Many women live in areas where abortion is not available. Women on Web (WoW) is a non-profit organization that provides online telemedicine for medical abortion up to 10 weeks of gestation.
It works like this. Women fill out a form, it is reviewed by a doctor, and if they meet the guidelines the misoprostol and mifepristone is mailed. There is a multilingual help desk for real-time support. Women pay what they can. but if they can’t afford anything the medical and support services are free. Four weeks later WoW asks for follow-up information via an e-mail request.
Is it effective and is it safe?
In a new study (BMJ) reserachers reviewed the data from use of this service by women in Ireland (both the North and the Republic). They used data from the request forms and the follow-up e-mail as well as any information sought from the help desk. They reviewed data from two years. During this time frame 1,636 women in Ireland were sent the medications and feedback was obtained from 1,181 women. There was no follow-up whatsoever from 431 women, so it was unknown if they even received the medications and if they did whether they used them or not. Another 24 confirmed they received the medication although no further follow up was provided so it is unknown if they took the medication.
Of the 1,181 women who confirmed that they received the medication and provided follow-up 1,023 actually used the pills. The ones who did not either miscarried in the intervening time frame, sought abortion by other means, or decided to not have an abortion. One had an ectopic pregnancy so did not use the medication. There were 1,000 women who used the medication for whom follow-up data was available.
The success rate of the mailed medication in ending the pregnancies was 94.7%. Another 4.5% needed a surgical procedure to complete their abortion. Symptoms of complications were reported by 9.3% of women and 3.1% required some kind of treatment for a complication (most were antibiotics but a few needed a blood transfusion). Complications were slightly more common in the 7-9 week gestational age group versus < 7 weeks.
As the outcome was self-reported it is hard to know if the complication rate is accurate. In addition, women who experienced complications or thought they were having a complication may not have disclosed their medication use and were likely to be seen by someone with little direct experience with medical abortion. This could have led to over or under treatment. In addition it is not known how many of the 455 women who provided no feedback took the medication and if so if they experienced complications.
Even with those limitations in mind the complication rates for women who provided follow up were fairly similar to those reported by formal telemedicine studies in countries where abortion is not illegal. For example, approximately 3-5% of the time medical abortion fails and a surgical procedure is needed and this happened to 4.5% of women in the WoW study. The blood transfusion rate and antibiotic rate were slightly higher than expected, but still very low (0.7% and 2.5% respectively).
This Internet-based telemedicine approach from another country appears safe for women who live in Ireland and who are willing to use the help desk and seek follow-up for complications. This experience cannot be translated to women accessing the medication from unknown sources with no guidance. When women use unknown sources for medication they may not be getting the right medication or dose. There are many sites selling fake abortion pills. Lack of formal support is also a concern with a DIY approach. This experience also can‘t be translated to countries where mail service may be scrutinized (in fact many women in the Republic had their medications shipped to the North for that very reason) or where accessing medical care may be harder due to lack of local resources, finances, or fear of prosecution.
Telemedicine is so safe for medical abortion that as long as women have access to a surgical procedure (D & C) for back up, antibiotics, blood (in the rare case) and an emergency room the success rate approaches 95%. While it is never ideal for women to need clandestine sources the approach offered by WoW is much safer medically than any do-it-yourself procedure or illegal provider and an Internet-based telemedicine abortion service can offer almost the same outcomes for medical abortion as in person clinics.