TELEHEALTH restrictions introduced by the federal Department of Health on 20 July 2020 discriminate against women seeking early medical abortion (EMA), making an already hard to access procedure even more out of reach.
Professor Danielle Mazza, Head of the Department of General Practice at Monash University, told InSight+ that telehealth offers an opportunity to address limited access to EMA during the COVID-19 pandemic and beyond.
“Telehealth is an amazing tool to increase equity of access because if you can’t get that service provided to you locally, you can get the service provided to you by another provider in a different geographical location,” Professor Mazza said.
“At the moment, 2317 GPs in Australia are currently registered prescribers of MS2Step (mifepristone and misoprostol), but we think far fewer actually go on to actively prescribe.
“Actually, setting up this service in your practice involves a number of other steps and having the confidence to do it, plus having the support of your colleagues in your practice, the front desk manager and the reception staff.
“So, you can do the course [in order to become a prescriber], but that doesn’t mean you’re actually going to deliver the service.”
“Telehealth therefore helps women to overcome that problem of not having a local provider in their region.”
With the advent of the COVID-19 pandemic the federal Department of Health introduced temporary Medicare Benefits Schedule (MBS) item numbers for telehealth GP consultations to enable patients to see their doctors in a contactless environment.
But since 20 July, new restrictions to those MBS item numbers have been implemented, namely restricting eligibility to only patients who have visited the GP or practice in the previous 12 months or those who have been referred by a specialist, except for where there is a current lockdown in place.
“The changes that were introduced on 20 July were trying to support continuity of care, and that’s a very important principle,” Professor Mazza said.
“I’m a GP. I understand the benefits of continuity of care, but you can’t have continuity of care if you don’t provide a service.”
In a Perspective published today by the MJA, Professor Mazza and colleagues wrote that the new restrictions “will greatly reduce women’s access to EMA”.
“Placing restrictions on the eligibility criteria for MBS-subsidised telehealth services severely affects women’s access to GPs who can provide EMA, and discriminates against women who have not recently engaged with a GP due to various forms of disadvantage, such as family violence and unemployment.
“Exemptions to the restrictions have already been identified for people who are homeless and for children aged less than 12 months.
“Therefore, a further exemption should also be issued so that registered prescribers of medical abortion are able to use MBS telehealth item numbers for the benefit of Australian women.”
Telehealth, Professor Mazza told InSight+, was a vital link in the provision of EMA, particularly to women in rural and regional settings.
“A lot of women don’t even know that a medical abortion is an option,” she said.
“Because abortion is so stigmatised in our society, when women have an unplanned pregnancy and make a decision to have an abortion, think about who they might talk to, to get information.
“[Initially] it’s their friends and family, who may not know much about abortions.
“Then they might turn to their GP, who if they’re not a provider themselves may not be familiar with the whole process of medical abortion. Or indeed their GP might be a conscientious objector to abortion, and who, again, may not really actively assist that woman to navigate the system to find a service.”
The impact of COVID-19 could not be underestimated, she said.
“There’s been a lot of talk and research to demonstrate how COVID-19 has impacted women’s lives – not only from a sense of fear about the future and about safety and wellbeing, but also increased burden in terms of mental health issues, problems with financial insecurity, women losing their jobs because they are often working casually or part-time and are the first to go, or their partners might have lost their jobs.
“And, of course, we’re all aware of the increased rates of domestic violence that unfortunately women are suffering during the pandemic.
“So, if you think about women who find themselves with an unplanned pregnancy facing all of those issues, more women are seeking information about their options and considering the option of not continuing with the pregnancy in those circumstances.”
Professor Mazza said she and her colleagues have had meetings with the Department of Health and ministerial advisors about gaining an exemption for EMA.
“There have been concerns about things like needing to be able to offer follow-up care,” she said.
“We’ve argued very strongly that the international protocols and guidelines endorse the fact that follow-up can be done remotely via telehealth. You can ascertain what’s going on with a woman at the end of the phone and work out how to help her in the small number of cases where the medical abortion may have some complications.
“It’s very feasible, and it’s acceptable to women to have a medical abortion via telehealth.”
The response from the Department? “They’re looking into it,” said Professor Mazza.
The exemption from the telehealth restrictions is not the only thing that could be done to improve access to EMA, she said.
In their Perspective, Professor Mazza and colleagues wrote that there were other measures which would optimise the ability of telehealth to improve access to EMA for all Australian women:
- a national hotline or online platform, similar to the 1800 My Options service (www.1800myoptions.org.au) in Victoria, which directs women to local abortion service providers, is required to assist women to identify an appropriate provider;
- changes are required to current Therapeutic Goods Administration and Pharmaceutical Benefits Scheme provisions restricting the prescription of MS-2 Step (mifepristone and misoprostol) to up to 63 days’ gestation – these criteria are outdated and discordant with current evidence demonstrating that EMA up to 70 days’ gestation is comparable in safety and efficacy to 63 days’ gestation or less;
- modifications are required to EMA protocols, particularly during the COVID-19 pandemic – the Royal Australian and New Zealand College of Obstetricians and Gynaecologists has already advised that a clinician may appropriately decide not to administer anti-D IgG before 10 weeks for the medical management of abortion, particularly when an additional visit may increase exposure of women and staff to COVID-19;
- in situations where obtaining an ultrasound is a significant barrier or poses a significant risk during the COVID-19 pandemic, EMA may proceed without the necessity of ultrasound assessment but only after careful screening for risk factors for ectopic pregnancy and where an accurate gestational age can be estimated from the woman’s history;
- in South Australia mifepristone can only be supplied in a hospital setting – this precludes South Australian women from being able to access EMA through community-based providers such as GPs or via telehealth; the relevant South Australian legislation therefore requires a change.
“In women’s reproductive lives, they need help with pre-conception care and with contraception. Contraception sometimes fails or there are reasons why women haven’t been able to use it,” Professor Mazza told InSight+.
“We know about the impact of unplanned pregnancies, not only on women’s lives but also on the lives of their other children and families, if women are not able to access abortion services when they need it.”
Also online at the MJA
Perspective: Diagnostic error: incidence, impacts, causes and preventive strategies
Scott and Crock; doi: 10.5694/mja2.50771 … FREE ACCESS for 1 week
Perspective: Chimeric antigen receptor T‐cell therapy for haematological malignancies
Selim and Tam; doi: 10.5694/mja2.50783 … FREE ACCESS for 1 week