Reproductive coercion on the rise

A new coalition of stakeholders are calling for improved access to early medical abortion – and in the time of COVID-19, it’s more important than ever, says one member

To mark the International Day of Action on Women’s Health on Thursday, the Sexual and Reproductive Health (SRH) and COVID-19 Coalition called for rapid policy and practice-based changes to improve the accessibility of early medical abortion (EMA) in Australia during COVID-19 and beyond.

These changes include:

  • Extending the gestational limit that applies to a woman being able to have an EMA from 63 to 70 days.
  • Removal of requirements for Rhesus determination and administration of Anti-D in known Rhesus negative women undergoing EMA prior to 70 days’ gestation.
  • Enabling EMA to proceed without the necessity of an ultrasound assessment under very stringent conditions and with patient consent in situations where obtaining an ultrasound is a significant barrier or poses a significant risk during the COVID-19 pandemic. 

These changes would align with new guidance that has been issued for healthcare professionals across the UK, US and Canada to minimise exposure to COVID-19, the coalition says.

“The coalition consensus statement highlights critical issues that can make access to early medical abortion difficult for Australian women and provides policy and practice solutions and approaches that need to be implemented to overcome them,” Professor Danielle Mazza said.

In Australia and New Zealand, an ultrasound prior to EMA is mandatory. The coalition is recommending that while this remains the best approach, practitioners can proceed without the necessity of an ultrasound if the woman is carefully screened for risk factors for ectopic  pregnancy, the gestational age of the pregnancy can be accurately assessed and there is an agreed robust follow up pathway. In addition, the woman will need to understand the risks of foregoing an ultrasound and consent to proceeding on this basis.

“The safety and efficacy of EMA up to 70 days’ gestation is well established.  Increasing the current gestational limit on the use of the TGA-approved medication mifepristone and misoprostol (MS-2 Step) from less than or equal to 63 days up to 70 days’ gestation is supported, but requires urgent change to TGA approvals and the PBS subsidy,” Professor Mazza said.

Dr Safeera Hussainy, Adjunct Senior Lecturer at the Department of General Practice, Monash University and formerly of its Faculty of Pharmacy and Pharmaceutical Sciences, told the AJP that earlier access to medical termination of pregnancy would allow women in all age groups, but particularly younger women, experiencing unwanted or unintended pregnancy to access “a medication regimen that is very safe, and can be taken within the home under the supervision of a nurse practitioner of a doctor”.

She noted that Australia has one of the highest abortion rates in the developed world, and one of the highest teenage pregnancy rates.

“We know that unintended and unwanted pregnancies have consequences for both the mother and the child – there are a myriad of poorer health outcomes in addition to poverty, unemployment, poor nutrition and so on,” she said.

She said that while this expanded access is important beyond COVID-19, the pandemic has thrown up particular challenges for some women around their reproductive health.

“Everybody has had to stay at home and indoors, and the literature says, and the key women’s health organisations have issued a statement saying, that we can expect a rise in reproductive coercion, a lot of the time which will be under the influence of alcohol,” she said.

“There needs to be more support in this area for women experiencing that.

“If they are undergoing reproductive coercion, then there is a risk that they would get pregnant – and carrying an unwanted pregnancy to term also has psychological impacts. So definitely, COVID-19 has enhanced the need for earlier medical termination of pregnancy.”

Dr Hussainy said that this move would see pharmacists practising further towards their full scope, at the same time as “serving the needs of women in reproductive health”.

“For me, the key is also then not having to choose surgical abortion over medical abortion,” she said.

She urged pharmacists to view the issue with a whole-of-life approach: “The World Health Organization highlights the need for early access to information around contraception, around preconception care, around menopause, post-partum and breastfeeding – and also in that is included the provision of abortion.

“This is not separate to any of those life events that could happen to any of us.

“We have to look at it through this lens: it’s a health issue, a human rights issue. Every woman should have control over their sexual and reproductive health.

“As pharmacists, we need to remember that we are public health practitioners above all, and that when we provide information and a health service, we do so without bias and without judgement.”

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