Introduction
Around 44% of pregnancies worldwide are unintended and approximately
half of these result in induced abortion(1). Restrictive laws on
access to abortion services do not decrease abortion rates but increases
the likeliness of abortions to be unsafe(2). Approximately 700
million women of reproductive age live in countries with restrictive
abortion laws (3).
Additional barriers to access services, irrespective of legal setting,
include long-waiting lists, long-distance, lack of transport, high costs
and stigma (4). Among
the 56 million abortions that were estimated to take place yearly
between 2010–2014, 25 million (45%) were estimated to be unsafe(5). In 2014 at least
22800 women worldwide died as a direct result of unsafe abortion(1).
Medical abortion with a combination of mifepristone and a prostaglandin
analogue was first developed in the 1980ies(6). Subsequently, the
method has been simplified and demedicalized while maintaining high
efficacy, safety and acceptability. This development included home use
of misoprostol, simplified follow up and task shifting to the midlevel
provider and to women themselves(7-10).
Telemedicine in terms of abortion care refers to the use of
telecommunications technology by health care professionals, to provide
information, counselling, and provision and clinical guidance of medical
abortion pills (11).
Telemedicine has become increasingly available, both in formal and
informal healthcare settings, and is a promising solution to make
abortion services more accessible, particularly for those living in
rural areas and legally restricted settings(12,
13). Studies of the use of medical
abortion in formal settings have found it to be non-inferior to
in-clinic provision of services(14-16). Similarly,
emerging evidence is showing that medical abortion through telemedicine
outside formal healthcare settings is safe, effective and an acceptable
method for women (11).
However, gaps remain in evidence on self-managed abortion through
telemedicine, and a comprehensive overview of trends in the usage is
lacking (17). Two
recent reviews on self-managed abortion identified critical areas of
future research, including further evidence on physical, social and
emotional experiences, and that study settings include diversity in
legal restrictions, geographic and social context(12,
17). Therefore, this study aims to
provide insight into the use and outcome of self-managed medical
abortion through Women on Web, a telemedical abortion service which is
operating worldwide, by evaluating follow-up data of women’s
self-managed abortion experiences over the past ten years.