Telemedicine
A DfC briefing, by Sean Rees
Introduction
Telemedicine is the use of information and communication technologies, such as telephones and video calls, to deliver medical information and remote consultations. In abortion care, telemedicine has come to represent the use of technology to reach women and pregnant people for consultations and then send a treatment package to enable the self-administration of abortion medications (both mifepristone and misoprostol).
A new pathway
Following the implementation of public health measures in response to the COVID pandemic, health services - including aboprtion care - had to be restructured to allow continued timely access to essential services during lockdown, whilst also mitigating against the risks of COVID exposure.
In order to deliver abortion care to women and pregnant people that was safe, effective, and accessible whilst also minismising the risk of COVID exposure to service users and providers, it became clear that the pre-pandemic legal and regulatory restrictions placed on abortion care services needed to be changed. Once these regulatory changes were made, the RCOG/BSACP guidelines recommended a new pathway for early medical abortion (EMA) that included remote consultations and self-administration of both abortion pills. These evidence-based guidelines drew on well-established models of service delivery already widely used internationally, but were previously limited by UK legal and regulatory restrictions.
As part of this pathway, women who request an abortion are offered a remote consultation, before which they are sent written information about the procedure; the remote consultation then takes place (meeting the same standards as in-person consultations), with the clinician leaving enough time to answer questions, gain informed consent, and explore safeguarding concerns if necessary. There is no need for routine blood tests, and ultrasound scanning is only recommended if a patient is unable to provide an LMP with reasonable certainty, or if a patient provides a history or has symptoms suggestive of a high-risk of an ectopic pregnancy.
UK abortion law
Abortion is the only medical or surgical procedure that is subject to specific legislation and criminal sanctions.
The current legal framework that governs abortion care is based largely on two important pieces of legislation: the Offences Against the Persons Act 1861 (“the 1861 Act”); and the Abortion Act 1967 (“the 1967 Act”).
The 1861 Act makes abortion illegal by prohibiting the use of any noxious substance or instrument to induce a miscarriage. It criminalises the woman and any third party, with a potential sentence of up to life in prison. The 1967 Act carves out a framework that gives a legal defence to anyone accessing or providing an abortion in circumstances that meet criteria laid out in the legislation.
Taken together, these criteria restrict access to abortion in the following ways:
abortion treatment must be carried out in an NHS hospital/clinic or other approved premises (approved by the Secretary of State)
two doctors must certify that the woman’s circumstances meet one of several grounds
only doctors can prescribe medications and perform procedures
An abortion is illegal if it is does not meet these criteria and the woman and third party are at risk of prosecution under the 1861 Act.
Temporary regulatory changes
In England, Wales and Scotland service providers can offer a complete EMA service using telemedicine technology, with treatment packages sent via post/courier or collected from the clinic. This change in services required direct action from health ministers to approve regulatory changes, which would allow women to self-administer both mifepristone and misoprostol at home (previous regulations had allowed home-use of misoprostol only).
On 30 March 2020, the Department of Health and Social Care (DHSC) in England published new regulations that allowed doctors to prescribe abortion medications from their home, included a woman’s home as a “registered place” where abortions can be carried out, and allowed the self-administration of mifepristone as well as misoprostol. These regulations applied only to pregnancies where the gestation had not exceeded nine weeks and six days. The Welsh Government published similar regulations on 31 March.
The Scottish government published new regulations on 31 March that allowed the home use of mifepristone and misoprostol without defining a gestational limit (although associated clinical guidelines recommend a limit of 11 weeks and six days). RCOG guidelines say that “where a gestational limit is not defined by law, healthcare professionals may judge when an early medical abortion at home is appropriate.”
In all three nations it is still a legal requirement (stipulated by the 1967 Act, section 1(1)) that two registered medical practitioners authorise the abortion by signing an HSA1 form. This process is necessary only to satisfy legal requirements and is entirely separate from the process of gaining valid consent.
These regulatory changes are only temporary, allowing services to continue within the current public health measures; but given the overwhelming evidence of their safety, efficacy, and improved accessibility, it is imperative that these temporary measures become permanent. The UK government and the devolved administrations of Wales and Scotland ran public consultations in early 2021 about the future arrangements of EMA services, with results to be published later in the year.
Safety and effectiveness
Abortion is a common and safe procedure: one in three women of reproductive age will have an abortion, and when performed in line with best practice it is safer than childbirth.
Telemedicine services have been previously shown to be as safe as in-person abortion care: a systematic review from 2019 concluded that rates of key outcomes and potential complications were at “similar levels to those reported after in‐person abortion care”. For this reason, telemedicine as a new model of service provision has been a key campaigning message for Doctors for Choice UK and other organisations for many years.
A more recent national cohort study compared, amongst other things, the safety of medical abortion before and after the introduction of telemedicine services: the study included 52,142 abortions (85% of all abortions provided in England and Wales during the study period) and found that there was no difference in the prevalence of serious adverse events between abortions provided via no-test telemedicine services and those provided in-person with routine ultrasound scanning. This study also found that rates of successful medical abortion (i.e. complete abortion) are high under a telemedicine service model, with “no evidence of a lower success rate” when compared with traditional in-person services.
Abortions are safer the earlier in pregnancy they are performed, so by improving access it can be argued that telemedicine services make abortion care even safer than in-person services. For example, the national cohort study found that 40% of abortions accessed via telemedicine were performed at six weeks’ gestation or less, much higher than the 25% performed at the same gestation before telemedicine services were introduced.
Access
Telemedicine services improve access to abortion care by reducing waiting times, enabling women and pregnant people to access services at earlier gestations, and by providing a more convenient and flexible service.
NICE guidance states that improving access to abortion services should be a key priority and their 2019 guidance recommends that remote services and reduced waiting times can improve the sustainability of and access to abortion services, most likely for those in vulnerable groups.
Data from the national cohort study show that the mean waiting time to treatment declined from 10.7 days in the traditional in-person pathway to 6.5 days in the telemedicine pathway. Data from BPAS show that the waiting time for an abortion through their service was reduced by 50% to just two days.
The reduction of waiting times is also cost effective, with NICE recognising that "a reduction of 1 day in the average waiting time would save the NHS £1.6 million per year on procedure costs and treating adverse events" (page 35).
Safeguarding
Concerns are often raised about the potential impact of telemedicine on the ability of abortion providers to effectively safeguard vulnerable patients, but these have proved to be unfounded. It is noted by the British Society of Abortion Care Providers that it is more common for men to control women’s access to healthcare (including abortion) than it is for them to force a woman to have an abortion against her will. Abortion providers have robust processes in place to flag safeguarding concerns and investigate them; independent providers report the same rate of detection of safeguarding issues before and after the introduction of telemedicine, and it has been suggested that better privacy at home enables women and pregnant people to talk more freely.
Ectopic pregnancies
There were initial concerns that, as a result of shifting to a service model that does not routinely perform ultrasound scanning to confirm an intrauterine pregnancy, women with undiagnosed ectopic pregnancies would come to harm. These concerns, however, have proved to be unfounded and should not prevent the further development of telemedicine services.
The rate of ectopic pregnancies in the general population in the UK and USA is reported as 1-2%, but ultrasound scanning is not routine and only indicated if a woman or pregnant person shows suggestive signs and symptoms. Indeed, ultrasound scanning for ectopic pregnancies in symptom-free women is associated with a high rate of false-positives when the prevalence is low and since the rate of ectopic pregnancy is 10 times lower in the population seeking abortions, there is no clinical reason to routinely scan for ectopic pregnancies in those seeking to end their pregnancies. The RCOG/BSCAP COVID guidelines recommend that women should have an ultrasound scan only if they are unable to provide an LMP with reasonable certainty, or if they provide a history or have symptoms suggestive of a high-risk of an ectopic pregnancy.
It is inevitable, however, that some of the nearly 200,000 women and pregnant people a year who have abortions will have an undiagnosed ectopic pregnancy and will go on to have mifepristone and misoprostol through a telemedicine service. The key is to ensure that these cases are detected before they come to harm rather than before they begin treatment for an early medical abortion by, for example, ensuring that patients receive the appropraite information during a robust clinical consultation and are aware of where to go for further information and support. A telemedicine service that facilitates 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”.
Gestational limits
The emergency regulations in England and Wales specify a gestational limit of nine weeks and six days, an arbitrary and clinically irrelevant limit that serves no discernible purpose. The emergency regulations in Scotland do not specify a gestational limit instead deferring to clinical guidelines, which stipulate a gestational limit of eleven weeks and six days. The preferred model would allow for such limits to be determined by clinical guidelines that are more responsive to a changing evidence-base and formulated by the relevant experts, rather than being at the discretion of politicians and civil servants.
There were initial concerns, similar to those regarding ectopic pregnancies, that, as a result of shifting to a model that did not routinely perform ultrasound scans to confirm gestational age, abortions would be inadvertently provided to women and pregnant people over the gestational limit of 10 or 12 weeks. There were few cases of abortions performed above the gestational limit (0.04% of cases in the telemedicine group in the national cohort study), but the consequences of providing a medical aboriton via telemedicine to these women are mostly medicially insignificant. There is evidence that a medical regimen is effective at nine-13 weeks’ gestation, and at 13-20 weeks’ gestation; the overall success rate of self-managed abortions at more than 12-24 weeks’ gestation is 93%, with an efficacy and safety profile similar to earlier gestations. It is inevitable to have cases of abortions performed over the gestational limit; the appropriate response, however, would not be to prevent futher develop of telemedicine services but rather to ensure that those accessing telemedicine services are informed of the potential risk of miscalculating their gestational age and how that would affect their experience of having an early medical abortion.
Beyond the pandemic
The UK government and devolved administrations recently held public consultations on the future arrangements of abortion provision, specifically the regulations around the home-use of mifepristone that allowed the expansion of telemedicine services. You can read our responses here (England, Wales, Scotland). Our main message was that telemedicine has improved access to abortion care more quickly and more safely in a way that is acceptable to women and service providers, although further improvements can be made (e.g. removal of need for two doctors’ signatures, opening up workforce to nurses and midwives, removal of gestational limits).
The efforts of DfCUK should now focus on ensuring that telemedicine moves from being an interim measure in unprecedented circumstances to a permanent feature of abortion care in a post-COVID landscape. Telemedicine, as it has been developed most recently, has clearly shifted the campaigning goals of pro-choice groups, but we should go further: to radically reset future reform goals, any interventions aiming to bring women into formal healthcare settings that are governed by laws and policies that dictate the legality of and terms of access to abortion care must be dropped. Our core message must remain that restrictive, punitive, and unnecessary laws “marginalise people, create vulnerability, and impose disadvantage in accessing safe abortion care”. Telemedicine is a welcome step in the right direction, but only decriminalisation, and efforts to destabilise power dynamics of care more broadly, can facilitate access to safe and dignified abortion care to all those who need it.