In the first 12 weeks of pregnancy, medical abortion can safely and effectively be self-managed outside of a health facility, for example, at home. WHO recommends self-management of medical abortion as one of several quality abortion options, provided there is access to accurate information, quality-assured medicines and support from a trained health worker if required. Self-management of medical abortion is also one of the self-care interventions for health recommended by WHO.
COVID-19 caused huge disruption to healthcare systems around the world, but with the challenges also came innovative and different ways of safely providing healthcare, including safe abortion care.
In Germany, one of those innovations was the introduction of telemedicine to support self-management of medical abortion.
The Schwangerschaftsabbruch-zuhause “Abortion at home” project
Abortion is legally permissible in Germany on request up to 12 weeks, and thereafter in certain circumstances. However, counselling is mandatory. Although German law stipulates that there must be a sufficient number of abortion facilities, this is not
the reality in many parts of the country, with women seeking safe abortion care often having to travel long distances.
Learning from the success of a telemedicine project in the United Kingdom that began during the pandemic, and supported by the latest WHO evidence-based recommendations, the Family Planning Center BALANCE in Berlin introduced a telemedicine project in December 2020 in partnership with Doctors for Choice Germany, and Pro-familia.
The aim was to improve access to safe abortion care and also demonstrate the feasibility of telemedicine for self-management of medical abortion in Germany.
“At BALANCE, we had the idea several years ago about introducing medical abortion telemedicine in Germany, but we weren’t sure how it would be received,” said Dr Jana Maeffert, one of the founders of Schwangerschaftsabbruch-zuhause. “Then the pandemic came, and we knew it was very much needed. In many ways, it was very much a grassroots project; at BALANCE we were just five really motivated women – three doctors, a nurse and a medical assistant.”
In compliance with German law, the project was structured as follows:
- BALANCE supervising all aspects of self-management of medical abortion via videoconferencing with the clients
- Doctors for Choice Germany providing information about telemedicine and medical abortion on: www.schwangerschaftsabbruch-zuhause.de
- Pro-familia and others publicizing the availability of the telemedicine option at BALANCE through their counselling centres.
How the project worked
- The telemedicine option was publicized via Pro-familia, other counselling centres, and the website.
- Clients seeking an abortion contacted BALANCE via telephone or email. Of those, more than half (56%) chose the medical abortion telemedicine option. They were then sent detailed information and all the required documentation through a data-safe chat
- A doctor from BALANCE video-called the client to clarify they had understood what the procedure would entail and to recommend that they had emotional and other support from family or friends.
- The client then reviewed and returned the required documents before being sent the medication needed to end the pregnancy via post.
- When the medication arrived, there was a second video call to clarify everything and for the doctor to watch the client take the first pill (Mifepristone). The client would then take the second medication (Misoprostol) two days later, this time without
a call but with a partner/friend with her. The 24/7 telephone helpline number was also available.
- 14 to 16 days later, the client took a low-sensitivity pregnancy test to confirm if the abortion had been successful. If not, as in approximately 2 out of 100 cases, there was a further video call to discuss whether the client should take the medication
again or be referred for a surgical abortion.
- From initial contact, the client had access to the data-secure chat as well as a 24-hour emergency number. They also had access to a free app “Medabb” which was available in six languages and had an extensive Frequently Asked Questions list.
To date, the project has reached around 320 clients.
“The counsellor I saw told me about my options and also mentioned telemedicine care, which is very new. For me it was the best option. Contacting the practice in Berlin was very quick and the care was very good,” a client explained. “During the telemedical support, especially after the video conversation with the doctor, I felt very well supported. She and a nurse were also available 24/7 via the on-call phone and App. They explained very clearly what can happen, how you might feel and when to go to the gynaecological clinic or emergency room.”
Having demonstrated the feasibility of self-management of medical abortion and telemedicine, the project has now become an integral part of the safe abortion services offered by BALANCE. As a next step, doctors from there are sharing their experiences
and providing capacity building to other practices in Germany. Gyn-Praxis Nova, a clinic in Berlin, has recently introduced medical abortion telemedicine and it is anticipated that others across the country will soon follow.
But it is not only German practitioners who have been learning from BALANCE’s experiences.
WHO facilitates learning exchange
Keen for others across Europe and Central Asia to learn from the experiences in Germany, WHO’s EURO office facilitated various learning exchange activities. For instance, a health worker from BALANCE engaged with Ministry of Health officials from
other countries in the European region including Romania, Kazakhstan, Tajikistan and Kyrgyzstan, through a webinar organized by WHO.
As well as outlining the steps taken during the project, the key messages provided by BALANCE, in line with WHO guidance and tools, were:
- Telemedicine is a safe and effective way of increasing access to self-management of medical abortion using digital health technology.
- It is a model that could work well in all countries regardless of income level low, middle- and high-income countries.
- It was a cost-effective approach, which can save costs for the patient as well as the health system.
WHO’s facilitation of the learning exchange has already led to further discussions about telemedicine and medical abortion in Romania and several Central Asian countries.