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Despite recent improvements to abortion access in Australia, inequities remain in access to pregnancy termination.
New research has found that access to abortion care in Victoria has improved, but the complex interplay between contraceptive use, unintended pregnancy and induced abortion requires further exploration.
The research, co-authored by Associate Professor Kristina Edvarsson from La Trobe University, found a decline in the induced abortion rate over a ten-year period, primarily in major cities where 67% of women lived.
“We found that the adjusted odds of having had an abortion declined among women living in major cities who gave birth in Victoria during 2010–2019, but they rose in regional and remote areas (but not statistically significantly),” Associate Professor Edvarsson and her colleagues wrote.
The overall decline in the induced abortion rate may be linked with the increased uptake of highly effective long-acting reversible contraception, they wrote, which may have resulted in fewer unintended pregnancies and abortions.
“Differences in the use of contraception in general and of more effective methods in particular have been reported in Australia, including lower rates among women born in non-English speaking countries,” they wrote.
“Lower rates have also been reported for Aboriginal and Torres Strait Islander women.”
The researchers, however, urged caution in the interpretation of the finding of fewer abortions in childbearing women who were born outside of Australia.
“It could indicate poor access to abortion care in their countries of origin or for overseas-born women in Australia,” Associate Professor Edvarsson and her colleagues wrote.
“However … reporting of abortion in some ethnic groups is influenced by the religious or legal status of abortion in their countries of origin, by discomfort about or fear of reporting a stigmatised health behaviour, and by lower English proficiency and the need to use interpreters.”
The long road to decriminalisation
Western Australia became the last state to decriminalise abortion in September 2023.
The state government reduced the number of health practitioners required to be involved in most abortion care from two to one, and expanded the list of practitioners that can provide the service.
In April 2023, the Australian Capital Territory (ACT) became the first Australian jurisdiction to offer free universal access to abortion services.
ACT residents will not need a Medicare card for the service.
However, Australia’s federated model, like the United States, presented “a fertile political ground for obscure opinions on reproductive rights,” wrote Dr Catrina Melville and Ms Bonney Corbin, in a Perspective published in the Medical Journal of Australia today.
“Antichoice sentiment is evident in state and territory parliaments through amendments introduced during the final hours of political debates on abortion law reform Bills, creating inconsistencies between state and territory abortion laws,” Dr Melville and Ms Corbin wrote.
“Most politicians are not doctors. This is why the next steps for abortion access reforms in Australia must be grounded in clinical evidence. We need to continue moving abortion out of legislation and into clinical guidelines and practice.”
Opportunity to redefine cultural safety
There are emerging opportunities for sexual and reproductive health reform beyond mainstream health and hospital systems, Dr Melville and Ms Corbin wrote.
“Populations that historically experienced reproductive discrimination, including forced sterilisation and forced child removals, are now in a position to redefine cultural safety in abortion care,” they wrote.
“Community controlled health organisations, including Aboriginal and Torres Strait Islander clinics, LGBTIQ+ clinics, migrant and refugee clinics, and disability clinics, can trial evolving methods of health care that privilege choice and autonomy.”
The emergence of telehealth also meant that abortion medication could be available in the privacy of community care settings, especially to people living in rural, remote and regional Australia, they said.
Prescribing and dispensing the medical abortion pill MS-2 Step
From 1 August 2023, the Therapeutic Goods Administration (TGA) removed the requirement for general practitioners (GPs) to undertake mandatory training, registration and reregistration every three years in order to prescribe the medication. Pharmacies are now also able to stock and dispense medical abortion medication like any other prescription.
Nurse practitioners are able to prescribe the medication, subject to state legislation.
Commenting on the changes for InSight+ in July 2023, Professor Danielle Mazza AM, Head of General Practice at Monash University and Chief Investigator and Director of the SPHERE Centre of Research Excellence, said that the reduction in red tape would increase GPs’ confidence in providing medical abortions for their patients.
“Previously, GPs have had to undertake mandatory training and register before they could provide the abortion pill, then re-register every three years,” Professor Mazza said at the time.
“This made GPs suspicious and hesitant to become a provider. Many were not sure about what the registration process entailed or why it was in place. They would think, ‘maybe there’s something about medical abortion that I don’t know.’”
As a result, only about 10% of GPs in Australia were registered to prescribe the medication.
Recent Senate Inquiry
The TGA’s move to ease prescribing and dispensing rules was in line with recommendations from the recent Senate Inquiry into Universal Access to Reproductive Health Care report.
The inquiry heard major concerns about access to sexual, maternity and reproductive health care, which stated Australians face a “postcode lottery” when seeking access to care.
Prominent campaigner, Associate Professor Barbara Baird, at Flinders University, has disputed the “lottery” description used by the inquiry’s parliamentarians.
“My research into abortion provision in Australia over the past 30 years doesn’t describe chance, but an inadequate system,” she wrote in The Conversation.
“Doctors’ historical unwillingness to provide abortions is central to the access problem — and it’s underwritten by the failure of medical schools to adequately train them in this essential aspect of health care.
“The public health system is culpable, too, for its lack of responsibility for ensuring fair access to abortion services.”
Medical abortions can cost hundreds of dollars and are available up to nine weeks’ gestation.
Surgical abortions can also cost hundreds (sometimes thousands) of dollars, with Medicare rebates covering some of the costs.
Read Associate Professor Edvarsson’s research in the Medical Journal of Australia.
Read the Perspective by Dr Catrina Melville and Bonney Corbin in the Medical Journal of Australia.
Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.