by Lesley Hoggart, Marge Berer
BMJ Sexual and Reproductive Health 23 June 2021 (Not open access)
The use of misoprostol at home to induce abortion began in Brazil in the 1980s and spread rapidly to many parts of the globe. The combination of mifepristone plus misoprostol with safe and effective dosages and regimens rapidly became available through clinical provision and was included on the World Health Organization (WHO) complementary essential medicines list in 2005. In 2018, it was moved to the WHO core list of essential medicines and approved for self-managed abortion (SMA) at home up to 12 weeks’ gestation, based on substantial evidence of efficacy, safety and acceptability in legally permitted settings.
Telemedicine counselling and long-distance provision of medical abortion pills for home use in legally restricted settings was begun in 2007 by Women on Web, a safe abortion hotline initiated by a feminist doctor. Access was greatly expanded when a second international hotline, Women Help Women, was launched in 2014. Telemedicine to counsel women and arrange SMA at home has been shown to be safe and acceptable in a systematic review of provision by both Women on Web and medical practitioners in the USA, Canada and Australia. A recent systematic scoping review on SMA found that telemedicine and SMA with abortion pills has high levels of effectiveness. The positive outcomes experienced by women, were with physician-supervised self-managed abortion where women had access to information and support via telemedicine during the abortion process. This article focuses on the issue of support with respect to the acceptability of telemedicine and SMA.…
…. robust research evidence confirms that telemedicine with SMA is a highly acceptable, valued option. On the basis of this evidence, telemedicine counselling with SMA up to the current limit of 10 weeks should be approved permanently and increased to 12 weeks in line with WHO advice. We believe future research should focus on examining existing models of support and how improved support might further increase acceptability, but with an approach that does not restrict clinic-based options. This requires research that considers in more depth the experiences and preferences of women who might not choose telemedicine SMA….
In [two] British studies, between 17% and 34% of women said they would prefer not to have telemedicine SMA if they needed an abortion again. Whilst it is unclear whether this reflects uncertainty about the telemedicine aspect or the SMA aspect, or both,…the research evidence on what may have been difficult for the women, and why, is sparse. [In two studies} clients who preferred face-to-face care mainly cited a desire for emotional and practical reassurance…. [Another study] found a strong association between satisfactory pain control and overall satisfaction…. Thus, support and adequate pain relief may make all the difference in making the experience a positive one… (continues)