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.