Awakening

My alarm startles me at 3.20am as it has done every other Tuesday morning for many months. I swiftly silence it as I’m determined not to rouse the rest of the family. One would think I might become accustomed to the rude awakening but it’s always a shock. This is the beginning of my regular 2500km round trip to deliver abortion care and other reproductive health services to regional, rural and remote Australians.

For most of the last 12 months, provision of abortion care in Australia has been even more challenging than usual due to the lack of commercial flight availability caused by movement restrictions in the COVID-19 pandemic. There is a long-term shortage of local abortion providers in regional and rural areas and we have regularly relied on fly-in, fly-out clinical staff to guarantee service provision. Since the start of the pandemic, we have been travelling to our regional clinics on a weekly charter flight supported by a grant from the State Government.

Barriers to access

Approximately 29% of Australia’s population live in rural and remote areas,¹ and in general these people have poorer health outcomes and a shorter life expectancy when compared with people living in metropolitan areas. Access to sexual and reproductive health (SRH) services such as contraception and abortion is hampered by several factors. Geographical remoteness from specialist services is compounded by conservative attitudes and conscientious objection to the provision of contraception and abortion.² Most regional public hospitals do not routinely provide abortion care except in the case of fetal anomalies, and often the only local alternative for healthcare is a faith-based private provider, where neither contraception nor abortion are offered as part of women’s healthcare services.

The challenges of providing early medical abortion

Early medical abortion can be provided up to 63 days gestation by clinicians including General Practitioners (GPs) who are certified prescribers of medical abortion. The dispensing pharmacist must also be certified with MS Health. Often these doctors provide services ‘under the radar’ for fear of repercussions should they become known as the local abortion provider. I have great sympathy for these clinicians as they are torn between providing holistic essential healthcare whilst protecting their own and their family’s privacy in small communities.

On my travels I’ve met some incredibly passionate women’s healthcare providers who are determined to provide a quality service. One such clinician told me they had jeopardised their career by attending the educational session hosted by the primary health network which I was speaking at. Another feared they would be ‘run out of town by anti-choice zealots’ if they openly provided medical abortion.

Of the 37,000 GPs in Australia, only 1491 are certified to prescribe medical abortion³ and not all of these clinicians will be actively delivering a medical abortion service. In mid-2021, Children by Choice, a Queensland service offering information, referrals, counselling and education on all pregnancy options, will be launching a publicly accessible online database of abortion and contraception providers, pharmacists and sonographers across the state. The interactive map will be searchable by postcode, provider type and fee information.⁴ This should improve reproductive healthcare access in Queensland by providing clear pathway information for individuals.

Telehealth models of care

A helpful change in recent years in Australia is the development of medical abortion via telehealth at home. Our service launched in 2015 as an access model to provide care for regional women in Australia. Since the start of the pandemic, many other organisations and individual practitioners have developed telehealth models of medical abortion delivery. Reassuringly, these services have been shown to be safe, efficacious and acceptable to both providers and women internationally and in Australia.⁵

In July 2020, access to telehealth MBS item numbers was restricted to the patient’s own GP or practice which impeded SRH care. A welcomed change in mid-2021 temporarily exempts SRH consultations such as provision of medical abortion from the previously required pre-existing relationship with a doctor. These item numbers will be further reviewed by the Federal Government in late 2021. We are hopeful that changes are afoot which will ensure that provision of this service remains a permanent and viable option for practitioners.

Accessing surgical abortion and abortion beyond nine weeks gestation

When the gestation advances beyond 63 days, or a medical abortion is contraindicated, the situation becomes even more challenging for our regional and rural women. Some public hospitals will offer late medical abortion (medical induction), but this is often limited to patients with pregnancies affected by fetal anomalies. Surgical abortion is currently the only option available to women over 63 days gestation who cannot access abortion within the public system. Surgical abortion is generally provided by specialist services in a day surgery outpatient setting. Unfortunately, regional and rural Australians may have to travel vast distances to the nearest surgical abortion provider.

This hardship is compounded if the woman has complex medical or psychosocial needs. Most day surgery settings are not suitable for women with complex requirements, and it can be incredibly challenging to find a hospital provider who will help. These same women who are denied abortion care will then have to undergo a high-risk pregnancy and be cared for in the local maternity setting; the irony of this situation is not lost on me. Although women presenting in the late 2nd trimester are in the minority, they will often have to travel to a city (either intra- or interstate) to access later surgical abortion because there are very few services equipped to offer this.

Women’s voices

What we must remember is the real women and their families at the heart of this issue. I am frequently in awe of the resilience and resourcefulness of my rural patients. I recall the woman whose nearest surgical abortion provider was 300km from her home but she would have been over their gestational limit by the next available appointment, so she drove right past this clinic for a further 700km to access care. Also, the woman who arrived at the clinic with her partner and several young children in the car having left home in the small hours of the night for a five-hour drive through the tail end of a cyclone. Her partner drove her home the same day as they had to tend to their livestock. I feel ashamed of my sporadic whinges about the length of my commute when I hear of the hardships these women and their families encounter.

So what now?

It’s clear that decriminalisation doesn’t equate to access and even more so outside metro areas. So how can we level the playing field for our regional, rural and remote patients seeking abortion care? Internationally, early medical abortion at home has been extended to 70 days gestation with very reassuring safety data.⁶ Other models of abortion care including nurse or midwifery-led have been shown to be safe and efficacious and are recommended by the World Health Organization and key Australian bodies.^{7 8}

As clinicians, we need to destigmatise abortion through education starting in medical school and continuing through general and specialist training. Abortion should be considered a matter of health and not politics or religion. After all, aren’t we all working for the same aim? To provide essential reproductive healthcare services to our patients with compassion and without judgement.

Coming home

As the sun sets, we begin our long journey home. The only light pollution is from our little Cessna and we are captivated with glimpses of shooting stars and satellites. The team are weary but hopeful that our service has made a positive impact on our patients’ lives.

1. Australian Institute of Health and Welfare. Rural & remote health. 2019; Available from: www.aihw.gov.au/reports/rural-remote-australians/rural-remote-health
2. Doran F, Hornibrook J. Barriers around access to abortion experienced by rural women in New South Wales, Australia. Rural and Remote Health. 2016;16:(3538).
3. MS Health (2021). Impact Report 2020, Melbourne, Australia: MSI Reproductive Choices. Available from www.mshealth.com.au
4. Children by Choice: Mapping Access Pathways Project (MAPP); Windsor, QLD 2021. Available from: www.childrenbychoice.org.au/forprofessionals/mapping-access-pathways-project
5. Fix L, Seymour JW, Sandhu MV, et al. At-home telemedicine for medical abortion in Australia: a qualitative study of patient experiences and recommendations. BMJ Sex Reprod Health. 2020;46(3):172-76.
6. Abortion Care. Nice Guideline 140. National Institute for Health and Care Excellence. 2019. Available from: www.nice.org.uk/guidance/ng140.
7. WHO Health worker roles in providing safe abortion care and post-abortion contraception. 2015. Available from: www.who.int/reproductivehealth/publications/unsafe_abortion/abortion-task-shifting/en/
8. Marie Stopes Australia Nurse-led medical termination of pregnancy in Australia: legislative scan. 2020. Available from: www.mariestopes.org.au/advocacy-policy/nurse-led-care/