Concern from health care professionals as abortion laws threatened in multiple states

Politics has put abortion back on the ballot in the United States, as well as in Queensland and South Australia. InSight+ spoke to health care professionals about their concerns as reproductive health care is influenced by both politics and postcode.

Dr Nisha Khot is the Vice President of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZOG). Dr Khot said that the fact that reproductive health care is being questioned by politicians in Queensland, South Australia and New South Wales is concerning.

“We have legalised it. We have decriminalised it. It should sit only in the purview of health care. It should not be a discussion that we should be having at all,” said Dr Khot.

“We’re very worried about it because we have done a lot of work towards making sure that health care practitioners, obstetricians, and gynaecologists have the ability to provide both medical and surgical termination services,” said Dr Khot.

Dr Khot says that the influence of American politics is outsized and dangerous.

“People say, ‘When America sneezes, the world catches a cold.’ There has always been and will always be a group of people who will have an anti-choice agenda and anti-abortion agenda. The reason we have been able to overcome it is because we have a stronger voice. It’s pro-choice and recognises that abortion is health care,” she said.

“Access is variable in every state and territory, but we know that access is challenging for women who live rurally and regionally,” said Dr Khot.

When it comes to both access and politics, the states are facing different challenges.

Queensland

This month, abortion and reproductive health care were significant factors in the Queensland state election when conservative politicians posited changing the 2018 decriminalisation legislation.

Ms Jill McKay is the CEO of Children by Choice, an organisation providing counselling, evidence-based education, and support around reproduction health in Queensland.

“We continuously say that you can’t ban abortion – you can only ban safe abortion,” said Ms McKay.

“After Roe v Wade was overturned in the US in 2022, we have been monitoring what access to abortion looks like in America,” she said.

“In the last month, we’ve seen women and pregnant people die in the US due to lack of access to reproductive health care. American health professionals have been confused about when to provide abortion care to support people with ectopic or non-viable pregnancies, with people being turned away from essential care. It’s about the state’s power to control the bodies of women and pregnant people,” says Ms McKay.

“The World Health Organization (WHO) recognises that abortion is health care. When we don’t provide abortion, women, pregnant people, fetuses and families suffer, and maternal fetal deaths are higher,” she said.

“In Queensland, we’ve heard things like, ‘We don’t think that abortion should be made a political issue.’ It was made a political issue when Robbie Katter said he wanted to repeal abortion laws,” said Ms McKay.

“It’s the canary down the coal mine for the rights for women,” she said.

South Australia

In South Australia, abortion was de-criminalised in 2021, with the Termination of Pregnancy Act. This year, a private member’s bill from a Liberal MP sought to require women to be induced and give birth after 28 weeks.

The bill was voted down, with a female MP returning from sick leave to vote against it.

Dr Heather Waterfall is an OB/GYN and South Australia and Northern Territory Chair of the RANZCOG. Dr Waterfall says that the decriminalisation Act was very well received by abortion providers in South Australia.

“Medical abortion can be accessed anywhere. A woman could do a telehealth appointment from anywhere in the state, speak to a doctor who can prescribe MS 2-step and access that medication,” said Dr Waterfall.

“The recent bill introduced by the Liberal Party Member essentially sought to wind back abortion rights after 28 weeks. And instead, those women should be told that if they wanted to end their pregnancy, they should be induced, forced to birth their baby and give that baby up for adoption,” said Dr Waterfall. 

“Thankfully it was defeated, but very narrowly: by one vote,” she said.

Dr Waterfall said that she feels lucky to be in Australia, because she can practise without fear.

“RANZCOG feels very strongly that abortion is part of reproductive health care and your ability to access a safe abortion is an integral part of reproductive health care. So anytime politicians are debating restricting access to abortion, they are taking away a woman’s right to access health care,” said Dr Waterfall.

“We need to preserve the idea that abortion is health care, and completely legitimate. Pregnancies happen when they’re not planned. And if a woman chooses to end that pregnancy, then that is her right,” she said.

“We would never treat a discussion about cancer in the same way. We would never talk about a men’s health care issue in the same way. It’s just not acceptable,” said Dr Waterfall.

Victoria

Ms Sally Hasler is CEO of Women’s Health Victoria (WHV). She said that Victoria is a leader in providing reproductive health care.

“Reproductive rights are under threat, and that could have severe consequences. The government’s already doing a lot, and Victoria is a leader in access to sexual and reproductive health (SRH). But what recent events prove is that we can never be complacent,” said Ms Hasler.

In Victoria, abortion was decriminalised in 2008.

This month, however, WHV released a report that showed ongoing inequities in abortion and contraception access across the state that disproportionately affect disadvantaged communities.

“The Realising Access report reveals significant inequities in access to abortion and contraception in Victoria, particularly regional, and socio-economically disadvantaged communities. Lack of access is effectively compounded for people who are in both of those groups,” says Ms Hasler.

WHV provides a reproductive health telephone helpline, 1800 My Options.

“For the first time ever, we’ve published data from 30 000 calls to the service. We’ve analysed that data alongside data from the Women’s Health Atlas that looks at access to medical abortion, and we’ve overlaid that with ABS socio-economic data to look at the gaps to access. Even in Victoria, there are still significant access barriers,” says Ms Hasler.

“We get over 30 calls a day from people trying to navigate access, the overwhelming majority are people trying to seek an abortion. We give them information about how to access services. But sometimes people have to travel huge distances,” says Ms Hasler.

“The first barrier is financial insecurity. A third of people calling us can’t afford an abortion. Through the private system, abortions can cost anywhere from $740 to $1200. In a cost-of-living crisis, more and more people are experiencing financial insecurity and should be able to access health care,” said Ms Hasler.

“The second thing is that, depending on where you live, access is limited. Two-thirds of Victorian local government areas (LGAs) have no surgical abortion providers at all, and 40% have no medical abortion pharmacies,” she said.

Ms Hasler says that people can be curtained off into what are sometimes called “abortion deserts”.

“The third thing the report found is delay of access. If you’re more disadvantaged, you’re more likely to call us after nine weeks – the point at which you can access a medical abortion through the PBS,” said Ms Hasler.

Ms Hasler says that part of the problem is that GPs need more support to be able to provide reproductive health care to patients at earlier stages of pregnancy.

“We need more hospital provision of surgical abortion, and access to medical abortion through GPs and pharmacies. There are huge parts of Victoria where pharmacies don’t provide medication abortion,” she said.

“We know that there are long wait lists for GPs in some rural areas, and that there might be limited support for GPs, and so they’re doing the best that they can,” said Ms Hasler.

Ms Hasler said that, as of mid-2023, only 17% of GPs were providing access to medication abortion. 

“Sometimes the barrier is conscientious objection, and lack of referrals to alternative providers. There’s a legal requirement that if a health provider is unable or unwilling to provide access to abortion services, that they provide a referral to an alternative provider,” she said.

“Up until late last year, there was a requirement that for GPs to prescribe medication abortion, the patient needed an ultrasound and a blood test. Since late last year, GPs no longer need an ultrasound and a blood test. But practice is taking a while to catch up, potentially due to a lack of training and support,” she said.

“There’s an incredible group, the Clinical Champions Project at the Royal Women’s Hospital that travels and works with health providers to support their understanding of abortion services,” said Ms Hasler.

Ms Hasler said that ultimately, Victoria needs more SRH hubs providing free, or very low cost services in disadvantaged areas and urban growth areas.

Ms Hasler says she wants services such as WHV’s 1800 My Options to be available Australia-wide. 

“The Senate Inquiry on Reproductive Rights last year recommended that the 1800 My Options service should be rolled out nationally. We can learn from its success,” said Ms Hasler.

New South Wales

Last week, the ABC reported that Orange Hospital, New South Wales, had directed its staff to not perform abortions except in cases of “early pregnancy complications”.

While the NSW Health Minister reported that the hospital would once again be providing abortion services, the news shocked many.

Dr Khot said what happened at the hospital should not have happened.

“The decision to not provide abortion care was not from the clinicians themselves, as they have always provided [abortion care] and they’re happy to continue providing it. The decision was more of a leadership executive decision,” said Dr Khot.

“As doctors, we have regulations. If we are conscientious objectors, we are obliged to refer it on to someone else who can provide that service,” she said.

“Health care executives and leadership, however, don’t seem to have these regulations. And it highlights probably a systemic objection to abortion services from health care leadership,” said Dr Khot.

“That is very, very worrying because ultimately, it’s the leadership of a hospital or a health care organisation that makes decisions to fund certain things versus not. This is where we need the political will amongst health care leadership to ensure that essential women’s health care be provided, no questions asked,” said Dr Khot.

Also in New South Wales, researchers have reported that a lack of services is causing many women to seek reproductive health care “underground”.

Dr Anna Noonan is a research fellow at the University of Sydney’s school of rural health, researching rural access to abortion, and SRH rights. Her recent research paper, Imagine if we had an actual service …, shows that lack of access to abortion and reproductive health care in rural New South Wales is widespread.

“One of the greatest obstructions to accessible abortion care in rural areas is its obfuscation from mainstream health services,” said Dr Noonan.

The report found that the state is affected by scarce abortion services, a lack of back-up support, and is subject to “interprofessional stigma, secrecy and obstruction”.

Despite being fully decriminalised in all states and territories, abortion remains a “grey and stigmatised area of health practice, outside the purview of mainstream medicine”.

The way forward

Dr Khot says that the way forward for abortion care is multifaceted.

“We should provide free contraception and health care should be free. A lot of countries are doing it now because it’s a good investment in health care. The second thing is that we need to ensure that public health care includes abortion care,” she said.

“RANZCOG has a sexual and reproductive health training pathway, so that we train a future generation of doctors and specialists who will be able to provide abortion care.

Dr Khot said that reproductive health care is a legal procedure and should not be a decision made with stigma.

“Ideally, we take abortion out of the legal framework completely, whether that is putting it in the Constitution or whatever form that takes,” said Dr Khot.

“Late abortion decisions are less than 2% of the abortions that happen in this country. They are really, really difficult decisions, and usually women are in really difficult circumstances when they make them. And what they need is health care and support, not judgement.”

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