The acceptability of implementing telemedicine for early medical abortion in South Africa: A substudy to a randomized controlled trial

Objective: Abortion is legal in South Africa, but significant challenges exist to access services. This study explores the experiences and perspectives of women who accessed abortion through telemedicine in a randomized controlled trial, and of providers and policy makers involved in abortion care services in South Africa. Our aim was to investigate the acceptability and implications of implementing telemedicine for early medical abortion in ours and similar settings. Method: Between April 2021 and December 2021, we conducted in-depth interviews with 13 women receiving medical abortion services, 7 health care providers and 2 policy makers. The interview texts were analysed using a validated theoretical framework for acceptability of health care interventions. Data on the perceptions and experiences of abortion through telemedicine were coded in relation to the seven constructs of this framework: affective attitudes, burden, ethicality, coherence, opportunity costs, perceived effectiveness, self-efficacy. Results: Women experienced that telemedicine abortion increased privacy, reduced the experience of stigma, and enabled a relationship with a trusted online provider. Self-efficacy was a prominent theme - expressed by women as convenience, the simplicity of the service, and their ability to access a provider and revisit online information at their own leisure. Providers and policy makers suggested that the intervention would be effective and reduce burden on facilities but that it required additional information technology skills on the part of providers, standardized guidelines for online consultations, and the need for consistent connectivity at clinics. A potential opportunity costs was the risks associated with inaccurate gestational age self-assessment assuming no in-clinic preabortion exam was performed, although this was nuanced by the finding that many women did not divulge their true gestational age for fear of being turned away. Conclusion: Our findings suggest that telemedicine is highly acceptable to women, providers and policy makers. However, context-specific challenges to an effective service may exist, and should be mitigated when telemedicine for abortion is incorporated into current standards of care.