It’s not just faith-based hospitals – state-run services are turning women away, with sometimes disastrous results.
Abortion may have been decriminalised in all states and territories, but a lack of public outpatient clinics means the changes have made very little difference.
RANZCOG’s Sexual and Reproductive Health Committee chair, Professor Kirsten Black, can recall at least four cases she has dealt with over the past few months where women were unable to easily access a publicly funded termination.
“Hospitals are meant to provide a pathway for abortion services, but they don’t – I had a woman who was 20 weeks pregnant, and her GP rang me really distressed,” Professor Black told The Medical Republic.
“[The GP] said that she’d rung 20 services to try and find this woman a public clinic – it’s legal for her to get an abortion [but nowhere would accept her].”
In that situation, Professor Black said she called the senior doctor at the Sydney hospital closest to where the patient lived and made a personal appeal on behalf of the patient.
Given the choice between paying about $500 out-of-pocket for an abortion – with the added cost of likely having to travel to the provider – and receiving fully state-funded maternity care, some women opt to carry unwanted pregnancies.
Another of Professor Black’s patients was unable to afford regular contraception and had to scrape together money for a private abortion.
Seven months later, the same patient had a second unwanted pregnancy.
This time, she gave birth to premature twins at 26 weeks.
“A total disaster,” Professor Black said.
Professor Black, who is also spokesman for Australian Clinicians for Choice, issued an open letter calling for surgical abortion to be made available in every public hospital in NSW, ahead of the state election in March.
The open letter, which doctors can still sign, also calls for a funded “hub and spoke model” that can provide training and advice, as well as a publicly funded directory of abortion and contraception providers.
Under the current environment in NSW, Professor Black said, it’s relatively simple for public hospitals to “wash their hands” of delivering abortion services by either claiming that they don’t have the theatre space or that there are no clinicians interested in providing the service.
“We provide care for women having a miscarriage or continuing a pregnancy,” she said.
“So why not for women who decide not to continue a pregnancy for social, medical or financial reasons?”
National Association of Specialist Obstetricians and Gynaecologists president Associate Professor Gino Pecoraro said that, viewing the situation through a cynical lens, abortion is a relatively easy service not to offer.
“People are much more likely to speak out publicly about not being able to access services to have a baby,” he told TMR.
“Whereas there’s still that element with termination of pregnancy services where it’s in the shadow and people don’t talk about it; there is still a stigma associated with it.”
Professor Pecoraro, who supports access to abortions, said that public obstetrics departments – particularly those in his home state of Queensland – were in a state of “freefall”.
The Rockhampton Base Hospital, for instance, is now down three of its four specialist obstetricians, with midwives reportedly beginning to resign due to safety concerns.
“There’s only going to be more pressure on O&G and women’s health, especially in the regions, not less,” Professor Pecoraro said.
Essentially, if a public hospital is pushed to capacity under the weight of its regular workload, it seems unlikely that it would voluntarily add on a termination-of-pregnancy service if it wasn’t forced to do so.
According to women’s health research collective SPHERE, the issue isn’t localised just to northeastern states, or even just to hospitals.
The Monash University-based group estimates that around a third of Australian women live in a region with no local GP provision of medical abortion: in rural areas, this jumps to one in two women.
In its submission to the Senate inquiry into universal access to reproductive healthcare, SPHERE said public hospital provision of surgical abortion was also “sparse and inconsistent”, especially in rural areas.
As of 2019, it was estimated that just 10% of abortion services were delivered in public hospitals across the country, despite the procedure being legal in most states and territories at that time.
“The low numbers, or in some cases, complete lack of public and private hospital abortion providers in some regional areas mean few referral pathways exist, particularly for surgical abortion,” SPHERE said.
“Many hospitals do not perform abortions as it may not be an explicit expectation under their service agreement, and some faith-based public and private hospitals prohibit provision of abortion and contraception.”
Even when public hospitals do offer terminations, recent research published in the Australian Journal of Primary Health found that most referral pathways were unclear at best, and actively discouraged public referrals at worst.
Seven of the 17 referral pathways analysed in the study indicated that public services were likely to be very difficult to access, with warnings like “does not provide routine [termination of pregnancy] service” and directions to consider private providers first.
“There has been a lot of talk in the media recently about religious hospitals, and that they may an ethical objection to providing those services,” lead author Dr Sonia Srinivasan told TMR.
“But what we found is that … there are a lot of public hospitals that aren’t religiously affiliated [that don’t offer abortions] and it’s not clear why this particular service has been chosen not to be made available.”
Dr Srinivasan said the current lack of national abortion data made it difficult to understand the reasons why so many public hospitals simply do not offer terminations, but it likely came down to inadequate funding and a lack of nationally endorsed guidelines.
These guidelines, according to the Australian Journal of Primary Health article, would set minimum recommendations for providing abortion services across a range of settings, publicising information about the number and location of abortion services and maximising workforce capability.
Creating and implementing national guidelines was a key recommendation in SPHERE’s submission to the Senate inquiry.
In its submission to the senate inquiry, the RACGP proposed a state or federal based funding mechanism that would reimburse the out-of-pocket costs for women who received a private abortion.
The college also recommended that the MS-2 Step medicines be added to the “prescriber’s bag” in order to make the process of accessing a medical abortion more efficient.
Pharmaceutical non-profit MS Health, which sponsors abortion medicine MS-2 Step, requested the TGA allow allied health staff to prescribe MS-2 Step and remove the recertification requirement for GPs.
The Senate committee is due to report back by early May.
Australian Journal of Primary Health 2022, online 16 December
