by Marge Berer
Introduction
Telemedicine for abortion care is the use of communications technology to arrange an abortion in a clinical setting or self-managed by the woman at home with medical abortion pills and for follow-up after the abortion. For International Safe Abortion Day, 28 September 2020, in the context of the Covid-19 pandemic, the International Campaign for Women’s Right to Safe Abortion (ICWRSA) is promoting the use of telemedicine to arrange and follow-up an abortion and to support women’s right to have an abortion at home in the first trimester of pregnancy with medical abortion pills if she so chooses.
This discussion paper provides a history of how the use of telemedicine and self-managed abortion with abortion pills at home have developed. Initially, in Brazil in the 1980s, women shared information about the use of misoprostol informally. Then, feminist-run safe abortion information hotlines were set up, starting in 2005, to provide women with the information they need (and in some cases provide the pills) to have an abortion at home. There are currently one or more such hotlines in at least 26 countries in all world regions. More recently, health professionals began to use what is now called telemedicine (or telehealth) for this same purpose. This paper is about telemedicine and the conditions that make self-managed abortion safe, and gives examples of abortion services that put telemedicine and self-managed abortion together. It also covers the role pharmacies can and are playing in support of these changes.
Telemedicine and self-managed abortion may not be feasible, preferred, appropriate or safe in all instances. They may be restricted by law and regulations, limited communications technology, lack of skills in conducting telemedical consultations, and/or lack of crucial conditions for women to abort at home, such as privacy. For the last almost 40 years, however, medical abortion pills have made it possible for women to take abortion into their own hands, and they are doing so increasingly and in greater and greater numbers, with a little help from their friends, safe abortion information hotlines, and a growing number of health professionals.
Given the changes that telemedicine is bringing into health care due to Covid-19, abortion services should be reconceptualised with a 21st century lens. This means access to telemedical consultations pre- and post-abortion where the in-person alternative carries a risk of infection. It means a choice between home-based, self-managed abortion and clinic-based abortions, the latter provided mostly by mid-level providers in primary-level and community-based services. It means recognition by the State of safe abortion as essential health care, the decriminalisation of abortion, the removal of unnecessary regulatory barriers, the training of mid-level providers, and women’s control over the abortion decision and where it takes place. Some of these changes are health systems issues. All of them depend on law, policy and practice that guarantees the right to a safe abortion at a woman’s request, no more, no less.
Background
In 1997, WHO published a health telematics policy in support of health-for-all.[1] By 2014 telemedicine was considered a “household term”. Since then, the use of telemedicine has entered healthcare in a wide range of specialisms, and very rapidly in 2020 due to the Covid-19 pandemic. In July 2020, the synonymous terms ‘telemedicine’ and ‘telehealth’ pulled up over 34K citations in PubMed and a number of specialist journals as well.
A 1999 article offered the following broad definition of telemedicine: “the use of electronic information and communications technologies to provide and support health care when distance separates the participants. Technologies used for telemedicine include “videoconferencing, telephones, computers, the internet, fax, radio, and television.”[2] Each of these has distinct advantages and disadvantages. Apps are also being used, e.g. when internet access is limited. The 1999 article goes on to say:
“The internet-fueled empowerment of consumers and their expectations for speed, access, and convenience are creating more unmet expectations of the traditional health care system… Online drugstores are attracting most attention. Potential benefits of telemedicine include improved access to care, greater efficiency in diagnosis and treatment, higher productivity, and market positioning for the coming century. Telemedicine will tax the economic, regulatory, legal, ethical, and clinical care expertise of the entire health care system. Studies of the effectiveness, cost, and societal implications of telemedicine are needed, along with practice models and standards, training programs, and solutions to regulatory, licensing, and legal questions.”
In addition to ‘telemedicine’ and ‘telehealth’, the terms electronic health (e-health) and mobile health (m-health) also appear. Whatever it is called, telecommunication requires specific skills, depending partly on whether the interaction is one-off or repeated; for routine, acute or chronic care; and for arranging, monitoring or following up such care. In each case, the interaction should be assessed to determine whether the intended outcomes have been achieved.
After 2010, reviews and articles began describing and assessing the use of telemedicine in specific specialisms, countries and regions. Important barriers to telemedicine use also began to be identified. These included the lack of the right technology to make telemedicine feasible, the need for training of staff and support staff, how to ensure patient privacy, how to achieve standardisation, and issues of reimbursement. It was also recognised that well-defined patient groups for whom telemedicine is (or is not) appropriate had to be identified. All these issues are now considered critical to ensuring the successful use of telemedicine in health service delivery.[3]
In 2020, a Lancet review reported that, due to the need for distancing with Covid-19, an almost overnight shift was taking place from in-person to virtual consultations between healthcare providers and patients in whole areas of healthcare.[4] Having surveyed Canada, China, Germany, India, Italy, South Africa, UK and USA, the review noted that in Canada, “steps to sweep aside regulatory and hegemonic professional barriers were being taken” with the support of senior medical staff. As one expert pointed out: “The regulatory barriers that have held virtual health care back for all these decades were never justifiable. [Covid-19] is an opportunity to blow all these barriers away. The question now is: ‘How far are we willing to go?’”
All of this is relevant to safe abortion care. For example, a 2014 study in South Africa[5] showed how mobile phones could be integrated successfully into abortion pill provision and replace in-person visits in three ways:
- coaching women through medical abortion using SMS/text messages;
- using a questionnaire to assess completion of abortion; and
- provision of information about post-abortion contraception.
Telemedicine has been found to be especially valuable for patients living in remote areas with few health professionals, as it makes long distance travel unnecessary for patients. This has been shown to be important for abortion care in Australia[6] for example.
It is in this context that this paper looks at the use of telemedicine for arranging and following up an abortion, with the abortion either in a clinical setting or with the use of medical abortion pills for self-managed abortion at home. It also involves information and support from a trained safe abortion information hotline, a trained pharmacist and/or a healthcare provider.
Telemedicine and self-managed abortion with pills began with safe abortion information hotlines
Since the 1980s, when it first became known in Brazil that misoprostol can induce an abortion, women have been accessing misoprostol via pharmacies, drug sellers, street markets and online pharmacies, and self-managing their abortions, legally or otherwise. The information rapidly spread on the grapevine across Latin America and then to other regions.
Pharmacies have long been the main source of abortion pills for home use in India. Of an estimated 15.6 million abortions in India in 2015, over 70% were with abortion pills, while only 14% were surgical and 5% other methods. Of all the abortions with pills, 91% took place outside healthcare facilities, with only 2% in public facilities and 7% in private facilities.[7] Although that study found that in most cases the pills were acquired without a prescription, chemists have reported in a newer study that between 71% and 100% of pills were obtained with a prescription.[8] Yet guidelines issued by India’s Ministry of Health and Family Welfare on 25 March 2020, which made it legal to practise some telemedicine in India,[9] did not include its use for abortion. Why not? The Medical Council of India is reported to have told the NGO Hidden Pockets that the Government of India allows only over-the-counter medicines to be e-prescribed, with only a few exceptions.[10]
Globally, wherever women cannot access abortion pills via the formal health system, they are getting them from pharmacies, web-based pharmacies, online services by independent abortion providers – and information on how to use them from hotlines run by safe abortion advocates. In 2005, Women on Web, whose founder is a doctor, used telemedicine to help women around the world obtain medical abortion pills to use at home. They were followed by Women Help Women[11] several years later, who not only counsel by telemedicine and provide pills, but have also encouraged the initiation of national safe abortion hotlines in many parts of the world to do the same and have supported networking between them.
Today, there are at least 31 safe abortion information hotlines in at least 26 countries, all listed on the ICWRSA’s website.[12] They provide women with information and support on safe abortion and often other sexual and reproductive health information as well – by phone, email, website, app and social media. In most cases, their staff and volunteers are trained using WHO guidance, and variously include medical professionals, feminist activists, trained counsellors and researchers, among others.[13]
The Ms Rosy Reproductive Health Information Hotline in Nigeria, a project of Generation Initiative for Women and Youth Network (GIWYN), is an example of a hotline addressing women’s needs during Covid-19.[14] Their staff are working from home to increase access to information on effective contraception, abortion options and essential medicines. They consider this one of the most cost-effective, practical community interventions available, which will help to reduce unintended pregnancy and preventable deaths from unsafe abortion, particularly with the public healthcare system heavily overburdened by Covid-19.
Comparable helplines were started decades ago by national family planning associations for women seeking contraception and expanded to cover other sexual and reproductive health services; others were initiated for people with HIV. They have informed and educated so many people on these issues often in the absence of this help from national health systems, just as safe abortion helplines are doing with abortion. Their help is an important part of the reason why illegal abortions are far less unsafe than in the past. Indeed, the clandestine use of medical abortion pills at home has reduced the need to access dangerous backstreet providers using invasive methods, whose elimination so many government have failed to take responsibility for, or achieve.
Why telemedicine for abortion care is not being used widely by health systems
An estimated 150,000 abortion take place every day around the world, and one in four pregnancies ends in an induced abortion.[15] On 1 June 2020, WHO declared (not for the first time) that safe abortion is essential health care.[16]
Given the rapid growth in the use of telemedicine due to Covid-19, why is telemedicine for abortion care not being used more widely? Travel is restricted, people are in lockdown, healthcare services have postponed many essential services to deal with the virus, and reducing in-person contact wherever possible is recommended.
The short answer is that although abortion methods are safer than most other clinical procedures, abortion is still criminalised and/or legally restricted in the great majority of countries. While unsafe abortion deaths have been falling, almost 7 million women per year receive post-abortion care in hospitals for complications of unsafe abortion.[17] In spite of decades of campaigns and support from a growing list of international bodies and meetings, it is still not possible for a woman to obtain an abortion at her own request up to 24 weeks of pregnancy (thus encompassing almost all abortions) except in a handful of countries. The contradictions are glaring.
Telemedicine is a valid use of widely available technology for abortion care. But it is this political reality that limits its use for abortion care.
First trimester abortion at home is a safe, acceptable alternative to a clinic-based abortion
In 2016, a wide-ranging review of qualitative research on women’s experiences of self-managed abortion found that overall self-management was acceptable to both women and providers, in both legal and legally restricted contexts, and with pills accessed through formal and informal systems.[18]
There was enough evidence for WHO to say in 2018 that self-managed abortion at home in the first trimester of pregnancy is safe.[19] Yet in most countries, home use of abortion pills is illegal. Faced with this contradictory situation, women who need an abortion are obtaining abortion pills and having abortions at home with or without permission, knowing the health system is there if they experience complications.
Telemedicine to arrange and follow-up an abortion can take place with the woman at home and the healthcare provider either at home or in a clinic. If managing abortion at home is not possible because of a woman’s circumstances or is not preferred by her, or if she is more than 12 weeks pregnant, the provider can arrange for her to have an in-person abortion. If she is less than 16 weeks pregnant, the abortion can be by aspiration (manual or vacuum) and take place in an outpatient setting, preferably at primary level by a mid-level provider. The procedure itself takes only minutes, simple protective clothing/masks can be worn, the sterile conditions of an operating theatre are not necessary, and it can all happen in a very short space of time. Nor is a gynaecologist required except for complicated cases or D&E. The overall reduction in in-person consultation and service delivery time and costs would be enormous.
The switch cannot be achieved overnight, but it is straightforward if it is not tied up in red tape or punitive regulations. Both the technology and the skills to use telecommunication with patients are needed. Abortion providers need to develop locally appropriate guidance that covers home use of abortion pills as well as in-person care. The in-person care should occur as close to home for both patient and provider as possible, with as few visits and the shortest possible in-person time as possible. Unnecessary barriers should be eliminated. Covid-19 alone calls for this, but it also makes good sense.
A 2013 analysis of data from the rural US state of Iowa showed that the introduction of telemedicine services for medical abortion was associated with a reduction in second‐trimester abortions and increased access to services for women living far from a clinic.[20]
Canada began to allow telemedicine for early abortions in 2014.[21] A systematic review of studies internationally up to November 2017,[22] published in 2019, where telemedicine was used for comprehensive medical abortion services, found, according to a linked commentary:[23]
“…reassuring evidence from a range of settings that telemedicine provision of medical abortion is safe, effective, and well‐liked by patients and providers. Clinical outcomes were found to be similar to those for models of care that involved an in‐person visit.”
In Europe, Ireland was the first country to allow telemedicine for abortion at the start of their Covid-19 pandemic in March 2020. Britain followed later in March and France in April,[24] but few others have done so, in spite of national advocacy efforts. Catalonia in Spain reduced the number of required clinic visits from two to one, but Spain has not permitted telemedicine. In Moldova, in contrast, the Reproductive Health Training Center had been preparing a national telemedicine abortion service since 2019, obtaining pills and developing materials, particularly videos for patients. Serendipitously, the programme was ready to launch when Covid-19 happened (Personal communication, Dr Rodica Comendant, RHTC Director, 29 April 2020).
In Great Britain, the British Pregnancy Advisory Service (Bpas) is the largest independent abortion provider, covering 72% of all abortions in England and Wales in 2018. They had to close 23% of their clinics in March 2020 when Covid-19 hit, due to self-isolation by staff and lack of sufficient personal protective equipment. The government decided to allow telemedicine for abortion from 30 March 2020 and for the duration of the pandemic in response to pressure from abortion rights advocates, parliamentarians and a range of medical professional bodies. Women can now obtain approval for an abortion telemedically, receive abortion pills in the post, self-manage their abortion at home, and have post-abortion follow-up telemedically.
With the support of outside advice, it took only one week for Bpas to get their telemedicine services up and running across the country. By the end of April 2020, they had treated 35% more women than usual, around 10% above pre-Covid-19 levels up to mid-July 2020. By that point, they had provided over 15,000 early medical abortions using telemedicine. Staff worked from home, causing a decline in Covid-19 infection, less need for self-isolation by staff or personal protective equipment.[25] In July, the government said they would hold a consultation on whether to allow telemedicine to continue post-pandemic.
Political resistance to telemedicine for abortion
The use of telemedicine is not simply a technical matter or the separate physical location of provider and patient. Politically motivated barriers must be overcome, and opposition to abortion rejected. It is not uncommon, unfortunately, for doctors (like governments) who control abortion services to want to retain control over them. A shift to telemedicine and home-based abortions may threaten their hegemony, their political support and/or their income, so they resist change. In the longer term, however, outdated practices and laws must be set aside. If not, more and more people will work around them or without them – because they can.
For example, Kenya published guidance on Covid-19 in April 2020 that called for maintaining continuity of reproductive, maternal, newborn and family planning care and services as essential services. The guidance suggested the use of telemedicine and other means of distancing for the safety of providers and patients. Yet it did not include legal abortions or post-abortion care in this, let alone telemedicine.[26] In May 2020, the Reproductive Health Network Kenya, a network of healthcare providers offering quality reproductive health services across most of the country, including safe abortion, launched a new hotline in Kenya for counselling and referral of women and girls in Kenya to trained, youth-friendly, safe abortion providers, which operates 24 hours a day.[27]
Self-managed abortion must be safe at a population level
Safety in an illegal, clandestine situation may be relative, however. In the years 2015-19, of the estimated 73.3 million abortions each year, it was unknown how many of the 7 million who sought post-abortion care had used medical abortion pills as opposed to dangerous and invasive procedures.
A study published in 2020 on abortion in six states of India – Assam, Bihar, Gujarat, Madhya, Pradesh, Tamil Nadu and Uttar Pradesh – covering 45% of the population, found that in 2015 a high proportion of all the women receiving post-abortion care were admitted with incomplete abortion after use of medical abortion pills – ranging from 33% in Tamil Nadu to 65% in Assam.[28] These numbers are obviously very concerning, but they will differ between countries, depending on the extent of access to information and support women have.
A qualitative study from Chile among 30 relatively privileged young women who had a self-managed medical abortion at home between 2006 and 2016, while attending university, provided a window on the personal experience of clandestine use of abortion pills at home.[29] The study recorded their pathways to abortion, how they used networks in the university to find the pills and learn how to use them, and their experiences during and after the abortion. These young women made use of formal healthcare services: they accessed ultrasound scans pre-abortion to rule out ectopic pregnancy and post-abortion, claiming they had miscarried, to check the abortion was complete. They also had support from contacts, partners and friends. Even so, the clandestine situation created uncertainty and fear, which dominated the whole process – from finding and purchasing the pills, to uncertainty about correct doses, whether the abortion was going as it should, and whether it was complete or not. There was a high perception that failure and complications might be occurring, which led many of them to seek post-abortion care, perhaps unnecessarily, but making them into statistics. The process was demanding, requiring information, time, privacy to have the abortion, support and resources – and the ability to deal with risk. This is not how “essential health care” should have to be obtained.
A Madagascar study conducted in 2015-16,[30] also qualitative, looked at the experiences of 19 young women (ages 16-21 at time of abortion) who had complications after use of misoprostol for abortion, with or without additional methods; what information they received before use; what dosages and regimens they used; what complications they experienced; and what treatment they received post-use. It found that these young women sought advice from partners, friends, family members, and traditional practitioners, as well as health care providers. Misoprostol was easily accessible through the formal and informal sectors, but the dosages and regimens they used on the advice of others were extremely variable and did not match WHO guidelines. They were ineffective, resulting in failed abortion, incomplete abortion, heavy bleeding/haemorrhage, strong pain and/or infection. The authors called for urgent training for health care providers and pharmacists in correct misoprostol use and treatment of complications, as well as for women.
Let us be clear. Self-managed abortion in such circumstances is not what WHO means by “self-care”[31] nor what the abortion rights movement means by “self-management” when in fact the health system is failing to do its job.
Again, however, the situation differs in other countries. A study in Nigeria in 2018, which used telemedicine in the research process, looked at the self-reported effectiveness of self-managed misoprostol abortion in a legally restrictive setting in which 394 women obtained misoprostol pills and information about their use from drug sellers. Although the drug sellers provided inadequate information about the pills, 94% of the sample reported a complete abortion without surgical intervention about 1 month after taking the medication. 86 women reported physical symptoms suggestive of complications, but only six of them said they needed health facility care, of whom four subsequently obtained care. The authors say that drug sellers are an important source of abortion pills in this setting, and despite the limitations of self-report, many women appear to have effectively self-administered misoprostol.[32] These authors also call for additional research, but meanwhile, what is becoming clear as more and more such studies are published is that self-managed abortion is happening across the world and far fewer women are at risk of their lives as they were in the past.
Criminal laws passed in the 19th and early 20th century by colonial powers such as Great Britain and France automatically became part of the criminal law in many former colonies. In many cases, those laws are still in place today. They made it illegal to use any substance or instrument on oneself or others to cause an abortion. In their time, these laws were meant to protect women from dangerous, invasive methods. Today, they are used against women instead. Prosecutions for using abortion pills have been initiated in the USA, Britain, Ireland and Australia, for example, and some women imprisoned.
Safe abortion information hotlines deserve a huge amount of credit for helping to ensure that self-managed abortions are safe in the absence of legal abortion. Hotlines run by volunteers cannot take the place of national health systems, but they could be supported by governments to expand their outreach to provide national cover. Meanwhile, the need for hotlines highlights the ethical imperative on health systems to ensure that information, support and bona fide pills are available to everyone seeking an abortion who, legally or not, will self-manage at home.
Countries with the most restrictive abortion laws have not made policy statements about abortion as essential healthcare nor taken up telemedicine for abortion during the Covid-19 pandemic. Nor has much evidence-based information emerged from them to date on how the pandemic is affecting access to abortion, or perhaps even more importantly, access to post-abortion care.[33] The reality is likely to be highly problematic, however.
Putting telemedicine and self-managed abortion together
Earlier this year, a sex education teacher and a doula created a set of eight podcasts called “Self-Managed, An Abortion Story in Eight Parts”, which introduces self-managed abortion, the story of a woman who has had a self-managed abortion, and in each subsequent podcast, a health professional, a lawyer and others who talk about the various aspects of the telemedicine services that support women managing their abortions at home in the USA.[34] This is an excellent teaching tool and could be adapted for local use.
In Australia, the Tabbot Foundation, founded by Dr Paul Hyland in 2016, was the first telemedicine service by health professionals to provide medical abortion for home use via telephone consultation across all but one state, where it was not allowed. They started in Tasmania and expanded to cover seven Australian states within a few short years. The process was as follows: an initial telephone consultation with an expert doctor led to a decision whether a medical termination at home was suitable. If so, the clinic provided all necessary medications through the post, so the woman did not have to go to a pharmacy. A registered nurse supported the woman by phone through the process, and a 24-hour doctor was on-call. Follow-up by phone confirmed the pregnancy had terminated safely. The Foundation had to close down in March 2019, not due to problems with provision or lack of demand. On the contrary, it closed because “the cost of running the service, in a country where grants, government subsidies and benefactors [did] not exist for such things, was too much”.[35]
Gynuity Health Projects initiated a telemedicine project in the USA called TelAbortion in 2018 that led to the opening of telemedicine abortion services in 13 US states who permit it legally. An evaluation of these services in five of the states was published in 2019.[36] It covered 32 months in which 248 packets of pills were posted, demonstrating the safety, efficacy and acceptability of the services, which used video-conferencing and the mail to provide everything the woman needed. All 159 patients who completed questionnaires were satisfied with the service. However, of the 217 who received pills and provided meaningful follow-up data (88%), one was hospitalised for post-operative seizure and another for excessive bleeding; 27 had other unscheduled clinical encounters, though 12 of the 27 required no treatment. These are very few complications indeed, but they confirm that backup services should always be part of the plan.
The role of pharmacies in telemedicine and self-managed abortion
In many countries, people can walk into pharmacies and buy medications on prescription, or over or under the counter. Misoprostol, which is also used to treat gastric ulcers, has been available in pharmacies without a prescription in much of the world for decades.
Pharmacies and drug sellers have had a central role to play in most countries of the global south in providing abortion pills, both legally and extra-legally. Studies in countries as different as Nepal and Canada have shown that with simple training, pharmacists can manage the provision of abortion pills, provide information on their safe use, and counsel on complications when required. In a Nepal study,[37] most of the 992 women seeking abortion pills were around six weeks pregnant, so the abortions were very early. The outcomes showed a high level of safety and effectiveness. The women were counselled on and purchased combined mifepristone-misoprostol abortion pills during a six-month period from pharmacies in two districts. In the one district, the pharmacists had been trained in 2010 to provide them; in the other district, the training took place near the time of the study in 2015. Complete abortions were achieved in 97-99% of cases in both districts, one primarily urban, the other more rural. The 2010 training was still in use in the one district in 2015. The women reported no serious complications, and satisfaction levels were high.
These authors also reported that trained pharmacists and pharmacy workers in Nepal have successfully delivered information and medications related to sexually transmitted infections, contraception and emergency contraception. Their success includes the ability to facilitate rapid access to medications, supplies, information and advice, while maintaining client confidentiality. Pharmacists are close to home and trusted for information about many health issues. Although Nepal is one of the world’s least resourced countries, their progressive law on abortion permit abortions up to 12 weeks on request and up to 18 weeks on a number of other grounds. This is an example for other countries to consider.
In Canada, direct-to-consumer telemedicine abortion services were initiated using methotrexate and misoprostol prior to approval of mifepristone. Canada adopted mifepristone with misoprostol only in 2017 but has moved fast ever since to update their policies. From April 2019, they have allowed direct access to abortion pills from a pharmacy without barriers, a blood test or a scan.[38] In April 2020, in response to the pandemic, they published a protocol for provision of medical abortion via telemedicine. That protocol recommends providing an additional dose of 800 mcg of misoprostol, buccally or vaginally to use if needed along with the standard regimen of mifepristone 200 mg orally and misoprostol 800 mcg buccally or vaginally. The extra misoprostol is to reduce the low but existing risk of incomplete abortion.[39] The recommendation of using additional doses of misoprostol if needed to achieve a complete abortion was first recommended in 2017 by FIGO and now seems to be more widely recommended.
WHO’s 2015 guideline on health worker roles in safe abortion care confirms that pharmacists can safely provide medical abortion pills during the first trimester of pregnancy, including assessing eligibility for medical abortion, administering the medications and managing the process and common side-effects independently, assessing completion of the procedure and the need, if any, for clinic-based follow-up.[40]
Thus, pharmacies and drug shops should officially become an important alternate source of medical abortion pills, including for young people. For young women in particular, the costs of using these sources may be less than the non-financial costs of travelling to and being seen accessing services in a public health facility.[41]
Many pharmacies and drug sellers see people as consumers. In many countries, pharmacies are a source of self-medication of all kinds. Others have physicians on call, while still others have the knowledge in-house to provide medicines advice safely. One pharmacy company with branches in many Latin American countries introduced a “doctor-in-the-house” policy, allowing those who are poor to consult a doctor at less cost and with less hassle than going to a public health clinic. However, not all countries regulate pharmacy services, and low- and middle-income countries may struggle with variable service quality, unregistered premises, untrained personnel and sub-standard commodities. Although easily accessible, this may result in reduced quality of care. (Personal communication, Lidia Casas Becerra, 24 August 2020)
WHO’s 2019 self-care guideline includes self-managed abortion
In 2019, the WHO Human Reproduction Programme published a consolidated guideline on self-care interventions for sexual and reproductive health and rights,[42] whose section on self-management of medical abortion in the first trimester is summarised from their 2015 guidance,[43] and is worth sharing in full:
“Self-management and self-assessment approaches can be empowering and also represent a way of optimizing available health workforce resources and sharing of tasks:
- To the full extent of the law, safe abortion services should be readily available and affordable to all women.
- Self-management approaches reflect an active extension of health systems and health care. These recommendations are NOT an endorsement of clandestine self-use by women without access to information or a trained health-care provider/health-care facility as a backup. All women should have access to health services should they want or need it.
- Individuals have a role to play in managing their own health and this constitutes another important component of task sharing within health systems.
- Therefore, the following recommendations for specific components were made related to self-assessment and self-management approaches in contexts where pregnant individuals have access to appropriate information and to health services should they need or want them at any stage of the process:
i. Self-assessing eligibility [for medical abortion] is recommended in the context of rigorous research.
ii. Managing the mifepristone and misoprostol medication without direct supervision of a health-care provider is recommended in specific circumstances, i.e. where women have a source of accurate information and access to a healthcare provider should they need or want it at any stage of the process.
iii. Self-assessing completeness of the abortion process using pregnancy tests and checklists is recommended in specific circumstances. We recommend this option in circumstances where both mifepristone and misoprostol are being used and where women have a source of accurate information and access to a healthcare provider should they need or want it at any stage of the process.”
Two additional notes are added from the WHO 2018 guideline “Medical management of abortion”:[44]
– “When using the combination mifepristone and misoprostol regimen, the medical abortion process can be self-managed for pregnancies up to 12 weeks of gestation, including the ability to take the medications at home, without direct supervision of a healthcare provider; it should be noted that there was limited evidence for pregnancies beyond 10 weeks.”
– “Pregnancy tests used to self-assess the success of the abortion process are low-sensitivity urine pregnancy tests, which are different from those tests commonly used to diagnose pregnancy.”
Limits of telemedicine and self-managed abortion
“Telemedicine is not a panacea. It is not always suitable for low-resource settings where internet or phone access is limited, for people who are [also] looking for a long-acting form of contraception to be fitted, who are seeking an abortion at later stages of pregnancy or who are facing complications from a previous abortion attempt. It is therefore essential that we also keep facility-based services open safely and maintain a choice of options for contraception and safe abortion. This is particularly important as we could see a greater demand for second trimester abortion services following lockdown.”[45]
Other reasons why telemedicine + self-managed abortion may not be acceptable or feasible include when the conditions do not exist at home for women and girls to go through the abortion, including privacy, safety from interference and violence from partner and/or family, not being able to give a reason to stop working, lack of safe 24-hour access to a toilet, inability to deal with the bleeding and the pain, and problems to dispose of the products of conception.[46]
Girls and women who live with their families may have no privacy even for a phone or video call, let alone to go through an abortion at home, alone or with a companion. Several young women described these problems in the Chilean study referred to earlier, and they have been noted elsewhere too. In settings such as camps for refugees and displaced persons, there may be no access to a private toilet in the living space, and it may be risky to go outside, especially at night, to a common toilet.
In fact, the feasibility of telemedicine for women living in conditions of poverty and with limited literacy, especially in remote, rural and low-resource settings with few healthcare providers, requires far more attention in order to develop appropriate support systems.
Telemedicine relies on internet access, and video requires strong connections. Apps can fill this gap, but health systems must support the education of pharmacists, lay community health workers and activists to ensure access to abortion pills for everyone, including those without internet (Susan Yanow, personal communication, 19 August 2020). Moreover, access to support when and if needed 24/7 is an important adjunct, and should be treated as an integral part of the process too.
Vacuum aspiration abortion as a continuing option
Some women would choose a first trimester aspiration abortion over abortion with pills if they could. The concept of choice of method in regard to contraception has been an issue since the 1970s and 80s because many women, particularly in the global south and from poor and ethnic minority communities, were often pushed to “accept” a contraceptive method chosen by the provider. This has re-emerged in recent decades (if it ever disappeared) with long-acting contraceptives being pushed to reduce the user failure rate and the need for abortion. Many in the medical profession (and donor community) still want to choose women’s methods for them, and abortion is no exception. A roundtable of views on this matter makes it clear, however, that providers too have differing views.[47] Supporting a woman’s choice of method, without outside pressure, remains crucial.
Second trimester self-managed abortions
Almost everything discussed in this paper is about first trimester abortions, and most research and documented practice has been about abortions up to 12 weeks. But second trimester abortions count too. Only a few hotline groups openly support women to have second trimester medical abortions at home; the Socorristas en Red in Argentina is among them.[48] They began providing this support to women having abortions up to 24 weeks in 2015, with good results. Their results are good not least because members of the group have developed good relations with certain hospitals where they know women can go for help without fear. They also recommend a medical check-up as part of the post-abortion process.
The Socorristas believe that the woman must decide and be in charge of what she wants to do, and they advise and support her to confront every aspect of the process before she makes decisions. They point out that a second-trimester abortion can be started at home, but the woman can always decide to go to a hospital to complete it. As one Socorrista explained:
“…We haven’t had [any] health complications…. When women have gone [to the hospital], it has been because of their decision to expel [the fetus] in hospital.”
Disposal of a second-trimester fetus at home is not an easy proposition. Moreover, sometimes women may think they have expelled everything when they have not. To mitigate these risks, some Socorristas recommend that everyone over 16 weeks goes to a hospital where there are sympathetic health professionals to complete the process. They say: “Studies to evaluate the safety, effectiveness or acceptability of second-trimester abortions using this model are sorely needed.” Meanwhile, continuing availability of second trimester abortion in clinical settings, at primary level if possible, including during the Covid-19 pandemic, remains crucial.
A study of hotline data from Indonesia, published in 2018, found that between 2012 and 2016, 96 women with pregnancies beyond the first trimester called the hotline for information on abortion pills; 91 received counselling support, of whom 83 women successfully terminated their pregnancies using medication and did not have to seek medical care. Five had warning signs of potential complications and sought medical care, one sought care after a failed abortion, and two were lost to follow-up. These findings are far more positive than some might expect. These authors also call for further study and documentation of the model.[49]
A recent study of case records on abortions between 13 and 24 weeks, from accompaniment groups based in Chile, Ecuador and Argentina, found that of 318 abortions, only 241 resulted in complete abortion with abortion pills alone. Surgical methods were needed to complete most of the rest (16 were not completed) and several in Chile led to complications (records of complications were not kept in Ecuador or Argentina).[50] The (perceived) high need for surgery is not a positive outcome. Dosage and regimens should be compared between studies like these to see if that made a difference.
While countries with restrictive abortion laws are unlikely to permitting self-managed abortion at any stage of pregnancy, it remains the case that the failure to provide safe abortions legally will continue to drive women to have them outside the health system.
Outdated abortion service delivery models and pointers for the future
Abortion law and policy in most countries still dictates where the abortion is done, how many and which health professionals must approve it, what cadres of health professional can provide it, at which level of clinic or hospital, inpatient or outpatient, how early and late in pregnancy it can be provided, whether permission is required from anyone in addition to the pregnant woman herself – as well as which methods may or may not be used and which grounds are permitted. Even though they are on the WHO Essential Medicines List, abortion pills are more regulated and restricted in some countries than most other drugs. And no matter how liberal the abortion law, there are still many places where the woman is not given a choice of abortion method. There are also far too many countries where D&C as an anaesthetised, in-patient procedure in a tertiary hospital is still imposed by diehard, out-of-date senior clinicians, who should all be forcibly retired as punishment.
Positive changes, all supported by WHO guidelines, include:
- Neither first nor second trimester medical abortions need to be done on an inpatient basis or in tertiary hospitals.
- Nurses, midwives, GPs, other mid-level providers should be trained to manage most abortions at primary level, and both they and pharmacists can provide abortion pills for self-managed abortions at home.
- (Manual) vacuum aspiration can be done by mid-level providers in outpatient, primary level clinics and family planning clinics.
- Scans and blood tests need not be routine and can be dropped in the first trimester.
Lastly, it is worth emphasising the findings of a review of studies from 1995 to 2019 on the self-use of abortion pills following online access:
- women were increasingly using the internet to access abortion medication;
- available services were of varying quality;
- women accessing non-interactive services reported feelings of distress related to the lack of medical guidance, and the demand from them for interactive guidance through the abortion process was high; and
- women using services led by healthcare staff reported high rates of satisfaction and similar rates of clinical outcomes as those of in-person abortion care.[51]
The first national assessment of telemedicine for sexual & reproductive healthcare and self-managed abortion: Britain
On 30 June 2020, the Faculty of Sexual & Reproductive Healthcare of the Royal College of Obstetricians & Gynaecologists in Britain published the findings of a survey of 1,000 of their members on changes to SRH care related to telemedicine during Covid-19. They reported that remote sexual and reproductive health consultations had risen from 18% at pre-pandemic levels to 89%.[52]
Regarding abortion, they learned that: “Since lockdown, remote telemedical abortions now account for 78% of early medical abortions and around two-thirds of total abortion procedures in England. The average waiting time for an abortion has decreased from 10 days in February to 4.46 days in June. The average gestation time at the time of the procedure has reduced from 8 weeks to 6.7 weeks.”
Their only cautionary note was that “The decreased availability of face-to-face consultations is having detrimental impacts on the SRH care of vulnerable groups. Without face-to-face consultations, picking up on safeguarding issues, domestic abuse and teenage pregnancy is more difficult. The availability of different modalities of consultation – face-to-face, remote and online – is vital to provide comprehensive SRH care for all women and girls now and beyond the pandemic…. Remote and online services are a complement, not a substitute, to face-to-face consultations and, irrespective of consultation modality, best practice and guidelines must be observed to ensure safety and quality of care.”
Conclusions
The studies summarised here show that the use of telemedicine – by trained healthcare providers, trained pharmacists and trained safe abortion information hotlines – to provide accurate information on using medical abortion pills for self-managed abortion at home up to 12 weeks of pregnancy, is safe and effective, and serious complications are rare. Adding additional misoprostol to the standard dosage found in most combi-pack brands would move the proportion of complete abortions close to 100%, greatly reducing the risk of incomplete abortion. Further research on the safety of second trimester abortions at home and the role of the health system in supporting them is called for.
While the safe abortion information hotlines who are trained to use WHO guidance are not part of official health systems, they provide accurate information and sympathetic support, they develop contact with health professionals and hospitals in case women need them, and in many cases they include people with a healthcare background themselves. These hotlines serve as models of what is possible in the countries where they are currently an important source of information and support for women needing abortions.
It is only when women have been left on their own to obtain pills whose quality is unknown, without information on correct dosage and regimen, and without ongoing support, that safety and effectiveness may be compromised. Even so, medical abortion pills are not killing women; since the first studies around 1989, they have proved to be far safer than the dangerous methods of the past, which are finally becoming history.
In the past 20 years, greatly improved, easy to use abortion methods and new models of abortion care have emerged, but women’s access to them remains grossly inequitable and far from universal. To change this situation globally, safe abortion must be recognised as essential health care, abortion must be fully decriminalised, and women must have the right to make the abortion decision and decide the conditions in which it takes place. Some of these changes demand substantial health systems reforms but above all, they require reforms in law, policy and practice which guarantee everyone with an unwanted pregnancy the right to a safe abortion. No more, no less.
Acknowledgements
Grateful thanks to Susan Yanow (USA), Lidia Casas Becerra (Chile) and Lynette Shumack (Australia) for valuable information and substantive comments on the paper. Any errors are my own.
Visual: http://groupe-tawhida.com/
References
[1] World Health Organization (WHO). A health telematics policy in support of WHO’s health-for-all strategy for global health development: report of the WHO group consultation on health telematics, 11–16 December, Geneva, 1997. Geneva: WHO, 1998. https://apps.who.int/iris/handle/10665/63857
[2] DM Angaran. Telemedicine and telepharmacy: current status and future implications. American Journal of Health-System Pharmacy 1999 Jul 15;56(14):1405-26. doi: 10.1093/ajhp/56.14.1405
[3] Abby Swanson Kazley, Amy C McLeod, Karen A Wager. Telemedicine in an international context: definition, use, and future. Advances in Health Care Management 2012;12:143-69. doi: 10.1108/s1474-8231(2012)0000012011
[4] Paul Webster, Virtual health care in the era of COVID-19. Lancet, 11 April 2020;395(10231). https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30818-7/fulltext?dgcid=hubspot_email_newsletter_tlcoronavirus20&utm_campaign=tlcoronavirus20&utm_source=hs_email&utm_medium=email&utm_content=86258831&_hsenc=p2ANqtz-8FAHxpLjL085A_T6dcGZL7gbcCWDyyekbJ-BakB18CRCuhQ1D_jdBDhJqsJ4_Z54jIhUNapt5ahKbPHtqQRerlG_e2SA&_hsmi=86258831#coronavirus-linkback-header
[5] Katharine Marianne de Tolly, Deborah Constant. Integrating mobile phones into medical abortion provision: intervention development, use, and lessons learned from a randomized, controlled trial. JMIR Mhealth and Uhealth. February 2014;14;2(1):e5. doi: 10.2196/mhealth.3165
[6] Sarah Ireland, Suzanne Belton, Frances Doran. ‘I didn’t feel judged’: exploring women’s access to telemedicine abortion in rural Australia. Journal of Primary Health Care March 2020; 12(1):49-56. doi: 10.1071/HC19050
[7] Susheela Singh, Prof Chandar Shekhar, Rajib Acharya, Ann M Moore, Melissa Stillman, et al. The incidence of abortion and unintended pregnancy in India, 2015. Lancet Global Health, 1 January 2018;6(1): e111-120. doi: 10.1016/S2214-109X(17)30453-9
[8] FRHS India, Pratigya Campaign for Gender Equality and Safe Abortion. Availability of medical abortion drugs in the markets of six India states. 2020 http://www.frhsi.org.in/pdf/Availability%20of%20MA%20Drugs%20across%206%20Indian%20states-%20An%20Executive%20Summary.pdf
[9] Ministry of Health and Family Welfare India. Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to Provide Healthcare Using Telemedicine. 25 March 2020. https://www.mohfw.gov.in/pdf/Telemedicine.pdf
[10] Nishitha Aysha Ashraf. Hidden Pockets, 17 April 2020. https://hidden-pockets.com/telemedicine-and-abortion-india-says-yes-or-no/
[11] See Women Help Women, at: https://womenhelp.org/ and Women on Web at: https://www.womenonweb.org/en/i-need-an-abortion
[12] Safe Abortion Information Hotlines, International Campaign for Women’s Right to Safe Abortion website, at: https://www.safeabortionwomensright.org/safe-abortion-3/safe-abortion-information-hotlines/
[13] Women Help Women, https://womenhelp.org/en/page/346/women-help-women-is-about-access-information-and-activism
[14] Sybil Nmezi. The Reproductive Health Information Hotline: an intervention towards addressing women’s challenges within the Covid-19 outbreak. International Campaign for Women’s Right to Safe Abortion Newsletter, 5 June 2020. https://www.safeabortionwomensright.org/feature-nigeria-reproductive-health-information-hotline-an-intervention-towards-addressing-womens-challenges-within-the-covid-19-outbreak/
[15] WHO. Preventing unsafe abortion. 26 June 2019. https://www.who.int/news-room/fact-sheets/detail/preventing-unsafe-abortion
[16] WHO. Maintaining Essential Health Services: operational guidance for the Covid-19 context.
1 June 2020. https://www.who.int/publications-detail/10665-332240
[17] Caitlin Gerdts, Divya Vohra, Jennifer Ahern. Measuring unsafe abortion related mortality: a systematic review of the existing methods. Plos One 2013;8(1):e53346. doi: 10.1371/journal.pone.0053346
[18] Megan Wainwright, Christopher J Colvin, Alison Swartz, Natalie Leon. Self-management of medical abortion: a qualitative evidence synthesis. Reproductive Health Matters 2016;24(47):155-67. doi: 10.1016/j.rhm.2016.06.008
[19] WHO. Medical management of abortion. Geneva: WHO, 2018. https://www.who.int/reproductivehealth/publications/medical-management-abortion/en/
[20] Daniel Grossman, Kate Grindlay, Todd Buchacker, Joseph E Potter, Carl P Schmertmann. Changes in service delivery patterns after introduction of telemedicine provision of medical abortion in Iowa. American Journal of Public Health 2013;103:73-78. https://ajph.aphapublications.org/doi/10.2105/AJPH.2012.301097
[21] Ellen R Wiebe. Use of telemedicine for providing medical abortion. International Journal of Obstetrics & Gynecology February 2014;124(2):177-78.