Abstract
Introduction
Telehealth medication abortion (teleMAB) is an option for expanding abortion access in the USA. In this study, we compared the accessibility of two no-test, direct-to-patient teleMAB regimens: mifepristone and misoprostol, and misoprostol-only.
Research design and methods
Over a 5-month period, we conducted an exploratory study surveying clients who received teleMAB services from an abortion clinic offering teleMAB. We calculated descriptive statistics focusing on the healthcare access dimensions of acceptability and accommodation. We conducted a content analysis of open-response comments focusing on convenience.
Results
Of the 218 clients in the study: 195 (89%) selected the mifepristone and misoprostol regimen and 23 (11%) selected the misoprostol-only regimen. Across all respondents, 88% reported they would use the service again if they needed an abortion in the future. Half of the respondents (52%) connected to the service using a smartphone, 99% owned the device that they used, 98% could easily hear and 99% could easily talk to the prescribing provider, and only 7% had a problem connecting to the service. Respondents felt that teleMAB was convenient because they had quality and trustworthy communications. It also accommodated their childcare needs, travel, and scheduling, felt private and comfortable, and facilitated a sense of reproductive autonomy.
Conclusions
Respondents found both teleMAB regimens to be acceptable, technologically accommodating and convenient. These results have promising implications for states positioned to expand insurance coverage and reimbursement for teleMAB, including misoprostol-only regimens. Results also inform a need to focus on policies that expand access to teleMAB through nationwide internet connectivity.
Keywords: Public Health, Sociodemographic Factors, Reproductive History, Social Medicine
WHAT IS ALREADY KNOWN ON THIS TOPIC
Telehealth provision of medication abortion is safe and acceptable, but data are based solely on models of care that use mifepristone and misoprostol.
WHAT THIS STUDY ADDS
This exploratory study assessed client experiences with mifepristone and misoprostol, and misoprostol-only regimens and found both to be acceptable, technologically accommodating and convenient.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The high acceptability of telehealth abortion irrespective of regimen has promising implications for states positioned to expand access to and options for telehealth services. These results also raise key questions for future research comparing experiences with both mifepristone and misoprostol, and misoprostol-only regimens.
Introduction
Telehealth provision of medication abortion (hereafter referred to as telehealth medication abortion (teleMAB)) using mifepristone and misoprostol (mifepristone/misoprostol),1,3 or misoprostol-only,4 5 are two safe and effective abortion care options. TeleMAB typically occurs when a client and provider are in different locations. Asynchronous telehealth occurs when the client and provider interact through a secure messaging platform, and synchronous telehealth occurs when the client and provider connect via live video or phone. In some teleMAB models, these medications are mailed directly to a client’s home, and in other models, a client may pick up the medications at a pharmacy or clinic site.6
There has been a rapid expansion of the provision of teleMAB services in the USA, with virtual abortion clinics, brick-and-mortar abortion-providing facilities with virtual options and online telemedicine services providing abortion medications to people throughout the USA. In the first 18 months following the Dobbs vs Jackson Women’s Health Organization (Dobbs) ruling that overturned the right to legal abortion in the USA, telehealth accounted for 19% of all abortions in the formal healthcare system.7 As teleMAB services continue to expand, there is a growing understanding of patient experiences. In states and countries where it is legal to provide teleMAB, services reduce distance to appointments and travel time8 and may open the availability of in-person appointments for those travelling to other states for abortion.9 Patients highlight the privacy and expediency of teleMAB,10 reporting that it is an acceptable way to receive abortion care,11 and that receiving medications by mail meets their need for autonomy,12 as well as preferences for privacy and confidentiality,13 convenience, comfort,14 and the ability to schedule appointments around personal responsibilities.15
Although medication abortion is not medically appropriate nor the desired abortion care option for all people, the distinct rise in teleMAB utilisation highlights an urgent need to understand client experiences across telehealth models. There is growing literature examining patient outcomes and experiences with teleMAB provision of mifepristone/misoprostol, and some research has examined experiences with misoprostol-only medications sent by mail.16 However, to date, no research has directly explored client experiences across both medication regimens and within the same client population. This is particularly important because there is an urgency to understand experiences with misoprostol-only. The dispensing of mifepristone is restricted in the USA and has faced numerous legal challenges, including the 2024 Supreme Court Case Alliance for Hippocratic Medicine vs US Food and Drug Administration, which mostly recently threatened mifepristone’s availability.
As the future availability of mifepristone is uncertain, evidence must be gathered regarding the safety, effectiveness and acceptability of alternative medication abortion regimens for those aiming to support people with abortions. This study broadens the knowledge based on no-test telehealth abortions and offers preliminary evidence on the experiences of clients who use mifepristone/misoprostol and misoprostol-only regimens. To address this gap in the literature, the objective of this study is to understand client experiences with two no-test direct-to-patient services in the USA: teleMAB using mifepristone used with misoprostol and misoprostol-only.
Methods
Study design
This study recruited respondents who received teleMAB services through Carafem, a virtual clinic with brick-and-mortar clinic sites serving the USA Because this was an exploratory study, we based our sample size on resource and study time constraints, aiming to recruit at least 200 respondents. Services were available to clients in Connecticut, Georgia, Iowa, Illinois, Maryland, Massachusetts, Michigan, New Jersey, Virginia and Washington D.C. Clients chose between teleMAB using mifepristone/misoprostol or misoprostol-only. The misoprostol-only regimen costs US$75 less than the mifepristone/misoprostol regimen. If a client wanted mifepristone/misoprostol and was concerned about cost, Carafem reduced the rate to provide mifepristone. The only clients for whom Carafem did not offer mifepristone were those who were medically ineligible. This was rare and only applied to those using long-term corticosteroids.
Services were available up to 10 weeks’ gestation for both regimens. Clients first connected with a clinic staff member via telephone or web platform to assess their eligibility. If eligible, clients connected online with a provider who prescribed the medication(s) and counselled them on the two regimens: mifepristone/misoprostol and misoprostol-only. Providers informed clients of medication(s) cost, side effects, pain and how to connect with staff if they have questions or concerns. Abortion care was provided using a ‘no-test’ telehealth model, meaning that no ultrasound, Rhesus factor or other in-person tests were conducted prior to the dispensing of medication. Medications were available by mail or pick-up at the closest clinic.
Patient and public involvement
Patients were not included in the research design or the research instrument developments. Because participants are anonymised, we cannot share the results with them. However, we aim to share the results of the study with the clinic from which we recruited the patients. The clinic may disseminate these findings with current clients and others.
Participants
Between 5 October 2021 and 6 May 2022, we recruited 251 survey respondents, and 218 were valid responses. Approximately 5% of clients selecting mifepristone/misoprostol, and 4% of clients selecting misoprostol-only responded to the survey. To be eligible to participate clients had to be at least 18 years old, provide consent and complete a self-administered online survey on their own device. This survey was presented in English and a digital flyer was sent to clients at the end of their telehealth consultation but prior to receiving medication. Each respondent received a US$35 online gift card and was entered into a raffle to win one of two US$100 gift cards.
Demographic survey items were informed by prior work aimed at creating survey questions that resonate with participants’ lived experiences and diverse identities.17 Survey items on the acceptability of services were sourced from prior telemedicine studies14 18 with adaptations for COVID-19, the recent removal of the preabortion ultrasound requirement and the expansion of Carafem’s telehealth model. Survey items on healthcare utilisation were sourced from the 2019 redesign of the National Health Interview Study.19 Select survey questions are in online supplemental appendix 1.
Analysis
We assessed two dimensions of patient-centred access to healthcare, drawn from Levesque et al’s conceptualisation of access within health systems and populations.20 Access is defined (broadly) as ‘the opportunity to reach and obtain appropriate healthcare services in situations of perceived need for care’. We focused our analyses on the dimensions of (1) Acceptability, the social factors determining the possibility for people to accept the aspects of the service and determined appropriateness for the person seeking care. (2) Accommodation, the corresponding ability for a person to seek, reach and engage with the service. Finally, we incorporate an additional element to our analysis by qualitatively examining the convenience of the model, as reported by open-response comments from survey respondents.
To understand regimen-specific differences, we compared measures across the two teleMAB regimens. We did not conduct statistical tests or bias checks between regimens because of the small sample size of misoprostol-only users. Descriptive analyses were conducted using R and R studio V.4.1717.
To understand the thematic nuances of convenience, two members of the research team conducted an inductive content analysis21 with a modified conventional analysis approach.22 We analysed 215 written responses to the survey question: ‘Please rate your level of agreement or disagreement with the statement telehealth is a convenient form of healthcare.’ If a respondent selected agree or disagree with the statement, they were asked to elaborate in an open-response format on their selection. This analysis was intended to illustrate the range of qualitative responses to a general question about the convenience of telehealth. Early in the coding process, we found thematic consistency across regimens, which removed the need to compare responses between regimens.
To establish intercoder consistency, we coded the first 50 comments separately, compared codes and discussed any discrepancies.23 The first 50 comments were chosen to balance available resources and researcher time. This represented about a quarter of all comments. After we double-coded 50 comments, we met to determine thematic consistency between the two coders and to confirm that no additional themes had emerged. We also compared notes and discussed discrepancies. At the time of manuscript preparation, we also met to discuss any potential new themes or perceptions and discuss the quotations that should be included in the manuscript.
Results
Participant characteristics
Of the 218 teleMAB clients who completed the survey, 195 (89%) selected mifepristone/misoprostol, and 23 (11%) selected misoprostol-only. Differences in characteristics by the type of regimen are in table 1. Across both regimens, 57% of clients had some college or a bachelor’s degree. Most were never married and currently single (38%) or never married and currently partnered (32%). Over half of clients were white (54%) and just over one-third were Black/African American (37%). Most were non-Hispanic (87%) and 13% were Hispanic. Nearly all participants selected ‘woman’ (76%) or ‘cisgender’ (34%) as a gender category that they identify with, however, participants could select multiple gender categories. Two respondents selected ‘yes’ that they were intersex. Over half (52%) had no children, 38% had previously had an abortion and 60% of previous abortions were with pills. The majority (70%) of clients had health insurance at the time. Compared with mifepristone and misoprostol users, a higher proportion of misoprostol-only users had some college or a bachelor’s degree, were black/African American, had children, were single and were uninsured.
Table 1. Characteristics by medication abortion regimen among clients who used teleMAB and responded to a client survey between 6 October 2021 and 6 May 2022.
| Overall(N=218)n (%) | Mifepristone and misoprostol(n=195)n (%) | Misoprostol-only(n=23)n (%) | |
| Education | |||
| Associate or some high school | 24 (11.0) | 23 (11.8) | 1 (4.4) |
| High school | 41 (18.8) | 38 (19.4) | 3 (13.0) |
| Some college | 61 (27.9) | 51 (26.2) | 10 (43.4) |
| Bachelor’s degree | 64 (29.4) | 57 (29.2) | 7 (30.4) |
| Master’s or doctorate degree | 22 (10.1) | 20 (10.2) | 2 (8.7) |
| Other | 6 (2.8) | 6 (3.1) | 0 (0.0) |
| Relationship status | |||
| Never married, single | 82 (37.6) | 68 (34.9) | 14 (60.9) |
| Never married, partnered | 70 (32.1) | 64 (32.8) | 6 (26.1) |
| Married | 40 (18.3) | 37 (19.0) | 3 (13.0) |
| Divorced or separated | 19 (8.7) | 19 (9.7) | 0 (0.0) |
| Prefer not to answer or missing | 7 (3.2) | 7 (3.6) | 0 (0.0) |
| Race* | |||
| American Indian or Alaska Native | 4 (1.8) | 4 (2.1) | 0 (0.0) |
| Black/African American | 81 (37.2) | 69 (35.4) | 12 (52.2) |
| East Asian or Southeast Asian | 9 (4.1) | 9 (4.6) | 0 (0.0) |
| Middle Eastern/North African | 3 (1.4) | 3 (1.5) | 0 (0.0) |
| Native Hawaiian/Pacific Islander | 3 (1.4) | 3 (1.5) | 0 (0.0) |
| White | 117 (53.7) | 107 (54.9) | 10 (43.5) |
| Unknown or not listed or prefer not to answer | 13 (5.9) | 12 (6.2) | 1 (4.3) |
| Ethnicity | |||
| Hispanic | 28 (12.8) | 24 (12.3) | 4 (17.4) |
| Non-Hispanic | 189 (86.7) | 170 (87.2) | 19 (82.6) |
| Prefer not to answer | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Gender* | |||
| Agender | 1 (0.5) | 0 (0.0) | 1 (4.3) |
| Cisgender woman | 73 (33.5) | 65 (33.3) | 8 (34.8) |
| Genderfluid | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Non-binary | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Woman | 169 (77.5) | 149 (76.4) | 20 (86.7) |
| Intersex | |||
| Yes | 2 (1.0) | 2 (1.0) | 0 (0.0) |
| No | 215 (98.5) | 192 (98.5) | 23 (100.0) |
| Prefer not to answer | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Children | |||
| 0 | 114 (52.3) | 104 (53.3) | 10 (43.5) |
| 1+ | 104 (47.7) | 91 (46.6) | 13 (56.5) |
| Previous abortion | |||
| Yes | 83 (38.1) | 75 (38.5) | 8 (34.8) |
| No | 133 (61.1) | 118 (60.5) | 15 (60.2) |
| Prefer not to answer | 2 (0.9) | 2 (1.0) | 0 (0.0) |
| Previous abortion type | |||
| Surgical abortion | 33 (15.1) | 32 (16.4) | 1 (4.3) |
| Abortion with pills, at home | 15 (7.0) | 10 (5.1) | 5 (21.7) |
| Abortion with pills, in clinic | 35 (16.1) | 33 (16.9) | 2 (8.7) |
| Insurance | |||
| Yes | 154 (70.6) | 149 (76.4) | 5 (21.7) |
| No | 64 (29.4) | 46 (23.6) | 18 (78.3) |
Multiple response.
teleMABtelehealth medication abortion
Acceptability
Most respondents found the no-test provision of mifepristone/misoprostol and misoprostol-only to be acceptable. Results on the acceptability of teleMAB by regimen are in table 2. Among respondents who selected mifepristone/misoprostol, 89% rated the telehealth visit as ‘excellent’, 96% would use the service again for a future abortion, 88% would recommend an abortion with pills and 97% would recommend this service to a friend. Among respondents who selected misoprostol-only, 82% rated the telehealth visit as ‘excellent’, 91% would use the service again for a future abortion, 87% would recommend an abortion with pills and 96% would recommend this service to a friend.
Table 2. Acceptability and accommodation of teleMAB service, by medication abortion regimen among clients who used teleMAB and responded to a client survey between 6 October 2021 and 6 May 2022.
| Overall(N=218)n (%) | Mifepristone and misoprostol(n=195)n (%) | Misoprostol-only(n=23)n (%) | |
| How would you rate the Carafem telehealth visit? | |||
| Excellent | 192 (88.1) | 173 (88.7) | 19 (82.6) |
| Good | 4 (1.8) | 3 (1.5) | 1 (4.4) |
| Very good | 18 (8.3) | 16 (8.2) | 2 (8.7) |
| Fair | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Poor | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Missing | 4 (1.8) | 3 (1.5) | 1 (4.3) |
| If I needed an abortion in the future, I would use the telehealth service again? | |||
| Yes | 208 (95.4) | 187 (95.9) | 21 (91.3) |
| Depends | 3 (1.4) | 2 (1.0) | 1 (4.3) |
| Not sure | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| No | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Prefer not to answer | 3 (1.3) | 2 (1.0) | 1 (4.3) |
| Missing | 3 (1.3) | 3 (1.5) | 0 (0.0) |
| If you had a friend who was pregnant and wanted to have an abortion with pills, would you recommend that they had a medical abortion (an abortion with pills)? | |||
| Yes | 191 (87.6) | 171 (87.7) | 20 (87.0) |
| Depends | 16 (7.3) | 15 (7.7) | 1 (4.3) |
| Not sure | 4 (1.8) | 4 (2.1) | 0 (0.0) |
| Prefer not to answer | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| No | 2 (0.9) | 1 (0.5) | 1 (4.3) |
| Missing | 4 (1.8) | 3 (1.5) | 1 (4.3) |
| If you had a friend who was pregnant and wanted to have an abortion with pills, would you recommend that they use the telehealth service? | |||
| Yes | 211 (96.8) | 189 (96.9) | 22 (95.6) |
| Depends | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Not sure | 0 (0.0) | 1 (0.5) | 0 (0.0) |
| No | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Prefer not to answer | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Which factor was the most important when you were deciding what type of abortion you were going to have | |||
| I wanted to have the abortion as soon as possible | 71 (32.6) | 62 (31.8) | 9 (39.1) |
| I wanted to have the abortion at my home | 41 (18.8) | 34 (17.4) | 7 (30.4) |
| I wanted to have an abortion that was affordable | 34 (15.6) | 30 (15.4) | 4 (17.4) |
| I wanted to have the abortion pill (medical abortion) | 22 (10.1) | 20 (10.3) | 2 (8.7) |
| I wanted to have an abortion without having to do an ultrasound | 5 (2.3) | 5 (2.6) | 0 (0.0) |
| I wanted to have a friend/family member with me when I was having my abortion | 5 (2.3) | 5 (2.6) | 0 (0.0) |
teleMABtelehealth medication abortion
Accommodation
The majority of respondents found the no-test provision of mifepristone/misoprostol and misoprostol-only to be accommodating. Results on the accommodation of teleMAB by regimen are in table 2. Both mifepristone/misoprostol and misoprostol-only users reported similar frequencies. Among respondents who selected mifepristone and misoprostol, the most important factors when deciding what type of abortion to have, in order of frequency, were the desire to have the abortion as soon as possible (32%), desire to have the abortion at their home (17%), wanting to avoid going to an abortion clinic (16%) and wanting an abortion that was affordable (15%). Among respondents who selected misoprostol-only, the most important factors were the desire to have the abortion as soon as possible (39%), to have the abortion at their home (30%) and wanting an abortion that was affordable (17%).
Within accommodation, we also examined the client’s technological engagement with the service measures of connectivity. Measures included multiple choice questions regarding what device people used to connect, their ability to digitally connect and their experiences with using the telehealth systems. Differences in the connectivity of teleMAB by regimen are in table 3. The most frequent way clients connected to the service was with a smartphone (50% for mifepristone-misoprostol and 60% for misoprostol-only). The vast majority owned the device that they used to connect (99% mifepristone-misoprostol and 100% misoprostol-only), found the telehealth system easy to understand (99% mifepristone-misoprostol and 99% misoprostol-only) and easy to use (99% mifepristone-misoprostol and 100% misoprostol-only). Most could easily hear (99% both regimens) and talk to the provider of the medication (99% mifepristone-misoprostol and 96% misoprostol-only). A small group had a problem connecting with the service (8% mifepristone-misoprostol and 4% misoprostol-only).
Table 3. Connectivity of teleMAB service, by medication abortion regimen among clients who used teleMAB and responded to a client survey between 6 October 2021 and 6 May 2022.
| Overall(N=218)n (%) | Mifepristone and misoprostol(n=195)n (%) | Misoprostol-only(n=23)n (%) | |
| What type of device did you use to connect? | |||
| Computer | 80 (36.27 | 74 (37.9) | 6 (26.1) |
| iPad/tablet | 11 (5.0) | 11 (5.6) | 0 (0.0) |
| Smartphone | 115 (52.8) | 99 (50.8) | 16 (69.6) |
| Telephone | 12 (5.5) | 11 (5.6) | 1 (4.3) |
| Do you own the device that you used to connect to the telehealth service? | |||
| Yes | 216 (99.1) | 193 (99.0) | 23 (100.0) |
| No | 2 (0.9) | 2 (1.0) | 0 (0.0) |
| If no, who owns the device? | |||
| ‘Employer’ | 2 (0.9) | 2 (1.0) | 0 (0.0) |
| The telehealth system is easy to understand | |||
| Yes | 216 (99.0) | 194 (99.5) | 22 (95.7) |
| No | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Declined | 1 (0.5) | 0 (0.0) | 1 (1.3) |
| The telehealth system is easy to use | |||
| Yes | 217 (99.5) | 195 (100.0) | 22 (95.7) |
| No | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Declined | 1 (0.5) | 0 (0.0) | 1 (1.3) |
| I had a problem connecting with the telehealth service | |||
| Yes | 16 (7.3) | 15 (7.7) | 1 (4.3) |
| No | 201 (92.2) | 180 (92.3) | 21 (91.3) |
| Declined | 1 (0.5) | 0 (0.0) | 1 (4.3) |
| I could easily hear the person who prescribed me the abortion pills | |||
| Yes | 214 (98.2) | 192 (98.5) | 22 (98.7) |
| No | 3 (1.4) | 3 (1.5) | 0 (0.0) |
| Declined | 1 (0.5) | 0 (0.0) | 1 (1.3) |
| I could easily talk to the person who prescribed me the abortion pills | |||
| Yes | 216 (99.0) | 194 (99.5) | 22 (95.7) |
| No | 1 (0.5) | 1 (0.5) | 0 (0.0) |
| Declined | 1 (0.5) | 0 (0.0) | 1 (1.3) |
teleMABtelehealth medication abortion
Convenience
Themes from the open-response comments were thematically consistent across regimens and excerpts illustrative of each theme are presented in figure 1. Overall, respondents found the no-test provision of mifepristone/misoprostol and misoprostol-only to be convenient and highlighted six aspects of this convenience. First, it met their need for childcare during their abortion. As one client wrote, ‘I do not have childcare, so telehealth made it convenient to have the appointment at home’. Others felt the communications they had with the clinic were high quality and fostered a sense of trustworthiness between client and provider. One client wrote, ‘It allowed me to reach out to a professional and receive quality information about a problem I was having’. And another wrote ‘I felt just as heard and cared for as I would in a regular in-person clinic’. Telehealth also met their scheduling needs and was efficient. A client wrote ‘It was no wait time; everything was clear & afterwards I could easily go on about my day’. Clients also expressed that the service facilitated reproductive autonomy, respondents felt that ‘abortion is a human right and telehealth made that right accessible’. They also highlighted the privacy and comfort of telehealth. One client wrote, ‘It’s discreet, it’s confidential, yet it was still a personal experience’. Finally, clients wrote that with telehealth, they were able to avoid travel, and it met a desire for being at home. As one client explained ‘Not everyone has a way to travel to a clinic, and for some like myself may be nervous and needing help fast. It felt safe, more comfortable than going into a clinic for the appointment’.
Figure 1. Themes and quotations from open responses to the question: Please tell us why you agree with the statement: ‘The telehealth visit was a convenient form of healthcare’.
Discussion
In this exploratory study of 218 clients who used no-test teleMAB services from Carafem, respondents found the service delivery model to be acceptable, technologically accommodating and convenient. The high acceptability findings in this study are consistent with prior research. Like a study of 1600 telehealth abortion patients in 2021 and 2022, we found that trust was high between patient and provider, and the vast majority of clients were satisfied with their treatment.24 Furthermore, our findings about the privacy of telehealth, and convenience of staying at home,12 are consistent with previous research. Our study offers preliminary data that suggest no difference in acceptability between no-test models using mifepristone/misoprostol and misoprostol-only, an important contribution as providers explore other models of telehealthcare.
We consider acceptability with the understanding that for those who want to have an abortion, obtaining any abortion (regardless of modality, pathway or medication abortion regimen) is likely seen as favourable when compared with no abortion access at all. Acceptability in this study is contextualised by the lack of resources and treatment options in a legally constrained context. This is critical to underscore. To ensure reproductive autonomy, people require access to a full range of safe and supported abortion methods.
These results have several policy-relevant implications. Clients find no-test medications dispensed by mail to be acceptable, convenient and accommodating. This is an important consideration for advocates working to ensure the option of mailing abortion medicines remains available in the USA. Preliminary evidence that acceptability rates do not differ between these two regimens is hopeful for providers who want to offer teleMAB options at different price points and/or to expand the care models available to clients. Given the surge in teleMAB use in the USA following the Dobbs decision, our results join other research findings that suggest a greater adoption of teleMAB services across various health models.
These results are timely as some continue to bring legal challenges and introduce policies that threaten the availability of mifepristone. As such, it is imperative that we understand client experiences with misoprostol-only teleMAB. In this study, 91% of misoprostol-only users rated their experience as ‘excellent’ or ‘very good’, and 96% said they would recommend the service to a friend. This is consistent with studies from within25 and outside26 formal healthcare settings that find misoprostol-only to be acceptable. However, these findings are limited by our sample size and more research is needed to understand client experiences with the telehealth provision of misoprostol.
Prior research has highlighted how telehealth will expand abortion access,27,29 and the rapid expansion of telehealth models broadly informs a need to focus on policies that democratise internet capabilities throughout the USA. 21 million people in the USA lack broadband connectivity,30 and neighbourhoods populated predominantly by people of colour lack access to technology resources, compared with higher-income white neighbourhoods.31 Over half of all respondents connected to the service using a smartphone. Nationwide access to broadband and high-quality cellular reception would actualise clients’ expressed desires for expedient digital access to care. These findings inform the necessity of such investments at a time when abortion access is becoming increasingly digital. To fully meet the needs of all abortion care seekers, we must address the structural inequalities within the digital systems facilitating new abortion care models.32
Finally, although this study was set in the USA, these findings have broader implications for abortion access as they further strengthen the evidence base regarding teleMAB as a cost-effective and accessible form of abortion care, particularly in low-resource settings.
Limitations
Our study has several limitations. First, this small convenience sample limits our ability to generalise these study findings to all teleMAB clients in the USA. Further, our small sample size of misoprostol-only users limits our ability to detect significant differences in acceptability across regimens, especially demographic subgroup differences. This small sample size of misoprostol-only users limits our understanding of experiences among those who chose this regimen. Overall misoprostol-only regimens are a much smaller proportion of Carafem’s teleMAB services. This is likely why there were so few misoprostol-only responses compared with mifepristone and misoprostol. Furthermore, we lack information on why individuals chose the medication regimen they used. However, understanding medication abortion regimen preferences and motivations is a key area for future research. This survey only captures respondents able to complete an online survey. Future research aimed at understanding the acceptability and connectivity (or lack thereof) among populations who are not able to respond to an online survey is necessary. Finally, this survey was only offered in English. Language access is crucial for navigating health systems, and this survey likely did not capture client experiences among adults with limited English language proficiency.
Conclusion
As teleMAB and similar models grow in the USA, more research is needed to understand how clients engage with and experience these models across different regimens. This is especially relevant because abortion restrictions and persistent legal challenges threaten the provision of mifepristone and telehealth models where pills are mailed. While our study is novel in its detailed focus on two core dimensions of acceptability and comparison across two medication abortion regimens, future research must expand on misoprostol-only user experiences and centre those for whom digital survey participation may be a challenge.
supplementary material
Acknowledgements
We would like to thank the Carafem staff for assisting with data collection.
None of the sources of funding had any involvement in the design and conduct of the study; the collection, management, analysis and interpretation of the data; the preparation, review or approval of the manuscript, or the decision to submit the manuscript for publication.
Footnotes
Funding: This study was supported by Carafem (Grant/Award: not applicable), a non-profit health care provider.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: This study involves human participants and was approved by the Western Institutional Review Board (WIRB)-Copernicus Group, IRIS protocol number 20212841. Participants gave informed consent to participate in the study before taking part.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data are available on reasonable request.