A total of 821 records were retrieved in the initial search, out of which 87 were duplicates. After reviewing the 734 remaining publications, only 21 met the eligibility criteria (Fig. 1).

PRISMA diagram: flow of search, screening, and selection of studies

Table 1 summarizes the characteristics of the 21 studies included in our review. Out of such studies published between 2011 and 2022, 20 were cross-sectional [18, 20, 24, 26, 28,29,30,31, 33, 34, 43,44,45,46,47,48,49,50,51,52] and 1 was an RCT [32]. Regarding their geographical distribution, 7 (33.3%) originated from.

European countries, 6 (28.6%) from the United States (US), 3 (14.3%) from Latin America, 2 (9.5%) from Australia, 2 (9.5%) were multi-country studies, and 1 (4.8%) was from South Africa. The overall risk of bias was from low to serious in the cross-sectional studies, while the RCT exhibited a high risk of bias (Fig. 2).

Bias risk assessment of the included studies

Furthermore, 14 (66.7%) evaluated MAB provided through telemedicine as the sole intervention, and 7 (33.3%) compared it with standard care. In terms of gestational weeks, 9 studies (42.8%) included pregnant people at up to 9 weeks of pregnancy, 7 (33.3%) at up to 10 weeks, 3 (14.3%) at up to 12 weeks, and 2 (9.5%) beyond 12 weeks. 16 studies (76.2%) reported on the effectiveness of MAB, 16 (76.2%) examined the safety of the procedure, and 9 (42.8%) addressed user acceptability or satisfaction with the service. Other outcomes assessed in the studies included follow-up (n = 4; 19%), feelings regarding the procedure (n = 3; 14.3%), and average waiting time to treatment (n = 1; 4.8%).

Sixteen studies evaluated the effectiveness of MAB, with ten exclusively evaluating telemedicine patients [18, 30, 31, 33, 34, 43, 45,46,47,48], and the remaining six comparing this outcome among telemedicine patients and standard patients [20, 26, 29, 32, 50, 52]. Treatment success was primarily confirmed through blood tests, followed by ultrasound. Only one study [20] used self-assessment to confirm termination of pregnancy.

In the studies that focused on telemedicine patients, the average effectiveness was 91.9%. All studies reported a standard regimen of 200 mg of orally, vaginally, or sublingually administered mifepristone, followed by an 800 µg dose of misoprostol after 24–48 h. Moreover, additional doses of misoprostol were administered after 3–4 h: six studies [18, 30, 34, 43, 46, 47] reported doses of up to 400 µg, three studies [31, 45, 48] reported doses of up to 800 µg, and one study [33] reported doses of up to 1600 µg. According to the results, increasing additional doses resulted in higher effectiveness rates (90.2%, 93.1%, and 98% respectively).

Six studies [26, 29, 32, 50, 52, 53] were conducted to compare the effectiveness of MAB between patients receiving telemedicine compared with standard care. 77,682 pregnant individuals made up the total sample size, with 43% using the telemedicine modality and 57% using standard care. A meta-analysis of the comparative effectiveness of the studies revealed no statistically significant differences between the two modalities of care (98.6% for telemedicine vs. 97.1% for standard care; RD = 0.01; 95% CI 0.00, 0.02).

Three of them [26, 32, 52] included pregnant people at up to nine weeks of pregnancy, two [20, 29] at up to ten weeks, and one [50] at up to twelve weeks. Moreover, one study [20] reported an additional 400-µg dose of misoprostol after 3–4 h, and two studies [26, 50] reported additional doses of up to 800 µg of misoprostol after the same time interval.

A subgroup analysis according to gestational age (Fig. 3) revealed that, in pregnancies of less than 12 weeks of gestation, there were 10 more successful cases in the standard care group than in the telemedicine group for every 1,000 MAB performed (RD = 0.01; 95% CI 0.01, 0.02). No statistically significant differences were observed among the subgroups of pregnancies under 9 and 10 weeks of gestation (RD = 0.01; 95% CI -0.00, 0.03 and RD = 0.01; 95% CI 0.00, 0.01, respectively).

Effectiveness of medication abortion via telemedicine compared to standard care by gestational week subgroups. A. Pregnant people up to 9 weeks pregnant, B. Pregnant people up to 10 weeks pregnant, C Pregnant people up to 12 weeks pregnant

Assessing effectiveness based on the method used to confirm successful abortion (Fig. 4), the meta-analysis revealed a slight advantage for standard care when either a blood test alone (RD = 0.02; 95%CI 0.01, 0.02) or informed clinical opinion (RD = 0.01; 95%CI 0.01, 0.02) were used, where for 1000 abortions performed, 20 or 10 cases of successful abortion were found in favour of standard care than in telemedicine, respectively. The certainty of the evidence for this outcome was low and moderate (supplementary Table 1).

Effectiveness of medication abortion via telemedicine compared to standard care by method of pregnancy confirmation. A Self-report, B Serology test, C Ultrasound, D Combined: serology test, urine test or ultrasound, E Combined: serology test or clinical concept

In their study, Kohn et al. [50] demonstrated a higher rate of ongoing pregnancy in standard patients compared to telemedicine patients (1.8% vs. 0.5%.; OR = 0.23; 95%CI 0.14, 0.39).

Two cross-sectional studies investigated the mortality associated with MAB provided via telemedicine [50, 52]. Both studies employed a standard dose of 200 mg of mifepristone and 800 µg of misoprostol, with variations in the additional doses of misoprostol. One of the studies did not employ any additional dose [52], whereas the other used up to an additional 800-µg dose [50]. No deaths were reported during the follow-up period.

Thirteen studies included surgical intervention as an adverse effect of MAB, with nine reporting the incidence of this event for telemedicine patients only [18, 30, 31, 34, 43, 45,46,47,48] and the other four comparing this outcome between telemedicine patients and standard patients [20, 26, 50, 52].

In the studies that focused on telemedicine patients, the average percentage of surgical interventions was 8.1%. In all these studies, additional doses of misoprostol were administered. Six studies [18, 30, 34, 43, 46, 47] used additional doses of up to 400 µg [20], and the average percentage of surgical interventions was 10.4%. The other 3 studies [31, 45, 48] reported using additional doses of up to 800 µg, and the average percentage of surgical interventions was 3.6%.

In the four studies that compared the percentage of surgical interventions between telemedicine patients and standard patients, the treatment regimens varied in terms of the additional doses of misoprostol. One study did not employ any additional dose [52], another used a 400-µg dose [20], and two studies reported using 800 µg of misoprostol [26, 50]. Regarding gestational weeks, two studies included pregnant people up to nine weeks [20, 26], one up to ten weeks [52], and one up to twelve weeks [50]. The combined effect analysis did not reveal any differences between the two forms of healthcare delivery (RD = 0.00; 95%CI—0.00, 0.00; n = 78, 098; I2 = 94%) (Fig. 5). In the subgroup meta-analyses (based on gestational weeks), no differences were found in the occurrence of surgical interventions following MAB. The certainty of the evidence was very low (supplementary Table 1).

Surgical intervention after medication abortion via telemedicine compared to standard care

Eight studies examined the occurrence of blood transfusion events following MAB, with four exclusively focusing on telemedicine patients [18, 34,