The coronavirus pandemic changed the way people all over the world accessed abortions. As lockdowns and other restrictions made it difficult to seek in-person terminations of unwanted pregnancies, some countries made-at-home abortions more accessible.
In France, the government temporarily changed the law in April 2020 to allow at-home abortion until seven weeks of pregnancy (or nine weeks since the last period). Teleconsultation abortions – where abortion medication is taken at home in consultation with a medical professional by phone or video call – are currently allowed until September 2021.
In a recent study, my colleagues and I investigated the increased demand for telemedicine abortion in France during lockdowns. Our findings show that people sought out this form of abortion for reasons that go beyond the conditions created by the pandemic.
Secrecy, privacy and comfort
Within the scope of our study, we examined online consultations received from France by Women on Web, a Canadian telemedicine abortion NGO that operates worldwide. The online consultation is a survey of 25 questions on an individual’s demographic and medical background, and also includes research questions on perceived barriers of access to local safe abortion care and motivations for choosing telemedicine for abortion.
At-home abortion was also made available in France via the health system, but national cohort data was not available for our study. Within the framework of this research, we worked on deidentified data obtained from Women on Web in 2020.
Analysing a total number of 809 Women on Web consultations, we found that the most common reasons people in France sought abortions via telemedicine were secrecy (46%), privacy (38%) and comfort (35%), followed by the coronavirus pandemic (31%). Individuals reported not being able to access local abortion services during the pandemic, because of travel restrictions and lockdowns, lack of availability and delays at health care institutions, and fear of virus contamination.
Only 31% of survey respondents indicated that their motivations for seeking telemedicine abortion were related to the pandemic. When we compared these consultations to those not related to coronavirus, we found similar motivations: privacy, secrecy and comfort were the key drivers of telemedicine abortion both for those who mentioned coronavirus among their reasons for seeking telemedicine for abortion, and those who did not.
We also found that, compared to women over 36, women aged 18–25 years are twice as likely to find at-home abortion via telemedicine empowering and three times more likely to prefer having someone with them during the procedure. This age group was also twice as likely to feel stigma about getting an abortion and encounter financial difficulties while accessing abortion care in France.
We found that women continue to encounter macro-level, individual-level and provider-level constraints while trying to access abortion in France. Macro-level constraints include sociopolitical conditions, legal restrictions and term limits, individual-level constraints are personal circumstances and preferences and, provider-level constraints are issues raised around service provision and access to available care.
In this context, women reported financial struggles, an abusive or controlling partner or family, past traumatic experiences, scheduling delays, judgemental service providers, and lack of available medical care as reasons for seeking out abortion online.
The need for self-managed abortions
While telemedicine abortion has been discussed most frequently in the context of the pandemic, it is not a new phenomenon. And there is a large amount of available evidence attesting to its safety, effectiveness and acceptability.
The World Health Organization suggests that individuals can self-manage their abortions, without the direct supervision of a medical practitioner, up to 12 weeks of pregnancy. The organisation also states that self-managed abortions can be appealing for several practical reasons, including the comfort of home, ease of scheduling, reduced transport needs, and providing people the ability to manage stigma.
In the UK, it has been argued that telemedicine can help extend abortion access in rural areas and is likely to benefit those who are most vulnerable, living in poverty and dealing with higher rates of stigma and judgement.
Despite the recommendations of the WHO and an increasing scientific evidence base, countries have been reluctant to allow at-home use of abortion pills until the pandemic. In fact, prior to the coronavirus outbreak, abortion pills were highly regulated, or as some would claim overregulated.
In France, for example, before the pandemic, abortion pills were not available in pharmacies and women were required to go a health facility to take abortion medication in the presence of a medical doctor or a midwife. Medical abortions were only allowed until five weeks of pregnancy and telemedicine was not authorised.
In the United States, the Food and Drug Administration long required that the abortion medication Mifepristone be dispensed in person – a requirement which was only lifted temporarily during the pandemic.
A recent study from the UK has shown that telemedicine abortions during the pandemic led to reduced waiting times and allowed terminations at an earlier gestational age. Another study examining at-home abortion in Scotland has concluded that telemedicine has high efficacy and high acceptability among women.
Building on this literature within the French context, our study suggests there is a case for extending telemedicine abortion care beyond the pandemic. Embracing a hybrid model that offers both in-clinic and remote abortion methods can help meet women’s needs, expand access and improve the quality of care.
Written by Hazal Atay Ph.D candidate, INSPIRE Marie Skłodowska-Curie Fellow, Sciences Po