Telemedicine early medical abortion at home: evaluation

Background

In Scotland, the great majority of abortions are performed using two medications, called mifepristone and misoprostol, to end the pregnancy.

Data from Public Health Scotland for 2021^[5] shows that most abortions are conducted at an early stage of pregnancy (less than 12 weeks pregnant) and that increasing proportions of these are cases where the patient takes one or both medications at home and passes the pregnancy at home rather than in a hospital or clinic – often referred to as early medical abortion at home (EMAH).

EMAH is not new in Scotland. What is new in Scotland is the option for patients to take the first medication (mifepristone) at home rather than swallow it in a clinic. This option became available at the start of the COVID-19 pandemic when, on 30th March 2020, Scottish Ministers issued an approval^[6] that allowed those eligible for EMAH to take mifepristone at home. Prior to this, patients had to attend a clinic to take mifepristone and could only take the second medication (misoprostol) at home^[7]. This change to home use of mifepristone was important to minimise the risk of transmission of COVID-19 through in-person clinic visits and unnecessary travel. Changes in clinical protocols that took place in response to the approval also included:

• consultations taking place by telephone or video call
• pre-abortion ultrasound scans were no longer conducted routinely but were instead conducted when judged to be clinically necessary (for example if there was uncertainty about the stage of pregnancy or if there was pain or bleeding and an ectopic pregnancy was suspected)
• option for abortion medication to be delivered to patients at home

These changes were supported by a number of organisations, including the Royal College of Obstetricians and Gynaecologists^[8] and Scottish Abortion Care Providers network.

These changes were also in line with World Health Organization guidelines that now recommend a) that medical abortion can be conducted with self-administration of both mifepristone and misoprostol at home in the first 12 weeks of pregnancy; and b) the use of telemedicine consultations^[9]. Guidance from the National Institute of Health and Care Excellence (NICE) on abortion care issued in 2019 also recommended that telemedicine consultations should be available as an option to improve access to abortion care for patients^[10].

The approval for home use of mifepristone was initially established as a temporary measure, whilst COVID-19 remained a considerable public health threat. Published evidence collected from one region of Scotland (NHS Lothian) in 2020 indicated that the newly introduced EMAH model was sufficiently safe, effective and acceptable to patients and service providers^[11]. At the same time, published evidence from England and Wales of over 29,000 EMAH cases also provided support for the safety and effectiveness of this model of care^[12] and survey data confirmed acceptability to patients^[13].

From September 2020 to January 2021, the Scottish Government undertook a public consultation exercise on whether the changes to abortion care that were introduced during COVID-19 should remain in place^[14]. The consultation revealed a range of strongly held views on future arrangements for EMAH, with many welcoming the new arrangements, but many others raising concerns around perceived risks. As an outcome of this consultation exercise, it was decided that a national evaluation on EMAH was needed, due to the concerns raised by a number of consultation respondents.

The Scottish Government subsequently commissioned this evaluation of the COVID-19-related arrangements for provision of EMAH to ensure that Ministers had sufficiently robust evidence available in relation to experiences in Scotland, in order to support their decisions about the future approach. It was also anticipated that the evaluation findings might identify examples of good practice or areas for improvement in service delivery around the country.

A note on terminology: The term ‘patient’ is used throughout the report because it is a gender-neutral term referring to a person receiving medical care. During staff interviews, staff referred to both ‘women’ and ‘patients’. Most people who seek and receive abortion care are (cisgender) women, but it is important to recognise that other people also receive abortion care. ‘Patient’ is a clear and accurate term that encompasses both groups. Furthermore, recent research demonstrates that people seeking abortion prefer the term ‘patient’^[15].