2020 developments in the provision of early medical abortion by telemedicine in the UK

Should we Relax Abortion Reporting Requirements in Great Britain?

In Great Britain, abortion has long proven to be contentious in the context of policy making, with it remaining a criminal offence. Despite progress over the last decade to permit home use of abortion medications and remote consultation, we have seen prosecutions in recent years. Regulatory frameworks such as this have been framed as 'abortion exceptionalism', such that termination of pregnancy is far more tightly regulated than comparable healthcare. One example of this exceptionalism is the strict abortion reporting requirements found in Great Britain. Per these requirements, any doctor providing abortion care must notify the relevant Chief Medical Officer or Public Health Scotland of each and every termination, including a startling amount of information about the patient. The extent of these requirements raises serious questions in relation to patient confidentiality and is, I suggest, an outlier in these terms. Further, it is questionable whether such reporting can be in any way said to be in the public interest. I begin by outlining the Abortion Regulations 1991, which apply in England and Wales, before considering the updated Scottish approach brought about by the Abortion (Scotland) Amendment Regulations 2021. I then move to examine the abortion reporting requirements against our general conception of patient confidentiality, highlighting the discordance. I ultimately argue that the requirements are not adequately justified and represent yet another, often forgotten, example of abortion exceptionalism in Great Britain. Thus, I suggest that all three nations that comprise Great Britain ought to further revise their approach to abortion data.

[Innovation in abortion care during the COVID-19 pandemic in Germany, France and Great Britain : Paths to maintaining access and building system resilience]

The COVID-19 pandemic has had a drastic impact on healthcare systems. They had to react, adapt and innovate in order to build resilience, that is maintain healthcare access and health equity. For example, access to abortion services during the pandemic was increasingly facilitated through "Telehealth for Early Medical Abortion" (TEMA).This narrative review article compares Germany, France and Great Britain in terms of abortion numbers, methods and settings from 2018 to 2023. Changes in the availability of services and legislation during the pandemic are presented, and the differences between the countries, as well as various innovation factors, are discussed. We used national statistics and conducted a literature and online search (Rapid Review).In the three countries, there are differences in abortion rates, the share of medical abortions and the impact of the pandemic. In France and Great Britain, where medical abortion is the main method of abortion and where abortion care was more accessible before the pandemic than in Germany, a series of innovations were officially introduced to facilitate access during the pandemic. They included teleconsultations and the mailing of abortion medication. Most changes have been sustained since then, contributing to addressing historic and systemic health inequities in terms of access. In Germany, innovations during the pandemic have been crafted mainly by civil society organisations, offering for the first time teleabortion services.The COVID-19 pandemic provoked or accelerated innovation in terms of abortion care in France, Germany and Great Britain. The sustainability and scaling-up of those innovations remain fragile, especially in Germany, where the disruptive approach of civil society organisations has not yet found its way into mainstream healthcare services.

"All hands on deck": a qualitative study of safeguarding and the transition to telemedical abortion care in England and Wales

The COVID-19 pandemic raised significant challenges for in-person healthcare provision, leading healthcare providers to embrace digital health like never before. Whilst changes were made as part of a public health response, many have now become permanent fixtures of the healthcare landscape, significantly altering the way care is provided not only for patients, but also for the healthcare professionals that provide care. In abortion care in England and Wales, previously stringent regulations on in-person care provision were relaxed to permit the use of telemedicine and self-administration of medications at home. These changes have since been made permanent. However, there remains opposition to remote abortion care pathways on the basis of safeguarding. Opponents argue that it is not feasible to effectively safeguard patients accessing abortion care remotely. We conducted a qualitative study using semi-structured interviews with abortion care providers in England and Wales. Participants were asked about their views and experiences of the transition to remote care provision, with a particular focus on how they adapted their safeguarding practice. In this article, we present three themes that highlight the changing roles of healthcare professionals in abortion care: (1) a challenging backdrop and resulting apprehension, (2) adaptive practices, and (3) the continued importance of professional curiosity. Across all three themes, participants reflected significantly on how changes were made and what they experienced in the period of transition to telemedicine. In particular, they discussed the changing nature of their professional roles amidst digitalisation. Our findings provide a basis for reflection on the increasing introduction of digital approaches to healthcare provision, highlighting points for caution and emphasising the need to involve professionals in the transition process to ensure vital buy-in. Through this, we articulate two novel understandings of digitalisation: (1) the impact of speed-associated pressures on professional adaptation during digitalisation, and (2) off-proforma safeguarding through telemedicine as a form of invisible non-routine work.

Medication abortion during the COVID-19 pandemic in France: A research based on the French national health insurance database

OBJECTIVES

During the COVID-19 pandemic in France, abortion was recognized as an essential service that cannot be delayed, and such care was therefore presumed to be maintained. The aim is to analyze the changes in the practice of abortion in 2020 to identify the consequences of the two lockdowns and the effects of the extension of the legal time limit.

METHODS

We analyzed the data collected by the French national health insurance system, which covers 99% of the population. All women who had an elective abortion, either surgical or with medication, in France in 2019 and 2020 were included in the study. Trend changes in abortions were analyzed by comparing the ratio of the weekly number of abortions in 2020 with the weekly number in 2019.

RESULTS

Both 2020 lockdowns were followed by a drop in abortions, particularly after the first and stricter lockdown. This may be explained not by an abrupt shutdown of access to abortion services, but rather by a decrease in conceptions during the lockdown weeks. The decrease was more marked for surgical abortions than for medication abortions in a hospital setting, and less so for medication abortions in non-hospital settings. Moreover, the proportion of the latter type of abortions continued to increase, showing the reinforcement of a previous trend.

CONCLUSIONS

Our findings indicate that expanding the legal time limit for abortion, diversifying the settings where abortions can be performed and the range of abortion providers help to facilitate access to this fundamental reproductive care.

Early telemedical abortion, safeguarding, and under 18s: a qualitative study with care providers in England and Wales

BACKGROUND

Telemedical early medical abortion (TEMA) was introduced in England and Wales as a temporary measure in 2020 and was made permanent in 2022. While there are considerable data showing the safety, efficacy, and acceptability of TEMA for patients, there have been objections raised to TEMA based on safeguarding-particularly for people under 18 years of age. Little is known about abortion care providers' views and experiences of carrying out their safeguarding duties with people aged under 18 in the shift to TEMA.

METHODS

This is a qualitative study involving online semi-structured interviews and reflexive thematic analysis. Audio-recorded, semi-structured interviews with abortion providers in England and Wales (n=20) generated data about their views and experiences of safeguarding in telemedical abortion care. Recordings were transcribed verbatim and then subject to reflexive thematic analysis to construct themes.

RESULTS

While the study was designed with adult safeguarding in mind, the safeguarding of under 18s became a key area of discussion. Three major themes were constructed in relation to under 18s: (1) age as a risk factor in safeguarding; (2) telemedicine as improving access to care; and (3) telemedicine as enhancing communication.

CONCLUSION

Care providers believe TEMA has benefitted the under 18s. There was a strong feeling both that TEMA had improved access (which, in turn, improved safeguarding) and that under 18s were comfortable communicating using remote means. Providers believe safeguarding proformas must account for the different nature of risks where service users are under 18, but that it is disproportionate to assume that TEMA is unsuitable for all under 18s or groups of under 18s.

Abortion Access and the Benefits and Limitations of Abortion-Permissive Legal Frameworks: Lessons from the United Kingdom

This paper argues that abortion access is an important subject for bioethics scholarship and reflects on the relationship between legal frameworks and access to care. The author uses the example of the United Kingdom to examine the benefits and limitations of abortion-permissive legal frameworks in terms of access. These are legal frameworks that enable the provision of abortion but subject to restrictions. An abortion-permissive regime-first in Great Britain and then in Northern Ireland-has gone some way to improving access to care over time. However, aspects of the regime (that lead to its description as permissive rather than supportive of abortion) have the potential to endanger abortion access in the future and so legal reform is necessary.

Improvidence, Precaution, and the Logical-Empirical Disconnect in UK Health Policy

The last decade has seen significant developments in UK health policy, with are largely claimed to be evidence based. However, such a characterisation ought, in many cases, to be questioned. Policies can be broadly understood as based primarily on either a logical or empirical case. In the absence of relevant empirical evidence, policymakers understandably appeal to logical cases. Once such evidence is available, however, it can inform policy and enable the logical case to be set aside. Such a linear policy process is not always the reality, and logical cases often continue to guide policy decisions in direct opposition to empirical evidence. In this paper, I discuss two recent examples of this disconnect between logical and empirical cases in UK health policy. The first-organ donation-illustrates an example of a significant policy change being made in opposition to the evidence. I refer to this as the improvidence approach. The second-abortion-provides an example of policymakers not making a change that has extensive supporting data. I refer to this using the more recognisable language of the precautionary approach. Ultimately, I argue that both the improvidence and precautionary approaches are examples of problematic public policy where policymakers provide no explicit justification for going against the evidence.

COVID-19 health policy evaluation: integrating health and economic perspectives with a data envelopment analysis approach

The COVID-19 pandemic is a global challenge to humankind. To improve the knowledge regarding relevant, efficient and effective COVID-19 measures in health policy, this paper applies a multi-criteria evaluation approach with population, health care, and economic datasets from 19 countries within the OECD. The comparative investigation was based on a Data Envelopment Analysis approach as an efficiency measurement method. Results indicate that on the one hand, factors like population size, population density, and country development stage, did not play a major role in successful pandemic management. On the other hand, pre-pandemic healthcare system policies were decisive. Healthcare systems with a primary care orientation and a high proportion of primary care doctors compared to specialists were found to be more efficient than systems with a medium level of resources that were partly financed through public funding and characterized by a high level of access regulation. Roughly two weeks after the introduction of ad hoc measures, e.g., lockdowns and quarantine policies, we did not observe a direct impact on country-level healthcare efficiency, while delayed lockdowns led to significantly lower efficiency levels during the first COVID-19 wave in 2020. From an economic perspective, strategies without general lockdowns were identified as a more efficient strategy than the full lockdown strategy. Additionally, governmental support of short-term work is promising. Improving the efficiency of COVID-19 countermeasures is crucial in saving as many lives as possible with limited resources.

Easing of Regulatory Barriers to Telemedicine Abortion in Response to COVID-19

For many people seeking abortion during the continuing COVID-19 pandemic, telemedicine abortion is the safest and most acceptable method, posing lower risk of exposure to the virus. In addition, by reducing in-person visits with health care providers, increased use of telemedicine for abortion can reduce pressure on overburdened health systems. Given the benefits of telemedicine during the pandemic, government agencies in several countries took measures to temporarily allow telemedicine abortion. We conducted key-word English-language searches to identify examples of government action to remove regulatory barriers to the practice of telemedicine abortion in response to the pandemic. We found instances of government agencies in eight countries taking steps to ease regulatory barriers to telemedicine abortion. Telemedicine abortion is safe, cost-effective, and may be the preferred method of abortion during acute periods of COVID-19 transmission, as well as after the pandemic has abated. As one step to expanding access to abortion with medicine where abortion is legal, health agencies and other regulatory bodies can take steps to remove barriers specific to telemedicine abortion.

Obstacles and opportunities: a qualitative study of the experiences of abortion centre staff with abortion care during the first COVID-19 lockdown in Flanders, Belgium

The COVID-19 pandemic and corresponding measures impacted the organisation of services for abortion on request in Flanders, Belgium. This study describes abortion centre staff's perceptions of the influence of protective measures on abortion consultations and procedures, and aims to identify obstacles and opportunities that arose from this situation. Through the anonymised patient records of one Flemish abortion centre, we compared the number of requests and abortions during the first lockdown (16 March-14 June 2020) with the same period in the five preceding years. Using a phenomenological approach, we documented the procedures and conducted interviews (all inductively coded in Nvivo) with the centre's coordinator, seven psychosocial staff members and three doctors. Though fewer people requested and had an abortion, the pressure on the staff was high due to changed procedures. A substantial change was the substitution of telephone for in-person consultations, which the staff perceived as less suited for discussing worries, contraception counselling, and building trust. The centre remained accessible, but the staff perceived an influence on the emotional reactions of clients. Staff agreed that the lockdown did not negatively influence the abortion procedure itself. However, they felt a negative influence on the level of psychological support they could offer, especially in interactions with clients who were less certain of their choice and clients with whom there was no common language. When the lockdown was relaxed, a triage system was set up to ensure emotionally safe abortion care - as perceived by staff - for all clients.

The Case for Telemedical Early Medical Abortion in England: Dispelling Adult Safeguarding Concerns

Access to abortion care has been hugely affected by the COVID-19 pandemic. This has prompted several governments to permit the use of telemedicine for fully remote care pathways, thereby ensuring pregnant people are still able to access services. One such government is that of England, where these new care pathways have been publicly scrutinised. Those opposed to telemedical early medical abortion care have raised myriad concerns, though they largely centre on matters of patient safeguarding. It is argued that healthcare professionals cannot adequately carry out their safeguarding duties if the patient is not in the room with them. These concerns lack empirical support. Emerging evidence suggests that safeguarding processes may, in fact, be more effective within telemedical abortion care pathways. In this article, we address two specific safeguarding concerns: (1) that a remote consultation prevents a healthcare professional from identifying instances of abuse, and (2) that healthcare professionals cannot reliably confirm the absence of coercion during a remote consultation. We demonstrate that such concerns are misplaced, and that safeguarding may actually be improved in telemedical care pathways as victims of abuse may find it easier to engage with services. It is inevitable that some individuals will fall through the net, but this is unavoidable even with in-person care and thus does not constitute a strong critique of the use of telemedicine in abortion care. These safeguarding concerns set aside, then, we argue that the current approval that enables telemedical early medical abortion should be afforded permanence.