Online access to abortion medications: a review of utilization and clinical outcomes

Foregrounding pain in self-managed early medication abortion: a qualitative study

OBJECTIVE

To explore experiences of pain in the context of early medical abortion (EMA) in the UK and to guide best practice around anticipatory guidance on pain.

METHODS

From late 2020 to early 2021, we recruited individuals from across the UK who had undergone abortion during the COVID-19 pandemic to participate in in-depth, semi-structured telephone interviews. A storytelling approach was used and data were analysed thematically using NVivo 12 software.

RESULTS

Focused coding and thematic analysis addressed accounts of pain, which were prominent in many interviews. We constructed the following subthemes: expected pain is manageable for some; the problem with unexpected pain; pain (co)produces fear; and problematising 'period-like pain'. The key issue which our analysis draws out is that while EMA pain experience might vary, for some it may be much worse than anticipated. Moreover, the common trope of likening it to 'period pain' can be misleading and a source of additional uncertainty at a potentially already challenging time.

CONCLUSIONS

For some individuals, pain experienced in EMA will be severe and/or worse than expected. Insufficient preparation for pain can result in extremely negative experiences of EMA. Alongside development of improved analgesia, improvements should be made to anticipatory guidance on pain, particularly for those self-manging EMA at home. Framings of 'period-like pain' do not clarify expectations and should be avoided.

'The abortion gave me my life back': the long-term impact of access to self-managed medication abortion through telemedicine on women's lives in legally restricted countries

Approximately 753 million women (38%) of reproductive age live in countries with restrictive abortion laws. To overcome these legal constraints, women access safe self-managed medication abortions through telemedicine abortion services. This study aimed to explore the long-term impact of accessing a self-managed medication abortion through telemedicine service on women's lives in countries with restrictive abortion laws. We conducted interviews with eleven women (from eleven different countries) who accessed a self-managed medication abortion through online telemedicine between 2014 and 2018 in a legally restricted country. We analysed interviews thematically. Three key themes were developed: (1) access to abortion positively impacted life plans; (2) the negative influence of the legally restricted environment wore off and their well-being improved; (3) participants are now using their own experiences to help others by either sharing information or facilitating access to abortion. In summary, our findings highlight the positive impact of access to self-managed medication abortion and underline the importance of ensuring access to abortion for everyone.

Primary care and abortion provider perspectives on mail-order medication abortion: a qualitative study

BACKGROUND

This qualitative study aims to assess perspectives of clinicians and clinic staff on mail-order pharmacy dispensing for medication abortion.

METHODS

Participants included clinicians and staff involved in implementing a mail-order dispensing model for medication abortion at eleven clinics in seven states as part of a prospective cohort study, which began in January 2020 (before the FDA removed the in-person dispensing requirement for mifepristone). From June 2021 to July 2022, we invited participants at the participating clinics, including six primary care and five abortion clinics, to complete a semi-structured video interview about their experiences. We then conducted qualitative thematic analysis of interview data, summarizing themes related to perceived benefits and concerns about the mail-order model, perceived patient interest, and potential barriers to larger-scale implementation.

RESULTS

We conducted 24 interviews in total with clinicians (13 physicians and one nurse practitioner) and clinic staff (n = 10). Participants highlighted perceived benefits of the mail-order model, including its potential to expand abortion services into primary care, increase patient autonomy and privacy, and to normalize abortion services. They also highlighted key logistical, clinical, and feasibility concerns about the mail-order model, and specific challenges related to integrating abortion into primary care.

CONCLUSION

Clinicians and clinic staff working in primary care and abortion clinics were optimistic that mail-order dispensing of medication abortion can improve the ability of some providers to provide abortion and enable more patients to access services. The feasibility of mail-order pharmacy dispensing of medication abortion following the Supreme Court Dobbs decision is to be determined.

TRIAL REGISTRATION

Registry: Clinicaltrials.gov.

TRIAL REGISTRATION NUMBER

NCT03913104. Date of registration: first submitted on April 3, 2019 and first posted on April 12, 2019.

Social connectedness and supported self-management of early medication abortion in the UK: experiences from the COVID-19 pandemic and learning for the future

Medication abortion has been established globally as safe and effective. This modality has increased accessibility and the opportunity to centre individual autonomy at the heart of abortion care, by facilitating self-managed abortion. Previous research has shown how self-managed abortion is beneficial in myriad settings ranging from problematic to (relatively) unproblematic contexts of access. In this paper we explore the relationship between self-management and sources of support (including health professionals, family, and friends); as well as considering issues of reproductive control and autonomy. Drawing on qualitative, experience-centred interviews, we utilise the concept of social connectedness to examine how supported self-managed abortion was experienced in the United Kingdom during the COVID-19 pandemic. Overall, self-management was welcomed, with participants speaking positively about managing their own abortion at home. However, a sense of connectedness was crucial in helping participants deal with difficult experiences; and functioned to support individual autonomy in self-care. This paper is the first to examine factors of connection, support, and isolation, as experienced by those undergoing self-managed abortion in the UK in detail. Our research suggests a continued need to advocate for high quality support for self-managed abortion, as well as for choice of abortion method, to support patient-centered care.

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.

Self-managed abortion via the internet: Analysis of one year of service delivery data from Women Help Women

Background: To better comprehend the demand for online medication abortion and to inform service delivery practice, we conducted an analysis of Women Help Women (WHW) service delivery statistics. The primary goals were to understand their user profile, evaluate self-reported outcomes and use of other medical services, and assess the overall experience both with the abortion itself and with the counseling and care provided by WHW. Methods: We retrospectively evaluated user characteristics, abortion outcomes, and acceptability of both the medication abortion and WHW’s services, using consultation data and corresponding evaluation data from a one-year period. For users who did not complete the evaluation form, WHW staff reviewed email correspondences to identify key outcomes. Results: From August 2016-July 2017, 3,307 individuals received abortion pills from WHW. Users were geographically located in thirty countries and correspondence was conducted in seven languages. Most reported their gestational age to be less than eight weeks. Of the 2,295 who took the pills and provided outcome information, almost all (99.1%, n=2275) reported that they were no longer pregnant. The majority (84.1%, n=1576/1875) used symptoms to confirm outcome; one fourth (22.8%, n=428) sought an ultrasound and one sixth (18.0%, n=338) used urine and/or serum testing. One in eight users (12.6%, n=292/2317) reported seeking additional medical care after taking the abortion pills. Most (87.5%, n=1551/1773) reported being satisfied or very satisfied with the abortion. Conclusions: Our study confirms that self-managed abortion is a process that people can do safely and effectively with community support and without medical supervision. In the context of a global backlash against abortion rights, self-managed abortion is an integral part of a spectrum of options for abortion care that must be made available to all.

Higher readability of institutional websites drives the correct fruition of the abortion pathway: A cross-sectional study

Background

In Italy, abortion services are public: therefore, health Institutions should provide clear and easily readable web-based information. We aimed to 1) assess variation in abortion services utilisation; 2) analyse the readability of institutional websites informing on induced abortion; 3) explore whether easier-to-read institutional websites influenced the correct fruition of abortion services.

Methods

We identified from the 2021 administrative databases of Tuscany all women having an abortion, and–among them–women having an abortion with the certification provided by family counselling centres, following the pathway established by law. We assessed variation in total and certified abortion rates by computing the Systematic Component of Variation. We analysed the readability of the Tuscan health authorities’ websites using the readability assessment tool READ-IT. We explored how institutional website readability influenced the odds of having certified abortions by running multilevel logistic models, considering health authorities as the highest-level variables.

Results

We observed high variation in the correct utilization of the abortion pathway in terms of certified abortion rates. The READ-IT scores showed that the most readable text was from the Florence Teaching Hospital website. Multilevel models revealed that higher READ-IT scores, corresponding to more difficult texts, resulted in lower odds of certified abortions.

Conclusions

Large variation in the proper fruition of abortion pathways occurs in Tuscany, and such variation may depend on readability of institutional websites informing on induced abortion. Therefore, health Institutions should monitor and improve the readability of their websites to ensure proper and more equitable access to abortion.

A qualitative study of abortion care providers' perspectives on telemedicine medical abortion provision in the context of COVID-19

BACKGROUND

Telemedicine for medical abortion care was rapidly introduced in Great Britain in response to the COVID-19 pandemic. A growing body of literature demonstrates that telemedicine abortion care is safe, effective and highly acceptable to patients. Less is known about the perspectives of abortion care providers (ACPs).

METHODS

Qualitative research within the telemedicine abortion service in Lothian (Edinburgh and surrounding region), UK. We conducted qualitative in-depth interviews with ACPs between May and July 2020 (doctors, n=6; nurses, n=10) and analysed the data thematically.

RESULTS

We present three themes from our qualitative analysis: (1) Selective use of ultrasound - the move away from routine ultrasound for determination of gestational age was generally viewed positively. Initial anxiety about non-detection of ectopic pregnancy and later gestations was expressed by some ACPs, but concerns were addressed through clinical practice and support structures within the clinic. (2) Identifying safeguarding issues - in the absence of visual cues some ACPs reported concerns about their ability to identify safeguarding issues, specifically domestic violence. Conversely it was acknowledged that teleconsultations may improve detection of this in some situations. (3) Provision of information during the consultation - telephone consultations were considered more focused than in-person consultations and formed only part of the overall 'package' of information provided to patients, supplemented by online and written information.

CONCLUSIONS

ACPs providing telemedicine abortion care value this option for patients and believe it should remain beyond the COVID-19 pandemic. Safeguarding patients and the selective use of ultrasound can be initially challenging; however, with experience, staff confidence improves.

Locating Autonomous Abortion Accompanied by Feminist Activists in the Spectrum of Self-Managed Medication Abortion

Diverse models of self-managed medication abortion exist-ranging from some interaction with medical personnel to completely autonomous abortion. In this commentary, we propose a new classification of self-managed medication abortion and describe the different modalities. We highlight autonomous abortion accompanied by feminist activists, called "acompañantes," as a community- and rights-based strategy that can be a safe alternative to clinical abortion services in clandestine as well as legal settings. To improve access, abortion needs to be decriminalized and governments must acknowledge and facilitate the diversity of safe abortion options so women may choose where, when, how, and with whom to abort.

Law, human rights and gender in practice: an analysis of lessons from implementation of self-care interventions for sexual and reproductive health

Self-care interventions for health are becoming increasingly available, and among the preferred options, including during the COVID-19 pandemic. This research assessed the extent of attention to laws and policies, human rights and gender in the implementation of self-care interventions for sexual and reproductive health (SRH), to identify where additional efforts to ensure an enabling environment for their use and uptake will be useful. A literature review of relevant studies published between 2010 and 2020 was conducted using PubMed, Scopus and Web of Science. Relevant data were systematically abstracted from 61 articles. In March–April 2021, semi-structured interviews were conducted with 10 key informants, selected for their experience implementing self-care interventions for SRH, and thematically analysed. Laws and policies, rights and gender are not being systematically addressed in the implementation of self-care interventions for SRH. Within countries, there is varied attention to the enabling environment including the acceptability of interventions, privacy, informed consent and gender concerns as they impact both access and use of specific self-care interventions, while other legal considerations appear to have been under-prioritised. Operational guidance is needed to develop and implement supportive laws and policies, as well as to ensure the incorporation of rights and gender concerns in implementing self-care interventions for SRH.

The Critical Role of Midwives in Safe Self-Managed Abortion

As access to legal abortion in the United States becomes more complex, there is increasing interest in self-managed abortion. Choosing to seek abortion care outside the clinical setting can also help people marginalized or harmed by existing health care systems to access needed care in a way that feels safe and empowering. However, patients and midwives alike often have a lack of information about expected outcomes and potential complications that may arise, as well as how to manage these in a health care system that may make appropriate follow-up difficult to access if needed. This article discusses patient education as a harm-reduction approach, and reviews ways that midwives may strategically and ethically participate in this patient education need. As trusted health care providers who are expert in pregnancy and reproductive health, midwives are ideally positioned to meet patient knowledge needs around self-managed abortion.

"No one should be alone in living this process": trajectories, experiences and user's perceptions about quality of abortion care in a telehealth service in Chile

Self-managed abortion is a common self-care practice that enables pregnant people to exercise their rights to health, bodily autonomy and to benefit from the advances of science even when living in contexts that do not guarantee these rights. In this interpretative qualitative study, we aimed to understand women’s abortion trajectories, experiences with self-managed abortion and assessments of the quality of care provided by Women Help Women (WHW, an international activist non-profit organisation working on abortion access). Grounded in feminist epistemology and health inequalities approaches, we conducted eleven semi-structured interviews in Santiago, Chile. We found that illegality, stigma and expectations surrounding motherhood and abortion determined women’s experiences. Participants perceived the WHW service as good, trustworthy, fast and affordable, and valued confidentiality and privacy; the quantity and quality of information; having direct, personalised and timely communication with service staff; being treated with respect; and feeling safe, cared for and supported in their decisions. Most participants considered self-managed abortion appropriate and acceptable given their circumstances. Fear was the dominant feeling in women’s narratives. Some participants mentioned missing instant communication, in-person support and professional care. We conclude that support, information and company are key to improving abortion seekers’ experiences and enabling their decisions, particularly in legally restrictive settings. Centring care in pregnant people’s needs and autonomy is fundamental to ensure safe, appropriate and accessible self-care interventions in reproductive health. Social and legal changes, such as public funding for abortion, destigmatisation and decriminalisation, are needed to realise people’s right to higher standards of healthcare.

Accessing abortion outside jurisdiction following legalisation of abortion in the Republic of Ireland

BACKGROUND

After having one of the most restrictive abortion laws worldwide, Ireland legalised abortion in January 2019. We examine how legalisation impacted on demand for online telemedicine outside the jurisdiction.

METHODS

We analysed anonymised data from 534 people from Ireland seeking online telemedicine abortion prior to legalisation (January-March and October-December 2018) and in the first 3 months following legalisation (January-March 2019). Numbers, characteristics and reasons for seeking the service before and after legalisation were compared. Content analysis of emails from people seeking the service following legalisation explored reasons for seeking care.

RESULTS

Half as many people contacted Women on Web in the 3 months immediately after legalisation as compared with contacts 12 months prior (103 vs 221). Of these, the proportion receiving the service reduced, from 72% prior to legalisation to 26% after legalisation (p≤0.001). After legalisation, access related reasons for seeking online telemedicine featured less while reasons relating to privacy, stigma and avoiding protestors featured more.

CONCLUSIONS

People continued to seek abortion through online telemedicine after legalisation, though the number of contacts reduced by half and the proportion receiving the service decreased considerably. To address access issues, policy measures should promote normalisation of abortion, legislate for safe zones around providers, and consider access in situations of coercive control or abuse including the role of telemedicine in the local model of care. Abortion provided through online telemedicine continues to be an important part of providing safe, accessible abortion even after legalisation.

Family medicine provision of online medication abortion in three US states during COVID-19

OBJECTIVE

To examine provision of direct-to-patient medication abortion during COVID-19 by United States family physicians through a clinician-supported, asynchronous online service, Aid Access.

STUDY DESIGN

We analyzed data from United States residents in New Jersey, New York, and Washington who requested medication abortion from 3 family physicians using the online service from Aid Access between April and November 2020. This study seeks to examine individual characteristics, motivations, and geographic locations of patients receiving abortion care through the Aid Access platform.

RESULTS

Over 7 months, three family physicians using the Aid Access platform provided medication abortion care to 534 residents of New Jersey, New York, and Washington. There were no demographic differences between patients seeking care in these states. A high percentage (85%) were less than 7 weeks gestation at the time of their request for care. The reasons patients chose Aid Access for abortion services were similar regardless of state residence. The majority (71%) of Aid Access users lived in urban areas. Each family physician provided care to most counties in their respective states. Among those who received services in the three states, almost one-quarter (24%) lived in high Social Vulnerability Index (SVI) counties, with roughly one-third living in medium-high SVI counties (33%), followed by another quarter (26%) living in medium-low SVI counties.

CONCLUSIONS

Family physicians successfully provided medication abortion in three states using asynchronous online consultations and medications mailed directly to patients.

IMPLICATIONS

Primary care patients are requesting direct-to-patient first trimester abortion services online. By providing abortion care online, a single provider can serve the entire state, thus greatly increasing geographic access to medication abortion.

Women's experiences of a telemedicine abortion service (up to 12 weeks) implemented during the coronavirus (COVID-19) pandemic: a qualitative evaluation

Objective

To explore the experiences of women in Scotland who accessed medical abortion at home up to 12 weeks’ gestation, delivered via a telemedicine abortion service implemented in response to the coronavirus (COVID‐19) pandemic, to identify areas for improvement and inform service provision.

Design

Qualitative interview study.

Setting

Abortion service in one National Health Service health board in Scotland.

Population or sample

Twenty women who accessed telemedicine abortion services and self‐administered mifepristone and misoprostol at home up to 12 weeks’ gestation.

Methods

Thematic analysis of semi‐structured qualitative interviews, informed by the Framework analytic approach.

Main outcome measures

Women’s experiences of accessing telemedicine for medical abortion at home, specifically: acceptability of the telephone consultation and remote support; views on no pre‐abortion ultrasound scan; and self‐administration of abortion medications at home.

Results

Novel study findings were three‐fold: (1) participants valued the option of accessing abortion care via telemedicine and emphasised the benefits of providing a choice of telephone and in‐person consultation to suit those with different life circumstances; (2) the quality of abortion care was enhanced by the telemedicine service in relation to access, comfort and flexibility, and ongoing telephone support; (3) participants described being comfortable with, and in some cases a preference for, not having an ultrasound scan.

Conclusions

This research demonstrates support for the continuation of telemedicine abortion services beyond the temporary arrangements in place during COVID‐19, and lends weight to the argument that offering the option of telemedicine abortion care can enable women to access this essential health service.

Tweetable abstract

#Telemedicine provision of medical #abortion at home up to 12 weeks’ gestation is acceptable and highly valued by #women #Research #SRHR @nbw80 @doctorjjrw @jeniharden @cameronsharon @mrc_crh @edinuniusher.

#Telemedicine provision of medical #abortion at home up to 12 weeks’ gestation is acceptable and highly valued by #women #Research #SRHR @nbw80 @doctorjjrw @jeniharden @cameronsharon @mrc_crh @edinuniusher.

This article includes Author Insights, a video abstract available at: https://vimeo.com/bjog/authorinsights16813

10-year evaluation of the use of medical abortion through telemedicine: a retrospective cohort study

OBJECTIVE

To provide a descriptive overview and evaluate changes in the use and outcome of abortions provided worldwide by telemedicine in the past 10 years.

DESIGN

Retrospective cohort study.

SETTING

Multi-country.

POPULATION/SAMPLE

30 344 women who completed the follow-up survey of the telemedical abortion service Women on Web from January 2009 till January 2020.

METHODS

Analyses of follow-up surveys, binary logistic regressions to test the association between year and outcomes.

MAIN OUTCOME MEASURES

Rate of complete abortions, surgical interventions, ongoing pregnancies, blood transfusions per year, socio-economic situation, knowledge on medical abortion, acceptability of receiving service, appropriateness of method and the likelihood of recommending the service to a friend.

RESULTS

Medical abortions were provided to 81 683 women, of whom 30 344 (37.2%) completed the follow-up survey. In total, 26 076 women reported doing the medical abortion, of whom 1.5% reported an ongoing pregnancy, 10.2% a surgical intervention and 0.6% a blood transfusion. Acceptability of the service was 99%, and 59.2% of the users reported previous knowledge of medical abortion. We found a significant increase in complete abortions in 2019 (odds ratio 1.92; 95% CI 1.59-2.31) and decrease in surgical interventions (odds ratio 0.49; 95% CI 0.40-0.60) compared with 2009.

CONCLUSION

Low follow-up rates present a limitation in analysing trends in telemedical abortion usage. However, our findings suggest that it is a highly acceptable method around the world and that there has been an increase in complete abortions by telemedical abortions and a decrease in surgical interventions in the last 10 years.

TWEETABLE ABSTRACT

In the last 10 years, there has been an increase in complete abortions and decrease in surgical interventions of telemedical abortion.

First Trimester Abortion Care in Low- and Middle-Income Countries

Access to first trimester abortions has increased significantly in the past few decades in low and middle-income countries. Manual vacuum aspiration is now standard of care for procedural abortion and postabortion care. Medication abortion has shifted abortions to being performed earlier in pregnancy and is becoming more widely available with new service delivery strategies to broaden access. Widespread availability of misoprostol has made abortions induced outside of the formal medical sector overall safer. In both legally restrictive and supportive environments, there is increased interested in self-managed abortions as part of a shift towards demedicalizing abortion through task-sharing.

Microcrystalline Cellulose and Crospovidone Identified in Placentas With Vaginal Misoprostol Use

Misoprostol is a prostaglandin analog commonly used to induce termination of pregnancy. Clandestine home terminations complicate forensic fetal autopsy when a history of misoprostol use is withheld and the gross and histologic findings are sparse, as is often the case. One hundred thirty-two placentas with no vaginal misoprostol use, low-dose misoprostol use, and high-dose misoprostol use were reviewed for the presence, volume, and locations of microcrystalline cellulose and crospovidone, common tablet fillers in misoprostol tablets. Microcrystalline cellulose and/or crospovidone was identified in 0 (0%) of 88 cases with no vaginal administration or low-dose vaginal administration and 29 (66%) of 44 placentas with high-dose vaginal administration. When identified, microcrystalline cellulose and/or crospovidone is most commonly present on the maternal surfaces of the extraplacental membranes. The presence of microcrystalline cellulose and/or crospovidone was associated with smaller placental weight (Mann-Whitney U, P = 0.019). These fillers have a reasonable sensitivity for high-dose vaginal tablet use and are very specific. Although they are not diagnostic for misoprostol administration, they provide a finding that may prompt additional investigation into the nature of the vaginal tablet administered and the circumstances surrounding birth.