Have telemedicine services improved access to abortion care in the UK ?
Having an abortion is a choice. A choice that provides a person or couple with the option to terminate a pregnancy before it reaches full term. There is a range of reasons as to why someone may choose abortion as an option; however, what is important is that having a choice to access abortion care and support services is a human right here in the UK.
During the International Conference on Population and Development (ICPD) in Cairo in 1994, reproductive rights were defined as ‘… the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes the right of all to make decisions concerning reproduction free of discrimination, coercion and violence.’
Despite this sentiment of having and maintaining high standards of sexual and reproductive health being cosigned by world leaders and their governments, many people still experience challenges and barriers to accessing abortion care and support services worldwide. Almost every country across the world permits abortion under some circumstances, however many people who may want to access abortion care to terminate a pregnancy still do not have adequate access due to the political, economic or religious climates that exist in various countries and regions, thereby negatively impacting a persons ability to exercise their reproductive rights and choices.
As a result, many people may undergo unsafe abortions to terminate their pregnancy. Data taken from the World Health Organisation (WHO) reveals that every 8 minutes a woman in a developing nations will die of complications arising from an unsafe abortion. Additional research found that around 7 million women are admitted to hospitals every year in developing countries, as a result of unsafe abortion. Often, an unsafe abortion is carried out by a person who lacks the professional medical skills and training needed to perform the abortion properly, in addition to the unsafe abortion taking place in an environment that does not meet the minimal medical standards - for example, lacking appropriate medical equipment to perform the procedure, pain relief and sterilisation equipment and supplies, thereby creating a dangerous and unsafe medical environment
Furthermore, undergoing an unsafe abortion can lead to long term physical, mental and emotional consequences or, worse, death. Additionally, there may also be a range of financial and social implications for individuals and their communities as a result. The WHO also highlights that three out of ten pregnancies end in induced abortion. Nearly half of all abortions are unsafe, and almost all of these unsafe abortions occur in developing countries - the global south.
Most abortions are carried out before 24 weeks. However, if a parent’s life is at risk or there are concerns that the unborn child will be born with a severe disability, an abortion may take place.
Telemedical abortions during the pandemic
During the coronavirus (COVID-19) pandemic, access to a range of services and support became significantly reduced in the UK - and across the world - in an attempt to adequately manage and navigate the COVID 19 response.
As a result, sexual and reproductive health care services have also been restricted, including abortion services and support, unfortunately leaving those in need of accessing a termination unable to do so. However, in response to the pandemic, the UK government approved the use of telemedicine for patients wishing to access abortion care, enabling women and girls to take both pills for early medical abortion (EMA) in their own homes up to 10 weeks’ (9 weeks and 6 days) gestation.
Telemedical services have been used for a number of years across a range of health care services and settings to provide clinical support, combat geographical barriers to accessing health care and overall improve health outcomes. The use of technology enables health professionals to engage with service users through video calls and telephone. The telemedical abortion service allows eligible patients the option to take both pills used for medical abortion to induce a termination up to 10 weeks in their own homes without attending a clinic. Providing service users meet the eligibility criteria, health providers then supervise the service users use of abortion pills via videoconferencing or telephone consultations.
“Telemedicine is a safe, effective, and woman-centred model for the provision of early medical abortion.” Says Clare Murphy, Chief Executive at BPAS.
She continued, “Telemedical abortion care has protected women’s health and wellbeing during the pandemic, and women have told us just how much they value this service and want it to continue so other women in the future can benefit. While other healthcare services have been suspended or seen significant increases in waiting times during the pandemic, access to abortion has not only been maintained but has improved, enabling women to end pregnancies at the earliest possible gestations. Telemedicine has eliminated these issues.”
“Abortion is an extremely safe procedure, and considerably safer than carrying a pregnancy to term, but the earlier it can be performed the better for women’s mental and physical wellbeing. We also know women are no longer seeking illegal abortion pills online because they cannot get to a clinic – whether its childcare issues, inability to take a day off work or challenges leaving the house under the watchful eye of an abusive partner, there have long been many reasons why women in some of the most difficult situations find access to legal care difficult.”
“The Government is currently consulting on whether to retain this service after the pandemic. It would make no sense to remove a delivery model that has clear benefits to the health and wellbeing of so many women. The UK is now in a position to secure a world-leading reproductive healthcare framework, and we’re urging the Secretary of State to do so by making telemedical abortion care a permanent option for women.”
Earlier this year, in February, Sky News launched a short documentary titled “Are abortion laws about to change?” which shines a light on the changes to abortion care access, whilst profiling the experiences of services users and clinicians alike. During this period, the UK government also launched a consultation period between November 2020 and February 2021 in which the UK public were invited to submit their views on whether or not to make permanent the current temporary measure allowing for home use of both pills for early medical abortions (EMA) up to 10 weeks’ gestation for all eligible women. This is currently undergoing review.
A recent study carried out by researchers at the University of Texas at Austin, the British Pregnancy Advisory Service (BPAS), MSI Reproductive Choices (MSUK) and National Unplanned Pregnancy Advisory Service (NUPAS) found that the telemedicine‐hybrid model for medical abortion was effective, safe, acceptable and improved access to care. The study analysed the outcomes of more than 50,000 early medical abortions that took place in England, Scotland and Wales between January and June 2020.
The study also found:
Waiting times from having a consultation to accessing treatment improved from 10.7 days to 6.5 days.
Patients were able to receive care much earlier in their pregnancy - thereby significantly reducing the duration of the pregnancy at the time of the abortion.
The effectiveness of the treatment remained the same for abortions carried out through the traditional service and the telemedicine service.
There were no cases of significant infection requiring hospital admission or major surgery - Contrary to misleading claims; no person died from having an early medical abortion at home
Eighty per cent of those accessing telemedicine said this was their preferred option and would choose it in the future. And no patients said they were not able to consult in private using teleconsultation.
Prior to the telemedicine services being approved and offered to patients seeking an abortion, patients would typically attend a face to face appointment at a clinic where they would receive an ultrasound scan to check how many weeks pregnant a patient is, followed by medication to start the termination process at the clinic. Although patients may not have needed to stay in the clinic or hospital overnight, they may have been required to attend a clinic for their appointments on different days to complete the procedure.
“To some degree, the launch of the telemedical abortion service is a sign of innovation in the sector, but I am unsure about how robust the criteria is for thoroughly assessing patient accessing the service, as well as how safe it may be.” Says Leonie Bellio, a Sexual Health Nurse from London. Prior to becoming a Sexual Health nurse, Leonie worked in termination service as a Nurse Practitioner and Ultrasound Scan Mentor for 4 years.
She continued, “When I worked in termination services, I would perform scans on patients before giving the pills to start the termination process. Here I’ve seen patients, who present as clinically well, then we perform a scan and we can see there is a live ectopic pregnancy.”
This happens when a fertilised egg implants in the fallopian tube and begins to grow outside of the uterus. According to NHS Choices around 1 in every 90 pregnancies in the UK are ectopic. This is around 11,000 pregnancies a year
“When this happens patients are usually blue lighted to the hospital for emergency care. The patient may need to have surgery to remove the fertilised egg potentially along with the affected fallopian tube which can impact their future fertility.”
“I have also performed a scan where a patient has said their last period was 6 weeks ago, but after having a scan we’ve seen that they’re 7 months pregnant. Sometimes patients can confuse implantation bleeding for a menstrual bleed which is why having a scan before accessing the pills can be vital.”
“We are relying on the patient we see to be transparent about their bodies, but also have a certain level of medical knowledge that we as health practitioners have trained and studied extensively for.”
Overall, the new telemedical service aims to improve access to abortion care services for a wide range of patients who want a termination, but understandably there will be some patients for who the service is not suitable. Anyone requesting an abortion can discuss their options and receive support from, a trained counsellor if they wish.
BPAS has launched a campaign called We Trust Women to keep telemedicine service for abortion care operating post lockdown in England, Scotland, and Wales. As part of the campaign, they are encouraging the public to write to their Member of Parliament, Member of the Scottish Parliament, or Member of the Welsh Senedd to ask them to help keep telemedical abortion care legal, safe, effective, and accessible for all who need it.
For more information on accessing abortion care and support, go to NHS Choices , The British Pregnancy Advisory Service (BPAS), the National Unplanned Pregnancy Advisory Service (NUPAS) or your local NHS sexual health website.
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