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LEGISLATIVE support for abortion is nationwide in Australia, to varying degrees, but that has limited value if there are not enough doctors willing to prescribe medical abortion, or public hospitals willing to provide access to surgical abortion, say experts.
With the overturn of Roe v Wade by the US Supreme Court (SCOTUS) last week, power to determine abortion access in the US has reverted to the states, with abortion bans in Arkansas, Kentucky, Missouri, Oklahoma, South Dakota, Utah and Alabama coming into immediate effect. Louisiana’s ban was temporarily blocked by a District Court judge. Idaho, Tennessee and Texas will implement abortion bans within 30 days of the SCOTUS decision. Abortion bans in Mississippi, North Dakota and Wyoming go into effect when legislative bodies certify the SCOTUS ruling.
Effectively people needing abortions in those states will be forced to either travel to a state where it is legal, carry the baby to term, or risk an illegal abortion with all the health and legal consequences that may entail.
So, surely Australian people needing abortion are in a stronger position than their US counterparts? It turns out, not so much.
“We’ve still got big challenges in terms of access,” said Professor Deborah Bateson, Professor of Practice at the University of Sydney and former Medical Director of Family Planning New South Wales.
Dr Philip Goldstone, Executive Director of Medical Services and Medical Director of MSI Australia, agreed.
“Ideally, women should have access to surgical abortion in their local health district through the local hospital, and ideally they should have access to medical abortion through a GP in their local area,” he told InSight+.
But in reality, for people needing abortion services outside the major cities, nothing could be further from the truth.
“There’s an outcry that US women are going to have to travel hundreds of kilometres across two states to access abortion now,” he said.
“Well, our states are bigger in Australia, and there are women that have to travel hundreds of kilometres from, for example, Far North Queensland to Brisbane or from the top of Western Australia down to Perth.
“We have huge ‘abortion deserts’ in Australia.”
Cost
Those “deserts” hugely increase the cost of a surgical abortion.
“It’s often the people that can least afford these costs that are faced with unplanned pregnancy,” said Dr Goldstone.
“There’s not only cost of the service [surgical abortion is partially subsidised by Medicare, but can involve out-of-pocket costs of between $600 and $800; the median out-of-pocket cost for medical abortion is $560], there is the time taken off work, childcare costs, accommodation costs.
“Yes, there are some state funding programs, but there’s still enormous barriers for people who live in areas [outside the large cities].”
Medical abortion providers
The advent of early medical abortion has increased access to care, particularly since telehealth access boomed thanks to the COVID-19 pandemic, but a lack of providers, especially in rural and regional Australia is problematic.
As of December 2021, according to data from MS Health, there were 3059 prescribers of medical abortion in Australia. According to Department of Health data, there were 31 620 registered GPs in Australia. Even if all medical abortion prescribers were GPs – they’re not – that would still represent just 9.7% of GPs trained and registered to dispense prescriptions.
So, why aren’t doctors willing to prescribe medical abortion?
“The training to become a certified prescriber takes a few hours,” Dr Goldstone said. “But I think stigma still plays a big part.
“Either a doctor doesn’t want to be known as the doctor that provides abortions, or, as we’ve heard anecdotally, other GPs in the practice, or even reception staff, are not onboard.
“That’s really unfortunate. What we would like to see is that every large general practice service has at least one GP that can provide medical termination in the same way that you might have a practice where one of the GPs does [intrauterine devices], for example. That’s the ideal scenario.”
Professor Bateson agreed.
“Back-up is also important and GPs may find that they don’t have the support from their colleagues in the practice, particularly if they’re in a small practice, potentially, in a small town,” she said.
“It’s important to ensure continuity of care during provision and follow-up of medical abortion, especially if you work part-time or want to be able to go on leave. Ideally there would be an agreement to provide this cover as there is for all other aspects of practice.”
Training pathways
Abortion care needs to be part of the core curriculum for GP and ob/gyn training, Dr Goldstone said.
“Ob/gyn trainees don’t get enough exposure to termination of pregnancy services, because it’s not provided in most public hospitals – that’s a big gap,” he said.
“The GP curriculum, while it talks about being competent in discussing unplanned pregnancy options and making referrals to abortion services, it actually doesn’t cover provision of medical abortion, which should be a basic part of GP training.”
There currently is no accredited training pathway in Australia for GPs or obstetrics/gynaecology trainees interested in providing abortion or contraception care.
Professor Kirsten Black, Chair of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Sexual and Reproductive Health Special Interest Group, told InSight+ that RANZCOG is now developing a 2-year pathway, but abortion clinics in the public health system were vital to giving trainees support and exposure.
“We need integration of abortion care into public hospitals so we can build that cadre of expertise,” Professor Black said. “Exposing students and trainees to abortion and contraceptive care is vital to ensure abortion is normalised as a health care issue.
“Some will decide those are not services they want to provide, but others will go on to take a special interest. Without that exposure, obviously, fewer will go on to provide that care.
“We need to push state governments to provide funding for those public services.
“Lots of funding is going towards [in vitro fertilisation], and that’s important for reproductive rights. But we also have to fund a person’s ability to plan the number, the timing and the spacing of pregnancies. That means abortion and contraception care.”
Professor Bateson said she was “greatly encouraged” by the strides being made in developing training pathways.
“Some regional hospitals (in NSW) have been very responsive to the abortion care needs of women in their area, especially for those with complex medical or psychosocial needs, which was not always the case even a couple of years ago. We now need more public hospitals to follow.
“It takes champions to lead the way and to make everyone around them feel more confident and supported to come on board. While we certainly can’t take access to abortion for granted there are some positive developments which will hopefully lead to equitable improvements across Australia.”
Public health access to surgical abortion
The National Women’s Health Strategy 2020–2030 states that equitable access to pregnancy termination services is one of its priorities, and aims to:
“Remove barriers to support equitable access to timely, appropriate and affordable care for all women, including culturally and linguistically sensitive and safe care [by] … [working] towards universal access to sexual and reproductive health information, treatment and services that offer options to women to empower choice and control in decision-making about their bodies, including contraception and options for addressing unplanned pregnancies, including access to termination services.”
“That will only happen if we get the involvement of public hospitals,” said Professor Black.
It’s apparent that the public hospital system’s attitude to providing surgical abortions lags behind the pace of law reform, according to Dr Goldstone.
“Prior to law reform, certainly here in NSW, health services hid behind the grayness of the law,” he told InSight+.
“It was an excuse for them not to become involved in provision.”
RANZCOG has tried mandating the provision of contraceptive care as part of its teaching hospital accreditation program, “with moderate success”, according to Professor Black.
The bottom line
In the end the SCOTUS ruling puts the US on a footing similar to Australia – no constitutional right to abortion, no national legislation, state control, access difficulties and a lack of “normalisation” of abortion.
“We can’t be complacent,” said Dr Goldstone.
“In an ideal world, we would have uniform laws across Australia, so you don’t have abortion tourism, where people may have to travel to another state.
“More importantly, we would mandate public provision of pregnancy termination services in all local health districts.”
Professor Bateson agreed.
“The Primary Health Networks can play a really important role in abortion care,” she said. “PHNs play a vital role assessing the needs of their communities and matching that to their health workforce and the delivery of services.
“This is the time to ensure the community’s abortion care needs are matched to the services that are provided.
“In the past couple of years we have seen the inclusion of medical abortion in the Therapeutic Guidelines and the development of the AusCAPPS Community of Practice, which supports GPs, nurses and pharmacists in providing medical abortion and long-acting contraceptive care. The increasing AusCAPPS membership highlights the growing appetite for belonging to a group passionate about providing high-quality sexual and reproductive health care to patients.”
Resources:
In Queensland there are 11 services providing surgical abortion services, none further west than Emerald or Toowoomba.
For information about surgical abortion clinics in NSW, visit the Family Planning NSW Clinics website.
In Victoria there are 24 services providing surgical abortion services, spread between Mildura in the north to Albury in the northeast, to Warrnambool in the southwest, and down to Wonthaggi on the south coast.
In Tasmania, three public hospitals provide surgical abortion services – Royal Hobart, Launceston General, and North West Regional.
In South Australia, seven services provide surgical abortions.
In the Northern Territory, there are two surgical abortion options – Royal Darwin Hospital and, at the other end of the NT, Alice Springs Hospital.
In Western Australia, where the abortion legislation is still the most restrictive in the country, two services provide surgical abortions – Nanyara and Marie Stopes Australia.
In the Australian Capital Territory, Marie Stopes Australia or Gynaecology Centres Australia offer surgical abortions up to 14–16 weeks gestation (depending on surgical risks). Canberra Hospital only provides surgical abortion in specific cases.
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Should we now look to Centrelink for guidance on moral/philosophical and medical questions?
Lack of citizenship and welfare eligibility would seem to put at risk of termination many more than just the unborn.
Max:
As far as I am aware, those that “perceive a much greater gravity and philosophical challenge inherent in the issue of termination of pregnancy” do not require citizenship be granted to conceived embryos, nor the commencement of child support, etc.. That would be a useful starting point.
Still should not be a reason against abortion.
J.P. O’Sullivan
Please educate yourself further on the ‘abortion procedure’ and the evidence around ‘the consequences’ that you outline, both for those undergoing abortion, and those being forced to carry pregnancies.
Also, what is the relevance of the 40 million number?
John Hayes:
Can you please ‘inform’ us ‘what happens’ in abortion?
Also, would you propose public billboards with graphic depictions of colonoscopies, caesarean sections, trauma surgery etc.?
Also, of course abortion is cheaper than continuing a pregnancy, and having a child. Is that in dispute?
Roy Horchner:
As above, please let me know your thoughts on citizenship for conceived embryos, and child support at conception etc..
Also, are you aware that only 264 adoptions were finalised in 2020-21, and that this has declined 63% over 25 years (https://www.aihw.gov.au/reports-data/health-welfare-services/adoptions/overview)? Where are the ‘many infertile couples who want babies’?
Anonymous:
Are you aware of a 100% effective form of contraception? Please let me know.
I struggle with providing “late” abortions, as an O&G. In one room I have a woman desperately holding on to a preterm pregnancy, in the next room another woman opting for a TOP of a perfectly normal pregnancy. Both 21 weeks. I have been told “I waited until after 20 weeks so I can get bereavement payments”. This is awful for everyone involved.
As a society we don’t offer many supports to women who choose to continue the pregnancy. In regional Australia to give your baby up for adoption you must birth in a city centre, certainly not easy on the single mother with responsibilities.
Fertilised ova may well be wasted at a huge rate in nature Sue Ieraci, but one does not have to be a Catholic to see that there is no equivalence between that and the entity that is being terminated in late-term abortion.
Somewhere along that time continuum, a great many considered commentators can ruefully and with sadness countenance abortion, which should indeed be legal, safe and rare.
It has been the stubborn insistence of abortion activists down the ages that what is being removed is ‘just a scrap of tissue’ (that is somehow magically transformed into a baby by transit down the birth canal) that incenses those who perceive a much greater gravity and philosophical challenge inherent in the issue of termination of pregnancy.
Pregnancy is a burden/opportunity unique to women, but that does not mean that any opinion offered by men is an intrusion of the patriarchy. There are many areas in medicine – most obviously voluntary assisted dying and suicide – where the community feels compelled to be allowed input into a decision which nevertheless apparently only involves an individual and how that person wishes to deal with their body and its well-being.
The SCOTUS decision on Roe vs Wade – in returning the decision on abortion to elected legislatues – will indeed allow us to see whether unfettered access to abortion does ‘reflect the view of the greater community’, with indirect if inexact application to Australia.
The anonymous commenter who asserts that just informing everyone that “Sex comes with consequences one of them is pregnancy” would have any effect on the rates of people seeking abortion is deluded. Unwanted pregnancy has been known – and acted upon – throughout human history, including in societies where extra-marital sex is severely punished.
There is abundant evidence that seeking to ban medical abortion does not save babies – it kills pregnant women.
Fertilised ova are wasted at a huge rate in nature. They are not “babies”.
Nobody is proposing that either having an abortion or performing abortion should be compulsory. But many commenters here would try to restrict the choices of others. That does not reflect the view of the greater community.
Many people, including medical practitioners, like myself, consider abortion the killing of an innocent, voiceless, unborn baby.
As such, many people, like myself, have a major problem with being in any way involved with the abortion procedure.
Pregnancy is not an illness and abortion should not be an available contraceptive method.
No one talks about the physical, psychological and mental consequences of this procedure on the mother, the family and the practitioner performing the termination of a human life.
It is estimated that there are over 40 million abortions performed around the world each year; that is more lives lost than WW1, WW2 or from the terrible suffering being inflicted on the people of the Ukraine by the Russian military.
When is the world going to wake up & realise we have to look after each other & that life is sacred and fragile, and that if we don’t the world becomes very savage indeed!!
Hear hear Patrick and Dr Phil. Completely agree.
Anusha – the MS2step site has a list of medical centres who have providers, so you could find a medical centre at the nearest metro location to you and then ask them who is a provider..? Otherwise talk to your RTO about linking you in? Or asking other trainees?
Ps I’m also a GP trainee who has done the training
Having witnessed a mid-term abortion as a student, I concluded that abortion is not healthcare but is evil. The sight of a small baby dismembered and gasping to breathe filled me with revulsion. The fact is that in Australia, the Public are never told what happens in abortion. In mid-west America there are many billboards informing the Public what happens when a baby is aborted. In these States, 70% of people oppose abortion or demand severe restrictions.
The Roe v Wade decision in 1973 was based on the “Right to Privacy” mentioned in the 14th Amendment .Even pro-abortion Law Professors have criticised the legal basis for that decision .
Scotus has NOT banned abortion but has passed it to the States to legislate, as happens in Australia. This is democracy in action.
What services do Governments provide to women who want to keep their babies ? The answer is NONE.
It is much cheaper to abort the baby. In the US , since the Roe decision was announced there has been around 30 attacks on Pregnancy Agencies and churches across America, including arson attacks. Of course the Australian Media never reports this.
Dr Horchner, who graduated in 1971, needs to accept that his views are his own, and that the world has moved on without him. His inability to see a bigger picture of the human condition and lack of pragmatism, replaced by dogmatism, suggest that it might be time to consider retirement.
Anonymous (2) refers to the “elephant in the room”, but fails to name that bastion which has no basis in rational thinking nor scientific evidence base. To end the post with “moral blackmail is repugnant” describes that same bastion exactly. It was a major player in running me out of a NSW regional centre where I was an abortion provider 25 years ago, with the cooperation of its adherents in the NSW parliament. They now have to accept that legislation has moved on in all states and territories. The latest census figures on religious affiliation show we as a nation, don’t have the same problems with religious manipulation of the legislature as the all too bizarre situation in the US. Anonymous (4) shows the same patronising simplistic homilies we have come to expect. Abortion must be safe legal and hopefully rare. Only education about sexual function and behaviour will make it rare. Impeding that sort of education is a major social problem in 2022. Let’s move more into evidence based living supported by evidence based medicine.
Abortion is the killing of an innocent human life which starts at the beginning of fertisation of the ovum. That child has a right to life the same as you and I. With every right comes a responsibility. As doctors, we have a responsibility to care for the patients who present to us, not exterminate them. That is enshrined in the Hippocratic oath that I took on graduation and I continue to practice and preach that. Let’s not pretend that abortion is “ health care.”
Let’s call it out for what it is, DISCRIMINATION against the most vulnerable and defenceless of human beings based on size, location, intelligence, and development. And, I thought there was a law in this country that stated that DISCRIMINATION was illegal. I propose ADOPTION as a viable alternative. If you don’t want your baby, there are many infertile couples who do. I’m not suggesting that process is easy but it’s far more preferable than abortion. We have a law in Qld that allows abortion on demand up to the moment of birth. So one moment before birth it’s Ok and one moment after birth it’s murder. Absolutely ludicrous!! I believe most doctors believe that abortion is wrong ( lack of uptake implied in your article). The law must be changed as is occurring in the USA.
I had an abortion in Sydney several years ago, I didn’t pay rent that week in order to cover part of the cost. I lied about getting a taxi home and had a friend who worked in the city meet me to exit the clinic. Then, friend went back to work and I got the bus home alone to self monitor (fortunately there weren’t any complications).
I use contraception, it failed. If I’d continued that pregnancy, it’s probable I would have finished my degree by now, but I certainly wouldn’t have graduated the following year and paid taxes from my professional wage for several years before having children. Instead I, and that potential child, would have been heavily dependent on social security payments for a number of years. A cost to the taxpayer far in excess of the cost of an abortion.
Sadly the article fails to address the elephant in the room, Abortion care is not a health service for the developing foetus, calling it care is a misnomer. No Government is going to legislate for compulsory access. Moral blackmail is repugnant.
The Poll is flawed. I would personally never perform an abortion. I do however believe that every GP and Ob/Gyn need to be able to deal with a person who has had an abortion +/- complications.
A broad “abortion care” question does not adequately make that distinction.
Abortion is not another form of contraception is the killing of a life in Uterus that should be reserve for only very special cases and very rare.In a country where contraception is cheap and easily available the emphasis shuld be not in providing more access to abortion but instead teaching boye and girls ,men and women to be responsable for their reproductive outcomes.Sex comes with consequences one of them is pregnancy ,there safe and cheap contraception that can avoid that.
The lists at the end of the article show how little legislative progress means if patients still cannot access services within the public system.
In the major city public hospital where I trained the head of O&G refused to perform surgical abortions and so, it seemed, did all the other consultants. All patients were referred to another public hospital on the other side of town, with unfamiliar staff and incompatible medical records systems. This was a shoddy service to patients, and I’m sure it wasn’t appreciated by staff at the referral hospital who must have felt their colleagues were passing the buck.
There should be systematic reporting of the actual availability of surgical abortions in major city public hospitals, so the public can know which institutions actually provide the comprehensive reproductive care that all women are entitled to.
Hi
I am a GP trainee who has completed the MS2step course. I would like to find out more about how I can be connected to resources/other clinicians who are trained in medical abortion. I live in a remote area so would also like to be able to provide these services in my area.