Portal de Periódicos da CAPES

Abortion care in Australasia: A matter of health, not politics or religion

2022; Wiley; Volume: 62; Issue: 2 Linguagem: Inglês

10.1111/ajo.13501

1479-828X

Catriona Melville,

Reproductive Health and Technologies

Induced abortion is presumably one of the most common gynaecological procedures in Australia, with an estimate of at least 100 000 abortions performed annually.1 We can only approximate the abortion rate as there is no national data collection on induced abortion. The most recent estimate of abortion rates for Australia and New Zealand is approximately 15 abortions per 1000 women of reproductive age.2 Around one in four women will undergo an induced abortion in their reproductive lifetime. There have been many developments in abortion care in the past decade. In 2012 Australia became one of the last high-income countries in the world to approve the use of mifepristone for medical abortion.3, 4 By the end of 2021, there were 3059 active prescribers of MS-2 Step® (a composite pack containing mifepristone Linepharma 1 × 200 mg tablet and GyMiso misoprostol 4 × 200 μg tablets) in Australia.5 Since 2012 the proportion of abortions performed surgically has declined while the proportion of medical abortions has increased. This trend has been demonstrated in other high-income countries where medical abortion now accounts for at least half of procedures, and in some countries such as Finland the proportion is as high as 97%.6 Importantly the increasing use of medical abortion does not reflect an overall increase in the abortion rate which in fact appears to be declining in Australia.2 Modernisation of abortion legislation has now occurred in New Zealand and every jurisdiction in Australia, decriminalising abortion care and allowing all women to legally access this service. This is a hard fought and important development. Critically, unintended pregnancy rates are highest in countries that restrict abortion access and lowest in countries where abortion is broadly legal.7 Restricting access to abortion serves only to increase the number of unsafe abortions and the associated maternal morbidity and mortality as witnessed by our neighbours in Papua-New Guinea (PNG).8, 9 Another gain for reproductive autonomy has been the introduction of safe access zones in all jurisdictions in Australia allowing pregnant people and staff to attend services free from harassment. Similarly, a Member’s Bill is currently being considered in the New Zealand parliament to grant safe areas around abortion services. This may seem inconsequential to those not involved in abortion care; however, if you have ever walked the gauntlet of protestors you will recognise it as a dreadful and unforgettable experience. I recently met a patient who told me she had attended the same service many years ago as a young woman. She remembers stumbling past the sea of accusatory, shouting protestors, and crying at the shame and guilt she felt. Fortunately her more recent experience of reproductive health care was quite different. The global pandemic has compelled abortion providers to reflect on best practice and remove unnecessary barriers to abortion. Very early medical abortion has evolved and ‘no-scan’ or ‘no-test’ abortion pathways have shown promising outcomes both in terms of safety and patient acceptability.10 In 2021 the prophylactic use of Rh D immunoglobulin in pregnancy care guideline was published by the National Blood Authority and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG).11 This guideline reflects others12 in affirming there is insufficient evidence to recommend the routine use of Rh D immunoglobulin for medical abortion prior to ten weeks gestation. The approval of a low-sensitivity urine pregnancy test by the Therapeutic Drugs Administration (TGA) in December 2019 (Check4® rapid human chorionic gonadotropin test) has allowed remote follow-up after medical abortion for many women. These developments enable most women to undergo early medical abortion (EMA) without the need to access any routine pathology. In many countries EMA takes place at home up to 70 days gestation; however, in Australia this is restricted to 63 days gestation. A similar extension to the indication in Australia would improve abortion access here. Despite pausing to celebrate this progress, there is no time for complacency as it is clear that decriminalising abortion does not equate to universal access for women. There remain many barriers to safe and timely abortion care such as financial limitations, lack of local services (including trained and/or willing staff), and geographical remoteness. These barriers are amplified for our most vulnerable people including First Nations peoples, young people, migrant and refugee populations and people with disabilities. Inequity in access has increased during the COVID-19 pandemic. Given there is a scarcity of trained abortion care providers and that a skilled and safe workforce are central to delivering safe abortion care, we need to consider innovative models of delivery. In this edition of the Journal, Desai et al13 present findings of a survey examining the attitudes and practices of registered midwives (RMs) and sexual health nurses (SHNs) in Queensland toward abortion. The researchers found that although there was a wide variety of views, over half of participants would support abortion provision in any situation at all, and less than 8% were completely opposed to abortion due to their views and beliefs or conscience. Interestingly there was a significant association between years since qualification and likelihood of supporting abortion, in that more recently qualified clinicians were more likely to support abortion in any circumstance. This may reflect changing views of the population and gives hope for a future workforce. Of all respondents, 92.9% felt that abortion care should be part of the core curriculum for RMs and SHNs in Australia. This is an important and timely study of reproductive healthcare professionals and the first of its kind in Australia. The demand to have mandatory education on abortion as part of the curriculum aligns with the views of Australian medical students. A study of Australian final year medical students found that around 80% reported inclusion of abortion care education in their curriculum;1 however, very few had direct exposure in an abortion clinic. All of those who did not receive any teaching on abortion would like this subject covered in the curriculum. Clinical placement within a dedicated service was highly valued. This in itself is challenging given the paucity of abortion services in public hospitals. The desire to include abortion care in the curriculum is not unique to medical undergraduates in our region. The majority of surveyed Fellows and specialist trainees of RANZCOG believe that education about induced abortion should be part of both Fellowship of RANZCOG and RANZCOG diploma training.14, 15 This aligns with another finding of this research, namely that most RANZCOG Fellows and trainees believe provision of induced abortion should be a routine part of general obstetric and gynaecological practice. Additionally over 90% of participants support public provision of abortion. Some clinicians who could provide abortion care in the public or private health system are unable to because they work within faith-based healthcare organisations. It is impossible to provide all aspects of reproductive health care, including contraception within this incongruous framework. In both these studies, some participants made a distinction between induced abortion for ‘social’ reasons and for maternal or fetal conditions. The term ‘social abortion’ is poorly defined and erroneous and further stigmatises those seeking abortion care. Some clinicians have personal or religious views which do not align with participating directly in abortion care; however, all clinicians still have a duty of care to their patients. As a minimum those of us who choose to work in women’s health should be equipped to offer compassionate and non-judgemental wraparound care including the management of complications of abortion and provision of contraception. To this end the mandatory abortion module introduced for all Integrated Training Program trainees in 2020 is a welcome development. An advanced training module in Sexual and Reproductive Health (SRH) which includes abortion care is also available, and the RANZCOG SRH Special Interest Group is developing a two-year advanced pathway in SRH for trainees with the aim of producing specialist obstetricians and gynaecologists who are the SRH experts of the future and can provide high-quality abortion care as part of their skillset. Education is critical in ensuring evidence-based information is provided to reproductive health providers. The belief that fetal pain perception occurs much earlier than the accepted developmental reality correlates with anti-choice views in the general public.16 It is important to examine one’s own ethical and moral framework and ensure opinions are based on the available evidence and not simply from inherited belief systems. Equitable access to abortion services for Australian women is a key priority of the National Women’s Health Strategy 2020–2030.17 Having established there is overwhelming support from the aforementioned professional groups for normalising abortion care within health, how do we design models of care which are sustainable and deliver a quality and safe service when there is a shortage of trained clinicians and limited resources for provision in our public health systems? Provision of EMA in community settings reduces waiting times,18 is safe and effective19 and can be delivered by a variety of clinicians including nurses and midwives.20 Internationally health workers other than doctors also provide first trimester vacuum aspiration abortion.21 Task sharing with other health professionals will require changes to the TGA guidelines for mifepristone and misoprostol, to state legislation in most jurisdictions, an amendment by the Pharmaceutical Benefits Advisory Committee to enable nurse practitioners and endorsed midwives to prescribe MS-2 Step®, and an extension of scope of practice by the Nursing and Midwifery Board. Care in the community should be provided in collaboration with secondary care specialist abortion providers for women with complex needs and those unable to have EMA due to gestational limits or other factors. Local systems such as HealthPathways should facilitate timely referrals. EMA provision via telehealth has been critical for providing services during the COVID-19 pandemic to both urban and rural clients and is a safe and acceptable model of care.22, 23 Telehealth models are especially crucial for supporting our regional and rural population; however, clinical networks and support local to women are still essential. Although we have made some promising advances in abortion care in Australia and New Zealand, we must not forget our neighbours in PNG which has one of the highest maternal mortality rates in the world. Abortion legislation in this low and middle income country is contained within criminal law (originally from 1899) and the sequelae of unsafe abortion such as sepsis including puerperal sepsis, are reported as the second leading cause of maternal mortality.9 Women are known to attempt abortion using unsafe methods such as traditional herbal abortifacients and physical and mechanical means. The use of misoprostol acquired from friends and relations who are health workers, for self-induced abortion is increasing, particularly among educated women.8 There is confusion or lack of clarity about the legal status of abortion in PNG among healthcare providers and a wide variety of views on provision of such a service. Legislative change, education and training to improve knowledge of abortion care and to reduce stigma is essential to achieve future reproductive justice in PNG. For too long abortion care has been politicised; however, now current legislation in Australia and New Zealand reflects the assertion that abortion care is simply a part of health care. As such it must be included in education and training so that we can equip the healthcare professionals of the future with the skills and experience they require to deliver safe and equitable services. We should adapt and respond to workforce challenges especially in the more remote areas of Australia and New Zealand and make use of our skilled and capable nursing and midwifery colleagues. I can think of no other area of health care that has been so stigmatised, marginalised and judged by policy makers and clinicians alike. As specialists in women’s health, should we not be here to support women and their choices through all stages of their reproductive lifespan and not just the parts we pick and choose?