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Rwanda expanded legal grounds for abortion in 2012, but limits provision to doctors in hospitals, resulting in unequal access. This study illustrates how technologies and infrastructure can bring first trimester medication abortion closer to more vulnerable populations within a restricted legal context.
A SAFE (safety, acceptability, feasibility, and effectiveness) study was implemented to assess a telemedicine model to enable primary care nurses to provide first-trimester medication abortion by teleconsulting with district hospital doctors. The doctors provided clinical guidance and authorized medication abortion remotely, while the nurses consulted with the client, provided medication, and conducted follow-up. The feasibility component of the study described the programmatic (service delivery protocol) and policy changes (level of provision) needed to comply with the restrictive laws while increasing access.
Primary care nurses (two per health center) were successfully trained in medication abortion provision using mifepristone-misoprostol combination and ultrasound. Teleconsultation between doctors and nurses created a channel for doctors to provide remote authorization and allowed clients to receive services in their communities. Between October 15, 2021 and May 15, 2022, 165 clients received medication abortion at the health centers. Protocol ensured high adherence rates; all clients completed treatment. Referrals to the hospital decreased as only those in the second trimester or < 15 years were referred.
We successfully brought medication abortion services to communities by maximizing available technologies and infrastructure. This research has applicability beyond Rwanda: It provides a concrete example of how to design a task-shifting model to reach vulnerable populations in a restricted legal environment.
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