Answering the call: how Telemedical Early Medical Abortion (TEMA) could protect women and pregnant people in danger

By Manna Mostaghim

Telemedical Early Medical Abortion (TEMA) in the UK allows women and pregnant people to access and use mifepristone and misoprostol (the drugs for a medical abortion) at home. TEMA was introduced across the UK (except for Northern Ireland) during the pandemic. But TEMA has now been made permanent in England and Wales.

TEMA has cut waiting times in accessing abortion care and it has allowed women and persons seeking abortions to get them earlier. An “independent poll, conducted by Savanta Com-Res, shows that the great majority of women and pregnant people in the UK” also prefer the option of at-home abortions. 

A central question as to the permanent implementation of TEMAs is its safeguarding of women and pregnant people that experience intimate partner violence (IPV). Anti-abortion advocates claim that TEMA have allowed for an unparalleled facilitation of reproductive coercion in IPV situations. Recent research from Parsons and Romanis counters that by saying TEMA could facilitate an increased protection of persons that experience IPV via adaptions to safeguarding measures in telemedicine. This is because evidence shows that TEMA allows for greater and safer access to reproductive choices for vulnerable women and pregnant people.

Why is the concern with IPV so prevalent in the abortion care? 

Women* in the UK that have abortions are more likely to be experiencing, or to have historical experiences, with IPV. This is because statistics record that women who have had an abortion are three times more likely to have incidents have IPV in their lifetime. Anti-abortion organisations use these statistics to demonstrate that women that have abortions are a more vulnerable population that could be more easily subject to reproductive coercion. 

Anti-abortion advocates also assert that women that experience IPV are more at risk of experiencing reproductive coercion in TEMA settings. This is due to the claim that TEMA could prevent healthcare practitioners from making visual assessments of IPV and/ or it would inhibit a women’s ability to confidentially disclose their experience of IPV. A major component of the objection to TEMA is that it prevents a healthcare practitioner from identifying an abusive person, in the patient’s physical proximity, who may influence their conduct and require them to hide their abuse.   

A joint briefing by several pro-choice organisations in 2018, alternatively claimed, that limiting access to abortion care by demanding in-patient appointments places vulnerable women in danger. This because women and pregnant people reported that it was travel to sexual and reproductive health services that increased the chances for abusive partners and relations to discover that they were seeking an abortion – which could lead to more abuse. 

In some cases, the desire to hide their abortions resulted in women and pregnant people taking desperate measures to access abortion care and services in secret. For example, prior to the implementation of TEMA, 8% of women were recorded as attempting to illegally procure abortion pills, risking significant jail time, to avoid their abortions being discovered in their abusive relationships. However, since the implementation of TEMA, illegal transactions to procure abortion pills online “ha[ve] fallen by 88%” in the UK. The uptake in using legal avenues to procure abortion pills has been attributed to the flexibility and safety provided by remote consultations. 

The risk of IPV in abortion care is significant. But TEMA may provide a safer setting for women and pregnant people that are seeking an abortion. However, safeguarding measures need to be adapted and implemented in TEMAs to ensure rigorous care for women seeking an abortion who may be experiencing IPV or reproductive coercion. 

What is safeguarding in a TEMA?

Healthcare practitioners that work in abortion care are required to identify abuse and neglect in persons that seek a pregnancy termination. According to BPAS, a basic standard for safeguarding a patient seeking an abortion is to determine whether a patient has capacity to make a voluntary and informed decision. But the definition of safeguarding can also be expansive in abortion care and demands a nuanced understanding of context and experiences of a patient. This requires a healthcare practitioner to identify language or cues that may indicate that the patient is experiencing IPV or reproductive coercion within the varied social, religious, and economic contexts of a wide spectrum of patients. 

Safeguarding to determine whether a patient is experiencing reproductive coercion requires a healthcare practitioner to then engage in active communication with a patient. Patients, whether receiving care in-person or over the phone, may omit truths about their context or be subject to coercion within an abusive relationship. According to a 2015 study, the identification of IPV in face-to-face treatment was not dependent on context but adequate training of relevant staff. The ability for a healthcare practitioner to identify IPV and reproductive coercion in a telemedical setting could then be aided by adequate training.  

According to recent research from Parsons and Romanis, TEMAs do not radically alter the practices of how safeguarding measures can be used by healthcare practitioners in abortion care. Like with in-patient care, healthcare practitioners are required to form a good rapport with patients that facilitate a conversation on sensitive topics. But a more concerted effort to train healthcare practitioners on how to spot visual clues of IPV in a video call or to spot conversational cues in telephone appointments may be required. For example, a healthcare practitioner should be made aware that a patient may be experiencing reproductive coercion or IPV if the patient’s:

“…eyes may keep glancing over the screen during a video call, or there may be long pauses/voices in the background during a telephone call. The provider can first ask additional questions in seeking to satisfy themselves that there is no cause for concern and, if that is insufficient, exercise clinical discretion in insisting on an in-person consultation”. 

The 2015 study, also explored the fact that providing information about IPV and forms of support, was potentially the most effective way of ensuring an end to physical abuse for patients. TEMAs do not prevent a healthcare practitioner from providing information to a patient about IPV support services. But the way to facilitate a patient’s access to social support and information may need to be adapted in TEMAs. 

Ultimately, TEMAs have proven to be effective in providing women and pregnant people access to flexible and legal avenues to abortions in the UK – due to cuts in waiting times and the decrease in the purchase of abortion pills via illegal vendors.  But telemedicine may require adaptions in how healthcare practitioners are required to employ safeguarding measures in abortion care. With adequate training and support for healthcare practitioners, TEMAs could therefore provide a safer way to access abortion services – and still safeguard patients.  

*The current, and available, snapshot of statistics in discussions about abortions and domestic violence only collects data on women. Although we acknowledge the gender diversity of persons that experiences abortions and IPV.    

Manna Mostaghim is a PhD Candidate in the Health Policy Department at the LSE. Her PhD thesis is on the provision of publicly subsidised IVF for women with a high BMI in the U.K. 

Her research especially examines the role of race and gender in the provision of healthcare and health infrastructure. She has presented her original research at Oxford University and the London School of Economics.

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