Effectiveness, safety and acceptability of no-test medical abortion provided via telemedicine: a national cohort study

Aiken, A. R. A.; Lohr, P. A.; Lord, J.; Ghosh, N.; Starling, J.

Objectives To compare the effectiveness, safety and acceptability of medical abortion before and after the introduction of no-test telemedicine abortion care. Design Cohort study to assess whether a no-test telemedicine-hybrid care model (telemedicine with in-person provision only when indicated) was non-inferior to the traditional service model (blanket in-person provision including ultrasound scan). Setting The three main abortion providers in England and Wales. Participants All patients having an early medical abortion in the two months before and after the service model change. Patient demographic and clinical characteristics were compared between the cohorts to adjust for any systematic differences in the two groups. Main outcome measures Access: waiting time, gestation at abortion Effectiveness: the proportion of successful medical abortions Safety: significant adverse events defined as: haemorrhage requiring transfusion, significant infection requiring hospital admission, major surgery, death. We also examined the incidence of ectopic pregnancy and late gestation. Acceptability: Patient-reported outcomes of satisfaction, future preference, and privacy of consultation Results The study sample included 52,142 medical abortions; 22,158 in the traditional cohort and 29,984 in the telemedicine-hybrid cohort, of which 61% were provided using no-test telemedicine. The cohorts accounted for 85% of all medical abortions provided in England and Wales during the study period. Mean waiting times were 4.2 days shorter in the telemedicine-hybrid cohort, and 40% were provided at <=6 weeks' gestation compared to 25% in the traditional cohort (p<0.001). There was no difference in success rates between the two groups (98.2% vs. 98.8%, p=1.0), nor in the prevalence of serious adverse events (0.04% vs. 0.02%, p=0.557). The incidence of ectopic pregnancy was equivalent in both cohorts (0.2%, p=0.796), with no significant difference in the proportions being treated after abortion (0.01% vs 0.03%, p=0.123). In 0.04% of cases the abortion appeared to have been provided at over 10 weeks' gestation; these abortions were all completed at home without additional medical complications. In the telemedicine-hybrid group, the effectiveness for abortions conducted using telemedicine (n=18,435) was higher than for those conducted in-person (n=11,549), 99.2% vs. 98.1%, p<0.001. Acceptability was high (96% satisfied), 80% reported a future preference for telemedicine and none reported that they were unable to consult in private using teleconsultation. Conclusions Medical abortion provided through a hybrid model that includes no-test telemedicine without routine ultrasound is effective, safe, acceptable, and improves access to care.