For the first time, WHO recommends telemedicine for abortion

For the first time, the World Health Organization is recommending the use of telemedicine for abortions, when appropriate. If someone only needs a medical abortion — which involves the use of medication rather than a surgical procedure — traveling to a facility isn’t necessary, according to the agency.

In new guidelines on abortion care — which were released Wednesday and include over 50 recommendations on clinical practice and health service delivery, as well as legal and policy interventions — WHO said health workers can use telemedicine to assess if someone is eligible for a medical abortion to end a pregnancy. Health workers could also use this method to provide counseling, instructions on how to get and then take the medication, and follow-up care after the abortion is over, including offering linkages to contraceptives.

This is the first time in a decade that the agency has published comprehensive abortion guidelines.

Nearly half of all abortions globally — amounting to tens of millions per year — are unsafe, and about 97% of these occur in lower-income countries. Unsafe abortions lead to the deaths of an estimated 39,000 people annually, with over 60% of these in Africa and 30% in Asia. This happens even though abortion, when done in accordance with recommendations, is a simple and safe health service.

With medical abortion, a patient will generally take one pill first and then a second set of pills at a later time. This is followed by a miscarriage-like process.

WHO’s guidelines have recommended the use of medical abortions since 2003. Two decades ago, the recommendations were that only physicians in hospitals should perform abortions. But since then, more evidence has piled up proving the safety of these medications, making it clear they can be distributed at primary levels of health and even with elements of self-management, especially in early pregnancy, Dr. Bela Ganatra — who leads WHO’s work on preventing unsafe abortion — told Devex in an interview.

“Some women might want to take the pills at home. Some women might prefer facility-based care. It's all about giving options and choices to women,” Ganatra said. For over a decade, WHO guidelines have said that a post-abortion scan isn’t routinely necessary to determine that the procedure is complete, although it is needed in some cases. But complications are rare if the abortion is conducted safely. If nothing goes wrong, the whole abortion could be completed through telemedicine, she said.

“In studies comparing telemedicine with in-person medical abortion care services, there was no difference between the two groups in rates of successful abortion or ongoing pregnancies,” according to the new guidance. Telemedicine could include a live interaction between a health care worker and a person seeking an abortion — through a call or video link, or through email, text, or audio messaging. WHO did not review hotlines, digital applications, or one-way communication methods, such as reminder text messages, for these recommendations.

This sort of health care delivery is particularly useful in areas where health facilities might be located far away or in circumstances like the COVID-19 pandemic, where mobility is restricted. During the pandemic, many health care services needed to be conducted outside centralized facilities.

While abortion of some kind is lawful in most countries, the circumstances vary in which it is allowed, and about 20 countries have no legal grounds for the procedure, according to WHO. More than three-fourths of countries have legal penalties for the person getting the abortion or those who aid in the process, which include long prison sentences and expensive fines. “It's an immense barrier to access,” Ganatra said.

Beyond laws, abortions are also stigmatized, meaning those seeking them at a health facility might be abused or even reported to police — consequences that can be avoided if the service can be accessed in the relative privacy of the home.

But Ganatra cautioned that telemedicine is not a silver bullet and that there is still a need for the basics: trained health workers and access to quality medicines.

“It's not the solution to the underlying issues that women continue to face in terms of access to abortion,” Ganatra said. “The barriers they face don't automatically go away if you use telemedicine, but some of them do.”

She added: “It doesn't solve everything. But it is super, super important. Otherwise, you would have found that unsafe abortion and mortality during the pandemic could have skyrocketed if there had been no alternative means to access safer abortion other than facility-based care.”

And beyond telemedicine, the guidelines advocate to expand the range of health care workers involved in providing medical abortions. Much abortion care is traditionally restricted to OB-GYNs, and in a departure from other health services, these restrictions are often written into laws and policies, Ganatra said. This made sense historically when abortions were primarily surgical procedures, but midwives and nurses can provide these pills just as safely, she said.

The new guidelines also advocate for “removing medically unnecessary policy barriers to safe abortion, such as criminalization, mandatory waiting times, the requirement that approval must be given by other people (e.g., partners or family members) or institutions, and limits on when during pregnancy an abortion can take place.”

The Center for Reproductive Rights called this the agency’s “most progressive guidance to date” on abortion.