Telemedicine for Medical Abortion Safe, Effective Option

Diana Phillips

May 16, 2017

A telemedicine-based service for termination of pregnancy with mifepristone and misoprostol is safe and effective in settings where access to abortion services is restricted, a new study shows.

A population-based analysis of women in the Republic of Ireland and Northern Ireland, which have some of the most restrictive abortion laws in the world, showed that women who used an online consultation service and self-sourced medical abortion during a 3-year period were able to successfully end their pregnancies with few adverse events.

In addition, women were able to self-identify the symptoms of potentially serious complications and seek medical attention when necessary, Abigail R. A. Aiken, PhD, from the University of Texas at Austin, and colleagues report in an article published online May 16 in the BMJ.

The findings add to existing evidence supporting the role of self-sourced abortion using online telemedicine as a realistic, positive option for some women, and "they clearly show that not at all abortions taking place outside the law are unsafe abortions," the authors write.

The study is based on data from Women on Web (WoW), an online telemedicine initiative that provides early medical abortion services in countries where access to safe abortion is restricted. The WoW telemedicine model includes an online consultation, after which women with an unplanned pregnancy of up to 9 weeks are referred to an online physician who checks for contraindications before sending the medication by mail to the patient for self-administration. A help desk team provides real-time instruction regarding medication use, as well as help and support during and after the abortion process.

The study population included women living in the Republic of Ireland and Northern Ireland who filled out an online consultation form on the WoW website and who received 200 mg mifepristone and 1200 μg misoprostol between January 2010 and December 2012.

WoW provided medications to 1636 women during the study period and had follow-up information for 1158 (71%). Of these, 1023 women confirmed using the medications, and follow-up information was available for 1000. Only those women who confirmed subsequent use of the medications and who provided follow-up information on abortion outcome were included in the analysis.

Of those 1000 women, 781 (78%) reported being less than 7 weeks pregnant and 219 (22%) reported being 7 to 9 weeks pregnant at the time of the online consultation request. Most of the women (n=726) were 30 years or older

All but 3 of the women reported being able to cope with their abortion decision; 23 had a medical condition that required additional screening to ensure the medical abortion could be carried out safely, the authors write.

Nearly all the women (94.7%) reported successfully ending their pregnancy without surgical intervention. Forty-five women (4.5%) required surgical intervention.

Rates of adverse events were low, with 3.1% reporting treatment for a possible adverse event, including 7 women (0.7%) who reported receiving a blood transfusion (no further information provided) and 26 (2.6%) who received antibiotics.

When compared by gestational age, there were no statistically or clinically significant differences in the proportion of participants reporting a successful medical abortion between women less than 7 weeks pregnant and those 7 to 9 weeks pregnant. Neither were there differences in the rates of adverse events, and no deaths were reported by family members, friends, or other sources.

Of the 987 women for whom information on self-reported symptoms was available, 92 reported experiencing a symptom of a potentially serious complication, including bleeding (51), fever (17), and persistent pain (24). Of these women, 87 sought medical care as advised.

"None of the five women who did not seek medical help reported an adverse outcome or treatment for a complication, and none of the women who did not report symptoms of a potentially serious complication reported an adverse event," the authors write.

The rate of successful medical abortion reported in this study is similar to the rates of medical abortions carried out in the formal system, "both when mifepristone and misoprostol are administered in clinic and when mifepristone is administered in clinic and misoprostol is taken at home," the authors report.

Of note, the rates of self-reported adverse events shown in this study "are lower than the risk of equivalent complications during delivery in the UK," the authors write. "They are also much lower than the equivalent risks associated with unsafe methods of abortion."

Because women who live in countries with highly restrictive abortion laws often turn to unsafe methods to end unwanted pregnancies, "self sourced medical abortion is a potentially lifesaving option," the authors state. "[S]trengthening services outside the formal healthcare setting could be a vital component of strategies to reduce maternal mortality from unsafe abortion."

Self-sourced medical abortion may also become more visible in Europe and the United States, "given the trajectory of abortion policy" in these regions, the authors hypothesize. "Investigating women's experiences, preferences, outcomes, and unmet needs in various settings is a critical goal for future research."

The current research provides insight into patient practices in countries with high-quality healthcare in which abortion services are legally restricted, Wendy V. Norman, PhD, from the University of British Columbia in Vancouver, Canada, and Bernard M. Dickens, PhD, LLD, from the University of Toronto, Ontario, Canada, write in an accompanying editorial. "What this study adds is an important exploration of whether women in jurisdictions with severe restrictions on abortion but good access to high quality healthcare will self assess and manage potential complications."

Until legislative reform is enacted to provide equitable abortion care for women in Irish jurisdictions, the editorialists write, medical abortion guided by physicians through telemedicine enables women of all social classes "equitable access to a reasonable alternative."

This study was funded by a grant from the Society of Family Planning and was supported in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health, and in part by grant to the office of population research at Princeton University. The study authors report financial or other relationships with the Society of Family Planning, the National Institutes of Health, and WoW. Dr Norman reports financial or other relationships with the Public Health Agency of Canada and the Canadian Institutes of Health Research, the Michael Smith Foundation for Health Research, the Society of Family Planning, the Society of Family Planning Research Fund, the North American Primary Care Research Group and the College of Family Physicians of Canada.

BMJ. 2017;357:j2011, j2237. Article, Editorial

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