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Obstet Gynecol. Author manuscript; available in PMC 2024 Jun 1.
Published in final edited form as:
Obstet Gynecol. 2023 Jun 1; 141(6): 1139–1153.
Published online 2023 May 3. doi:10.1097/AOG.0000000000005192
PMCID: PMC10440237
NIHMSID: NIHMS1883724
PMID: 37141602
Emily M. Godfrey, MD, MPH, Anna E. Fiastro, MEM, MPH, Molly R. Ruben, MPH, Elizabeth V. Young, MD, MSc, Ian M. Bennett, MD, PhD, and Elizabeth Jacob-Files, MA, MPH, Consultant
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The publisher's final edited version of this article is available at Obstet Gynecol
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Abstract
OBJECTIVE:
To explore patient perspectives regarding patient–cliniciancommunication during telemedicine medication abortion compared totraditional, facility-based, in-clinic visits.
METHODS:
We conducted semi-structured interviews with participants whor*ceived either live, face-to-face telemedicine or in-clinic medicationabortion from a large, reproductive healthcare facility in Washington State.Using Miller’s conceptual framework for patient-doctor communicationin telemedicine settings, we developed questions exploringparticipants’ experiences of the medication abortion consultation,including the clinician’s verbal and non-verbal interpersonalapproach and communication of relevant medical information, and the settingwhere care was received. We used inductive-deductive constant comparativeanalysis to identify major themes. We summarize patient perspectives usingpatient–clinician communication terms outlined in Dennis’quality abortion care indicator list.
RESULTS:
Thirty participants completed interviews (aged 20–38 years),20 of whom had medication abortion by telemedicine and 10 who receivedin-clinic services. Participants receiving telemedicine abortion servicesreported high-quality patient–clinician communication, which camefrom their freedom to choose their consultation location and feeling morerelaxed during clinical encounters. In contrast, most in-clinic participantsportrayed their consultations as lengthy, chaotic, and lacking comfort. Inall other domains, both telemedicine and in-clinic participants reportedsimilar levels of interpersonal connection to their clinicians. Both groupsappreciated medical information about how to take the abortion pills andrelied heavily on clinic-based printed materials and independent onlineresources to answer questions during the at-home termination process. Bothtelemedicine and in-clinic participant groups were highly satisfied withtheir care.
CONCLUSION:
Patient-centered communication skills used by clinicians duringfacility-based, in-clinic care translated well to the telemedicine setting.However, we found that patients receiving medication abortion throughtelemedicine favorably ranked their patient–clinician communicationoverall as compared to those in traditional, in-clinic settings. In thisway, telemedicine abortion appears to be a beneficial patient-centeredapproach to this critical reproductive health service.
Précis:
Telemedicine appears to be a beneficial patient-centered approach tocritically needed first-trimester abortion services.
Today, medication abortion makes up more than half of all abortions occurring inthe United States (U.S.).1 Abortion bytelemedicine became more prevalent during the COVID-19 Public Health Emergency (PHE)when the U.S. Food and Drug Administration (FDA) temporarily, and then permanentlysuspended the mifepristone in-clinic dispensing requirement.2 Requests for direct-to-patient telemedicinemedication abortion services, in which patients choose where they receive care areexpected to increase following the 2022 U.S. Supreme Court case Dobbsdecision.3,4
Despite its growing use, data regarding best practices for patient-cliniciancommunication when providing abortion care through telehealth are lacking.Patient-clinician communication is considered a critical element of patient-centeredcare, and has been associated with valuable health system outcomes, including increasedpatient trust, improved treatment adherence, overall positive patient experience,improved healthcare efficiency, and lower cost.5–7
For abortion care, however, patient-clinician communication considerations areunique because of both stigma and the systemic access issues that often compromise theability for care to be patient-centered.8 Unlike other aspects of reproductive health care, patients oftenobtain abortion care from someone other than their usual clinician, further compromisingcomfort and trust.9–11 By interviewing participants who receiveddirect-to-patient telemedicine medication abortion services, we explored the setting andhow clinicians’ interpersonal and communication behaviors affected the patientexperience of patient–clinician communication compared to traditional, in-clinicmedication abortion care.
METHODS
We conducted a cross-sectional, in-depth, semi-structured interview study ofpatients who had recently received an in-clinic or telemedicine medication abortion.This study received institutional review board (IRB) approval by the University ofWashington (UW) Human Subjects Division (ID: STUDY00013954) and is reported usingthe Consolidated Criteria for Reporting Qualitative Research (COREQ)guidelines.12
The team consists of a Principal Investigator (PI) who is a Complex FamilyPlanning Fellowship-trained physician with master-level training in qualitativeresearch (EMG), a PhD candidate in public health with experience working in abortionpolicy and qualitative research (AEF), a medical anthropologist and amaster’s level qualitative methods consultant (EAJ), a research coordinatorwith a masters of public health in maternal/child health (MRR), a medical student(EVY) and a family physician who provides abortion care with research expertise inimplementation science (IMB). Throughout the study period, we enlisted a CommunityAdvisory Board that represented Latina, young adult, and rural communities, twoabortion advocacy organizations and a staff member from the clinic where werecruited participants.
We used Miller’s conceptual framework for the evaluation ofpatient-clinician communication in telemedicine settings (Fig. 1).13 We chose this model because it incorporates core components ofpatient-centered communication that have been widely quoted in the literature. TheMiller framework also includes a category with factors related to the medium (e.g.,telemedicine) used for the patient–clinician encounter, a key aspect wesought to evaluate among our participants.
Fig. 1:
Adaptation of Miller’s definitions to indicators related topatient–clinician communication within quality abortion care. *Clientprovider interactions, decision making. †Informationprovision, support, technical competence.
This study used convenience sampling of all patients who had been given theoption to receive medication abortion either by telemedicine or in-clinic from aWashington State independent, high-volume reproductive healthcare clinicorganization, Cedar River Clinics (CRC). CRC is certified by several networks,including the National Abortion Federation. CRC began offering telemedicinemedication abortion services using live, face-to-face video conferencing software inApril 2020, in addition to continuing traditional in-person, clinic appointments.Telemedicine appointments require a known last menstrual period within 7 days,regular periods, no symptoms or risk factors for ectopic pregnancy and verbalconfirmation of a positive pregnancy test, without requiring an ultrasound exam forgestational dating. Washington State permits nurse practitioners to providemedication abortion services, thus participants’ clinical encounters involvedeither a physician or nurse practitioner.
To be eligible, participants had to speak and understand English, be atleast 18 years old, had either telemedicine or in-clinic medication abortion in theprior month, and agree to an audio-recorded interview. Because we were mostinterested in evaluating patient–clinician communication with novel telehealthabortion, we purposively enrolled more telemedicine than in-clinic participants. Torecruit participants, CRC staff asked every eligible patient to indicate theirinterest in being contacted by the UW study team when they signed their consent forabortion services. On a weekly basis, CRC staff provided contact information ofinterested patients to the research coordinator, who then attempted to contact eachinterested participant up to three times by email, text, or call over a two-weekperiod. Contacted participants completed an eligibility survey in a secure REDCapdatabase,14 providedinformed consent and scheduled an interview using an online calendar platform or byphone. Each participant received a $50 electronic gift card by email following theirinterview.
The qualitative methods consultant conducted semi-structured, in-depthinterviews using HIPAA-compliant conferencing software at a time and place of theparticipant’s choosing between September 2021-January 2022.
The research team developed the interview guide based on Miller’sconceptual framework. Questions included the decision about the medication abortionservice type (telemedicine vs. in-clinic), scheduling and attending theirappointment, the clinician encounter, the setting where the encounter occurred,satisfaction with the care and clinical outcomes. Prior to initiating the interview,the qualitative methods consultant provided a brief description of the study teamand assured participants their information would not be reported back to CRC. Eachinterview ranged between 35–60 minutes, was audio-recorded and transcribed.The interviewer recorded field notes after each interview, reflecting on datacollection, personal biases, and patterns. No interviews were repeated. After theresearch team completed all the interviews, CRC provided the team with requestedparticipant characteristic information (Table1). Although an imperfect measure, we chose to list race/ethnicity as aproxy of shared lived experience to highlight the voices that informed thisstudy.15
Table 1:
Selected participant characteristics by medication abortion service(N=30)
| Characteristic | Telemedicine (N=20) | In-clinic (N=10) |
|---|---|---|
| Mean ±SD | Mean ±SD | |
| Participant age (years) | 31.0 ±5.7 | 27.0 ±5.9 |
| Gestational age at time of service (days) | 43.6 ±21.5 | 43.6 ±15.6 |
| Self-reported prior abortion(s)* | N (%) | N (%) |
| 0 | 10 (50.0) | 7 (70.0) |
| 1 or more | 10 (50.0) | 3 (30.0) |
| Self-reported race/ethnicity | ||
| Declined to specify | 3 (15.0) | 2 (20.0) |
| Hispanic/Latino | 5 (25.0) | 1 (10.0) |
| Non-Hispanic/Latino | ||
| Additional (unspecified) racesand ethnicities | 10 (50.0) | N/A |
| Asian | 1 (5.0) | 1 (10.0) |
| Black or African American | N/A | 2 (20.0) |
| White | 1 (5.0) | 4 (40.0) |
| Area of residence | ||
| Large metro area (1 million+population) | 7 (35.0) | 6 (60.0) |
| Other (<1 millionpopulation) | 13 (65.0) | 4 (40.0) |
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*Includes medication and surgical abortions
N/A=No participants identified in this category
We used descriptive statistics to report participant characteristics. Weused inductive-deductive constant comparative analysis to identify major themes andsummarize patient perspectives consistent with Miller’s conceptualmodel.16 The analysts (EAJand AEF) both coded the first ten interviews, meeting regularly to discuss codingdiscrepancies until they agreed on the codebook. After that point, they codedindependently. The analysts created memos as they coded to track and synthesizethematic discussion and generate consensus. We defined data saturation as the pointat which no relevant new themes related to the areas of focus wereidentified.17 The analystspresented iterative summaries of the interviews to the larger research team and thecommunity advisory board during the study’s data collection and analysisphases. Dedoose software (version 9.0.62) was used to organize and manage the data .To increase the applicability of our findings to the abortion care settingspecifically, we summarize patient perspectives using patient–cliniciancommunication terms used in Dennis’ quality abortion care indicator list(Fig 1).18
RESULTS
Of 42 patients who enrolled and scheduled interviews, our final study sampleconsisted of 30 individuals; 20 who received telemedicine and 10 who receivedin-clinic services (see Fig 2). Table 1 lists the selected sociodemographiccharacteristics of the study population. Twenty-three participants received theircare from nurse practitioners and seven from physicians.
Fig. 2:
Study participant recruitment and enrollment flow diagram.
We identified four separate domains of patient-clinician communication.Within these domains, we identified 8 relevant categories and 17 factorsrepresenting the perceptions of patients who received either telemedicine orin-clinic care. Domains, categories, factors, and illustrative quotations are listedin Table 2. Based on our findings, wesummarize best practices for patient–clinician communication for medicationabortion services (Box 1).
Table 2:
Representative quotations, comparing telemedicine and in-clinicmedication abortion care
| Category | Factor | Telemedicine | In-clinic |
|---|---|---|---|
| Domain 1: Service geographicaccessibility, efficiency of services, perception of space wherecare is received | |||
| Setting | Geographic accessibility | “I wanted telehealth appointmentsbecause I live very rural. And I live on a farm and so access toservices is really hard to get here and the community that my farm isnear [a town that] is against all kinds of access to services like[abortion care].” (Participant 32, Telemedicine) | “Since I had to drive [more than 60miles] to the clinic, [the in-clinic visit] …was like a whole dayI spent doing that to take that first pill. Which if I had done itonline and if I could take the pill at home, then I could have stillgone about my day regularly and not wasted a day.” (Participant26, In-clinic) |
| Setting | Efficiency of services | “I liked the flexibility of doingthings virtually, so I was able to just do it while I was at work. Ididn’t have to take time off because I [have to be at workduring] the time that clinics are open.” (Participant 08,Telemedicine) | “[While at the clinic I felt] likecattle herding, go in, get it done, go out and go to the next room. Shedidn’t really say anything to me or walk me through anything,which I would have liked. But then [when you do get explained things],it felt redundant because you already get a big packet of paperworkwhile you’re waiting… everyone is just reiterating thesame thing, walking through the exact same thing. From Google I read it,I read it in the packet, I get told in the rooms and with the doctor,they tell me the same thing. So it kind of was redundant.”(Participant 11, In-clinic) “Everybody was kind.Ultrasound tech was wonderful. And then I met the [clinician]. She wasstrained, I could see. She kept telling me, “I know it’syou, I have not forgotten about you.” And every time she passedby, she gave me some reassurance and very thorough, made sure Iunderstood all the instructions. I just think it was just the waiting inbetween, that it could have been better.” (Participant 09,In-clinic) |
| Setting | Privacy | “The doctor did tell me we were in asecure location, there wasn’t anybody else around that had todeal with the appointment or anything. So I felt completely comfortablecontinuing on with the appointment via telemedicine.”(Participant 15, Telemedicine) | “In the waiting room and there were 12other women…And I was in that waiting room, I think for abouthalf an hour. And then someone else came and brought me into an officetype room. So there was the main meeting room, the ultrasound room, thesecond waiting room, and now I’m in an office room.”(Participant 10, In-clinic) |
| Setting | Perception of space where care received | “I took the call on my lunch break fromwork…I was comfortable at a friend’s apartment using herroom…It was ideal for me…If it was in person, Iwould’ve been more emotional. I’m glad that I was in asafe place that if I needed anything, my friends were there…Ifelt very secure…Also I could be close to home versus travelingacross the state to have this appointment…I would’ve hadto get time off work. I didn’t want to get in trouble with work.A video call made it way better.” (Participant 03,Telemedicine) | “[The clinic space could have had] amore human touch to it. Like, hey, maybe there is like a vending machineor just something to distract yourself a little bit. Like they had a TV,but it wasn’t on and it’s just you get kind of antsywaiting there of course…just maybe a little cozier or somethingto put you at ease a bit more.” (Participant 30,In-clinic) “The building was kind of set back away fromthe road. And there were two ladies with signs, right by the sidewalk,by the road. So I was in my car and I was just turning. But yeah, I sawa couple of protestors as I was leaving.” (Participant 40,In-clinic) |
| Domain 2: Client-clinicianinteractions, decision making | |||
| Client-clinician interactions | Respectful care | “[For the clinician] time seemed likeit wasn’t a concern. It wasn’t like, ‘Oh, I onlyhave 15 minutes. Do you have any other concerns?’ It was moremaking sure I felt comfortable, giving me that reassurance, going overthe procedure, asking me if I had any questions.” (Participant,22, Telemedicine) | “I felt more heard than I ever have byany [clinician] ever prior talking to [Clinician Name] about birthcontrol options....She gave me exactly what I asked for, which was athree month trial. And said I could come back for the rest of the yearif I decide I like it.” (Participant 37, In-clinic) |
| Client-clinician interactions | Positive interactions, promote an atmosphereof trust | “…I felt really comfortable withthe doctor. He introduced himself, asked me about myself, told me aboutthe process that he was going to go through…He was reallyknowledgeable, but also intentionally answered my questions in anaccessible way. His whole demeanor was really calm andpersonable…He wasn’t trying to hurry me along to get tohis next appointment. And whenever I’d ask a question,he’d wait a second, he’d say something positive toindicate he had heard my question, and then he would think for a secondand then he would answer thoughtfully.” (Participant 08,Telemedicine) | “She gave me time to ask questions andwas reassuring that [abortion is a] pretty common thing, and it’snot super scary…Her demeanor was supportive and she humored mewith whatever I had to say. She behaved like a friendly mother…She gave you space and was not being overly scientific. I don’tmind that in any other kind of medical interaction, but I think[abortion] needs a little bit more air to breathe and a little bit morehuman touch.” (Participant 30, In-clinic) “…when I was with the doctor, she was making sure, ‘Are youcomfortable with this? Are you understanding this?’ Not justspeaking at me, she was definitely checking in repeatedly, ‘Areyou getting this? Is this what you want?’ So that wasnice.” (Participant 11, In-clinic) |
| Client-clinician interactions | Promote patient’s dignity | “…hearing from another woman[the clinician] that they understand why I am thinking about this option[was important], ‘I totally understand why you’re feeling[an abortion] might be necessary, you have a 3 ½ month oldbaby,’…she was very relaxed, knowledgeable, and shecommunicated really well, so it helped make my decision.”(Participant 35, Telemedicine) | “[The clinician] had a social workerfeel to her…we were both seated and [she had good] eyecontact…she let me vent…I think every woman that makes itthere might have some emotional baggage, so just being able to listen tothat.” (Participant 9, In-clinic) |
| Client-clinician interactions | Tailored care | “… I’d already [had amedical abortion] once before, so I knew what I was doing....but I[still] needed more information because ..from the time that I took thefirst pill to when I take the second dose, the timeframe had changed.That was confusing to me… but I was rest assured because I knew Iwas getting [printed] information with the medication.”(Participant 42, Telemedicine) | “The [clinician] got me in and out. Shewas like, ‘I know you’ve been here all day…I can gothrough everything. Or, since you’ve said you’ve [had anabortion] before, you can tell me if you don’t need me to gothrough this or if you want me to go through it again.’ I toldher I honestly just want to leave. So [she honored that]. She just spedthrough the things that she absolutely needed to tell me.”(Participant 23, In-clinic) |
| Decision-making | Interactions absent of bias or coercion,trusting patient to make informed decision | “[The clinician] started off the callby saying, ‘This is a no judgment zone. We just want to make sureit’s your decision and you’re not being influenced byanybody. And as long as it’s what’s best for you, thenthat would be the right decision.’…That gave me thereassurance that I need to know that I’m making the bestdecision…it’s a huge weight lifted off myshoulders.” (Participant 22, Telemedicine) | “She asked me how I’m doing, andif anyone pressuring me to come and do it..she reassured me....sheasked, ‘Why are you here?’ And I told her,‘It’s just not the right timing. I have a life to build. Ican always have kids later’…I appreciated that alot.” (Participant 27, In-clinic) “[The clinician]definitely asked when I was going to take the second [set of] pills,just so that she could have note of it and if I had a day that would bebest. Since I did have work on the weekend, I wanted to take it as soonas possible so I could be back to kind of normal as soon aspossible…I kind of had my mind made up already, so when she askedI kind of had my answers ready that I knew, regardless of if she had anyopinion on it.” (Participant 11, In-clinic) |
| Domain 3: Clinicianinformation provision, assessing support system, technicalcompetence | |||
| Information provision | Explanation of abortion process | “She was very thorough with the healthinformation…the information was actually quiteoverwhelming…there was a really long list of different symptomsthat may arise from the pill, the whole process of taking thepill…Even if I were to go to the clinic, there is not really anyway around that.” (Participant 04,Telemedicine) “[The clinician] told me, ‘This ishow often you will be needing to change your padding.’ And Iasked, ‘What’s a lot? Because I have a heavyperiod…And then he asked me to describe my level of flow. And hesaid, ‘No, it would be a lot heavier than that…’Hewas really specific in when I should be concerned and when Ishouldn’t be concerned. And the description that he gave wasreally accurate to my experience.” (Participant 08,Telemedicine) | “…[the clinician] talked throughthe abortion pill procedure…about what would happen in my body,things to expect before going ahead…I took the first one, and wetalked through when to take the next one, and again, what to expect. Shewas really thorough.... I appreciated that she read the materials withme, instead of handing me some things to read later. I have a copy sothat I could look back on it, but really explaining what things mean,taking time to make sure that I understand what’s going tohappen.” (Participant 37, In-clinic) “[Theclinician] highlighted specific things, the big takeaways from the[written instructions], so that was nice.” (Participant 11,In-clinic) “[The clinician] reminded me, you’regoing to want to take it easy and you’re going to expect thebleeding, and the size of the blood clots, how long I could be bleedingfor…There was certainly a lot of bleeding, but I was prepared forthat…he also told me that I would feel like I kind of like flulike symptoms, so I knew I was going to feel crummy…”(Participant 41, In-clinic) |
| Information provision | Information about possible complications andhow to obtain appropriate care | “[The clinician] did tell me that theyhave 24-hour telephone support, so if I had any concerns or neededanything…that made me feel more comfortable, and it made me feela lot better about their organization, just knowing that they havepeople that care enough to be on call 24 hours a day in case you wouldneed something. Because it’s something you don’t want tojust call like a friend or a regular doctor to ask about because a lotof people have varying opinions on abortion.” (Participant 16,Telemedicine) “I definitely felt if there were moreserious medical problems, then I could reach out to the clinic, but no[I did not need to call them], all of the symptoms that she said wouldhappen, happened, and I was prepared for that…”(Participant 04, Telemedicine) | “[The clinic staff] let me know thatthere was going to be a 24-hour service line, I could call if I neededany help or if I had any questions or if I was worried aboutsomething.” (Participant 12, In-clinic) “[It wasparticularly helpful they said] to call them if there’s anyexcessive bleeding over the four to six hour period….there’s also a 24-hour support line, if something is out of theordinary or if there’s excessive bleeding, I felt comfortablethat I could call them and ask any questions.” (Participant 26,In-clinic) |
| Information provision | Post-abortion contraceptive careinformation | “[The clinician] told me that she wouldsend to the pharmacy Plan B just in case I do need it for thefuture…Not only did she care about the right now, she was tryingto make sure I was good for future.” (Participant 22,Telemedicine) | “[The clinician] gave me some plan Bs,which was really helpful.” (Participant 27, In-clinic) |
| Support | Patient support systems | “[The clinician] asked if I had asupport system and she was very concerned about who was going to be mycare person. Which I thought was cool because it wasn’t broughtup to me in my first two visits at [an outside clinic]. And I thoughtlooking back that was something that would’ve been extremelyimportant… I had a lot of blood loss with my first [medicationabortion] and it scared me to death and I didn’t have anybody forhelping me… [at this clinic], you have to have a care person. AndI think that’s absolutely how it should be.” (Participant07, Telemedicine) | “[The clinician] did say to have asupport person, have someone to take care for your child [during the4–5 hours of pain when passing the pregnancy]”(Participant 09, In-clinic). |
| Technical competence | Appropriate pain management | “I think what really helped is the tipthat [the clinician] gave for while that process [of passing thepregnancy] was happening, to have a heating pad for the discomfort,because that helped more than anything. I didn’t want to feelnauseous of having more pain medicine, so using the heat pad really,really eased everything.” (Participant 02,Telemedicine) “The only thing that I would complain aboutis pain. I mean, [the clinician] had Naproxen sent to me, but…Naproxen…just wasn’t what I needed because of howbad the pain was. And like me crying on the toilet because I’m inso much pain and basically screaming, yelling out because of the pain,it shouldn’t be that bad.” (Participant 29,Telemedicine). | “They gave me a tracking form to trackmy symptoms and track when I took the medication, so that was nice.Really easy process. I do remember there was one scary part on one ofthe forms that I filled out. It said that this might be the most painthat you’ve ever experienced in your whole life…I’ve birthed two children…it wasn’t really painfulat all.” (Participant 40, In-clinic) “It washorrible pain, and Naproxen didn’t do anything. I also tookTylenol…[The clinician] told us we could use a hot waterbag…But the amount of cramping and the bleeding, it’s justreally hard to manage at home…” (Participant 09,In-clinic). |
| Domain 4: Outcomeindicators: Patient knowledge and attitudes | |||
| Client knowledge | Understand information given during clinicvisit | “… Another nice thing is theysend you a brochure with the medication. It was a quick, easy referenceto answer common questions. I’m like, ‘Oh, is this normalwhen I was taking it?’ I could reference that pamphlet and thatwas super nice.” (Participant 03, Telemedicine) | “[the clinical staff] gave me a lot ofpapers to read and I found those really, really good and all the kind ofstatistics and information and the things that could potentially gowrong. I thought that was really helpful and I felt comfortable becauseonly recently I’ve heard at about the abortion pill.”(Participant 26, In-clinic) |
| Client attitudes | Patient satisfaction | “I really felt cared for and evenrespected of how to take care of myself.” (Participant 02,Telemedicine) | “[The clinician] was…easily thebest doctor’s appointment I have ever had. If I had to rank theexperience, it would be a 10 out of 10 despite the wait.”(Participant 37, In-clinic) |
| Client attitudes | Level of clinical competency | “I did end up bleeding a bunch and itwas crazy. I was grateful that I was aware enough to say, ‘[Theclinician] said to call this number on this paper.’ [My husbandcalled it and the nurse explained] to massage my stomach and it willhelp stop the bleeding and he did that and it worked.”(Participant 25, Telemedicine) | “I didn’t have anything happen[with the first pill], no cramping, no bleeding from that. 24 hourslater almost exactly I dissolved the pills in my mouth. After the 30minutes I swallowed them, and then probably 15 minutes later I threweverything up and I had to Google because I was like, ‘Oh my god,did I just mess this whole thing up?’ But I googled it and itbasically was like, ‘Yeah, it’s fine as long as you let itdissolve for 30 minutes.’ So I was like, ‘Well, hopefullythat still works.’ That was the only thing that I was like,‘They didn’t tell me I could throw upthen.’” (Participant 11,In-clinic) “Honestly the process seems kind ofsimple…. if it was super complicated, I’m sure [theclinician] probably could have dumbed it down, but you know, you justreally put the pills in your mouth and let them sit there andwhatever.” (Participant 23, In-clinic) |
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Box 1: Best practices for patient–physician communication formedication abortion encounters based on 30 in-depth interviews at a singlehealthcare facility
Patient–physicianinteractions:
|
Provide the patient necessaryinformation:
|
Support:
|
Setting:
|
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Domain 1: Medical Consultation Settings
Factors related to the medical consultation setting includes: (1)geographic accessibility of the appointment with the clinician, (2) efficiencyof services and (3) perception of space where care was received in terms ofprivacy and comfort, all of which affected participants’ attitudes aboutthe consultation visit. Factors related to telemedicine consultation settingscontrasted considerably with in-clinic (Table2, Domain 1).
Participants who received telemedicine reported feeling like the carewas accessible and efficient. They appreciated choosing where their medicalconsultation occurred. Examples of telemedicine consultation settings includedone’s own bedroom, a friend’s home, or their car. Participantschose these spaces because they were quiet, familiar, convenient, away from kidsor workplaces, providing a more controlled and relaxed consultation compared tothe in-clinic setting. Many emphasized that telemedicine allowed them to talkmore freely and openly, and feel more confident about the privacy of theirabortion decision. For example, one participant shared, “I definitelyfelt at greater ease doing a telemedicine appointment when it came to going overthe information…just because I was more comfortable in my own environmentversus having to go to a doctor’s office” (Participant 15,Telemedicine).
In contrast, participants described in-clinic visits as less accessible,inefficient, chaotic, and lacking privacy. Many struggled with transportation,traveling several hours to get to and from the clinic and expressed concernabout potentially encountering someone they might know at the clinic. Comparedto the shorter time spent with telemedicine, in-clinic appointments required afull day off work, with many describing having to wait for 4–6 hours,being moved to different waiting rooms and seeing multiple clinicians. In-clinicparticipants reported the setting as confusing, redundant and inefficient, with“lots of shuffling around.” One participant shared feelingindifferent about the in-clinic setting, and thus did not connect with theirclinician, stating: “I really didn’t care who I spoke with.Honestly, I just wanted to get out…Get it done.” (Participant 23,In-clinic). Many in-clinic participants expressed frustration about perceivedCOVID-19 restrictions of not being allowed to bring snacks, a support person, ortheir children, which would have made them more comfortable.
Domain 2: Patient–Clinician Interactions and Decision Making
This domain includes factors related to patient screening, how patientsare treated by clinicians and staff, and respect for patients’ ability tomake decisions about their care. We did not detect major differences within thisdomain between participants who received their care through telemedicine versusin-clinic (Table 2, Domain 2).
Participants were given thoughtful, thorough and complete answers fromtheir clinicians and felt respected and heard. Participants describedemotionally empathetic, attentive, and non-judgmental interactions facilitatedby clinicians with strong interpersonal skills. Telemedicine and in-clinicpatients valued clinicians who personally customized the medical information tomeet participant needs, concerns, and histories. A few participants preferredencounters that were brief and direct. In those instances, clinicians pivoted tothat communication preference: “The doctor had a very straight to thepoint, matter-of-fact tone, and for me personally, that was helpful”(Participant 01, Telemedicine).
Domain 3: Clinician information provision, Postabortion Contraceptive Care,and Technical Competence
Within this domain, we compare factors related to participants receivingcomplete information about the medication abortion process and post-abortioncontraceptive care, where to call if questions or complications arise, andquality of pain management. We did not detect differences within this domainbetween participants who received their care through telemedicine versusin-clinic (Table 2, Domain 3).
Most participants valued highly clinicians’ thorough explanationof the medication abortion process and symptom management. They appreciated whenclinicians clearly and chronologically walked through the steps of medicationabortion, including how to take the pills, when to expect symptoms to begin andend, and how to manage typical and atypical symptoms. They valued realistic,detailed information about how much blood to expect, especially compared to whatis “normal,” intensity and length of pain, frequency of vomitingor diarrhea, and when symptoms typically subside. Most participants alsoappreciated clinicians’ suggestions regarding how to set up a supportiveenvironment, such as requesting time off work, reassigning childcareresponsibilities, and identifying a support person. Participants overwhelminglyapplauded knowing about the clinic’s 24/7 nurse hotline forabortion-related questions, although few utilized it. “I didn’tfeel as if I needed to (call) because I went online and I found my answerspretty easily…and everything seemed to be fine” (Participant 01,Telemedicine).
Many patients reported appreciating that the visit was not just aboutthe abortion itself but included information about post-abortion contraceptiveoptions: “We spent the bulk of the time talking about birthcontrol…I said I wasn’t super worried about the abortion. I wasmore worried about birth control options because that’s something that Ihave struggled to figure out” (Participant 37, In-clinic). Participantsexpressed clinicians who took “extra” time to set up acontraceptive plan helped them feel confident that they would not need to pursuefuture abortions.
Clinicians seemed to lack technical competence related to adequate paincontrol, regardless of service type. Telemedicine and in-clinic participantsequally made a point to mention the pain control recommendation given byclinicians was something they would have changed about their service.Participants appreciated hearing their options to treat the pain and crampingassociated with pregnancy expulsion, such as heating pads, massage andover-the-counter medications and some conveyed adequate pain control.Nonetheless, a number of participants in both groups wished they had betteraccess to pain relief (Table 2, Domain3).
Domain 4: Outcomes Related to Patient Knowledge and Attitudes
Health outcomes include participants’ feeling like theyunderstood the information provided, overall satisfaction, and having trust andconfidence in the clinicians (Table 2,Domain 4).
Participants in both groups reported they had sufficient and accurateinformation that allowed them to comply with the medication regimen. They alsoreported the ability to recall clinician-shared information to manage symptomsat home and remain autonomous throughout their abortion. When asked if they feltprepared regarding pill taking and abortion side effects, most participants felttheir clinicians provided sufficient levels of detail and they were, in turn,able to describe those details during the interviews, while others used clinichandouts or conducted web-searches. Regardless, some telemedicine and in-clinicparticipants reported being unprepared for amount and duration of vagin*lbleeding and pelvic pain.
Overall, telemedicine and in-clinic participants shared high levels ofsatisfaction of care. Telemedicine participants overwhelmingly reported beingsatisfied with their abortion visit, many stating that they would pursue itagain or recommend it. In-clinic participants, on the other hand, reported thatpatients should have the option to decide between telemedicine and in-clinicservices, with about half stating “next time” they would choosetelemedicine. Both telemedicine and in-clinic participants also shared similarattitudes about trusting the clinic to provide high-quality abortion care.Feelings of trust were especially evident with a telemedicine participant whobecame stressed about waiting online for her clinician who was running 30minutes behind schedule but had not been notified by the clinic about thisdelay. Despite feeling uncertain, the participant’s attitude toward theclinic as a place to trust made her satisfied about this particular encounter:“What stuck out to me [as I was waiting for the clinician] is that I feltreally confident…like everything was going to be fine and that they werereally there to support my choice…” (Participant 32,Telemedicine).
DISCUSSION
Our results show that both telemedicine and in-clinic participants feltrespected, heard, understood, and valued by their clinician who provides abortion.The ability to choose the consultation location allowed telemedicine participants tofeel like their encounter was more controlled and relaxed, while most in-clinicparticipants portrayed it as lengthy, chaotic, and lacking comfort. Because thisstudy occurred when COVID-19 infection was still widespread, we surmise that many ofthe in-clinic participant experiences were due to unpredictable staff absences andsocial distancing requirements limiting clinic capacity. These in-clinic constraintsultimately compromised overall patient-clinician communication.
Both telemedicine and in-clinic participants had less favorable views aboutthe clinic’s pain control regimen, with several expressing they feltunprepared for the pain associated with medication abortion. This is unsurprisinggiven the limited high-quality evidence regarding adequate pain management duringmedication abortion.19 Whileparticipants stated they knew about the 24/7 nurse line, for reasons we did notthoroughly explore, participants who felt unprepared about the pain asserted theywish they had more pain medications at the moment of their abortion. This suggeststhat even if they had phoned the 24/7 line, they would have had to wait for aprescription to be called into a pharmacy for pick up, which may not have met theirneeds. Future studies should define patient characteristics associated with the needfor additional pain medication to better inform clinic protocols.
Patient satisfaction with telemedicine over in-clinic care is consistentwith other telemedicine abortion studies.20, Similar to other comparative telehealth and in-clinicstudies, our telehealth participants appreciated reduced appointmenttimes.21,22 In contrast to a prior qualitative study inwhich some telemedicine participants stated they felt reduced personal interactionswith their clinician than if they had seen them in-clinic, we detected no suchdifference.23 This presentstudy found that many of the patient–clinician interactions were consistentwith behaviors and attributes associated with patient-centered communication. Inessence, we showed that patient-centered communication qualities traditionallyprovided in the in-person abortion care setting can readily be translated to live,face-to-face video telemedicine.
The present study has several strengths. Based on our recruitment methods,each participant had had a medication abortion within the prior month. We alsosampled to saturation and enrolled a relatively diverse participant population.Nonetheless, our study was limited by a convenience sample of participants whosought medication abortion within a single healthcare entity in Washington State,when the nation and state were still under a COVID-19 PHE. Thus, our findings maynot be generalizable to all abortion care settings or to a time-period when thenation/state is not under a PHE. Our study evaluated participants who had live,face-to-face video telemedicine abortion care, which may not be applicable toasynchronous, online abortion care. Although we chose a conceptual framework thatincludes core components of patient-centered communication, we recognize it is amultifaceted construct, making it difficult to succinctly measure.6,24,25 Ideally,patient–clinician communication is evaluated more comprehensively, usingcombinations of direct observations of clinical encounters or with standardizedpatients, validated survey measures that patients complete after the clinicianencounter, post-visit patient interviews, and peer-colleague assessments.6 Given the stigmatizing nature ofabortion services, direct observations between clinicians and patients provedinfeasible. Additionally, while there is a growing interest to develop and validatea person-centered abortion scale, such a scale has not been implemented for patientsreceiving abortion services through telemedicine.26
In conclusion, telemedicine is a beneficial patient-centered approach tocritically needed first-trimester abortion services. To be patient-centered clinicsshould provide telemedicine abortion in the setting of the patient’s choiceand apply principles of patient-centered communication, including clinicians beingnon-judgmental, demonstrating respect and trust, tailoring to meet patients’needs, and explaining medication abortion processes and post-abortion contraceptivecare as understood by patients. Clinics should also provide printed information withinstructions about abortion pill use and where to call for questions andemergencies.
Supplementary Material
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Acknowledgments:
The authors thank the Cedar River Clinics for their collaboration on thiswork; and the community advisory board members for their insights regarding theinterview script, participant recruitment strategies and research findings; andparticipants who contributed to this research study; and Azelea Sayavong in theUniversity of Washington Department of Family Medicine for her editorialassistance.
Funding:
This study was supported in part by the National Center for AdvancingTranslational Sciences of the National Institutes of Health under Award NumberUL1 TR002319 and by the Society of Family Planning Research Fund (SFPRF15-MSD2).The funders were not involved in this manuscript. The information presented inthis manuscript is solely the responsibility of the author(s) and does notnecessarily represent the views of the NIH or SFPRF.
Footnotes
Each author has confirmed compliance with the journal’srequirements for authorship.
Presented at the American Anthropological Association Annual Meeting,November 11, 2022, Seattle WA, and at the NACRG Conference, November 19, 2022,Phoenix, AZ.
Financial Disclosure:
Emily M. Godfrey and Ian M Bennett receive honoraria from Organon asNexplanon trainers, unrelated to the submitted work. The other authors did notreport any potential conflicts of interest.
Contributor Information
Emily M. Godfrey, Departments of Family Medicine and Obstetrics and Gynecology,School of Medicine, University of Washington.
Anna E. Fiastro, Department of Family Medicine, School of Medicine, University ofWashington.
Molly R. Ruben, Department of Family Medicine, School of Medicine, University ofWashington.
Elizabeth V. Young, School of Medicine, University of Washington.
Ian M. Bennett, Department of Family Medicine, School of Medicine, University ofWashington.
Elizabeth Jacob-Files, Department of Family Medicine, School of Medicine, University ofWashington.
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