The procedure should be simple and straightforward, but complex state laws and moral attitudes can prove a hindrance
When Dr Heather McNamee started doing medical abortions at her clinic in Cairns in Queensland five years ago, people told her to expect threats.
“I actually wrote ‘Termination of Pregnancy’ across the windows and people were saying to me, ‘you can’t do that’ and ‘people are going to throw bricks at you’,” Dr McNamee, a GP and sexual health expert, told The Medical Republic. “There is a lot of fear in Australia in the medical profession around becoming involved in abortion,” she said.
“It’s a fear that is totally misguided really. I live in the far north of Queensland, which is not in some ways one of the most broad-minded areas on the planet. When I opened my clinic in 2013, we listed the services we offered – and absolutely nothing happened.”
Sure, there was the annual “hate fax” from a specialist at a local hospital, said Dr McNamee. But she knew exactly who was sending it.
“It would just be an article from some religious magazine saying everyone who offers abortion is a baby killer.”
In reality, threats were rare.
“The number of anti-choice fanatics in Australia are actually numerically very low. Unfortunately, they are very well organised, generally well-funded and some are prepared to go to extremes to obstruct abortion.
“But I’ve been very vocal about abortion, very public about it right from day one and, apart from these faxes that I just shred, I’ve really not come up against any intimidation or threats whatsoever.”
But, by way of contrast, another GP was so rattled by a recent threat sent to their place of work that they didn’t want to draw more attention to their abortion services by speaking with The Medical Republic for this story.
A doctor recently posted about this issue in a closed Facebook group for medical abortion prescribers.
“I don’t think it’s common but it’s certainly a concern that gets raised and expressed occasionally,” said Dr Philip Goldstone, the medical director at Marie Stopes Australia.
Some GPs had actually been blocked by other doctors from offering abortions at their clinic, because of fears the practice would become a target, he said.
“But the reality is that providing medical abortion in general practice is a private consultation that occurs in a doctor’s room and, in fact, nobody really needs to know to be honest.”
Cairns is now one of the best-serviced cities in Australia for medical abortions.
But women must be nine weeks pregnant or less to be prescribed mifepristone (RU486) and the chaser medication misoprostol (taken buccally 24-48 hours after the first medication).
Women further along in their pregnancy who require a surgical abortion still have to travel south to Townsville, Brisbane or Sydney. The last remaining surgical abortion provider in Cairns retired 18 months ago and had not been replaced, “which is a disgrace”, Dr McNamee said.
Some regions in Queensland were known as “black holes” because they had no providers of medical or surgical abortions, a spokesperson for Children By Choice, a Queensland-based counselling service, said.
“This means that some women have to travel a huge distance to access a procedure, which may affect caring responsibilities or ability to take time off work,” she said.
It is estimated one in 25 women has to travel interstate to have an abortion.
Tasmania’s last remaining surgical abortion provider, gynaecologist Dr Paul Hyland, shut his business down at the start of this year, citing low demand and a lack of government funding.
This left women no option other than to travel to Melbourne for the procedure.
Abortion has become a topic of hot debate in Tasmania, after a Cricket Australia employee was recently sacked for criticising the state government’s stance on abortion from a private twitter account.
“Nobody should have to go through what I went through to access a legal health procedure,” she said.
In many rural and regional areas of Australia few (if any) GP clinics offer medical abortion services.
Some GPs only secretly offer medical abortions to existing patients to avoid being labelled as “the abortion doctor” by the community.
In Victoria, the website “1800 My Options” maintains a database of abortion providers who consent to being listed online. The map shows there are only 10 practitioner providers outside of Melbourne offering medical abortions that wish to be identified.
“I think most doctors are reticent to be listed on some publicly available site and understandably so,” Dr Goldstone said.
Telehealth medical abortion services are available across most of Australia through Marie Stopes Australia and the Tabbot Foundation, but there’s usually an out-of-pocket fee of a few hundred dollars.
Women accessing this service have all their consultations with doctors by phone, get blood tests and ultrasounds done locally, and are sent medication by mail.
Women on low incomes are occasionally able to secure charitable support, but accessing affordable abortion services remains far from easy in many parts of the country.
Some GPs strongly object to abortion on moral grounds, and a small subset of GPs choose to direct patients in line with their own conservative views.
“The women I see are extremely grateful for the care,” Dr McNamee said. “Unfortunately, some of the GPs they’ve seen prior to seeing me have been incredibly disrespectful to the point of, I would say, professional misconduct.
“I’ve had to encourage some of the women to make formal complaints to try to protect other women from those rogue GPs who seem to feel they have a right to lecture a woman around her morality, even though she’s a simple contraceptive failure.”
A study published in in the Australian and New Zealand Journal of Public Health (2008) showed that more than half of women presenting for an abortion had been using contraception prior to becoming pregnant.
The pill is five to 20 times more likely to fail than long-acting reversible contraceptives, but only around 6% of Australian women use an IUD and 5% use an implant, while one-third rely on oral contraceptives.
“I would rather no woman in Australia ever had to have an abortion,” Dr McNamee said. “It’s a stressful, emotionally challenging thing to go through. Physically challenging.
“One of my aims is to reduce the rate of unplanned pregnancy and abortion in Australia … by implementing long-acting contraceptives. I’ve come across anti-choice GPs who just want to criticise me for offering abortion but don’t make any active effort on the other side of the equation.”
According to Queensland counselling service Children by Choice, it is estimated half of Australian women will experience an unplanned pregnancy in their lifetime and around one-quarter of all pregnancies are terminated. Other estimates suggest the unplanned pregnancy figure is closer to around one-third of women.
So even though abortion is one of the most common procedures performed for women, it can be inaccessible, expensive and heavily stigmatised.
There is also the spectre of criminality in some states. For example, in New South Wales and Queensland abortions are illegal unless a doctor decides that a pregnancy puts a women’s health or life at risk.
“Abortion is the only medical procedure in the country where this is the case. Where the patient’s wishes are inconsequential,” federal MP Tanya Plibersek, deputy leader of the opposition and shadow minister for education and women, said in a speech last year.
Queensland’s conservative abortion laws were written in 1899, but the legislation now has a few sub-paragraphs that make it fairly easy for GPs who offer abortions to stay on the right side of the law.
Abortions are legal in Queensland if the termination is necessary to prevent serious danger to the woman’s physical or mental health, taking into account the woman’s psychosocial circumstances.
GPs could argue that any woman experiencing an unwanted pregnancy was likely to be at risk of psychosocial harm “so, by not offering abortion we would be damaging the woman’s health”, Dr McNamee said.
“Realistically, the chances of a patient or a doctor who is following good practice being prosecuted under the current law is extremely low, but that doesn’t remove the fear factor,” she said.
Dr Goldstone, the medical director at Marie Stopes Australia, said there was probably some reticence among GPs in states where the law is confusing and there was a lack of clarity because those GPs felt they could potentially be open to prosecution. This was not an issue or concern for those practising in Victoria or the states where the procedure had been completely decriminalised.
A few recent abortion cases in Cairns served to underline the shockingly backward legislative environment, Dr McNamee said.
Two years ago, the parents of a 12-year-old girl had to go all the way to the Queensland Supreme Court to fight for their child’s right to a medical abortion. In 2010, a couple was prosecuted, and later acquitted, for terminating a pregnancy with drugs imported from Ukraine.
Every few weeks a woman asks Dr McNamee whether abortions are legal in Queensland.
“And that’s quite a complicated thing to explain,” she said.
“I’m no lawyer. We should be concentrating on our health, not getting caught up in an explanation of an outdated law.”
Dr McNamee was confident that a legislative change was coming in Queensland this year. “And we are hoping that will have a knock on effect in New South Wales that they will follow a similar path,” she said.
The legislative confusion also dissuaded bureaucrats from funding surgical abortions in public hospitals in most states, Dr Goldstone added. “There’s very little public provision in New South Wales and Queensland except in cases of fetal abnormality or a maternal health reason,” he said.
South Australia is the only state where virtually all terminations are provided in the public health system. For all other states, terminations generally occur in the private system.
Dr Goldstone suggests that is a skewing of priorities. “If a women falls pregnant and decides to continue the pregnancy, the public health system will provide her with everything that she needs right through to birth and beyond but if she chooses not to continue the pregnancy, she’s virtually left to fend for herself,” he said.
The lack of access to surgical abortions in public hospitals means women often have no choice but to accept a medical abortion, even though some women find the idea of miscarrying at home distressing and would prefer a surgical option.
For women who prefer a medical abortion, the ability to miscarry in private at home, supported by a partner, offers some comfort. Some women said that a medical abortion felt more natural, as it involved termination at an early stage of development when there was the 20% chance they would miscarry anyway, Dr McNamee said.
Dr McNamee was involved in surgical terminations over 20 years in the UK before moving to Australia, but she never saw the level of shame and stigma that is present in Australia in 2018.
“If I were to explain to my British colleagues what we have to go through in Queensland to achieve good healthcare for a woman they would be absolutely horrified,” she said.
Ironically, Australia was actually a world leader in primary care provision of medical abortions. We were one of the first countries to allow GPs to prescribe mifepristone and misoprostol for home abortions.
Scotland and Wales now also allow women to take abortion drugs at home. But in England, women still have to take abortion drugs at a licenced clinic, meaning they usually experience heavy bleeding and cramping on the way home.
Australia was only so far ahead because we were so far behind in legalising medical abortions in the first place, Dr Goldstone said.
Medical abortions had been around since 1988, but the TGA only registered mifepristone and misoprostol in 2012.
“By the time it was registered in Australia there was almost three decades of experience with the medicine, so there was a lot of safety data that probably wasn’t there for other countries,” Dr Goldstone said.
Originally, mifepristone and misoprostol was used for abortion up to 49 days of pregnancy in Australia. This was later extended to 63 days.
At the start, only GPs who were authorised prescribers could access the drug through a Special Access Scheme. These regulations were later loosened, and GPs were permitted to manage medical abortions after registering online and completing a training course with MS Health, the pharmaceutical company set up by Marie Stopes Australia to import mifepristone and misoprostol, known as an MS 2-step composite pack.
MS 2-step was PBS-listed in 2013, dropping the cost from around $300 to $39.50 for Medicare card holders and $6.80 for Health Care Card holders.
“When it was first registered the medical indemnity companies were requiring GPs to hold a higher level of insurance,” Dr Goldstone said.
“Now [they] have dropped that requirement. So GPs don’t need any extra level of insurance to provide medical abortions.”
Despite Australia’s relatively liberal stance on primary care provision of MS 2-step, relatively few GPs have become prescribers. In 2016, only 1,244 doctors were registered with MS Health, representing around 5% of the estimated 30,000 GPs and gynaecologists in the country and only 2,715 out of 29,000 pharmacies were dispensing MS 2-step.
“There is gradual uptake of early medical abortion by GPs, although it has not been as rapid or as widespread as we hoped when we campaigned for overturning of the Harradine amendment in 2005-2006 and imported mifepristone for use in private practice,” said Caroline de Costa, an O&G professor at James Cook University College of Medicine. (The Harradine amendment was a federal law passed in 1996 banning mifepristone.)
And Australia keeps poor records of abortions; only South Australia and Western Australia regularly publish statistics.
The most recent figures from Western Australia showed that medical abortions increased from 0.1% in 2007 to 18.4% in 2015. A South Australian report shows that GPs provided around 5.4% of abortions in 2015.
“It really should be something that most GPs can offer as part of holistic women’s reproductive healthcare, but we haven’t reached that point yet,” Professor de Costa said. “But for doctors who are interested and have sufficient patients, there is no reason why every large medical centre couldn’t have a prescriber.”
While registration, training and medical indemnity insurance for medical abortions was relatively straightforward, the counselling and management of complications could be difficult.
Around 3% of women have clots or products left behind in the uterus after a medical abortion.
“That’s the area that is medically most grey and most difficult to manage, because you are sort of caught between not wanting to over-investigate and over-operate and yet not wanting to leave a woman at risk of infection and other difficulties,” Dr McNamee said.
“And that’s where I think your clinical judgment comes in.”
Medical abortions have around a 2% failure rate. If a woman has a medical abortion but is still pregnant, a surgical abortion is required because mifepristone and misoprostol are category X drugs that can result in malformations in the fetus.
Dr McNamee’s practice has developed a good relationship with the gynaecologists at the local hospital and can generally get women into surgery the next day. It was important to have the pregnancy terminated quickly to minimise the patient’s distress, she said.
“It is a bit of a concern when I do, for instance, Skype consultations in other small towns in Queensland because I don’t know the lay of the land with the local gynaecologists,” Dr McNamee said.
“As far as I’m concerned, they have a duty of care to offer surgery because of the nature of the drugs the pregnancy has been exposed to, but there is a general reluctance within Queensland health facilities to have anything to do with abortion.
“I haven’t actually had a case yet where I’ve I had to phone up a gynaecologist and encourage them to live up to their responsibilities,” she said.
Abortions should just be considered a normal and essential part of healthcare, Dr Goldstone added.
“It should be treated in the same way as accessing STI screening or pap smears or anything else that is simple and straightforward. But it’s not, unfortunately. It’s discrimination against women. That’s what it comes down to.”
