By Laura Fix,1 Jane W Seymour,1 Monisha Vaid Sandhu,2 Jacquie O’Brien,2 Catriona Melville,2 Danielle Mazza,3 Terri-Ann Thompson1
Telemedicine delivery of medical abortion is common and safe
In the midst of the COVID-19 pandemic, telemedicine has emerged as key to sustaining access to essential reproductive health care services. Medical abortion care provided via telemedicine has been shown to be safe, effective, and acceptable to patients and providers. Prior to the current restrictions on local and global travel due to the pandemic, several different telemedicine models have been used in high-resource countries, such as Australia and the United States, to regularly deliver abortion care during the first trimester. In the U. S., the only service currently available for telemedicine for medical abortion is a clinic-to-clinic model, in which patients at one clinic are seen remotely by a provider at another clinic.
In Australia, an at-home telemedicine model is used by Marie Stopes Australia (MSA), in which eligible patients can opt to receive an express-mailed mifepristone and misoprostol medication pack at home after completing an eligibility screen and any necessary testing locally. Patients then take the medications at home in order to complete the abortion, with access to a 24-hour clinical helpline for support. Such a model, which can accommodate a patient’s need to have their abortion procedure at home, under the direction and with the support of clinicians, may have benefits beyond this era in which in-person visits must remain limited; this model can also accommodate patients who may otherwise have difficulty reaching a provider due to geographic distance, limited financial resources to facilitate travel or an absence from work, or caregiving responsibilities that reduce their availability.
Patient experiences with an at-home telemedicine service in Australia
In our paper published in the July issue of BMJ Sexual & Reproductive Health, we report findings from qualitative interviews with 24 patients who used the MSA at-home telemedicine service for medical abortion. We asked patients to share their experiences obtaining services, including their abortion decision-making process, locating a provider, selection of the at-home telemedicine service instead of in-person care, and utilization of the service and post-abortion follow-up care.
Participants selected the at-home telemedicine model for the: (1) convenience, (2) lack of travel required to access the service, and (3) ability to obtain care with minimal or no disruption in work and childcare responsibilities. Most participants reported satisfaction with the medical abortion service, felt the information they received was clear, and the interactions they had with the provider were positive. Participants also perceived the level of privacy in the at-home telemedicine visit to be equal to or better than privacy of an in-person visit.
Most said they would recommend the service to a friend or family member.
Attending to key domains to improve abortion access
has, in many cases, forced a transition in sexual and reproductive health care delivery from in-person to remote care, which will likely persist long after the population health effects of the pandemic are mitigated. As such, there is a need to direct attention and resources to key areas in order to successfully incorporate telemedicine into abortion care in Australia and other high-income countries.
Logistical support is essential to ensure that providers have stable infrastructure, equipment, and programs that comply with privacy regulations, as well as training to support efficient and high-quality delivery of remote patient care. Funding for such logistical support is crucial, as is establishing payment parity between telemedicine and in-person services from public and private payers to ensure that telemedicine services are financially accessible for all patients and sustainable for providers.
Additionally, there is a need for cooperation within the health care sector to explore and trial innovations in provision of telemedicine including moving towards “no-touch” telemedicine provision, which facilitates care delivery without requiring an in-person visit. In Australia, new Medical Benefits Scheme item numbers for telemedicine consultations were created for temporary use during the pandemic. It is critical that this innovation be extended post-pandemic to ensure ongoing access to and affordability of services.
Policy recommendations
Permanent policy changes will be necessary to expand and sustain access to telemedicine for medical abortion. Broadening the range of providers who can offer medical abortion, and who can provide it via telemedicine, is necessary for improving access and supporting long-term availability of services in the context of increased demand on health care systems as a result of both the pandemic and an increased utilization of health care via telemedicine. Similarly, consideration must be given to ensuring that the gestational limits for medical abortion are in line with international research and standards.
Greater focus must be given to the harmonization of abortion laws in order to ensure uninterrupted access to abortion care. For example, women in South Australia still cannot access telemedicine due to existing abortion laws in that state. In the U.S., a July federal court decision temporarily allows providers to mail the abortion medication mifepristone to their patients during the pandemic, but this may be limited by restrictive abortion laws in some states. Similarly, in the UK, legislation to allow for mifepristone use at home is only temporary and a permanent change to the law is necessary for on-going remote provision of medical abortion. This turning point in telemedicine utilization and support across the world affords a number of opportunities to expand access to medical abortion using evidence-based service delivery models that truly center the patient experience; with thoughtful investment in key domains and long-term policy change, the promise of this moment can be realized for sexual and reproductive health.
Affiliations:
- Ibis Reproductive Health: @IbisRH
- Marie Stopes Australia: @mariestopesaus
- Monash University: @Danielle_Mazza