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Introduction
About a quarter of the world's population lives in countries with highly restrictive abortion laws. 1 Women in these countries often resort to unsafe methods to end their pregnancies. Globally, each year an estimated 43000 women die as a result of lack of access to safe legal abortion services through their countries' formal healthcare systems. 2 Millions more have complications. 3 Worldwide, the fourth leading cause of maternal mortality is unsafe abortion. 4
Yet in many countries, self sourced medical abortion provides a vital alternative to dangerous methods such as using sharp objects or noxious substances. Women source mifepristone and misoprostol (or misoprostol alone) themselves and use the medications outside the formal healthcare system. In some settings, women buy the medications from pharmacies or markets. 5 In other settings, they can self source using online telemedicine initiatives that provide medications as well as help and support by email or instant messaging. 6
One setting in which online telemedicine has dramatically changed women's access to abortion is in the Republic of Ireland and Northern Ireland. Abortion laws in both the Republic and Northern Ireland are among the most restrictive in the world. 1 Abortion is allowed only to save a women's life and, in Northern Ireland only, her permanent physical and mental health. 7 8 Although Northern Ireland is part of the UK, the Northern Irish legislature did not adopt the 1967 Abortion Act, which legalised abortion carried out by registered medical practitioners in England, Scotland, and Wales. As a result, abortion under most circumstances remains illegal there under the Offences Against the Person Act of 1861, which provides a maximum penalty for the woman undergoing the abortion of life imprisonment. 9
Women from the Republic and Northern Ireland who do not want to, or feel they cannot, continue with a pregnancy have traditionally had three options: those with the requisite financial and logistical means can travel abroad to access abortion in a clinic, while those who do not must either self induce using an unsafe method or continue their unwanted pregnancy. For the past decade, however, women of all financial means have also had the option to self source early medical abortion through online telemedicine. 10 11
Despite having been used by thousands of...