Objective To compare outcomes before and after implementation of medical abortion (termination of pregnancy) without ultrasound via telemedicine.Design Cohort analysis.Setting The three main abortion providers.Population or sample Medical abortions at home at ≤69 days' gestation in two cohorts: traditional model (in-person with ultrasound, n = 22 158) from January to March 2020 versus telemedicine-hybrid model (either in person or via telemedicine without ultrasound, n = 29 984, of whom 18 435 had no-test telemedicine) between April and June 2020. Sample (n = 52 142) comprises 85% of all medical abortions provided nationally.Methods Data from electronic records and incident databases were used to compare outcomes between cohorts, adjusted for baseline differences.Main outcome measures Treatment success, serious adverse events, waiting times, gestation at treatment, acceptability.Results Mean waiting time from referral to treatment was 4.2 days shorter in the telemedicine-hybrid model and more abortions were provided at ≤6 weeks' gestation (40% versus 25%, P < 0.001). Treatment success (98.8% versus 98.2%, P > 0.999), serious adverse events (0.02% versus 0.04%, P = 0.557) and incidence of ectopic pregnancy (0.2% versus 0.2%, P = 0.796) were not different between models. In the telemedicine-hybrid model, 0.04% were estimated to be over 10 weeks' gestation at the time of the abortion; all were completed safely at home. Within the telemedicine-hybrid model, effectiveness was higher with telemedicine than in-person care (99.2% versus 98.1%, P < 0.001). Acceptability of telemedicine was high (96% satisfied) and 80% reported a future preference for telemedicine.Conclusions A telemedicine-hybrid model for medical abortion that includes no-test telemedicine and treatment without an ultrasound is effective, safe, acceptable and improves access to care.

Increased demand for self-managed medication abortion in states with in-clinic restrictions or high infection rates during the coronavirus disease 2019 (COVID-19) pandemic demonstrates the need for remote abortion care models.