The Royal College of Obstetricians and Gynaecologists is promoting a new cohort study into the safety, efficacy, and acceptability of telemedicine early medical abortion by Aiken et al. published in BJOG here. RCOG laud this as the largest data study into telemedicine abortion, whilst the authors caution that there are gaps and possible inconsistencies in the data. Our freedom of information investigation provides related data from the Regulator and from within the NHS, which may help to better inform this timely and very important discussion.
The study authors ask the UK government to listen to the data presented and to then make telemedicine abortion-at-home permanent. Data were presented from 18,435 women using telemedicine abortion between 06 April and 30 June 2020. Given this focus on the data, it is important to first consider the limitations noted by the authors, in particular not being able to actively follow up with patients after posting out the abortion treatment packs. They note gaps in the consistency of reporting complications and incidents and express a lack of confidence in the related communications between the NHS and abortion providers. We too, ask the government to listen to the data and recommend that the DHSC gather and review all relevant data from not just the abortion providers but also the regulators and the NHS.
The authors celebrate this new pathway for no-test (no ultrasound scan) telemedicine abortion and downplay concerns about the safety and wellbeing of women who might use the abortion pills at home when beyond the 10-week gestational limit. They remain confident in the abortion providers’ reliance on women being able to accurately self-assess the gestational age of their pregnancy based on recall of the date of their last period. It is not clear from the study nor from DHSC official guidance, how the abortion provider is recording the gestational age, is this the GA on the day of the first call with the woman, on the day of posting out the abortion treatment, or using a specific assumption of how quickly the woman will start her self-administration of the abortion pills after receiving these. One of the benefits lauded by advocates of telemedicine is the new freedom this presents women in being able to choose a day and time which suits them best when starting their abortion, this of course will not always be on the day the pills are received.
The authors note 11 cases in which the reported gestation of the delivered fetus was greater than 10-weeks, and that in each case the medical abortion was completed at home without additional complications. In response to our freedom of information request, the Care Quality Commission provided data from the same period, of 17 incidents reported to it in which women who had accessed an early medical abortion were subsequently treated in hospital following the delivery of a fetus with gestation greater than expected, including four cases in which the GA was beyond 24 weeks. This demonstrates the importance of using data from multiple sources in order to assess the impact more completely.
The authors present data indicating just seven cases of haemorrhage and no infections arising from 29,984 medical abortions in the period 06 April to 30 June 2020, a case rate which is less than half that previously reported by the DHSC based on submission of the HSA4 forms by abortion providers. It is possible that this low reported rate of adverse events is because of the limitation noted by the authors, namely the lack of follow up contact with patients after the treatment packs have been posted and the possibility that these women might present to other healthcare providers when facing such complications.
Responses to our freedom of information requests show that in 2020, six hospitals provided treatment for 69 women diagnosed with haemorrhage or sepsis after taking the abortion pills. Based on population numbers, this rate of complications is more than five times higher than the rate reported by this study and by the DHSC in 2019 and 2020.
Our FOI data from NHS Ambulance services revealed that on average every month, 36 women call 999 seeking medical assistance for complications arising from the taking of abortion pills; each month across England and Wales there are an average of 20 ambulance emergency responses for complications related to medical abortion at home.
The authors claim that telemedicine abortion-at-home is very effective noting that in the period April – June 2020, across 29,984 medical abortions, 208 women were treated surgically for the removal of retained products of conception (ERPC), a rate of 0.7%. This is much lower than the expected rate of 2-3% as published in guidance from the abortion provider organisations.
Using the FOIA, we asked NHS hospitals to provide data about ERPC cases. These data show that every month across England and Wales, 250 women are treated surgically in hospital for the removal of retained products of conception after using the abortion pills at home. This reported rate of ERPC is three times higher than that reported in the study and is consistent with the previously reported rate of 2-3%.
Currently the DHSC only uses the data about complications and incidents which are reported to it on the HSA4 forms submitted by the abortion providers. The CQC and NHS data which we obtained under the FOIA are easily and readily available to the Secretary of State for Health and Social Care and his team; it would be prudent and proper for the DHSC to use all such available data when considering whether to make telemedicine abortion-at-home permanent.