TelAbortion: evaluation of a direct to patient telemedicine abortion service in the United States

Social connectedness and supported self-management of early medication abortion in the UK: experiences from the COVID-19 pandemic and learning for the future

Medication abortion has been established globally as safe and effective. This modality has increased accessibility and the opportunity to centre individual autonomy at the heart of abortion care, by facilitating self-managed abortion. Previous research has shown how self-managed abortion is beneficial in myriad settings ranging from problematic to (relatively) unproblematic contexts of access. In this paper we explore the relationship between self-management and sources of support (including health professionals, family, and friends); as well as considering issues of reproductive control and autonomy. Drawing on qualitative, experience-centred interviews, we utilise the concept of social connectedness to examine how supported self-managed abortion was experienced in the United Kingdom during the COVID-19 pandemic. Overall, self-management was welcomed, with participants speaking positively about managing their own abortion at home. However, a sense of connectedness was crucial in helping participants deal with difficult experiences; and functioned to support individual autonomy in self-care. This paper is the first to examine factors of connection, support, and isolation, as experienced by those undergoing self-managed abortion in the UK in detail. Our research suggests a continued need to advocate for high quality support for self-managed abortion, as well as for choice of abortion method, to support patient-centered care.

Are We Adequately Measuring Patient Satisfaction with Telemedicine? A Systematic Review with a Meta-Analysis

Introduction: Telemedicine has gained significant attention as an effective means of providing health care remotely, particularly during the COVID-19 pandemic. Patient satisfaction is a critical aspect of implementing telemedicine, but we have no comprehensive understanding of satisfaction levels and the associated factors. The aim of this systematic review and meta-analysis was to assess patient satisfaction related to telemedicine consultations and to identify key factors influencing satisfaction levels. Results: The search yielded a total of 147 cross-sectional studies, of which 107 met the criteria for inclusion in the meta-analysis. Overall, patient satisfaction with teleconsultations was found to be high, with satisfaction levels ranging from 38 to 100 on a scale of 0 to 100. Only a small percentage (2.72%) of the studies reported satisfaction levels below 75%. Surprisingly, most studies used nonvalidated satisfaction questionnaires, which highlight the need for the development of standardized measurement instruments. Conclusions: This systematic review and meta-analysis provide evidence that patients generally exhibit high levels of satisfaction with telemedicine consultations. The use of nonvalidated satisfaction questionnaires in many studies, however, suggests a need for more standardized assessment tools. Factors such as the time interval between the consultation and the assessment were found to influence satisfaction levels. Understanding these factors can help health care providers improve telemedicine services and patient-provider relationships and optimize health care delivery in the context of telemedicine. Further research is warranted to develop validated satisfaction measurement instruments and explore any additional factors that influence patient satisfaction with telemedicine.

Evaluation of telemedicine medical abortion using a no-test protocol in the Eastern Europe and Central Asian region: Evidence from Ukraine, Uzbekistan, and Azerbaijan

OBJECTIVE

To evaluate safety, feasibility, and acceptability of a telemedicine medical abortion service without pre-treatment in-person tests in Ukraine, Uzbekistan, and Azerbaijan.

METHODS

We conducted an open-label, prospective, observational clinical study at five clinics in the three countries. Interested and eligible participants scheduled a telemedicine consultation with a study provider by phone or video. Medical abortion pills could be obtained by mail or courier or picked up at the study clinic or a pharmacy. Study providers contacted participants 1 week after mifepristone ingestion to assess abortion outcomes based on symptoms, and 3 weeks later to review the result of an at-home, high-sensitivity, urine pregnancy test. Participants were referred to in-person visit based on symptoms, urine pregnancy test results, or initiative by the participant.

RESULTS

In all, 300 women participated in the study. Almost all participants received medical abortion medications the same day as their first contact with the study clinic, and the majority (n = 297, 99.0%) did not experience any problems receiving them. All except two women (0.67%) followed provider instructions on administration of medications. The majority of participants had a complete abortion without a procedure (Ukraine: n = 115, 95.8%; Uzbekistan: n = 127, 97.7%; Azerbaijan: n = 49, 98.0%), few had in-person visits (Ukraine: n = 30, 25.0%; Uzbekistan: n = 3, 2.3%; Azerbaijan: n = 4, 8.0%), and most were very satisfied or satisfied with the service (Ukraine: n = 116, 96%; Uzbekistan: n = 128, 98%; Azerbaijan: n = 45, 90%). No serious adverse events occurred.

CONCLUSION

Telemedicine medical abortion using the no-test protocol is safe, feasible and acceptable for women in Ukraine, Uzbekistan, and Azerbaijan.

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening

Importance

Before 2021, the US Food and Drug Administration required mifepristone to be dispensed in person, limiting access to medication abortion.

Objective

To estimate the effectiveness, acceptability, and feasibility of dispensing mifepristone for medication abortion using a mail-order pharmacy.

Design, Setting, and Participants

This prospective cohort study was conducted from January 2020 to May 2022 and included 11 clinics in 7 states (5 abortion clinics and 6 primary care sites, 4 of which were new to abortion provision). Eligible participants were seeking medication abortion at 63 or fewer days' gestation, spoke English or Spanish, were age 15 years or older, and were willing to take misoprostol buccally. After assessing eligibility for medication abortion through an in-person screening, mifepristone and misoprostol were prescribed using a mail-order pharmacy. Patients had standard follow-up care with the clinic. Clinical information was collected from medical records. Consenting participants completed online surveys about their experiences 3 and 14 days after enrolling. A total of 540 participants were enrolled; 10 withdrew or did not take medication. Data were analyzed from August 2022 to December 2023.

Intervention

Mifepristone, 200 mg, and misoprostol, 800 µg, prescribed to a mail-order pharmacy and mailed to participants instead of dispensed in person.

Main Outcomes and Measures

Proportion of patients with a complete abortion with medications only, reporting satisfaction with the medication abortion, and reporting timely delivery of medications.

Results

Clinical outcome information was obtained and analyzed for 510 abortions (96.2%) among 506 participants (median [IQR] age, 27 [23-31] years; 506 [100%] female; 194 [38.3%] Black, 88 [17.4%] Hispanic, 141 [27.9%] White, and 45 [8.9%] multiracial/other individuals). Of these, 436 participants (85.5%; 95% CI, 82.2%-88.4%) received medications within 3 days. Complete abortion occurred after medication use in 499 cases (97.8%; 95% CI, 96.2%-98.9%). There were 24 adverse events (4.7%) for which care was sought for medication abortion symptoms; 3 patients (0.6%; 95% CI, 0.1%-1.7%) experienced serious adverse events requiring hospitalization (1 with blood transfusion); however, no adverse events were associated with mail-order dispensing. Of 477 participants, 431 (90.4%; 95% CI, 87.3%-92.9%) indicated that they would use mail-order dispensing again for abortion care, and 435 participants (91.2%; 95% CI, 88.3%-93.6%) reported satisfaction with the medication abortion. Findings were similar to those of other published studies of medication abortion with in-person dispensing.

Conclusions and Relevance

The findings of this cohort study indicate that mail-order pharmacy dispensing of mifepristone for medication abortion was effective, acceptable to patients, and feasible, with a low prevalence of serious adverse events. This care model should be expanded to improve access to medication abortion services.

Effectiveness and safety of telehealth medication abortion in the USA

Telehealth abortion has become critical to addressing surges in demand in states where abortion remains legal but evidence on its effectiveness and safety is limited. California Home Abortion by Telehealth (CHAT) is a prospective study that follows pregnant people who obtained medication abortion via telehealth from three virtual clinics operating in 20 states and Washington, DC between April 2021 and January 2022. Individuals were screened using a standardized no-test protocol, primarily relying on their medical history to assess medical eligibility. We assessed effectiveness, defined as complete abortion after 200 mg mifepristone and 1,600 μg misoprostol (or lower) without additional intervention; safety was measured by the absence of serious adverse events. We estimated rates using multivariable logistic regression and multiple imputation to account for missing data. Among 6,034 abortions, 97.7% (95% confidence interval (CI) = 97.2-98.1%) were complete without subsequent known intervention or ongoing pregnancy after the initial treatment. Overall, 99.8% (99.6-99.9%) of abortions were not followed by serious adverse events. In total, 0.25% of patients experienced a serious abortion-related adverse event, 0.16% were treated for an ectopic pregnancy and 1.3% abortions were followed by emergency department visits. There were no differences in effectiveness or safety between synchronous and asynchronous models of care. Telehealth medication abortion is effective, safe and comparable to published rates of in-person medication abortion care.

Self-diagnosing the end of pregnancy after medication abortion

This qualitative study conducted between November 2020 and March 2021 in the US state of Mississippi examines the experiences of 25 people who obtained medication abortion at the state's only abortion facility. We conducted in-depth interviews with participants after their abortions until concept saturation was reached, and then analysed the content using inductive and deductive analysis. We assessed how people use embodied knowledge about their individual physical experiences such as pregnancy symptoms, a missed period, bleeding, and visual examinations of pregnancy tissue to identify the beginning and end of pregnancy. We compared this to how people use biomedical knowledge such as pregnancy tests, ultrasounds, and clinical examinations to confirm their self-diagnoses. We found that most people felt confident that they could identify the beginning and end of pregnancy through embodied knowledge, especially when combined with the use of home pregnancy tests that confirmed their symptoms, experiences, and visual evidence. All participants concerned about symptoms sought follow-up care at a medical facility, whereas people who felt confident of the successful end of the pregnancy did so less often. These findings have implications for settings of restricted abortion access that have limited options for follow-up care after medication abortion.

Abortion Clients' Perceptions of Alternative Medication Abortion Service Delivery Options in Mississippi

OBJECTIVES

We assessed Mississippi abortion clients' perceptions of alternative medication abortion service delivery options that were restricted under state law but available elsewhere.

METHODS

We conducted in-depth interviews with medication abortion clients between November 2020 and March 2021 at Mississippi's only abortion facility. We described alternative service delivery models: telemedicine, medications by mail, and follow-up care in their community versus returning to the facility. We asked if participants would be interested in using any of these models, if available, and how use of each model would have changed their abortion experience. We used thematic analysis, organizing codes into common themes based on participants' preferences and concerns for each option.

RESULTS

Of the 25 participants interviewed, nearly all (n = 22) expressed interest in at least one option and reported that, had they been available, these would have alleviated cost, travel, and childcare barriers. Many believed these options would further ensure privacy, but a minority thought abortion was too sensitive for telemedicine or were concerned about mailing errors. Participants not interested in the alternative options also feared missing valued aspects of face-to-face care. Most did not return to the facility for follow-up (n = 19), citing financial and logistical barriers. Largely, participants were not interested in obtaining follow-up care in their community, citing concerns about provider judgment, stigma, and privacy.

CONCLUSIONS

Mississippi abortion clients were interested in models that would make abortion care more convenient while ensuring their privacy and allowing for meaningful client-provider interaction. These features of care should guide the development of strategies aimed at helping those in restricted settings, such as Mississippi, to overcome barriers to abortion care following the implementation of abortion bans in many states following the overturn of Roe v. Wade.

Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion

Hemorrhage after abortion is rare, occurring in fewer than 1% of abortions, but associated morbidity may be significant. Although medication abortion is associated with more bleeding than procedural abortion, overall bleeding for the two methods is minimal and not clinically different. Hemorrhage can be caused by atony, coagulopathy, and abnormal placentation, as well as by such procedure complications as perforation, cervical laceration, and retained tissue. Evidence for practices around postabortion hemorrhage is extremely limited. The Society of Family Planning recommends preoperative identification of individuals at high risk of hemorrhage as well as development of an organized approach to treatment. Specifically, individuals with a uterine scar and complete placenta previa seeking abortion at gestations after the first trimester should be evaluated for placenta accreta spectrum. For those at high risk of hemorrhage, referral to a higher-acuity center should be considered. We propose an algorithm for treating postabortion hemorrhage as follows: (1) assessment and examination, (2) uterine massage and medical therapy, (3) resuscitative measures with laboratory evaluation and possible reaspiration or balloon tamponade, and (4) interventions such as embolization and surgery. Evidence supports the use of oxytocin as prophylaxis for bleeding with dilation and evacuation; methylergonovine prophylaxis, however, is associated with more bleeding at the time of dilation and evacuation. Future research is needed on tranexamic acid as prophylaxis and treatment and misoprostol as prophylaxis. Structural inequities contribute to bleeding risk. Acknowledging how our policies hinder or remedy health inequities is essential when developing new guidelines and approaches to clinical services.

Telemedicine Abortion

Telemedicine has become a substantial part of abortion care in recent years. In this review, we discuss the history and regulatory landscape of telemedicine for medication abortion in the United States, different models of care for telemedicine, and the safety and effectiveness of medication abortion via telemedicine, including using history-based screening protocols for medication abortion without ultrasound. We also explore the acceptability of telemedicine for patients and their perspectives on its benefits, as well as the use of telemedicine for other parts of abortion care. Telemedicine has expanded access to abortion for many, although there remain limitations to its implementation.

The Provision of Abortion Care via Telehealth in the United States: A Rapid Review

INTRODUCTION

The recent Supreme Court decision Dobbs v. Jackson Women's Health that has overruled Roe v. Wade has resulted in severe limitations of abortion access throughout the United States. Telehealth has been put forth as one solution for improving access for reproductive health care, including abortion services. Telehealth has demonstrated safety and efficacy in several health care disciplines; however, its use for abortion care and services has not been explored and synthesized.

METHODS

As part of a larger review on telehealth and general reproductive health, our team identified a moderate amount of literature on telehealth and abortion care. We conducted a rapid review searching for eligible studies in MEDLINE, Embase, and CINAHL. Information was extracted from each included study to explore 4 key areas of inquiry: (1) clinical effectiveness, (2) patient and provider experiences, (3) barriers and facilitators, and (4) the impact of the coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

Twenty-five studies on the use of telehealth for providing abortion services published between 2011 and 2022 were included. Telehealth for medical abortion increased during the COVID-19 pandemic and was found to be safe and clinically effective, with high patient satisfaction. Overall, telehealth improved access and removed barriers for patients including lack of transportation. Legal restrictions in certain states were cited as the primary barriers. Studies contained limited information on the perspectives and experiences of health care providers and diverse patient populations.

DISCUSSION

Abortion care via telehealth is safe and effective with high satisfaction and may also remove barriers to care including transportation and fear. Removing restrictions on telehealth for the provision of abortion services may further improve access to care and promote greater health equity.

Self-Managed Medication Abortion: Implications for Clinical Practice

Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women.

Summary

Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.

Implications of using home urine pregnancy tests versus facility-based tests for assessment of outcome following medication abortion provided via telemedicine

OBJECTIVES

To assess whether planning high-sensitivity urine pregnancy tests (HSPT) rather than facility-based tests for medication abortion follow-up may increase risk of unplanned clinical visits or procedural completion of the abortion.

STUDY DESIGN

We used data from the TelAbortion Project, a 5-year study assessing the safety and feasibility of providing mifepristone and misoprostol by telemedicine and mail in the United States. We categorized participants by whether the pretreatment follow-up plan included HSPT at home 3-5 weeks after treatment or facility-based tests (ultrasound or serum human chorionic gonadotropin) within 2 weeks after treatment. We used multivariable logistic regression to compare likelihood of post-treatment unplanned, abortion-related clinical visits and procedural intervention in these groups.

RESULTS

Of 1324 patients who planned HSPT follow-up and 576 who planned facility-based tests, 85% and 83%, respectively, provided outcome information. Post-treatment clinical visits were less frequent in the HSPT group (19%) than in the facility-based test group (79%); most of the latter were to obtain the planned test. However, unplanned, abortion-related visits were significantly more common in the HSPT group (adjusted risk difference: 6.5%; p < 0.01). The likelihood of procedural completion did not differ by group. Planned follow-up test was not associated with delay in procedural completion or detection of ongoing pregnancy.

CONCLUSIONS

Follow-up of medication abortion with home HSPT was associated with fewer post-treatment clinical visits, modestly more unplanned, abortion-related clinical visits, and no increase in the risk of procedural interventions or delayed identification or management of treatment failures. This option is an appropriate follow-up approach after medication abortion.

IMPLICATIONS

Use of home high-sensitivity pregnancy tests rather than facility-based tests for outcome assessment after medication abortion is associated with a modest increase in unplanned clinical visits but does not lead to an increase in procedural interventions or delays identification and management of treatment failure.

History and Politics of Medication Abortion in the United States and the Rise of Telemedicine and Self-Managed Abortion

This article examines the decades-long campaign to increase access to abortion pills in the United States, including advocates' work to win US Food and Drug Administration approval of mifepristone and misoprostol for abortion, the continuing restrictions on mifepristone, and the multiple strategies advocates have pursued to challenge these restrictions, including lobbying the FDA to remove the restrictions, obtaining a limited research exemption from FDA restrictions, and suing the FDA during the COVID-19 pandemic. The article pays particular attention to the influence of research conducted on the safety and efficacy of medication abortion as well as research on the impact of increased availability of abortion pills through telemedicine during the pandemic. The article also addresses self-managed abortion, wherein people obtain and use mifepristone and/or misoprostol outside the formal health care system, and it documents the growing network of organizations providing logistical, medical, and legal support to people self-managing abortion. The article concludes with reflections on the role abortion pills might play in the post-Roe era amid increasingly divergent abortion access trends across different regions of the United States.

Medication abortion via digital health in the United States: a systematic scoping review

Digital health, including telemedicine, has increased access to abortion care. The convenience, flexibility of appointment times, and ensured privacy to abortion users may make abortion services via telemedicine preferable. This scoping review systematically mapped studies conducted on abortion services via telemedicine, including their effectiveness and acceptability for abortion users and providers. All published papers included abortion services via telemedicine in the United States were considered. Articles were searched in PubMed, CINAHL, and Google Scholar databases in September 2022. The findings were synthesized narratively, and the PRISMA-ScR guidelines were used to report this study. Out of 757 retrieved articles, 33 articles were selected based on the inclusion criteria. These studies were published between 2011 and 2022, with 24 published in the last 3 years. The study found that telemedicine increased access to abortion care in the United States, especially for people in remote areas or those worried about stigma from in-person visits. The effectiveness of abortion services via telemedicine was comparable to in-clinic visits, with 6% or fewer abortions requiring surgical intervention. Both care providers and abortion seekers expressed positive perceptions of telemedicine-based abortion services. However, abortion users reported mixed emotions, with some preferring in-person visits. The most common reasons for choosing telemedicine included the distance to the abortion clinic, convenience, privacy, cost, flexibility of appointment times, and state laws imposing waiting periods or restrictive policies. Telemedicine offered a preferable option for abortion seekers and providers. The feasibility of accessing abortion services via telemedicine in low-resource settings needs further investigation.

Mailing abortion pills does not delay care: A cohort study comparing mailed to in-person dispensing of abortion medications in the United States

OBJECTIVE

Given the substantial barriers to abortion access in the United States, many clinics now mail patients abortion medications. We examined whether dispensing the medications by mail prolonged time to medication use.

STUDY DESIGN

We analyzed data from no-test medication abortions with medication provided either by mail or in a clinic from 11 United States clinics from February 2020 to January 2021. We examined mean number of days from patients' first contact with the clinic to mifepristone ingestion, its two-component intervals (first contact to medication dispensing and dispensing to mifepristone ingestion), and pregnancy duration at mifepristone ingestion. We used Poisson regression to compare mean outcomes across three dispensing methods: in-person, mailed from the clinic, and mailed from a mail-order pharmacy.

RESULTS

Among the 2600 records, patients took mifepristone on average at 49 days of gestation (95% CI, 47-51) and 7 days (95% CI, 4-10) after first contact. Mean time from first contact to mifepristone ingestion was 6 days when medications were dispensed in-person and 9 days when mailed (p = 0.38). While time from first contact to dispensing was similar across methods (6 days in-person, 5 days mailed, p = 0.77), more time elapsed from dispensing to mifepristone ingestion when medications were mailed (4 days from clinic, 5 days from mail-order pharmacy) versus dispensed in-person (0.3 days, p < 0.001). Time to mifepristone ingestion was shorter with higher pregnancy duration. Pregnancy duration at ingestion was similar across methods (48 days in-person, 50 days mailed).

CONCLUSIONS

Mailing medications did not significantly prolong time from patients' first contact with the clinic to mifepristone ingestion or increase pregnancy duration at mifepristone ingestion.

IMPLICATIONS

Abortion providers should offer a range of medication abortion dispensing options, prioritizing patient preference.

Abortion Care in the United States - Current Evidence and Future Directions

Abortion Care in the United StatesAbortion services are a vital component of reproductive health care. Jung and colleagues review medication abortion and procedural abortion as well as implications of increasing restrictions on access in the United States.

Interest in advance provision of abortion pills: a national survey of potential users in the USA

OBJECTIVE

To assess interest in clinician-administered advance provision of abortion pills among potential users in the USA.

METHODS

Using social media advertisements, we recruited people living in the USA who were aged 18-45 years and assigned female at birth, who were not pregnant or planning pregnancy, for an online survey on reproductive health experiences and attitudes. We explored interest in advance provision of abortion pills, participant characteristics, including demographics and pregnancy history, contraceptive use, abortion knowledge and comfort, and healthcare system distrust. We used descriptive statistics to assess interest in advance provision, and ordinal regression modelling to evaluate differences in interest controlling for age, pregnancy history, contraceptive use, familiarity and comfort with medication abortion, and healthcare system distrust, reporting adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs).

RESULTS

From January-February 2022, we recruited 634 diverse respondents from 48 states, among whom 65% were interested, 12% neutral, and 23% disinterested in advance provision. There were no differences among interest groups by US region, race/ethnicity, or income. In the model, variables associated with interest included being aged 18-24 years (aOR 1.9, 95% CI 1.0 to 3.4) versus 35-45 years, using a tier 1 (permanent or long-acting reversible) or tier 2 (short-acting hormonal) contraceptive method (aOR 2.3, 95% CI 1.2 to 4.1, and aOR 2.2, 95% CI 1.2 to 3.9, respectively) versus no contraception, being familiar or comfortable with the medication abortion process (aOR 4.2, 95% CI 2.8 to 6.2, and aOR 17.1, 95% CI 10.0 to 29.0, respectively), and having high healthcare system distrust (aOR 2.2, 95% CI 1.0 to 4.4) versus low distrust.

CONCLUSION

As abortion access becomes more constrained, strategies are needed to ensure timely access. Advance provision is of interest to the majority of those surveyed and warrants further policy and logistical exploration.

An examination of loss to follow-up and potential bias in outcome ascertainment in a study of direct-to-patient telemedicine abortion in the United States

OBJECTIVES

To examine associations between factors associated with loss to follow-up and effectiveness in the TelAbortion project, which provided medication abortion by direct-to-patient telemedicine and mail in the United States.

STUDY DESIGN

The study population for this descriptive analysis included abortions among participants enrolled in the TelAbortion study with data present in a web-based database tool from November 2018 to September 2021 who were mailed a medication package. The analysis included information on abortions across nine sites. In this analysis, we used generalized estimating equations to examine factors associated with loss to follow-up and effectiveness.

RESULTS

Of the 1831 abortions included in this analysis, 1553 (84.8%) were classified as having complete follow-up and 278 (15.2%) were classified as lost to follow-up. In a multivariable analysis, factors significantly associated with loss to follow-up included history of medical abortion, education, gestational age, study site, and whether the TelAbortion was performed pre- or post-COVID-19 onset (p < 0.05). The rate of treatment failure (i.e., abortions resulting in continuing pregnancy or uterine evacuation) reported in this study was 5.1%. The only covariate associated with both loss to follow-up and treatment failure was higher gestational age. However, using gestational age to impute missing abortion outcomes did not substantially change the estimated failure rate.

CONCLUSIONS

Abortions that were lost to follow-up differed substantially from those with complete follow-up, which could bias the effectiveness estimate. However, imputing outcomes based on available and appropriate pretreatment data did not substantially affect the estimate. This finding is encouraging, although it does not exclude the possibility of bias due to unmeasured factors.

IMPLICATIONS

Significant differences between abortion cases with complete follow-up and those lost to follow-up provide insights into abortion cases that may be at a higher risk for being lost. The low treatment failure rate indicates that the telemedicine provision of medication abortion is effective.

Abortion bans and their impacts: A view from the United States

A retrospective study of abortion facilities in and around Texas by White et al.¹ and a spatial analysis by Rader et al.² are combined to illustrate the detrimental effects of abortion bans enacted in the United States.

Challenges to the implementation of telemedicine in abortion care for victims of sexual violence in Brazil

The article focuses the recent dynamics resulting from state institutions adding more legal and regulatory barriers to abortion care access, particularly against the use of telemedicine for sexual violence victims in Brazil. It presents a case study from a lawsuit targeting a pioneer public health service on the city of Uberlandia to ban telemedicine in abortion care. The case study highlights human rights violations of women's right to health as well as the recent threats to the right to safe legal abortion care. It also provides legal arguments-based on scientific evidence and international human rights standards-that support the use of telemedicine for abortion care.

Person-centered, high-quality care from a distance: A qualitative study of patient experiences of TelAbortion, a model for direct-to-patient medication abortion by mail in the United States

CONTEXT

Direct-to-patient telemedicine abortion allows people to receive mifepristone and misoprostol for medication abortion in their home without requiring an in-person visit with a healthcare provider. This method has high efficacy and safety, but less is known about the person-centered quality of care provided with telemedicine.

METHODS

We interviewed 45 participants from the TelAbortion study of direct-to-patient telemedicine abortion in the United States from January to July 2020. Semi-structured qualitative interviews queried their choices, barriers to care, expectations for care, actual abortion experience, and suggestions for improvement. We developed a codebook through an iterative, inductive process and performed content and thematic analyses.

RESULTS

The experience of direct-to-patient telemedicine abortion met the person-centered domains of dignity, autonomy, privacy, communication, social support, supportive care, trust, and environment. Four themes relate to the person-centered framework for reproductive health equity: (1) Participants felt well-supported and safe with TelAbortion; (2) Participants had autonomy in their care which led to feelings of empowerment; (3) TelAbortion exceeded expectations; and (4) Challenges arose when interfacing with the healthcare system outside of TelAbortion. Participants perceived abortion stigma which often led them to avoid traditional care and experienced enacted stigma during encounters with non-study healthcare workers.

CONCLUSION

TelAbortion is a high quality, person-centered care model that can empower patients seeking care in an increasingly challenging abortion context.

Improving experience of medical abortion at home in a changing therapeutic, technological and regulatory landscape: a realist review

OBJECTIVE

To inform UK service development to support medical abortion at home, appropriate for person and context.

DESIGN

Realist review SETTING/PARTICIPANTS: Peer-reviewed literature from 1 January 2000 to 9 December 2021, describing interventions or models of home abortion care. Participants included people seeking or having had an abortion.

INTERVENTIONS

Interventions and new models of abortion care relevant to the UK.

OUTCOME MEASURES

Causal explanations, in the form of context-mechanism-outcome configurations, to test and develop our realist programme theory.

RESULTS

We identified 12 401 abstracts, selecting 944 for full text assessment. Our final review included 50 papers. Medical abortion at home is safe, effective and acceptable to most, but clinical pathways and user experience are variable and a minority would not choose this method again. Having a choice of abortion location remains essential, as some people are unable to have a medical abortion at home. Choice of place of abortion (home or clinical setting) was influenced by service factors (appointment number, timing and wait-times), personal responsibilities (caring/work commitments), geography (travel time/distance), relationships (need for secrecy) and desire for awareness/involvement in the process. We found experiences could be improved by offering: an option for self-referral through a telemedicine consultation, realistic information on a range of experiences, opportunities to personalise the process, improved pain relief, and choice of when and how to discuss contraception.

CONCLUSIONS

Acknowledging the work done by patients when moving medical abortion care from clinic to home is important. Patients may benefit from support to: prepare a space, manage privacy and work/caring obligations, decide when/how to take medications, understand what is normal, assess experience and decide when and how to ask for help. The transition of this complex intervention when delivered outside healthcare environments could be supported by strategies that reduce surprise or anxiety, enabling preparation and a sense of control.

Virtual postoperative visits following robotic gynecologic surgery: a study of patient satisfaction, safety, and feasibility

Since the onset of the COVID-19 pandemic the use of telehealth has burgeoned. Numerous surgical specialties have already adopted the use of virtual postoperative visits, but there is data lacking in both robotics and gynecology. In this single-institution prospective cohort study we sought to evaluate the patient satisfaction, feasibility and safety of postoperative telehealth visits following robotic gynecologic surgery. Thirty-three patients undergoing robotic gynecologic procedures participated in a postoperative telehealth visit approximately 2 weeks following surgery, of which 27 completed a survey which assessed participant satisfaction with the telehealth visit, overall health-related quality of life following surgery, exposure to telehealth visits, and social determinants of health. The mean satisfaction score was just below 'excellent'. Only 2 participants (6.3%) required an in-person visit. Postoperative telehealth visit satisfaction score was significantly associated only with BMI (Pearson r = 0.45, p = 0.018). These data suggest that telehealth visits following robotic gynecologic procedures appear to be safe and feasible, and are associated with a high level of patient satisfaction.

The association of U.S. state-level abortion restrictions with medication abortion service delivery innovations during the early COVID-19 pandemic

OBJECTIVES

To assess whether state-level abortion restrictions resulted in differential uptake of innovative medication abortion practices such as changing ultrasound requirements, offering telehealth, or dispensing medications without a physical exam during the early COVID-19 pandemic.

METHODS

We used data from a prospective national survey of abortion providers to assess the association between a novel index of state-level abortion hostility and adoption of medication abortion services innovations during the pandemic.

RESULTS

Clinics in states with low or medium hostility were more likely to adopt innovative practices than those in high or extreme hostility states.

CONCLUSIONS

Clinics in abortion hostile states were less likely to adopt clinical recommendations and public health best practices for abortion care during the COVID-19 pandemic.

Remote Delivery in Reproductive Health Care: Operation of Direct-to-Patient Telehealth Medication Abortion Services in Diverse Settings

PURPOSE

Established models of reproductive health service delivery were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This study examines rapid innovation of remote abortion service operations across health care settings and describes the use of telehealth consultations with medications delivered directly to patients.

METHODS

We conducted semi-structured interviews with 21 clinical staff from 4 practice settings: family planning clinics, online medical services, and primary care practices-independent or within multispecialty health systems. Clinicians and administrators described their telehealth abortion services. Interviews were recorded, transcribed, and analyzed. Staff roles, policies, and procedures were compared across practice settings.

RESULTS

Across all practice settings, telehealth abortion services consisted of 5 operational steps: patient engagement, care consultations, payment, medication dispensing, and follow-up communication. Online services and independent primary care practices used asynchronous methods to determine eligibility and complete consultations, resulting in more efficient services (2-5 minutes), while family planning and health system clinics used synchronous video encounters requiring 10-30 minutes of clinician time. Family planning and health system primary care clinics mailed medications from clinic stock or internal pharmacies, while independent primary care practices and online services often used mail-order pharmacies. Online services offered patients asynchronous follow-up; other practice settings scheduled synchronous appointments.

CONCLUSIONS

Rapid innovations implemented in response to disrupted in-person reproductive health care included remote medication abortion services with telehealth assessment/follow-up and mailed medications. Though consistent operational steps were identified across health care settings, variation allowed for adaptation of services to individual sites. Understanding remote abortion service operations may facilitate dissemination of a range of patient-centered reproductive health services.Annals "Online First" article.

Effectiveness and safety of a direct-to-patient telehealth service providing medication abortion targeted at rural and remote populations: Cross-sectional findings from Marie Stopes Australia

OBJECTIVES

We assessed the safety and effectiveness of direct-to-patient telehealth provision of medication abortion in Australia.

STUDY DESIGN

We included all medication abortions (January 2017-December 2018) from Marie Stopes Australia's patient management and adverse event reporting systems. We defined effectiveness as whether the patient had a continuing pregnancy, incomplete abortion, and/or subsequent vacuum aspiration or procedural abortion and safety as whether the patient experienced any adverse event.

RESULTS

Direct-to-patient telehealth was more effective than in-clinic provision (97.2% versus 95.4%). The proportion of adverse events did not differ between groups.

CONCLUSIONS

This direct-to-patient telehealth service is safe and effective.

Telemedicine for medical abortion service provision in Mexico: A safety, feasibility, and acceptability study

OBJECTIVE

We aimed to obtain evidence about the safety, acceptability, and feasibility of a direct-to-patient telemedicine medical abortion service in Mexico's private health sector.

STUDY DESIGN

A prospective observational one-group study to evaluate a telemedicine abortion service, referred to as TeleAborto, was conducted at three private clinics and one non-clinician community-based provider. Information about the study was provided by phone, websites, and social media. Abortion seekers were screened for eligibility and underwent any pre-abortion tests requested by the study site at services close to home. Eligible participants received packages with abortion medication, analgesics, and instructions and a remote follow-up contact was scheduled for 7-14 days later. Primary outcomes include abortion outcome, management of adverse events, acceptability, and feasibility measures such as package reception and follow-up contact, and challenges to get pre- and post-abortion tests.

RESULTS

We conducted 581 screenings and sent 378 study packages, all successfully received, reaching abortion seekers in all 32 states. All participants took medications before 70 days gestational age as per study protocol. Abortion outcome was determined for 87% participants (330/378); 93% (306/330) had a successful abortion without intervention and 18 with intervention; six individuals decided to continue the pregnancy. Participants reported high satisfaction with TeleAborto, citing convenience as their most valued aspect (85%; 264/311).

CONCLUSIONS

This study showed that guided self-management telemedicine abortion is safe, acceptable, and feasible in Mexico. The model has the potential to close the access gap for indigenous and rural populations, particularly those that rely on public sector services.

Safety and effectiveness of self-managed medication abortion provided using online telemedicine in the United States: A population based study

Background

As access to clinical abortion care becomes increasingly restricted in the United States, the need for self-managed abortions (i.e. abortions taking place outside of the formal healthcare setting) may increase. We examine the safety, effectiveness, and acceptability of self-managed medication abortion provided using online telemedicine.

Methods

We retrospectively examined records of the outcomes of abortions provided by the sole online telemedicine service providing self-managed medication abortion in the U.S. We calculated the prevalence of successful medication abortion (the proportion who ended their pregnancy without surgical intervention); the prevalence of serious adverse events (the proportions who received intravenous antibiotics and blood transfusion); and assessed whether any deaths were reported to the service. We also examined the proportions who were satisfied and felt self-management was the right choice.

Findings

Between March 20th 2018 and March 20th 2019, abortion medications were mailed to 4,584 people and 3,186 (70%) provided follow-up information. Among these, 2,797 (88%) confirmed use of the medications and provided outcome information, while 389 (12%) confirmed non-use. Overall, 96.4% (95% CI 95.7% to 97.1%) of those who used the medications reported successfully ending their pregnancy without surgical intervention and 1.0% (CI 0.7%–1.5%) reported treatment for any serious adverse event. Among these, 0.6% (CI 0.4% to 1.0%) reported receiving a blood transfusion, and 0.5% (CI 0.3% to 0.9%) reported receiving intravenous antibiotics. No deaths were reported to the service by family, friends, the authorities, or the media. Among 2,268 who provided information about their experience, 98.4% were satisfied and 95.5% felt self-management was the right choice.

Interpretation

Self-managed medication abortion provided using online telemedicine can be highly effective with low rates of serious adverse events. In light of increasingly restricted access to in-clinic abortion in the U.S., it may offer a safe and effective option for those who cannot access clinical care.

Funding

The Society of Family Planning and The National Institutes of Health.

Association Between Distance to an Abortion Facility and Abortion or Pregnancy Outcome Among a Prospective Cohort of People Seeking Abortion Online

IMPORTANCE

Many people face barriers to abortion care, including long distances to an abortion facility.

OBJECTIVES

To investigate the association of distance to the nearest abortion facility with abortion or pregnancy outcome.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data from the Google Ads Abortion Access study, a prospective cohort study of individuals considering abortion recruited between August 2017 and May 2018. Individuals from 50 states and Washington, District of Columbia, who were pregnant and considering abortion based on self-report were recruited online using a stratified sampling technique. Participants completed online baseline and 4-week follow-up surveys. Data were analyzed between May and August 2021.

EXPOSURES

Driving distance to an abortion facility calculated from participant zip code and grouped into 4 categories (<5 miles, 5-24 miles, 25-49 miles, and ≥50 miles).

MAIN OUTCOMES AND MEASURES

Abortion or pregnancy outcome reported at 4-week follow-up, categorized as had an abortion, still seeking an abortion, or planning to continue pregnancy. Other measures included reported experience of 8 distance-related barriers to abortion, such as having to gather money for travel expenses and having to keep the abortion a secret.

RESULTS

Among 1485 pregnant individuals considering abortion who completed the baseline survey and provided contact information, 1005 individuals completed follow-up (follow-up rate, 67.7%) and 856 participants were included in the analytic sample (443 individuals ages 25-34 years [51.8%]; 208 Black individuals [24.3%]; 101 Hispanic or Latinx individuals [11.8%], and 468 White individuals [54.8%]). Most participants had at least some college education (474 individuals [55.5%]). Distance to an abortion facility was less than 5 miles for 233 individuals (27.2%), 5 to 24 miles for 373 individuals (43.6%), 25 to 49 miles for 85 individuals (9.9%), and 50 or more miles for 165 individuals (19.3%) (mean [SD] distance = 28.3 [43.8] miles). Most participants reported at least 1 distance-related barrier (763 individuals [89.1%]), with a mean of 3.3 barriers (95% CI, 3.2-3.5 barriers) reported. For 7 of 8 distance-related barriers, an increased percentage of participants living farther from an abortion facility reported the barrier compared with participants living less than 5 miles from a facility; for example, 61.8% (95% CI, 53.5%-69.4%) of individuals living less than 5 miles reported having to gather money for travel expenses, while 81.2% (95% CI, 70.8%-88.5%; P = .002) of those living 25 to 49 miles and 75.8% (95% CI, 69.9%-81.0%; P = .02) of those living 50 or more miles from a facility reported this barrier. At follow-up, participants living 50 or more miles from a facility had higher odds of still being pregnant and seeking abortion (adjusted odds ratio [aOR] = 2.07; 95% CI, 1.35-3.17; P = .001) or planning to continue pregnancy (aOR = 1.96; 95% CI, 1.06-3.63; P = .03) compared with participants living within 5 miles.

CONCLUSIONS AND RELEVANCE

This study found that greater distance from an abortion facility was associated with delays in obtaining abortion care and inability to receive abortion care. These findings suggest that innovative approaches to abortion provision may be needed to mitigate outcomes associated with long distances to abortion facilities.

Outcomes and Safety of History-Based Screening for Medication Abortion: A Retrospective Multicenter Cohort Study

IMPORTANCE

Screening for medication abortion eligibility typically includes ultrasonography or pelvic examination. To reduce physical contact during the COVID-19 pandemic, many clinicians stopped requiring tests before medication abortion and instead screened patients for pregnancy duration and ectopic pregnancy risk by history alone. However, few US-based studies have been conducted on the outcomes and safety of this novel model of care.

OBJECTIVE

To evaluate the outcomes and safety of a history-based screening, no-test approach to medication abortion care.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included patients obtaining a medication abortion without preabortion ultrasonography or pelvic examination between February 1, 2020, and January 31, 2021, at 14 independent, Planned Parenthood, academic-affiliated, and online-only clinics throughout the US.

EXPOSURES

Medications for abortion provided without preabortion ultrasonography or pelvic examination and dispensed to patients in person or by mail.

MAIN OUTCOMES AND MEASURES

Effectiveness, defined as complete abortion after 200 μg of mifepristone and up to 1600 μg of misoprostol without additional intervention, and major abortion-related adverse events, defined as hospital admission, major surgery, or blood transfusion.

RESULTS

The study included data on 3779 patients with eligible abortions. The study participants were racially and ethnically diverse and included 870 (23.0%) Black patients, 533 (14.1%) Latinx/Hispanic patients, 1623 (42.9%) White patients, and 327 (8.7%) who identified as multiracial or with other racial or ethnic groups. For most (2626 [69.5%]), it was their first medication abortion. Patients lived in 34 states, and 2785 (73.7%) lived in urban areas. In 2511 (66.4%) abortions, the medications were dispensed in person; in the other 1268 (33.6%), they were mailed to the patient. Follow-up data were obtained for 2825 abortions (74.8%), and multiple imputation was used to account for missing data. Across the sample, 12 abortions (0.54%; 95% CI, 0.18%-0.90%) were followed by major abortion-related adverse events, and 4 patients (0.22%; 95% CI, 0.00%-0.45%) were treated for ectopic pregnancies. Follow-up identified 9 (0.40%; 95% CI, 0.00%-0.84%) patients who had pregnancy durations of greater than 70 days on the date the mifepristone was dispensed that were not identified at screening. The adjusted effectiveness rate was 94.8% (95% CI, 93.6%-95.9%). Effectiveness was similar when medications were dispensed in person (95.4%; 95% CI, 94.1%-96.7%) or mailed (93.3%; 95% CI, 90.7%-95.9%).

CONCLUSIONS AND RELEVANCE

In this cohort study, screening for medication abortion eligibility by history alone was effective and safe with either in-person dispensing or mailing of medications, resulting in outcomes similar to published rates of models involving ultrasonography or pelvic examination. This approach may facilitate more equitable access to this essential service by increasing the types of clinicians and locations offering abortion care.

An observational study of patient experiences with a direct-to-patient telehealth abortion model in Australia

BACKGROUND

While abortion care is widely legal in Australia, access to care is often poor. Many Australians must travel long distances or interstate to access abortion care, while others face stigma when seeking care. Telehealth-at-home medical abortion is a potential solution to these challenges. In this study, we compared the experience of accessing an abortion via telehealth-at-home to accessing care in-clinic.

METHODS

Over a 20-month period, we surveyed patients who received medical abortion services at Marie Stopes Australia via the telehealth-at-home service or in-clinic. We conducted bivariate analyses to assess differences in reported acceptability and accessibility by delivery model.

RESULTS

In total, 389 patients were included in the study: 216 who received medical abortion services in-clinic and 173 through the telehealth-at-home service. Telehealth-at-home and in-clinic patients reported similarly high levels of acceptability: satisfaction with the service (82% vs 82%), provider interaction (93% vs 84%), and recommending the service to a friend (73% vs 72%). Only 1% of telehealth-at-home patients reported that they would have preferred to be in the same room as the provider. While median time between discovering the pregnancy to first contact with a clinic was similar between groups, median time from first contact to taking the first abortion medication was 7 days longer for telehealth-at-home patients versus in-clinic patients (14 days (IQR 9-21) vs 7 days (IQR 4-14); p<0.01).

CONCLUSION

The telehealth-at-home medical abortion service has the potential to address some of the challenges with provision of abortion care in Australia.

U.S. Abortion Care Providers' Perspectives on Self-Managed Abortion

State-level restrictions on abortion access may prompt greater numbers of people to self-manage their abortion. The few studies exploring perspectives of providers towards self-managed abortion are focused on physicians and advanced practice clinicians. Little is known about the wider spectrum of abortion care providers who encounter self-managed abortion in their clinic-based work. To gain a deeper understanding of this issue and inform future care delivery, we conducted in-depth interviews with 46 individuals working in a range of positions in 46 abortion clinics across 29 states. Our interpretative analysis resulted in themes shaped by beliefs about safety and autonomy, and a tension between the two: that self-managed abortion is too great a risk, that people are capable of self-managing an abortion, and that people have a right to a self-managed abortion. Our findings highlight the importance of increasing knowledge and clarifying values among all abortion care providers, including clinic staff.

Addressing Structural Inequities, a Necessary Step Toward Ensuring Equitable Access to Telehealth for Medication Abortion Care During and Post COVID-19

Telehealth, one of the newest health innovations, has been promoted as a tool to enhance access to health care services in ways that center patient needs. However, integrating telehealth within an inequitable health system undermines its potential. This perspective highlights policies and practices that foster structural inequities and names their impact on the use and acceptability of telehealth for medication abortion among specific communities of color. Communities of color have a higher prevalence of abortion use but face many barriers, including financial and geographic barriers, to abortion access. Preliminary evidence on telehealth for medication abortion shows that it is highly acceptable, accommodating of patient needs, and may allow patients to access abortion care at earlier gestational ages. However, evidence during the COVID-19 pandemic shows that utilization of telehealth is lower among communities of color. We describe how systemic barriers, including regulations on or laws banning telehealth for medication abortion, disinvestments in digital access, and restrictions on public insurance coverage, could perpetuate lower utilization of telehealth for medication abortion care among communities of color. We call for systems changes that will remove these barriers and make this health care innovation available to all who may desire it.

Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with historical controls

Background

Clinical trials have established the high effectiveness and safety of medication abortion in clinical settings. However, barriers to clinical abortion care have shifted most medication abortion use to out-of-clinic settings, especially in the context of the COVID-19 pandemic. Given this shift, we aimed to estimate the effectiveness of self-managed medication abortion (medication abortion without clinical support), and to compare it to effectiveness of clinician-managed medication abortion.

Methods

For this prospective, observational cohort study, we recruited callers from two safe abortion accompaniment groups in Argentina and Nigeria who requested information on self-managed medication abortion. Before using one of two medication regimens (misoprostol alone or in combination with mifepristone), participants completed a baseline survey, and then two follow-up phone surveys at 1 week and 3 weeks after taking pills. The primary outcome was the proportion of participants reporting a complete abortion without surgical intervention. Legal restrictions precluded enrolment of a concurrent clinical control group; thus, a non-inferiority analysis compared abortion completion among those in our self-managed medication abortion cohort with abortion completion reported in historical clinical trials using the same medication regimens, restricted to participants with pregnancies of less than 9 weeks' gestation. This study was registered with ISCRTN, ISRCTN95769543.

Findings

Between July 31, 2019, and April 27, 2020, we enrolled 1051 participants. We analysed abortion outcomes for 961 participants, with an additional 47 participants reached after the study period. Most pregnancies were less than 12 weeks' duration. Participants in follow-up self-managed their abortions using misoprostol alone (593 participants) or the combined regimen of misoprostol plus mifepristone (356 participants). At last follow-up, 586 (99%) misoprostol alone users and 334 (94%) combined regimen users had a complete abortion without surgical intervention. For those with pregnancies of less than 9 weeks' gestation, both regimens were non-inferior to medication abortion effectiveness in clinical settings.

Interpretation

Findings from this prospective cohort study show that self-managed medication abortion with accompaniment group support is highly effective and, for those with pregnancies of less than 9 weeks' gestation, non-inferior to the effectiveness of clinician-managed medication abortion administered in a clinical setting. These findings support the use of remote self-managed models of early abortion care, as well as telemedicine, as is being considered in several countries because of the COVID-19 pandemic.

Funding

David and Lucile Packard Foundation.

Translations

For the Arabic, French, Bahasa Indonesian, Spanish and Yoruba translations of the Article see Supplementary Materials section.

Miles and days until medical abortion via TelAbortion versus clinic in Oregon and Washington, USA

BACKGROUND

Medical abortion provided via telemedicine is becoming more widely available, potentially decreasing travel time for in-person abortion evaluation.

METHODS

We conducted a retrospective chart review of all outpatient medical abortions from October 2016 through December 2019 at our academic medical centre in Portland, Oregon, USA. Using mifepristone administration logs, we identified patients who underwent abortion via direct-to-patient telemedicine or in clinic. Both groups had pre-abortion ultrasound examination. We extracted patient characteristics and geographic data to compare travel distance to clinic, ultrasound facility, and nearest advertised abortion clinic. We compared time from first contact until mifepristone ingestion and gestational age at mifepristone ingestion.

RESULTS

Median distance from mailing address to clinic for 80 telemedicine and 124 clinic medical abortions was 95 (range 4-377) and 12 (range 0-184) miles (p<0.01). Distance travelled to ultrasound facility was shorter for telemedicine patients (median 7 miles, range 0-150 vs 12 miles, range 0-184; p<0.01) excluding outliers >200 miles. Distance to nearest advertised abortion clinic was equal between groups (median 7 miles, p=0.4). Time to mifepristone administration (ingestion) was longer (11 vs 6 days; p<0.01) and median gestational age was higher (49 vs 44 days; p=0.01) for telemedicine.

CONCLUSIONS

Telemedicine increases the reach of abortion providers and provides care to more geographically distant patients. Patients chose telemedicine abortion even when they had an equidistant option, suggesting that patients value telemedicine for reasons other than geographic convenience. This telemedicine delivery model that included ultrasound testing prior to abortion resulted in up to a 5-day delay in abortion initiation, which was not clinically significant.

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

Access to abortion care has been hugely affected by the COVID-19 pandemic. This has prompted several governments to permit the use of telemedicine for fully remote care pathways, thereby ensuring pregnant people are still able to access services. One such government is that of England, where these new care pathways have been publicly scrutinised. Those opposed to telemedical early medical abortion care have raised myriad concerns, though they largely centre on matters of patient safeguarding. It is argued that healthcare professionals cannot adequately carry out their safeguarding duties if the patient is not in the room with them. These concerns lack empirical support. Emerging evidence suggests that safeguarding processes may, in fact, be more effective within telemedical abortion care pathways. In this article, we address two specific safeguarding concerns: (1) that a remote consultation prevents a healthcare professional from identifying instances of abuse, and (2) that healthcare professionals cannot reliably confirm the absence of coercion during a remote consultation. We demonstrate that such concerns are misplaced, and that safeguarding may actually be improved in telemedical care pathways as victims of abuse may find it easier to engage with services. It is inevitable that some individuals will fall through the net, but this is unavoidable even with in-person care and thus does not constitute a strong critique of the use of telemedicine in abortion care. These safeguarding concerns set aside, then, we argue that the current approval that enables telemedical early medical abortion should be afforded permanence.

Acceptability of no-test medical abortion provided via telemedicine during Covid-19: analysis of patient-reported outcomes

INTRODUCTION

The English government approved both stages of early medical abortion (EMA), using mifepristone and misoprostol under 10 weeks' gestation, for at-home use on 30 March 2020. MSI Reproductive Choices UK (MSUK), one of the largest providers of abortion services in England, launched a no-test telemedicine EMA pathway on 6 April 2020. The objectives of this study were to report key patient-reported outcome measures and to assess whether our sample was representative of the whole population receiving no-test telemedicine EMA.

METHODS

A sample of all MSUK's telemedicine EMA patients between April and August 2020 were invited to opt in to a follow-up call to answer clinical and satisfaction questions. A total of 1243 (13.7% of all telemedicine EMAs) were successfully followed-up, on average within 5 days post-procedure.

RESULTS

Patients reported high confidence in telemedicine EMA and high satisfaction with the convenience, privacy and ease of managing their abortion at home. The sample responding were broadly equivalent to the whole population receiving telemedicine. No patient reported that they were unable to consult privately. The majority (1035, 83%) of patients reported preferring the telemedicine pathway, with 824 (66%) indicating that they would choose telemedicine again if COVID-19 were no longer an issue.

CONCLUSIONS

Telemedicine EMA is a valued, private, convenient and more accessible option that is highly acceptable for patients seeking an abortion, especially those for whom in-clinic visits are logistically or emotionally challenging. Evidence that this pathway would be a first choice again in future for most patients supports the case to make telemedicine EMA permanent.

Effects of the COVID-19 pandemic on family planning services

PURPOSE OF REVIEW

The COVID-19 pandemic has highlighted existing healthcare disparities worldwide and has challenged access to family planning (FP) services.

RECENT FINDINGS

Research has identified ways in which government regulations and healthcare programs have inhibited or increased access to FP services, as well as how the pandemic has changed individuals' sexual and reproductive health behaviors and intentions.

SUMMARY

The pandemic has had both positive and negative effects on access to FP services. Innovations in various delivery services, extended use of contraception, telehealth for medication abortion, and a no-test medication abortion protocol have decreased the need for in-person visits and improved access to FP services.

Pharmacist dispensing of the abortion pill in Canada: Diffusion of Innovation meets integrated knowledge translation

BACKGROUND

Since Canadian drug regulatory approval of mifepristone for medical abortion in 2015 and its market availability in January 2017, the role of pharmacists in abortion provision has changed rapidly. We sought to identify the factors that influenced the initiation and provision of medical abortion from the perspectives of Canadian pharmacists, bridging two frameworks - Diffusion of Innovation in Health Service Organizations and integrated knowledge translation.

METHODS

We conducted one-on-one semi-structured interviews with pharmacists residing in Canada who intended to stock and dispense mifepristone within the first year of availability. Our data collection, analysis, and interpretation were guided by reflexive thematic analysis and supported by an integrated knowledge translation partnership with pharmacy stakeholders.

RESULTS

We completed interviews with 24 participants from across Canada: 33% had stocked and 21% had dispensed mifepristone. We found that pharmacists were willing and able to integrate medical abortion care into their practice and that those who had initiated practice were satisfied with their dispensing experience. Our analysis indicated that several key Diffusion of Innovation constructs impacted the uptake of mifepristone, including: innovation (relative advantage, complexity and compatibility, technical support), system readiness (innovation-system fit, dedicated time, resources), diffusion and dissemination (expert opinion, boundary spanners, champions, social networks, peer opinions), implementation (external collaboration), and linkage. Participants' experiences suggest that integrated knowledge translation facilitated evidence-based changes to mifepristone dispensing restrictions, and communication of those changes to front line pharmacists.

CONCLUSIONS

We illustrate how Diffusion of Innovation and integrated knowledge translation may work together as complimentary frameworks for implementation science research. Unlike in the USA, UK, and other highly regulated settings globally, pharmacists in Canada are permitted to dispense mifepristone for medical abortion. We contribute to literature that shows that mifepristone dispensed outside of hospitals, clinics, and medical offices is safe and acceptable to both patients and prescribers. This finding is of particular importance to the current COVID-19 pandemic response and calls for continued and equitable access to abortion care in primary practice.

Clinical and service delivery implications of omitting ultrasound before medication abortion provided via direct-to-patient telemedicine and mail

OBJECTIVES

To compare outcomes among patients who did or did not have pre-abortion ultrasound or pelvic exam before obtaining medication abortion (MA) via direct-to-patient telemedicine and mail.

STUDY DESIGN

We analyzed data from participants screened for enrollment into the TelAbortion study at five sites from March 25 to September 15, 2020. We compared participants who had preabortion ultrasound or pelvic exam ("test-MA") to those who did not ("no-test MA"). Outcomes were: abortion not complete with pills alone (i.e., had procedure intervention or ongoing pregnancy), ongoing pregnancy separately, ectopic pregnancy, hospitalization and/or blood transfusion, and unplanned clinical encounters. We used propensity score weighting and multivariable logistic regression to adjust for baseline characteristics.

RESULTS

Our analysis included 287 participants who had no-test MA and 125 who had test-MA. Abortion was not complete with pills alone in 16of 287 (5.6%) no-test MA patients compared to 2of 123 (1.9%) test-MA patients (adjusted risk difference [aRD] = 4.3%, 95% confidence interval [CI]: 1.4%-7.1%). No ectopic pregnancies were detected. Groups did not differ regarding hospitalization and/or blood transfusion (p = 0.76) or ongoing pregnancy diagnosis (p = 0.59). Unplanned clinical encounters were more common in no-test MA patients (35of 287, 12.5%) than test-MA patients (10of 125, 8.0%, aRD = 6.7%, 95% CI: 0.5%-13.1%).

CONCLUSIONS

Compared to patients who had pre-abortion ultrasound, patients who had no-test MA via telemedicine were more likely to have abortions that were not complete with pills alone and/or unplanned clinical encounters. However, both no-test and test-MA patients had similar and very low rates of ongoing pregnancy and hospitalization or blood transfusion.

IMPLICATIONS

Omitting pre-abortion ultrasound before provision of medication abortion via telemedicine does not appear to compromise safety or result in more ongoing pregnancies. However, compared to patients who have preabortion ultrasound, patients who do not have pre-abortion tests may be more likely to seek post-treatment care and have procedural interventions.

Medication Abortion With Pharmacist Dispensing of Mifepristone

Medication abortion with pharmacist-dispensed mifepristone is effective, with a low prevalence of adverse events, and patients are satisfied with the model of care.

To estimate effectiveness and acceptability of medication abortion with mifepristone dispensed by pharmacists.

Civil Disobedience and Abortion Services After Roe v Wade: Legal and Ethical Considerations

The future of Roe v Wade is uncertain. If it is overturned, protection of reproductive rights will be determined by the acts of individual state governments, some of which have already signaled that they will ban or severely restrict access to abortion. Health care professionals working in states that maintain the laws that applied in the time before the overturn of Roe may wish to provide assistance-anything from consultation to shipping medications-to women living in more restrictive venues. However, it is important for health care professionals to be aware of the legal consequences of those acts, as well as ethical considerations, when deciding whether to adhere to or to defy laws that they believe threaten the well-being of women. It is likely that legal consequences will vary with the type of act in which a physician engages. This article will review legal considerations, to the extent that they can be known at this point, as well as the ethics of civil disobedience.

COVID-19 Remote Consultation Services and Population in Health Inequity-Concentrating Territories: A Scoping Review

Background: This review aimed to map initiatives for measuring the satisfaction of vulnerable populations with teleconsultation services offered by public and private health care providers in their territories, during the coronavirus disease (COVID-19) pandemic. Systematic studies on the opinions of people most affected by health inequities are limited. Therefore, we included evaluations of teleconsultation-based services offered to socioeconomically disadvantaged and clinically vulnerable populations globally, with a focus on surveillance, treatment, and prevention of COVID-19.

Materials and Methods: This review includes analytical and descriptive observational studies primarily from MEDLINE, EMBASE, SCOPUS, and Web of Science databases, published after the World Health Organization received the first warnings about COVID-19 from Chinese authorities in December, 2019, until December 2020. The search strategy combined aspects of COVID-19, telemedicine, patient satisfaction, and key concepts of vulnerable populations.

Results: We selected 33 studies for full-text reading and 10 for critical appraisal. Two categories emerged from the qualitative analysis: telehealth evaluation and services during COVID-19, and opinions of vulnerable populations. Television and social networks play a crucial role in providing information. Although teleconsultations are practical and cost effective for patients, the majority preferred receiving in-person treatment in primary care clinics.

Conclusions: Listening to the opinions of vulnerable groups and their caregivers is critical both before and during adoption of COVID-19 control measures. Health managers need to monitor the health of and delivery of services to socioeconomically and clinically vulnerable people closely, to improve services, and provide care from a human rights perspective.