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Primary care providers play an integral part in medical abortion access, but many barriers are preventing uptake of medical abortion provision.
Access to safe and affordable abortion is essential health care and a human right.
Medical abortion — via administration of the combined mifepristone–misoprostol regimen (MS-2 Step) — is becoming more accessible, thanks to increased access via telehealth models and subsidisation in the Pharmaceutical Benefits Scheme.
However, medical abortion is still not widely available in primary care, and geographic and financial barriers remain.
A systematic review, published in the Medical Journal of Australia, has analysed existing research to learn what barriers are preventing greater uptake of medical abortion provision in primary care.
“Centring the provision of abortion within primary care and supportive regulatory and policy environments are crucial to achieving universal access, according to the World Health Organization,” Dr Greta Skahill and Dr Mridula Shankar wrote.
“Prior to August 2023, only 7% of general practitioners and 22% of pharmacists were active MS-2 Step providers, and most were in major cities.”
“The aim of our review is to synthesise primary research findings about factors that affect medical abortion provision by general practitioners, nurses, midwives, and pharmacists in Australia.”
Navigating conscientious objection
The review found that individual conscientious objection continues to be a barrier to the provision of medical abortion.
“Colleagues who conscientiously object to abortion care greatly limit its provision and clinical training,” the authors wrote.
“In such cases, the service (including the dispensing of MS-2 Step) is not offered, care is delayed, or providers must offer care clandestinely.”
There is also concern that legal clauses that permit conscientious objection are used without adequate justification and without fulfilling professional obligations of continuity of care.
“The challenges posed by conscientious objection must prompt consideration of laws that protect the right to decline involvement in pregnancy termination, which allow practitioners to avoid their professional duty to provide essential reproductive health care,” the authors wrote.
The authors note that values clarification workshops could improve providers’ awareness of their professional duties in abortion care.
“These workshops foster supportive attitudes and reduce active opposition among providers with diverse beliefs and in different contexts,” the authors wrote.
A fragmented and secretive system
The review found that inadequate access to ancillary services, such as pathology, ultrasound and surgical referral in an emergency, are barriers to providing medical abortion.
“Establishing such a network, including guaranteeing the support of local hospitals for emergency and after-hours care, is logistically difficult for general practitioners, as some services obstruct or refuse to support medical abortion provision,” the authors wrote.
There is also a lack of knowledge and training, with limited opportunities to gain clinical experience unless practitioners pursue external training.
The continued stigmatisation of abortion and privacy concerns means that many practitioners operate by stealth, with referrers relying on rumours to identify providers offering abortion care.
These issues are compounded by geographic location, with rural general practitioners in particular affected.
“General practitioners in rural areas who offer abortion care feel isolated, anticipate stigmatisation, and experience pressure and emotional distress, especially when working in towns or areas with conscientious objectors,” the authors wrote.
“Funding models do not consider these problems, and some rural providers do not have adequate resources or financial compensation to meet community needs, leading to staff burnout, poor workforce retention, and reduced quality of care.”
The gendered nature of abortion care
The review found that most medical abortion providers are women, who already face challenges from gender pay disparities and organisational glass ceilings.
“Offering person-centred abortion care requires time and empathic communication that is not financially compensated by the current funding system, leaving providers feeling undervalued,” the authors wrote.
As the Medicare Benefits Scheme (MBS) rebates for women’s health procedures are smaller than for men’s health procedures, providers can be discouraged from engaging in women’s health care.
“Widespread uptake of medical abortion services in general practice is unlikely without redressing these imbalances, and we welcome the recent announcement of a gender-based audit of the MBS system.”
Abortion care belongs in primary care
Despite the barriers and challenges, the review supported the notion that early medical abortion belongs in primary care.
“General practitioner providers are motivated by the belief that abortion care is integral to women’s health care and should be financially, geographically, and socially accessible,” the authors wrote.
“Medical abortion provision in primary care provides greater continuity of care (eg, for follow-up and contraception) and facilitates the tailoring of care to the needs of the woman and the community, including with telehealth.”
“Regulatory, governance, funding, and service coordination barriers need to be overcome to improve early medical abortion delivery in Australian primary care. Such care is important for supporting the National Women’s Health Strategy goal of equitable access to abortion care.”
Read the systematic review in the Medical Journal of Australia.
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