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Abstract
Background After having one of the most restrictive abortion laws worldwide, Ireland legalised abortion in January 2019. We examine how legalisation impacted on demand for online telemedicine outside the jurisdiction.
Methods We analysed anonymised data from 534 people from Ireland seeking online telemedicine abortion prior to legalisation (January–March and October–December 2018) and in the first 3 months following legalisation (January–March 2019). Numbers, characteristics and reasons for seeking the service before and after legalisation were compared. Content analysis of emails from people seeking the service following legalisation explored reasons for seeking care.
Results Half as many people contacted Women on Web in the 3 months immediately after legalisation as compared with contacts 12 months prior (103 vs 221). Of these, the proportion receiving the service reduced, from 72% prior to legalisation to 26% after legalisation (p≤0.001). After legalisation, access related reasons for seeking online telemedicine featured less while reasons relating to privacy, stigma and avoiding protestors featured more.
Conclusions People continued to seek abortion through online telemedicine after legalisation, though the number of contacts reduced by half and the proportion receiving the service decreased considerably. To address access issues, policy measures should promote normalisation of abortion, legislate for safe zones around providers, and consider access in situations of coercive control or abuse including the role of telemedicine in the local model of care. Abortion provided through online telemedicine continues to be an important part of providing safe, accessible abortion even after legalisation.
- abortion
- therapeutic
- reproductive health
- reproductive rights
- health policy
Data availability statement
Data may be obtained from a third party and are not publicly available. Women on Web (www.womenonweb.org) hold these data and may make fully de-identified data availble to researchers on application.
Statistics from Altmetric.com
Key messages
Despite legalisation of abortion in Ireland on 1 January 2019, people in Ireland continue to seek online telemedicine abortion outside the jurisdiction.
Half as many people contacted an online telemedicine provider in the first 3 months following legalisation, citing privacy and avoiding stigma and protestors as their reasons for doing so.
Telling people contacting an online telemedicine abortion service about legally accessible abortion locally considerably reduced the number receiving the service but did not eliminate it.
Introduction
In May 2018, a majority of voters voted in favour of legalising abortion in the Republic of Ireland (hereafter Ireland), repealing one of the most restrictive abortion laws worldwide. Abortion in Ireland is regulated by Health (Regulation of Termination of Pregnancy) Act (HRTPA) 2018,1 implemented on 1 January 2019. Abortion is permitted without restriction up to 12 weeks’ gestation and thereafter, where there is risk to the life, or of serious harm to the health, of the pregnant person, or where there is a condition indicating fetal death within 28 days of birth. The law requires a 3-day wait between first consultation and receiving care.
Abortion is provided free of charge in primary care up to 9 completed weeks’ gestation by general practitioners (GPs) and women’s health clinics, and in maternity hospitals between 10 and 12 weeks’ gestation. Abortion after 12 weeks is provided in maternity hospitals.2 On implementation in January 2019, 290 of 2500 GPs and 9 of 15 hospitals provided abortion,2 rising to 373 GPs and 10 hospitals by April 2020.3 Medical abortion is the principal method available and surgical abortion availability is very limited. The Health Service Executive (HSE) funds a phoneline and website (‘MyOptions’) providing information on providersand counselling services and a 24-hour nursing helpline.
Before 2019, people travelled to access abortion or accessed medical abortion through online telemedicine services.4–6 This article discusses contact by people from Ireland with the online telemedicine abortion service Women on Web (WoW) immediately before and after legalisation of abortion comparing numbers, patterns and reasons for seeking the service. No previous literature discusses the impact of legalisation on demand for online telemedicine abortion outside the jurisdiction. The data were generated prior to onset of COVID-19 when use of telemedicine in abortion services in Ireland was introduced on a temporary basis.
Women on Web (WoW)
WoW is a non-profit organisation using online telemedicine to provide abortion care in areas with no or restricted access.5 6 People contact WoW through their website by filling out an online form describing their circumstances, gestational age and medically relevant pre-existing conditions (online supplemental appendix 1). If clinical criteria are met, a physician prescribes according to the World Health Organization (WHO) recommended dosage regimen for medical termination of pregnancy7 up to 12 completed weeks’ gestation. WoW provides guidance on taking the pills, monitoring the process, possible adverse effects and how to respond if these occur. A trained help desk team provide help throughout the abortion process.
Supplemental material
Research suggests telemedical abortion procedures rarely result in adverse effects and risks are no different for telemedical abortion services than in-person abortion services.5 8 People from Ireland used WoW to access abortion care before legalisation of abortion.4 ,4 9 10 Since legalisation, people from Ireland contacting the service receive an automatic response explaining the availability of legal abortion services locally. Those who still cannot access abortion locally are provided with the service and invited to explain why they need the service by email.
Methods
WoW provided anonymised data on people from Ireland accessing their services during the first 3 months and the last 3 months of 2018 prior to legalisation, and during the first 3 months of 2019 after legalisation to compare use of the service after legal change.
In an online questionnaire (online supplemental appendix 1), people provided their age; last menstrual period (LMP); number of previous pregnancies, abortions, children and miscarriages; gestational age; whether or not they had a pregnancy test or ultrasound; reasons for contact; and their location. All data were anonymised and exported into SPSS for analysis. Data from 2018 and 2019 were analysed separately and compared. To analyse differences, t-tests were performed on quantitative variables and z-tests were performed on categorical variables.
Some 71 of 103 people from Ireland who completed the WoW online questionnaire in January–March 2019 corresponded further by email with the help desk. This email correspondence was collated, anonymised and exported into MS Word for content analysis. A codebook (online supplemental appendix 2) was generated inductively reflecting content in the data to identify reasons for seeking online telemedicine abortion services.
Supplemental material
People provided informed consent to the anonymous evaluation of their data at the time they completed the online form. WoW removed all identifying information before providing the data for analysis, therefore no ethics approval was required.
Patient and public involvement
It was not appropriate or possible to involve patients in the design, conduct, reporting or dissemination plans of this research.
Results
Analysis of online questionnaire
The number of people from Ireland who contacted WoW, that is, completed the online form, for the three time periods is compared (table 1). In the 3 months immediately preceding legalisation, October–December 2018, 210 people contacted WoW. In the first 3 months after legalisation, January–March 2019, 103 people contacted WoW, a decrease of 52%.
Demand for Women on Web services from Ireland
One year prior to legalisation, (January–March 2018) 221 people made contact, compared with 103 people in the first 3 months after legalisation (January–March 2019), a significant decrease of 54% (p≤0.001).
Considering the number and proportion of contacts from Ireland proceeding to receive the service (complete requests), in the 3 months prior to legalisation (October–December 2018), 134/210 (64%) contacts received the service. By comparison, in the 3 months immediately after legalisation (January–March 2019), 27/103 (26%) contacts received the service.
One year prior to legalisation (January–March 2018), 158/221 (72%) contacts received the service compared with 26% receiving the service 3 months after legalisation (January–March 2019), a significant decrease of 46% (p≤0.001).
Characteristics of those contacting WoW in 2018 (January–March and October–December) and 2019 (January–March) were similar regarding mean age, LMP, number of pregnancies, number of previous abortions, number of previous miscarriages and number of children (p=0.226 to 0.972) (table 2).
Characteristics of people from Ireland contacting Women on Web by time period
A smaller percentage had taken a pregnancy test at the time of contact in 2019 than in 2018 (89.3% compared with 97.5%, p<0.001). The percentage with pregnancies between 7 and 10 weeks’ gestation decreased (p<0.001), with no one of this gestational age in 2019 but 20 (19%) of this gestational age in 2018 contacting WoW.
Reasons for contacting WoW were indicated on the questionnaire from a predefined list (online supplemental appendix 1). These data were available for 212/221 contacts from January–March 2018 and 95/103 contacts from January–March 2019 and analysed in table 3. After legalisation, reasons relating to access were cited less frequently. The proportion citing ‘abortion pills are not available in my country’ decreased from 38% to 13% (p<0.001), the proportion citing distance as a barrier to access decreased from 34% to 16% (p<0.001), and the proportion citing legal restrictions decreased from 89% to 44% (p<0.001).
Reasons women accessed Women on Web by time period
Conversely, reasons relating to privacy and stigma were cited by a greater proportion after legalisation. The proportion who wanted to keep their abortion private increased from 26% to 41% (p=0.008), and the proportion needing to keep their abortion secret from family increased from 12% to 32% (p<0.001). Stigma was cited as a reason to seek WoW services in 9% of cases in 2018 compared with 22% of cases in 2019 (p=0.002). Not wanting to deal with protestors was cited by 5% in 2018 but increased to 11% in 2019 (p=0.087).
Content analysis of emails
In the 3 months after legalisation, 103 people from Ireland completed WoW’s online questionnaire requesting the service. All received an automatic response explaining how to access abortion locally, of which 71 corresponded further with WoW by email and 27 received the service. Content analysis of this correspondence explored reasons for seeking online telemedicine outside the jurisdiction following legalisation.
Reasons cited included not wanting to deal with protestors and feeling uncomfortable about going to their own GP for privacy reasons or fear of judgement. Fears regarding privacy or judgement related to living in small communities or having long-standing personal or professional relationships with their GP.
“Abortion is legal only 2 weeks and anti-abortion protest are around many GP practices which you have to walk through. I am worried that I would know someone and I do not want this to happen.” [NB. This correspondence took place in early January 2019 and the person is stating that the time of writing is only 2 weeks after legalisation of abortion and the introduction of abortion services.]
“While abortion was recently made legal in Ireland, I live in a small rural town. My neighbour is the secretary in my doctor’s office and my doctor herself has been very vocal about how she feels abortion is wrong.”
Many mentioned time and distance as barriers to accessing local services, citing some counties with no providers, and others where there were long waits to see a provider. Some reported GPs in their area not taking new patients. Mindful of the 12-week gestational limit, women sought care from WoW when concerned about delays in the process.
“I’ve been on the website and it takes too long to go through as they want to offer counselling first and double check if I want to go ahead, which I 100% do.”
Being in an abusive relationship which prevented women making the two consultations required by law also featured.
“I’m doing this, this way through you, as I can’t let my husband know anything and I won’t be able to make it out of the house for doctor’s appointments and stuff … I really need your help.”
Some explained they were not able to access local abortion care because they were undocumented or illegal immigrants.
Discussion
Our findings show that over a 3-month timeframe half as many people from Ireland contacted online telemedicine abortion service WoW seeking care following legalisation as had contacted the service 3 and 12 months prior to legalisation. Most made contact after 10 weeks’ gestation, suggesting that approaching the 12-week gestational limit for unrestricted abortion raised concerns about potential delays or the required waiting period preventing people receiving care locally. WoW provided information to facilitate accessing abortion locally and clarify misconceptions, for example, that counselling is not required before accessing abortion care, or that accessing care through WoW can be more expeditious than accessing local services. Informing people of local availability of abortion led to a considerable reduction in the number progressing to receive the service, though did not eliminate it.
Women cited concerns about privacy, stigma or encountering protestors or reported difficulty attending for two appointments due to partner surveillance and control. Only women who could not use local services for reasons such as an abusive partner, accessed the services of WoW. Measures to redirect people to local services where possible contributed to the considerably lower uptake of online telemedicine services in January–March 2019 at 26% compared with January–March 2018 at 72%. Notwithstanding, one in four (26%) contacting WoW after legalisation proceeded to receive the service.
Data from the UK confirm people from Ireland continued to travel to access abortion after legalisation (375 in 2019) with one in four (98) under 12 weeks’ gestation, when they would have qualified for abortion in Ireland.11 ,12 Analysis of WoW data here provides further evidence that people in Ireland continued to seek abortion outside the jurisdiction after legalisation.
Content analysis of emails gives some insights into the reasons why. There was confusion over how the service is provided, for example, assuming the need to register with a GP provider which is not necessary. Concerns about confidentiality and stigma meant people avoiding attending local GP surgeries. Delays accessing services due to the mandatory 3-day wait or misconceptions that counselling must be attended before accessing abortion also directed people away from local services. Misconceptions about the law featured at this early stage of implementation. Many were unaware they could access abortion without restriction up to 12 weeks’ gestation on a no-cost basis and of the ‘MyOptions’ information service.
A key limitation of this study is that data analysed are generated during service delivery and are more limited than if generated specifically to explore reasons seeking online telemedicine. However, this is a hidden and hard to reach population and being able to derive these insights are important. A strength of this study is triangulation; the online questionnaire and email data informed and validated each other.
Conclusions
People from Ireland continued to seek abortion through online telemedicine after legalisation, though the number of contacts reduced by half and the proportion receiving the service decreased considerably. This article’s findings suggest policy measures are needed to promote normalisation of abortion, to address access issues, for example, for women experiencing coercive control or violence, and to legislate for safe zones in the vicinity of abortion providers. They suggest a role for telemedicine within the Irish model of abortion care. Since COVID-19, a temporarily revised model of care introduced telemedicine and our data strongly support the continuation of this facility. Abortion provided through online telemedicine continues to be an important part of providing safe, accessible abortion even after legalisation. Analysis of data generated by WoW for a much longer time period comprising the years 2019 and 2020 is underway by the authors to assess contact with online telemedicine outside the jurisdiction as legal abortion care became more established.
Data availability statement
Data may be obtained from a third party and are not publicly available. Women on Web (www.womenonweb.org) hold these data and may make fully de-identified data availble to researchers on application.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @conlonce
Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.
Contributors RG and ARAA planned and designed the study. RG generated the study data. SB and MK carried out the data analysis and wrote up an extended version of the findings from which SB, MK, RG and ARAA developed an extended discussion. CC devised the format for this article using extended analysis and discussion by SB, MK, RG and ARAA, distilled the discussion and developed the conclusions. All authors contributed to revisions for the final draft. CC submitted the article and is the corresponding author.
Funding CC’s contribution to this study was supported by funding from the HSE Award Number 16123 Unplanned Pregnancy and Abortion Care (UnPAC) study for which CC is the Principal Investigator.
Competing interests None declared.
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.
Provenance and peer review Not commissioned; externally peer reviewed.