Innovation through telemedicine to improve medication abortion access in primary health centers: findings from a pilot study in Musanze District, Rwanda

In 2012 Rwanda expanded legal grounds for abortion to include cases of rape, incest, forced marriage, the health of a pregnant person or fetus at risk, and for minors on request in 2018. The penal code limits abortion care to doctors in hospitals, impeding access for many women. We tested an intervention that provides first-trimester medication abortion at primary health centers, using telemedicine to connect nurses/midwives to doctors in district hospitals for authorization of services. We implemented a 15-month prospective study to assess the feasibility, effectiveness, safety, and client acceptability of a hybrid telemedicine model. In the model tested, doctors provided clinical guidance by reviewing client data and lab results, and authorized the procedure via telemedicine, while the nurses/midwives consulted with the client, provided medication at the health center, and conducted follow-up over the phone or in person. Service data record forms were completed using the REDCap online platform and client exit interviews were conducted after completion of the abortion. During implementation, 242 clients received medication abortion at the health centers, with 50% of clients interviewed during client exit interviews. The protocol ensured high adherence rates; 96% completed abortion. Post-procedure complications were rare (3%) and were largely managed at health centers with remote support from a medical doctor. Vaginal bleeding (36%) and abdominal pain (41%) were the prevalent side effects experienced by clients; only 10% of clients who reported side effects needed to see a provider for management. Overall client satisfaction with services was very high (98%) and the perceived quality of services was also very high (97-99%). We conclude that this hybrid telemedicine model for the provision of first-trimester medication abortion is feasible, effective, safe and accepted by clients. Results from this study will enable revisions to the abortion clinical guidelines to include task-sharing with mid-level providers, such as nurses and midwives, via telemedicine in health centers.