Abortion via Teleconsultation in France: Interview with Dr. Philippe Faucher
by Clémence Chbat*
Philippe Faucher is an obstetrician-gynecologist, he is head of the orthogenics unit at Trousseau hospital in Paris. He is specialized in abortion, contraception and the monitoring of women living with HIV. In 2004, he founded REVHO, a network of doctors that link the city to the hospital. This network implements the new regulations and protocols about abortion in doctors’ offices outside health facilities. REVHO allows, by training health professionals and informing patients, greater quality and access to abortion. Since 2019, Philippe Faucher has been associate editor for the British Medical Journal in Sexual and Reproductive Health.
Can you introduce yourself? What are the elements of your professional and personal career that have led you to take an interest in abortions?
I am a trained obstetrician-gynecologist. In 1995, I was offered a job as head of the orthogenesis center. In general, we go towards “more prestigious” specialties [laughs]. But I wanted to continue to work in a public hospital, so I accepted. I was trained “on the job” so to speak because there was at the time very little training in abortion and contraception. I then resigned for other reasons. I found myself without a hospital and then accepted a position at Saint-Denis hospital [in the Paris region], and met Danielle Hassoun, who is a reference in abortion! She interested me, took me with her to Vietnam, Tunisia, South Africa ... to do trainings. Since that date, I have worked at Bichat Hospital and then at Trousseau Hospital, where I still work, on contraception and abortion. I write articles when I can.
What would you say about the journey of women who want a medical abortion in France?
For me, there is a problem of access and delays to make an appointment.
For example, I suggest an appointment through Doctolib, that facilitates access, but this is not the case for many doctors. There is a “cocooning philosophy” in France, you have to surround women, they can see advisers ... there is a cleavage or a small opposition between the supporters of a very direct access, like in the Anglo-Saxon or Nordic fashion, and supporters of an interview with a counselor, having them on the phone to make an appointment etc.
Direct access saves them the hassle of appointments, but that's not the case everywhere, and the phone can ring in the void. Lack of access is what characterizes territorial inequalities. For example, between the inner suburbs in Paris and the outer suburbs, or between urban and rural areas, there is a real difference of access.
For me, the biggest challenge is to be able to access abortion quickly. And telemedicine allows this rapid access.
Why do you think there is this cleavage?
[Hesitates] I don't know .. I wouldn't want to say something that is unfounded.
Can you describe to me the first days of confinement in France in your unit, before government measures were taken? What have you put in place in your unit, for example?
I made a video that went around a lot, telling women not to be afraid to come for a consultation. For the hospital part, there is the website ivglesadresses.org so that women do not hesitate to consult. I sent an email to all my medical colleagues listed in REVHO, to offer training in abortion by vaccum aspiration by doing local anesthesia, which is done in one day. I had a lot of answers, whereas before I had few answers. This part was a benefit of the covid.
So it was a bit of activism, a tribune in Le Monde newspaper, which called for an extension of the legal frame from 14 to 16 weeks [of amenorrhea], and the launch of abortion by telemedicine.
When the Minister of Health said I see no connection between abortion and the pandemic[1], we opened his eyes a little, with this tribune signed by political, medical and cultural personalities. This helped to point out inconsistencies, such as hospitalization between 7 and 9 weeks [of amenorrhea]. The DGS [General Directorate of Health] has moved, we can do an abortion for up to 9 weeks now without hospitalization. Or pick up the drugs at the pharmacy. However, they refused to extend the abortion to 16 weeks [of amenorrhea].
They accepted telemedicine even though they disseminated this information very little. It didn't work out that much.
They realized that there were inconsistencies such as the use of Géméprost. This drug has to be stored in the freezer, it became impossible to offer abortion without hospitalizing women between 7 and 9 weeks. They were therefore forced to review the recommendations and replace Géméprost with misoprostol as it is done around the world.
The Minister of Health seized the HAS [Haute Autorité de Santé], it was beneficial. They have been issuing recommendations a month ago, where there is no hospitalization up to 9 weeks.
But after the recommendations, it must be put into practice.
Have you had any feedback from doctors, or have you yourself performed abortion by telemedicine?
Out of 350 REVHO members, 50 answered our questionnaire, only one doctor did consultations from A to Z. The others mainly did telemedicine for a consultation, for example for the check-up. But that’s not doing abortion by telemedicine!
And yourself, have you been able to put it into practice?
The problem is that it only concerned doctors working outside hospitals, not in hospitals. It was not designed for hospitals. So I couldn't bill for these treatments. I did 5 telemedicine consultations. The patients were delighted. But they had troubles with pharmacists! The pharmacist had to be notified by the doctor, etc. whereas before, it was the doctor who would collect these drugs from the pharmacy.
We had done a little acceptance questionnaire, but a little one. Women did not regret it, and the idea that they did not have to come to an orthogenetic center pleased them. There was one who told me "yes even psychologically, it is stigmatizing, there is the heavy side of this abortion unit"
There, she goes to the pharmacy to take her medicines, she takes them, it feels like a miscarriage, another said to me: “I lived it much better than if I had had to do it in an abortion center I think ”.
And other colleagues at the hospital?
In my hospital, I am the only one to do abortions.
The other doctors don't. Billing is different between the city and the hospital. The central hospital pharmacy has a budget which is included in the general hospital budget. In the city it's different.
In your opinion, is this a tool to perpetuate after the state of emergency?
Absolutely! They forgot about the hospitals again... but telemedicine should be available everywhere. City doctors don't want to, they need to be well supervised. If we, in hospitals, start doing it, we will be able to publish French studies, published in French, showing that there were no complications in France.
But these studies exist...
Even if these studies exist, we are chauvinistic you know!
In REVHO, we're going to do one. We’re going to ask which doctors are ready to do it, and we’re going to do acceptability studies for women to spread it. There is still a lot of reluctance. So to get to do it without testing (without ultrasound, without rhesus test), it will take time to lighten the process. There are still women who come with 3 ultrasounds!
There is the fear of ectopic pregnancy, the fear of being sued, and there is always someone to describe a case… one woman… who almost died of an ectopic pregnancy ... But we will take her in charge very quickly, and on the contrary, if the rate of B-HCG does not decrease, we will know how to take her in charge, and quickly!
In France, doctors who practice in mistrust of the scientific approach, in contempt of international studies ... Look at Raoult during the covid crisis!
Do you think there is a training problem?
Yes, there is a big weakness in France in postgraduate training. But I have a lot of hope with young GPs, doctors, midwives. With young people, it will be fine. But you have 40 to 60-year-old doctors who don't get training, who don't go to conventions. These you will not see them unfortunately.
* This interview was conducted by Clémence Chbat, midwife and master student in public health at the École des Hautes Etudes de Santé Publique in France. Her internship takes place with Women On Web around telemedicine abortion in France. In order to support her research, she interviewed experts and actors in the field to better understand the issues surrounding this subject.