By Ilaria Bertini
The 30th of March 2021 marks an year since the UK Government implemented the new guidelines on medical abortion in response to the COVID-19 pandemic. Thanks to the use of telemedicine women’s homes have been approved as a class of place for both stages of early medical abortion (EMA up to 10 weeks of pregnancy). According to the new regulations, in-person appointments – to discuss the reasons for considering an abortion and the methods available to perform one – have been replaced by phone or video calls. An ultrasound to date exactly and locate the pregnancy is offered only in particular cases whereas before the pandemic it was routinely performed. Finally, the medications (two pills, mifepristone and misoprostol) to terminate the pregnancy are either posted to the woman’s home or collected from the nearest pharmacy or clinic. Before, the first pill was administered in the clinic under the supervision of a healthcare professional, while the second could be taken at home.
In order to assess the success of this new policy, the period running between April and June 2020 has been under strict scrutiny from the Government and stakeholders. The results recently appeared in a study whose main purpose was to assess whether this temporary measure should be made permanent.
The study includes 85% of all medical abortions provided in England and Wales during the first six months of 2020. It compares the total EMAs carried out under the old system between the 1st of January and the 1st of March 2020 (22,158) and the EMAs performed between the 6th of April and the 30th of June (29,984) when the new guidelines came into force. The latter cohort has been divided into two subgroups: the first one comprises the EMAs provided via telemedicine only (18,435/ 61%) while the second includes the EMAs carried out in-person (11,549/ 39%).
Overall, the research shows wider access to abortion in terms of numbers in three respects, although the fact that the authors were unable to actively follow-up patients post-abortion might significantly undermine the usefulness of the statistics.
First of all, telemedicine has reduced waiting times because there is no need to attend a clinic in person and medications can be delivered more “efficiently.” In fact, both pills can be despatched to the home as soon as a phone/video call assessment envisages no risks related to the woman gestational age or to a potential ectopic pregnancy. The first risk is ruled out if the patient can provide the date of the last menstrual period (LMP). The second is ruled out if none of the following applies: an history of ectopic pregnancy, an intrauterine device at the time of conception, abdominal pain or a known problem in the Fallopian tubes.
On the one hand, the study reports few cases of later than expected gestational age and undiagnosed ectopic pregnancy that would have been ruled out under the former system. On the other hand, the improved access would reflect a falling rate in women seeking abortion medication illegally. Now the question is whether women, who would have turned elsewhere to terminate their pregnancy, have found a new “legal short cut” that leaves them still emotionally and physically in the dark or whether they have found a service that supports them from the choice to get an abortion up to post-abortion care.
The second finding relates to the falling of gestational age at the time of the abortion. The authors relate this phenomenon both to reduced waiting times and to a possible change in behaviour prompted by the COVID-19 pandemic. In fact, discovering an unplanned pregnancy in the midst of a global pandemic, which has introduced additional fear and uncertainty about the future, can make abortion seem the only viable option. However, a rush decision is not always a good decision, in particular if driven by anxiety and loneliness. Emotions that sometimes can be spotted only under the gaze of a fellow human being who can walk the patient through a clear decision-making process.
Finally, the research emphasized the fact that vulnerable women would certainly benefit from easier access to medical abortions. Everything can be sorted in one call. However, the question is whether a vulnerable woman seeking a termination of pregnancy needs just an efficient service or needs looking after. The National Institute for Health and Care Excellence (NICE) offers clear guidelines for healthcare providers in order to coordinate a care plan for pregnant women with complex social factors. In fact, it points out that some women may need extra [support] because of their personal circumstances, such as problems with alcohol or drugs, or because they have a violent partner or family member. It also emphasizes the importance of in-person appointments with a doctor or midwife because they can provide the best opportunity for the woman to disclose difficult circumstances to a third person. And in this case, the NICE guidelines recommend offering longer and additional appointments to give the patient more time to talk about the problems she is experiencing in order to get the right help and support. The question is then whether the new policy on medical abortion merely digs a deeper trench around vulnerable women leaving them with a second-class plan of treatment and ultimately without a chance of getting the help and support they deserve. Unfortunately, not being able to follow up on the patients who had an EMA under the new regulations leaves all these questions unanswered.
Author(s): Ilaria Bertini
Affiliations: Research Fellow Bios Centre (London, UK)
Competing interests: None
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