Adherence to treatment and prevalence of side effects when medical abortion is delivered via telemedicine: a prospective observational cohort study during COVID-19

Society of Family Planning Clinical Recommendation: Telemedicine in family planning care part 2 - Abortion

This Clinical Recommendation provides evidence-informed, person-centered, and equity-driven guidance to optimize medication abortion management via telemedicine in the US. Key recommendations include: We recommend telemedicine medication abortion with or without pre- or posttreatment testing as a safe option before 12 0/7 weeks of gestation. No-test telemedicine medication abortion (NTMA) and hybrid models are shown to be safe and effective (GRADE 1B). We recommend over-the-counter nonsteroidal anti-inflammatory agents as the first line for pain management for telemedicine medication abortion with consideration of opioids as needed when providing telemedicine medication abortion care (GRADE 1C). We recommend principles of noncoercive person-centered communication be applied to meet the abortion counseling needs of the person receiving care (GRADE 1B). We suggest assessing the person's desire for contraceptive counseling at the time of telemedicine medication abortion and, depending on the preference of the person receiving care, either defer it to a later time to allow for deliberation and increased autonomy or provide contraceptive counseling if desired (GRADE 2C). We recommend assessing telemedicine medication abortion completion using a standardized patient symptom checklist (such as the sample validated checklist in Table 2) two weeks after mifepristone ingestion in conjunction with a home pregnancy test (GRADE 1C). This document builds upon the Society of Family Planning Committee Statement: Telemedicine in family planning care part 1 - Background and overarching principles and parallels recommendations outlined in the Society of Family Planning Clinical Recommendation: Telemedicine in family planning care part 3 - Contraception. Readers are encouraged to review parts 1 and 3 for this additional context.

Early medical abortion

Early medical abortion (EMA) with mifepristone and misoprostol is expanding access to safe abortion across the world. The drug regimen has changed and the steps involved in EMA have been significantly simplified since EMA was first introduced over 35 years ago. Evidence shows that women can safely self-administer both mifepristone and misoprostol themselves at home and self-manage the procedure including confirming the success of the procedure with a self-performed pregnancy test. Telemedicine has expanded access to EMA and evidence shows that it is associated with similar outcomes to traditional models of delivery and is acceptable to both women and clinicians. Further research is required to optimise the analgesic regimen for EMA. Greater efforts are required to expand availability of medical abortion at home at both very early gestations (less than 6 weeks) and up to the end of the first trimester. More evidence is needed to develop guidelines to support provision in remote settings.

Foregrounding pain in self-managed early medication abortion: a qualitative study

OBJECTIVE

To explore experiences of pain in the context of early medical abortion (EMA) in the UK and to guide best practice around anticipatory guidance on pain.

METHODS

From late 2020 to early 2021, we recruited individuals from across the UK who had undergone abortion during the COVID-19 pandemic to participate in in-depth, semi-structured telephone interviews. A storytelling approach was used and data were analysed thematically using NVivo 12 software.

RESULTS

Focused coding and thematic analysis addressed accounts of pain, which were prominent in many interviews. We constructed the following subthemes: expected pain is manageable for some; the problem with unexpected pain; pain (co)produces fear; and problematising 'period-like pain'. The key issue which our analysis draws out is that while EMA pain experience might vary, for some it may be much worse than anticipated. Moreover, the common trope of likening it to 'period pain' can be misleading and a source of additional uncertainty at a potentially already challenging time.

CONCLUSIONS

For some individuals, pain experienced in EMA will be severe and/or worse than expected. Insufficient preparation for pain can result in extremely negative experiences of EMA. Alongside development of improved analgesia, improvements should be made to anticipatory guidance on pain, particularly for those self-manging EMA at home. Framings of 'period-like pain' do not clarify expectations and should be avoided.

Telemedicine for the provision of medication abortion to pregnant people at up to twelve weeks of pregnancy: a systematic literature review and meta-analysis

BACKGROUND

Telemedicine represents an important strategy to facilitate access to medication abortion (MAB) procedures, reduces distance barriers and expands coverage to underserved communities. The aim is evaluating the self-managed MAB (provided through telemedicine as the sole intervention or in comparison to in-person care) in pregnant people at up to 12 weeks of pregnancy.

METHODS

A literature search was conducted using electronic databases: MEDLINE, Embase, Cochrane (Central Register of Controlled Trials and Database of Systematic Reviews), LILACS, SciELO, and Google Scholar. The search was based on the Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework, and was not restricted to any years of publication, and studies could be published in English or Spanish. Study screening and selection, risk of bias assessment, and data extraction were performed by peer reviewers. Risk of bias was evaluated with RoB 2.0 and ROBIS-I. A narrative and descriptive synthesis of the results was conducted. Meta-analyses with random-effects models were performed using Review Manager version 5.4 to calculate pooled risk differences, along with their individual 95% confidence intervals. The rate of evidence certainty was based on GRADE recommendations.

RESULTS

21 articles published between 2011 and 2022 met the inclusion criteria. Among them, 20 were observational studies, and 1 was a randomized clinical trial. Regarding the risk of bias, 5 studies had a serious risk, 15 had a moderate risk, and 1 had an undetermined risk. In terms of the type of intervention, 7 compared telemedicine to standard care. The meta-analysis of effectiveness revealed no statistically significant differences between the two modalities of care (RD = 0.01; 95%CI 0.00, 0.02). Our meta-analyses show that there were no significant differences in the occurrence of adverse events or in patient satisfaction when comparing the two methods of healthcare delivery.

CONCLUSION

Telemedicine is an effective and viable alternative for MAB, similar to standard care. The occurrence of complications was low in both forms of healthcare delivery. Telemedicine services are an opportunity to expand access to safe abortion services.

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.

How can patient experience of abortion care be improved? Evidence from the SACHA study

BACKGROUND

Models of abortion care have changed significantly in the last decade, most markedly during the COVID-19 pandemic, when home management of early medical abortion with telemedical support was approved in Britain.

OBJECTIVE

Our study aimed to examine women's satisfaction with abortion care and their suggestions for improvements.

DESIGN

Qualitative, in-depth, semi-structured interviews.

METHODS

A purposive sample of 48 women with recent experience of abortion was recruited between July 2021 and August 2022 from independent sector and National Health Service abortion services in Scotland, Wales and England. Interviews were conducted by phone or via video call. Women were asked about their abortion experience and for suggestions for any improvements that could be made along their patient journey - from help-seeking, the initial consultation, referral, treatment, to aftercare. Data were analyzed using the Framework Method.

RESULTS

Participants were aged 16-43 years; 39 had had a medical abortion, 8 a surgical abortion, and 1 both. The majority were satisfied with their clinical care. The supportive, kind and non-judgmental attitudes of abortion providers were highly valued, as was the convenience afforded by remotely supported home management of medical abortion. Suggestions for improvement across the patient journey centred around the need for timely care; greater correspondence between expectations and reality; the importance of choice; and the need for greater personal and emotional support.

CONCLUSION

Recent changes in models of care present both opportunities and challenges for quality of care. The perspectives of patients highlight further opportunities for improving care and support. The principles of timely care, choice, management of expectations, and emotional support should inform further service configuration.

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.

Using telemedicine to improve early medical abortion at home (UTAH): a randomised controlled trial to compare telemedicine with in-person consultation for early medical abortion

OBJECTIVES

To compare telephone consultations with in-person consultations for the provision of medical abortion (using mifepristone 200 mg and misoprostol 800 µg). We hypothesised that telemedicine consultations would be non-inferior to in-person consultations with a non-inferiority limit of 3%.

DESIGN

Randomised controlled trial with 1:1 allocation.

SETTING

Community abortion service housed within an integrated sexual and reproductive health service in Edinburgh, UK.

PARTICIPANTS

The trial began on 13 January 2020, but was stopped early due to COVID-19; recruitment was suspended on 31 March 2020, and was formally closed on 31 August 2021. A total of 125 participants were randomised, approximately 10% of the total planned, with 63 assigned to telemedicine and 62 to in-person consultation.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome: efficacy of medical abortion, defined as complete abortion without surgical intervention.

SECONDARY OUTCOMES

satisfaction with consultation type, preparedness, unscheduled contact with care, complication rate, time spent in clinical contact and uptake of long-acting contraception.

RESULTS

Primary outcome was available for 115 participants (lost-to-follow-up telemedicine=2, in-person=8), secondary outcomes were available for 110 participants (n=5 and n=10 in telemedicine and in-person groups did not complete questionnaires). There were no significant differences between groups in treatment efficacy (telemedicine 57/63 (90.5%), in-person 48/62 (77.4%)). However, non-inferiority was not demonstrated (+3.3% in favour of telemedicine, CI -6.6% to +13.3%, lower than non-inferiority margin). There were no significant differences in most secondary outcomes, however, there was more unscheduled contact with care in the telemedicine group (12 (19%) vs 3 (5%), p=0.01). The overall time spent in clinical contact was statistically significantly lower in the telemedicine group (mean 94 (SD 24) vs 111 (24) min, p=0.0005).

CONCLUSIONS

Telemedicine for medical abortion appeared to be effective, safe and acceptable to women, with less time spent in the clinic. However, due to the small sample size resulting from early cessation, the study was underpowered to confirm this conclusion. These findings warrant further investigation in larger scale studies.

TRIAL REGISTRATION NUMBER

NCT04139382.

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.