Patient and provider experiences using a site-to-site telehealth model for 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.

Telemedicine Abortion in Primary Care: An Exploration of Patient Experiences

PURPOSE

The purpose of the study was to explore patients' experiences and perspectives obtaining telemedicine medication abortion (TeleMAB) through their primary care health system.

METHODS

We conducted in-depth telephone interviews with 14 English-, Spanish-, and/or Portuguese-speaking patients who received a TeleMAB between July 2020 and December 2021, within a large primary care safety-net community health system in Massachusetts. We created and piloted a semistructured interview guide informed by patient-clinician communication frameworks and prior studies on patient experiences with TeleMAB. We analyzed data using reflexive thematic analysis and summarized main themes.

RESULTS

Overall, participants found TeleMAB services in their primary care health system acceptable, positive, and easy. Participants discussed how TeleMAB supported their ability to exercise control, autonomy, and flexibility, and decreased barriers experienced with in-clinic care. Many participants perceived their primary care health system as the place to go for any pregnancy-related health care need, including abortion. They valued receiving abortion care from their established health care team within the context of ongoing social and medical concerns.

CONCLUSIONS

Patients find TeleMAB from their primary care health system acceptable and beneficial. Primary care settings can integrate TeleMAB services to decrease care silos, normalize abortion as a part of comprehensive primary care, and improve access through remote care offerings. TeleMAB supports patients' access and autonomy, with the potential to benefit many people of reproductive age.

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.

Implementing medical abortion through telemedicine in Colombia: a qualitative study

The non-governmental organisation Profamilia developed and implemented medical abortion through telemedicine in response to the Covid-19 pandemic. This service is now integrated as an alternative to in-person care and available to abortion-seekers across Colombia. Previous research has emphasised bottlenecks in abortion provision, but less is known about implementation processes and experiences. We assessed the feasibility and acceptability of telemedicine for medical abortion from the perspectives of key informants involved in the implementation in Colombia. We conducted 15 in-depth interviews with healthcare professionals, coordinators and support staff implementing telemedicine for medical abortion in the early phase of implementation, between March and October 2021. We analysed the data using the framework method and applied the normalisation process theory in our analysis and interpretation of findings. Our findings show that strong leadership, organisational efforts on pre-implementation training, monitoring and evaluation, and collaboration between diversely skilled and experienced providers are essential for successful implementation. Participants were generally positive towards the use of telemedicine for medical abortion; concerns related to effectiveness, safety and safeguarding existed mainly among providers with less clinical experience. We identified contextual barriers, such as social opposition, regulatory barriers, providers' unavailability, and poor phone and internet connections in rural areas, which impacted the feasibility of the intervention negatively. In conclusion, to ensure stakeholders' buy-in and for the service to reach all abortion seekers in need, future implementation endeavours must address concerns about safety and effectiveness, and tackle identified contexual barriers.Plain Language SummaryIn telemedicine for medical abortion, all or some components of abortion care, such as initial consultations, home delivery of abortion medication, and post-abortion follow up are provided with the use of telecommunications. Telemedicine for medical abortion has been shown to be a safe and effective form of service delivery.In this study, we interviewed 15 healthcare providers and staff involved in the implementation of a telemedicine service for medical abortion in Colombia to determine whether they deemed the service to be acceptable and feasible. We found that collaboration between providers of different backgrounds and levels of experience, appropriate training and strong leadership were key factors for successfully implementing the service. However, some healthcare providers, especially those with less clinical experience, were concerned that telemedicine for medical abortion may not be safe and may risk the health and well-being of abortion-seekers. Further, social opposition to abortion, unclear regulation and limited access to technology were identified as barriers that need to be addressed to ensure the service reaches all abortion-seekers in need.In conclusion, despite contextual barriers and some provider's concerns about medical safety, telemedicine for medical abortion was viewed as a positive and feasible form of service delivery in Colombia.

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.

Patient Perspectives Regarding Clinician Communication During Telemedicine Compared With In-Clinic Abortion

OBJECTIVE

To explore patient perspectives regarding patient-clinician communication during telemedicine medication abortion compared with traditional, facility based, in-clinic visits.

METHODS

We conducted semi-structured interviews with participants who received either live, face-to-face telemedicine or in-clinic medication abortion from a large, reproductive health care facility in Washington State. Using Miller's conceptual framework for patient-doctor communication in telemedicine settings, we developed questions exploring participants' experiences of the medication abortion consultation, including the clinician's verbal and nonverbal interpersonal approach and communication of relevant medical information, and the setting where care was received. We used inductive-deductive constant comparative analysis to identify major themes. We summarize patient perspectives using patient-clinician communication terms outlined in Dennis' quality abortion care indicator list.

RESULTS

Thirty participants completed interviews (aged 20-38 years), 20 of whom had medication abortion by telemedicine and 10 who received in-clinic services. Participants who received telemedicine abortion services reported high-quality patient-clinician communication, which came from their freedom to choose their consultation location, and reported feeling more relaxed during clinical encounters. In contrast, most in-clinic participants portrayed their consultations as lengthy, chaotic, and lacking comfort. In all other domains, both telemedicine and in-clinic participants reported similar levels of interpersonal connection to their clinicians. Both groups appreciated medical information about how to take the abortion pills and relied heavily on clinic-based printed materials and independent online resources to answer questions during the at-home termination process. Both telemedicine and in-clinic participant groups were highly satisfied with their care.

CONCLUSION

Patient-centered communication skills used by clinicians during facility based, in-clinic care translated well to the telemedicine setting. However, we found that patients who received medication abortion through telemedicine favorably ranked their patient-clinician communication overall as compared with those in traditional, in-clinic settings. In this way, telemedicine abortion appears to be a beneficial patient-centered approach to this critical reproductive health service.