Implementing telemedicine for medical abortion within the public health system: A qualitative study on implementation bottlenecks and solutions in South Africa

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Telemedicine for medical abortion is an alternative model that has been found to be a safe, effective, and acceptable option to increase access to abortion services. This study aimed to understand how key informants view telemedicine for medical abortion and how they view potential bottlenecks and solutions concerning implementation in the public sector of South Africa. Methods Interviews were conducted between February and March 2023 with 19 experts across telemedicine and medical abortion provision, policy, and research. The study had a qualitative design and interviews were analysed using inductive content analysis. Baker et al.’s model of the implementation pathway was used to conceptualise and discuss the findings. Results The findings showed that telemedicine was perceived as a valuable complement to in-clinic care to increase access to safe abortions. Respondents identified clinical concerns and logistical challenges as implementation bottlenecks which could be overcome with innovative thinking and by drawing on existing resources. Research, leadership, collaboration, and policy alignment were suggested to increase stakeholder willingness and capacity to build health system readiness. Across the implementation process, it was viewed as necessary to consider users’ needs and adapt to contextual differences. Conclusions Telemedicine was found to be a valuable model for increasing access to safe abortion services. Considerations and actionable steps to overcome implementation bottlenecks were provided to guide implementing telemedicine for medical abortion in the public sector of South Africa and similar settings. Telemedicine medical abortion public health access implementation bottlenecks South Africa Figures Figure 1 Background Providing safe and comprehensive abortion care is key to reducing the burden of preventable morbidity and mortality from unsafe abortions ( 1 ). Medical abortion is a safe, effective and highly acceptable abortion method using two medications, mifepristone and misoprostol, or using misoprostol alone ( 2 ). The development and availability of medical abortion have led to an expansion of different service delivery models in which abortion in the first trimester can be self-managed either in whole or in part ( 3 ). Telemedicine for medical abortion uses technology, such as telephone or email, to provide abortion care when there is a distance between the user and provider ( 4 ). Telemedicine has been found to be an effective and acceptable support for self-managed abortion in the first trimester and is now recommended by the WHO ( 3 , 5 ). Eligibility screening, counselling, medication instructions, and follow-up care are some components of a telemedicine model for medical abortion ( 3 ). Telemedicine for medical abortion has been implemented and found to be effective in several countries, including Australia ( 6 , 7 ), Mexico ( 8 ), the UK ( 9 ), and the US ( 10 , 11 ). The use of telemedicine has also been perceived to evade stigma and increase access to abortion care for underserved groups, such as people in rural areas and those relying on public services ( 8 , 12 ). In South Africa, abortion on request is legal up to 13 weeks gestational age and under certain conditions, such as risk to the pregnant person’s physical or mental health if the pregnancy is continued, up to the 20th week ( 13 ). Despite South Africa’s liberal laws, abortion is still largely inaccessible due to barriers such as limited information on safe abortions and unregulated belief-based denial of service ( 14 , 15 ). Almost half (45%) of abortion seekers do not receive care on their first clinic visit, resulting in delayed or denied care ( 16 ). Consequently, there are more second-trimester abortions than in other legal settings and higher usage of abortion methods outside the formal health sector, which may be unsafe and have a higher risk of complications ( 17 , 18 ). In response to these barriers to access and the strict lockdowns against COVID-19, non-profit organisations have started to support self-managed abortions by telephone and email ( 19 ). While the public sector does not yet offer telemedicine for medical abortion, these services are currently provided by Marie Stopes South Africa ( 20 ) and Abortion Support South Africa at varying levels of cost to the user ( 21 ). The majority of South Africans rely on the public sector of the healthcare system, which is state-funded and consistently faces budget cuts, resulting in decreasing capacity to meet the population’s health needs, especially those in rural areas ( 22 ). Telemedicine for medical abortion has been found to be safe, effective and acceptable in the South African context ( 23 , 24 ). This mode of service delivery has shown high acceptability among users, providers, and policymakers, resulting in increased user self-efficacy and reduced burden on facilities ( 24 ). However, providers and policymakers have raised the need to address potential implementation challenges, such as improving information and communication technology (ICT) infrastructure and developing standard guidelines for telemedicine services ( 24 ). Questions remain surrounding the feasibility of integrating and expanding telemedicine models within the South African public health sector, where it is yet to be implemented. Implementation science offers theories, frameworks, and models to promote the adoption of evidence-based practices into routine healthcare services ( 25 ). Studies on implementation processes of telemedicine for medical abortion in Colombia and the US have shown that some components of successful implementation are organisational readiness, motivated champions, and collaboration with innovators, while regulatory barriers and providers’ limited ICT skills were perceived as obstacles ( 12 , 26 ). However, these aspects have not been explored in a South African context. Addressing this knowledge gap can accelerate implementation efforts, bridge the gap between evidence and practice, and increase abortion access with meaningful impacts on sexual and reproductive health and rights. This study aimed to understand how key informants view telemedicine for medical abortion and how they view potential bottlenecks and solutions concerning implementation in the public sector of South Africa. Methods Study design and setting We performed a qualitative study based on interviews with stakeholders involved in abortion care in South Africa. The study followed a randomised controlled trial (RCT) on telemedicine and abortion in the same setting ( 23 ) and was part of the evaluation of this intervention ( 24 ). We employed an inductive qualitative approach to explore the perspectives of key informants. We defined key informants as experts who had experience with telemedicine or medical abortion in their professional roles across the private, public, research, and civil society sectors. Semi-structured interviews took place physically in Cape Town or online. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) ( 27 ). Tanahashi’s model of health service coverage provides a foundation for measuring coverage of an intervention in the target population and identifying bottlenecks in implementation ( 28 ). The implementation pathway, an adaptation of Tanahashi’s model by Baker et al., describes the stages of accessibility coverage, availability coverage, and effective coverage and shows where implementation bottlenecks can be identified between these stages ( 29 ). We drew on these understandings of implementation bottlenecks to conceptualise the research questions, develop the interview guide, and interpret the results. Furthermore, we situated our findings into Baker et al.’s model of the implementation pathway to understand how these challenges impact the potential coverage of telemedicine for medical abortion in the South African public sector. Participant recruitment We used purposive sampling, guided by a mapping of experts with specific experiences and roles in the provision of abortion care services, systems, and policies applicable to abortion care or telemedicine policy in South Africa (such as abortion providers, policymakers, ICT specialists, or lawyers). Based on recommendations from initial participants, we also used snowball sampling. We contacted 25 professionals via phone or email, informed them about the study’s purpose, and asked if they were willing to participate. Six did not respond to the request and 19 agreed to participate. Once we had interviewed sufficient professionals to cover a range of backgrounds, the sample size was assessed to be adequate to answer the research questions. Data collection A semi-structured and pilot-tested interview guide was used to explore participants’ views on telemedicine for medical abortion with 19 key informants. Interviews took place during February and March 2023, either in-person or online via Zoom or Microsoft Teams. Before the interview, we obtained written informed consent electronically or in person to take notes, audio-record, and transcribe verbatim. Interviews were conducted in English and lasted between 50 to 80 minutes. Participants were not compensated as they were invited in their professional capacity. All identifying information was removed to protect confidentiality. We obtained ethical approval from the University of Cape Town Health Sciences Human Research Ethics Committee (HREC Ref: 837/2020) as an ethical amendment to the original RCT’s ethical approval. Data analysis Transcripts were coded in Dedoose ( 30 ) using inductive content analysis, a commonly used qualitative methodology to inform guidelines and policy ( 31 ). SS identified meaning units and inductively recorded them as fine-grained codes through a predominantly manifest coding approach. The study team organised the collection of codes and revised them into categories and subcategories to create a coding schema. We reread the data excerpts of the categories and subcategories and discussed their interpretation in an iterative process. The interpretation process was influenced by Baker et al.’s model of the implementation pathway and the research questions ( 29 ). In consideration of our perspectives and research interests, we endeavoured to limit the influence of personal bias during analysis and reporting. Quotes are presented to increase data dependability and the trustworthiness of the findings. While all participants’ perspectives are represented in the results, we selected appropriate quotes from some participants. Results A total of 19 experts were included in this study, representing diverse backgrounds in abortion policy, research, and provision as well as expertise in telemedicine, ICT infrastructure, and healthcare innovation. Most participants, 13 out of 19, were medically trained as doctors, midwives, or nurses, although many currently held roles working in a government department or research. Nine of the professionals worked at the national level, while the others brought experiences from four provinces. Additional participant details can be seen in Table 1 . The analysis generated four categories: 1) Telemedicine as a complement to in-clinic care: increasing access, options and autonomy; 2) Out-of-the-box thinking to overcome implementation bottlenecks; 3) Increasing willingness and capacity to build health system readiness; and 4) Not one size fits all: adapting telemedicine models to users and their contexts. The findings are presented in Table 2 according to categories. Table 1 Participant characteristics Participant characteristics Number of participants - Professional training - Medical doctor 10 - Nurse or midwife 3 - Pharmacist 1 - Psychologist 1 - Attorney 1 - Other 3 Sector - Public 8 - Private 3 - Non-profit 5 - Academic 3 Telemedicine experience - Provision 5 - Policy 5 - Research 2 - Infrastructure 2 - Limited/none 5 Respondents perceived telemedicine as a valuable complement to in-clinic care with the potential to increase access to medical abortion. They identified various clinical and logistical bottlenecks to the implementation of telemedicine for medical abortion but described ways to overcome these challenges with innovative thinking and by utilising existing resources. To build health system readiness, respondents suggested increasing willingness with research and supportive leadership and building implementation capacity by creating strategic partnerships and aligning policies. Counteracting these bottlenecks to implement telemedicine for medical abortion in the public sector was perceived as possible and respondents recommended considering contextual differences and responsive adaptations to provide a spectrum of telemedicine service models. Table 2 Categories and subcategories generated from inductive content analysis 1 Telemedicine as a complement to in-clinic care: increasing access, options and autonomy 1.1 Telemedicine is easier and more accessible for users 1.2 In-clinic care is difficult but still important 2 Out-of-the-box thinking to overcome implementation bottlenecks 2.1 Navigating clinical concerns with screening, information, and trust 2.2 Drawing on existing resources to address logistical challenges 3 Increasing willingness and capacity to build health system readiness 3.1 Offsetting the resistance to change with leadership and research 3.2 Aligning partnerships and policies to build implementation capacity 4 Not one size fits all: adapting telemedicine models to users and their contexts 4.1 Accommodating users’ contexts, needs, and preferences 4.2 Adapting to contextual differences and varying implementation readiness 1 Telemedicine as a complement to in-clinic care: increasing access, options and autonomy While various challenges to accessing in-clinic care were described by the respondents, in-clinic care was still viewed to be necessary. Telemedicine was viewed as valuable but positioned as a complement to in-clinic care by increasing access. 1.1 Telemedicine is easier and more accessible for users Respondents relayed how telemedicine could increase access to abortion services by mitigating various barriers to in-clinic abortion care, such as insufficient abortion providers and belief-based denial of service. Telemedicine was described as a potential channel to circumvent stigma and direct users to accessible services and supportive abortion providers. This was perceived as especially important for geographically dispersed communities where access to in-clinic services for abortion is limited. "I think it is an excellent opportunity to increase access, especially where we have health systems that are really constrained, where we have people who can't always get to a health facility, where we have a lot of stigma around abortion services… It's definitely something that can address so many limitations and barriers that we see today in reproductive health care." (Researcher) Respondents reasoned that telemedicine could decrease delays in accessing abortion care, thereby reducing the number of second-trimester abortions with higher costs and risks of complications. They further recounted benefits such as reducing the psychological capital of navigating in-clinic abortion services and alleviating experiences of judgment. Telemedicine was perceived as giving users a greater sense of autonomy and described as less disruptive to a person’s education, economic activity, and general health. "It would save her so much time. It would save her so much money. It would save her so much of the trauma of having to find shelter in a city far away from where you live until someone can help you with your situation." (Attorney) 1.2 In-clinic care is difficult but still important Interviews revealed the perceived challenges to accessing in-clinic care in South Africa today, including the inability of overburdened healthcare facilities to meet the high demand for abortion services, long travel times, inconvenient clinic opening hours, and users being denied access or turned away by gatekeepers at facilities. “They travel to the nearest city to try and get an abortion. They get there most of the time and there's a long line and they have to then either sleep outside or like, you know, just find some shelter until they can be seen… The demand is so much and the actual provision of the service is so low that even with telemedicine there will still be a gap.” (Attorney) Limited public abortion provision and unaffordable private services were viewed as drivers of unsafe abortion. While telemedicine would decrease this gap in service delivery, respondents stressed there will always be a need for in-clinic care and telemedicine should operate in parallel to it rather than replacing it. Respondents highlighted the perceived importance of providing options for abortion care to meet users’ needs. They also emphasised the perceived need to increase access to in-clinic services to meet the needs of users who are not eligible for telemedicine or prefer in-clinic care. “It's a very good way of overcoming barriers to access. We know that many women prefer this option even if there are other options available. So it's not just about improving access, it's also about women's choices and preferences. But that being said, we will always need brick-and-mortar clinics. It's not an alternative. It's additional.” (Non-profit provider) 2 Out-of-the-box thinking to overcome implementation bottlenecks Interviews highlighted various perceived clinical and logistical bottlenecks to the implementation of telemedicine for medical abortion, but solutions were usually presented concurrently. 2.1 Navigating clinical concerns with screening, information, and trust Some respondents were apprehensive about the absence of an in-clinic visit and viewed this as a lost opportunity for additional health checks. Among their concerns were the lack of ultrasound or physical examination to confirm gestational age and discover ectopic pregnancies, that users would not accurately identify their gestational age (due to poor menstrual literacy or lying out of desperation), or that users would not administer the medication correctly. “You'd need to have quite a rigorous screening for the women that want to take part in telemedicine and think if there's any question mark on the validity or the accuracy or the honesty of the woman's answers, then she needs to be referred for in-person care.” (Non-profit provider) Respondents explained these concerns could be mitigated by conducting thorough eligibility screening and giving clear instructions on how to take the medication, what to expect, how to determine success, and what to do in case of complications. They also suggested standard operating procedures, consent forms, clear referral pathways to in-clinic care, record-keeping for telemedicine consultations, and clarity on where responsibility lies. “In this case, we're saving the woman's life because the risk is that she will go to an illegal provider.” (Pharmaceutical expert) Some respondents were worried that a telemedicine service would be used to get pills to sell informally and fuel unsafe abortions, while other respondents suggested telemedicine could shift more users to formal healthcare and reduce unsafe abortions. Increased comprehensive sexuality education, knowledge of reproductive rights, and awareness of where to access services were described as ways to support users in identifying their pregnancy earlier and knowing where to seek safe abortion care. Furthermore, interviews revealed the perceived need to be patient, trust users, and rely on their agency and self-knowledge. 2.2 Drawing on existing resources to address logistical challenges Medication collection should be easy and have multiple options Respondents noted the combination of mifepristone and misoprostol is more effective but limited by mifepristone’s high cost. Producing a generic version by government tender was suggested to improve access. Respondents shared various ideas for how users could get abortion medications, such as couriers, decentralised pick-up locations, vending machines, or pharmacies. They referred to other distribution mechanisms for inspiration, like decentralised collection points for chronic medication and government partnerships with private pharmacies to provide contraceptives. While respondents mentioned user verification during the collection or distribution of the medication, the focus was to make the experience simple and safe for users. "In terms of collecting the medication, how can we make it easy for you to collect it? And because it might also not be possible to do a courier service in an informal settlement or something like that. So we need to think a little bit outside of the box and don't think that it won't work." (Non-profit provider) There are implementation costs, but telemedicine may be more cost-effective Respondents discussed various telemedicine service models with differing resource needs, ranging from low-budget implementations to high-level structural costs. Speculated costs included medications, call centres, and staff training. Respondents raised concerns about the decreasing health budget due to competing demands and advised strategic partnerships with private organisations to manage resources. Regardless of the model, respondents emphasised that services should be free for users, with the economic burden on the government. Respondents described how the option of telemedicine could reduce costs by decreasing in-clinic costs, surgical abortion rates, and complications from unsafe abortions. While telemedicine was expected to be more cost-effective over time, an economic evaluation was called for to show the return on investment of implementing telemedicine. “But from cost-effectiveness or cost, like an economic evaluation side of things, we need to also think of the costs averted by implementing telehealth services… So with each call you make, there's one less person in the clinic.” (Provincial policymaker) Telemedicine can work now, but ICT infrastructure needs to be developed for scale-up Some respondents believed the basic ICT infrastructure for implementation was already in place and that telemedicine models should be designed based on what already exists. Others argued that more advanced digital structures were needed, including an electronic registry with user information, data security management, ICT infrastructure in public facilities, as well as database linkages to share clinical management and include telemedicine users in caseload totals. To meet consent requirements, verbal consent and recorded calls were positioned as easier than requiring a signed consent form. Respondents shared how telemedicine services are already happening to some degree on WhatsApp, but concerns around data protection and privacy were raised. Respondents emphasised the perceived need for an official, secure digital platform for telemedicine. “At its most simplistic level, this could be implemented as a service on a proof of concept basis, if you like, using existing infrastructure and technologies and services. But if you really wanted to scale services more widely, then you need to get the dependencies in place.” (Public health ICT specialist) Health workers’ roles can adapt to include telemedicine Respondents had different ideas of who would provide telemedicine services, who would be responsible for it, and whether it would be managed from a facility, provincial, or national level. Most respondents suggested that nurses trained in abortion provision could adopt telemedicine services with a doctor on call for queries. Other trained personnel, like community healthcare workers and pharmacists, were also suggested to play key roles in service delivery and follow-up. Respondents discussed how health worker roles could be adapted to include telemedicine or how new roles could be created to exclusively deliver telemedicine services. Either way, they highlighted that providing telemedicine services should not increase the current burden on abortion providers. To facilitate sustainable implementation, respondents suggested engaging health workers in telemedicine service delivery and integration as well as developing their ICT skills and professional confidence in the telemedicine system. “I think you develop a digital bedside manner when you do telemedicine… you have to have a specific kind of mindset to do this work.” (Public health telemedicine specialist) 3 Increasing willingness and capacity to build health system readiness Respondents suggested supportive leadership and advocacy from researchers to increase implementation willingness as well as utilising strategic partnerships, updating training, and aligning policy to build implementation capacity. 3.1 Offsetting the resistance to change with leadership and research While respondents perceived an increased appreciation of telemedicine since the COVID-19 pandemic, some still sensed a lack of willingness to implement this in the public sector. They attributed this reluctance to the fear of the unknown, resistance to change, and a high bar for clinical safety. To build telemedicine support from leadership, respondents suggested intentional engagement with stakeholders, champion recognition, and innovation showcases. Advocacy and commitment from national and provincial leaders were framed as facilitators of implementation, while apathetic or anti-choice attitudes of people in power would limit implementation. “It’s difficult to change culture in a hospital if it isn’t a decree from above. There’s always fear… I think you would need to have a formal directive to say this is acceptable and we can do this.” (Public provider) Respondents proposed allowing stakeholders to voice their concerns, acknowledging their apprehension, and using research to address these issues. They focused on sharing evidence of safety and examples of successful implementation to obtain buy-in. Furthermore, respondents called on researchers to become advocates and negotiate with the government to develop policy changes and build implementation capacity. They also encouraged researchers to share findings widely, engage with local leadership, and gain public support. “Researchers really hold the tools and the knowledge that can inform a successful intervention in our country… I think when we bring that together and we present it to the decision makers together, collectively, we solidify this approach that this is effective.” (Researcher) 3.2 Aligning partnerships and policies to build implementation capacity Some respondents believed sufficient evidence and willingness exists but the government is uncertain on how to move forward with implementing telemedicine services. They recommended piloting different models integrated with existing models of care to figure out what works, what needs to be improved, and what additional resources are needed. Respondents proposed partnerships across public, private, academic, and civil society sectors to support a collaborative model and suggested engaging with experts on telemedicine for medical abortion to guide sustainable implementation. “Government wants to implement it. I think they just don't quite know how to do it… They need to rely on experts in this and we can tell them this is safe. This is the international standard now and the WHO says it’s safe.” (Non-profit provider) To build implementation capacity and confidence, interdepartmental collaboration was recommended to update curricula for training healthcare professionals with the integration of telemedicine and new demands in practice. In addition to training providers on telemedicine procedures, respondents highlighted training for other healthcare professionals on the option of telemedicine for medical abortion to assist with referral and reduce stigma. They also described the perceived importance of aligning policies, such as national telehealth guidelines and clinic designation processes, to integrate telemedicine for medical abortion. “It’s the responsibility of the service staff to consider how telehealth might make services to citizens better. Then it’s the responsibility of the policy and the system, i.e. us, to provide them with the tools, support, and guidelines they need to do that easily and safely.” (Provincial policymaker) 4 Not one size fits all: adapting telemedicine models to users and their contexts Interviews revealed the perceived value of contextually adapted and user-centred approaches to support the usability and acceptability of telemedicine for medical abortion. 4.1 Accommodating users’ contexts, needs, and preferences Respondents perceived the usability of telemedicine for medical abortion to depend on users’ access to the internet, privacy, and language. Respondents noted that data was costly, despite high digital penetration in South Africa, and suggested a data-free platform and toll-free call centre. While telemedicine could provide privacy for some users, respondents discussed how privacy might be more difficult for users who share a phone and live in confined spaces. They proposed a private space in facilities for users to utilise telemedicine services. Respondents also reflected on how the service could be designed to accommodate for language barriers, such as using illustrations and confirming the user understands the information. "Considering everybody and their abilities to access the service and to understand how to do it is important for a model in South Africa." (Researcher) Respondents differed in their expected acceptability from users, such as mixed views on whether it would be more popular for younger or older users. They anticipated a potential lack of trust from users and suggested clear information to mitigate fears. Raising awareness through media campaigns and providing accessible information on abortion options were also suggested to increase acceptability. Respondents elaborated that telemedicine models should be informed by users’ contextual challenges and responsive to their needs and preferences. They agreed that telemedicine would not be the solution for everyone, but it could be the right option for some people. “This isn't going to be a one size fits all for every single client. There are going to be some clients where telemedicine is appropriate and some clients where it's not.” (Non-profit provider) 4.2 Adapting to contextual differences and varying implementation readiness Respondents reflected on the cultural, geographical, and socioeconomic diversity of South Africa and considered the value of telemedicine in areas with limited abortion services as well as the challenges to implementation in these contexts. They suggested targeting different community groups according to their needs and providing options for in-clinic care or connectivity for telemedicine services. Respondents also described the marked provincial differences in abortion service provision and varying levels of readiness to adopt telemedicine as potential challenges to scaling up telemedicine services. To navigate these differences, they suggested engaging with provincial stakeholders to appropriately adapt telemedicine models. “We have a vastly varied population… with vastly different challenges and opportunities in those different areas. And so I think we need to acknowledge that we can't have a provincial level like one size fits all.” (Provincial policymaker) Interviews revealed a common perception that implementation was possible but would require work and out-of-the-box thinking. Respondents expressed that major organisational changes were not necessary, but rather figuring out where telemedicine fits in existing systems and adapting models accordingly. “Everything that you could consider to be a barrier or a risk is either already addressed in the research or is simply just a design barrier… just because something is difficult, doesn't mean you can't do it. You just have to address it.” (Provincial policymaker) These findings identified various bottlenecks to coverage of telemedicine for medical abortion, indicated along Baker et al.’s implementation pathway in Fig. 1 . Discussion The results indicate that telemedicine for medical abortion was perceived as a valuable complement to in-clinic care but various implementation bottlenecks and potential solutions were discussed. We will examine our findings through the lens of Baker et al.’s model of the implementation pathway to understand what bottlenecks limit accessibility, availability, and effective coverage of telemedicine for medical abortion ( 29 ). From the view of the implementation pathway, our study found that telemedicine for medical abortion was positioned as a beneficial intervention to increase coverage of safe abortion services in the public sector of South Africa. This mirrors previous findings from South Africa and other contexts that accessing in-clinic care can be difficult and telemedicine for medical abortion could provide an easier and highly acceptable option for users and providers, ( 9 , 24 , 32 ). While the perceived merit of telemedicine was clear, it was acknowledged that in-clinic care needed to be strengthened to support referrals and respond to complications. According to Baker et al.’s implementation pathway, our findings revealed bottlenecks in access which affect accessibility coverage , restricting the proportion of the target population for whom telemedicine for medical abortion would be accessible ( 29 ). A scoping review on abortion stigma highlighted its impact on limiting awareness of abortion rights, access to information, and referral to safe services, including telemedical services ( 33 ). While our respondents described telemedicine as a channel to alleviate stigma, they also showed concern that users would struggle to correctly determine their gestational age to self-assess their eligibility for telemedicine services. Findings from Colombia echo poor menstrual knowledge as a barrier to accessing telemedicine for medical abortion ( 12 ). To increase knowledge and acceptability, our results proposed improved comprehensive sexuality education and awareness campaigns, inspired by the positive impact of HIV awareness campaigns ( 34 ). Contextual differences in users’ connectivity, privacy, and language needs were also perceived as potential barriers to access. A study on ethical considerations for mobile phone interventions in South Africa described obstacles such as participants sharing a mobile phone and receiving messages for other people, changing their phone number due to theft, and struggling to afford airtime, get network coverage, or charge their phone ( 35 ). Our respondents mirrored these concerns and suggested data- or toll-free options. Similarly, research in Mexico found that targeted telemedicine approaches are needed to support underserved, geographically dispersed populations ( 8 ). Differences in language and literacy were also raised as implementation challenges and our respondents called for telemedicine models to accommodate language barriers and use visual aids. A study in the US on language-specific challenges to general telemedicine services added having language representation in telemedicine providers and using interpretation services ( 36 ). Baker et al.’s implementation pathway illustrates how availability coverage is curbed by bottlenecks in health facility readiness, restricting the proportion for whom telemedicine for medical abortion is available ( 29 ). Our results showed that the availability of telemedicine services depended on the type of delivery model and working with existing systems to maximise implementation capacity was suggested, such as utilising available human resources, medication systems, and ICT infrastructure. Respondents encouraged using current abortion providers and addressing staffing constraints, supported by research findings that a lack of trained providers hinders the integration of telemedicine and the importance of building organisational capacity before implementation by confirming the availability of trained providers ( 12 , 37 ). Our respondents’ perceptions of medication distribution were aligned with a scoping review of medication distribution which found new methods, such as automated pharmacy dispensing units and smart lockers, to be cheaper and better for users than collecting medication from facilities ( 38 ). A study in the US noticed that clinics with the required medication and ICT resources to provide telemedicine for medical abortion were able to implement services more efficiently ( 26 ). Some of our respondents believed the required ICT infrastructure for telemedicine already existed while others insisted on developing more complex digital systems. On telemedicine for general health services in African settings, research reflects that limitations in ICT infrastructure can reduce the availability of services, but simple telemedicine technologies could optimise initial set-up costs ( 37 , 39 ). A review of telemedicine services in the OECD supports the notion of cost-effectiveness, although poor reporting and quality limited generalisability ( 40 ). Similarly, our respondents perceived telemedicine could be more cost-effective in the long term but encouraged an economic evaluation to determine this and inform multisectoral collaboration. Public-private partnerships and collaboration with civil society organisations were highlighted as central to building implementation capacity and health system readiness. In other contexts, collaboration has been shown to support implementation feasibility, such as developing network infrastructure with mobile technology operators, receiving information materials from civil society organisations, and reaching agreements with delivery companies ( 12 , 26 , 41 ). Our findings echo the perceived importance of support from organisational leadership, champion providers, and engaged academics that have been linked to sustainable implementation ( 26 , 39 , 41 ). At the last stage of Baker et al.’s implementation pathway, bottlenecks in clinical practice influence effectiveness coverage , further impacting the proportion of the target population who receive telemedicine for medical abortion services as intended ( 29 ). Our results identified clinical concerns about telemedicine for medical abortion regarding the lack of ultrasound or physical examination, despite evidence that the absence of ultrasound in telemedicine models does not result in more complications than models using ultrasound before an abortion and ultrasound dating could suitably be excluded for the majority of pregnant people who were certain of their last menstrual period ( 11 , 42 ). Our respondents also raised concerns about complications and misuse, which have been linked to the lower acceptability of implementing telemedicine for medical abortion among less experienced providers in Colombia ( 12 ). Addressing these concerns, the RCT in South Africa found high adherence to medication instructions in addition to high safety, acceptability, and effectiveness ( 23 ). Our findings promoted research dissemination to address knowledge gaps and encourage evidence-based practices, as reflected in an implementation study in the US ( 26 ). Our respondents called for ICT training for telemedicine providers and increased awareness of telemedicine for medical abortion in other healthcare professionals to facilitate decision-making support and referral. The need for telehealth training, value clarification activities, and clear guidelines is supported by other implementation studies ( 12 , 26 ). Our respondents discussed integrating information on telemedicine for medical abortion and basic abortion procedures into the training curriculum for nurses. This connects to other research calling for the inclusion of abortion training in South African medical education as well as the introduction to general telemedicine technology ( 39 , 43 ). In South Africa and Colombia, implementation research has identified how policies can create barriers for those most in need of telemedicine services, like requirements for video calls, and limit provision, such as strictly regulating telehealth in providers’ scope of practice ( 12 , 41 ). To support provision of appropriate and effective telemedicine services, our findings indicated policy alignment would be needed. Our respondents also acknowledged that service-delivery models should be adapted according to varying access needs, implementation readiness, and clinical skills to increase the intervention coverage of telemedicine for medical abortion. The findings of this study highlight key steps towards effective implementation: telehealth and medical abortion policies should be aligned for consistency, medication distribution systems should be mapped to ensure telemedicine models achieve national coverage, the national ICT infrastructure should be evaluated for practical integration with telemedicine, awareness campaigns should be conducted to guide users and referrals toward available telemedicine services, and stakeholders should be engaged in establishing partnerships that expand access to telemedicine for medical abortion. Strengths and limitations The application of a theoretical model strengthens the credibility of the results and informs on the identified bottlenecks to implementing telemedicine for medical abortion in South Africa and similar settings. By drawing on experiences from a wide range of experts across different sectors in South Africa, this study provided rich detail on perceived implementation bottlenecks and potential solutions. However, participants were selected based on their connection to telemedicine or medical abortion, so they are likely to be more permissive participants than the general population of healthcare professionals or associated professionals. This might have given a more positive impression of stakeholder readiness and the ability to overcome implementation bottlenecks than what exists in reality. Most informants also came from a management, policy, or research background, so there are limited perspectives from potential public providers of telemedicine for medical abortion and stakeholders working on the ground. Conclusions This study has shown that professionals perceived telemedicine to be a valuable option for abortion provision that will increase access and convenience for users, especially in tandem with in-clinic care. However, clinical concerns and logistical challenges were identified as bottlenecks to implementation which could be overcome with innovative thinking and working with existing resources. Professionals also suggested building implementation readiness and adapting telemedicine models to contextual differences. Active steps should be made in policy and practice toward implementing telemedicine for medical abortion in the public sector to increase access to safe abortions in South Africa. Abbreviations COREQ The Consolidated Criteria for Reporting Qualitative Research COVID-19 Coronavirus disease 2019 HIV Human immunodeficiency virus ICT Information and communication technology OECD The Organization for Economic Cooperation and Development RCT Randomised controlled trial WHO World Health Organization UK United Kingdom US United States Declarations Ethics approval and consent to participate Ethical approval for the study was obtained from the University of Cape Town Health Sciences Human Research Ethics Committee (HREC Ref: 837/2020). All participants provided written informed consent to participate in this study. Consent for publication Not applicable. Availability of data and materials All qualitative data were obtained from interviews with study participants. The data is not publicly available to protect study participant privacy. Competing interests The authors declare that they have no competing interests. Funding This study was funded by the Swedish Research Council (2020-04421). The funder did not have a role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors' contributions ME had the idea for the study. SS, AC and ME designed the study. SS conducted the interviews and developed the analysis with feedback from AC and ME. SS drafted the manuscript. AC and ME reviewed the manuscript and provided supervision. All authors contributed to the article and approved the final manuscript. Acknowledgements We are grateful for the participation of all interviewees and appreciate the important work they do to increase access to healthcare services. Authors' information Not included. Footnotes Not applicable. References Owolabi OO, Biddlecom A, Whitehead HS. Health systems’ capacity to provide post-abortion care: a multicountry analysis using signal functions. Lancet Glob Health. 2019;7(1):e110–8. 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South Afr Fam Pract [Internet]. 2020 Dec 10 [cited 2024 Dec 28];62(4). Available from: https://www.ajol.info/index.php/safp/article/view/234854 Favier M, Greenberg JMS, Stevens M. Safe abortion in South Africa: ‘We have wonderful laws but we don’t have people to implement those laws’. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2018;143(Suppl 4):38–44. Gerdts C, DePiñeres T, Hajri S, Harries J, Hossain A, Puri M, et al. Denial of abortion in legal settings. J Fam Plann Reprod Health Care. 2015;41(3):161–3. Amnesty International. Barriers to Safe and Legal Abortion in South Africa [Internet]. Amnesty International Publications. 2017. Report No.: AFR53/5423/2017. Available from: https://www.amnesty.org/en/documents/afr53/5423/2017/en/ Harries J, Daskilewicz K, Bessenaar T, Gerdts C. Understanding abortion seeking care outside of formal health care settings in Cape Town, South Africa: a qualitative study. Reprod Health. 2021;18(1):190. Dhlamini M. Pills and phone calls: How COVID restrictions forced us to conduct abortions telephonically [Internet]. Bhekisisa. 2020 [cited 2023 Jan 10]. Available from: https://bhekisisa.org/article/2020-09-29-pills-and-phone-calls-how-covid-restrictions-forced-us-to-conduct-abortions-telephonically/ Marie. Stopes [Internet]. [cited 2024 Dec 28]. Reproductive and Sexual Health Services | Marie Stopes South Africa. Available from: https://www.mariestopes.org.za/ I Need an Abortion. - Abortion Support South Africa [Internet]. [cited 2024 Dec 28]. Available from: https://abortionsupport.co.za/ Rensburg R, The Conversation. 2018 [cited 2024 Dec 28]. New healthcare plan promises to overhaul South Africa’s massively skewed system. Available from: http://theconversation.com/new-healthcare-plan-promises-to-overhaul-south-africas-massively-skewed-system-99404 Endler M, Petro G, Gemzell Danielsson K, Grossman D, Gomperts R, Weinryb M, et al. A telemedicine model for abortion in South Africa: a randomised, controlled, non-inferiority trial. Lancet Lond Engl. 2022;400(10353):670–9. Somefun OD, Constant D, Endler M. The acceptability of implementing telemedicine for early medical abortion in South Africa: A substudy to a randomized controlled trial. SSM - Qual Res Health. 2023;3:100241. Rapport F, Clay-Williams R, Churruca K, Shih P, Hogden A, Braithwaite J. The struggle of translating science into action: Foundational concepts of implementation science. J Eval Clin Pract. 2018;24(1):117–26. Godfrey EM, Fiastro AE, Jacob-Files EA, Coeytaux FM, Wells ES, Ruben MR, et al. Factors associated with successful implementation of telehealth abortion in 4 United States clinical practice settings. Contraception. 2021;104(1):82–91. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. Tanahashi T. Health service coverage and its evaluation. Bull World Health Organ. 1978;56(2):295–303. Baker U, Peterson S, Marchant T, Mbaruku G, Temu S, Manzi F, et al. Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania. Bull World Health Organ. 2015;93(6):380–9. Home. | Dedoose [Internet]. [cited 2024 Dec 28]. Available from: https://www.dedoose.com/ Vears DF, Gillam L. Inductive content analysis: A guide for beginning qualitative researchers. Focus Health Prof Educ Multi-Prof J. 2022;23(1):111–27. Killinger K, Günther S, Gomperts R, Atay H, Endler M. Why women choose abortion through telemedicine outside the formal health sector in Germany: a mixed-methods study. BMJ Sex Reprod Health. 2022;48(e1):e6–12. Sorhaindo AM, Lavelanet AF. Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care. Soc Sci Med. 2022;311:115271. Peltzer K, Parker W, Mabaso M, Makonko E, Zuma K, Ramlagan S. Impact of National HIV and AIDS Communication Campaigns in South Africa to Reduce HIV Risk Behaviour. Sci World J. 2012;2012:e384608. Jack CL, Mars M. Ethical considerations of mobile phone use by patients in KwaZulu-Natal: Obstacles for mHealth? Afr J Prim Health Care Fam Med. 2014;6(1):7. Sharma AE, Lisker S, Fields JD, Aulakh V, Figoni K, Jones ME, et al. Language-Specific Challenges and Solutions for Equitable Telemedicine Implementation in the Primary Care Safety Net During COVID-19. J Gen Intern Med. 2023;38(14):3123–33. Ayo-Farai O, Ogundairo O, Maduka CP, Okongwu CC, Babarinde AO, Sodamade OT. Telemedicine in Health Care: A Review of Progress and Challenges in Africa. Matrix Sci Pharma. 2023;7(4):124. Mash R, Christian C, Chigwanda RV. Alternative mechanisms for delivery of medication in South Africa: A scoping review. South Afr Fam Pract [Internet]. 2021 Aug 24 [cited 2024 Dec 28];63(3). Available from: https://www.ajol.info/index.php/safp/article/view/235096 Dodoo JE, Al-Samarraie H, Alzahrani AI. Telemedicine use in Sub-Saharan Africa: Barriers and policy recommendations for Covid-19 and beyond. Int J Med Inf. 2021;151:104467. Eze ND, Mateus C, Hashiguchi TCO. Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS ONE. 2020;15(8):e0237585. Sibuyi IN, de la Harpe R, Stakeholder-Centered NPA. mHealth Implementation Inquiry Within the Digital Health Innovation Ecosystem in South Africa: MomConnect as a Demonstration Case. JMIR MHealth UHealth. 2022;10(6):e18188. Constant D, Harries J, Moodley J, Myer L. Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study. Reprod Health. 2017;14(1):100. Harries J, Constant D. Providing safe abortion services: Experiences and perspectives of providers in South Africa. Best Pract Res Clin Obstet Gynaecol. 2020;62:79–89. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Oct, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 10 Jan, 2025 Editor assigned by journal 10 Jan, 2025 Submission checks completed at journal 09 Jan, 2025 First submitted to journal 08 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5790305","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":400503803,"identity":"4f91f7c6-d680-461a-98b9-c6f7d0a1b67f","order_by":0,"name":"Simone Storey","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYDACZjBpAeVVgESYG4jRIsHAA6bPgEQYCWhhQNbC2AYm8WuRb+dOfFxQIWFvz9778DHvvNpo/naglh8V23BqMTjMu9l4xhmJxB6e48bGvNuO5844zNjA2HPmNm4tzLzbpHnbJBJ4JNLYpHm3HcttAGphZmzDrUW+GaTln4Q9UAv7b945x3LnE9LCcBikpUGCsQdoCzNvQ03uBkJawH7hOQb0y5ljzJJzjh3I3QjUchCfX+T7z258zFNjY8/e3sb44U1NXe6884cPPvhRgcdhyICJh+EwmHGAOPVAwPiDoY5oxaNgFIyCUTByAADLKlIJYo3RAwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Cape Town","correspondingAuthor":true,"prefix":"","firstName":"Simone","middleName":"","lastName":"Storey","suffix":""},{"id":400503804,"identity":"e109883c-f247-425a-9cce-c05d022aac01","order_by":1,"name":"Amanda Cleeve","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Cleeve","suffix":""},{"id":400503805,"identity":"a2e1fc38-cddb-43e7-9bfd-b0f7fd88f8b4","order_by":2,"name":"Margit Endler","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Margit","middleName":"","lastName":"Endler","suffix":""}],"badges":[],"createdAt":"2025-01-08 15:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5790305/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5790305/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-24690-0","type":"published","date":"2025-10-09T15:58:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73630298,"identity":"ab6d2949-aa67-4b4c-a7b7-fd4f325ceca0","added_by":"auto","created_at":"2025-01-13 06:15:27","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":98027,"visible":true,"origin":"","legend":"\u003cp\u003eFindings in relation to Baker et al.’s implementation pathway\u003c/p\u003e","description":"","filename":"Figure1.FindingsinrelationtoBakeretal.simplementationpathway.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5790305/v1/70cd2216824fbc23db566c20.jpg"},{"id":93420027,"identity":"1144eab0-215a-4d8f-b18c-8102b85d5484","added_by":"auto","created_at":"2025-10-13 16:09:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1378197,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5790305/v1/d0900cb2-3024-47d2-b4ac-738762c86179.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing telemedicine for medical abortion within the public health system: A qualitative study on implementation bottlenecks and solutions in South Africa","fulltext":[{"header":"Background","content":"\u003cp\u003eProviding safe and comprehensive abortion care is key to reducing the burden of preventable morbidity and mortality from unsafe abortions (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Medical abortion is a safe, effective and highly acceptable abortion method using two medications, mifepristone and misoprostol, or using misoprostol alone (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The development and availability of medical abortion have led to an expansion of different service delivery models in which abortion in the first trimester can be self-managed either in whole or in part (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTelemedicine for medical abortion uses technology, such as telephone or email, to provide abortion care when there is a distance between the user and provider (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Telemedicine has been found to be an effective and acceptable support for self-managed abortion in the first trimester and is now recommended by the WHO (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Eligibility screening, counselling, medication instructions, and follow-up care are some components of a telemedicine model for medical abortion (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Telemedicine for medical abortion has been implemented and found to be effective in several countries, including Australia (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), Mexico (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), the UK (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and the US (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The use of telemedicine has also been perceived to evade stigma and increase access to abortion care for underserved groups, such as people in rural areas and those relying on public services (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn South Africa, abortion on request is legal up to 13 weeks gestational age and under certain conditions, such as risk to the pregnant person\u0026rsquo;s physical or mental health if the pregnancy is continued, up to the 20th week (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Despite South Africa\u0026rsquo;s liberal laws, abortion is still largely inaccessible due to barriers such as limited information on safe abortions and unregulated belief-based denial of service (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Almost half (45%) of abortion seekers do not receive care on their first clinic visit, resulting in delayed or denied care (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Consequently, there are more second-trimester abortions than in other legal settings and higher usage of abortion methods outside the formal health sector, which may be unsafe and have a higher risk of complications (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn response to these barriers to access and the strict lockdowns against COVID-19, non-profit organisations have started to support self-managed abortions by telephone and email (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). While the public sector does not yet offer telemedicine for medical abortion, these services are currently provided by Marie Stopes South Africa (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and Abortion Support South Africa at varying levels of cost to the user (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The majority of South Africans rely on the public sector of the healthcare system, which is state-funded and consistently faces budget cuts, resulting in decreasing capacity to meet the population\u0026rsquo;s health needs, especially those in rural areas (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTelemedicine for medical abortion has been found to be safe, effective and acceptable in the South African context (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This mode of service delivery has shown high acceptability among users, providers, and policymakers, resulting in increased user self-efficacy and reduced burden on facilities (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, providers and policymakers have raised the need to address potential implementation challenges, such as improving information and communication technology (ICT) infrastructure and developing standard guidelines for telemedicine services (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Questions remain surrounding the feasibility of integrating and expanding telemedicine models within the South African public health sector, where it is yet to be implemented.\u003c/p\u003e \u003cp\u003eImplementation science offers theories, frameworks, and models to promote the adoption of evidence-based practices into routine healthcare services (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Studies on implementation processes of telemedicine for medical abortion in Colombia and the US have shown that some components of successful implementation are organisational readiness, motivated champions, and collaboration with innovators, while regulatory barriers and providers\u0026rsquo; limited ICT skills were perceived as obstacles (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). However, these aspects have not been explored in a South African context. Addressing this knowledge gap can accelerate implementation efforts, bridge the gap between evidence and practice, and increase abortion access with meaningful impacts on sexual and reproductive health and rights.\u003c/p\u003e \u003cp\u003eThis study aimed to understand how key informants view telemedicine for medical abortion and how they view potential bottlenecks and solutions concerning implementation in the public sector of South Africa.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eWe performed a qualitative study based on interviews with stakeholders involved in abortion care in South Africa. The study followed a randomised controlled trial (RCT) on telemedicine and abortion in the same setting (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and was part of the evaluation of this intervention (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). We employed an inductive qualitative approach to explore the perspectives of key informants. We defined key informants as experts who had experience with telemedicine or medical abortion in their professional roles across the private, public, research, and civil society sectors. Semi-structured interviews took place physically in Cape Town or online. The study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTanahashi\u0026rsquo;s model of health service coverage provides a foundation for measuring coverage of an intervention in the target population and identifying bottlenecks in implementation (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The implementation pathway, an adaptation of Tanahashi\u0026rsquo;s model by Baker et al., describes the stages of accessibility coverage, availability coverage, and effective coverage and shows where implementation bottlenecks can be identified between these stages (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). We drew on these understandings of implementation bottlenecks to conceptualise the research questions, develop the interview guide, and interpret the results. Furthermore, we situated our findings into Baker et al.\u0026rsquo;s model of the implementation pathway to understand how these challenges impact the potential coverage of telemedicine for medical abortion in the South African public sector.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant recruitment\u003c/h3\u003e\n\u003cp\u003eWe used purposive sampling, guided by a mapping of experts with specific experiences and roles in the provision of abortion care services, systems, and policies applicable to abortion care or telemedicine policy in South Africa (such as abortion providers, policymakers, ICT specialists, or lawyers). Based on recommendations from initial participants, we also used snowball sampling. We contacted 25 professionals via phone or email, informed them about the study\u0026rsquo;s purpose, and asked if they were willing to participate. Six did not respond to the request and 19 agreed to participate. Once we had interviewed sufficient professionals to cover a range of backgrounds, the sample size was assessed to be adequate to answer the research questions.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eA semi-structured and pilot-tested interview guide was used to explore participants\u0026rsquo; views on telemedicine for medical abortion with 19 key informants. Interviews took place during February and March 2023, either in-person or online via Zoom or Microsoft Teams. Before the interview, we obtained written informed consent electronically or in person to take notes, audio-record, and transcribe verbatim. Interviews were conducted in English and lasted between 50 to 80 minutes. Participants were not compensated as they were invited in their professional capacity. All identifying information was removed to protect confidentiality. We obtained ethical approval from the University of Cape Town Health Sciences Human Research Ethics Committee (HREC Ref: 837/2020) as an ethical amendment to the original RCT\u0026rsquo;s ethical approval.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eTranscripts were coded in Dedoose (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) using inductive content analysis, a commonly used qualitative methodology to inform guidelines and policy (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). SS identified meaning units and inductively recorded them as fine-grained codes through a predominantly manifest coding approach. The study team organised the collection of codes and revised them into categories and subcategories to create a coding schema. We reread the data excerpts of the categories and subcategories and discussed their interpretation in an iterative process. The interpretation process was influenced by Baker et al.\u0026rsquo;s model of the implementation pathway and the research questions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In consideration of our perspectives and research interests, we endeavoured to limit the influence of personal bias during analysis and reporting. Quotes are presented to increase data dependability and the trustworthiness of the findings. While all participants\u0026rsquo; perspectives are represented in the results, we selected appropriate quotes from some participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 19 experts were included in this study, representing diverse backgrounds in abortion policy, research, and provision as well as expertise in telemedicine, ICT infrastructure, and healthcare innovation. Most participants, 13 out of 19, were medically trained as doctors, midwives, or nurses, although many currently held roles working in a government department or research. Nine of the professionals worked at the national level, while the others brought experiences from four provinces. Additional participant details can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e The analysis generated four categories: 1) Telemedicine as a complement to in-clinic care: increasing access, options and autonomy; 2) Out-of-the-box thinking to overcome implementation bottlenecks; 3) Increasing willingness and capacity to build health system readiness; and 4) Not one size fits all: adapting telemedicine models to users and their contexts. The findings are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e according to categories.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of participants\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Professional training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Medical doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Nurse or midwife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Pharmacist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Psychologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Attorney\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSector\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Public\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Private\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Non-profit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Academic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTelemedicine experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Provision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Policy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Infrastructure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e- Limited/none\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRespondents perceived telemedicine as a valuable complement to in-clinic care with the potential to increase access to medical abortion. They identified various clinical and logistical bottlenecks to the implementation of telemedicine for medical abortion but described ways to overcome these challenges with innovative thinking and by utilising existing resources. To build health system readiness, respondents suggested increasing willingness with research and supportive leadership and building implementation capacity by creating strategic partnerships and aligning policies. Counteracting these bottlenecks to implement telemedicine for medical abortion in the public sector was perceived as possible and respondents recommended considering contextual differences and responsive adaptations to provide a spectrum of telemedicine service models.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCategories and subcategories generated from inductive content analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e1 Telemedicine as a complement to in-clinic care: increasing access, options and autonomy\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.1 Telemedicine is easier and more accessible for users\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.2 In-clinic care is difficult but still important\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 Out-of-the-box thinking to overcome implementation bottlenecks\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.1 Navigating clinical concerns with screening, information, and trust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.2 Drawing on existing resources to address logistical challenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 Increasing willingness and capacity to build health system readiness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.1 Offsetting the resistance to change with leadership and research\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.2 Aligning partnerships and policies to build implementation capacity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4 Not one size fits all: adapting telemedicine models to users and their contexts\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.1 Accommodating users\u0026rsquo; contexts, needs, and preferences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.2 Adapting to contextual differences and varying implementation readiness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1 Telemedicine as a complement to in-clinic care: increasing access, options and autonomy\u003c/h2\u003e \u003cp\u003eWhile various challenges to accessing in-clinic care were described by the respondents, in-clinic care was still viewed to be necessary. Telemedicine was viewed as valuable but positioned as a complement to in-clinic care by increasing access.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1.1 Telemedicine is easier and more accessible for users\u003c/h3\u003e\n\u003cp\u003eRespondents relayed how telemedicine could increase access to abortion services by mitigating various barriers to in-clinic abortion care, such as insufficient abortion providers and belief-based denial of service. Telemedicine was described as a potential channel to circumvent stigma and direct users to accessible services and supportive abortion providers. This was perceived as especially important for geographically dispersed communities where access to in-clinic services for abortion is limited.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"I think it is an excellent opportunity to increase access, especially where we have health systems that are really constrained, where we have people who can't always get to a health facility, where we have a lot of stigma around abortion services\u0026hellip; It's definitely something that can address so many limitations and barriers that we see today in reproductive health care.\" (Researcher)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents reasoned that telemedicine could decrease delays in accessing abortion care, thereby reducing the number of second-trimester abortions with higher costs and risks of complications. They further recounted benefits such as reducing the psychological capital of navigating in-clinic abortion services and alleviating experiences of judgment. Telemedicine was perceived as giving users a greater sense of autonomy and described as less disruptive to a person\u0026rsquo;s education, economic activity, and general health.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"It would save her so much time. It would save her so much money. It would save her so much of the trauma of having to find shelter in a city far away from where you live until someone can help you with your situation.\" (Attorney)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e1.2 In-clinic care is difficult but still important\u003c/h3\u003e\n\u003cp\u003eInterviews revealed the perceived challenges to accessing in-clinic care in South Africa today, including the inability of overburdened healthcare facilities to meet the high demand for abortion services, long travel times, inconvenient clinic opening hours, and users being denied access or turned away by gatekeepers at facilities.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They travel to the nearest city to try and get an abortion. They get there most of the time and there's a long line and they have to then either sleep outside or like, you know, just find some shelter until they can be seen\u0026hellip; The demand is so much and the actual provision of the service is so low that even with telemedicine there will still be a gap.\u0026rdquo; (Attorney)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLimited public abortion provision and unaffordable private services were viewed as drivers of unsafe abortion. While telemedicine would decrease this gap in service delivery, respondents stressed there will always be a need for in-clinic care and telemedicine should operate in parallel to it rather than replacing it. Respondents highlighted the perceived importance of providing options for abortion care to meet users\u0026rsquo; needs. They also emphasised the perceived need to increase access to in-clinic services to meet the needs of users who are not eligible for telemedicine or prefer in-clinic care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's a very good way of overcoming barriers to access. We know that many women prefer this option even if there are other options available. So it's not just about improving access, it's also about women's choices and preferences. But that being said, we will always need brick-and-mortar clinics. It's not an alternative. It's additional.\u0026rdquo; (Non-profit provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2 Out-of-the-box thinking to overcome implementation bottlenecks\u003c/h2\u003e \u003cp\u003eInterviews highlighted various perceived clinical and logistical bottlenecks to the implementation of telemedicine for medical abortion, but solutions were usually presented concurrently.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Navigating clinical concerns with screening, information, and trust\u003c/h2\u003e \u003cp\u003eSome respondents were apprehensive about the absence of an in-clinic visit and viewed this as a lost opportunity for additional health checks. Among their concerns were the lack of ultrasound or physical examination to confirm gestational age and discover ectopic pregnancies, that users would not accurately identify their gestational age (due to poor menstrual literacy or lying out of desperation), or that users would not administer the medication correctly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;You'd need to have quite a rigorous screening for the women that want to take part in telemedicine and think if there's any question mark on the validity or the accuracy or the honesty of the woman's answers, then she needs to be referred for in-person care.\u0026rdquo; (Non-profit provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents explained these concerns could be mitigated by conducting thorough eligibility screening and giving clear instructions on how to take the medication, what to expect, how to determine success, and what to do in case of complications. They also suggested standard operating procedures, consent forms, clear referral pathways to in-clinic care, record-keeping for telemedicine consultations, and clarity on where responsibility lies.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In this case, we're saving the woman's life because the risk is that she will go to an illegal provider.\u0026rdquo; (Pharmaceutical expert)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome respondents were worried that a telemedicine service would be used to get pills to sell informally and fuel unsafe abortions, while other respondents suggested telemedicine could shift more users to formal healthcare and reduce unsafe abortions. Increased comprehensive sexuality education, knowledge of reproductive rights, and awareness of where to access services were described as ways to support users in identifying their pregnancy earlier and knowing where to seek safe abortion care. Furthermore, interviews revealed the perceived need to be patient, trust users, and rely on their agency and self-knowledge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Drawing on existing resources to address logistical challenges\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eMedication collection should be easy and have multiple options\u003c/h2\u003e \u003cp\u003eRespondents noted the combination of mifepristone and misoprostol is more effective but limited by mifepristone\u0026rsquo;s high cost. Producing a generic version by government tender was suggested to improve access. Respondents shared various ideas for how users could get abortion medications, such as couriers, decentralised pick-up locations, vending machines, or pharmacies. They referred to other distribution mechanisms for inspiration, like decentralised collection points for chronic medication and government partnerships with private pharmacies to provide contraceptives. While respondents mentioned user verification during the collection or distribution of the medication, the focus was to make the experience simple and safe for users.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"In terms of collecting the medication, how can we make it easy for you to collect it? And because it might also not be possible to do a courier service in an informal settlement or something like that. So we need to think a little bit outside of the box and don't think that it won't work.\" (Non-profit provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThere are implementation costs, but telemedicine may be more cost-effective\u003c/h2\u003e \u003cp\u003eRespondents discussed various telemedicine service models with differing resource needs, ranging from low-budget implementations to high-level structural costs. Speculated costs included medications, call centres, and staff training. Respondents raised concerns about the decreasing health budget due to competing demands and advised strategic partnerships with private organisations to manage resources. Regardless of the model, respondents emphasised that services should be free for users, with the economic burden on the government. Respondents described how the option of telemedicine could reduce costs by decreasing in-clinic costs, surgical abortion rates, and complications from unsafe abortions. While telemedicine was expected to be more cost-effective over time, an economic evaluation was called for to show the return on investment of implementing telemedicine.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;But from cost-effectiveness or cost, like an economic evaluation side of things, we need to also think of the costs averted by implementing telehealth services\u0026hellip; So with each call you make, there's one less person in the clinic.\u0026rdquo; (Provincial policymaker)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTelemedicine can work now, but ICT infrastructure needs to be developed for scale-up\u003c/h2\u003e \u003cp\u003eSome respondents believed the basic ICT infrastructure for implementation was already in place and that telemedicine models should be designed based on what already exists. Others argued that more advanced digital structures were needed, including an electronic registry with user information, data security management, ICT infrastructure in public facilities, as well as database linkages to share clinical management and include telemedicine users in caseload totals. To meet consent requirements, verbal consent and recorded calls were positioned as easier than requiring a signed consent form. Respondents shared how telemedicine services are already happening to some degree on WhatsApp, but concerns around data protection and privacy were raised. Respondents emphasised the perceived need for an official, secure digital platform for telemedicine.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;At its most simplistic level, this could be implemented as a service on a proof of concept basis, if you like, using existing infrastructure and technologies and services. But if you really wanted to scale services more widely, then you need to get the dependencies in place.\u0026rdquo; (Public health ICT specialist)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eHealth workers\u0026rsquo; roles can adapt to include telemedicine\u003c/h2\u003e \u003cp\u003eRespondents had different ideas of who would provide telemedicine services, who would be responsible for it, and whether it would be managed from a facility, provincial, or national level. Most respondents suggested that nurses trained in abortion provision could adopt telemedicine services with a doctor on call for queries. Other trained personnel, like community healthcare workers and pharmacists, were also suggested to play key roles in service delivery and follow-up. Respondents discussed how health worker roles could be adapted to include telemedicine or how new roles could be created to exclusively deliver telemedicine services. Either way, they highlighted that providing telemedicine services should not increase the current burden on abortion providers. To facilitate sustainable implementation, respondents suggested engaging health workers in telemedicine service delivery and integration as well as developing their ICT skills and professional confidence in the telemedicine system.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think you develop a digital bedside manner when you do telemedicine\u0026hellip; you have to have a specific kind of mindset to do this work.\u0026rdquo; (Public health telemedicine specialist)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3 Increasing willingness and capacity to build health system readiness\u003c/h2\u003e \u003cp\u003eRespondents suggested supportive leadership and advocacy from researchers to increase implementation willingness as well as utilising strategic partnerships, updating training, and aligning policy to build implementation capacity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Offsetting the resistance to change with leadership and research\u003c/h2\u003e \u003cp\u003eWhile respondents perceived an increased appreciation of telemedicine since the COVID-19 pandemic, some still sensed a lack of willingness to implement this in the public sector. They attributed this reluctance to the fear of the unknown, resistance to change, and a high bar for clinical safety. To build telemedicine support from leadership, respondents suggested intentional engagement with stakeholders, champion recognition, and innovation showcases. Advocacy and commitment from national and provincial leaders were framed as facilitators of implementation, while apathetic or anti-choice attitudes of people in power would limit implementation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It\u0026rsquo;s difficult to change culture in a hospital if it isn\u0026rsquo;t a decree from above. There\u0026rsquo;s always fear\u0026hellip; I think you would need to have a formal directive to say this is acceptable and we can do this.\u0026rdquo; (Public provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents proposed allowing stakeholders to voice their concerns, acknowledging their apprehension, and using research to address these issues. They focused on sharing evidence of safety and examples of successful implementation to obtain buy-in. Furthermore, respondents called on researchers to become advocates and negotiate with the government to develop policy changes and build implementation capacity. They also encouraged researchers to share findings widely, engage with local leadership, and gain public support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Researchers really hold the tools and the knowledge that can inform a successful intervention in our country\u0026hellip; I think when we bring that together and we present it to the decision makers together, collectively, we solidify this approach that this is effective.\u0026rdquo; (Researcher)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Aligning partnerships and policies to build implementation capacity\u003c/h2\u003e \u003cp\u003eSome respondents believed sufficient evidence and willingness exists but the government is uncertain on how to move forward with implementing telemedicine services. They recommended piloting different models integrated with existing models of care to figure out what works, what needs to be improved, and what additional resources are needed. Respondents proposed partnerships across public, private, academic, and civil society sectors to support a collaborative model and suggested engaging with experts on telemedicine for medical abortion to guide sustainable implementation.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Government wants to implement it. I think they just don't quite know how to do it\u0026hellip; They need to rely on experts in this and we can tell them this is safe. This is the international standard now and the WHO says it\u0026rsquo;s safe.\u0026rdquo; (Non-profit provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTo build implementation capacity and confidence, interdepartmental collaboration was recommended to update curricula for training healthcare professionals with the integration of telemedicine and new demands in practice. In addition to training providers on telemedicine procedures, respondents highlighted training for other healthcare professionals on the option of telemedicine for medical abortion to assist with referral and reduce stigma. They also described the perceived importance of aligning policies, such as national telehealth guidelines and clinic designation processes, to integrate telemedicine for medical abortion.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026rsquo;s the responsibility of the service staff to consider how telehealth might make services to citizens better. Then it\u0026rsquo;s the responsibility of the policy and the system, i.e. us, to provide them with the tools, support, and guidelines they need to do that easily and safely.\u0026rdquo; (Provincial policymaker)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e4 Not one size fits all: adapting telemedicine models to users and their contexts\u003c/h2\u003e \u003cp\u003eInterviews revealed the perceived value of contextually adapted and user-centred approaches to support the usability and acceptability of telemedicine for medical abortion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Accommodating users\u0026rsquo; contexts, needs, and preferences\u003c/h2\u003e \u003cp\u003eRespondents perceived the usability of telemedicine for medical abortion to depend on users\u0026rsquo; access to the internet, privacy, and language. Respondents noted that data was costly, despite high digital penetration in South Africa, and suggested a data-free platform and toll-free call centre. While telemedicine could provide privacy for some users, respondents discussed how privacy might be more difficult for users who share a phone and live in confined spaces. They proposed a private space in facilities for users to utilise telemedicine services. Respondents also reflected on how the service could be designed to accommodate for language barriers, such as using illustrations and confirming the user understands the information.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\"Considering everybody and their abilities to access the service and to understand how to do it is important for a model in South Africa.\" (Researcher)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRespondents differed in their expected acceptability from users, such as mixed views on whether it would be more popular for younger or older users. They anticipated a potential lack of trust from users and suggested clear information to mitigate fears. Raising awareness through media campaigns and providing accessible information on abortion options were also suggested to increase acceptability. Respondents elaborated that telemedicine models should be informed by users\u0026rsquo; contextual challenges and responsive to their needs and preferences. They agreed that telemedicine would not be the solution for everyone, but it could be the right option for some people.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;This isn't going to be a one size fits all for every single client. There are going to be some clients where telemedicine is appropriate and some clients where it's not.\u0026rdquo; (Non-profit provider)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e4.2 Adapting to contextual differences and varying implementation readiness\u003c/h2\u003e \u003cp\u003eRespondents reflected on the cultural, geographical, and socioeconomic diversity of South Africa and considered the value of telemedicine in areas with limited abortion services as well as the challenges to implementation in these contexts. They suggested targeting different community groups according to their needs and providing options for in-clinic care or connectivity for telemedicine services. Respondents also described the marked provincial differences in abortion service provision and varying levels of readiness to adopt telemedicine as potential challenges to scaling up telemedicine services. To navigate these differences, they suggested engaging with provincial stakeholders to appropriately adapt telemedicine models.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have a vastly varied population\u0026hellip; with vastly different challenges and opportunities in those different areas. And so I think we need to acknowledge that we can't have a provincial level like one size fits all.\u0026rdquo; (Provincial policymaker)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eInterviews revealed a common perception that implementation was possible but would require work and out-of-the-box thinking. Respondents expressed that major organisational changes were not necessary, but rather figuring out where telemedicine fits in existing systems and adapting models accordingly.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Everything that you could consider to be a barrier or a risk is either already addressed in the research or is simply just a design barrier\u0026hellip; just because something is difficult, doesn't mean you can't do it. You just have to address it.\u0026rdquo; (Provincial policymaker)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese findings identified various bottlenecks to coverage of telemedicine for medical abortion, indicated along Baker et al.\u0026rsquo;s implementation pathway in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe results indicate that telemedicine for medical abortion was perceived as a valuable complement to in-clinic care but various implementation bottlenecks and potential solutions were discussed. We will examine our findings through the lens of Baker et al.\u0026rsquo;s model of the implementation pathway to understand what bottlenecks limit accessibility, availability, and effective coverage of telemedicine for medical abortion (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom the view of the implementation pathway, our study found that telemedicine for medical abortion was positioned as a beneficial intervention to increase coverage of safe abortion services in the public sector of South Africa. This mirrors previous findings from South Africa and other contexts that accessing in-clinic care can be difficult and telemedicine for medical abortion could provide an easier and highly acceptable option for users and providers, (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). While the perceived merit of telemedicine was clear, it was acknowledged that in-clinic care needed to be strengthened to support referrals and respond to complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAccording to Baker et al.\u0026rsquo;s implementation pathway, our findings revealed bottlenecks in access which affect \u003cb\u003eaccessibility coverage\u003c/b\u003e, restricting the proportion of the target population for whom telemedicine for medical abortion would be accessible (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). A scoping review on abortion stigma highlighted its impact on limiting awareness of abortion rights, access to information, and referral to safe services, including telemedical services (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). While our respondents described telemedicine as a channel to alleviate stigma, they also showed concern that users would struggle to correctly determine their gestational age to self-assess their eligibility for telemedicine services. Findings from Colombia echo poor menstrual knowledge as a barrier to accessing telemedicine for medical abortion (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). To increase knowledge and acceptability, our results proposed improved comprehensive sexuality education and awareness campaigns, inspired by the positive impact of HIV awareness campaigns (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eContextual differences in users\u0026rsquo; connectivity, privacy, and language needs were also perceived as potential barriers to access. A study on ethical considerations for mobile phone interventions in South Africa described obstacles such as participants sharing a mobile phone and receiving messages for other people, changing their phone number due to theft, and struggling to afford airtime, get network coverage, or charge their phone (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Our respondents mirrored these concerns and suggested data- or toll-free options. Similarly, research in Mexico found that targeted telemedicine approaches are needed to support underserved, geographically dispersed populations (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Differences in language and literacy were also raised as implementation challenges and our respondents called for telemedicine models to accommodate language barriers and use visual aids. A study in the US on language-specific challenges to general telemedicine services added having language representation in telemedicine providers and using interpretation services (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBaker et al.\u0026rsquo;s implementation pathway illustrates how \u003cb\u003eavailability coverage\u003c/b\u003e is curbed by bottlenecks in health facility readiness, restricting the proportion for whom telemedicine for medical abortion is available (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Our results showed that the availability of telemedicine services depended on the type of delivery model and working with existing systems to maximise implementation capacity was suggested, such as utilising available human resources, medication systems, and ICT infrastructure. Respondents encouraged using current abortion providers and addressing staffing constraints, supported by research findings that a lack of trained providers hinders the integration of telemedicine and the importance of building organisational capacity before implementation by confirming the availability of trained providers (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Our respondents\u0026rsquo; perceptions of medication distribution were aligned with a scoping review of medication distribution which found new methods, such as automated pharmacy dispensing units and smart lockers, to be cheaper and better for users than collecting medication from facilities (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). A study in the US noticed that clinics with the required medication and ICT resources to provide telemedicine for medical abortion were able to implement services more efficiently (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Some of our respondents believed the required ICT infrastructure for telemedicine already existed while others insisted on developing more complex digital systems.\u003c/p\u003e \u003cp\u003eOn telemedicine for general health services in African settings, research reflects that limitations in ICT infrastructure can reduce the availability of services, but simple telemedicine technologies could optimise initial set-up costs (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). A review of telemedicine services in the OECD supports the notion of cost-effectiveness, although poor reporting and quality limited generalisability (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Similarly, our respondents perceived telemedicine could be more cost-effective in the long term but encouraged an economic evaluation to determine this and inform multisectoral collaboration. Public-private partnerships and collaboration with civil society organisations were highlighted as central to building implementation capacity and health system readiness. In other contexts, collaboration has been shown to support implementation feasibility, such as developing network infrastructure with mobile technology operators, receiving information materials from civil society organisations, and reaching agreements with delivery companies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Our findings echo the perceived importance of support from organisational leadership, champion providers, and engaged academics that have been linked to sustainable implementation (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAt the last stage of Baker et al.\u0026rsquo;s implementation pathway, bottlenecks in clinical practice influence \u003cb\u003eeffectiveness coverage\u003c/b\u003e, further impacting the proportion of the target population who receive telemedicine for medical abortion services as intended (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Our results identified clinical concerns about telemedicine for medical abortion regarding the lack of ultrasound or physical examination, despite evidence that the absence of ultrasound in telemedicine models does not result in more complications than models using ultrasound before an abortion and ultrasound dating could suitably be excluded for the majority of pregnant people who were certain of their last menstrual period (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Our respondents also raised concerns about complications and misuse, which have been linked to the lower acceptability of implementing telemedicine for medical abortion among less experienced providers in Colombia (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Addressing these concerns, the RCT in South Africa found high adherence to medication instructions in addition to high safety, acceptability, and effectiveness (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Our findings promoted research dissemination to address knowledge gaps and encourage evidence-based practices, as reflected in an implementation study in the US (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur respondents called for ICT training for telemedicine providers and increased awareness of telemedicine for medical abortion in other healthcare professionals to facilitate decision-making support and referral. The need for telehealth training, value clarification activities, and clear guidelines is supported by other implementation studies (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Our respondents discussed integrating information on telemedicine for medical abortion and basic abortion procedures into the training curriculum for nurses. This connects to other research calling for the inclusion of abortion training in South African medical education as well as the introduction to general telemedicine technology (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn South Africa and Colombia, implementation research has identified how policies can create barriers for those most in need of telemedicine services, like requirements for video calls, and limit provision, such as strictly regulating telehealth in providers\u0026rsquo; scope of practice (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). To support provision of appropriate and effective telemedicine services, our findings indicated policy alignment would be needed. Our respondents also acknowledged that service-delivery models should be adapted according to varying access needs, implementation readiness, and clinical skills to increase the intervention coverage of telemedicine for medical abortion.\u003c/p\u003e \u003cp\u003eThe findings of this study highlight key steps towards effective implementation: telehealth and medical abortion policies should be aligned for consistency, medication distribution systems should be mapped to ensure telemedicine models achieve national coverage, the national ICT infrastructure should be evaluated for practical integration with telemedicine, awareness campaigns should be conducted to guide users and referrals toward available telemedicine services, and stakeholders should be engaged in establishing partnerships that expand access to telemedicine for medical abortion.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe application of a theoretical model strengthens the credibility of the results and informs on the identified bottlenecks to implementing telemedicine for medical abortion in South Africa and similar settings. By drawing on experiences from a wide range of experts across different sectors in South Africa, this study provided rich detail on perceived implementation bottlenecks and potential solutions. However, participants were selected based on their connection to telemedicine or medical abortion, so they are likely to be more permissive participants than the general population of healthcare professionals or associated professionals. This might have given a more positive impression of stakeholder readiness and the ability to overcome implementation bottlenecks than what exists in reality. Most informants also came from a management, policy, or research background, so there are limited perspectives from potential public providers of telemedicine for medical abortion and stakeholders working on the ground.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study has shown that professionals perceived telemedicine to be a valuable option for abortion provision that will increase access and convenience for users, especially in tandem with in-clinic care. However, clinical concerns and logistical challenges were identified as bottlenecks to implementation which could be overcome with innovative thinking and working with existing resources. Professionals also suggested building implementation readiness and adapting telemedicine models to contextual differences. Active steps should be made in policy and practice toward implementing telemedicine for medical abortion in the public sector to increase access to safe abortions in South Africa.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOREQ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Consolidated Criteria for Reporting Qualitative Research\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eCOVID-19\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCoronavirus disease 2019\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHIV\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman immunodeficiency virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eICT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eInformation and communication technology\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eOECD\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eThe Organization for Economic Cooperation and Development\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eRCT\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRandomised controlled trial\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organization\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUK\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited Kingdom\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch4\u003eEthics approval and consent to participate\u003c/h4\u003e\n\u003cp\u003eEthical approval for the study was obtained from the University of Cape Town Health Sciences Human Research Ethics Committee (HREC Ref: 837/2020). All participants provided written informed consent to participate in this study.\u003c/p\u003e\n\u003ch4\u003eConsent for publication\u003c/h4\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch4\u003eAvailability of data and materials\u003c/h4\u003e\n\u003cp\u003eAll qualitative data were obtained from interviews with study participants. The data is not publicly available to protect study participant privacy.\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eCompeting interests\u003c/h4\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch4\u003eFunding\u003c/h4\u003e\n\u003cp\u003eThis study was funded by the Swedish Research Council (2020-04421). The funder did not have a role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003ch4\u003eAuthors\u0026apos; contributions\u003c/h4\u003e\n\u003cp\u003eME had the idea for the study. SS, AC and ME designed the study. SS conducted the interviews and developed the analysis with feedback from AC and ME. SS drafted the manuscript. AC and ME reviewed the manuscript and provided supervision. All authors contributed to the article and approved the final manuscript.\u003c/p\u003e\n\u003ch4\u003eAcknowledgements\u003c/h4\u003e\n\u003cp\u003eWe are grateful for the participation of all interviewees and appreciate the important work they do to increase access to healthcare services.\u003c/p\u003e\n\u003ch4\u003eAuthors\u0026apos; information\u003c/h4\u003e\n\u003cp\u003eNot included.\u003c/p\u003e\n\u003ch4\u003eFootnotes\u003c/h4\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOwolabi OO, Biddlecom A, Whitehead HS. Health systems\u0026rsquo; capacity to provide post-abortion care: a multicountry analysis using signal functions. 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Focus Health Prof Educ Multi-Prof J. 2022;23(1):111\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKillinger K, G\u0026uuml;nther S, Gomperts R, Atay H, Endler M. Why women choose abortion through telemedicine outside the formal health sector in Germany: a mixed-methods study. BMJ Sex Reprod Health. 2022;48(e1):e6\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSorhaindo AM, Lavelanet AF. Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care. Soc Sci Med. 2022;311:115271.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeltzer K, Parker W, Mabaso M, Makonko E, Zuma K, Ramlagan S. Impact of National HIV and AIDS Communication Campaigns in South Africa to Reduce HIV Risk Behaviour. Sci World J. 2012;2012:e384608.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJack CL, Mars M. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ajol.info/index.php/safp/article/view/235096\u003c/span\u003e\u003cspan address=\"https://www.ajol.info/index.php/safp/article/view/235096\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDodoo JE, Al-Samarraie H, Alzahrani AI. Telemedicine use in Sub-Saharan Africa: Barriers and policy recommendations for Covid-19 and beyond. Int J Med Inf. 2021;151:104467.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEze ND, Mateus C, Hashiguchi TCO. Telemedicine in the OECD: An umbrella review of clinical and cost-effectiveness, patient experience and implementation. PLoS ONE. 2020;15(8):e0237585.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSibuyi IN, de la Harpe R, Stakeholder-Centered NPA. mHealth Implementation Inquiry Within the Digital Health Innovation Ecosystem in South Africa: MomConnect as a Demonstration Case. JMIR MHealth UHealth. 2022;10(6):e18188.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConstant D, Harries J, Moodley J, Myer L. Accuracy of gestational age estimation from last menstrual period among women seeking abortion in South Africa, with a view to task sharing: a mixed methods study. Reprod Health. 2017;14(1):100.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarries J, Constant D. Providing safe abortion services: Experiences and perspectives of providers in South Africa. Best Pract Res Clin Obstet Gynaecol. 2020;62:79\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Telemedicine, medical abortion, public health, access, implementation bottlenecks, South Africa","lastPublishedDoi":"10.21203/rs.3.rs-5790305/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5790305/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbortion in South Africa is legal, but there are still many barriers to access and high utilisation of the informal sector. Telemedicine for medical abortion is an alternative model that has been found to be a safe, effective, and acceptable option to increase access to abortion services. This study aimed to understand how key informants view telemedicine for medical abortion and how they view potential bottlenecks and solutions concerning implementation in the public sector of South Africa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterviews were conducted between February and March 2023 with 19 experts across telemedicine and medical abortion provision, policy, and research. The study had a qualitative design and interviews were analysed using inductive content analysis. Baker et al.’s model of the implementation pathway was used to conceptualise and discuss the findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings showed that telemedicine was perceived as a valuable complement to in-clinic care to increase access to safe abortions. Respondents identified clinical concerns and logistical challenges as implementation bottlenecks which could be overcome with innovative thinking and by drawing on existing resources. Research, leadership, collaboration, and policy alignment were suggested to increase stakeholder willingness and capacity to build health system readiness. Across the implementation process, it was viewed as necessary to consider users’ needs and adapt to contextual differences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTelemedicine was found to be a valuable model for increasing access to safe abortion services. Considerations and actionable steps to overcome implementation bottlenecks were provided to guide implementing telemedicine for medical abortion in the public sector of South Africa and similar settings.\u003c/p\u003e","manuscriptTitle":"Implementing telemedicine for medical abortion within the public health system: A qualitative study on implementation bottlenecks and solutions in South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-13 06:07:23","doi":"10.21203/rs.3.rs-5790305/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-10T13:29:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-10T09:05:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-09T11:53:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-01-08T15:20:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13e522ee-7306-4e34-8390-6fe434df3ed7","owner":[],"postedDate":"January 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:06:57+00:00","versionOfRecord":{"articleIdentity":"rs-5790305","link":"https://doi.org/10.1186/s12889-025-24690-0","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-10-09 15:58:05","publishedOnDateReadable":"October 9th, 2025"},"versionCreatedAt":"2025-01-13 06:07:23","video":"","vorDoi":"10.1186/s12889-025-24690-0","vorDoiUrl":"https://doi.org/10.1186/s12889-025-24690-0","workflowStages":[]},"version":"v1","identity":"rs-5790305","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5790305","identity":"rs-5790305","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}