Restrictive abortion laws, COVID-19, telehealth, and medication abortion in the SDG era
Authors: Ibraheem O Awowole, Omotade A Ijarotimi
Journal: The Lancet Global Health (2021)

Annual worldwide abortion rates reportedly increased from 55·7 million between 2010 and 2014, to 73·3 million in 2015–19.1Ganatra B Gerdts C Rossier C et al.Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model.Lancet. 2017; 390: 2372-2381Summary Full Text Full Text PDF PubMed Scopus (409) Google Scholar, 2Bearak J Popinchalk A Ganatra B et al.Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019.Lancet Glob Health. 2020; 8: e1152-e1161Summary Full Text Full Text PDF PubMed Scopus (350) Google Scholar About 4·7–13·2% of maternal deaths annually are abortion-related, with the highest burden in Asia and Africa.3Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (3208) Google Scholar Elimination of unsafe abortion, defined by WHO4WHOPreventing unsafe abortion.https://www.who.int/news-room/fact-sheets/detail/preventing-unsafe-abortionDate: Sept 25, 2020Date accessed: November 11, 2021Google Scholar as "an abortion that is carried out either by a person lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both", is therefore a critical step towards achieving the UN Sustainable Development Goal (SDG) target of reducing the global maternal mortality ratio to less than 70 per 100 000 livebirths (SDG 3.1) and ensuring universal access to sexual and reproductive health-care services by 2030 (SDG 3.7). Some of the relevant factors that might impact positively on abortion-related morbidity and mortality are discussed here. Asia, Latin America, and Africa have some of the most legally restrictive abortion laws, yet these regions account for 97% of the global burden of unsafe abortions.1Ganatra B Gerdts C Rossier C et al.Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model.Lancet. 2017; 390: 2372-2381Summary Full Text Full Text PDF PubMed Scopus (409) Google Scholar, 3Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (3208) Google Scholar Abortion rates in settings with restrictive laws are not necessarily lower than in regions with permissive laws. In fact, almost 62% of all abortion-related deaths are recorded in Africa alone.3Say L Chou D Gemmill A et al.Global causes of maternal death: a WHO systematic analysis.Lancet Glob Health. 2014; 2: e323-e333Summary Full Text Full Text PDF PubMed Scopus (3208) Google Scholar These predominantly restrictive abortion laws lead to delayed decisions to seek care until advanced gestational ages, when the abortion becomes more difficult to undertake, and care is often sought from clandestine sources to circumvent the law. Nigeria and Argentina, which were selected by Heidi Moseson and colleagues5Moseson H Jayaweera R Egwuatu I et al.Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with historical controls.Lancet Glob Health. 2021; (published online Nov 18.)https://doi.org/10.1016/S2214-109X(21)00461-7Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar for their research, are countries with some of the highest rates of unsafe abortion. Therefore, the findings of this research are relevant to many other countries with similar prevailing circumstances. The American College of Obstetrics and Gynaecology defines telehealth as "the technology-enhanced health care framework that includes services such as virtual visits, remote patient monitoring, and mobile health care".6American College of Obstetrics and GynecologyACOG Committee Opinion Summary, Number 798: implementing telehealth in practice.Obstet Gynecol. 2020; 135: 493-494Crossref PubMed Scopus (48) Google Scholar With the COVID-19 pandemic, use of telehealth has become widespread in many aspects of health-care delivery systems. Specifically, with respect to abortion, telehealth not only facilitates access for women seeking abortion services, but also provides the additional benefits of confidentiality and avoidance of stigmatisation, with similar clinical outcomes to facility-based management.7Bras J Gomperts R Kelly M Aiken A Conlon C Accessing abortion outside jurisdiction following legalisation of abortion in the Republic of Ireland.BMJ Sex Reprod Health. 2021; 47: 200-204Crossref PubMed Scopus (4) Google Scholar, 8Kohn JE Snow JL Simons HR Seymour JW Thompson TA Grossman D Medication abortion provided through telemedicine in four U.S. States.Obstet Gynecol. 2019; 134: 343-350Crossref PubMed Scopus (33) Google Scholar However, in low-income and middle-income countries (LMICs), such as Nigeria, termination for any reason apart from saving maternal life is not only illegal, but the provider of such medications and services is liable to 14 years imprisonment. Such laws might significantly impede the optimal use of telehealth for abortion services across various regions of the world. Medication abortion has been in use for at least two decades, with current regimens including misoprostol alone and misoprostol and mifepristone in combination. Evidence supports the effectiveness and efficiency of medication abortion, especially in pregnancies of less than 10 weeks, which was further affirmed by the findings from Moseson and colleagues.5Moseson H Jayaweera R Egwuatu I et al.Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with historical controls.Lancet Glob Health. 2021; (published online Nov 18.)https://doi.org/10.1016/S2214-109X(21)00461-7Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar Medication abortion is also associated with lower risks of cervical injuries, uterine perforations, and post-abortion sepsis than is surgical abortion, and might therefore reduce abortion-related morbidity and maternal mortality.9Guttmacher InstituteMedication abortion.https://www.guttmacher.org/state-policy/explore/medication-abortionDate: Oct 1, 2021Date accessed: November 11, 2021Google Scholar, 10Bello FA Fawole B Oluborode B et al.Trends in misoprostol use and abortion complications: a cross-sectional study from nine referral hospitals in Nigeria.PLoS One. 2018; 13e0209415Crossref Scopus (11) Google Scholar However, conventional medication abortion is physician supervised, and initially involves hospital admission. The cost of health facility visits can be prohibitive in LMICs, where people pay out-of-pocket for health care and might be living on less than US$1 per day. Apart from the social stigma associated with abortion, women cannot seek health care without the permission and accompaniment of a male relative in some cultural and religious settings. Moseson and colleagues5Moseson H Jayaweera R Egwuatu I et al.Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with historical controls.Lancet Glob Health. 2021; (published online Nov 18.)https://doi.org/10.1016/S2214-109X(21)00461-7Summary Full Text Full Text PDF PubMed Scopus (38) Google Scholar showed that self-managed medication abortion is highly effective at early gestational ages, obviating the need for health facility visits. The study also showed that home-managed abortion with accompaniment support by trained, non-medical personnel was non-inferior to historical controls who underwent physician-supervised, facility-based management. These findings might influence access to and safe management of abortion, thereby facilitating reproductive health decision making by women, with more efficient use of resources through telemedicine and task shifting. However, such benefits might remain impossible to explore in settings with restrictive abortion laws. There is also a need to balance these benefits against the possibility of abuse, exploitation, and forced abortions by male partners at home, especially in settings where women are less empowered to make decisions concerning their reproductive health. Further qualitative research is needed for strategic planning towards SDG targets 3.1 and 3.7. Although this can be achieved without hindrance in some settings, it is unclear how much data might be obtainable from regions within restrictive abortion jurisdictions, where the line between legality and illegality could easily be crossed by researchers unless laws are revised. We declare no competing interests. Effectiveness of self-managed medication abortion with accompaniment support in Argentina and Nigeria (SAFE): a prospective, observational cohort study and non-inferiority analysis with historical controlsFindings from this prospective cohort study show that self-managed medication abortion with accompaniment group support is highly effective and, for those with pregnancies of less than 9 weeks' gestation, non-inferior to the effectiveness of clinician-managed medication abortion administered in a clinical setting. These findings support the use of remote self-managed models of early abortion care, as well as telemedicine, as is being considered in several countries because of the COVID-19 pandemic. Full-Text PDF Open Access