ABSTRACT
ObjectiveTo examine the numbers and characteristics of women and pregnant people in Malta seeking at-home medical abortion using online telemedicine from 2017 to 2021. DesignPopulation-based study. SettingRepublic of Malta ParticipantsBetween 1 January 2017 and 31 December 2021, 1090 women and pregnant people requested at-home medical abortion through one online telemedicine provider (Women on Web). Mifepristone and misoprostol were shipped to 658 women (60.4% of requests). Main Outcome MeasuresThe numbers and demographics of persons to which abortion pills were shipped, their reasons for termination of pregnancy, and reasons for requesting medical abortion between January 2017 and December 2021 were analysed. Selected data were compared across different groups. ResultsThe number of persons in Malta to whom medical abortion pills were shipped increased significantly during the COVID-19 pandemic. Women and pregnant people requesting medical abortion were diverse with respect to age, pregnancy circumstances and reasons for seeking termination. More than half were mothers and over 90% reached out to Women on Web at < 7 weeks. Among those completing a medical abortion, 63% did not use contraception (n=412), and in 30% (n=197) there was contraception failure. The most common reasons for ordering medical abortion pills online were difficulty accessing abortion because of legal restrictions (73%) and abortion pills not being available (45%) in the country. ConclusionsDespite a complete ban on abortion, the number of women and pregnant people residing in Malta completing at-home medical abortions is considerable and has increased since the COVID-19 pandemic. Summary BoxesO_ST_ABSWhat is already knownC_ST_ABSLegal restrictions do not impede women and pregnant people from accessing abortion care but make them liable to criminal prosecution. What this study addsSince abortion is criminalised in Malta, there are no official statistics related to abortion. This is the first study looking at the number and characteristics of women and pregnant people who access abortion care outside the formal healthcare system in this highly restrictive legal regime. Despite the abortion ban, women and pregnant people in Malta are increasingly accessing telemedicine and self-managing their abortions.
ABSTRACT
ObjectivesIn most European countries, patients seeking medication abortion during the COVID-19 pandemic are still expected to attend healthcare settings in person despite lockdown measures and infection risk. We assessed whether demand for self-managed medication abortion provided by a fully remote online telemedicine service increased following the emergence of COVID-19. DesignWe used regression discontinuity to compare the number of requests to online telemedicine service Women on Web in eight European countries before and after they implemented lockdown measures to slow COVID-19 transmission. We examined the number deaths due to COVID-19, the degree of government-provided economic support, the severity of lockdown travel restrictions, and the medication abortion service provision model in countries with and without significant changes in requests. SettingEight European countries served by Women on Web. Participants3,915 people who made requests for self-managed abortion to Women on Web between January 1st, 2019 and June 1st, 2020. Main Outcome MeasuresPercent change in requests to Women on Web before and after the emergence of COVID-19 and associated lockdown measures. ResultsFive countries showed significant increases in requests, ranging from 28% in Northern Ireland (p=0.001) to 139% in Portugal (p<0.001). Two countries showed no significant change in requests, and one country, Great Britain, showed an 88% decrease in requests (p<0.001). Countries with significant increases in requests were either countries where abortion services are mainly provided in hospitals or where no abortion services are available and international travel was prohibited during lockdown. By contrast, Great Britain authorized teleconsultation for medication abortion and provision of medications by mail during the pandemic. ConclusionThese marked changes in requests for self-managed medication abortion during COVID-19 demonstrate demand for fully remote models of abortion care and an urgent need for policymakers to expand access to medication abortion by telemedicine. O_TEXTBOXO_TEXTBOXNOWhat this paper addsC_TEXTBOXNO What is already know on this subjectO_LIThe COVID-19 pandemic has presented challenges to patients seeking medication abortion, including lockdown travel restrictions and infection risk during in-person clinic visits. C_LIO_LIYet in most European countries, medication abortion must still be provided through in-person models of care. The sole exception is Great Britain, where a fully remote medication abortion service was introduced in response to the pandemic. C_LIO_LIAnecdotal reports suggest that patients are struggling to access in-person abortion services and may turn to self-managed abortion as a result. However, to date there has been no systematic assessment of this possibility. C_LI What this study addsO_LIOur study provides the best evidence to date that demand for self-managed medication abortion provided using online telemedicine increased following the emergence of the COVID-19 pandemic. C_LIO_LIThe largest increases were observed in countries where medication abortion is provided mainly in hospitals and where travel restrictions were most stringent. By contrast, in the one country that implemented fully remote services, demand for self-managed abortion declined almost to zero. C_LIO_LIOur findings demonstrate the urgent need for policymakers to expand access to telemedicine models of medication abortion within the formal healthcare setting. C_LI C_TEXTBOX
