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)