In a digital age that renders us more connected than ever before, telehealth, or remote clinical services between medical professionals and patients, points to an optimistic future of patient care services. Ranging from virtual care sessions for advice on a new skin condition, to wearable biosensors monitoring your vitals, telehealth has the potential to expand care exponentially. And all you need, in theory, is a personal device and an internet connection.

Yet in the world of telemedical abortion services, the barriers to care are not always technological – oftentimes they are more insidious and systemic, rooted in social norms and further enacted via legislative channels.

We sat down with Victoria Satchwell to talk about her work as a telemedical abortion provider at Women on Web, an international non-profit that provides online abortion services. We discuss abortion care and digital rights, algorithmic censorship, patient autonomy, and what the future holds for telemedical abortion services.

Can you tell me about the work that you do at Women on Web?

Women on Web is an online or telemedical abortion service that’s been pioneering self-managed abortion since 2005. We’re a group of abortion activists, doctors, researchers, and trained help desk providers. Women and pregnant people can visit our website to do a consultation. We ask them about their gestational age, medical history, and demographic details, and we get their consent. Then our doctors review each case, and when it’s medically safe to do so, abortion pills are sent to their home and then they self-manage their abortion. We also do a lot of research and advocacy around telemedical abortion as well as digital rights on the internet, and access to abortion in various countries.

Women on Web has been around for a while. What are some of the changes that you are seeing in reproductive health care right now, as it relates to technological advancements and abortion access?

It’s taken a lot of advocacy work and research for opinions and policy to change around telemedical abortion. With COVID, many women couldn’t get access because they couldn’t get to a clinic during lockdowns. But of course, abortions still needed to happen, and we saw a willingness from for example the French and UK governments to improve access through telemedicine. Also, with the overturning of Roe v. Wade, there’s been a big push to respond to restrictions with telemedical provision and an openness to self-managed abortion. We see a growing realisation that telemedicine is not just about improving access, it’s also about women’s preferences. Some women prefer telemedicine even when in-clinic options are accessible because self-management can support autonomy and privacy or just be a bit more convenient.

A few years back we saw news articles warning about the danger of ordering abortion pills online, but recently I saw an article in The New York Times saying that the biggest provider of abortion is the US postal system. So, there’s really been a change. Telemedical abortion is standard care in a growing number of countries and the WHO (World Health Organization) guidelines on abortion now recommend self-management.

What are some of the concerns that people still have about telemedical abortion services?

We hear concerns about a woman’s ability to accurately report her gestational age. How do women know how far along their pregnancy is and how do we know that they are telling us the truth if we don’t examine them? Abortion pills can be used safely at home until 13 weeks (first trimester), according to the WHO. There have been multiple studies showing that women can determine gestational age by reporting the first day of their last menstrual period – they don’t need an ultrasound or physical exam.

This concern is primarily about trust. It is about people not trusting women with their own bodies. Our service is based on trust, because we see that women know best how to take care of themselves and make good health decisions when provided with information, resources, and when their autonomy is supported.

We also hear concerns about the safety and efficacy of telemedical abortion. Recently, together with Karolinska and University of Cape Town, we were involved in a randomised controlled trial on telemedical abortion. The study supported prior research findings and showed that telemedicine is non-inferior to in-clinic care – just as safe and effective. We know that if women can’t access safe abortion, they still have abortions, they’re just going to be unsafe. Models of abortion care that increase access, as telemedicine does, are increasing safety. And if they aren’t getting abortions, they’re going to be giving birth, which is much less safe than having an abortion. So, despite the barriers, medical abortion and telemedical abortion is a much safer option.

You’re speaking about how a lot of this has to do with a fundamental mistrust of women. As I see it, there’s this double layer of mistrust in women and their judgment and then there’s an additional layer of mistrust in telemedicine – there’s almost a moral panic around having a doctor present to regulate care. What do you think needs to be untangled in order to expand this sort of care?

I don’t see a moral panic around telemedicine, I think that it’s about abortion, and it’s about women. Imagine a patient with a skin condition having their doctor assess them over a web call and being prescribed topical medication that they use at home. I don’t think anyone’s getting upset about that or feeling concerned. Telemedicine is widely accepted. The moral panic is around women having more power over their reproduction and being outside of direct medical control.

In terms of changing that, we go straight ahead and provide these services, backed by research showing that this option is effective, improves access, and is acceptable to women. Service provision itself – making the telemedicine option available irrespective of what doctors or governments think of it – is part of changing perceptions around abortion. We won’t tolerate not having access to abortion. And abortion, also self-managed abortion, is common and normal.

We’ve been providing care for more than 16 years. Now it’s about policymakers, implementers, and doctors coming to the table to listen to women, act on the research, and integrate telemedical abortion in national health services – making it standard care and funding it.

Besides these social elements, do you experience any technological barriers to expanding telemedical abortion care?

Particularly in the developing world, a lack of internet access can be a barrier to digital health options. Telemedical services can’t be provided where these are no mobile phones and internet access, but we also need digital literacy and financial access, i.e., access to online payment options. In this way, abortion access has become intertwined with digital rights. Internet penetration, particularly in African countries, can pose a problem, but we can solve this with alternative models. For example, community health worker supported telemedicine – a community health worker with access to a phone and internet who can connect her community to services. In South Africa, where many people have a mobile phone, but data costs are very high, we are looking at providing a data-free service.

Another concern is payment mechanisms. Women on Web is a donation-based service, and many women don’t have a credit card or access to PayPal, so they are unable to make a donation at all. These are problems we can anticipate across telemedicine and digital health, not just in abortion care.

What about navigating national authorities when providing abortion care on such a global scale – do you ever experience censorship?

We have seen our site censored by several governments, for example in Saudi Arabia, in Spain, and in Korea. We just won a Supreme Court case against Spain for blocking our website. It was during the lockdown that they censored the website, when thousands of people were trying to access our services. We also experience financial censorship where payment gates like PayPal shut us down so we can’t receive donations from women using our services or the public.

Another critical issue we face relates to our searchability on the internet. We provide online services and are therefore reliant on Google algorithms to return safe results to women’s searches for abortion information and care – our website can be pushed down in the rankings overnight and then women can’t find us. Google is not effectively determining the difference between safe and unsafe abortion services or anti-choice media. We see that they may allow unsafe services and anti-abortion groups to advertise or go uncensored while making it harder to find our service. Google has an obligation to make sure that women can access accurate information on reproductive health, and they are obstructing that.

One of the big promises of telehealth and telemedicine has been its potential to expand access to care. Does telemedicine lessen discrepancies in access to abortion for those who are disproportionately facing barriers especially across lines of socioeconomic status, sexuality, and race?

Access to abortion is a social justice issue. Rich women are more able to overcome barriers to abortion access. A wealthy person living in Saudi Arabia, where abortion is illegal, will fly to the Netherlands for abortion care, but the many migrant workers in Saudi don’t always have that option. Telemedicine can eliminate the need for expensive travel and ensure access also for less well-off women.

In countries where abortion is legal, cost may be a barrier. Telemedicine and self-management are often a lot more affordable than alternatives. But it’s not just about the cost, access also encompasses distance to services, convenience/time and the navigability of the healthcare system, privacy, and treatment by healthcare providers. For people living in rural areas where clinics may be far away necessitating travel, time off work, and an explanation to your employer, telemedicine is a good option. The privacy of telemedicine may be preferable for people in abusive relationships or those who don’t want their partner knowing about their abortion. Telemedicine can help marginalised groups avoid mistreatment and stigmatisation at clinics – those with HIV, sex workers, young people, and trans people are more likely to experience mistreatment during an abortion and may be prefer a no-touch service.

And how do we ensure that telemedicine continues to lessen these barriers?

The orientation that we take in designing healthcare technology needs to change – we need to be designing for marginalised users based on an understanding of the reality of their lives. Women on Web is conducting a clinical trial on a new contraceptive. The reason that we’re doing this is because currently, contraceptives are not designed with users in mind. We’re researching if mifepristone, the abortion pill, can be used as an on-demand contraceptive. When you have sex regularly you use it once a week, if you’re not having sex you don’t need to use it, or you can use it as an emergency contraceptive meaning you take it just after or before you have sex. Most oral contraceptives aren’t responsive to the reality of women’s lives – not everyone can take a pill every day – maybe they can’t afford it, maybe it’s hard to integrate into their life, or they don’t want the side effects of daily use, especially when they aren’t having sex regularly.

Women on Web has insight into how women from various backgrounds interact with reproductive health because we work with women every day. We’re talking to them one-to-one and learning what women want and need to support their health. That is why we can constantly work on improving access. I think that’s just an orientation; the people that design and decide on healthcare services and technologies, whether it’s a new contraceptive or a policy on over-the-counter access to emergency contraceptives, are often not the most marginalised and that leads to blind spots.

Looking towards the future, how do you hope to see telemedical abortion care develop?

We need to identify the places where self-care works, and where in-person care is a better option. There are many cases when patients seeing healthcare professionals adds a lot of value, but there are a lot of cases where it doesn’t make sense in terms of access or in terms of cost to patients and healthcare systems. And once we determine where we need to deregulate, we need to demedicalise and develop technologies that support people’s autonomy in their own health.

We’ve seen that our healthcare systems do not cope well with shocks and crises – that even in times of relative peace, we aren’t able to provide services, particularly to marginalized groups. We need to invest in empowering people and give up a little bit of power from the medical side, which is tough. Doctors don’t want to give up power, but we need to recognize that patients can take care of themselves, and then we need the laws and the policies and the technologies to focus on empowering users.

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Victoria Satchwell is a helpdesk member at Women on Web and Director at Abortion Support South Africa. She’s been a telemedical abortion provider for the past 4 years and is setting up a telemedical abortion service in South Africa. Before that she coordinated a clinical trial on mifepristone, the ‘abortion pill‘, as a weekly contraceptive. She has an MSc in Health Economics and a background in philosophy.

Read more about Women on Web’s work here.

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CHECK-UP is a Q&A series by Maya Ellen Hertz and Sarah Frosh exploring advancements and providing critical reflections on innovations in digital health. From telemedicine and electronic health records to wearables and data privacy concerns, the article series includes interviews with experts in fields across law, engineering, and NGOs who shed light on the myriad of complexities that must be considered in the wake of new digital health technologies.