Medication abortion via digital health in the United States: a systematic scoping review

Digital health, including telemedicine, has increased access to abortion care. The convenience, flexibility of appointment times, and ensured privacy to abortion users may make abortion services via telemedicine preferable. This scoping review systematically mapped studies conducted on abortion services via telemedicine, including their effectiveness and acceptability for abortion users and providers. All published papers included abortion services via telemedicine in the United States were considered. Articles were searched in PubMed, CINAHL, and Google Scholar databases in September 2022. The findings were synthesized narratively, and the PRISMA-ScR guidelines were used to report this study. Out of 757 retrieved articles, 33 articles were selected based on the inclusion criteria. These studies were published between 2011 and 2022, with 24 published in the last 3 years. The study found that telemedicine increased access to abortion care in the United States, especially for people in remote areas or those worried about stigma from in-person visits. The effectiveness of abortion services via telemedicine was comparable to in-clinic visits, with 6% or fewer abortions requiring surgical intervention. Both care providers and abortion seekers expressed positive perceptions of telemedicine-based abortion services. However, abortion users reported mixed emotions, with some preferring in-person visits. The most common reasons for choosing telemedicine included the distance to the abortion clinic, convenience, privacy, cost, flexibility of appointment times, and state laws imposing waiting periods or restrictive policies. Telemedicine offered a preferable option for abortion seekers and providers. The feasibility of accessing abortion services via telemedicine in low-resource settings needs further investigation.


INTRODUCTION
In recent years, the availability of intelligent digital health solutions has transformed the population and personalized healthcare 1 . The U.S. Food and Drug Administration (FDA) states that digital health is comprised of categories that include health information management (HIM) technology, mobile health (mHealth), personalized medicine, telehealth and telemedicine, and the use of wearable medical devices 2 . Telehealth and telemedicine allow the delivery of healthcare services such as counseling, assessment, and clinical guidance from a distance through electronic means of communication 3 . They also facilitate a personalized and targeted approach to improve patients' experience 4 . Regarding medication abortion services provided outside of inpatient healthcare settings before 12 weeks of gestational age, telemedicine and telehealth technologies present an alternative to in-clinic abortion services 5 . Previous studies have reported that the effectiveness of abortion services through telemedicine is comparable to that of in-person provision of abortion services [5][6][7] . The demand for medication and abortion services via telemedicine increased in the United States, particularly following the COVID-19 pandemic 8,9 . As the availability of telemedicine has increased, the ability of health providers to offer abortion services using this technology has varied widely. In some locations, only a limited number of abortion services, such as counseling or consenting, were available via telemedicine, while others were offered a wider range of services that included medication abortion [10][11][12] . The dispensing of the oral abortifacient mifepristone via telemedicine was originally permitted under an FDA investigational new drug application (INDA) protocol given the FDA restricted its provision via telemedicine and permitted its administration only under the supervision of certified clinicians at a health facility 13 . This restriction was suspended temporarily in July 2020 during the public health emergency presented by the COVID-19 pandemic [14][15][16] and was lifted permanently on December 16, 2021 17 . This opened the door for more people to access medication abortion and other relevant health services via telemedicine, ultimately resulting in increased access to fully remote abortion services via telemedicine in some states, including California 18 . However, some states have now blocked the use of telemedicine for abortion services 19 . According to the Guttmacher Institute, 14 states no longer allow the provision of abortion services. During 2021 and 2022, different states adopted a total of 158 abortion restrictions, 108 in 2021 and 50 in 2022 20 , and the attempt for further restrictions has continued to increase during 2023. Despite the adoption of various abortion-related restrictions in recent years and the removal of federal protection for abortion services by the Supreme Court, abortion remains a common practice in many states. In 2020, a total of 930,160 abortions were performed in the United States, which represents an increase of 8% increase from those performed in 2017 21 .
This scoping review systematically mapped studies conducted on abortion services through digital healthcare and telemedicine services, including e-counseling, e-consenting, e-prescribing, and evaluated their effectiveness, success rate, acceptability for potential abortion users and the perspectives of both abortion users and providers on abortion services offered via telemedicine.

RESULTS
Our articles screening strategy for this scoping review is shown in Fig. 1. We identified a total of 757 studies and removed 88 duplicates and 527 other articles based on information in the title and abstract. The remaining 141 studies were subjected to fulltext review, and 108 were excluded for reasons that included failure to report medication abortion through telemedicine as an outcome variable, studies contacted outside of the United States, or review papers. The final scoping review included 33 studies (Fig. 1).

Telemedicine and abortion access
The results and themes identified from the included studies are shown in Table 2. Six studies assessed the role of telemedicine in increasing access to abortion care 25,32,34,38,41,43 , particularly for potential abortion users living in remote areas 38 . Grossman et al. (2013) reported that the proportion of potential abortion users who used medication abortion increased from 46% to 54% following the introduction of telemedicine 38 . Similarly, Kohn et al. (2021) showed that the proportion of medication abortion users in Montana increased from 60% to 65%, and the number of abortion users for those in Nevada increased from 461 to 735 after the implementation of abortion via telemedicine 41 . Finally, a study by Thompson et al. (2021) suggested that making abortion care available via telemedicine could increase the abortion access rate from 11.1 to 12.3 per 1000 reproductive-age women 34 (Table 2).

Providers' view and experience of telemedicine
Six studies explored the views and experiences of abortion care providers regarding the provision of medication abortion via telemedicine 12,[23][24][25][26]29 . These providers expressed their feelings that telemedicine had expanded the access to medication abortion for their patients 29 and that telemedicine needed to adopt processes similar to those used in in-person clinic visits, with minor additional technological arrangements to facilitate the electronic interface between patients and doctors 12 .
Qualitative studies of the providers' experiences suggested that the provision of medication abortion via telemedicine facilitated a more user-centered approach, with abortion seekers receiving the services closer to their homes, thereby reducing the need for longdistance travel by both patients and physicians 12,26 and providing flexible appointment times 26 . However, in a study conducted among telehealth leaders, a few participants expressed concerns that in providing abortion services via telemedicine, care providers would be unable to verify their patient's identity, would experience difficulties in ensuring that the abortion medication provided via telemedicine would be taken by the right patient, and the potential that abortion services might be accessed by minors in the absence of parental consent 24 .
Abortion users' views on abortion via telemedicine Seven studies assessed the views and perceptions of potential abortion users regarding their access to abortion services via telemedicine 11,15,26,28,29,33,45 . Overall, the perceptions of potential abortion users regarding telemedicine abortion services were positive 26 . Many users who had abortions supported the use of telemedicine for medication abortion, particularly during the COVID-19 pandemic period, and felt that the effectiveness of telemedicine service was almost equivalent to that of in-person abortion service 45 . A survey conducted among 1567 abortion users reported that 56% of overall participants and 64% of   medication abortion participants preferred to receive abortion services via telemedicine 33 .
According to the study conducted by , potential abortion users reported that the availability of abortion services through telemedicine made these services more accessible and convenient relative to the services provided in-clinic 15 .
The study further elaborated that abortion services via telemedicine were the option preferred by patients because their receipt of counseling via telemedicine and abortion medication by mail eliminated a long waiting time for appointments and the need for other arrangements, including transportation and childcare required for in-clinic service 15 . Similarly, abortion users in another study reported that using abortion services via telemedicine helped them to minimize the financial, travel, and time-related burdens necessitated by in-person visits 11 . However, a significant number of potential abortion users expressed worry about the time-sensitive nature of abortion in case the medication should not arrive within the recommended time 28 .
The majority of the abortion users reported that addressing their concerns and medical-related questions to the care providers over telemedicine was similar to or more comfortable than faceto-face visits 26,29 . However, some users felt less personally and emotionally connected with the care providers on telemedicine video calls, felt that video calls were less legitimate than in-person visits, or expressed concerns about scams and breaches of privacy and therefore preferred to be in the same room with their abortion care providers 11,26,29,45 . Moreover, several participants of the study described by  reported that they did not find the information script provided through telemedicine to be informative, either because of its content or delivery method (i.e., felt that using telemedicine to deliver the information would be weird) 11 .

Reason for choosing abortion services via telemedicine
Ten studies reported the reasons that potential abortion users elected to use telemedicine rather than face-to-face meetings for their abortion services 11,12,15,16,22,26,27,30,32,36 . The most common reasons for preferring telemedicine included the long distance from their homes to the abortion clinics 11,16,22,30,36 , convenience 11,15,16,32 , privacy 11,16,22,30,36 , cost (unaffordable cost of inclinic abortion or personal financial hardship) 11,16,27,30,36 , the flexibility of appointment times 16,32,36 , state laws that included a waiting period or specified restrictive policies for accessing an abortion clinic 22,27,36 , perceived stigma 16,22,36 , and preference for talking via a video call 32 . Two studies by  reported that 69-73% of potential abortion users who selected the use of telemedicine did so because of their inability to afford in-clinic abortion services, while 39-49% did so for reasons of privacy 30,36 . On the other hand, Kaller et al. (2021) reported that 73% of the users they surveyed chose to receive their abortion services via telemedicine because it was more convenient than a clinic visit 32 .  Grossman et al. (2011) reported that 99% of abortions among telemedicine users were successful, while the success rate was 97% for face-to-face patients 37 .

Effectiveness of abortion via telemedicine
The majority of the studies we reviewed reported that ≤6% of abortions were completed without the need for additional surgical intervention 14,16,18,40,42,44 . The rates of clinically adverse effects reported ranged from none to ≤ 1% 7,18,37,42 , and no deaths were reported 7,42 . However, a study by Women on Web conducted  Three themes: ✓ Temporal dimensions of abortion access: the mandatory 72-h waiting period (to avoid restriction or potential abortion users pursued the service from other states) ✓ Material dimension: the lack of nearby facilities (opted for telemedicine largely because of travel distance) ✓ Social dimensions: privacy, stereotypes, or negative views Fiastro et al. 2022 23 ✓Most facilities did not provide online abortion services before the COVID-19 pandemic. ✓Most clinics included in the study-initiated telemedicine medication abortion services and integrated them into existing in-clinic services Fix et al. 2018 24 Four themes: ✓ Opinions of appropriate uses for telemedicine: services that do not require physical presence or contact are appropriate for telemedicine. ✓ Knowledge and opinions of medication abortion provision via telemedicine felt telemedicine well-suited for medication abortion. ✓ Knowledge and opinions of telemedicine abortion restrictions: ○ Had limited knowledge of abortion restriction laws. ○ Opposed bans on abortion services through telemedicine. ✓ Restrictions on other telemedicine services: the broader field of telemedicine experienced similar restrictions due to the requirements for provider-patient-relationships, and difficulties in monitoring the user-controlled substances by remote prescription Godfrey et al. 2021 25 Implementation of telemedicine abortion services needs ✓ Access to inter-organizational networks ○ Appropriate professional organizations ○ Mentorship from telemedicine service innovators ✓ Readiness of organizations for telemedicine service implementation ○ Working electronic health records ○ Options for virtual provider-patient interactions Effective and motivated clinic workers Grindlay et al. 2013 26 Advantages of telemedicine compared with an in-person provision ✓ It decreases physicians' and patients' travel ✓ Greater availability of different locations and appointment times ✓ Abortion users were either indifferent or had positive views about conversation through telemedicine ○ Some felt private, or secure ○ Some are even more comfortable than in-person communications Some preferred to be in the same room with care providers   12 Participants experience the provision of medication abortion through telemedicine ✓ It facilitated a user-centered service provision approach ✓ Integrating new technology into the existing clinical service is easy ✓ Impacts of telemedicine on patients: ○ Flexibility in appointment times ○ Reduction in patient travel ✓ Impacts of Telemedicine on Clinics and Providers ○ Low impact on patient-provider interaction and clinic flow ○ Improve the efficiency of the clinic ✓ Suggestions for service improvement: ○ Make the patient not see herself in the monitor ○ Ensure everyone knows who is in the room Navigate between the medical chart and the patient video Grossman 41 After the implementation of telemedicine In Montana ○ The proportion of abortion users who utilized medication abortion services increased from 60% to 65% ○ The mean appointment time for abortion services decreased from 14 to 12 days ○ The mean distance traveled (one way) for abortion service decreased from 134 to 115 miles In Nevada ○ The number of abortion users who utilized medication abortion services increased from 461 to 735 ○ The mean distance traveled (one way) for abortion services decreased from 47 to 34 miles between 2016 and 2019 among 131 recipients of medication abortion at ≥13 gestational weeks via telemedicine stated that 29% of the abortion users reported adverse events such as fever or heavy bleeding, that 43% received additional care, and that 18% of the abortion procedures occurred by aspiration 39 . Similarly, Raymond et al. (2019) reported that 7% of the participants visited an emergency center for urgent care 16 .
Regarding the development of adverse events, almost all studies reported no significant difference in the development of clinically significant adverse effects among telemedicine users and standard or face-to-face abortion care users 37 . However, the use of an aspiration procedure was less common among telemedicine users as compared to standard procedure user patients (1.4% vs. 4.5%) 42 . More patients also used the telemedicine service for unscheduled communications with office assistants than did patients who received their care in-person (46.2% vs. 21.6%) 44 .

Telemedicine abortion service during the COVID-19 pandemic
A few studies reported how the COVID-19 pandemic influenced the utilization of abortion services via telemedicine 8,14,23,35 . The demand for abortion services by telemedicine greatly increased during the COVID-19 pandemic 8,14,23 . Most clinics integrated telemedicine services into clinical care to supplement existing abortion services in the clinic and for other patient appointments 23 .
A study conducted among 100 clinics reported that 87% of the clinics made changes to their service protocols due to the COVID-19 pandemic, including initiating or increasing the use of telemedicine for patient screening, consultations, or follow-up, eliminating or reducing the requirement for pre-abortion testing such as ultrasound and blood tests to screen for Rh factor, and providing rapid access to abortion pills. Facilities in the North reported a higher increase in the use of telemedicine for abortion services (73%) than did facilities in the South (23%) 35 .  45 ○ 44% of the participants supported the use of telemedicine for medication abortion during the pandemic ○ 35 % opposed ○ 21% were not sure about the decision Themes identified: ○ Safety-related perceptions were tied to attitudes toward using telemedicine for medication abortion ○ Participants had a concern about the legitimacy of telemedicine for medication abortion ○ Participants felt that abortion should be carried out as early as possible Madera et al. 2022 28 Themes identified: ○ Viewed telemedicine as a "godsend" ○ Shipping delays, fears of scams, and surveillance made ordering pills online a "nerve-racking" experience ○ A "personal touch" calmed fears and fostered trust in telemedicine ○ Worried about the "what ifs" of abortion through telemedicine experience ○ Online telemedicine met their needs Pleasants et al. 2022 43 Living ≥50 miles away from the facility providing abortion care was associated with seeking an abortion or planning to continue pregnancy four weeks later Raymond et al. 2019 16 Three hundred sixty-three were scheduled for telemedicine abortion evaluations with clinicians ○ 89% reported convenience, cost, speed, or lack of options at their locality as reasons for choosing telemedicine service ○ 13% specifically reported cost as a reason for choosing telemedicine ○ 21% reported privacy concerns as a reason • 94% of abortions are completed by surgical or medical interventions. • Four abortion users had ongoing pregnancies after ingestion of mifepristone • Five abortion users developed bleeding Rivlin et al. 2022 33 ✓ 546 used medication abortion services ✓ 56% of all participants reported that they prefer telemedicine service ✓ 64% of abortion users who received medication abortion preferred telemedicine services ✓ 1.4% of all participants mistrusted abortion service providers, while 1% of medication abortion users mistrusted service provider Ruggiero et al. 2022 29 ✓ The majority of the telemedicine users felt comfortable talking to care providers over telemedicine and faced no problems while using the telemedicine technology ✓ Health care providers believe that telemedicine expanded access to medication abortion service Thompson et al. 2021 34 ✓ The analysis included 3107 counties, which had a total of 62.5 million reproductive-age females ✓ The estimated mean abortion rate per 1000 reproductive-age female residents was 11. ○ 71% moved follow-ups to telemedicine modalities such as video or phone ○ 41% initiated or increased telemedicine service for screening and consultations ○ 43% reduced Rh testing ○ 42% reduced other tests ○ 15% omitted the pre-abortion ultrasound requirements ✓ 20% of the facilities allowed quick pickup of abortion pills ✓ 4% of the facilities began mailing abortion pills to patients after a telemedicine consultation ✓ Clinical practice changes such as starting or increasing telemedicine services were reported across the U.S. ✓ The clinical practice changes were higher in the Northeast (73%) compared to clinics located in the South (23%)

DISCUSSION
This scoping review synthesized evidence from 33 studies that describe access to abortion via telemedicine, including its effectiveness, the reasons that abortion users preferred to receive abortion service via telemedicine, and the views and perceptions of abortion users and providers in the United States. The use of telemedicine in general became prevalent during COVID-19, and telemedicine became user-friendly for the provision of medication abortion services 8,14,23 . The present review determined that telemedicine increased access to abortion care in the country, especially for potential abortion users who lived in remote places 16,23,31 . Care providers felt that telemedicine increased access to medication abortion, facilitated a more user-centered approach, and reduced long-distance traveling time by both patients and physicians. Although telemedicine is believed to make abortion services more accessible, the study conducted in Brazil revealed inequalities in the utilization of abortion services via telemedicine across various regions, which varied based on income, and among different racial groups 47 . Given that provision of services via telemedicine requires access to advanced technologies such as high internet speed, populations who lack reliable internet access or who lack knowledge and education about the use of these technologies could be disproportionally affected by limited ability to utilize the service. The identified gaps indicate that further studies will be needed to explore the feasibility of using abortion services through telemedicine, particularly in low-resource settings and among racialized groups. The present scoping review points out that abortion services via telemedicine are highly acceptable by both potential abortion users and care providers, a finding that was also reported by another review 48 . Participants and care providers believed that the provision of abortion service via telemedicine facilitated a pregnant person-centered approach, provided flexibility in appointment times, and reduced costs and travel requirements by patients and physicians. Pregnant persons showed several layers of conflicting emotions about receiving abortion services via the modality of telemedicine. Most abortion users preferred to receive abortion services via telemedicine due to its convenience, low cost, and their belief that the telemedicine service could maintain confidentiality. However, a significant number of abortion seekers raised concerns that talking over a video made them feel impersonal, that they felt difficulty in connecting emotionally with the care providers over telemedicine, and that the information script they received was not informative. Waiting for mifepristone to arrive via mail also created a delay in abortion initiation 31 . Although telemedicine is believed to have increased access to abortion services and is considered convenient by many, especially during the COVID-19 pandemic, it is important not to overlook the patients' concerns lest they be deterred from effectively utilizing telemedicine services. Further research could also be needed on how to address these concerns.
The effectiveness of telemedicine in providing abortion services was measured in various ways, including complete uterine evacuation without additional medical or surgical intervention, the absence of adverse effects such as heavy bleeding, blood transfusion, hospitalization, and death, and no longer being pregnant. Several studies reported the success rate of abortion service via telemedicine, with ≤6% of the abortions being completed with the help of additional surgical intervention 14,16,18,40,42,44 , and only a few patients experiencing severe adverse outcomes. Abortion service via telemedicine was reported to be as effective as abortion services provided in-clinic 49,50 . This is consistent with the results of a study conducted outside of the United States 51 .
This study possesses some limitations. Firstly, the limited number of available studies and the inconsistent reporting across these studies prevented us from effectively synthesizing and pooling some of the findings. In addition, we were unable to discern the influence of socio-economic and race-related factors on the utilization of telemedicine for abortion. In conclusion, this scoping review aims to provide a comprehensive synthesis of findings from published literature on abortion services via telemedicine in the United States. The findings of this review showed that telemedicine increased access to abortion care in the United States, particularly for those who resided in remote areas or who feared the potential stigma of receiving abortion care from the clinic. Studies reported that there was no significant difference regarding the effectiveness of abortion offered via telemedicine and in-person clinic visits. Overall, both abortion care providers and users had positive perceptions of abortion services via telemedicine service. However, findings from the potential abortion users show that they felt a range of conflicting emotions about abortion services via the modality of telemedicine. The majority of the abortion users preferred telemedicine over inperson visit abortion services, while some users preferred to be physically present in the same room with their care providers. As digital technologies, including telemedicine, drive the health industry toward more comprehensive equitable solutions 52 and interactive tailored platforms for care navigation and delivery, there are still notable gaps in the availability, access, quality, and affordability of these technologies in delivering care related to abortion, miscarriage, and other related issues. To maintain or increases the acceptability of abortion service via telemedicine, addressing the participants' concerns about the use of telemedicine should not be overlooked.

METHODS Protocol
This study employed a scoping review protocol consistent with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) 53 . After the review was conducted, the four phases of the PRISMA flow chart were completed to show the screening process we used.

Article Search
We used Google Scholar to conduct an exhaustive search for primary studies in the United States that were published in the English language. Additionally, MeSH terms and CINHAL headings were used to identify references in the PubMed and CINHAL databases. The search strategy combined two main concepts: medication abortion and telemedicine. Similar keywords and vocabulary were combined using the Boolean terms OR and AND between the two concepts. The search terms emerged from "medication abortion," "self-managed abortion," "misoprostol," "tele abortion," "telemedicine," "telehealth," and "United States." The article search was conducted in September 2022.

Eligibility criteria
All primary studies that addressed the issue of medication abortion via telemedicine in the United States were included, including those using qualitative, quantitative, and mixed-method approaches. Medication abortion via telemedicine includes ecounseling, e-consenting, and/or e-prescribing abortion pills for users residing in the United States, regardless of the service provider's location. Participants for the included studies were either potential abortion users or care providers. The studies we included also examined the effectiveness, acceptability, and perspectives of providers and users of abortion services offered via telemedicine. We excluded ineligible studies based on our exclusion criteria, including duplicate studies, conference papers, anonymous reports, and review papers, and did not report any finding related to medication abortion via telemedicine, editorials, and theoretical papers.

Screening
First, we searched for relevant articles using specific search terms and applied filters. To facilitate the screening process, we exported the selected articles to Covidence, a web-based systematic review software (Veritas Health Innovation, Melbourne, Australia; available at www.covidence.org). After removing the duplicates, the studies were screened based on the inclusion criteria using the information included in titles and abstracts. Finally, we conducted a full-text review of the eligible papers to determine their inclusion. Two authors (FK and RP) handled the article screening process. Any disagreement between these two authors on the inclusion or exclusion of the articles was resolved through discussion with ASN, who oversaw the screening process and the overall activities of this review.

Data charting process and synthesis
We followed the recommendations for scoping reviews in performing data extraction, analysis, and presentation of results, using a Microsoft Excel spreadsheet for data extraction 54 . The list of authors, study objective, design, participants, data collection time, publication year, sample size, and outcome of interest was abstracted, and the major study characteristics and their findings were summarized using a table. The findings were synthesized narratively. Data extraction and synthesis of the finding was performed by F.K., while A.S.N. and R.P. reviewed the synthesized draft and provided their critical comments.

Reporting summary
Further information on research design is available in the Nature Research Reporting Summary linked to this article.