Abortion pills are as safe and effective when obtained through telehealth services and self-administered as they are when used in doctors’ offices, according to the largest study of telehealth abortions to date.

Prior studies of a few hundred pregnancies have shown telehealth abortions are safe. To investigate further with a larger sample size, at the University of California, San Francisco, and her colleagues collected data on more than 6000 telehealth abortions across 20 US states and Washington DC. All participants were less than 10 weeks pregnant. About 72 per cent of them obtained abortion pills through secure text messaging and the rest had appointments throughĚývideo calls.

The researchers followed up with participants between three and seven days after their abortion, and again two to four weeks later. The team found that almost 98 per cent of the abortions effectively ended the pregnancy. Additionally, only 0.25 per cent of participants experienced serious side effects like uncontrollable bleeding or infection. By comparison, in-person use of mifepristone is more than 97 per cent effective and leads to adverse events 0.3 per cent of the time.

Abortion access is a contentious political issue in the US. In 2021, the US Food and Drug Administration (FDA) dropped in-person dispensing requirements for the abortion medication mifepristone, allowing people to get the pill through telehealth services and the mail. Anti-abortion groups are now challenging this decision in the US Supreme Court.

“These findings are consistent with the bounty of evidence that we have that mifepristone is safe and effective, and that the FDA’s decision to remove the in-person dispensing requirement was scientifically sound,” says Upadhyay.

“The outcomes are basically indistinguishable between telehealth and patients coming into a brick-and-mortar clinic,” says at reproductive health non-profit Planned Parenthood of Montana. Telehealth abortions are critical for providing care to people in rural areas or those who may not feel safe travelling to an abortion clinic due to abusive partners, he says.

On 8 November, US voters will decide whether Democrats maintain their slim majority in both houses of Congress. This, in turn, will determine whether the administration of President Joe Biden will be able to pursue its agenda for the next two years. The midterm election – which takes place halfway through each presidential term – is also set to change the balance of power in state governments, with races in every state legislature and 36 gubernatorial elections.

Here is how the election results could affect three key scientific issues: climate change, reproductive healthcare and covid-19 policy.

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Climate change

The Inflation Reduction Act passed by Congress in August of this year represented the first serious climate legislation from the federal government and has been a key achievement trumpeted by Democrats in midterm debates. The more than $300 billion it puts towards climate and energy initiatives will accelerate the race to decarbonise in the US and elsewhere, with measures in the bill projected to reduce US greenhouse gas emissions by as much as 44 per cent below 2005 levels by 2030.

That is now the law, but control of Congress will shape how it is implemented, says at the Niskanen Center, a right-leaning think tank based in Washington DC that advocates for environmental policy. Democratic control of Congress would give the Biden administration a freer hand to push for clean energy and other projects supported by the bill, as well as climate priorities, on the international stage. A Republican majority in either house could complicate things. “That policy becomes the focus of efforts to repeal, eliminate and investigate,” Schrodt says.

If Republicans gain control of both houses of Congress, they would have a legislative path to repeal the law through a process called budget reconciliation, but Schrodt says that would be unlikely. “It is still a difficult path and industries may react poorly to a repeal,” he says. He also says he has seen “nuggets” of climate-related proposals in Republican platforms related to things like faster permitting to mine the critical to batteries and renewable energy. “I don’t think if there is a Republican majority it will completely be the end of climate action,” he says.

A proposal from West Virginia Senator Joe Manchin to speed up permitting for energy projects, including the transmission lines necessary to decarbonise the grid, was scrapped in September in the face of opposition from both Republicans and progressive Democrats. Permitting reform has since become an urgent issue for Democrats concerned that a Republican-controlled Congress would speed fossil fuel development more than clean energy projects. State elections will also affect interstate transmission line projects, among other clean energy and climate priorities.

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Access to abortion

The 2022 midterms will be the first US election in 50 years in which access to abortion is not a right guaranteed by the Constitution.

The issue shot to the centre of US politics in June when the US Supreme Court overturned Roe v. Wade – the landmark 1973 case that guaranteed a woman’s right to an abortion prior to viability of the fetus. In Dobbs v. Jackson Women’s Health Organization, the court’s conservative majority argued that abortion is not a right guaranteed by the Constitution, thus leaving the issue to state governments or Congress to decide.

In the months since that decision, there have already been signs that doctors are delaying lifesaving care for women due to concerns about legal prosecution, and medical organisations such as the American College of Obstetricians and Gynecologists remain emphatic that “”.

Since the Dobbs decision, Democrats in Congress have tried to pass legislation that would guarantee abortion rights in all states; two such bills passed the House but didn’t have the votes to make it to the Senate. Some Republicans in Congress have pushed for nationwide restrictions on abortion, such as a bill introduced by South Carolina Senator Lindsey Graham that would ban most abortions after 15 weeks of pregnancy. Other Republican leaders have said decisions about abortion access should be left up to the states.

States have already made changes. Thirteen states now in most cases. Five states have passed laws to ban abortions beyond a certain gestational limit. Ten states have bans or more restrictive laws that have been blocked by courts as legal challenges play out.

“Battles to protect access to abortion and all reproductive healthcare have been and will continue to be fought at the state level,” says , at the Guttmacher Institute, a reproductive health research and advocacy group.

Beyond the races, California, Michigan and Vermont have measures on the ballot to protect the right to abortion and support people seeking abortions from out of state. Voters in Kentucky (where abortion is already banned in all cases) and Montana (where a ban on abortion after 20 weeks was blocked by state courts) will decide on additional anti-abortion measures.

A recent study found the number of abortions increased by 11 per cent after the Dobbs decision in states with few restrictions on abortion procedures, suggesting people are travelling between states to access care. The number of abortions nationwide decreased by 6 per cent.

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Covid-19

More than a million Americans have died from covid-19, more have symptoms of long covid and the virus continues to kill more than 300 people a day in the US, according to compiled by The New York Times. What’s more, a soup of new variants is expected to drive a wave of new infections in the weeks ahead.

Despite its ongoing impact, the pandemic has played much less of a role in midterm politics than it did in the 2020 elections. Democrats haven’t centred on the issue. And Republicans have focused more on grievances about past closures and mandates.

Still, the outcome of the election will decide who is in power during the third winter of covid-19, which could see cases increase with new variants and lowered restrictions, not to mention the impact of an ongoing surge of respiratory syncytial virus cases in the US and the possibility of a “twindemic” with flu. Who is in power could also shape funding priorities for health agencies, vaccination initiatives, testing and other health measures. Republican control of Congress may also mean investigations related to the origins of the virus as well as the federal response to the pandemic during the Biden administration, according to by STAT.

There is that Republican-voting counties see more covid-19 deaths than majority Democratic-voting ones, mostly due to different attitudes around vaccination and other mitigation efforts. If the federal public health emergency declared in 2020 ends in 2023 – which Politico is the working assumption in the White House – it would leave more decisions about how to manage covid-19 to the governors and state legislatures elected on 8 November.

New state laws banning abortion in the US include exemptions that allow doctors to end pregnancies “to save the life of the mother”. But in practice the vague nature of these exemptions could endanger patients’ lives and open up medical care providers to lawsuits and criminal charges.

As of 28 June, at least , according to the reproductive health research organisation the Guttmacher Institute. Another 18 states are expected to institute bans in the weeks ahead, in the wake of the US Supreme Court decision repealing Roe v Wade, the 1973 ruling that protected the right to abortion.

So far, all of these bans include exceptions for when the pregnant person’s life is in danger, but the way these exemptions are written doesn’t provide much protection for healthcare providers, says at the Guttmacher Institute. “Abortion opponents see exceptions as loopholes so they design them to be nearly meaningless,” she says.

In states where abortion is banned, life-saving exemptions will often be the only legal basis for someone to obtain a safe abortion. But doctors may still be hesitant to perform the procedures for fear of legal action being taken against them, putting lives at risk.

Such effects were seen in the aftermath of a 2021 law in Texas that effectively banned abortions after around six weeks of pregnancy. After with 25 clinicians, researchers at the University of Texas found that abortions were delayed until they became medical emergencies or in some cases until embryonic cardiac activity was no longer detectable. As one interviewee put it, “People have to be on death’s door to qualify.”

The study also found that there was uncertainty around whether medical professionals could even discuss abortion with their patients.

“The individuals writing these laws are not medical experts,” Jen Villavicencio at the said in a statement. “The language is often incorrect, not clinically meaningful, and therefore confusing to those practicing medicine.”

If a doctor can’t tell what the law is or means, it could have life-threatening consequences, said Villavicencio. “No one facing a medical crisis should have to fear their physician pausing, or even halting, when in the midst of doing what the patient needs in order to resolve or avoid the threat of prosecution,” said Villavicencio.

There are many circumstances, including heart failure or serious infection, in which abortion is an essential, life-saving procedure. Additionally, for certain conditions, risk of serious injury or death is reduced by intervening early – before things have deteriorated and the danger is imminent.

For example, in the case of severe preeclampsia, a blood pressure condition that can be fatal, one of the potential treatments is to end the pregnancy in the third, fourth or fifth month, said of ACOG at a press conference last week. But at those stages, the patient may not yet be considered in grave enough danger that the doctor feels they can legally intervene.

“[These laws] will leave physicians looking over our shoulders, wondering if a patient is in enough of a crisis to permit an exception,” said Hoskins. “It leaves them fearing that the evidence-based care that they are providing is leaving them susceptible to discipline, punishment, lawsuits, loss of licence and criminal penalty.”

Abortion is set to be outlawed under most circumstances in more than half of US states following the Supreme Court’s decision on 24 June to repeal Roe v Wade, the 1973 landmark ruling that protected the right to an abortion. US President Joe Biden “a realisation of an extreme ideology and a tragic error by the Supreme Court”.

The decision was forecast when a leaked draft was released in May. Following the official ruling by the court, protests broke out in Washington DC and across the US.

The repeal is based on a case challenging a Mississippi abortion ban, known as Dobbs v Jackson, which was upheld in a 6-3 vote by Supreme Court justices. They then voted 5-4 to overturn Roe v Wade. , justice Samuel Alito said: “The Constitution does not prohibit the citizens of each State from regulating or prohibiting abortion.”

It will now fall to each state to decide. Thirteen states have so-called trigger laws set to ban the procedure in the case of Roe v Wade being overturned; in some states this has already come into effect while in others it will be enacted after 30 days or once signed off by an official. Several other states have abortion restrictions that were in place before 1973 that may now be enforced.

“Without Roe, 26 states are certain or likely to ban abortion to the fullest extent possible,” said at the Guttmacher Institute, a reproductive rights research group, in . Six in 10 US women aged 13 to 44 live in one of these 26 states, which are primarily in the South and the Midwest.

In a , Supreme Court justices Elena Kagan, Sonia Sotomayor and Stephen Breyer wrote: “With sorrow – for this Court, but more, for the many millions of American women who have today lost a fundamental constitutional protection – we dissent.”

Their opinion doesn’t change the ruling, but goes into the public record. It states that this decision undermines bodily autonomy: “It says that from the very moment of fertilisation, a woman has no rights to speak of.”

The allow exceptions to save the life of the pregnant person, but most don’t include exceptions for rape or incest.

A found that 61 per cent of people in the US say abortion should be legal in all or most circumstances. For those who say abortion should be against the law in most or all cases, 46 per cent say exceptions should be made if the health or life of the woman is threatened.

“Abortion is still going to be accessible in nearly half the country and we need to make sure patients are aware of that,” says Gabriela Aguilar, a doctor in New York who specialises in obstetrics and gynaecology. “We had a patient who had come to our clinic today from Florida, and as she was brought into the operating room and about to fall asleep she expressed fear and panic. She had gotten a notification about the decision and in an exasperated manner asked if she could still have her procedure.”

Aguilar says there are doctors and organisations dedicated to getting people to states where abortions are still legal and providing medications for self-managed abortions. “We’re devastated, we’re disappointed, but we will persevere.”

In response to the historic ruling, US attorney general Merrick Garland that women must remain free to travel to states that provide abortion and people or organisations must be able to inform and counsel others about reproductive care available in other states.

He also said that states cannot ban mifespristone, a medication for self-managed abortion, which is approved by the US Food and Drug Administration.

However, what is and isn’t legal in terms of abortion advice, travel and medication is now unclear in many states, and many legal challenges are expected in coming weeks and months.

The repeal of Roe v Wade comes at a time when abortion rates are growing in the US. The Guttmacher Institute found that in 2020 , to about 930,000 abortions that year. “More than one in three of these abortions were obtained in states that are now certain or likely to ban abortion,” said Palacio.

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