Governments at all levels have been urged to take systemic action to address “terrifying” inequalities in access to abortion services in rural, regional and remote areas.
Dr Amy Coopes reports on the 16th National Rural Health Conference for the Croakey Conference News Service.
Amy Coopers writes:
One in three Australian women live in an area where there is no access to medical abortion and states like New South Wales remain an information ‘vacuum’ on where to access care for an unwanted pregnancy via “clandestine” networks based 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 start of the COVID-19 pandemic. 19.
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 controversial Roe vs. Wade decision of the United States Supreme Court. The ruling, which effectively set back abortion rights in the United States by decades, grabbed headlines and sparked protests in countries like Australia.
Abortion is legal in all Australian states and territories, although it is still governed by the criminal code in Western Australia, and the conditions under which abortion can take place vary widely. South Australia was the last party in the Federation to decriminalize abortion.
Between a quarter and a third of Australian women will have an abortion in their lifetime, with estimates suggesting that half of all pregnancies are unplanned and of these, one in two is terminated.
As with many aspects of health service delivery, access to abortion care varies widely by geographic location, with providers concentrated in metropolitan areas and rural women facing significant barriers, said the conference.
Dr Samantha Chakraborty, from the NHMRC-funded SPHERE Center for Research Excellence in Sexual and Reproductive Health for Women in Primary Care, presented the results of a study looking at the provision of abortion care by general practitioners by area statistical.
It is estimated that around 10% or 3,000 of Australia’s 35,000 GPs have undergone medical training using the combination of mifepristone and misoprostol (MS-2 Step), but these figures do not 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. The centre’s director, Dr Danielle Mazza, called the results “frightening”.
“What we found is that 30% of women in Australia live in a statistical area where no GP actually provides this service, and that rate increases even more in rural areas,” Mazza told Croakey on the sidelines of the “shocking” data conference. The data was collected in 2019, before the introduction of specific MBS article numbers for telehealth abortion services.
“Women are at a huge disadvantage because they can’t access locally,” Mazza said.
The SPHERE team found significant variation in age-standardized rates of two-stage SP dispensing by remoteness area per 1,000 women. In the big cities, the MS in 2 stages was dispensed to 3.3 per 1000 women against 6.53 in the peripheral regions – clearly above the national average of 3.79.
Average distribution rates were highest in the ACT, at 3.15 per 1,000, and lowest in the Northern Territory, at 7.16. Tasmania and the Northern Territories had the worst results overall, with the outer regional areas of these jurisdictions offering a grim picture of access (8.43 and 9.75 per 1,000, respectively).
Barriers to Access
Anna Noonan, a researcher at the University of Sydney, examines the abortion care experiences of rural women and healthcare providers in western New South Wales. His findings, which remain embargoed as part of his doctoral studies, were presented in a preliminary format at last week’s conference.
Overall, Noonan said the work “confirms what we already know that access is difficult, travel expensive, complicated and there are aggravating factors that make accessing services really tricky. “.
Despite decriminalization, Noonan said the system remained opaque to people wanting to access an abortion — a category she said did not apply exclusively to cisgender 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 to access abortion care.” In New South Wales, there remained “a void, there’s just no publicly available information,” Noonan said.
“It’s this really strange and fragmented environment that rural women in NSW live in,” Noonan told Croakey after her speech.
“And the frustrating thing is that there are no service providers, because we know there are – we talked to them… [It’s] that they don’t publicly advertise their service, for many reasons, and that it’s really hard to find them. »
Participants interviewed for Noonan’s research described a “kind of weird underground 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 even access information to help them make a decision in “three or four very urgent weeks,” she said.
For local providers, Noonan said a variety of factors play into the reluctance to promote their credentials in this space, including fear that they themselves will be stigmatized as an “abortion doctor” by city, and that the demand would be such that it would crowd out their other work.
Noonan said some doctors were also concerned that, although they themselves were strongly in favor of providing abortion services, they were operating in settings where – if a medical termination was not successful – options were locally limited for escalation of care.
“There’s some nervousness among providers that if they’re providing this service but they know the hospital is antagonistic towards abortion care, then they’re preparing that person to potentially end up in an environment where it’s is beyond their reach and they are unlikely to receive non-judgmental care,” Noonan said.
Mazza has just returned from a Churchill Fellowship trip through Europe and North America, examining models for integrating abortion into primary care. On international comparisons, she said Australia compared “pretty badly”.
In countries like the UK, Ireland and Sweden, Mazza said governments take “full responsibility to ensure women have access to abortion in their publicly funded health services. State”, while in Australia it remained – to a large extent – a private sector issue.
The lack of standardized and uniform education and training on abortion care, from medical school to training general practitioners, was a big part of the problem, Mazza said, also echoing Noonan’s sentiments about the lack of local and regional specialist support for primary care physicians in this space. .
“GPs need to be sure that in the rare event there is a complication, they can quickly access support for their patient at the local hospital,” she said.
Mazza also highlighted stigma as an issue for rural GPs.
“They are afraid of being known, of being discriminated against, of retaliation or God knows what from anti-abortion people in their area,” she said.
At the policy level, Mazza said there is a lot that states and federal governments can do to address this issue, including directing Primary Health Networks (PHNs) to conduct needs assessments and commission service delivery for care. abortion in their area.
Both Mazza and Noonan agreed that there was a place for telehealth to increase offerings in the telehealth space – in fact, Noonan’s research found that some women preferred a “transactional experience” that was distinct and not supplied by their usual supplier.
But Mazza said it was only part of the solution, arguing that abortion care should only be seen as one element of “comprehensive health services for women” offered in primary care.
“GPs know their patients, they know their social situation, they know their families, and they can help women with other ongoing issues regarding, for example, 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 want power over the care they receive,” added Noonan.
“It’s just health care. You show 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 a choice, and don’t stuff them so they don’t waste really critical time.”
She called on NSW to follow the example of Victoria, Queensland and Tasmania and establish a public directory of services, ‘or better yet’ to roll out such an offer nationally, pointing to the ‘problematic’ example of the states States where, following the Roe v Wade decision, abortion had defaulted from a federal issue to a state issue.
Mazza said the “appalling” developments in the US had both shown how far Australia still had to go, but also sparked an openness to change that should be seized.
“I think it also galvanized people to realize that if we don’t really address these issues, abortions can become very insecure.”