Chapter 3. Recommendations and best practice statements across the continuum of abortion care
Supported service-delivery approaches: Recommendation 48 (Telemedicine) and Best Practice Statement 49 (3.6.1)
3.6.1 Supported service-delivery approaches
Medical abortion services can be obtained from and provided or supported by a multitude of actors within the health system. Services may be delivered through a comprehensive model that addresses the full spectrum of abortion care or may include only specific components on the care pathway. Services could be delivered through the public or private sectors or nongovernmental organizations (NGOs), and may be received at a community-based, off-site location or even at home, and a variety of service-delivery models can co-exist at national, subnational and local levels.
Approaches to service delivery are not static and as the role of digital technologies grows and the science and evidence on effective interventions evolves, innovations will also continue to evolve. For this guideline, available evidence on various modalities of providing and/or supporting abortion care were reviewed. Examples of service-delivery approaches that were identified in the systematic reviews conducted for this guideline included:
- Accompaniment models: Where a community health worker provides support by accompanying the individual through the medical abortion process (by phone, secure technological platform, or in person), including providing information, counselling, emotional/moral support and/or logistical support (including referrals to and support interacting with local health-care facilities in the event that care is needed or desired).
- Community outreach: This includes health services that mobilize health workers to provide services to the population or to other health workers, away from the location where they usually work and live (159). This is a strategy to mobilize health workers to remote or rural areas, such as mobile clinics. However, documented evidence on the use of this model for abortion care provision is limited.
- Digital support tools: These included apps providing information, text messaging reminders, and tools to assist in the assessment of pregnancy duration.
- Harm reduction models: Service models in the clinic setting, in which women are supported with pre-abortion information, are told where to find the medicines and how to use them and can return for post-abortion support if needed, but are not actually provided with the medicines to terminate the pregnancy.
- Hotlines: This typically refers to telephonic information services that can support women in accessing quality abortion care. Abortion hotlines may be limited to providing evidence-based information about services or may be linked to other service-delivery models that facilitate access to medicines and support women through the abortion process and after the abortion.
- Social marketing: Broadly defined as the application of marketing techniques to social problems and aims to persuade or motivate people to adopt specific sources of action or behaviour which are generally accepted as being beneficial. This approach to marketing has been well studied as a successful model for distribution of health interventions/commodities (e.g. condoms), however, documentation related to quality abortion care (i.e. abortion medicines and instructions) is more limited. It may be an option for increasing access and making care more affordable.
- Social franchising: This is described as a system of contractual relationships usually run by an NGO which uses the structure of a commercial franchise to achieve social goals. The overarching difference between social and commercial franchising is that social franchising seeks to fulfil a social benefit whereas commercial franchising is driven by profit. However, the limited evidence illustrates the potential inequities of such models (160).
- Telemedicine: This is a mode of health service delivery where providers and clients, or providers and consultants, are separated by distance. The interaction may take place in real time (synchronously), using telephone or video link, or asynchronously using a store-and-forward method, when a query is submitted and an answer is provided later (e.g. by email, text or voice/audio message) (161).
Across the range of service-delivery options, interactions between an abortion seeker and a health worker can take place in person or remotely. After review and assessment of the evidence by the expert panel, it was agreed that there was sufficient quantity and quality of evidence to support the formulation of a specific recommendation in relation to using telemedicine approaches as an alternative to in-person interactions for provision of medical abortion (see Recommendation 48).
The available evidence was inadequate to support the formulation of recommendations on any of the other service-delivery models. Instead, given the contextual nature of service-delivery approaches, the heterogeneity of the types of interventions and the overlaps between the approaches, a two-part best practice statement was developed to apply to all of them, with reference to service delivery in general, rather than any specific modality/model of service delivery (see Best Practice Statement 49).
SERVICE DELIVERY Recommendation 48 (NEW): Telemedicine approaches to delivering medical abortion care
Recommend the option of telemedicine as an alternative to in-person interactions with the health worker to deliver medical abortion services in whole or in part.
- The above recommendation applies to assessment of eligibility for medical abortion, counselling and/or instruction relating to the abortion process, providing instruction for and active facilitation of the administration of medicines, and follow-up post-abortion care, all through telemedicine.
- Hotlines, digital apps or one-way modes of communication (e.g. reminder text messages) that simply provide information were not included in the review of evidence for this recommendation.
- Telemedicine services should include referrals (based on the woman’s location) for medicines (abortion and pain control medicines), any abortion care or post-abortion follow-up required (including for emergency care if needed), and for post-abortion contraceptive services, which may apply to both medical and surgical abortion.
A systematic review was undertaken to address this key question. Ten studies reporting on medical abortion provision through telemedicine were identified by the search strategy. Four randomized controlled trials were conducted in Bangladesh, Cambodia, Egypt and Indonesia, and six observational studies took place in Canada, Peru and the USA. In studies comparing telemedicine with in-person medical abortion care services, there was no difference between the two groups in rates of successful abortion or ongoing pregnancies (based on very low-certainty evidence). Referrals for surgical intervention were fewer among women who used telemedicine (based on low-certainty evidence). Satisfaction with telemedicine services was high and comparable to the usual clinical services (based on very low-certainty evidence). A summary of the evidence is presented in Supplementary material 3, EtD framework on Telemedicine.
SERVICE DELIVERY Best Practice Statement 49 (NEW):
Part 1: There is no single recommended approach to providing abortion services. The choice of specific health worker(s) (from among the recommended options) or management by the individual themself, and the location of service provision (from among the recommended options) will depend on the values and preferences of the woman, girl or other pregnant person, available resources, and the national and local context. A plurality of service-delivery approaches can co-exist within any given context.
Part 2: Given that service-delivery approaches can be diverse, it is important to ensure that for the individual seeking care, the range of service-delivery options taken together will provide:
- access to scientifically accurate, understandable information at all stages;
- access to quality-assured medicines (including those for pain management);
- back-up referral support if desired or needed;
- linkages to an appropriate choice of contraceptive services for those who want post-abortion contraception.
A summary of the evidence is presented in Supplementary material 3, EtD framework on Medical abortion provided in different settings.
- Service-delivery approaches should, where feasible, be co-created with the people who will benefit from the intervention.
- All models should be tested and adapted for the local context in which they will operate.
- Not all service-delivery approaches may function at scale but for those that are being considered for national programmes, appropriate pilot testing is needed prior to scaling up.
- All service-delivery models should have mechanisms for monitoring quality and ensuring accountability.
KEY HUMAN RIGHTS CONSIDERATIONS RELEVANT TO SERVICE-DELIVERY MODELS
- States should develop and enforce evidence-based standards and guidelines for the provision and delivery of sexual and reproductive health (SRH) services, and such guidance must be routinely updated to incorporate medical advancements. At the same time, States are required to provide age-appropriate, evidence-based, scientifically accurate comprehensive education for all on SRH.
- SRH services must be available, accessible, affordable, acceptable and of good quality. This means that delivery of services must be respectful of the culture of individuals, minorities, peoples and communities, and sensitive to gender, age, disability, sexual diversity and life-cycle requirements.
- States must take steps to reduce maternal mortality and morbidity.
- States must make accurate, evidence-based abortion information available to individuals on a confidential basis
- States must ensure delivery of services on the basis of non-discrimination and equality.
- States must ensure delivery of services in a way that respects the right to scientific progress, meaning that States should ensure access to modern and safe forms of contraception, including emergency contraception, abortion medicines, assisted reproductive technologies, and other SRH goods and services, on the basis of non-discrimination and equality.