The Case for Telemedical Early Medical Abortion in England: Dispelling Adult Safeguarding Concerns

"All hands on deck": a qualitative study of safeguarding and the transition to telemedical abortion care in England and Wales

The COVID-19 pandemic raised significant challenges for in-person healthcare provision, leading healthcare providers to embrace digital health like never before. Whilst changes were made as part of a public health response, many have now become permanent fixtures of the healthcare landscape, significantly altering the way care is provided not only for patients, but also for the healthcare professionals that provide care. In abortion care in England and Wales, previously stringent regulations on in-person care provision were relaxed to permit the use of telemedicine and self-administration of medications at home. These changes have since been made permanent. However, there remains opposition to remote abortion care pathways on the basis of safeguarding. Opponents argue that it is not feasible to effectively safeguard patients accessing abortion care remotely. We conducted a qualitative study using semi-structured interviews with abortion care providers in England and Wales. Participants were asked about their views and experiences of the transition to remote care provision, with a particular focus on how they adapted their safeguarding practice. In this article, we present three themes that highlight the changing roles of healthcare professionals in abortion care: (1) a challenging backdrop and resulting apprehension, (2) adaptive practices, and (3) the continued importance of professional curiosity. Across all three themes, participants reflected significantly on how changes were made and what they experienced in the period of transition to telemedicine. In particular, they discussed the changing nature of their professional roles amidst digitalisation. Our findings provide a basis for reflection on the increasing introduction of digital approaches to healthcare provision, highlighting points for caution and emphasising the need to involve professionals in the transition process to ensure vital buy-in. Through this, we articulate two novel understandings of digitalisation: (1) the impact of speed-associated pressures on professional adaptation during digitalisation, and (2) off-proforma safeguarding through telemedicine as a form of invisible non-routine work.

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

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.

Improvidence, Precaution, and the Logical-Empirical Disconnect in UK Health Policy

The last decade has seen significant developments in UK health policy, with are largely claimed to be evidence based. However, such a characterisation ought, in many cases, to be questioned. Policies can be broadly understood as based primarily on either a logical or empirical case. In the absence of relevant empirical evidence, policymakers understandably appeal to logical cases. Once such evidence is available, however, it can inform policy and enable the logical case to be set aside. Such a linear policy process is not always the reality, and logical cases often continue to guide policy decisions in direct opposition to empirical evidence. In this paper, I discuss two recent examples of this disconnect between logical and empirical cases in UK health policy. The first-organ donation-illustrates an example of a significant policy change being made in opposition to the evidence. I refer to this as the improvidence approach. The second-abortion-provides an example of policymakers not making a change that has extensive supporting data. I refer to this using the more recognisable language of the precautionary approach. Ultimately, I argue that both the improvidence and precautionary approaches are examples of problematic public policy where policymakers provide no explicit justification for going against the evidence.