Main Findings
We found that no-test telemedicine without routine ultrasound for
medical abortion up to 10 weeks’ gestation is an effective, safe and
acceptable service model. Clinical outcomes with telemedicine are
equivalent to in-person care and access to abortion care is better, with
both waiting times and gestational age at the time of abortion
significantly reduced. Further evidence that the new telemedicine-hybrid
model improved access comes from a study showing that the rate of women
seeking abortion medication outside the formal healthcare setting
reduced significantly in the UK following implementation of
telemedicine.(22) The most likely explanation is easier access as the
opposite effect was seen in several other European countries who made no
such provision. The implication is that those previously too vulnerable
to attend in-person have been able to access care through telemedicine,
potentially benefiting from the safeguarding, counselling and
contraceptive services provided by regulated providers.
Our study confirms previous literature that medical abortion is safe and
effective with low rates of significant complications.(23) The slight
increase in effectiveness we observed in the group that received
telemedicine – even after controlling for lower average gestational age
compared to the in-person group – may be due to the ability of patients
to better control the timing at which they took the medication.
The telemedicine-hybrid model resulted in very low rates of undiagnosed
ectopic pregnancy and later than expected gestations. Although the rate
of ectopic pregnancy in the general population in the UK and USA is
reported as 1-2%,(24, 25) the rate reported among patients having an
abortion is 10 times lower,(26) which is consistent with our findings.
Ultrasound is not used to screen for ectopic pregnancy in the general
population – it is only used where signs and symptoms suggest a
need.(25) Routine screening of symptom-free women is associated with a
high false positive rate when the prevalence of ectopic pregnancy is
low, as is the case in women seeking abortion, and therefore it is
unlikely there would be significant benefits.(27) There is no clinical
justification for maintaining this inconsistency in care between women
wishing to continue their pregnancies and those choosing EMA.(28, 29)
However, given that over 200,000 people access abortion care each year
in the UK alone, some will inevitably have an asymptomatic ectopic
pregnancy and so will proceed with having mifepristone and misoprostol
either through telemedicine or after a false negative scan. The
essential issue for safety is that these are detected prior to causing
harm rather than prior to beginning medical abortion treatment;
treatment with mifepristone and misoprostol in itself will have no
effect on an underlying ectopic pregnancy. Indeed, the reduction in
waiting times afforded by the telemedicine model may facilitate earlier
detection than traditional pathways where women present later, or are
sent away to give additional time to visualise an intrauterine pregnancy
on scan. Proceeding with early medical abortion without a scan may
permit earlier diagnosis of a developing ectopic pregnancy owing to
increased surveillance and index of suspicion, for example where there
is minimal bleeding after misoprostol.(9, 16)
The proportion of cases where gestational age was later than expected
based on LMP was low, as might have been expected given the evidence
that women can determine the gestational age of their pregnancy with
reasonable accuracy by LMP alone.(29) Nevertheless inadvertent treatment
of gestations over 10 weeks is inevitable and, consistent with our
findings, the consequences for most are unlikely to be medically
significant.(30) The 10 weeks’ gestation limit in the English
government’s approval order is arbitrary, and not based on evidence of
safety or effectiveness. The Scottish government did not stipulate a
limit, leaving the decision to the discretion of the clinician in
consultation with their patient. Moreover, the reported success of
self-managed abortions at >12–24 weeks’ gestation is 93%,
with safety similar to that expected in earlier gestations.(31)