COVID-19 forced many people’s jobs online – even for doctors who provide abortions. Read what Marie Stopes learned when they helped nearly 50 patients terminate pregnancies over the phone.
It was the beginning of April when we received our first call.
South Africa was just about two or so weeks into a hard economic lockdown as the government tried to curb the spread of the coronavirus gripping the globe. No one could leave their homes, unless they needed to buy groceries or go to the doctor.
Thandi — a university student — was eight weeks pregnant. She needed to have an abortion. But the lockdown meant that she had to return home from varsity. Both her parents were around and she felt uncomfortable to tell them her plans.
As her pregnancy progressed, the young student was getting anxious: How would she leave the house? Where would she say she was going?
That’s when she called Marie Stopes South Africa, where I’m the director of clinical services and a medical doctor. “Don’t worry,” I told the panicked student on the telephone. “The package will be delivered to your doorstep. You should receive it in three to four days.”
COVID-19 made clinics rethink how to provide safe abortions
Thandi was our first case of a self-managed abortion conducted via telemedicine.
Over the phone, I instructed her what to do.
“There will be two sets of tablets,” I explained. “One set is called Mifepristone. You need to drink these with water — it will block the hormone that maintains the pregnancy and will help to detach it from your uterine wall. The next set of tablets, four Misoprostol pills, you have to take 24 hours later. These pills will contract the uterus and expel the pregnancy tissue.”
I explained to Thandi that she needed to put the Misoprostol tablets under her tongue and that she could start feeling cramps within 30 minutes. But it could take up to two hours for the symptoms to start showing.
Then bleeding would follow.
Four days later, Thandi received her couriered parcel with the pills and other necessities at home.
People like her, who were in the early stages of pregnancy, but couldn’t get to us, made us rethink how we provided safe abortion services during COVID-19 lockdowns.
Before the pandemic hit South Africa, Marie Stopes was conducting just over 2 000 terminations per month across the country. But when the economic lockdown was enforced, our caseloads drastically reduced.
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It was important that we found another way to help people in need of terminations to have one — or they may have resorted to illegal, unsafe abortions.
A 2017 study published in The Lancet journal found that each year almost half of the 55.7-million abortions that take place worldwide are unsafe. The World Health Organisation says up to 13% of deaths among pregnant women can be attributed to unsafe terminations of pregnancy. And although abortion has been legal in South Africa for more than 20 years — any woman can have a medical, pill-based abortion up to 12 weeks of pregnancy, those who are pregnant between 13 and 20 weeks can have surgical abortions under specified conditions and pregnancies beyond 20 weeks can be terminated in limited circumstances — access to safe abortions have been a challenge.
A 2005 International Journal of Obstetrics & Gynaecology study revealed that just more than half of a sample of about 50 women in South Africa, who had had illegal abortions, did so because they “did not know about the law”. Fifteen percent knew about their legal rights, but “didn’t know about a legal facility”.
After Thandi’s termination by phone in April, we conducted another 43 similar abortions. And in July, four months after Marie Stopes set up its self-managed abortion service in response to the lack of access to safe abortions during lockdown, the popularity of the service had increased so much that we conducted more than 700 terminations via telemedicine in that month alone.
Thandi was one of them.
Because her pregnancy had progressed to only eight weeks, she could have a medical, pill-based abortion that is possible to do via telemedicine.
Thandi could choose whether she wanted to have the package with the medicine couriered to her house or if she wanted to collect it from one of our clinics.
During our phone conversation, I explained which signs she needed to look out for to know that the abortion was taking place as expected. And if it wasn’t, we had a nurse on standby who she could call for help.
In the parcel Thandi received, we also included a short-acting form of contraception — women can choose between a one month supply of oral contraceptives or a birth control patch. Clients have the option of getting a longer prescription, if they pay for it.
Moreover, the parcel contained a pregnancy test Thandi had to use three to four weeks after her termination to confirm that the abortion was successful. The package and consultation cost her R1 750. If she had chosen to collect the medication, she would have paid R1 500.
About a month after Thandi had performed the procedure at home, we conducted a follow-up phone consultation with her.
She had just taken her pregnancy test. It had come out negative and she reported no symptoms associated with an unsafe abortion.
Our first self-managed, telemedicine abortion was officially a success.
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Self-managed abortions via telemedicine have been taking place since 2005 in Brazil — where abortion is mostly illegal — when hotlines were set up by feminists in the country to help women who needed terminations of pregnancies to access it. Today, similar hotlines exist in at least 26 countries across the world, according to the International Campaign for Women’s Right to Safe Abortion. One example is the Ms Rosy Reproductive Health Information Hotline in Nigeria — a project of the non-profit Generation Initiative for Women and Youth Network.
South Africa has been conducting research on self-managed abortions since 2012. At the time, women were being assisted via SMS messages. But this has never developed into a complete service.
According to the national health department’s spokesperson, Popo Maja, the department doesn’t have policy guidelines for self-managed abortions. In the early stages of lockdown the Health Professions Council of South Africa amended its telemedicine guidelines advising doctors that they no longer needed an established doctor-patient relationship to practise telemedicine and could therefore engage in this way with first time patients. The guidance, however, did not address abortions either.
For a termination under 12 weeks in South Africa, the standard operating procedure is that women need to consult with a doctor or a nurse in person before they’re given misoprostol tablets to administer at home.
But with self-managed abortions, this face-to-face consultation is replaced with a 30 to 45 minute phone consultation with a doctor or nurse. They ask the clients a series of questions about their menstruation cycle to determine how far along they are with their pregnancy. The doctor or nurse also explains to patients how to use the relevant medication, as in Thandi’s case.
Studies have shown that self-managed abortions conducted via telemedicine are safe and effective, if performed correctly. A 2019 systematic review published in the International Journal for Obstetrics and Gynaecology, that evaluated 13 studies, reported a success rate of up to 96% and continued pregnancies as low as 2%.
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Moreover, the World Health Organisation (WHO) recommends the self-administration of mifepristone and misoprostol for abortions if the individual has “a source of accurate information and access to a healthcare provider should they need or want it at any stage of the process”. Research also shows that self-managed abortions via telemedicine can increase access to safe terminations. For example, a study published in the American Journal of Public Health in 2013, found that telemedicine abortions in Iowa in the United States increased access to medical abortions for women in rural areas. Simultaneously, it also decreased the number of women who sought terminations in their second‐trimester of pregnancy, because self-managed abortions reduced barriers, such as transportation, to earlier abortion.
It’s not all good news. Clients can potentially misjudge how far along they are in their pregnancy
There are, however, also concerns with regards to telemedicine abortions. Patients can, for instance, miscalculate how far along they are in their pregnancies, because ultrasounds, that tell doctors the gestational age of patients’ pregnancies, can’t be conducted on the phone. The WHO says more evidence is still needed to establish if it’s safe for someone to self-assess the gestational age of their pregnancy.
When women miscalculate the gestational age of their pregnancies, it could result in self-managed abortions failing or being conducted too late in a pregnancy — culminating in complicated procedures with the potential for heavy bleeding and serious complications that require medical treatment.
Another challenge with self-managed abortions is that women who have ectopic pregnancies — when a fertilized egg implants and grows outside the main cavity of the uterus — can be misdiagnosed during telephonic consultations. In traditional abortion settings, ultrasounds would detect ectopic pregnancies.
Although the World Health Organisation’s policy guidelines for safe abortions allow for self-managed abortions with mifepristone and misoprostol to be conducted up to 11 weeks of pregnancy, Marie Stopes only provides the service to clients who are nine or fewer weeks pregnant.
Courier services can therefore present complications. If the consultation with a client takes place late into the eighth week of their pregnancy and the medication needs to be sent to them, it could potentially only arrive when the patient is more than nine weeks pregnant — particularly if they live in a rural area where couriers take a few days to deliver parcels.
But the advantages of self-managed abortions outweigh the disadvantages.
When someone is desperate to get an abortion, they will do almost anything to access one. This, and the stigma attached to terminations, often leads to women having unsafe, illegal abortions — even in countries such as South Africa, where terminations are legal.
Self-managed abortions via telemedicine is one way of offering a safer, less invasive option. It bypasses stigma, because these terminations can be performed in the privacy of clients’ homes — and they don’t require transport, have to queue in long lines or be put on endless waiting lists.
The one obstacle that, however, remains, is cost, as this service is only available in the private sector in South Africa — and at a price.
Melusi Dhlamini is a medical officer in obstetrics and gynaecology and is the director of clinical services at Marie Stopes.