Summary of "Using Telemedicine for Termination of Pregnancy With Mifepristone and Misoprostol in Settings Where There is No Access to Safe Services," Gomperts et al., British Journal of Obstetrics & Gynaecology, July 2008.
Without access to safe abortion services, women often will risk their health and lives to obtain abortions from unqualified people in unhygienic settings. Nineteen million women each year experience unsafe abortions, and 68,000 women die from complications associated with unsafe procedures. Although mifepristone, which is used in combination with misoprostol to induce abortion, has been on the list of essential medicines of the World Health Organization since 2005, neither drug is available in many countries.
Rebecca Gomperts, founder of Women on Waves, and colleagues conducted a survey of women who accessed mifepristone and misoprostol on the Web site Women on Web, which provides women a safe alternative in countries where there is no access to safe abortions. After an online consultation, responses from women who are fewer than nine weeks' pregnant are referred to a physician, and the drugs and a pregnancy test are sent by mail if there are no contraindications. The study aimed to review women's reports about the Web service and the consequences experienced through self-administering the medication abortion drugs.
Methods and Findings
Gomperts and colleagues conducted interactive Web-based questionnaires, follow-up forms, e-mails and telephone calls among 265 of the 484 women who received the drugs between April 2006 and December 2006 to determine the outcome of the procedure, complications, acceptability and contraceptive use. To increase the amount of follow-up information, the researchers conducted an additional survey among all the women who used the drugs to induce a medication abortion in January 2007. For the month of January, women who did not return the follow-up form were actively contacted by phone.
Of the 484 women who received the drugs, 387 were less than seven weeks' pregnant and 97 were between seven and nine weeks' pregnant. The gestational age was confirmed by ultrasound among 382 women. The average age of the women was 27, and 39 were teenagers. In addition, 227 women had never given birth, and six women reported an unplanned pregnancy as a result of rape.
According to the researchers, 265 women provided information through the routine follow-up form or by e-mail. Sixteen of the 265 women reported that they decided not to use the medication after they had received it. Of the remaining 249, 13.6% reported undergoing a curettage/vacuum aspiration for an incomplete miscarriage or for excessive bleeding. In addition, about 0.8% reported using antibiotics for an infection, and 1.6% reported a continuing pregnancy. The researchers noted that two of the women might have made a mistake when completing the form online. Of the 249 women, 58.2% said they were grateful for the service; 30.9% said they felt stressed but found the experience acceptable; 9.8% had no specific feelings about the service; and 1% reported that if they had known before how stressful it would be, they would not have performed the abortion themselves. In the separate analysis of the 174 women who received the medication in January 2007, 135 women returned a follow-up form, e-mail or were contacted by telephone. Of the 135 women, 12.6% decided not to use the medication, 6.8% had a curettage/vacuum aspiration for an incomplete miscarriage and about 2.5% received antibiotics.
Discussion
The researchers noted that the "main difference" between the Women on Web service and abortions performed in outpatient settings is that with the Web site services, a physician does not confirm gestational age by a physical examination. In addition, there is an increased risk when women obtain medication via the Web site that they will underreport their gestational age to access help. To respond to these challenges, the Web site provides warnings about the risk of complications with longer gestational ages. In addition, during the online consultation, women are advised to have an ultrasound to establish the duration of the pregnancy and to reduce the risk of an ectopic pregnancy.
According to the researchers, the findings of the survey are "reliant on self-reporting and therefore prone to potential inaccuracies." They added that although the results are potentially "limited" because of this, as well as a low response rate, "whether or not complications occur is a question that will not be influenced by the mode of reporting." The researchers conclude that as long as there are countries where abortion access is restricted, the online service provides women a "good alternative to other traditional procedures" and can reduce "maternal mortality and morbidity from unsafe" abortions.
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