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Key messages On 21 March 2020, in response to the coronavirus COVID-19 outbreak, the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives (RCM), the Faculty of Sexual and Reproductive Healthcare (FSRH) and the British Society of Abortion Care Providers (BSACP) produced clinical guidance for the provision of abortion care. These guidelines were introduced in order to reduce the risk of transmission of COVID-19 to abortion providers and women seeking abortion while allowing service provision through lockdown.1 As a result, telemedicine was introduced as recommended by NICE guidelines on abortion care.2 Telemedicine utilises information and communication technology to deliver healthcare services at a distance to increase a client’s access to healthcare. This allows healthcare professionals to deliver a service via telephone, video call and the internet. Since the introduction of the COVID-19 restrictions, 85% of abortion consultations are undertaken via telephone or video call in England.3 These conversations need to be conducted remotely in as safe a manner as possible, and additionally there needs to be the flexibility to provide a face-to-face appointment for those clients who may have difficulty accessing telemedicine or who do not have a private space in which to access a telephone or video call. During March 2020, the law changed to allow women to undergo an early medical abortion (EMA) in their own home. This change allowed …

INTRODUCTION The safety and acceptability of medical abortion using mifepristone and misoprostol at home at ≤9+0 weeks' gestation is well established. However, the upper gestational limit at which the procedure remains safe and acceptable at home is not known. To inform a national guideline on abortion care we conducted a systematic review to determine what gestational limit for expulsion at home offers the best balance of benefits and harms for women who are having medical abortion. MATERIAL AND METHODS We searched Embase, MEDLINE, Cochrane Library, Cinahl Plus and Web-of-Science on 2 January 2020 for prospective and retrospective cohort studies with ≥50 women per gestational age group, published in English from 1995 onwards, that included women undergoing medical abortion and compared home expulsion of pregnancies of ≤9+0 weeks' gestational age with pregnancies of 9+1 -10+0 weeks or >10+1 weeks' gestational age, or compared the latter two gestational age groups. We assessed risk-of-bias using the Newcastle-Ottowa scale. All outcomes were meta-analyzed as risk ratios (RR) using the Mantel-Haenszel method. The certainty of the evidence was assessed using GRADE. RESULTS Six studies (n = 3381) were included. The "need for emergency care/admission to hospital" (RR = 0.79, 95% confidence interval [CI] 0.45-1.4), "hemorrhage requiring transfusion/≥500 mL blood loss" (RR = 0.62, 95% CI 0.11-3.55), patient satisfaction (RR = 0.99, 95% CI 0.95-1.03), pain (RR = 0.91, 95% CI 0.82-1.02), and "complete abortion without the need for surgical intervention" (RR = 1.03, 95% CI 1-1.05) did not differ statistically significantly between the ≤9+0 and >9+0 weeks' gestation groups. The rates of vomiting (RR = 0.8, 95% CI 0.69-0.93) and diarrhea (RR = 0.85, 95% CI 0.73-0.99) were statistically significantly lower in the ≤9+0 weeks group but these differences were not considered clinically important. We found no studies comparing pregnancies of 9+1 -10+0 weeks' gestation with pregnancies of >10+0 weeks' gestation. The certainty of this evidence was predominantly low and mainly compromised by low event rates and loss to follow up. CONCLUSIONS Women who are having a medical abortion and will be taking mifepristone up to and including 10+0 weeks' gestation should be offered the option of expulsion at home after they have taken the misoprostol. Further research needs to determine whether the gestational limit for home expulsion can be extended beyond 10+0 weeks.

Very few terminations take place in the final weeks of the second trimester: in 2016 less than 2% of all abortions undertaken in England and Wales were at over 20 weeks. The total number of abortions at all gestations was 185,596.

Young men experiencing abortion often have feelings of relief but can also suffer from emotional distress and feelings of powerlessness. It is important that they too have access to information and emotional support.

Very few terminations take place in the final weeks of the second trimester: in 2016 less than 2% of all abortions undertaken in England and Wales were at over 20 weeks. The total number of abortions at all gestations was 185,596.