Population and Cohorts
The study population comprised all patients who accessed an early medical abortion (EMA) at the three largest abortion providers in England and Wales - British Pregnancy Advisory Service (BPAS), MSI Reproductive Choices (MSUK), and the National Unplanned Pregnancy Advisory Service (NUPAS) - two months before and after the service model change. Medical abortion is defined as the use of medications to cause termination of a pregnancy without primary surgical intervention and ‘EMA’ applies to these procedures in the first trimester.(14) The recommended EMA regimen uses the anti-progestogen mifepristone in an oral dose of 200mg then, after 24-48 hours, 800mcg of the prostaglandin analogue misoprostol by the sublingual, vaginal or buccal route.
Our dataset consisted of information on EMAs extracted directly from electronic service records and included fully de-identified patient clinical and demographic characteristics, as well as clinical outcomes. All data were extracted six weeks after the end of the study period to ensure the reporting of complications was as complete as possible.
Two cohorts were defined. The “traditional” cohort comprises all patients having an EMA between January 1st and March 1st 2020, prior to service model change. All patients in this cohort received care using the traditional pathway that included an in-person assessment and an ultrasound scan. The “telemedicine-hybrid” cohort comprises all patients accessing an EMA between April 6th and June 30th 2020, in a two month period after the service model change at each provider. Patients in this cohort received care using no-test telemedicine if they had low risk of ectopic pregnancy and their self-reported last menstrual period (LMP) indicated a gestation of less than 10 weeks. Those who were not eligible for telemedicine had an in-person assessment with ultrasound. Providers followed organisation-specific evidence-based policies informed by the RCOG(9) and associated decision aid(15) (figures 1 and 2) and earlier RCOG and NICE guidelines for general abortion care including in-person medical abortion.(16, 17)
In the traditional cohort, whilst some aspects of the pre-abortion consultation may have been carried out by phone, an in-person assessment with ultrasound scan and in-clinic administration of mifepristone were always required. In the telemedicine-hybrid cohort, we defined patients served by telemedicine as those who received medications for home use (either by mail or collection with minimal contact from a clinic) following a phone or video consultation and who did not receive an ultrasound scan or other tests.
We omitted the month of March 2020 because of the uncertainty and challenges posed by the emergence of COVID prior to the definitive service model change. The dates of the telemedicine-hybrid cohort take into account the roll-out of the telemedicine service across individual clinics within a provider network. For the analysis of ectopic pregnancies, we applied the timeframes stated above to all abortion consultations rather than all abortions provided because some patients with suspected ectopic pregnancies were referred to Early Pregnancy Assessment Units (EPAU) and did not proceed to an abortion.