Medical abortion via telemedicine – a revolution in patient-centred care?

Posted 25 Jan 2021

Date: 25 Jan 2021

Author: Dr Jonathan Lord

In this month’s eFeature, Dr Jonathan Lord examines the impact telemedicine and the temporary approval of the home use of pills for early medical abortion (EMA) has had on women and abortion care services.

This is an image of Dr Jonathan LordVery occasionally in medicine you witness an innovation or advance that you suspect will transform care and benefit patients for a generation. Saturday 21 March 2020 marked one such event – the publication of the joint RCOG / RCM / FSRH / BSACP Coronavirus (COVID-19) infection and abortion care guidelines.

It was already well known that telemedicine offered advantages. The National Institute for Health and Care Excellence (NICE) abortion care guideline in 2019 recommended that services should provide “abortion assessments by phone or video call, for women who prefer this”. With about one in three women in the UK needing to access abortion services in their lifetime, and over 200,000 people needing abortions every year in England and Wales, any intervention that improves access will help large numbers of patients.

 

What’s changed?

The joint RCOG / FSRH guideline empowered providers to offer telemedicine and offered practical guidance on who could be effectively managed through medical abortion. The governments in Great Britain approved home-use mifepristone by 30 March 2020, and within a week the main providers had started to transform their pathways.

The first step in the pathway is to determine whether the patient is eligible for no-test medical abortion by assessing if they are at low risk of ectopic pregnancy and that their self-reported last menstrual period (LMP) indicates a gestation of less than 10 weeks. If they are suitable then, usually following a more detailed telephone assessment and counselling with a nurse, medications are delivered to patients via post or made available for collection from a clinic for use at home. Those not suitable for telemedicine are booked an in-person assessment with ultrasound.

Assessing the impact of the new pathway

The rapid implementation and large numbers of patients needing care meant there was a unique opportunity to assess the impact of the new pathway. The British Society of Abortion Care Providers (BSACP) brought the three main abortion providers in the UK and academics together to conduct the largest study yet in UK abortion care. This was a cohort study to compare the “traditional model” (where all patients received in-person care including an ultrasound) with the new pathway in which those eligible had no-test telemedicine, with the remainder having in-person assessment including ultrasound (“telemedicine-hybrid model”).

Each cohort included all patients having a medical abortion over a two-month period before and after the implementation of telemedicine at each provider. The total sample of 52,142 patients represents 85% of all medical abortions performed nationally during the study period. Of the 29,984 in the telemedicine-hybrid arm, 62% received no-test telemedicine with the remainder requiring in-person assessment.

Access

There is no doubt that the introduction of telemedicine has improved access to abortion care. At a time when the COVID-19 pandemic had meant many NHS services were restricted and waiting times soared, the mean waiting time for medical abortion was reduced. Furthermore, the gestation at abortion has reduced significantly. These findings are significant not only statistically but also practically – for the majority of patients an unwanted pregnancy is distressing and their decision to have an abortion very clear, so it is kindest to relieve that distress as quickly as possible. Moreover, NICE found that for every day’s reduction in waiting time, the NHS in England would save £1.6m per year owing to reduced complications and fewer needing to opt for a surgical abortion.

"There is no doubt that the introduction of telemedicine has improved access to abortion care." - Dr Jonathan Lord

It is worth noting that access to contraception has been difficult during the pandemic, especially to access long-acting reversible contraception (LARCs). Only yesterday on my abortion list I saw a patient with a four-month baby who could not access effective post-partum contraception, and one who was ten months overdue for her implant renewal; most weeks there are several who are on waiting lists for LARCs. Whilst telemedicine cannot solve these long-standing issues, if patients only needed to attend their abortion provider once and that can be to fit LARC, ideally immediately after their abortion, it would seem likely that many would choose this. Access to STI testing is also variable, but where it is commissioned, we have found postal kits to be well received.

Acceptability

This image shows the silhouette of a womanPatients rated telemedicine highly, with the majority rating their care as good or very good, and that they would choose telemedicine again in the future. It was especially reassuring that no patient reported that they were unable to consult in private using telemedicine, indeed many highlighted that telemedicine offered them greater privacy than having to attend clinic.

However, whilst most would choose telemedicine again even if COVID-19 were no longer an issue, 22% did report they would prefer face-to-face care, mainly for personal contact and reassurance. This was slightly more likely in those under 20 and in Black / African / Caribbean groups. Whilst telemedicine suits the majority, it is not a panacea and providers still need to offer quality, local services for those who need or prefer face-to-face assessment.

Examples of free-text responses from patient survey

  • “[It was] easier to speak over the phone, and [client] did not feel judged.”

  • “[Client was] very happy with the service and treatment… really valued being able to have treatment in the comfort of her own home. [Client] could cry – she is so happy!”

  • “Really nice to have that choice – as a woman we should have the right to make our own choices and it’s harder to talk face-to-face than over the [phone].”

  • “Everything was amazing, the support was amazing. I hope this carries on [as] it helps people like me with children. The 24 hour helpline was so helpful. From start to finish… it has been amazing.”

Outcomes and Complications

Our study confirmed that medical abortion is a safe and effective procedure. Significant adverse events were rare in both cohorts. Rates of ectopic pregnancy were equivalent in both groups with no significant difference to the proportions being managed after EMA. 

Safeguarding

Before telemedicine was introduced, we knew that telephone consultations were effective in identifying vulnerable individuals. Two notable examples from 2019 included successfully identifying and rescuing three human trafficking victims and safeguarding a very young person who had suffered statutory rape from family members for years.

Our experience has been that telemedicine has made abortion safer for people with safeguarding risks. Those previously too frightened to discuss intimate or distressing details in person can talk more openly and privately via telephone and are no longer reliant on a coercive partner to take them to a clinic. We have seen an increase in safeguarding disclosures during the pandemic, including those from survivors of domestic abuse and sexual violence.

The Future

We have found that no-test medical abortion via telemedicine without routine ultrasound is an effective, safe and acceptable service model. Clinical outcomes with telemedicine are equivalent to in-person care and access to abortion care is better, with both waiting times and gestational age at the time of abortion significantly reduced. Given the advantages for patients, the evidence is compelling that no-test telemedicine should become routine in the provision of abortion care.

The data cited in this article is in publication having been through peer-review. 

Royal College of Obstetricians and Gynaecologists (RCOG), Royal College of Midwives (RCM), Faculty of Sexual & Reproductive Healthcare (FSRH), et al. Coronavirus (COVID-19) infection and abortion care. In: RCOG, ed. London, UK: Royal College of Obstetricians and Gynaecologists, 2020

National Institute for Health and Care Excellence (NICE). Abortion Care. In: National Institute for Health and Care Excellence (NICE), ed. NICE Guideline. London, 2019. 

More information on Telemedicine services at MSI Choices UK

Published in the January 2021 edition of the Sexual Health, Reproductive Health and HIV Policy eBulletin. The content of all eFeatures represents the views and opinions of the authors. FSRH and coalition partners do not necessarily share or endorse the views expressed within them.