Telemedicine early medical abortion at home: evaluation

Recommendations

1. Continuation of approval for home administration of mifepristone for EMAH.

The evaluation was commissioned to inform this decision and provides evidence to support effectiveness and acceptability to patients and staff of home use of mifepristone. Whilst there was insufficient data to draw robust conclusions on safety in relation to rare complications, there were conversely no indications to suggest any concerning increase in complications. There should therefore be continuing approval for home use of mifepristone.

2. Develop quality information around abortion care for national use.

All Health Boards provide patient information on EMAH that they have developed locally, but some boards may find it more difficult than better resourced boards to keep this information updated when changes are introduced to models of care. The Health Board pathways and responses to the patient survey suggested some differences in the written and oral information provided about the abortion and other related services. There is an opportunity with the national website NHS Inform to provide standardised, quality information in a range of formats (including audiovisual animations or films) and languages easily accessible to support informed choice and access to telemedicine EMAH across Scotland. This should include clear information on what the procedure involves, including better information to help patients understand the pain and bleeding they are likely to experience in line with feedback from the patient survey.

3. Improve equity of access to telemedicine EMAH across Scotland.

The Health Board pathways showed variations in access to appointments for abortion consultations across Scotland. With availability of telemedicine there is the opportunity to provide consultations more flexibly across the week to improve consistency of the service patients are offered across different Health Boards. Given the challenges faced by smaller Health Boards, consideration could also be given by boards to formalising arrangements for one or more boards to work more closely together to bridge gaps in availability of telemedicine EMAH services.

4. Optimise the patient pathway for EMAH across Scotland with more choice of options around elements of care including a wide choice of post abortion contraception.

Given variability between Health Boards in the models of EMAH and the patient survey feedback reflecting the desire for choice of options, patient pathways should be optimised across Health Boards to ensure they are patient-centred. Specifically, choices should be offered on: the mode of consultation - in-person or telephone/ video (unless there is a clinical need for an in-person visit)^[23]; whether to have an ultrasound scan (unless this is clinically indicated); choice to have EMAH up to 12 weeks’ gestation; choice of how to access medications, and a wide choice of contraceptive options and availability of options for testing for sexually transmitted infections.

5. Increase support (funding, training, leadership) for staff of abortion services to help them implement improvements to EMAH care.

This recommendation is applicable to abortion services more generally. Through staff interviews in particular it was apparent that because abortion services in Scotland are part of a larger services (hospital or sexual and reproductive health) they must compete with funding or staffing in other parts of the service to implement service improvements. Smaller Health Boards with fewer staff may find this most challenging. Continuing support for the abortion care providers network across Scotland will provide support for service improvements, including the development of shared national guidelines, opportunities for collaborative research, and peer support.