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New study shows safety of Internet telemedicine for medical abortion in Ireland

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Many women live in areas where abortion is not available. Women on Web (WoW) is a non-profit organization that provides online telemedicine for medical abortion up to 10 weeks of gestation.

It works like this. Women fill out a form, it is reviewed by a doctor, and if they meet the guidelines the misoprostol and mifepristone is mailed. There is a multilingual help desk for real-time support. Women pay what they can. but if they can’t afford anything the medical and support services are free. Four weeks later WoW asks for follow-up information via an e-mail request. 

Is it effective and is it safe?

In a new study (BMJ) reserachers reviewed the data from use of this service by women in Ireland (both the North and the Republic). They used data from the request forms and the follow-up e-mail as well as any information sought from the help desk. They reviewed data from two years. During this time frame 1,636 women in Ireland were sent the medications and feedback was obtained from 1,181 women. There was no follow-up whatsoever from 431 women, so it was unknown if they even received the medications and if they did whether they used them or not. Another 24 confirmed they received the medication although no further follow up was provided so it is unknown if they took the medication.

Of the 1,181 women who confirmed that they received the medication and provided follow-up 1,023 actually used the pills. The ones who did not either miscarried in the intervening time frame, sought abortion by other means, or decided to not have an abortion. One had an ectopic pregnancy so did not use the medication. There were 1,000 women who used the medication for whom follow-up data was available.

The success rate of the mailed medication in ending the pregnancies was 94.7%. Another 4.5% needed a surgical procedure to complete their abortion. Symptoms of complications were reported by 9.3% of women and 3.1% required some kind of treatment for a complication (most were antibiotics but a few needed a blood transfusion). Complications were slightly more common in the 7-9 week gestational age group versus < 7 weeks. 

As the outcome was self-reported it is hard to know if the complication rate is accurate. In addition, women who experienced complications or thought they were having a complication may not have disclosed their medication use and were likely to be seen by someone with little direct experience with medical abortion. This could have led to over or under treatment. In addition it is not known how many of the 455 women who provided no feedback took the medication and if so if they experienced complications.

Even with those limitations in mind the complication rates for women who provided follow up were fairly similar to those reported by formal telemedicine studies in countries where abortion is not illegal. For example, approximately 3-5% of the time medical abortion fails and a surgical procedure is needed and this happened to 4.5% of women in the WoW study. The blood transfusion rate and antibiotic rate were slightly higher than expected, but still very low (0.7% and 2.5% respectively).

This Internet-based telemedicine approach from another country appears safe for women who live in Ireland and who are willing to use the help desk and seek follow-up for complications. This experience cannot be translated to women accessing the medication from unknown sources with no guidance. When women use unknown sources for medication they may not be getting the right medication or dose. There are many sites selling fake abortion pills. Lack of formal support is also a concern with a DIY approach. This experience also can‘t be translated to countries where mail service may be scrutinized (in fact many women in the Republic had their medications shipped to the North for that very reason) or where accessing medical care may be harder due to lack of local resources, finances, or fear of prosecution. 

Telemedicine is so safe for medical abortion that as long as women have access to a surgical procedure (D & C) for back up, antibiotics, blood (in the rare case) and an emergency room the success rate approaches 95%. While it is never ideal for women to need clandestine sources the approach offered by WoW is much safer medically than any do-it-yourself procedure or illegal provider and an Internet-based telemedicine abortion service can offer almost the same outcomes for medical abortion as in person clinics.

Discussion

7 thoughts on “New study shows safety of Internet telemedicine for medical abortion in Ireland

  1. Forgive me if I’m mansplaining:

    The law around abortion is the same in Great Britain (England and Wales, and Scotland) as it is in Northern Ireland and the Republic of Ireland; it is the Offences against the Person Act of 1861 [as amended]. There has been a recent, minor, change to this in the Republic which permits abortion is very limited circumstances and when multiple physicians are in agreement.

    In GB, the 1967 Abortion Act provides a legal defence to a charge of procuring an abortion when two physicians have agreed that the women’s health would otherwise suffer. This is not decriminalisation.

    It remains illegal in all jurisdictions for people/women to obtain abortifacients, for example as described here, from Women on Web. The maximal sentence is imprisonment for life. In Great Britain, women can be prescribed such medications in the usual and entirely legal way through a general practitioner with the cost covered by the NHS.

    In the Republic of Ireland particularly, Customs officials and the Post Office can and do intercept packages suspected to contain abortifacients. The percentage of packages intercepted in this way is unknown.

    In N Ireland, one woman was recently tried before a court on a charge of procuring abortifacients (a ‘poison’); she was convicted and sentenced. [I believe that this also happened in England, but I have no reference.]

    These problems may explain, in some part, the incompleteness of the data provided.

    Posted by korhomme | June 29, 2017, 2:33 pm
    • Yes, I did make note of the mailing issue and why many women elect to have their medications mailed to the North.

      Posted by Dr. Jen Gunter | June 29, 2017, 2:50 pm
      • To date, I haven’t heard that the medications are subject to the same scrutiny in N Ireland as in the Republic; I’ve not heard of packages being intercepted here. Nonetheless, not all women in the Republic have the convenience of an address in the North, or relatives/friends willing to accept such packages.

        (You may have heard that the UK government has agreed to fund the cost of abortions for women from N Ireland who travel to Great Britain. Some women from the South can make use of an address in the North.)

        Posted by korhomme | June 29, 2017, 2:58 pm
    • While the law in ROI & NI technically allows abortion in exceptional cases (life of the mother is at risk, in cases of rape and incest, etc), in practice authorisation just doesn’t happen. Girls and women in appalling situations are turned away as a matter of course.

      Some of the cases are unequivocally awful (raped children, anencephalic foetuses, suicidal patients), yet the person seeking abortion is refused help. In more than one case doctors have told women to “Go home and have a cup of tea, and calm down, let nature take its course”. Some doctors have lied to patients about what gestational stage they’re at, or have downplayed horrific foetal abnormalities, the law is essentially meaningless if doctors won’t abide by it.

      This is what happens when religion and medicine mix. Fortunately WOW exists, activists and grass roots groups also stockpile mifepristone and misoprostol to help women who don’t have the luxury of using an address elsewhere.

      There are also charities like the Abortion Support Network who exist solely to help Irish girls and women to get to the UK for abortions. They’re an amazing organisation and I’m proud to be one of their donors. Some of the stories in their monthly newsletter are a heartbreaking testament to how useless the law is, and how badly it fails women.

      Posted by Boostick | June 29, 2017, 7:22 pm
      • In both the North and the Republic, the only permissible grounds for abortion are a serious risk to the life of the mother or to her mental health. Rape and incest, by themselves, are not permissible grounds.

        And yes, I’ve heard all about how so many women are refused abortions; there was a recent case in the Republic where it seems that the woman was to be sectioned for wanting an abortion.

        I agree abut ASN, and I too am a donor. (They also offer support to the Isle of Man.)

        Posted by korhomme | June 30, 2017, 12:14 am
      • I know whereof you speak. Thanks for letting the rest of us know, too. Just because “certain” kinds of abortion are (theoretically) legal doesn’t mean anything in most cases. Kind of like in the U.S. in some states.

        Posted by bri65 | July 9, 2017, 2:24 pm
  2. With the climate in the US with this new administration, this is a serious discussion, and one that may be needed here. I’m glad women in Ireland were given this opportunity.

    Posted by Katie | June 30, 2017, 9:00 am

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