Is telemedicine abortion safe?

Does abortion pill reversal work?

Is telemedicine abortion safe?

During the COVID-19 pandemic, a small number of countries implemented full telemedicine abortion, whereby a woman could obtain abortion pills in the post to take at home without ever seeing a medical professional in person. It has been claimed that this is perfectly safe and effective – some even claim it is more safe and cost-effective because it leads to abortions at earlier gestations, therefore leading to fewer complications.

A number of concerns have been raised, including by some of the UK’s most senior medics, that such a system is unsafe, for various reasons:

1. Safeguarding: Coerced abortions are common, and the widely acknowledged best way to guard against these was for a woman to be seen in private in a clinic, without anyone else present. This is impossible through telemedicine. Moreover, abortion, especially repeat abortion (about 42% of abortions), is associated with domestic abuse, and women being seen in person can be a helpful way of screening such women for abuse.
2. Delayed gestation: Since there is no real determination of gestational age by examination or ultrasound (only by last menstrual period, which is not reliable), and since there can be a significant delay between receiving the pills and taking them, women can take (accidentally or deliberately) abortion pills long past the ‘safe’ limit (10 weeks), posing moral, legal and physical risks, including risk of Rhesus isoimmunisation. Abortions at home well beyond the limit of 10 weeks (and even beyond the general legal limit of 24 weeks) have occurred in significant numbers in the UK.
3. Ectopic pregnancy: Since there is no ultrasound or examination prior to the abortion, there is no opportunity to screen the woman properly for a possible ectopic pregnancy, which could rupture and cause fatal haemorrhage. Worse, since the symptoms of medical abortion and ectopic pregnancy are very similar, symptoms of a ruptured ectopic could be masked by the symptoms of medical abortion, which typically last 2 weeks and often more. Ruptured ectopics have been seen in the UK and elsewhere from abortion without ultrasound.
4. Interval between mifepristone and misoprostol: to be fully effective, the correct interval must be observed between the two drugs. Lack of proper interval can lead to various complications. If the administration of the drugs is not observed, the interval can be well outside the appropriate limits.
5. Limited sexually transmitted disease testing: Department of Health data from the UK show that 10-12% of women having abortions were not screened for chlamydia in the years leading up to telemedicine, while 20% were not screened in 2020. This lack of screening will probably lead to increased transmission of chlamydia in the population.
6. Limited contraceptive provision: Of the different contraceptive options, only LARCs (long acting reversible contraceptives) are reliable with typical use – other non-LARC options have 70-94% effectiveness, meaning they fail at a rate of 6-30% per year. Over several years of use, it is not at all unlikely that they will fail. Contraceptive injections have a typical use failure rate of 94%, meaning that over 10 years there is a 46% chance of becoming pregnant, for example. The chance of becoming pregnant using condoms alone over 10 years is more like 86%. Hence LARCs significantly affect the number of unwanted pregnancies. Prior to telemedicine, around one third of women received LARCs after abortion. During telemedicine, only 8.7% did.
7. Lack of examination for other findings: Examination (perhaps including blood tests) could pick up on a variety of other potential issues, such as anaemia, reproductive tract infection, or multiple pregnancy. Anaemia would put a woman at greater risk of severe problems from haemorrhage as a result of the abortion, and multiple pregnancy would likewise complicate the procedure (and perhaps affect her decision). Abortion can likewise be significantly complicated by pre-existing infection.

This is only a very short overview of the problems. For a full summary of these issues, with references, see my Routledge book chapter on the topic (available on request).

Does abortion pill reversal work?

I currently have a paper under review on this topic, which is available on request. The key points are:

1. People who support choice should support research towards, and the availability of, abortion pill reversal. It is odd that people who are pro-choice are so vehemently opposed to it.
2. There is some provisional evidence it works: the mechanism makes sense, it works in animal models, and there is a reasonably large case series with promising results (and a cancelled randomised trial, which is too small to say much from but which also looked promising). However, more work is needed. Still, as long as women are informed that the evidence is relatively limited (but still promising), it should be available to them.
3. The evidence of safety concerns is completely spurious, relying on a minuscule study finding that one woman in the treatment group went to hospital for haemorrhage (but needed no treatment at all). Two women in the control group had haemorrhages, but for a variety of reasons (including the fact that these women did not receive the treatment, by definition) this says nothing about the safety of abortion pill reversal.
4. Hence, as long as women are appropriately informed, abortion pill reversal should be available on a provisional basis. Further research should be conducted.

For more detail, see my paper.