Evidence from Over 52,000 People in England and Wales Shows Telemedicine Abortion Without Ultrasound is Safe, Effective and Improves Care

Abigail Aiken, Patricia A Lohr, Jonathan Lord, Nabanita Ghosh, and Jennifer Starling

Introduction

People who seek abortion at a clinic or hospital early in their pregnancy have two options: medical abortion, also known as medication abortion or abortion with pills, or surgical abortion. In the United Kingdom (UK), people seeking medical abortion traditionally were required to go to a clinic to receive counseling, an ultrasound scan to determine how far along the pregnancy was, and, if eligible, were given the medications in person. The abortion patient then took one of the medications (mifepristone) while still in the clinic and was given another medication (misoprostol) to take at home.

The Covid-19 pandemic prompted the UK’s Royal College of Obstetricians and Gynaecologists to publish guidelines to safeguard abortion care in the UK. These new guidelines allowed for the delivery of medical abortion via telemedicine for people with pregnancies up to 10 weeks’ gestation.

Telemedicine is the use of information and communication technologies to increase access to care and medical information, and has been shown to decrease costs and increase convenience and safety. Improving access to abortion through telemedicine is likely to benefit those who are most vulnerable.

Emergency legal orders went into effect on March 30, 2020 to allow for a fully telemedicine service delivery model for medical abortion. Under the new guidelines, abortion providers could offer abortion consultations by telephone or video call and then either send the abortion medications by mail or arrange for the patient to pick them up at the clinic for use at home. No ultrasound or any other clinical test was required. Providers would only require an in-person visit for an ultrasound scan or other tests if they considered it necessary to determine how many weeks the patient had been pregnant or to rule out an ectopic pregnancy.

This brief reports on a recent study that compared the safety, effectiveness, access, and acceptability of medical abortion provided up to 10 weeks’ gestation before and after widespread implementation of no-test telemedicine. Because some of the patients who initially sought no-test telemedicine abortion were required to go to the clinic for an in-person visit, the authors refer to the post-Covid-19 group as “telemedicine-hybrid” patients.

The study population includes all 52,142 patients who accessed an early medical abortion at the three largest abortion providers in England and Wales two months before and two months after the service model change. Patients in the pre-Covid-19 in-person care group numbered 22,158 and those in the telemedicine-hybrid group numbered 29,984. Within the telemedicine-hybrid group, 18,435 (61%) received no-test telemedicine abortion.

Key Findings

Safety: Significant adverse events in both groups were extremely rare – hemorrhage requiring transfusion was reported in 0.02% of cases in the telemedicine-hybrid group and 0.04% in the traditional in-person group – or did not occur: no cases for significant infection requiring hospitalization, major surgery or death were reported in either group.
Effectiveness: rates of successful medical abortion were high for both service delivery models: 98.8% in the telemedicine-hybrid group vs. 98.2% in the traditional in-person group.
Access: people seeking abortion waited fewer days, on average, to receive treatment in the telemedicine-hybrid model than in the traditional in-person model (6.5 days vs. 10.7 days). Average gestational age was also lower in the telemedicine-hybrid group (40% of abortions performed at 6 weeks’ gestation or less vs. 25% in the traditional in-person group).
Acceptability: 96% of people who responded about their telemedicine experiences said they were either satisfied or very satisfied with their care and 85% reported that they would choose telemedicine in the future or that it was their preferred option.

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Policy Implications

This study provides compelling evidence that no-test telemedicine should become routine in the provision of abortion care. No-test telemedicine abortion would improve access to care, especially among vulnerable groups and in resource-poor healthcare systems or where patients have to fund their own care.

No-test telemedicine for medical abortion likely would save the UK health system money. According to the UK’s National Institute for Health and Care Excellence, a four-day reduction in abortion patient waiting times could potentially save the health service in England and Wales over 6 million pounds (> 8 million US dollars). Savings would come from providing fewer unnecessary ultrasounds as well as from fewer people experiencing complications or needing a surgical abortion.

A recent study also demonstrated that the new telemedicine-hybrid model likely reduces the number of people seeking abortion outside of the formal healthcare setting by reducing barriers to care. For example, telemedicine abortion reduces the need to take time off work and find transportation and childcare to make a clinic visit possible.

People seeking to continue their pregnancies are not screened for ectopic pregnancy unless signs and symptoms suggest a need to do so. Therefore, requiring an ultrasound scan for people seeking abortion who have no symptoms is not clinically justified. In addition, proceeding with early medical abortion without a scan may permit earlier diagnosis of a developing ectopic pregnancy owing to increased surveillance, for example where there is minimal bleeding after taking the second pill.

These findings also provide important takeaways for policymakers in the United States. As the Biden Administration considers directing the Food and Drug Administration to reconsider their restrictions on access to mifepristone, this study provides critical evidence demonstrating the safety, effectiveness, and acceptability to patients of the no-test telemedicine model.

Reference

Aiken, A., Lohr, P.A., Lord, J., Ghosh, N. & Starling, J. (2021). Effectiveness, safety and acceptability of no-test medical abortion provided via telemedicine: a national cohort study. BJOG: an International Journal of Obstetrics & Gynaecology. Published online ahead of print.

Suggested Citation

Aiken, A., Lohr, P.A., Lord, J., Ghosh, N. & Starling, J. (2021). Evidence from over 52,000 people in England and Wales shows telemedicine abortion without ultrasound is safe, effective and improves care. PRC Research Brief 6(3). DOI: 10.26153/tsw/11699.

About the Authors

Abigail Aiken (araa2@utexas.edu) is a faculty research associate in the Population Research Center and an associate professor in the Lyndon B. Johnson School of Public Affairs at The University of Texas at Austin; Patricia A Lohr is the medical director at British Pregnancy Advisory Service; Jonathan Lord is the medical director at MSI Reproductive Choices and a consultant physician; Nabanita Ghosh is the medical director at National Unplanned Advisory Service; and Jennifer Starling is a statistician at Mathematica Policy Research.

Acknowledgements

This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (P2C HD042849), awarded to the Population Research Center at The University of Texas at Austin. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.