“As the COVID-19 pandemic shifts the architecture of choice in abortion care, we must continue to accommodate patient preferences.”

By Rebecca Blaylock and Dr Shelly Makleff

Our new research1 shows what factors contribute to shaping people’s preferences for the sort of abortion they want. For example, patients may be influenced by a previous good abortion experience they hope to emulate again, they may be worried about privacy issues in shared housing, or they might find the idea of surgery scary. Whilst some people’s preferences are based in a priori fears or misinformation, many have reasonable expectations and desires for what they want their abortion to be like. Our findings are important in light of changes to abortion care in the UK during the COVID-19 pandemic.

It is beyond doubt that UK abortion services have been one of the few winners of the pandemic. Whilst services were beset with challenges in the first wave, and staff shortages and clinic closures threatened services with collapse, providers were quick to adapt. The first medications for telemedical abortion were posted out within just ten days of government approval.

The incorporation of telemedicine into mainstream abortion services in the UK has been the most revolutionary service-change since the advent of medical abortion in the early 1990s. New research shows that ‘no-test’ abortion services are safe, effective2, and crucially, acceptable to patients. Patient satisfaction is very high, and a large majority of service-users would opt to have an abortion by telemedicine again, even outside of a pandemic.3-5

The shift to telemedicine has required a total step-change. Abortion providers have undergone massive upheaval, as they contend with decisions about what care they can sustainably provide in the context of economic uncertainty, how to protect their staff and patients against COVID-19 infection, and how to future-proof their organisations going forwards. For some this has meant closing clinic doors for the final time and making long-serving, dedicated staff redundant. All these decisions are being made whilst we are still unsure whether telemedical services will become a permanent fixture when the sun sets on the emergency COVID regulations.

Currently, the majority of patients seeking abortion care under ten weeks’ gestation will be offered a no-test telemedical abortion. The aforementioned research suggests that a very large proportion will be satisfied with their care, and they would probably choose to have their abortion this way should they need abortion care again. However, we know that there will always be a cohort of patients who providers need to see in the clinic. This includes people at a higher risk of an ectopic pregnancy and where there are safeguarding concerns, and providers have accommodated their needs since the introduction of telemedical services.  In addition to these patients, there will be people who want in-clinic care for a whole host of other reasons – be that because they had a good surgical abortion previously, or because they want to access post-abortion contraception that cannot be sent in the post.

The big question for providers is how to balance a sustainable service that meets the greatest number of people’s needs during the pandemic and beyond against meeting people’s individual preferences. NICE, the WHO, and the RCOG all advocate for patients being able to choose what sort of abortion to have. Offering a range of methods that patients can choose from is currently best practice, but we know that in reality these ‘choices’ are already guided by factors such as what is clinically appropriate for a patient, appointment availability, and clinicians’ skillsets. It is perhaps fairer to frame such choices as ‘preferences’ that providers aim to meet where they can.

So where does this leave telemedical abortion services? Should they become the default treatment for patients who are eligible? The recommendation for offering patients a choice over what sort of abortion they want to have still stands, and for many patients under ten weeks’ gestation, we predict that they will choose to have a no-test telemedical abortion at home. But in-clinic options must remain available, not just for those who are ineligible for telemedicine, but for patients who have looked at their options and decided that in-clinic treatment best meets their needs.

Just as we have made abortion-at-home a safe and effective option for patients, we must ensure that in-clinic abortion care is an option that remains available to all who want it. Let the pandemic help us to build a bigger and bolder architecture of choice in abortion care.

References:

  1. Blaylock R, Makleff S, Whitehouse KC, Lohr PA. Client perspectives on choice of abortion method in England and Wales. BMJ Sexual & Reproductive Health. Published Online First: 20 September 2021. Available from: doi:10.1136/bmjsrh-2021-201242 [Accessed: 3rd October 2021].
  2. Aiken ARA, Lohr PA, Lord J, Ghosh N, Starling J. Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study. BJOG.2021; 128: 1464– 1474.
  3. Porter Erlank C, Lord J, Church K. Acceptability of no-test medical abortion provided via telemedicine: analysis of patient-reported outcomes. BMJ Sexual & Reproductive Health. Published Online First: 18 February 2021. Available from: doi:10.1136/bmjsrh-2020-200954 [Accessed: 24th February 2021].
  4. Reynolds-Wright JJ, Johnstone A, McCabe K, Evans E, Cameron S. Telemedicine medical abortion at home under 12 weeks’ gestation: a prospective observational cohort study during the COVID-19 pandemic. BMJ Sexual & Reproductive Health. Published Online First: 04 February 2021. Available from: doi:10.1136/bmjsrh-2020-200976 [Accessed: 24th February 2021].
  5. Meurice M, Whitehouse KC, Blaylock R, Chang J, Lohr PA. Client satisfaction and experience of telemedicine and home use of mifepristone and misoprostol for abortion up to 10 weeks’ gestation at British Pregnancy Advisory Service: A cross-sectional evaluation. Contraception. 2021;104(1):61-66.

 

Read more: Client perspectives on choice of abortion method in England and Wales

Rebecca Blaylock is the Research and Engagement Lead at the Centre for Reproductive Research and Communication, British Pregnancy Advisory Service (BPAS). She is also a UK Trainee Editor at the BMJ SRH.

Dr Shelly Makleff is a Research Fellow at Global and Women’s Health, Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences at Monash University.

Rebecca and Shelly would like to thank the study’s co-authors, Dr Kate Whitehouse and Dr Patricia Lohr, both at BPAS. For more information on their work please visit their website and follow them on Twitter.

 

 

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