’t Offer What Women Need

Why aren’t innovative women-centric health care startups providing abortion?

Lux Alptraum

Jun 17, 2019·9 min read

In early April, I attended a press breakfast highlighting new initiatives and startups in the world of reproductive health care. Held in a meeting room in a swanky midtown New York hotel, the event — billed as “The Future Is Female-Centered Healthcare” — featured a panel discussion of women from a number of reproductive health care-focused startups, including the birth control telemedicine services Nurx, IVF clinic Kindbody, women’s clinic Tia, and online pharmacy Capsule. The president of the National Institute for Reproductive Health was also present.

In the weeks prior to this breakfast, I was reporting about abortion practices in so-called “safe” states — places where abortion is still considered to be easily available — and I had been learning how, even in places where the procedure is legally protected, abortion access is often thin on the ground. As longtime providers age out and retire, and younger doctors opt out of learning the basics of abortion care, the number of people offering abortion services is dwindling. In 2011, there were 1,720 facilities providing abortions in the United States; in 2014 — the last year that the Guttmacher Institute, a leading research and policy organization, released nationwide numbers on abortion providers — that number had declined by 3% to 1,671.

Complicating matters even further, doctors who do provide abortions are often clustered at clinics in dense urban areas: in both New York state and California, over 40% of counties have zero abortion providers. Nationwide, a full 90% counties have no local providers.

I was anticipating a fruitful conversation about how these innovative, female-centered health care companies were planning to address this issue head-on. And as the panel conversation turned to the topic of abortion, I saw an opening.

“What are all of you doing to improve access to abortion?” I asked, directing my line of questioning at the organizations with brick-and-mortar clinics in New York state, where barriers to providing the service are low — but where the options for abortion are still wanting.

“Currently we are just doing our fertility services, but we will be expanding our GYN services in the next few months, and then yes, we will be,” said Dr. Fahimeh Sasan, founding provider of Kindbody. Carolyn Witte, the co-founder and CEO of Tia Clinic promoted the pre- and post-abortion counseling services the clinic currently provides, before saying that abortion is on the list of services they plan to expand into.

The willingness of these reproductive health startups and clinics to embrace abortion as a part of their future offerings sounded like an important step worth covering. And yet when I reached out over email to learn more, both companies altered their stances. “We don’t have immediate plans to expand into abortion services,” a representative from Kindbody told me after declining to do an interview. The women’s clinic Tia also declined, stressing their “comprehensive all-options counseling and seamless referrals into top abortion providers in NYC” in lieu of a discussion of the possibility of the clinic offering abortions on-site.

Abortion access in the United States is facing a critical moment. In Georgia and Alabama, legislators recently passed bills that outlaw all but the earliest abortions — a restriction that many argue amounts to an outright ban of the procedure. Missouri’s only abortion clinic is at risk of closure. With a right-wing majority on the Supreme Court, experts say Roe v. Wade may be under threat as legislators in anti-abortion states gear up to take advantage of that judicial support.

“We need innovation in abortion care.”

Abortion is a common procedure, with nearly one in four U.S. women having an abortion in their lifetime. Though there’s not reliable data for the number of abortions performed each year in the U.S., estimates suggest between 650,000 and 750,000 are performed annually. Yet even where abortion is readily available, it’s often expensive and difficult to access. Many people — particular residents of rural states — are forced to travel hours to get to the nearest clinic, where they may spend an entire day waiting to receive their procedure. A 2017 study published in the journal The Lancet Public Health reported that in 2014, one in five women in the U.S. would need to travel at least 43 miles to reach the nearest abortion clinic. The average cost of an abortion is a little over $500; but it can easily be much more expensive, and it’s not always covered by insurance. In states where the Hyde Amendment is in effect, Medicaid recipients must pay that cost out of pocket.

“We need innovation in abortion care,” says Elisa Wells, co-founder and co-director of Plan C, an advocacy organization that provides information about access to medication abortion. Even in states like New York, where there are few legal restrictions to providing abortion care, people seeking out the service are limited to a handful of clinics mostly based in major cities. Wait times can be long and appointments limited and at inconvenient times. Even something as simple as increasing the number of abortion providers could have a dramatic impact on women’s access and experience — and yet fewer than 2,000 doctors in the U.S. provide abortion services.

If so many reproductive health care startups recognize and understand that abortion is an essential component of women’s health, why are so few stepping up to disrupt abortion access and make the service effortless to obtain?

Abortion providers in the U.S. face a number of challenges, including the punitive legal restrictions, which are on the rise across the country. While the laws passed by Georgia and Alabama are often difficult to enforce (if not outright unconstitutional), onlookers say the restrictions have a chilling effect on doctors and clinics that might otherwise offer abortion services.

Providers also face a business model that requires them to provide a high-cost service to an often low-income client base. On top of that, providing abortion is still stigmatized work — work that can put a physician in the crosshairs of potentially violent anti-abortion zealots. “Why does anyone do this work?” says Melissa Grant, co-founder and COO of the abortion provider Carafem, with a laugh.

Carafem is an anomaly. It’s a new health care company that’s investing in and streamlining reproductive health care using modern technology. Abortion is their primary service.

Grant came to Carafem after years of working with family-planning organizations across the U.S. As she worked to connect people to abortion providers, she became frustrated with the barriers to access, and she wanted to figure out a way to make it easier to get an abortion. Her co-founder, Christopher Purdy, came from a more international background — as CEO of DKT International, he spent his career improving contraceptive marketing and messaging in the developing world — and the job left him befuddled about the state of abortion access in one of the richest countries in the world. “He pondered out loud why it was possible that in some areas of the U.S. it was more challenging to get an abortion than to get one in Ethiopia,” Grant says. (While Ethiopian law places some restrictions on who can have an abortion, the service is available at the majority of venues that are capable for providing abortion, including 98% of the country’s public hospitals.)

When Grant discusses Carafem’s work, she doesn’t sound very different from other health care startup founders. The organization’s goal, she tells me, has always been to focus on efficiency, creating low-cost facilities that streamline a patient’s visit, eliminate unnecessary waiting time and paperwork, and prioritize the client’s needs over presumed best practices — though, it should go without saying, within the parameters of sound medicine. In developing the model, Grant and Purdy found themselves asking themselves lots of whys. “Why do we do this? Why do we do that? Does it have value?” — all the while working with clients to make sure they were providing the best possible experience.

Four years after opening their first clinic, Carafem now operates in four different cities, including Atlanta, Georgia — where, their website reminds visitors that abortion is still legal. They’ve also partnered with the TelAbortion study, a research study examining the effects of providing medical abortions through a telemedicine platform, to provide abortion pills by mail, enabling Georgia residents — 58% of whom live in a county with no abortion providers — to access abortion services without traveling to a clinic. (Due to FDA restrictions, telemedicine abortion is only legally available through approved research studies like the TelAbortion study.)

As passionate as Grant is about her work, she’s not particularly surprised that Carafem is one of the few organizations approaching abortion in such a direct manner.

On the other end of the spectrum, startups are likely deterred from entering the abortion space because the work to do so comes with significant stigma. In many states, there are strict restrictions that significantly reduce the number of people who are legally allowed to provide abortions. The restrictions can also create major roadblocks — like requiring anyone who provides a medical abortion to register with a national database — which can deter providers from the job. Even in states like New York, where abortion is legally supported, there are numerous complications, like conservative communities, or local hospitals that are unfriendly to abortion, that make the work more challenging. Even in the best case scenario, there’s no obvious or easy path to profitability.

“Not everyone wants to become involved in abortion care,” says Grant. “It’s not the same as other types of health care, it comes with a political conversation on top of providing health care” — and doing both of those things well can be a difficult balancing act.

More pressingly for companies that are reliant on venture capital investment, Grant says that the business model for providing abortion care is a challenging one. The avalanche of new restrictions put in place in the U.S. since 2011 require abortion providers to nimbly navigate a rapidly changing landscape. It’s challenging enough for non-profit advocacy groups and abortion providers to adapt to the onerous new measures being ratified in some of America’s more anti-abortion states. For a company that’s focused on profits, the unpredictability of abortion’s legal status creates an unappealing uncertainty, one that could upend one’s carefully plotted profitability projections in an instant. Unlike, say, shipping generic Viagra or birth control pills through the mail, abortion isn’t an easy moneymaker — especially since many of the people who seek out abortion do so because they are struggling financially.

Which leads to one of the most significant differences between Carafem and many of its peers in the women’s health care disruption space: Carafem is a non-profit, supported by donations rather than investors, driven by its mission rather than its bottom line. The energy and innovation percolating through the health care startup space could radically transform how we think of abortion services and access. Which is why it’s disappointing that so few women’s health care startups are making abortions a service.

Grant says she wishes that startups were less hesitant about stepping into the abortion space. “I think that innovation and the ability to look at a problem in a different way and solve it, giving people different options, is crucial in any field,” she says. And it’s all the more crucial in a space facing as many different restrictions and setbacks as reproductive rights.

Yet while startups may shy away from devoting attention and resources to providing abortions, there are other innovators working behind the scenes to make abortion more accessible, regardless of its legal status. As Wells reminds me, it was Latin American women who — driven underground by severe restrictions on abortion — realized that the ulcer medication misoprostol could induce an abortion on its own. “The people who are innovating are the ones who need the abortion services,” she says. And all around the globe, people have developed innovative ways to increase access to abortion, from the sea-based abortion clinic Women on Waves to more recent web-based initiatives like Aid Access.

But more help is welcome. “2019 has become the year when anti-abortion politicians make clear that their ultimate agenda is banning abortion outright, at any stage in pregnancy and for any reason,” writes Elizabeth Nash, the senior state issues manager of Guttmacher Institute. If the companies positioning themselves as the cutting edge of reproductive health care access believe that abortion is an essential part of their mission, they need take inspiration from these boundary-pushing organizations and step into the fray.