イギリスのRCOG, FSRH, BSACPの合同声明
1. 中絶は、世界中の女性や少女にとって安全で一般的な手続きです。妊娠期間に関係なく、中絶は妊娠を継続するよりも安全です。どのような妊娠期間であっても、中絶が、妊娠を継続することを選択した女性や少女の場合よりも精神衛生上の成果を悪くするという証拠はありません1。 妊娠を自宅で経過させる自己管理による中絶は、英国では数十年前から中絶医療における標準的な実践となっています2。
2. 若者が中絶サービスを利用する際には、遠隔医療を含め、他のすべての患者と同じ品質と水準のケアを受けることが不可欠である。これは、超音波がすべての中絶手術に適応されるわけではないことを示す証拠に裏打ちされなければなりません。超音波の提供を条件として日常的に中絶治療を提供することが求められる場合、プロバイダーにとって倫理的な検討が必要です。9 イングランドとウェールズでは、毎年およそ7,500人の18歳未満の患者が合法的な中絶を利用している14。 .
6. NICEが最近作成した「乳幼児・子ども・若者の医療体験に関するガイドライン（案）」13 にあるように、若者はプライバシーと機密保持について特別なニーズを持っており、これを尊重し管理しなければならない。彼らが医療制度を信頼し、安心して医療従事者と関われることが不可欠である。これは、例えば名誉に基づく暴力のリスクにさらされている人々など、一部のグループにとって特に重要である。若者は、守秘義務に違反することなく医療施設に通うことがより困難であると感じるかもしれません。虐待を受ける可能性のある人に知らせることなく、プライバシーを守りながら相談できるようなシステムが必要です。そのため、遠隔医療によるリモートアクセスが不可欠である。
In March 2020, the governments of England, Scotland, and Wales changed regulation to enable the administration of mifepristone for an Early Medical Abortion (prior to 10 weeks in England and Wales, and 12 weeks in Scotland) at home. This enabled the provision of telemedicine – with consultations provided by nurses, midwives, or doctors over video or telephone, and medications being received in the post.
In the first three months of this regime, 22,000 abortions in England and Wales were provided using this method – roughly 43% of all abortions during the period. Providers report that in the first year of operation, somewhere in the region of 75,000 early medical abortions have been provided using this method.
During this period, telemedicine has been available in principle to all abortion patients – with decisions made at individual patient level as to whether face-to-face consultation, scanning, or further tests are required. Blanket age restrictions are not a part of the legal regulation and have not been recommended by RCOG or BSACP.
Safeguarding is an essential element of abortion care. The experiences of providers are that the new pathways introduced in response to the COVID-19 pandemic15 have improved the quality of safeguarding. NICE had recommended telemedicine precisely because of good evidence that it improves access for vulnerable groups16, and now that at least 75,000 women and girls have accessed this care it is borne out by experience.
The experience of young people
Over 140 people under the age of 18 receive abortion care every week in England14 and there is a duty to ensure they can access the same quality of care as everybody else without barriers.
After detailed questioning and assessment by providers trained in safeguarding, the vast majority of young people who access abortion care do not need further safeguarding or referral. Many young people who present for abortion care do so in the context of an ongoing, consensual relationship. Assessing these young people for safeguarding concerns is essential, but ultimately only around 1 in 20 require a safeguarding referral.
However, there is evidence that a shift to telemedicine has resulted in improved detection of those young people who do require further safeguarding involvement. Both major abortion providers have reported a more than 20% increase in the proportion of young people receiving a safeguarding referral since the introduction of telemedicine. One provider also reports a significant increase in the severity of the cases identified (52% of concerns identified required multi-agency referral after telemedicine was introduced compared to 24% when all were face-to-face) [MSI annual safeguarding report, 2021 in press].
Another major provider found that, when asked, 99% of clients said they were able to ‘find a private space, with no interruptions, for the duration of the telephone consultation’, 93% said they would have felt able to share any concerns regarding their safety at home or in a relationship, and 24% said that they had discussed such concerns with a member of the abortion provider’s team. Evidence from the UK telemedicine programme found that no patients from a representative sample of 1243 women were unable to consult in private17 .
Whilst some patients do prefer face-to-face consultations, more find it easier to divulge highly distressing and intimate details when they can do so confidentially and remotely, usually with greater privacy (not needing to rely on a parent or potential abuser for transport and with no fear of having to debrief them afterwards).
The need for continued access to telemedical abortion care
The sector feels strongly that the new pathway has delivered one of the biggest improvements in quality in a generation, and will benefit hundreds of thousands of patients every year. There is a strong evidence base that has now been peer-reviewed and published that demonstrates the new pathways are safe, effective and preferred by patients5 8 9 18 . The evidence demonstrates that access to abortion care has significantly improved, with reduced waiting times and gestation at abortion, even though most NHS services were severely restricted during this time.
There is evidence of a reduction in illicit sourcing of abortion care19, and that the most vulnerable groups who previously risked severe criminal sanction and bypassed NHS care are now able to access care from regulated providers with all the safeguarding and resources they offer.
It is essential that young people are not discriminated against and have access to the same quality of care and standards of safeguarding.
Changes to the early medical abortion pathway Changes to clinical practice in all areas took place at pace following the introduction of the first lockdown of the pandemic and the associated pressures on the NHS and healthcare providers.
Prior to the introduction of telemedicine, thousands of abortion appointments were cancelled, many clinics were forced to close as a result of staff sickness and PPE shortages, and patients were struggling to access transport to attend appointments. Patients who were shielding were unable to access any form of abortion care as home care was illegal.
Prior to the pandemic, the changes had already been recommended by NICE following a review of the literature, with NICE noting that telemedicine should be especially beneficial for vulnerable groups4 16 . Telemedicine and home use of abortion medication had also long formed a part of abortion care in other parts of the world.
Providers were acutely aware of the lack of ability to undertake pilots and began data-gathering immediately following the launch of the telemedical service. A full evaluation of the pathway change was conducted, resulting in the largest study to date in UK abortion care with 52,142 participants5 . There was also another study that used different methodology but had identical results conducted in Scotland9 . Taken together these studies provide compelling and definitive data.
Safeguarding processes were not significantly altered, as providers already had extensive expertise of delivering effective safeguarding via multiple routes including telephone assessment. However the impact of lockdown and the introduction of telemedicine is clearly demonstrated in the increased proportions of cases identified by providers. Whilst it is impossible to discern how much of this increase is attributable to the stresses of lockdown, and how much from better identification from telemedicine, there is no evidence that the new pathway has worsened identification of vulnerable patients.
Abortion care providers agree that the needs of young people are of paramount importance – both in providing high quality safeguarding services, and enabling young people to access the safe, legal, essential abortion care that they need.
Consultations via telemedicine
In some cases, it is easier for patients under coercive control to be able to speak privately if they can do so via telephone or internet link as they can choose a time when the abuser is away, or they can take action to be alone (e.g. speak from the bathroom or car). In contrast, if they have to attend an appointment they are likely to need to divulge the reason why they have to visit an abortion clinic. This is especially the case for young people who rely on others for transport and would be missed if they were absent from home or school.
Providers report that some of the most significant safeguarding cases have been identified via phone consultations, including honour-based violence, rape, and identification of a human trafficking ring.
In no field of medicine is proof of identity sought or required (other than gamete donation), and it is unclear why there is a presumption of dishonesty for women and young people seeking an abortion such that they should be seeking healthcare under false pretences. There is a wealth of evidence in support of telemedicine across many areas of medicine20 , but dishonesty is not raised as an issue in other sectors.
As recognised by – amongst others – the British Medical Association – the requirement of identity documents to access healthcare places providers in the invidious position of checking patients’ immigration status and can dissuade patients who need care from presenting. As stated above, the additional privacy from a potential abuser that confidential remote access affords reduces the potential for exploitation by an abuser.
Requiring face-to-face for young people would pose a number of difficulties
We believe this suggestion to be disproportionate to the risk involved, and would prove discriminatory - denying young people, without evidence, access to the quality of care available to other groups solely on the basis of their age. It would also deny them privacy and best-practice safeguarding. It is likely to increase the risk of a young person failing to engage with healthcare services, with the worst outcomes being missed opportunities to identify abuse or a concealed pregnancy and birth.
Where ultrasound is performed, it is for a wider assessment than just detecting mid-trimester pregnancy and therefore any suggestion that young people have a scan solely for this indication would be inappropriate. However even if transvaginal ultrasound were deemed too invasive for young people, abdominal ultrasound can be distressing, intrusive and conveys distrust in the patient, especially given the accuracy of her dating is 99.96%5 . There is no evidence that young people disproportionately need a scan to ‘exclude mid trimester pregnancies’.
Our main concern is that it involves a mandated visit to a clinic or hospital which is likely to breach the young person’s privacy and expose them to potential abuse, and it also introduces delay into the care pathway which is distressing and unnecessarily unkind.
Access to contraception
A discussion around and offer of long acting and reversible contraception is beneficial for many patients, and presentation for abortion gives the opportunity to organise that. This is a routine part of abortion care, and covered by the NICE guideline and quality standards.
There is no evidence that integrated contraceptive counselling increases the uptake of contraception as a whole, or long acting reversible contraception (LARC) – particularly given that intrauterine contraception cannot be fitted at the time of early medical abortion, and that patients are advised that injectables (e.g. DMPA) may reduce the success rates of early medical abortion. A study by one major provider found that telephone contraception counselling separate from abortion care may serve some women better than integrated counselling, including a higher rate of choosing and receiving a method of contraception, and providing a higher quality service for non-white women, those who had previously had difficulty accessing contraception, and those who had not been using contraception at the time of conception21 .
Follow-up care for young people
Given that abortion care is so effective there is no need for routine follow-up, and NICE recommends that patients are offered self-assessment after medical abortion. The dominant emotion after abortion is relief, with no evidence of any emerging regret22 , and most patients simply want to move on without further interference.
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