ENGLAND & WALES – Early telemedical abortion, safeguarding, and under 18s: a qualitative study with care providers in England and Wales

by Elizabeth Chloe Romanis, Jordan A Parsons

BMJ Sexual & Reproductive Health, 2023;49(4)


Background: Telemedical early medical abortion (TEMA) was introduced in England and Wales as a temporary measure in 2020 and was made permanent in 2022. While there are considerable data showing the safety, efficacy, and acceptability of TEMA for patients, there have been objections raised to TEMA based on safeguarding—particularly for people under 18 years of age. Little is known about abortion care providers’ views and experiences of carrying out their safeguarding duties with people aged under 18 in the shift to TEMA.

Methods: This is a qualitative study involving online semi-structured interviews and reflexive thematic analysis. Audio-recorded, semi-structured interviews with abortion providers in England and Wales (n=20) generated data about their views and experiences of safeguarding in telemedical abortion care. Recordings were transcribed verbatim and then subject to reflexive thematic analysis to construct themes.

Results: While the study was designed with adult safeguarding in mind, the safeguarding of under 18s became a key area of discussion. Three major themes were constructed in relation to under 18s: (1) age as a risk factor in safeguarding; (2) telemedicine as improving access to care; and (3) telemedicine as enhancing communication.

Conclusion: Care providers believe TEMA has benefitted the under 18s. There was a strong feeling both that TEMA had improved access (which, in turn, improved safeguarding) and that under 18s were comfortable communicating using remote means. Providers believe safeguarding proformas must account for the different nature of risks where service users are under 18, but that it is disproportionate to assume that TEMA is unsuitable for all under 18s or groups of under 18s.

From the Introduction

Telemedical early medical abortion (TEMA)—encompassing both remote consultation and at-home administration of both abortion medications—was temporarily lawful in England and Wales in 2020–2022. In 2022, TEMA was made permanently lawful. Data have clearly established that TEMA is safe, effective, and acceptable to service users. It also improved individuals’ (experiences of) access to care. Importantly, all providers have multiple points in their TEMA care pathway where there can be a change to in-person care (e.g., for consultation or to collect the medication) if the service-user requests it or it is deemed necessary. Despite the benefits, there is opposition to TEMA on the grounds that it prevents abortion care providers (ACPs) from safeguarding abortion seekers adequately.

Where an under-18 seeks abortion care without a person with parental responsibility to consent on their behalf, ACPs must ensure that the young person is competent to make decisions about their medical treatment, and that the Fraser guidelines (see below) suggest that abortion provision without parental consent is indicated.

Box 1: Fraser Guidelines

-The young person has sufficient maturity and intelligence to understand the nature and implications of the proposed treatment.

-The young person cannot be persuaded to inform their parents/relevant persons with parental responsibility, nor will they permit the healthcare professional to inform on their behalf.

-The young person is likely to continue having or begin having sex with or without contraceptive treatment.

-The young person’s physical and/or mental health is likely to suffer without advice and/or treatment.

-The best interests of the young person require them to receive advice and/or treatment regardless of whether there is parental consent.

Authors’ Note: Our study intended to focus on adult safeguarding. However, when asked to compare, participants discussed their experiences of under-18s at length. This paper reports findings related specifically to under-18s. Such data are timely. The Royal College of Paediatrics and Child Health recently published guidance on safeguarding young people in abortion care. The guidance indicated that providers “should aim for all (children and young people) to be given an appointment for an in-person consultation at some point in the early medical abortion care pathway unless there is a compelling indication to do otherwise”.

PHOTO: The Guardian, d3sign/Getty Images, 30 March 2022