Accessing abortion in a highly restrictive legal regime: characteristics of women and pregnant people in Malta self-managing their abortion through online telemedicine

To ex amine t he number s and c harac t e ri stic s o f w omen and pre gnant p eo ple in M a l ta se ekin g at -home m edica l abor tion u sing online tel emedic in e fr om 201 7 to 2021 . Des i gn: Popul a tion -ba s ed s t ud y. Setting : Re public of M alta Par ticipa nt s: Betwe en 1 Janu ary 2017 and 31 Decembe r 2021, 10 90 wo men and pr e gnant p eo ple reque s ted a t- home m edica l ab orti on thr ough one onli ne tel emed icine pr ovider ( Women o n We b) . Mifep ri st o n e and mi s opr os tol we re ship pe d to 658 women (6 0 .4% of r e qu e s t s ). Main Outcome Mea s ure s: The number s a nd demog r a phic s o f pe rson s t o whic h abortion p ill s we re shipp ed, t h e ir rea s on s f or t ermina tion o f pr e gnanc y, a nd re a son s fo r requ e sting m edica l abor tion betwe e n Janu a r y 2017 a nd Dec e mber 20 21 were ana lysed. S elec t e d da ta w er e comp ared ac r o s s diff er ent group s .

Th e number of pe rson s in Mal ta t o whom me dica l abor tion pi ll s were shi pped increa s ed signific antly dur i ng th e C OV ID -19 pand e mic. Wome n and p reg nant p eopl e requ e st i ng medi c al aborti on w ere div e rse w ith re s p ect t o ag e, pregna ncy circu m s tanc e s and re a son s for s e e king termina tion . M o re t ha n h alf w er e moth e rs and ov er 90% r ea ched out to W o men on Web a t < 7 we eks . Among tho s e c ompleting a med ic al aborti on, 63% did n ot u s e con trac ep t i o n (n=412 ), and in 30% (n=197) t h e r e wa s con t rac ep tion fai l ur e . The mo st c ommon rea son s for o r de rin g medic al aborti on pi ll s online wer e dif fic ul ty a cce ssing a bor t i on b ec au s e o f lega l r e st ric t i on s (73 %) a nd aborti on pi ll s not b eing ava ilable (45%) in the cou ntry. Conc lus ions: Despi te a c ompl ete b an on a bort i on , th e numbe r o f women a nd p re gna nt peopl e re siding i n Malt a c ompleting a t- home m ed ical abor tion s i s con side rable an d ha s i nc rea sed since t he CO VI D -19 p andemi c. Keyw ords me d ical abor tion, s elf -mana g e d abo r ti on, M a l ta, t elem e dicin e, termina tion o f p r e gnanc y. Summa r y Boxes What is already k nown Le gal re stric tion s do no t im pede w omen and pregnan t pe opl e f rom ac ce s sing ab o r tion car e but mak e them l iabl e to criminal pro s ec uti on . What this study adds Si nce a bortio n i s crimina li s e d in M al t a , t here a re no o f fi ci al sta tis tic s rela ted to a bor tio n . This i s t he fir s t s tudy lo oking at th e numbe r a n d cha r a cte ris t ic s of women and preg na nt pe o ple who a cce ss aborti on c are ou t side the formal h ealthc are system in thi s highl y re s t ric t i ve le gal reg ime. De spit e th e abor tion b an , wo men and pre gnant pe op le in Ma l ta a re inc re a singly acc es s in g telem e dicin e and sel f -mana ging t h e ir ab ortion s. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint

With a po pul ation of h al f a mi llion, Ma lta is th e small e st, sou the r n mo s t na t io n s t a te i n th e EU and it s aborti on l aws a re a mong t he mo st r e s tri c t iv e in t he world . T ermina tion o f p r eg na nc y (TOP) i s ille gal under a ll c ir c um st a nce s.¹ M edic al d oct or s , fe a r i ng pro secu tion, clai m to u se the d oc t rine o f doubl e ef fec t t o pr o tec t the li fe o f at -r i sk mothe r s such a s i n pre te r m pr e ma ture ruptu r e of membran e s. ² Never thel es s , the Crimina l Code c le arly stat e s tha t tha t an yone w ho in tent iona lly i nduces a misca r ri ag e i s liab le to up to thre e year s of impri sonmen t, wh ile an y he a lt h ca re p rof es s i o nal as s i s ti ng a wom an in proc uring an abo rti on risk s up t o fou r yea rs o f impri sonmen t a nd lo s s of t he ir lic ens e. ³ The option s ava ilab le fo r w omen a nd pr e gnan t peopl e l iving in Malta who ha ve a pregnanc y they do not w ant or o ne th at th ey fe el th ey ca nnot continu e with, h ave a lwa ys be en li mite d. Hi st o ric ally, wom en hav e eith er tr ave lled to c ount r i e s w her e ab ortion i s l egal or r em ain ed p r e g nant, but bac kstree t abo rt i on s w e re no t the no rm. ⁴ On av er age, be tween 2011 a nd 2019 , 56 Malte se re siden t s acc e ssed T OP s ervic e s in Eng la nd a nd Wale s .⁵ Trave l ha s nev e r be en a n ea sy option ; wom en woul d need t o t a ke t ime of f wor k, fin d chil dcare , f u nd the ab orti on, a ll w h ile k eeping th e rea son for t r a vel a secr et from mo st frie n ds a nd family. Whil e surmoun table for some, the se bar r i ers se rve a s a stark r emi nder o f t he di spari ty in acc es s to e ss enti al h eal th c are . Si nce the COVI D-19 p a ndemic , th e numb e r o f r e siden t s f rom Malt a tr ave lling t o the U K to acc e s s aborti on s ervic e s decl in ed dra s tical ly: 20 in 202 0 and o nly 4 in 2021 , eve n though trave lling in 2021 wa s n ot a s re st r i cted as p rev iou s l y. Mor e w omen reac h ed ou t to a ctivi s t and abo rtion suppo rt groups du ring t he M arch to M ay 2020 lock down pe r i od ¹, w hile th ere w a s a signifi c ant su rge in purcha s e s o f a bortion pill s f rom Women on Web ( W oW ) in variou s Europ ean cou ntrie s inc luding Malta . ⁶ This cha nge r efl ec t s po licy or pro t oc ol c hange s t o fac ili ta te acc e ss to tele me dici ne fo r se lf - mana ged a bortio n s i mplem ente d i n vari ous Eu r o pe an co un t ri e s. ⁷ While s uc h cha nges we re obv ious l y not p os s i ble in M a l ta, gra s sroo ts o rgani sat ion s s t e p ped in t o b r id ge th e g aps. In Augu st 2020 , thr e e pro -choic e o rga ni s a t i on s i n Malta l au nche d a v olunt ee r- r un helpli n e to fac ili ta te ac ce s s by pr ov iding informati on on r e p r oduc tive choic e s . Thi s Fam ily Pl anning Advi sory Serv ice ( F PAS ) as s i s t ed 4 79 indiv idual s in it s fi r st year al one.⁸ Si nce 2 006, the n on -p r ofi t orga niza t i o n WoW ha s provid ed online tel em edic ine t o w omen in co untr ie s w he re abo rtio n c are i s leg ally re strict ed. ⁹ I n 2008, a M alt es e new s pa p e r r e ported t h a t aborti on pi ll s were a l s o avai l able to women i n Malt a ¹⁰ an d women have had th e op t io n o f at -hom e medi cal abor t i on th r o ugh onli n e tel eme dicine s i nc e then . Be twee n 2013 and 20 1 7, 465 w omen liv ing in Malta c ontac ted W o W to pu rc ha s e ab orti on pil l s on line .¹¹ A l t ho ugh thi s o ption c o s t s much les s th an t ravel abr oad, w omen in Mal ta hav ing me dica l aborti on s at home d o so without th e rea s s ura nc e of h a ving doctor s t h e y c an co nfide in s ho uld any compli cation s a ris e whi le ex pos i ng them selve s to p ot entia l crimi n al li ability. WoW provid es a n initial onl ine c on sult ati on form whi ch is revi ewed by a medica l doc t or . If t h e ges tati on i s l e ss than 10 week s a nd t her e are no cont ra -indic ati on s, a pr e scripti on and pac kag e co nt a ining mif epri s t one and mi sop ro st ol is di s pa t c hed a gain s t a do na tion, w hich i s re duc ed or wa ived in ca s e s o f fin a ncia l hard sh ip. Wo men i n Malta u su all y rece ive t h e pack ag e within tw o we eks . A help d e s k team pr ovi de s r e al - ti me ins tr uc tio ns and foll ow up b y ema il. A 10 -year s tudy using da t a f r o m over 26 000 w omen wh o us e d the se rvice in c ountr i e s w ith hig hly re str ic tive leg is l a tion s worldwi de co n f i r m e d tha t s e l f-ma nage d medic al a bortion i s saf e and e ff ec tive. ¹ ² . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint The aim of thi s stu dy w as t o exami ne the numb er and c har acte ris tic s of wom en in Mal t a s e eking at - home medic al abo rtion throug h te lem ed ic ine from W oW, t he ma in onli n e medic a l a bort i o n provide r . Simil ar s tudi e s ha ve be e n cond u cted in Ire land, Nor the rn Ir eland, H un g ary, Ge rmany , and Italy in rec ent y ea r s . ¹³ ¯¹⁸ S mall e r a l tern a tive s ervic e s e.g. , W om en H elp Wome n, are al so av aila ble, such th at thi s c oh ort do e s not re pre sen t the e n tir e p opula tion ob taining medic al ab or ti on pill s o n l in e .

We re trieve d all requ e s t s to W o W for m ed ical abor tion from wome n in Mal t a wh o c ompleted a n onli ne con sult ation b etwe en J a n uary 20 17 and D e cemb er 2 021. T his d at e range was ch o s en bec au se th e c on s ul ta t i on form s th at ha d been devel oped ov e r t i me had b ecome c ons tan t s u ch that alm ost c omplet e da ta were a vail a ble. T h e co ns ul ta tion f or m inclu de s in for m a tion about demog r a phic s, me dical a nd preg nancy hi st or y, and h e alth sta tu s. W ome n al so sel ec t t he ci r c umsta nce s of thei r pregn ancy, t he re ason s for n eeding an ab or ti on and th eir r ea son s to o rder medi cal abor t i on pill s onl in e. All the que st i on s ha ve p r e de fined an swe rs and wo men can c hoos e a s m a n y r e s pons es as t he y w i s h . As n at i o nal it y i s n ot i n cl u d e d , we ca n n ot d is t i n g u is h b e t w ee n cit iz e ns and non-ci tizen s , altho ug h it is e st i ma ted that 20% of the popu l ation are no n -Ma lt ese citize ns .¹ ⁹ De -iden tifi ed da ta w ere provided by Wo W and analy s ed u s in g Micro so f t SPSS . W omen ha d co ns e nte d t o ano nym is ed u se of their d a ta fo r re s earch pur p o se s. Th e Fac ul ty for S ocial Wellbei n g Res earch E thics Commit tee , U niv er s ity o f Malta r ev iewed t h i s study. We ana lysed the nu mbe r of wome n to whom medic ation wa s shippe d b etwe e n 2 017 a nd 2021 . For all five year s combi ne d, w e exa mined th e age distribu tion , n umber o f chi ldre n, we eks of ge st atio n, ci r c umsta nce s of p regna ncy, r ea son s f or TOP a nd r ea son s f or a cce ssing te l emedic ine. We compa red data be fo r e and d u r in g CO VI D f or w ome n grea te r or l e ss t han 2 0 yea rs and t h o s e w ith or wi t hou t ch ildren. The Chi squar e te s t wa s us ed to inv est ig a te the a s socia t i on be twee n ca t eg orical variab l e s . Fi ndings we re con sider ed sta ti s tic ally s i g nifica nt at a p valu e of < 0 .0 5. Mo st w omen di d not co mplete the foll ow-u p ev alua t io n, whic h wa s th ere for e no t includ e d in th e a nalys i s. Patient and public i n volveme nt s tatement Although thi s a nalysi s did n ot i nvolv e pat ient s in i ts de sign, man ag emen t or re por t i ng, the r e sea rch que stion s wer e i nfo r me d by th e experie n ces o f wom en and pre gnan t peop l e in Ma lta who rel y on WoW to acc es s a bortio n. Som e pr e limin ary r e s ult s we re publi shed in a M alt e se n ew s pa p er ²⁰ and pre sen ted in a n ac a demic con fe r e nc e. ²¹ F eedba ck from p ublic and ac ad emi c pee rs wa s c onsi der ed.

The number o f w omen liv ing i n Malta se ek ing med ical abor tion th rough WoW inc r e a s e d stea dily from 78 i n 2017 t o 509 in 2021, a more t han six fol d inc r e a se. B etwe en J a nu ary 20 17 and D e cemb er 2021 , 1090 women contac t e d WoW to requ e s t me d ical abor tion and me dic atio n wa s shippe d to 658 wom en (60.4% of r eque s t s ) . Th e remain de r were c anc e lled e i t h e r beca u se the y c ho se to con tinue the pr egn ancy, exp erie nce d a mi sca r ri a ge, or dec id ed on tra vel to termin a te their pregna ncy abroad . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint Figu r e 1 show s th e number of a b or ti on p ack ages shipp ed per ye ar. T he re wa s a 3 3% de crea se in t h e number o f shipm ent s be twee n 2017 and 201 8, but a 4 5% inc rea se be twe en 2018 and 201 9, a 1 08% increa s e b etwee n 2 019 and 2020, and a 6 5% inc reas e betw e en 2020 and 20 21. T he s h a r pe s t increa s e w a s ob se r v ed in 2020, c orr e sp o nding to the o ns et o f th e COV ID - 1 9 pand e mic. Shipmen ts increa s ed by 47% betwe e n March a n d Ju ne 20 19 and t he s a me mon th s o f 2020 ( 2 7 and 51 , re sp e c t i v e l y ) . Table 1 show s th e c harac teri s t i cs of wom en and preg n ant pe ople to whom a bort i o n medic ation w a s s hi pp ed be twe en 2017 and 20 21. I t fu rt her dif fe ren tiat e s be twee n be fo re and d ur i ng the CO VI D- 19 pandemi c. T he mea n ag e was 29.3 ye ar s , but th e c ohort includ e d wome n f r om all reproduc tive a ge groups. Ju st ov er hal f (53.7 % ) we r e b etw een 25 and 34 yea rs old, n early a qua rt er (22%) w ere women 35 ye ars a n d over, a nd anoth er q ua r t er (24 .3 %) we r e und er 25. T he majo rity (52%) w ere mother s w ith a me an number o f 1 .72 c hi ldren w hile a lmo s t a quar ter (24%) ha d t wo or more chil dr e n. 92% made t he r e que s t a t a ge st ational ag e of l ess than sev en we e ks . W h en de scribi ng the ci r c um s ta n ce s of th eir pregna ncy, most w omen w ere ei the r not u sing contrac e ption (63% ) or had ex perienc e d failur e of con trac ep t i o n (30%) . T he mos t common r ea s on s cited for th e t e rmina tio n of pr egna ncy were no t be ing a bl e to hav e a c hild a t t h i s po int in th eir li fe (69%) a nd hav ing no money to r ai se a chi l d (34%). The mo st co mmon re a son s f or ac ce ssing telem edic ine wer e leg al re s tr ic ti on s (73 %) an d unav ailabi li ty of med ical ab orti on pill s (46% ) . There w er e som e signi fic an t dif fe rence s i n the cha r a c ter istic s of women acc e ssing abortio n thro ugh telem edi cine in th e peri od be fore compa r e d with during COVI D- 19 . Signifi can tly more wome n with thr e e or mor e chi ldren ac ce s se d abor tio n during t h e COVI D- 19 p eriod (n=33 ) c ompared to b ef or e the pand e mic (n= 7 ) ( p < 0.0 01) . Wome n w ere al so mor e li kely to purcha s e a borti on pills e arlie r i n the pr egnan cy d ur i ng the pa ndemic ( p < 0.0 01) . Dur i ng COV ID- 19 mor e wome n re s pon d ed ‘My partn er doe s n ot want a chi ld ’ a s a rea s o n for t ermina ting the p regna ncy ( n = 38 c ompared to n =0 ). ( p < 0. 001 ) Table 1 Characteristics of women and pregnant people living in Malta to whom abortion packages were shipped through . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint WoW, 201 7 – 202 1 ( n=658) Re po r ted Chara cte r istic Tot al ( n =6 58 ) % Pr e - CO V I D ¹ (n=240) % COV ID ² (n=418) % Age (y e a rs) Und e r 2 0 5 7 5 20 - 2 4 19 20 18 25 - 2 9 30 29 30 30 - 3 4 24 23 24 35 - 3 9 15 15 15 40 - 4 4 6 6 7 45 a n d over 2 1 1 Numbe r of chi ldre n 0 48 49 47 1 22 24 22 2 17 20 15 3 5 3 6⁴ 4 or m ore 2 0 2 No data ³ 7 4 8 W e eks of g e sta tio n Fe we r tha n 7 weeks 92 87 95 Betwe en 7 an d 10 wee k s 8 13 5⁴ Ci r c u m stances o f pr e g n a n cy I di d no t u s e contra ceptives 63 63 63 I w a nted a pre gnancy first, but sit u a ti o n c ha n g ed 3 1 4 I w as raped 2 2 1 The con trace p tive s I used did not work 30 33 28 Re a so ns fo r t erminating pregnancy ⁵ I j ust ca n n o t ha ve a c hi ld at t h i s point i n m y life 69 72 67 I hav e n o m o n e y to ra i se a ch i l d 34 36 32 I a m t oo yo ung 17 17 16 My f a mily i s c om plete 14 16 14 I w a nt t o f i ni s h sch o o l 14 17 11 I a m t oo o l d 5 6 5 My p a rt n e r does n o t wa nt a chi l d 5 0 9⁴ I a m i ll 1 1 1 No data 7 1 10 Top Reason s for A c cess in g t e le m e di c i n e⁶ It is hard for me to a cce ss abo rti o n beca u s e o f leg a l re strictions 73 80 70 I pref e r to ac ces s a b ort ion t hro u g h WOW beca u s e ab o rti o n pil ls a re n o t av aila b l e i n m y co untry 46 44 47 I pref e r to ac ces s a b ort ion t hro u g h WOW beca u s e I w oul d r at h er keep m y ab o rti o n pri v ate 31 33 30 I p r e fe r t o a c c e s s a bo r t i o n t hr o ug h W O W b e c a us e I w o u l d b e m or e c om f or t a bl e a t h om e 25 27 24 It is hard for me to a cce ss abo rti o n beca u se o f c ost 21 22 20 It is hard for me to a cce ss abo rti o n beca u s e o f d ist a n c e 20 19 21 I pref e r to ac ces s a b ort ion t hro u g h WOW beca u s e I w oul d r at h er take car e my ow n ab ortio n 20 20 20 It is hard for me to a cce ss abo rti o n beca u s e I nee d t o k eep my a borti on a secr e t 19 24 17 I pref e r to ac ces s a b ort ion t hro u g h WOW beca u s e I w oul d r at h er ha ve some o ne w it h m e 19 20 19 B e c a us e of C or o na V i r us ⁷ 19 0 26 ⁴ It is hard for me to a cce ss abo rt io n beca u s e o f w o rk o r scho o l com mitme nts 11 11 11 ¹Ja nu a ry 2 0 17 – M a rc h 2 0 2 0 ²A pril 2020 – Dece m ber 202 1 ³An sw ere d YE S to hav ing c hil dren b ut m i s si ng dat a o n nu m b e r of chil d re n ⁴P < 0 . 001 ⁵Cou l d c hoose more tha n one rea son ⁶ A v a il a b l e f r om 2 0 1 8 o nw a r d s ( n=580) ⁷From March 2 0 20 o nwards (n=418) . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint Tab le 2 c ompare s th e c ir c ums t a nce s o f p regn ancy and re as on s fo r te r m inati on s el ec ted by women wi t h and w it h out chil d r en . H a ving chil dr e n se em s t o in fluenc e the rea son s for s e e king a n aborti on since mo ther s w er e s i gnific an tly mo r e lik el y to s elec t ‘ I am too ol d’ and ‘My famil y is com plet e’ th an wom en withou t c hildr en. Tho se wit hout c hildren w ere mo re li kely to wan t to fini sh sch ool o r se lect ‘I ha ve no money t o r a i s e a c hild’ a s a r e a s on . Women wh o wer e mo t h e rs we r e al s o les s l ikely to b e using c ont r a cep tion t h a n tho se withou t c hildren (70 % c ompar ed to 60% ) a nd w omen w ithout ch ildren we r e mo re lik ely to e xpe rienc e c ontr a c eptio n fa ilu re th an tho s e w ho wer e mot h e r s (36% co mpared t o 25% ). Ta b le 2 C om pariso n of se lect e d chara cte ri st i cs of pe rso ns wit h a nd w it h o u t c h i l d re n t o wh om ab o rt ion p a cka ge s we r e s h i p pe d through W o W , 20 1 7 – 2 0 21 Ch i l d r e n S e le c t ed C h ar a ct e r i s ti c Ye s (n=344) No (n=314) Ci r c u m stances o f pr e g n a n cy ( p = 0.0 36) I di d no t u s e contra ceptives 7 0 (241) 6 0 (1 88 ) I w a nted a pre gnancy first, but sit u a ti o n c ha n g ed 3 (1 1 ) 2 (6 ) I w as raped 2 (6 ) 2 (6 ) The con trace p tive s I used did not work 25 ( 86 ) 3 6 (1 13 ) Re a so ns fo r t erminating pregnancy (p < 0. 001) I j ust ca n n o t ha ve a c hi ld at t h i s point i n m y life 6 0 (206) 7 2 (2 26 ) I hav e n o m o n e y to ra i se a ch i l d 29 ( 98 ) 3 6 (1 12 ) My f a mily i s c om plete 27 ( 93 ) 3 (8 ) I w a nt t o f i ni s h sch o o l 5 (1 6 ) 2 0 (62) I a m t oo o l d 9 (3 2 ) 2 (5 ) My p a rt n e r does n o t wa nt a chi l d 5 (1 7 ) 5 ( 16) Al l d a ta are given as a percentage (n ) The r e a s o n s t hat younge r per so ns gav e f or acc e ss i ng abor tion al s o di f f e r e d from the older c oh or t (Tab le 3) . Wome n young e r t h an 20 w er e signific an tly mor e like ly to s tat e tha t th e y w anted to fi n ish school (21% v ers u s 11% ), tha t they ha ve no money t o r a i se a ch ild (59% vers us 3 2 %) and were l e ss lik ely t o stat e tha t th ei r f a mily w as comp l ete (3% v ers u s 15% ) ( p < 0. 001 ) . Te enag e rs more freq uen tly s el ecte d the n eed t o k eep ab or tion a s ecre t, th e c ost, a nd school and work commitme nts and fewe r rep ort ed hav ing a par tner o r f r i end wi t h t h e m during th e pr oc e s s ( p = 0.041). Te ena ger s and adult s did no t dif fe r signi f i can tly in t erms o f ge st atio n whe n requ e sting ab o r t ion p ills . Ta b le 3 C om pariso n of se lect e d chara cte ri st i cs of pe rso ns o v er and u n der 2 0 t o wh o m ab o rti on p a c ka g es wer e shipped through W o W , 20 1 7 – 2 0 21 . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint Age Re po r ted Chara cte r istic 20 (n=619) W e eks of g e sta tio n (p = 0.203) Fe we r tha n 7 weeks 97 ( 38 ) 9 2 (5 68 ) Betwe en 7 an d 10 wee k s 3 (1 ) 8 ( 51) Re a so ns fo r t erminating pregnancy (p < 0. 001) I j ust ca n n o t ha ve a c hi ld at t h i s point i n m y life 69 ( 27 ) 69(427) I hav e n o m o n e y to ra i se a ch i l d 59 ( 23 ) 3 2 (1 98 ) My f a mily i s c om plete 3 (1 ) 1 5 (93) I w a nt t o f i ni s h sch o o l 21 ( 54 ) 1 1 (68) I a m t oo o l d 0 (0 ) 6 ( 37) My p a rt n e r does n o t wa nt a chi l d 5 (2 ) 5 ( 31) Top Reason s for A c cess in g t e le m e di c i n e ( p = 0 . 04 1 ) It is hard for m e to a cce ss abo rti o n beca u se o f leg a l re strictions 72 ( 28 ) 6 4 (3 96 ) It is hard for me to a cce ss abo rti o n beca u s e o f c ost 33 ( 13 ) 1 8 (1 11 ) It is hard for me to a cce ss abo rti o n beca u s e o f d ist a n c e 39 ( 15 ) 99 ( 9 ) I pref e r to ac ces s a b ort ion t hro u g h WOW beca u s e I w oul d ra t h er take car e my ow n ab ortio n 23 ( 9 ) 1 7 (1 05 ) It is hard for me to a cce ss abo rti o n beca u s e I nee d t o k eep my a borti on a secr e t 33 ( 13 ) 1 6 (99) I pref e r to ac ces s a b ort ion t hro u g h WOW beca u s e I w oul d r at h er ha ve some o ne w it h m e 15 ( 6 ) 1 7 (1 05 ) B e c a us e of C or o na V i r us * 13 ( 5 ) 1 6 (99) It is hard for me to a cce ss abo rti o n beca u s e o f w o rk o r scho o l com mitme nts 23 ( 9 ) 8 ( 50) Al l d a ta are given as a percentage (n ) Dis c us sion The mos t c ommon r ea son s ci ted by w omen an d pregn ant pe ople in Mal ta for ac c es s i ng abo rtio n through t ele medic in e we r e l ega l re stric t i on s a n d the la ck o f avai labili ty of abo rtio n pil ls , f u rther ev idenc e th at leg al r e st ric t i on s d o no t st op a borti on s tak ing p lace . Esp eci ally s in c e the C OVI D-19 pand emic, abo rtion ca r e by w omen in Ma lta ha s shi fte d fr om tr a vell ing ab r oa d t o countrie s whe re aborti on i s l e gal to sel f -man aging medic a l ab or tio n af t e r pu r c ha sing a bor t io n pill s onli ne. The signific ant and inc rea sing deman d f o r s el f-ma na ged a bo r tio n s i s c ongru ent wi t h d evel opmen ts in other region s w her e abor tion c ar e i s re s t ric t e d . A lite rat ure an a lysi s o f s tudi e s in Latin A me r i can co untr ie s found t ha t women valu e the p r ivac y tha t m edica l abor tion a ll ows a s we l l as th e po s sibility of ha ving s om eon e with them duri ng the proc e s s . T hey pe r c eive it a s le s s p ain ful, sa fe r, more prac t i cal, l e s s ex pen sive, and mor e na tu ra l than o ther a bo rtion meth od s . ²² The implic ation o f the inc rea sing deman d f o r a t -h om e medic al a b or ti on is t ha t more wome n in Malta a r e now br e a king the law to ac ce s s a bo rt i on , inc r e a s i ng t heir n ee d for s ec re cy due to pot enti al crimi nal pro secu tion. In a G ua r di an int er vie w ²³, one woman de s c ribed he r f ea r w hen a loca l poli t ic ian t h rea t e n ed to p ro s e cu te w ome n wh o had sough t a bor t io n car e in oth er coun t rie s . Whil e this fe ar wa s un f o u nded , sinc e women who se ek abor tion c ar e out s i d e Mal te se ju risdic tion cann o t be p r o sec u t e d on their retu rn, t his i s no t t h e ca s e for w omen w ho mana ge thei r o w n abortion s wi t hi n the c oun t ry. A s i ndica t e d in the L a tin Americ a n s tudy , th e d isad vantag e of medic al a bor t i on i s the po s sible n e ed to se ek me dica l ca r e where t hey may be repo rt ed to t he pol ice f o r h aving an aborti on. In an oth er a bo r tion story ² ⁴, t h e w oman rec oun ted exp e r i encin g prolo n ge d bleed ing, pa i n, and disorie n t a t i on and h e r r e luc tanc e to se ek m edica l ca r e du e to the ri sk o f pr o s ec ut i on . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint In a contex t whe re a bo rt io n is no t lega lly a vail able thr ough fo r ma l heal t hc ar e s erv ic es , women who se ek a bor t i on ca re t hr oug h tel emedi cine are div erse i n ter m s o f a ge an d circ um s t anc e s. At 29 .3, t h e medi an ag e i s very s imi la r to th at found i n s tud ie s in count rie s s uc h a s It aly , Hungary, and Ir ela nd whe r e th e mean age wa s 30. Teen a ger s c ons t i t u te 5 % of w omen r ec eiving abor ti on pil ls , whic h i s similar to Ir ela nd (4.6% ), high e r th a n Hu ngary (2. 9%) but l e s s than I taly (7 .8% cal culated a t 18 or you nger). A lthough M alta h as the l owe s t fe r til i t y rat e in the EU, i t ha s a hi gher - t h a n-ave rag e teen a ge bir th rat e (11 .9 birth s p e r 1 000 gi r ls a ged 15 to 19 in 2 019, c ompared t o the EU averag e of 8.9). Thi s high ra te i s p artly due to the to tal ban on ab orti on, c on s id e r i ng tha t te e na ger s fa c e mo r e barrie r s t o acc e ss a bo r tio n servi ce s²⁵. Ind eed, t he fi ndings from t hi s study highli ght how t e en age rs are mo re vulnerab l e sinc e t h e y oft en f ac e ec onomic and soc ial di ffic ul tie s and lac k the sup por t of a famil y membe r or p art n e r. Simila r f i ndin gs we r e rep orted in studi e s o f Ita lian and German w omen se ekin g abor tion th rough W o W ¹⁶ ¹ ⁷. Cont rary to the p rev ailin g s t e reo type tha t mos t women who te rmina te t h ei r preg nanc ie s are young and pr om i s c uou s, mo s t w omen se ek ing a bor ti on t h roug h tel emed icine in M alta were in t h e ir lat e twenti e s o r ea r l y thirti e s and al re ady mo ther s, a nd t he ir main re a son f or te rminat ion is t h a t th ey feel t he i r family i s comple te or th ey c ann ot co pe wi t h an oth er chi ld. N otably, amo ng this g r oup , the lac k of use of con trac e pt i on rat her than c ont rac e ption fa ilu re wa s the main rea so n w hy w omen bec ame p r eg n ant . In a rec ent st udy, the r a t e o f unin tend ed pregn anc ie s wa s repo rted a t 2 3%, mai nly due to not u sing c on tr a cep tion a t all (20 %) or due to rel ying on le s s r el iabl e m ethod s suc h a s wi t hd r a wal, na tur a l famil y pla nning, o r c ondoms .² ⁶ Mal ta la ck s a f a mily plannin g polic y or publ ic famil y pla nning c linic s an d mos t cont rac e ption i s av ailabl e up on pa yment from pri va te heal t h se rvice s.² ⁵ The increa s e i n women with more c hildren a cc essi ng aborti on during C OVI D-19 mi ght b e indi cative o f the fina ncia l a nd c are -giv ing ha r ds hip s tha t wom en wi t h large r famil i es faced du r i ng the pand emic. The fea r a nd unc er t a in ty tha t the pa nd emic brought wi t h i t might ha ve le d to more partn er s pr e ssu r i ng w omen to t ermina te thei r pre gnanc y. In c oncl us i on , s i nce 2 018, th e prac tice of aborti on c are amo ng women and preg na nt peopl e in Malt a has ste adily s hi fted t o acc e s s ing at -home med ical aborti on thr ough tel e medic ine , ex ace r ba t e d by travel re stric tion s during t h e C O V ID -19 p a ndemic and by the lo cal p r ov isi on of vo l untary service s such a s F P AS provi ding in forma tio n and s upport . Although a t-h ome medi cal TOP i s medica lly saf e, women and p regna n t peopl e in Malta who ac ce s s WoW s e r v ice s ri sk c r imi nal pr os ecuti on, dr a wing att entio n to th e urge n t ne ed to dec riminal i s e aborti on to m ake i t saf er a nd t o addr e ss the ineq uitie s in acc e ssing re pr o duc tive health se rvic e s, a s recom mended by th e WH O . ² ⁷ This study fu rth er highl ight s t h e ne ed fo r be t t er f amil y pla nning s ervic e s to r educ e barr i ers to ac ce s s esp ec ially among women with c hildren , a nd the pr omotio n of m ore r e li able me t hods o f co nt rac e ption . It further ind ic ate s that t eena ge r s s eek ing s elf -man a ged a bo r tion might be in a mo r e vul nerable si tuati on si nc e th ey are mor e lik ely t o lac k suppo rt. Ack nowledge ment s T h e a u t h or s t h an k Pr of L ib e r at o C a m i lle r i, U n i v e rs i t y o f Ma lt a f o r a s s ist an c e w i t h st at i s t i ca l d a ta . Contributors AD and I S de signe d th e s tudy. R G s u pplie d the da ta. JK pe rformed the s t ati stic al a nalys i s. A D and IS wrote th e initi al ma nu s c ript , inte rpre ted the da ta , and rev ised s ub sequ e nt d r a ft s. All rea d an d . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint approv ed th e fin a l dra ft o f th e manu s c r i pt fo r submi s s i on and a cc ept r e s pon sibil i t y for th e pap e r a s publi s h ed . I S is the g uar anto r. Competing Int e r est s All a utho rs hav e c omplet ed th e I CMJ E un iform di sclo sur e fo rm at ht tp: // w ww.ic m je.org/di sclo su re - of -int ere s t / an d decl are tha t A D is a me mbe r of t he Wom en’ s Right s Foun da t i o n , Malta ; RG i s th e found er o f Wome n on Web ( WoW ) and I S is s ec re tary t o Doc tor s f or C h oice Mal t a; no s uppor t f rom any organis ation for the submit ted w ork ; no fin ancia l r ela tion ship s wi t h any orga n isa tion s t h a t might hav e an inte r e s t in t he s ubm itted work i n t h e pr eviou s thre e year s; no oth er re la tion ship s or ac tivitie s th at c ould ap pe ar to have in flu enc ed th e su bmitt ed w ork; Copyrig ht / Lic ens e for P ublication The Corre spondin g Au tho r ha s the right t o grant o n beh alf o f all a u t h o r s a nd doe s grant on be h alf o f all autho rs, a worldw ide l icenc e to th e P u blish ers an d it s l ice ns ee s in pe rpe tuity, i n a ll form s, forma t s and media ( w he the r know n now or crea t ed i n the futu re ), to i ) publ i s h, rep r odu c e , di stribu te, di splay and stor e the Con tribu tion, ii ) tran s l at e t he Con tribu tion in to ot h e r langua ge s , cr eat e adap tati on s, reprin t s , inclu de withi n coll ection s a nd cr eat e summa rie s, ex trac t s a nd / or , a b s t rac ts o f th e Cont ributi on, i ii) cr ea te any o t h e r d e r i vat ive work(s ) ba sed on the Cont r ib ut i o n, iv) to exploi t a ll sub s i dia ry right s in the Con tr ibu t io n, v) t he i nclusi on o f elec tronic link s from t he C ontributi on to third par ty ma t e r i al wh ere -e ver it ma y b e l ocate d; and, v i) lic e nce any third p a r ty t o do any or all o f the a bove . Ethic s Approval The Fac ulty fo r Soc ial W e llb eing Re se arc h E t hi cs C ommitt ee, Univ e rsity o f M a lt a r evie wed thi s st u dy. Transpa rency Statement Is abel St abile , t h e manu scri pt's gua r a nto r a ffi r m s tha t th e ma nu s c ript i s an hon e s t, ac cura te, a n d tran s p a r e n t acc ount o f th e study be ing r eport ed; that n o importa nt a sp ect s o f th e s t udy hav e been omitted ; a nd t hat any di scre panc ie s fr o m t h e study a s origina lly p lann ed (a n d, if rele van t, regi st er ed) hav e bee n expl ain ed. Fundi ng No fundi ng was rec e ived by any autho r f or thi s s tudy. Data Sha r ing The autho rs c on firm t hat they are wil ling to sh are a ll a no nymis ed dat a on whi ch t he a naly sis , re sul ts, and conc lusi on s rep o r t ed i n the p ape r a re bas ed. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint

s 1. C a r ua n a - F i n k el L . A b or t i on i n t h e t i m e o f C O V ID - 1 9: pe r s pe ct iv es fr om M a lt a . S e x R ep r o d Health M at ter s [In t e rne t] . 2 020;28(1 ):17 80679. A v aila ble from: http: //dx. doi. org/10 .1080/2641 0397.20 2 0.17806 79 2. Cili a R. A bor tion s ca r ri ed out in ce r t ai n circ ums t anc e s in Mal ta. The Malta Independent . 201 8 Dec 16. Ava ilabl e f r om: ht t p s: //doi. o r g / 1 0. 1080/264103 97.2020. 1780679 . 3. Crimina l Code 1 854. (Mal ta) Articl e s 2 41( 1), 241 (2) , 242, 243. 4. Mif sud M, Bu ttigi eg GG, S avona -Ve ntu r a C, D elic at a S. Rep roductiv e h eal th in Mal ta. Eur J Cont race p t Rep rod Heal th C a r e [ I n t e r ne t]. 2 009;14 (4) :249 –57. Av ail abl e from: http: //dx. doi. org/10 .1080/1362 5180903 072047 5. Offi ce f or he a lth improve m ent an d di s p a ritie s . Abor tion st ati s tic s for En gland and Wale s. 2010 – 202 0 [Int ern et ] . 2022. A v ail a ble fr om: http s:/ /www .gov.u k/ h ea lth -and - soci a l- ca r e /ab ortion . 6. Aike n ARA , Sta rling JE, Gomp ert s R , Scott JG, Aike n CE. Dema nd for s el f-ma naged online telem e dicin e abo rtio n in eight Eu r op e an co unt rie s du ring the CO VI D-19 pandemi c : a regre s s io n di scon tinuity an alys i s . BMJ S e x Reprod Hea l th [ Int er n e t]. 2021;47 (4 ) :2 38–45. Ava ilable fr om: h t tp :/ /dx.doi. o r g / 10 .1 13 6/bmjs rh -202 0 -200880 7. Bojov ic N, S t a ni s l jevic J, Giu nti G . The im pac t of COVI D -19 on abor tion ac ce ss: In si ghts f rom the Eu r op e an Unio n a nd th e Unit ed King dom. Heal th Policy [ Int ern et ]. 2021;1 25 ( 7):841–58 . Ava ilable fr om: h t tp :/ /dx.doi. o r g / 10 .1 01 6/j.heal thpol .2021.05 .005 8. Pie rso n C, Ca r u a na F inkel L. Abo rtio n c ar e in h ighly r e strictiv e l ega l regim e s : the e xperie nce s of hea l th and soc ial c a re pro f essi ona l s i n Malta . University of Liverpool 2021.L iver pool. ac .uk . [ci t e d 2022 Oct 1 3] . Avail abl e fr om: http s : / /livrepo si tory.liv e r p ool .ac .uk /312831 0/ 1/M alta Brie fing P aper May 2021FIN AL. pdf 9. Women on We b. Wh o we are . ht tp s : //w ww .womeno nweb.org /en /page / 521 / w ho-we -ar e 10. Gr e ch H. Abor tion for Mal te s e just a c lic k aw ay. T imes o f Malt a [In t e r ne t ] . 2008; Ava ilabl e from: h ttp s:/ / time sofmal t a .c om/ar ticle s/ view / a bortion -f or -malt es e -jus t-a -clic k - aw ay.21 6560 11. Dimitrijev ic L , Dibbe n A. Wome n’ s Right s Foundation . Wom en’ s sex ual and r epro ductiv e hea lth a nd righ ts: Po siti on Pa p er [In t e r n e t]. 2018. Av aila bl e f rom: http s : / /www .wrf.o rg.mt / po st / w omen - s-sex ual -and -r eprod uc t i ve -hea l t h -a nd -r i gh ts-mal t a . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint 12. Nortén H , Il ozumba O, Wilki nson J, G em zell -Dan i els son K , G o mpe rts R. 1 0 -yea r ev aluation of the u se o f me dica l ab orti on thr ough tel e medic ine: a re t r o spectiv e co h or t s tudy. B JOG [In ter net ] . 2022;1 29(1 ):151–9 . Avail able from: h ttp :/ / dx .doi .org/10 .111 1/ 1 471 -05 28.1 6765 13. Aike n ARA , Gompe rts R, T r u s s ell J. E xperi enc e s and c har acte ris tic s of wo men se ek ing and co mpleting at - ho m e medic al te rmina ti on of pregna ncy t hroug h onlin e tel emedi ci ne in Irelan d and No rth ern I reland : a popul a t i o n-ba se d anal ys i s . B JO G [ Inte r ne t]. 2017 ;124(8) :1208 –15. Av ail abl e f rom: h t t p: //dx.doi .or g / 10 .1111 /1471-05 28.1440 1 14. Aike n ARA , Pad ron E , Bro uss ard K, Joh ns on D. T he impa c t of Nor t hern Irel and’ s a bortion law s on wome n’ s ab ort i on dec i s io n - m aki ng and ex perienc e s. BMJ S ex Reprod H ea lth [In ter net ] . 2018;4 5(1 ):3–9 . Av ailab l e fr o m: http: //dx.do i. org/ 1 0 .1136/bmj sr h -2 0 18-20019 8 15. Bra s S, Gomp er ts R , Kell y M, Aik en AR A, Conlon C. Acc e ssing abo rtio n out sid e jurisdicti on follow ing l egali s a tion o f abor tion in the R epublic of I rela nd. BM J Sex Repr od Heal t h [In ter net ] . 2021; 47(3 ):200–4 . Availa ble fr om: http :/ / dx .doi .org /10.1136 / bmj srh -2 020- 2008 49 16. Brandel l K, Vanb e n s c hot en H, P arac hini M, G omp e r t s R, Gemzell - Dani el ss on K. T elemedi cin e as an al te rnative way t o acc es s a bortion i n Italy and c har ac t e ri stic s of requ es t s d u r in g the CO VI D -19 p andemi c. B MJ S ex Rep r od H e a lth [ Int ern et ] . 2021;bmj s rh -2021-20 128 1. Av ailabl e from: h ttp ://dx.d oi .org/10 .1136/bmj srh -2 021-20128 1 17. Kill inger K, G ünth er S , Gomper ts R, A tay H, Endle r M. W hy wome n choos e a bo r tio n thr oug h telem e dicin e ou tsid e th e fo rmal h eal th s ector in Germany: a mi xed -met hod s st ud y . BMJ Se x Reprod H ea lt h [In t e r ne t ] . 2022;48( e1 ):e 6 –12. A v aila bl e fr om: http: //dx. doi. org/10 .1136/bmj srh -2020- 2007 89 18. Le s K , Gomp erts R , Gemz ell- Dani e l sson K . Experien ce s o f wom en liv ing in H un gary se ek ing a medi cal abor t i on onlin e . Eur J Con trace p t Repro d Heal th Ca re [ I n t e r n et ]. 2 017;22 (5):36 0 –2. Ava ilable fr om: h t tp :/ /dx.doi. o r g / 10 .1 08 0/1362518 7.2017.1 397112 19. Euros t a t . For eign born pop ula t i on 2021 [ Inte rne t] . Av ailabl e fr om: http s : / /ec. europ a .e u/e ur o s tat / d a tabr owse r/ vi ew/ tp s 001 78/d e fault / t ab le ?la ng= e n 20. Cal leja L . Demand for ab ort i on pill s doub l es du r i ng pand emic. Ma lta Tod a y [In te r net ]. 2022 ; Ava ilable fr om: http s : / /www .maltat oday.com.m t/n ews / national /1167 71/d emand _f or_ ab ortion_ pills_ doubl es _during _ pand emic _#.Y zGJgHZBxPY . 21. Dibben A, Stabi le I, Gompe rt s R. Char act eri stic s o f wom en com pleting a t -h om e m edic al aborti on thr ough online tel em edic ine in t h e Rep ubli c of M al t a : 2017-20 21 FI APA C Con fer enc e, Rig a , L atvia, 9-11 S e pte mbe r. 2022. . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint 22. Za mberlin N, Rom ero M, Ra mo s S. L atin Americ an wom en’ s expe rie nc es with m e dica l aborti on i n se tting s w he re ab orti on i s l e gally restric te d. R epro d Heal th [ Int erne t ]. 2012 ;9(1) :34. Ava ilabl e f r o m: ht t p: // dx.d oi. or g / 10. 1186/1742 -475 5 -9-34 23. Cook e R . Women a r e t r ea t e d lik e wa lkin g incuba tors: M alta ’s fig ht for a b or ti on . T he Guardi an [In terne t ]. 2 022 Jun 19 ; Availa b le from : http s : / /www .t h eguar dia n.com /world /20 22/jun/19/ t h e - fight - for-ab o r tion -in -ma l t a . 24. Risk your lif e or go to pri s on: The s tr ic t e st a bortion law s in Europe [In te rne t] . ENT R; 202 2. Ava ilable fr om: ht t ps :/ / w ww . yo u t u b e. c om / w at ch ? v= r F_ 2 a qB qw 4 c 25. Dibben A. Rep roductiv e p olitic s : P olicy re s p on se s to t eena g e pregn ancy and mo th erhood . In: Brown M, Br i guglio M, edito r s . Soci al w el far e is s u e s in south ern E ur o p e. Lo ndon , Eng land: Routledg e; 2022 . p. 160 - 1 78. 26. Fe nech C ont i F. F amily planni ng and cont race pti on prac tic e s of M alt es e wom en. [ Ms i d a, Malta ]: Univ e rsity o f Malt a; 202 2. 27. World He alth O rgani sa tion. Abo rtion c ar e gu ideline . Sex ual a nd Re produc t iv e He alth Res earch [In t e r ne t ] . 2 022. Av ailabl e fr o m: http s : / / w ww .who.in t/public a tion s/ i /i te m/97892 4003948 3 . . CC-BY-NC-ND 4.0 International licenseIt is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted October 17, 2022. ; https://doi.org/10.1101/2022.10.17.22281157doi: medRxiv preprint