An examination of patient experience with telehealth medication abortion services in the United States

BackgroundAbortion is very common - about one in four women will terminate a pregnancy during their lifetime - but access to clinic-based care is heavily restricted in the United States. Medication abortion is a safe, effective, and non-invasive option for terminating early pregnancies, and has become more widely available via telehealth services, with medications mailed directly to patients. Abortion services that improve service to communities in need of care warrant careful evaluation to ensure that best practices are followed and improve upon. Specifically, little today is known about the patient experience with telehealth abortion options, perspectives on these services, and how these models of care impact access to care. Aims (1) Examine how sociodemographic characteristics differ between those who received telehealth versus in-clinic care, (2) understand how patients choose between modalities of care and their subsequent satisfaction with their experience, and (3) examine how patients communicate with providers when receiving asynchronous telehealth abortion care. Methods This mixed-methods study consists of multivariate cross-sectional regression analyses with electronic medical record patient data of individuals who received medication abortions from two clinics (quantitative) and thematic coding of patient-provider email communication and in-depth interviews with a subset of patients (qualitative). Findings Study 1: Nearly one-quarter received a telehealth visit (n=383, 22.7%). Participants were ethnically/racially diverse: self-identifying as 17.7% Asian/Native Hawaiian/Other Pacific Islander, 18.9% Black/African American, 15.3% Hispanic/Latino, 29.7% White. Compared to White individuals, those who identified as Multi-racial/Other race were more likely to receive telehealth (aOR=4.35, 95% CI: 2.80-6.76). Likelihood of choosing telehealth was higher for those who lived farther from the clinic (aOR=1.02, 95% CI: 1.01-1.03), and who had at least one prior abortion (aOR=1.54, 95% CI: 1.16-2.05). Likelihood of choosing in-clinic medication abortion services was higher among non-English speakers, participants with at least one health issue (Non-English vs. English speakers aOR=0.06, 95% CI: 0.02-0.27; one health issue aOR=0.23, 95% CI:0.15-0.36; 2+ issues aOR=0.16, 95% CI: 0.10-0.25 vs. No issues) and younger individuals (aOR=0.44, 95% CI:0.24-0.80 for patients <20 years; aOR=0.34, 95% CI: 0.22-0.54 for 21-25-year-olds; aOR=0.59, 95% CI: 0.40-0.86 for 26-30-year-olds vs. 30-35-year-olds). Study 2: Of our racially/ethnically diverse sample, the majority were aged 30-35 (range: 20-38) and half were in the first 6 weeks of pregnancy at the time of care. Across all participants, the most important consideration for choosing modality of medication abortion care was how soon a clinic appointment was available. Participants preferred telehealth services due to convenience, ease of access, comfort, and familiarity with telemedicine healthcare. Other than challenges with completing online paperwork prior to appointments, telehealth patients were highly satisfied with their care. Some participants preferred in-clinic services over telehealth options to ensure their care was from a “legitimate” healthcare provider. Many found the clinic-based experience to be unpleasant and would not choose again, expressing interest in telehealth. Study 3: About half of patients sent messages responding to service questions or asking questions of their own (56%, n= 287). Among those, the mean number of patient-service messages was 10 (median=8, range: 1-29). Primary topics included 1) responding to questions to confirm eligibility for asynchronous telehealth abortion, 2) requesting reduced payment, 3) timing, packaging of medication delivery, and 4) physical process of abortion. Most communication was related to non-clinical concerns. Message volume did not differ by patient demographics (age, consultation language, gestational duration, prior pregnancies, or abortions). Significance Understanding how and why patients choose different modalities of care, as well as how they use services can better equip providers to best meet patient needs when providing care. Furthermore, understanding how telehealth services may address or introduce disparities in access to abortion care can support providers in efforts to offer equitable services and mitigate disparities in access

ACCESS, DELIVERED: A Toolkit for Providers Offering Medication Abortion

This Provider Toolkit offers a step-by-step guide for initiating a modern medication abortion service within your primary care practice. It provides information on setting up the service, patient-centered standards of care, and resources for understanding federal and state regulations on abortion services. This resource is part of Access, Delivered: an initiative to create new channels of abortion access in the U.S. in partnership with Plan C (plancpills.org) and the University of Washington Department of Family Medicine. As part of the initiative and under the leadership of Dr. Emily Godfrey, the team uses implementation science methods to inform, improve, and share innovative models of medication abortion care for primary care practices. In addition to regular updates to the Provider Toolkit, we will evaluate the acceptability and feasibility of this model among providers and medication abortion users. The COVID-19 pandemic has dispelled the myth that physical clinics are needed to safely provide early abortion care. Primary care and other clinicians have a unique opportunity to shape the future of abortion access in the United States by using “no test” protocols and providing service via telemedicine with pills mailed directly to patients. The Provider Toolkit Second Edition includes key updates: • The most recent FDA guidance on Mifepristone dispensing • Additional information on regulatory compliance • Improved “Dispensing and Distributing the Medications” section, including information on dispensing from your clinic or partnering with a mail-order pharmacy along with visual aid for providers • Gender-inclusive abortion provision with resources on further education and trainin