Introduction
Improved access to abortion care would deliver significant advantages for both healthcare systems and the women who use them. Abortion is a common reason for needing healthcare – the global abortion rate is estimated at 39 abortions per 1000 women aged 15–49 years,(1) with 28% of all pregnancies in developed countries ending in abortion.(2) There is clear evidence that restricting access to abortion does not reduce abortion rates, it simply makes abortion less safe.(1, 3) Improving access is likely to benefit those who are most vulnerable,(4) especially in resource-poor settings or where care has to be self-funded. In its 2019 guideline on abortion care, the National Institute for Health and Care Excellence (NICE) stated that improving access to abortion was a key priority.(5)
Telemedicine, the use of information and communication technologies to improve patient outcomes by increasing access to care and medical information,(6) has been noted to decrease costs and increase convenience and safety.(7) It is an established service delivery model for abortion care in many settings,(8) and it is recommended to improve access.(4) The COVID-19 pandemic required urgent action by clinicians and policymakers to ensure delivery of essential health services, including abortion. In March 2020, the Royal College of Obstetricians and Gynaecologists (RCOG) published guidelines to safeguard abortion care in the UK.(9) The guidelines profoundly changed the way medical abortion care is delivered in Great Britain. Prior to the emergence of COVID-19, all patients seeking medical abortion were required to attend in-person to receive an ultrasound scan and have mifepristone administered within the clinic. Under the new guidelines, consultations were encouraged to take place by telephone or video call; an ultrasound scan was required only if indicated. All the British governments had issued emergency legal orders by March 30th 2020 to allow mifepristone to be used at home along with misoprostol up to 10 weeks’ gestation.(10-12) These approvals permitted abortion providers to implement a telemedical service delivery model for medical abortion.
Great Britain’s new pathway for no-test telemedicine abortion is unusual among existing models because it is fully remote: no clinic visit, tests or ultrasound scan are required and both mifepristone and misoprostol are delivered by mail or collected from a clinic for use at home. This new service model thus presents an important opportunity to evaluate a potentially better way to provide medical abortion that could improve access and reduce the barriers posed by in-person care.(13) We examined and compared the effectiveness, safety and acceptability of medical abortion provided up to 10 weeks’ gestation before and after the service model change.