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This article was first published on Wednesday, August 10, 2022.
Governments at all levels have been urged to take systemic actions to address “chilling” inequities in access to abortion services in rural, regional and remote areas.
Dr Amy Coopes reports from the 16th National Rural Health Conference for the Croakey Conference News Service.
Amy Coopes writes:
One in three Australian women lives in a region where there is no access to medical abortion and states like New South Wales remain a “vacuum” of information about where to access care for an unwanted pregnancy via “underground” networks relying on word of mouth.
These were some of the messages delivered at last week’s National Rural Health Conference in Brisbane, bringing together 700 delegates from across rural, regional and remote Australia for the first time since the beginning of the COVID-19 pandemic.
The focus on women’s reproductive health at the conference – with a number of presentations on abortion care in rural, regional and remote areas – was timely given the recent US Supreme Court’s controversial Roe vs Wade decision. The move, which effectively set the clock back decades on abortion rights in the United States, made headlines and sparked protests in countries including Australia.
Abortion is legal in all Australian states and territories, although still under the criminal code in Western Australia, and the conditions under which termination can take place varies widely. South Australia was the most recent party in the Federation to decriminalise abortion.
Between one quarter and one third of Australian women experience an abortion in their lifetime, with estimates suggesting half of all pregnancies are unplanned and, that of these, one in two are terminated.
As with many aspects of health service provision, access to abortion care varies widely by geographic location, with providers concentrated in metropolitan areas and rural women facing significant barriers, the conference heard.
Dr Samantha Chakraborty, from the NHMRC-funded SPHERE Centre for Research Excellence in Sexual and Reproductive Health for Women in Primary Care, presented the findings of a study looking at GP provision of abortion care by statistical area.
About 10 percent or 3,000 of Australia’s 35,000 GPs are estimated to have completed medical termination training, using the dual-drug combination mifepristone and misoprostol (MS-2 Step), but those figures don’t represent the number who are actually, in practice, offering this service.
Using PBS data on MS 2-Step prescribing and dispensing, and disaggregating it by location, the SPHERE team was able to map where, exactly, GPs were offering medical abortion services. Centre director Dr Danielle Mazza described the findings as “chilling”.
“What we found was that 30 percent of women in Australia live in a statistical area where no GP is actually providing this service, and that this rate goes up even higher in rural areas,” Mazza told Croakey on the sidelines of the conference of the “shocking” data. The data was collected in 2019, before the introduction of specific MBS item numbers for telehealth abortion services.
“Women are very much disadvantaged because they can’t get local access,” Mazza said.
The SPHERE team found significant variation in the age-standardised rates of MS 2-Step dispensing by remoteness area per 1,000 women. In major cities, MS 2-step was dispensed to 3.3 per 1000 women compared with 6.53 in outer regional areas – significantly above the national average 3.79.
Average rates of dispensing were highest in the ACT, at 3.15 per 1,000, and lowest in the Northern Territory, at 7.16. Tasmania and the NT scored the worst overall, with outer regional areas in those jurisdictions offering a bleak picture to access (8.43 and 9.75 per 1,000, respectively).
Barriers to access
Sydney University researcher Anna Noonan is examining abortion care experiences of rural women and health care providers in western NSW. Her findings, which remain under embargo as part of her PhD studies, were presented in preliminary format at last week’s conference.
In the main, Noonan said the work “confirms what we already know, which is that access is hard, travel is costly, it’s complicated, and there are compounding factors that make accessing services really tricky.”
Despite decriminalisation, Noonan said the system remained opaque for people wanting to access an abortion – a category that she noted did not exclusively apply to cisgendered women – and NSW stood in stark contrast to jurisdictions like Victoria and Queensland in terms of transparency and accessibility.
Both states had interactive online directories and maps detailing “all the different ways and places you can access abortion care”. In NSW, there remained “a vacuum, there’s just no publicly available information at all,” Noonan said.
“It’s this really strange and kind of fragmented environment in which rural NSW woman are living,” Noonan told Croakey after her talk.
“And the frustrating thing is that it’s not that there aren’t service providers, because we know that there are – we have talked to them… [It’s] that they don’t advertise their service publicly, for lots of reasons, and finding them is really hard.”
Participants interviewed for Noonan’s research described a “weird underground kind of potluck, this kind of antiquated process” where they had to rely on word of mouth and local connections to find someone locally to provide abortion care, or to even access information to help them make a decision in “a very time-critical three or four weeks”, she said.
For local providers, Noonan said a variety of factors played into the reticence promoting their credentials in this space, including a concern that they themselves would be stigmatised as the ‘abortion doctor’ in town, and that demand would be such it would crowd out their other work.
Noonan said there was also a concern for some doctors that, while they were themselves strongly supportive of abortion service provision, they operated in settings where – were a medical termination to not succeed – options were limited locally for escalating care.
“There is a nervousness among providers that if they do provide this service but they know that the hospital is antagonistic towards abortion care, then they are setting that person up to potentially end up in an environment where it’s out of their ambit and they’re unlikely to receive non-judgmental care,” said Noonan.
Mazza has just returned from Churchill Fellowship travels through Europe and North America, examining models of abortion integration into primary care. On international comparisons, she said Australia compared “pretty poorly”.
In countries like the UK, Ireland and Sweden, Mazza said governments assumed “full responsibility for ensuring that women have access to abortion in their publicly-funded health services”, while in Australia it remained – in large measure – a private sector issue.
Lack of standardised, uniform education and training about abortion care from medical school right through to GP training was a significant part of the issue, Mazza said, also echoing Noonan’s sentiments around the lack of local and regional specialist support for primary care doctors in this space.
“GPs need to feel confident that, in the rare case that there is a complication they can rapidly access support for their patient in the local hospital,” she said.
Mazza also highlighted stigma as an issue for rural GPs.
“They are fearful that they might become known, might face discrimination or retaliation or goodness knows what from people who are anti-abortion in their region,” she said.
At a policy level, Mazza said there was plenty state and federal governments could do to address this issue, including tasking primary health networks (PHNs) to conduct a needs assessment of and commission service provision for abortion care in their region.
Both Mazza and Noonan agreed there was a place for telehealth to augment offerings in the telehealth space – in fact, Noonan’s research had found that some women preferred a “transactional experience” that was separate from and not delivered by their usual provider.
But Mazza said it was only part of the solution, arguing that abortion care should be seen as just one element of “comprehensive women’s health services” offered in primary care.
“GPs know their patients, they know their social circumstances, they know their families and they can assist women with other ongoing issues around, for instance, the need for ongoing contraception,” Mazza said. “You can’t put in an IUD remotely, or give a Depo injection remotely, if that’s what the woman wants.”
The overarching message was that “rural women do want to have agency over the care that they receive,” added Noonan.
“It’s just healthcare. You turn up to your GP, you want them to be able to help you,” she said. “Please, just get the information you need to be able to give rural women choice, and not stuff them around so they are not wasting really critical time.”
She called for NSW to follow the lead of Victoria, Queensland and Tasmania and establish a public directory of services, “or better still” roll out such an offering at a national level, pointing to the “problematic” example of the United States where, following the Roe v Wade decision abortion had defaulted from a federal to a state-based issue.
Mazza said the “appalling” developments in the US had shown both how far Australia still had to go but also sparked an openness to change that should be seized upon.
“I think it has also galvanised people to realise that unless we really address these issues, abortions can become very precarious indeed.”