By Louise McCudden
‘Acceptability of no-test medical abortion provided via telemedicine: analysis of patient-reported outcomes’ is the latest in a growing body of evidence highlighting the benefits of telemedicine abortion. This paper by Dr Jonathan Lord, Chelsey Porter and Kathryn Church from MSI Reproductive Choices UK describes not only the clinical benefits but also patient experiences of telemedicine, explaining why it should be retained as a permanent option after the COVID-19 pandemic ends.
In March 2020, as the global COVID-19 pandemic peaked and health service access became restricted, the government approved home use of both mifepristone and misoprostol for Early Medical Abortion.
Early Medical Abortion at home, or ‘telemedicine’, was initially presented as a temporary measure for the duration of the pandemic. The UK government is now rightly consulting on whether to make telemedicine permanent in England (the Scottish and Welsh governments held their own consultations). At MSI Reproductive Choices UK, we believe the global evidence to support telemedicine is now so strong that it’s hard to see how removing this pathway could be justified.
There is no clinical reason to deny patients the option of telemedicine. This new paper, ‘Acceptability of no-test medical abortion provided via telemedicine: analysis of patient-reported outcomes’ shows that not only is telemedicine clinically effective, but that when surveyed on their preferences, 83.3% of patients told us they prefer telemedicine. Two thirds said they would choose telemedicine again, should they ever need a future abortion, even if the pandemic was not a factor.
As well as being preferred by most patients, telemedicine has real clinical benefits. It has reduced waiting times by, on average, over four days, which in turn has reduced the average gestation at which abortion is carried out. In fact, the availability of telemedicine in England led to 40% of abortions being provided at under six weeks gestation. Under the non-telemedicine pathway, that figure is just 25%. Every abortion we provide is safe, but the earlier the gestation, the safer it is.
Safety was our primary concern in designing the telemedicine pathway. There is no reason to imagine that taking both abortion pills at home is inherently less safe than taking one of them in a clinic. Medical abortion, whether provided at home or in a clinic is only available to clinically eligible patients. We designed our pathway in full alignment with guidance from the National Institute for Health and Care Excellence (NICE), the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM). Indeed, the team won an award for innovation during the pandemic. Trained clinical advisors hold a telephone consultation with each patient; if there are any clinical risks (such as signs of an ectopic pregnancy or lack of certainty around gestation), the patient is referred for a detailed in-person assessment. Making telemedicine available also doesn’t stop patients from choosing face-to-face consultations or surgical abortion.
Of course, safety is about more than just clinical safety. Another important finding from this paper is that telemedicine makes abortion safer for people with safeguarding risks, such as an abusive partner who may coerce them into or out of having an abortion. Our team members are trained to recognise and address safeguarding risks as well as clinical ones over the phone and online. Many patients have been helped via these routes of support.
Medical privacy is important for all healthcare, but it’s especially vital when providing sensitive, highly stigmatised services like abortion. The telemedicine pathway was designed with privacy at its heart. This paper shows the success of that design. 95.3% of patients were able to speak with their trained health advisor in private. A further 4.6% were able to speak in private when they sought out privacy, for example by organising childcare. None of our surveyed patients said they were completely unable to talk privately, and none of the ‘free text’ comments indicated any pressure or coercion.
In fact, far from telemedicine creating privacy challenges, many patients preferred having the consultation over the phone precisely because visiting a clinic in person can exacerbate privacy risks and add stress. Many people fear judgment about abortion, even from clinicians, and anti-abortion groups harass people (usually women) outside clinics. Without telemedicine, patients can be dependent on others for transport. Even with independent transport, it can be difficult to leave the house without the people you live with finding out why. Having telephone consultations and receiving medicines by post removes this barrier.
Despite this, we recognise that telemedicine isn’t right for everybody. Of the patients surveyed, 22% would prefer in-person care for any future abortion. This is a sizeable minority, and significantly, the paper shows that Black, Asian and Minority Ethnic (BAME) patients and those under 20 appear more likely to prefer an in-person pathway in the future. More research is needed to better understand this correlation, but it’s clear that a one-size-fits-all pathway isn’t best practice for abortion care. Patients should be offered a range of options, then trusted to make their own choices.
All this marries with the findings from MSI Reproductive Choices Australia as published by the BMJ last July. Indeed, there’s now such a comprehensive body of evidence supporting telemedicine that it’s hard not to conclude that the only reasons to oppose it as a permanent option are rooted in sexism. Much of the anti-telemedicine rhetoric is based on assumptions that women are unable to make their own medical decisions, are unable to effectively cope with pain, and are unable to know their own best interests.
As a pro-choice organisation, we are not only committed to the right to choose an abortion, but the right to choose the pathway that is best for individual patient needs. Those needs might be clinical, logistical, safeguarding, or emotional. It’s widely accepted that telemedicine is clinically effective. We can now say confidently that it’s also preferable for many patients. Removing the option of telemedicine now would be to outright ignore those patient’s voices. We hope the government decides instead to trust them.
Louise McCudden is the Advocacy and Public Affairs Advisor for MSI Reproductive Choices UK. Louise has previously worked as a journalist for several outlets including national and regional press.