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04 Jul 2019

Can telemedicine services increase access to safe medical abortion care?

Gynuity Health Projects, Marie Stopes International

Topics:

Pathways to care, Client experience, WHO guidelines, Task sharing, New technologies, Self-administration, Medical Abortion (MA), Humanitarian context, Women's rights, Sustainability, Policy guidance, Non-judgmental services, Counselling

We know that barriers to safe abortion care continue to put women at risk globally. Between 2010 and 2014, over 45% of abortions were performed by unskilled practitioners or using outdated or harmful methods, classifying them as unsafe.

According to the World Health Organization’s guidelines on the roles of health workers in providing safe abortion care and post-abortion contraception, many components of abortion care in the first trimester can be provided on an outpatient basis, as well as by mid-level providers. In parallel, the guidelines share that women can self-administer abortion medication safely, as well as self-assess whether the abortion is complete at home. The emerging use of telemedicine has been found to assist women with this self-administration process safely and effectively.

pathways to care

What do telemedicine services for medical abortion cover?

Telemedicine services use the phone or internet to provide care remotely, and as shared in a recent systematic review, have huge potential to expand access to safe abortion through remote counselling, assessment or clinical guidance. Telemedicine can form part of a local health care service, can work in combination with in-person care, or can operate independently to overcome geographical or legal barriers to abortion.

Below, we share an example of how these services can work in action, as well as the evidence on whether telemedicine can expand access safely, effectively and with a positive client experience.

TelAbortion: A pathway to safe abortion care via telemedicine and mail

In the United States, access to abortion is becoming increasingly limited. At least 6 states have only 1 abortion provider and many women travel 50 or more miles to reach the nearest facility. As well as distance, barriers to accessing abortion care at clinics include:

  • The cost of travel, accommodation, and lost wages
  • Laws in certain states that require multiple in-person visits
  • Difficulties with taking time off work or arranging childcare
  • Long waiting times for appointments
  • Harassment from clinic protesters.

To address some of these barriers, Gynuity Health Projects launched a telemedicine project in 2016 called TelAbortion, which does not require a patient to go to an abortion clinic, but rather provides abortion services via telemedicine and mail.

The TelAbortion process involves four steps:

  1. At initial contact, the patient hears about TelAbortion, undergoes a pre-screening process and schedules a video evaluation.
  2. During the video evaluation, the provider records the patient’s medical history, obtains informed consent electronically, and identifies facilities for screening and follow-up tests if needed.
  3. The provider reviews the results of the screening tests. If the patient wants to proceed and is eligible for the service, the provider sends a package containing instructions and the abortion medications.
  4. The patient takes the medication and obtains follow-up tests. A follow-up consultation is conducted 7-14 days later.

As of April 2019, the project has served 375 women in Colorado, New Mexico, Georgia, Hawaii, Oregon, Washington State, Maine, and New York. Ninety-five percent of participants completed their abortion without surgery, and satisfaction has been high among both patients and providers. Most participants report that the process is convenient and that they would recommend it to a friend. Gynuity Health Projects have developed a one-page guide to the project, and published its results in Contraception.

Reporting on the first 32 months of the project, the authors concluded:

the model has the potential to increase abortion access by enhancing the reach of providers and by offering people a new option for obtaining care conveniently and privately.

Assessing telemedicine: safety, efficacy and client experience found equal to in-person care

Echoing Gynuity Health Projects' findings, a recent systematic review of telemedicine services in middle- and high-income settings has found that medical abortion through telemedicine is highly acceptable to both women and providers.

For women in the first 10 weeks of pregnancy who used telemedicine services, the review found:

  • Abortions were successfully completed: between 93.8 to 96.4% of abortions were found to be complete, which is comparable to clinic-based care. Between 0.9 to 19.3% received additional surgical evacuation after taking the medications.
  • Complications were rare: Between 0 to 0.7% of clients required a blood transfusion and between 0.07 to 2.8% required hospitalisation. These rates are similar to clinic-based medical abortion outcomes in the first 10 weeks of pregnancy.
  • Most clients felt satisfied with the service and would recommend it: Between 64 and 100% of women who received the service shared that they were satisfied, and between 90 to 98% of clients reported they would recommend the service to a friend.

Similarly, for women over 10 weeks of pregnancy, the review found the following:

  • Most abortions were successfully completed: 1.3 to 2.3% of clients experienced continued pregnancy and 8.5 to 20.9% received additional surgical evacuation.
  • Clients felt satisfied with the service: between 90 to 100% of people who used the service reported satisfaction.

The full study can be accessed via the International Journal of Obstetrics & Gynaecology.

What do these studies say about the potential to increase access to safe services?

Both Gynuity Health Projects' study and the systematic review from the World Health Organization and others found similar results: safety, effectiveness and client satisfaction in telemedicine services are comparable with outcomes of in-person services.

In short, although further research is required on the safety, efficacy and client experience of telemedicine in low-resource settings, the initial findings of both the systematic review and Gynuity Health Projects' study are promising. Both studies demonstrate the potential for telemedicine to expand access to safe services in a discrete, convenient and client-centred way, particularly in settings where barriers prevent access to in-person services.


Find out more about Gynuity Health Projects' telemedicine study via their research one-pager and read the full systematic review from the World Health Organization and others via the Journal of Obstetrics and Gynaecology.

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