Introduction
Around 44% of pregnancies worldwide are unintended and approximately half of these result in induced abortion(1). Restrictive laws on access to abortion services do not decrease abortion rates but increases the likeliness of abortions to be unsafe(2). Approximately 700 million women of reproductive age live in countries with restrictive abortion laws (3). Additional barriers to access services, irrespective of legal setting, include long-waiting lists, long-distance, lack of transport, high costs and stigma (4). Among the 56 million abortions that were estimated to take place yearly between 2010–2014, 25 million (45%) were estimated to be unsafe(5). In 2014 at least 22800 women worldwide died as a direct result of unsafe abortion(1).
Medical abortion with a combination of mifepristone and a prostaglandin analogue was first developed in the 1980ies(6). Subsequently, the method has been simplified and demedicalized while maintaining high efficacy, safety and acceptability. This development included home use of misoprostol, simplified follow up and task shifting to the midlevel provider and to women themselves(7-10).
Telemedicine in terms of abortion care refers to the use of telecommunications technology by health care professionals, to provide information, counselling, and provision and clinical guidance of medical abortion pills (11). Telemedicine has become increasingly available, both in formal and informal healthcare settings, and is a promising solution to make abortion services more accessible, particularly for those living in rural areas and legally restricted settings(12, 13). Studies of the use of medical abortion in formal settings have found it to be non-inferior to in-clinic provision of services(14-16). Similarly, emerging evidence is showing that medical abortion through telemedicine outside formal healthcare settings is safe, effective and an acceptable method for women (11).
However, gaps remain in evidence on self-managed abortion through telemedicine, and a comprehensive overview of trends in the usage is lacking (17). Two recent reviews on self-managed abortion identified critical areas of future research, including further evidence on physical, social and emotional experiences, and that study settings include diversity in legal restrictions, geographic and social context(12, 17). Therefore, this study aims to provide insight into the use and outcome of self-managed medical abortion through Women on Web, a telemedical abortion service which is operating worldwide, by evaluating follow-up data of women’s self-managed abortion experiences over the past ten years.