When Maria began feeling unwell during the fall of 2020, she immediately went to a COVID-19 test centre for what she assumed would be a confirmation that she had contracted the virus.
Though her COVID test came back negative, Maria (not her real name) did get a positive result as well – she was pregnant. A few days later, she phoned her family physician’s office to discuss her options. During the call, her doctor told her she would not provide the necessary medications to end her pregnancy. The nearest hospital providing surgical abortions was nearly three hours’ drive away.
“It was a really hard knock,” she says. “I had thought, ‘I have a female doctor, this will be no problem.’ She told me that while she supported my choice, she didn’t feel ‘ethically good’ about prescribing it. I was panicking and scared, and I didn’t know what to do.”
While her doctor was willing to provide a referral, she “didn’t know who to send it to,” says Maria.
Although abortion care is available in every Canadian province, the distribution of centres providing medical and surgical terminations of pregnancy are not evenly spread, with clustering of access in city centres. At the onset of the pandemic, leaders across the country quickly affirmed abortion as an essential service. However, ongoing travel restrictions, increased vulnerability of marginalized populations and rising domestic violence raised concerns that seeking care may be more difficult than ever, even with commitments by providers to remain open.
In response, the Society of Obstetricians and Gynecologists of Canada mobilized to produce the Canadian Protocol for the Provision of Medical Abortion via Telemedicine, laying out instructions for “no-touch” or “low-touch” medical abortions, in which as much care as possible is offered without patient and provider meeting face-to-face. For an ideal patient with an early pregnancy, this could eliminate the need for ultrasounds or laboratory testing, requiring only confirmation with two urine pregnancy tests. Patients could pick up their abortive medication, Mifegymiso, from their pharmacy of choice, without ever setting foot in a hospital.
For Julie Thorne, staff physician at Mount Sinai and Women’s College Hospitals in Toronto and co-author of the protocol, that represented an acceleration in the direction her field was already taking.
“The COVID pandemic allowed an interesting opportunity for us to take existing evidence on safety and efficacy (of no-touch abortions) and say, now we have an urgent reason to put this into practice,” says Thorne.
Women’s College Hospital was at the forefront of this movement, integrating telemedicine in abortion care within a few months of the first wave.
“We were all very cautious in the beginning, but as time went on, people began to see that the success of this approach is similar to the success of seeing (patients) in person,” she says. “We saw that patients can give reliable histories if you take the time to ask the questions, and that we can reliably use their answers to determine whether someone might need an ultrasound, further lab tests or a visit to a clinic. And we became more confident.”
Thorne’s stance is supported by global evidence as abortion providers have doubled down on telemedicine as a solution to pandemic-related barriers to access. A recently published cohort study of more than 50,000 women in the United Kingdom found no difference in treatment success or serious adverse events between those seen through a traditional, in-person approach with ultrasounds and those seen via telemedicine. Mean time from referral to treatment was 4.2 days shorter in the telemedicine group. Indeed, over the past several decades, advocacy organizations like Women on Web have provided international access to abortive pills through the mail using only virtual consultations, an approach deemed to be safe and effective by the World Health Organization.
As restrictions placed on clinical medicine across Canada ease, we are now faced with a new question in the abortion debate: Should we take a step backward and restrict abortion care once more to our tried-and-true, in-person assessments, or embrace telemedicine and contactless care as a new normal?
For Sarah Warden, lead physician for the medical abortion program at the Bay Centre for Birth Control at Women’s College Hospital in Toronto, the answer is clear. “We have always felt that (no-touch abortion) had applications beyond the pandemic,” she says. “And at this point, more of our patients are accessing it due to geographical concerns than concerns over the pandemic.”
In reviewing the data from the past 12 months, Warden says she is confident of the safety and efficacy of the treatment, sharing that they have had only one failed abortion (a patient for whom medical management was insufficient and who ultimately required a surgical abortion), and no serious adverse events in more than a year of providing no-touch abortions.
Erika Feuerstein, a family physician and abortion provider in Toronto, agrees. Although her clinic does not offer telemedicine for abortion at this time, she says telemedicine would offer enhanced access to care for many patients.
“Should we embrace telemedicine and contactless abortion care as a new normal?”
“I think the biggest benefit is to be able to expand to provide service where it’s not readily available,” she says. “Virtual care is a whole new realm to provide equity in access to abortion.”
However, she says that no-touch abortion should not entirely replace in-person protocols. “Telemedicine is an amazing add-on, but abortion is a very personal experience and for some people, virtual won’t work,” Feuerstein. “What might be safe for one person might not be safe for another, and many of our patients do want to come into the clinic to be seen.”
For patients outside of urban centres, or whose social or financial circumstances make attending clinic appointments challenging, contactless care can make all the difference. However, the novelty of the no-touch approach means not many providers – much less patients – know this is an option. Several weeks after her initial visit with her family physician, Maria was able to access a surgical abortion at a hospital. She was not offered a no-touch option.
“If someone had been able to just prescribe me the pills over the phone, I would definitely have chosen that,” she says. “I would have been able to be at home and have my partner there. And I wouldn’t have had to go through weeks of knowing that I was pregnant and having to struggle with the decision over and over again.”
Maria was able to make the six-hour round trip to the hospital in the same day for her initial assessment, but when it came time for her procedure a week later, she arrived the night before and stayed in a hotel nearby. Her partner made the trip with her for support, but also because she was too ill with morning sickness to safely drive on her own. Both were able to secure time off and follow the hospital’s pre-operative quarantine and COVID test policies prior to arrival.
“I think of a teenager, or someone who couldn’t take time off work, or pay for the trip, or have support from a partner or family, what would you do? What would you do? I’m so lucky,” says Maria.
With ample support from providers and patients, the case for telemedicine’s role in termination of pregnancy seems strong. Yet there are still challenges to be overcome in establishing the protocol as an option outside of the pandemic.
Mifegymiso is not readily available at all pharmacies, and physicians may have difficulty prescribing medication for out-of-province patients. Smaller abortion centres may face an up-front cost in establishing the internal infrastructure required to confidentially share consent forms and other medical documentation between patients and their EMR. In Ontario, there is no equivalent virtual billing code for in-person abortion counselling, meaning primary care physicians may not be adequately remunerated for the comprehensive care they are providing.
Still, Thorne says that the temporary provisions in place can not only be made permanent but built upon. She calls for national data reporting from sites offering no-touch abortions to confirm safety and effectiveness, and for continued advocacy to support the use of telemedicine in abortion care at provincial and federal government levels.
“Virtual care is going to change the landscape of mainstream care and improve equity everywhere,” she says. “Ultimately, we need to move away from thinking of telemedicine as a pandemic-centred measure and start thinking of it as a patient-centred measure.”
Illustration by the author, Meghan McGrattan.