Accessing abortion in a highly restrictive legal regime: characteristics of women and pregnant people in Malta self-managing their abortion through online telemedicine

Abstract

Objective

To examine the numbers and characteristics of women and pregnant people in Malta seeking at-home medical abortion using online telemedicine from 2017 to 2021.

Design

Population-based study.

Setting

Republic of Malta

Participants

Between 1 January 2017 and 31 December 2021, 1090 women and pregnant people requested at-home medical abortion through one online telemedicine provider (Women on Web). Mifepristone and misoprostol were shipped to 658 women (60.4% of requests).

Main outcome measures

The numbers and demographics of persons to which abortion pills were shipped, their reasons for accessing abortion, and reasons for requesting medical abortion via telemedicine between January 2017 and December 2021 were analysed. Selected data were compared across different groups.

Results

The number of people in Malta to whom medical abortion pills were shipped increased significantly in the 5 years analysed. Women and pregnant people requesting medical abortion were diverse with respect to age, pregnancy circumstances and reasons for seeking an abortion. More than half had existing children and over 90% reached out to Women on Web at <7 weeks. Among those completing a medical abortion, 63% did not use contraception, and in 30% there was contraception failure. The most common reasons for ordering medical abortion pills online were difficulty accessing abortion because of legal restrictions (73%) and abortion pills not being available (45%) in the country.

Conclusions

Despite a complete ban on abortion, the number of women and pregnant people residing in Malta completing at-home medical abortions is considerable and has been steadily increasing.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Legal restrictions do not impede women and pregnant people from accessing abortion care but make them liable to criminal prosecution. Since abortion is criminalised in Malta, there are no official statistics related to abortion.

WHAT THIS STUDY ADDS

• Despite the total abortion ban, women and pregnant people in Malta are increasingly accessing telemedicine abortion services. This study gives further insight on the number and characteristics of women and pregnant people self-managing their abortions.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

• Malta lacks a family planning policy or public family planning clinics. This study highlights the need for a change in abortion legislation and for services to reduce barriers to access, especially among women with children.

Introduction

With a population of half a million, Malta is the smallest, southernmost nation state in the EU and its abortion laws are among the most restrictive in the world. The Criminal Code states that anyone who intentionally induces a miscarriage is liable to up to 3 years of imprisonment, while any healthcare professional assisting a woman in procuring an abortion risks up to 4 years of imprisonment and loss of their licence.¹

The options available for pregnant people living in Malta who have an unwanted pregnancy have always been limited. Historically, women have either travelled to countries where abortion is legal or remained pregnant, but backstreet abortions were not the norm.² On average, between 2011 and 2019, 56 Maltese residents accessed abortion services in England and Wales.³ Travel has never been an easy option; women would need to take time off work, find childcare, fund the abortion, all while keeping the reason for travel a secret from most friends and family. While surmountable for some, these barriers serve as a stark reminder of the disparity in access to essential healthcare.

Since the COVID-19 pandemic, the number of residents from Malta travelling to the UK to access abortion services declined drastically; 20 in 2020 and only four in 2021. More women reached out to activist and abortion support groups during the March to May 2020 lockdown period,⁴ while there was a significant surge in purchases of abortion pills from Women on Web (WoW) in various European countries including Malta.⁵ This change reflects policy or protocol changes to facilitate access to telemedicine for self-managed abortions implemented in various European countries.⁶ While such changes were obviously not possible in Malta, grassroots organisations stepped in to bridge the gaps. In August 2020, three pro-choice organisations in Malta launched a volunteer-run helpline to facilitate access by providing information on reproductive choices. This Family Planning Advisory Service assisted 479 individuals in its first year alone.⁷

Since 2006, the non-profit organisation WoW has provided online telemedicine to women in countries where abortion care is legally restricted.⁸ In 2008, a Maltese newspaper reported that abortion pills were also available to women in Malta⁹ and women have had the option of at-home medical abortion through online telemedicine since then. Between 2013 and 2017, 465 women living in Malta contacted WoW to purchase abortion pills online.¹⁰ Although this option costs much less than travel abroad, women in Malta having medical abortions at home do so without the reassurance of having doctors they can confide in should any complications arise, while exposing themselves to potential criminal liability.

WoW provides an initial online consultation form which is reviewed by a medical doctor. If the gestation is less than 10 weeks and there are no contraindications, a prescription and package containing mifepristone and misoprostol is dispatched against a donation, which is waived in cases of financial hardship. Women in Malta usually receive the package within 2 weeks. A helpdesk team provides real-time instructions and follow-up by email. A 10-year study using data from over 26 000 women who used the service in countries with highly restrictive legislations worldwide confirmed that self-managed medical abortion is safe and effective.¹¹

The aim of this study was to examine the number and characteristics of women in Malta seeking at-home medical abortion through telemedicine from WoW, the main online medical abortion provider. Similar studies have been conducted in Ireland, Northern Ireland, Hungary, Germany, Italy, and the USA in recent years.^12–18 Smaller alternative services, for example, Women Help Women, are also available, such that this cohort does not represent the entire population obtaining medical abortion pills online.

Methods

We retrieved all requests to WoW from women in Malta who completed an online consultation between January 2017 and December 2021. This date range was chosen because the consultation forms that had been developed over time had become constant such that almost complete data were available. The consultation form includes information about demographics, medical and pregnancy history, and health status. Women also select the circumstances of their pregnancy, the reasons for needing an abortion, and their reasons to order medical abortion pills online. All the questions have predefined answers and women can choose as many responses as they wish. As nationality is not included, we cannot distinguish between citizens and non-citizens, although it is estimated that 20% of the population constitutes non-Maltese citizens.¹⁹

De-identified data were provided by WoW and analysed using IBM SPSS. Women had consented to anonymised use of their data for research purposes. The Faculty for Social Well-being Research Ethics Committee, University of Malta reviewed this study (reference number: SWB-2022–0270).

We analysed the number of women to whom medication was shipped between 2017 and 2021. For all 5 years combined, we examined the age distribution, number of children, weeks of gestation, circumstances of pregnancy, reasons for abortion, and reasons for accessing telemedicine. We compared data before and during COVID-19, for women greater or less than 20 years of age and those with or without children. The χ² test was used to investigate the association between categorical variables. Findings were considered statistically significant at a p value <0.05. Most women did not complete the follow-up evaluation, which was therefore not included in the analysis.

Patient and public involvement statement

Although this analysis did not involve patients in its design, management or reporting, the research questions were informed by the experiences of pregnant people in Malta who rely on WoW to access abortion. Some preliminary results were published in a Maltese newspaper²⁰ and presented in an academic conference.²¹ Feedback from public and academic peers was considered.

Results

The number of women living in Malta seeking medical abortion through WoW increased steadily from 78 in 2017 to 509 in 2021, a more than sixfold increase. Between January 2017 and December 2021, 1090 women contacted WoW to request medical abortion, and medication was shipped to 658 women (60.4% of requests)(figure 1). The remainder were cancelled either because they chose to continue the pregnancy, experienced a miscarriage, or decided on travel to access abortion.

Figure 1.

Number of abortion packages shipped per year. There was a 29% decrease in the number of shipments between 2017 and 2018, but a 56% increase between 2018 and 2019, a 108% increase between 2019 and 2020, and a 47% increase between 2020 and 2021. The sharpest increase was observed in 2020, corresponding to the onset of the COVID-19 pandemic. WoW, Women on Web.

Table 1 shows the characteristics of women and pregnant people to whom abortion medication was shipped between 2017 and 2021. It further differentiates between the pre- and during COVID-19 period; however, the bivariate analysis carried out in this study cannot support any causal conclusions since there could be other contributing factors, and persons accessing abortion care before and during COVID-19 could be systematically different. The mean age was 29.3 years, but the cohort included women from all reproductive age groups. Just over half (53.3%) were between 25 and 34 years old, nearly a quarter (22%) were women 35 years and over, and another quarter (24.3%) were under 25. The majority (52%) were mothers with a mean number of 1.72 children, while almost a quarter (24%) had two or more children; 92% made the request at a gestational age of less than 7 weeks.

Table 1.

Characteristics of women and pregnant people living in Malta to whom abortion packages were shipped through WoW, 2017–2021 (n=658)

Reported characteristic	Total (n=658) %	Pre-COVID* (n=240) %	COVID†† (n=418) %
Age (years)
Under 20	5	7	5
20–24	19	20	18
25–29	30	29	30
30–34	24	23	24
35–39	15	15	15
40–44	6	6	7
45 and over	2	1	1
Number of children
0	48	49	47
1	22	24	22
2	17	20	15
3	5	3	6†
≥4	2	0	2
No data‡	7	4	8
Weeks of gestation
Fewer than 7 weeks	92	87	95
Between 7 and 10 weeks	8	13	5†
Circumstances of pregnancy
I did not use contraceptives	63	63	63
I wanted a pregnancy first, but situation changed	3	1	4
I was raped	2	2	1
The contraceptives I used did not work	30	33	28
Reasons for accessing abortion care§
I just cannot have a child at this point in my life	69	72	67
I have no money to raise a child	34	36	32
I am too young	17	17	16
My family is complete	14	16	14
I want to finish school	14	17	11
I am too old	5	6	5
My partner does not want a child	5	0	9†
I am ill	1	1	1
No data	7	1	10
Top reasons for accessing telemedicine¶
It is hard for me to access abortion because of legal restrictions	73	80	70
I prefer to access abortion through WoW because abortion pills are not available in my country	46	44	47
I prefer to access abortion through WoW because I would rather keep my abortion private	31	33	30
I prefer to access abortion through WoW because I would be more comfortable at home	25	27	24
It is hard for me to access abortion because of cost	21	22	20
It is hard for me to access abortion because of distance	20	19	21
I prefer to access abortion through WoW because I would rather take care my own abortion	20	20	20
It is hard for me to access abortion because I need to keep my abortion a secret	19	24	17
I prefer to access abortion through WoW because I would rather have someone with me	19	20	19
Because of COVID-19**	19	0	26†
It is hard for me to access abortion because of work or school commitments	11	11	11

*January 2017–March 2020.

†P<0.001.

‡Answered YES to having children but missing data on number of children.

§Could choose more than one reason.

¶Available from 2018 onwards (n=580).

**From March 2020 onwards (n=418).

††April 2020–December 2021.

WoW, Women on Web.

When describing the circumstances of their pregnancy, most women were either not using contraception (63%) or had experienced failure of contraception (30%). The most common reasons cited for accessing abortion care were not being able to have a child at this point in their life (69%) and having no money to raise a child (34%). The most common reasons for accessing telemedicine were legal restrictions (73%) and unavailability of medical abortion pills (46%).

Table 2 compares the circumstances of pregnancy and reasons for abortion selected by women with and without children. Having children seems to influence the reasons for seeking an abortion since mothers were significantly more likely to select ‘I am too old’ and ‘My family is complete’ than women without children. Those without children were more likely to want to finish school or select ‘I have no money to raise a child’ as a reason. Women who were mothers were also less likely to be using contraception than those without children (70% compared with 60%), and women without children were more likely to experience contraception failure than those who were mothers (36% compared with 25%).

Table 2.

Comparison of selected characteristics of persons with and without children to whom abortion packages were shipped through WoW, 2017–2021

Selected characteristic	Children
	Yes (n=344)	No (n=314)
Circumstances of pregnancy (p=0.036)
I did not use contraceptives	70 (241)	60 (188)
I wanted a pregnancy first, but situation changed	3(11)	2(6)
I was raped	2(6)	2(6)
The contraceptives I used did not work	25 (86)	36 (114)
Reasons for accessing abortion care (p<0.001)
I just cannot have a child at this point in my life	60 (206)	72 (226)
I have no money to raise a child	29 (98)	36 (112)
My family is complete	27 (93)	3(8)
I want to finish school	5(16)	20 (62)
I am too old	9 (32)	2(5)
My partner does not want a child	5(17)	5(16)

All data are given as a percentage (n).

WoW, Women on Web.

The reasons that younger persons gave for accessing abortion also differed from the older cohort (table 3). Women younger than 20 were significantly more likely to state that they wanted to finish school (21% vs 11%), and that they had no money to raise a child (59% vs 32%) and were less likely to state that their family was complete (3% vs 15%) (p<0.001). Teenagers more frequently selected the need to keep abortion a secret, the cost, and school and work commitments, and fewer reported having a partner or friend with them during the process (p=0.041). Teenagers and adults did not differ significantly in terms of gestation when requesting abortion pills.

Table 3.

Comparison of selected characteristics of persons over and under 20 years of age to whom abortion packages were shipped through WoW, 2017–2021

Reported characteristic	Age
	<20 (n=39)	>20 (n=619)
Weeks of gestation (p=0.203)
Fewer than 7 weeks	97 (38)	92 (568)
Between 7 and 10 weeks	3 (1)	8 (51)
Reasons for accessing abortion care (p<0.001)
I just cannot have a child at this point in my life	69 (27)	69(427)
I have no money to raise a child	59 (23)	32 (198)
My family is complete	3(1)	15 (93)
I want to finish school	21 (54)	11 (68)
I am too old	0 (0)	6 (37)
My partner does not want a child	5(2)	5 (31)
Top reasons for accessing telemedicine (p=0.041)
It is hard for me to access abortion because of legal restrictions	72 (28)	64 (396)
It is hard for me to access abortion because of cost	33 (13)	18 (111)
It is hard for me to access abortion because of distance	39 (15)	99 (9)
I prefer to access abortion through WoW because I would rather take care my own abortion	23 (9)	17 (105)
It is hard for me to access abortion because I need to keep my abortion a secret	33 (13)	16 (99)
I prefer to access abortion through WoW because I would rather have someone with me	15 (6)	17 (105)
Because of COVID-19*	13 (5)	16 (99)
It is hard for me to access abortion because of work or school commitments	23 (9)	8 (50)

All data are given as a percentage (n)

WoW, Women on Web.

Discussion

The most common reasons cited by pregnant people in Malta for accessing abortion through telemedicine were legal restrictions and the lack of availability of abortion pills, further evidence that legal restrictions do not stop abortions taking place. Abortion care by women in Malta seems to be shifting from travelling abroad to countries where abortion is legal to self-managing medical abortion after purchasing abortion pills online. This upward trend in the number of pregnant people accessing telemedicine has continued in 2022, with 316 abortion packages shipped to Malta (personal communication with WoW), marking a further 21% increase from 2021.

The increasing demand for self-managed abortions is congruent with developments in other regions where abortion care is restricted. A literature review of studies in Latin American countries found that women value the privacy that medical abortion allows as well as the possibility of having someone with them during the process. They perceive it as less painful, safer, more practical, less expensive, and more natural than other abortion methods.²² Furthermore, Malta’s public landscape has also changed in recent years. Abortion remains a highly stigmatised subject,⁸ and for decades, anti-abortion voices dominated public discourse; however, since 2018, a vocal pro-choice movement has led to counter discourses in the public sphere, and there is widespread provision of information on safe abortion access outside formal healthcare settings.⁸ An online platform that provides a space for women to tell their abortion stories anonymously included several (circa 12 out of 67 stories) where women specifically recounted their experiences of self-managing their medical abortion.²³

The implication of the increasing demand for at-home medical abortion is that more women in Malta are now breaking the law to access abortion, increasing their need for secrecy due to potential criminal prosecution. In an interview in the Guardian newspaper,²⁴ one woman described her fear when a local politician threatened to prosecute women who had sought abortion care in other countries. While this fear was unfounded, since women who legally seek abortion care outside Maltese jurisdiction cannot be prosecuted on their return, this is not the case for women who manage their own abortions within the country. As indicated in the Latin American study, the disadvantage of medical abortion is the possible need to seek medical care where they may be reported to the police for having an abortion. In another abortion story,²⁵ a woman recounted experiencing prolonged bleeding, pain, and disorientation, yet she was reluctant to seek medical care due to the risk of prosecution. It is worth noting that in the most recent survey that focused on the current criminal sanctions, most respondents (53.3%) did not agree with jailing women, a six-point increase from a similar survey carried out 1 year earlier.²⁶ Recently, the prime minister also raised the issue, stating that he has personally talked with women who self-managed their abortion, indicating the potential for a change in policy direction in relation to the decriminalisation of abortion care.²⁷

In a context where abortion is not legally available through formal healthcare services, women who seek abortion care through telemedicine are diverse in terms of age and circumstances. At 29.3 years, the median age of women in Malta is very similar to that in countries such as Italy, Hungary, and Ireland where the mean age was 30. Teenagers constitute nearly 5% of women receiving abortion pills, which is similar to Ireland (4.6%), higher than Hungary (2.9%), but less than Italy (7.8% at 18 or younger). Although Malta has the lowest fertility rate in the EU, it has a higher-than-average teenage birth rate (11.9 births per 1000 girls aged 15 to 19 in 2019, compared with the EU average of 8.9). This high rate is partly due to the total ban on abortion, given that teenagers face more barriers accessing abortion services.²⁸ Indeed, the findings highlight how teenagers are more vulnerable since they often face economic and social difficulties and lack the support of a family member or partner. Similar findings were reported in studies of Italian and German women seeking abortion through WoW.^{16 17}

Contrary to the prevailing stereotype that most women who access abortion are young and promiscuous, most women seeking abortion through telemedicine in Malta were in their late 20s or early 30s and were already mothers, and their main reason for accessing abortion was that they felt their family was complete or they could not cope with another child. Notably, among this group, the lack of use of contraception rather than contraception failure was the main reason why women became pregnant. In a recent study, the rate of unintended pregnancies was 23%, mainly due to not using contraception at all (20%) or due to relying on less reliable methods such as withdrawal, natural family planning, or condoms.²⁹ Malta lacks a family planning policy or public family planning clinics, and most contraception is available on payment from private health services.²⁸

In conclusion, since 2018, abortion care among pregnant people in Malta is steadily shifting to accessing at-home medical abortion through telemedicine. These changes might have been accentuated by travel restrictions during the COVID-19 pandemic and by the local provision of voluntary services providing information and support.

Although at-home medical abortion is medically safe, pregnant people in Malta who access WoW services risk criminal prosecution, drawing attention to the urgent need to decriminalise abortion to address the inequities in accessing reproductive health services, as recommended by the WHO.³⁰

This study further highlights the need for better family planning services and the promotion of more reliable methods of contraception. It further indicates that teenagers seeking self-managed abortion might be in a more vulnerable situation since they are less likely to have support.

Data availability statement

Data are available upon reasonable request. The authors confirm that they are willing to share all anonymised participant data on which the analysis, results, and conclusions reported in the paper are based. Data are available from Dr Andreana Dibben who can be contacted on andreana.dibben@um.edu.mt.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The Faculty for Social Wellbeing Research Ethics Committee, University of Malta reviewed this study. Reference Number: SWB-2022-0270