Telemedicine Abortion in Primary Care: An Exploration of Patient Experiences

Study Design, Setting, and Sample

From March-May 2022, we interviewed a convenience sample of patients who received TeleMAB within a large primary care safety-net community health system in Massachusetts. This health system cares for a culturally diverse patient population of approximately 120,000 patients who mostly hold public or subsidized health insurance. Eligibility criteria included patients who received a TeleMAB between July 28, 2020 and December 31, 2021, had medications delivered, and spoke and understood English, Spanish, and/or Portuguese (n = 47). Using electronic medical records, D.N. generated a list of eligible participants. Interviewers called patients via encrypted teleconferencing software up to 5 times over 2 weeks and shared study information. Consent forms were e-mailed in the participant’s language or patients provided verbal consent. D.N. did not call any patient for whom she had provided care and only identified as a researcher and not a physician. The 2 Institutional Review Boards of the involved institutions, University of Washington and Cambridge Health Alliance, approved this study. We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guidelines.³⁰

Telemedicine Medication Abortion Workflow

Primary care clinics in this health system began providing in-clinic medication abortion (MAB) in 2003. In July 2020 the health system implemented direct-to-patient, TeleMAB services, which entailed the use of video visits or synchronous telephone calls between the clinician and patient. When patients expressed the need for a medication abortion, the health system offered them in-clinic or TeleMAB appointments. For patients who chose TeleMAB, the clinician assessed eligibility for remote care including patient location in Massachusetts at time of visit and assessment of gestational dating and ectopic pregnancy risk based on clinical history. The clinician counseled eligible patients on expected process, e-mailed consent forms for electronic signature, and placed a pharmacy order to send a package which was delivered by the health system’s courier with mifepristone, misoprostol, anti-nausea medications, analgesics, a urine pregnancy test, and an instruction printout. The clinic scheduled each patient for a 1- to 2-week follow-up telemedicine appointment. Patients could choose to have any or all aspects of care via telemedicine or in-clinic.

Data Collection

We created a semistructured interview guide (Supplemental Appendix, 1.0 - 2.0) informed by the Miller patient-provider communication framework, prior studies on patient experiences with TeleMAB, and the research team’s ongoing work exploring patients’ experiences with TeleMAB at a primary care–based reproductive health clinic.^31-34 We chose Miller’s framework because it includes key components of patient-centered communication and the medium of communication used, ie, telemedicine. Interviewers (D.N., S.S., A.E.F.) each pre-tested the guide with people of reproductive age and refined the questions based on their feedback (Supplemental Appendix, 3.0). All interviews were audio recorded, transcribed, and quality checked.^35,36 After the interview, participants self reported sociodemographic characteristics (Supplemental Appendix, 4.0) and received a $50 gift card.

Analysis

S.S. and A.E.F. performed the study analysis using reflexive thematic analysis.³⁷ They read transcripts, made conceptual notes, met to discuss potential codes, developed a codebook, and considered how the constructs related to a broader framework of patient experience. S.S. and A.E.F. used Dedoose software (SocioCultural Research Consultants) to manage, sort, and code data. They simultaneously coded 4 transcripts, discussed discrepancies in coding after each one, and refined the codebook accordingly. They coded the remaining transcripts independently (5 each) and met to refine study findings. The analytic team reached data saturation on key themes.³⁸

Research Team and Reflexivity

D.N., A.T., and H.M. are family physicians who provided primary care including abortion at the study site. H.M. spearheaded TeleMAB implementation at the study site in June 2020. H.M., A.T., and D.N. were mentored and trained in key concepts of qualitative research by A.E.F. at the beginning of this study. S.S. is an MPH graduate and is a PhD student with a focus on reproductive health research with 4 years of experience conducting qualitative research. A.E.F. is a PhD graduate in public health with experience working in abortion policy and qualitative research. E.M.G. is a complex Family Planning Fellowship–trained practicing physician with master-level training in qualitative research. In terms of reflexivity, the team used Miller’s framework which is based in patient-centered communication to shape the collected data and analysis. The analysts incorporated a reflexive process that deepened interpretations of the data and helped build cohesive and structured findings while reflecting on their own biases. A.E.F. is pro-telehealth and medication abortion, and A.F., D.N., H.M., and E.M.G. are pro-primary care, which may have influenced our interpretation of the data and the summary of findings.

Ease of Process of Obtaining TeleMAB in Primary Care

Overall, participants found TeleMAB in primary care acceptable, beneficial, and straightforward (Table 1). Participants felt provider counseling prepared them well and expressed confidence in having necessary information to successfully complete their abortion. One noted, “I was very confident and relaxed that everything was going to go right. They made me feel good about it. I wasn’t scared” (ID 10, age unknown). They received clear instructions regarding medication use, expected side effects, and contact information for questions. Additionally, participants highlighted how caring interactions with staff amplified the ease of the process. For example, one participant, who initially felt overwhelmed by their pregnancy-related decisions, ultimately felt the experience was easy because of the support they received from their clinician and support staff.

Participants felt comfortable calling the health system or using their online patient portal to contact their providers to schedule appointments or ask questions. They shared having positive experiences with the medication delivery system, noting the simplicity and reliability of the service: “[The medications] came at the time and date that it was supposed to come” (ID 10, age unknown). When asked what one participant liked about the delivery service, they responded, “All I had to do was just sit back at home and wait. It was great. It was the best part” (ID 15, age 31).

Existing relationships within the participants’ primary care network made them feel comfortable navigating their care. While some participants were cared for by their own primary care physicians (PCPs), many participants received care by providers who were not necessarily their primary care doctor. Their trust extended from their provider to the health system. Participants felt more comfortable reaching out to their primary care network than to unfamiliar abortion clinics (Table 1, #6). While some felt comfortable asking their provider about pregnancy options because of existing relationships (Table 1, 7), others knew the health system provided abortion from prior pregnancy experiences (Table 1, #8 & #9). Despite being cared for by multiple individuals—administrative staff, nurses, and physicians—participants described smooth transitions of care.

Advantages of Telemedicine

Participants discussed how TeleMAB supported their ability to exercise control, autonomy, and flexibility (Table 1). In particular, patients described decreased interruptions to their daily lives, increased agency over their chosen surroundings and access to preferred coping mechanisms. For example, one participant shared that they completed their appointment while at work. Another participant noted a sense of agency by having their appointment at their desired location. One participant felt too sick from pregnancy symptoms to travel and valued staying home during the appointment. One shared, “It just made it an overall easy experience, and I didn’t even have to go to my doctor for this. I’m doing this in my own time, my own energy, in my own home” (ID 33, age 26). Being in their own space gave participants greater access to coping strategies that helped decrease their anxiety and helped them feel safer expressing emotions and private information, “I could be a lot more vulnerable because I was right in my bed. And then you didn’t have to worry about crying or wiping your face up and seeing people after that. Or people overhearing you in the office or something. You were just at home so you could just be like… this is worrying me” (ID 9, age 32).

Primary Care Normalizes Abortion Care

Many participants perceived their primary care system as the place to go for pregnancy-related needs, including abortion. Their first instinct when they missed their period was “to call [their] PCP” (ID 54, age 33). Participants felt abortion should be part of routine primary care, whereas an independent abortion clinic seemed more isolating and “strange.” Participants felt comfortable knowing that their abortion providers had access to their medical histories: “It was just comforting knowing I know the person [doing the abortion care] and we’ve seen each other multiple times before and she knows a little bit of my history and what I was going through at the time, so we had a good relationship as far as communication” (ID 10, age unknown). Another participant shared how their physician considered their history of gastrointestinal issues and the potential interaction of their chronic medications, noting, “she actually probably saved me from an overdose, too” (ID 9, age 32). They appreciated that their provider delivered care in the full context of their health and social needs.

Although complications from MABs are extremely rare, when medical or social challenges did arise participants reported their PCPs helped assuage difficult situations (Table 1). One participant had excessive bleeding after taking the medications and visited the emergency department, but felt relieved to talk to their PCP throughout the complication. Another participant inadvertently initially visited a crisis pregnancy center where they felt pressured to continue the pregnancy despite being certain about wanting an abortion. They subsequently had an overall affirming abortion experience with their PCP, however, as “I feel like my doctor did a really good job of giving me my options, but also giving me the opportunity to choose what I want to do, regardless of what they believe or regardless of what they feel is right,” highlighting the importance of a trusted PCP relationship as a protective force in difficult situations (ID 33, age 26).