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Medication abortion via digital health in the United States: a systematic scoping review

Our articles screening strategy for this scoping review is shown in Fig. 1. We identified a total of 757 studies and removed 88 duplicates and 527 other articles based on information in the title and abstract. The remaining 141 studies were subjected to full-text review, and 108 were excluded for reasons that included failure to report medication abortion through telemedicine as an outcome variable, studies contacted outside of the United States, or review papers. The final scoping review included 33 studies (Fig. 1).

Fig. 1

Articles screening process regarding digital health and telemedicine access to medication abortion in the United States, 2023.

The characteristics of the included studies are shown in Table 1. Of the studies included in the final review, 11 were qualitative studies11,12,15,22,23,24,25,26,27,28,29, 6 were cross-sectional studies30,31,32,33,34,35, and 13 were cohort (prospective, retrospective, or follow-up) studies8,10,16,18,36,37,38,39,40,41,42,43,44. One study used mixed methods approach45, one used a multicenter single-arm clinical trial46, and one used an investigational new drug application (INDA) approach13. The participants in 26 studies were potential abortion users7,8,10,11,14,15,16,18,22,27,28,31,32,33,34,36,37,38,39,40,41,42,43,44,45,46, the participants of two studies included both abortion users and providers26,29, and those of the remaining five studies were abortion care providers12,23,24,25,26,35 (Table 1).

Table 1 Characteristics of studies included in digital health and medicine for medication abortion in the United States, 2023.

Telemedicine and abortion access

The results and themes identified from the included studies are shown in Table 2. Six studies assessed the role of telemedicine in increasing access to abortion care25,32,34,38,41,43, particularly for potential abortion users living in remote areas38. Grossman et al. (2013) reported that the proportion of potential abortion users who used medication abortion increased from 46% to 54% following the introduction of telemedicine38. Similarly, Kohn et al. (2021) showed that the proportion of medication abortion users in Montana increased from 60% to 65%, and the number of abortion users for those in Nevada increased from 461 to 735 after the implementation of abortion via telemedicine41. Finally, a study by Thompson et al. (2021) suggested that making abortion care available via telemedicine could increase the abortion access rate from 11.1 to 12.3 per 1000 reproductive-age women34 (Table 2).

Table 2 Results or themes identified from the included studies in medication abortion via telemedicine in the United States, 2023.

Providers’ view and experience of telemedicine

Six studies explored the views and experiences of abortion care providers regarding the provision of medication abortion via telemedicine12,23,24,25,26,29. These providers expressed their feelings that telemedicine had expanded the access to medication abortion for their patients29 and that telemedicine needed to adopt processes similar to those used in in-person clinic visits, with minor additional technological arrangements to facilitate the electronic interface between patients and doctors12.

Qualitative studies of the providers’ experiences suggested that the provision of medication abortion via telemedicine facilitated a more user-centered approach, with abortion seekers receiving the services closer to their homes, thereby reducing the need for long-distance travel by both patients and physicians12,26 and providing flexible appointment times26. However, in a study conducted among telehealth leaders, a few participants expressed concerns that in providing abortion services via telemedicine, care providers would be unable to verify their patient’s identity, would experience difficulties in ensuring that the abortion medication provided via telemedicine would be taken by the right patient, and the potential that abortion services might be accessed by minors in the absence of parental consent24.

Abortion users’ views on abortion via telemedicine

Seven studies assessed the views and perceptions of potential abortion users regarding their access to abortion services via telemedicine11,15,26,28,29,33,45. Overall, the perceptions of potential abortion users regarding telemedicine abortion services were positive26. Many users who had abortions supported the use of telemedicine for medication abortion, particularly during the COVID-19 pandemic period, and felt that the effectiveness of telemedicine service was almost equivalent to that of in-person abortion service45. A survey conducted among 1567 abortion users reported that 56% of overall participants and 64% of medication abortion participants preferred to receive abortion services via telemedicine33.

According to the study conducted by Kerestes et al. (2021), potential abortion users reported that the availability of abortion services through telemedicine made these services more accessible and convenient relative to the services provided in-clinic15. The study further elaborated that abortion services via telemedicine were the option preferred by patients because their receipt of counseling via telemedicine and abortion medication by mail eliminated a long waiting time for appointments and the need for other arrangements, including transportation and childcare required for in-clinic service15. Similarly, abortion users in another study reported that using abortion services via telemedicine helped them to minimize the financial, travel, and time-related burdens necessitated by in-person visits11. However, a significant number of potential abortion users expressed worry about the time-sensitive nature of abortion in case the medication should not arrive within the recommended time28.

The majority of the abortion users reported that addressing their concerns and medical-related questions to the care providers over telemedicine was similar to or more comfortable than face-to-face visits26,29. However, some users felt less personally and emotionally connected with the care providers on telemedicine video calls, felt that video calls were less legitimate than in-person visits, or expressed concerns about scams and breaches of privacy and therefore preferred to be in the same room with their abortion care providers11,26,29,45. Moreover, several participants of the study described by Ehrenreich et al. (2019) reported that they did not find the information script provided through telemedicine to be informative, either because of its content or delivery method (i.e., felt that using telemedicine to deliver the information would be weird)11.

Reason for choosing abortion services via telemedicine

Ten studies reported the reasons that potential abortion users elected to use telemedicine rather than face-to-face meetings for their abortion services11,12,15,16,22,26,27,30,32,36. The most common reasons for preferring telemedicine included the long distance from their homes to the abortion clinics11,16,22,30,36, convenience11,15,16,32, privacy11,16,22,30,36, cost (unaffordable cost of in-clinic abortion or personal financial hardship)11,16,27,30,36, the flexibility of appointment times16,32,36, state laws that included a waiting period or specified restrictive policies for accessing an abortion clinic22,27,36, perceived stigma16,22,36, and preference for talking via a video call32. Two studies by Aiken et al. (2020, 2021) reported that 69–73% of potential abortion users who selected the use of telemedicine did so because of their inability to afford in-clinic abortion services, while 39–49% did so for reasons of privacy30,36. On the other hand, Kaller et al. (2021) reported that 73% of the users they surveyed chose to receive their abortion services via telemedicine because it was more convenient than a clinic visit32.

Effectiveness of abortion via telemedicine

Ten studies investigated the effectiveness of medication abortion services offered via telehealth in the United States7,14,16,18,27,37,39,40,42,44. Kerestes et al. (2021) reported that 97% of telemedicine users completed their abortion without requiring additional surgical intervention, compared to 93.6% of clinic visit patients40. Similarly, Grossman et al. (2011) reported that 99% of abortions among telemedicine users were successful, while the success rate was 97% for face-to-face patients37.

The majority of the studies we reviewed reported that ≤6% of abortions were completed without the need for additional surgical intervention14,16,18,40,42,44. The rates of clinically adverse effects reported ranged from none to ≤ 1%7,18,37,42, and no deaths were reported7,42. However, a study by Women on Web conducted between 2016 and 2019 among 131 recipients of medication abortion at ≥13 gestational weeks via telemedicine stated that 29% of the abortion users reported adverse events such as fever or heavy bleeding, that 43% received additional care, and that 18% of the abortion procedures occurred by aspiration39. Similarly, Raymond et al. (2019) reported that 7% of the participants visited an emergency center for urgent care16.

Regarding the development of adverse events, almost all studies reported no significant difference in the development of clinically significant adverse effects among telemedicine users and standard or face-to-face abortion care users37. However, the use of an aspiration procedure was less common among telemedicine users as compared to standard procedure user patients (1.4% vs. 4.5%)42. More patients also used the telemedicine service for unscheduled communications with office assistants than did patients who received their care in-person (46.2% vs. 21.6%)44.

Telemedicine abortion service during the COVID-19 pandemic

A few studies reported how the COVID-19 pandemic influenced the utilization of abortion services via telemedicine8,14,23,35. The demand for abortion services by telemedicine greatly increased during the COVID-19 pandemic8,14,23. Most clinics integrated telemedicine services into clinical care to supplement existing abortion services in the clinic and for other patient appointments23.

A study conducted among 100 clinics reported that 87% of the clinics made changes to their service protocols due to the COVID-19 pandemic, including initiating or increasing the use of telemedicine for patient screening, consultations, or follow-up, eliminating or reducing the requirement for pre-abortion testing such as ultrasound and blood tests to screen for Rh factor, and providing rapid access to abortion pills. Facilities in the North reported a higher increase in the use of telemedicine for abortion services (73%) than did facilities in the South (23%)35.