The barriers to medical abortion

Australian women are choosing medical abortion less often than international peers because there are barriers to access, argue two experts

In an invited editorial published in the Australian and New Zealand Journal of Obstetrics and Gynaecology, Associate Professor Kirsten Black and Dr Deborah Bateson of the Discipline of Obstetrics, Gynaecology and Neonatology at the University of Sydney, write that “medical abortion is fundamental to women’s health care”.

“It provides a safe and effective alternative to early surgical abortion and can occur in the privacy of a woman’s home,” they say.

And in countries where mifepristone has been available for some time, about half of women seeking to terminate a pregnancy choose it over surgical termination, the authors say.

Access in Australia is relatively recent – prior to 2013 use of mifepristone was severely restricted and a composite pack of mifepristone and misoprostol has only been available since 2015 – and at this stage only about a third of women seeking abortion choose the medical route.

This is due to several barriers, A/Prof Black and Dr Bateson write.

“As a result of law reform in six of eight Australian jurisdictions, abortion can be performed lawfully subject to various conditions in these jurisdictions but it has been fully decriminalised only in the Australian Capital Territory.

“Abortion remains a crime in New South Wales (NSW) and Queensland and can only be performed lawfully at all as a result of case law permitting abortion where it is necessary to prevent serious risk to the life or health of the woman.

“Practitioners report that the current complex and varied legal status of abortion across Australia has a significant impact on service provision and compromises patient care.”

The two write that access is also limited by the cost of “largely private provision and lack of access for women in rural regions where few private services operate”.

“Public hospitals have abrogated responsibility for abortion service provision, leaving the private sector, including independent abortion clinics and a small number of motivated general practitioners (GPs), to fill the need.

“Although private services provide high-quality medical care, they can be costly and out of financial reach for some women.”

The authors cite a study that showed women who had to travel for four or more hours to a city-based clinic, compared to women from metropolitan areas, were more likely to present later than nine weeks’ gestation – which rules out the possibility of medical abortion.

These women were more likely to identify as Aboriginal or Torres Strait Islander, were less likely to be able to afford abortion, and had a lower understanding of medical abortion.

A/Prof Black and Dr Bateson argue that “primary care services delivered through general practice, family planning clinics and sexual health services ought to be enhanced”.

While it had been hoped that PBS listing mifepristone and misoprostol would help improve access, uptake of accreditation by GPs appears to be low.

One innovation is telemedicine medical abortion services, which “together with the use of remote access communication technologies, is ideally suited to the Australian context where repeat clinic visits can be challenging but follow-up is required”.

Encouraging health professionals to prescribe, dispense and otherwise participate in providing abortion services is essential, the authors say.

“As a nation we continue to fail to address the issue of equity of access to one of the most common procedures women will require in their lifetime.

“More needs to be done to ensure that our health system does not fail to provide the basic services which every woman has a right to access, regardless of her financial circumstances or where she lives.”

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