A small but influential number of medical practitioners who obstruct abortion care or are uninterested in providing it are leaving women unable to access abortion in many parts of rural New South Wales, a study has found.
It has led to informal and often underground networks of health workers providing information and access to abortion care to patients, the study found, with these providers burning out due to high demand and attitudes toward them.
Dr Anna Noonan, a research fellow at the University of Sydney’s school of rural health, interviewed 16 healthcare providers, including GP registrars, GP obstetricians, nurses, midwives and women’s health nurses asking them about unintended pregnancy.
All of the staff worked in the western region of NSW, where 17% of the population is female and of reproductive age (15 to 44 years), and where there is only one publicly advertised abortion service.
“We found the decision of one person in a position of power can result in there being no access to an abortion service at all,” Noonan said.
“What I ended up hearing from the primary care providers was that they experienced this constant, often passive obstruction by the health system at multiple layers.”
For example, doctors training as rural generalists and willing to provide abortion healthcare found the rural clinical hospitals where they did their work placements did not provide abortions.
“So they’re learning to provide healthcare without receiving any clinical training or exposure to abortion,” Noonan said. “It meant many felt underprepared and undertrained to provide (surgical abortion) care.”
The study – published in the journal Rural and Remote Health – found that one tertiary institution had even requested censorship of education about abortion services during student clinical placements.
One health worker told researchers: “The problem is that you do have a number of conscientious objectors in the hierarchy of these larger hospitals … that is going to be super hard to get past, because they’re the people that make the rules.”
Most study participants identified professional stigma as a reason why abortion services were limited, hidden and unadvertised.
One health worker said patients who Googled the name of a gynaecologist providing abortion would not find any information about the service online. “It’s just like this underground service that he provides,” the health worker said.
Another study participant described how “it’s kind of whispered in corridors, like – ‘Do you know anyone who does abortions?’”
The unwillingness of providers to openly share information even about where medicines to end early pregnancies could be prescribed or dispensed meant some health workers spend considerable clinical time searching for answers, ringing around pharmacies, asking if they stock the medication, and coming up with a plan for the patient.
Noonan said those health workers trying to refer patients on to services found it hard to navigate who to call and where to go. Some health workers come up with their own informal, underground workarounds, the study found.
A nurse at one rural clinic shared that she would connect patients to an interstate GP who would prescribe medication for abortion via telehealth. Nurse practitioners and midwives are not allowed to prescribe abortion medication in NSW. The nurse then took on all pre- and post-abortion care.
“That was working well for two years,” the nurse said, until “we got a new medical director, and he axed it”.
Noonan said this kind of workaround was sometimes scrapped because managers believed abortion care should be provided by obstetricians and gynaecologists, and because it was too time-consuming for general health service providers to manage on top of other healthcare.
“Australia has taken the most extraordinarily narrow view on abortion, often perceiving it as an obstetrics and gynaecology issue,” Noonan said.
“And maybe it is for the really complicated surgical cases, but it isn’t for the routine prescribing of an abortion pill for an under nine-week pregnancy. We are still holding on to this catastrophising of abortion, this exceptionalising of abortion, where abortion is seen as something so specialised that it needs to be managed by a minute population of the health workforce, and it’s a misguided approach.”
Evidence from the World Health Organization shows that nurse- and midwife-led abortion care models are safe and effective. Noonan said delays finding a provider of medical abortion might mean a patient reaches beyond nine weeks of pregnancy, leaving surgical abortion the only option, which is also hard to access.
The study found that the paucity of GP abortion providers meant existing services were “flooded with requests from other primary healthcare workers trying to find local options, creating tension and overwhelm”.
An obstetrician, who did not want to be named due to the attitudes of some colleagues towards abortion, told Guardian Australia that one in four Australian women need an abortion during their reproductive years.
The clinician, who is also a spokesperson for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, agreed with Noonan that abortion care should be seen as normal, routine healthcare but often was not.
“Abortion care is a high demand service,” she said. “I think another part of the reason health services are reluctant to provide it is because there’s such a chronic shortage of funding for women’s health, and the Medicare rates for providing women’s health are very low.
“To do a more complex ultrasound on a woman, you actually get paid less than doing a very simple scrotal ultrasound on a man.”
She said some health services feared being overwhelmed by an increase in patient numbers if they were to provide abortion.
“For that reason they want to keep abortion care outside of normal care,” she said. “It doesn’t make financial sense to provide it, when women’s health services are so underfunded already.”
She said any hospital funded with public money should be working within the full scope of their facilities to provide all women’s health services, including abortion.
Greg Johnson is the managing director of MSI Australia, a non-profit advocate and provider of abortion and contraception services. He said while Noonan’s study was small and focused on one region, “the experiences ring true with all of the things that we hear at MSI Australia across rural and regional care”.
“Fundamentally, abortion is still at the periphery of an unaccommodating health system,” he said.
“Abortion care should be truly seen as an equal and accepted part of healthcare. Until we get there, we’ll continue to have the problems that we currently have, particularly in rural and regional Australia.”
Do you know more? melissa.davey@theguardian.com
