Author: Professor Danielle Mazza, Director of the SPHERE Centre for Research Excellence and Head of the Department of General Practice at Monash University.
Access to early medical abortion (EMA), using mifepristone followed by misoprostol to end an early pregnancy, remains a challenge in Australia, especially for women from vulnerable groups and those living in rural and regional areas.
Low numbers of general practitioner providers, lack of peer networks to support the establishment and ongoing provision of EMA services, and stigma are real barriers as is a broader lack of knowledge regarding medical abortion among health professionals.
Many women are unaware of the availability of EMA and the current gestational limit of 63 days. They also face difficulties navigating the health system to find an EMA provider, particularly when they encounter conscientious objections. Women can also face other barriers such as needing to travel to access services, take time off work or find childcare, and many need to source financial support to meet the costs.
During the pandemic, there has been an increase in the demand for abortion because of a rise in unplanned pregnancies. Increases in domestic violence, financial insecurity and delays in accessing abortion services, due to travel restrictions or other pandemic-related stressors, means that women are often presenting for an abortion at a later gestational age.
The availability of Medicare Benefits Schedule (MBS) telehealth item numbers, introduced as part of the government’s response to the pandemic has meant that telehealth EMA can be delivered through Medicare to eligible patients. However, since 20 July 2020, the government has imposed restrictions on the temporary MBS items for telehealth GP consultations – namely restricting eligibility to only those who have visited the GP or practice in the previous 12 months or those who have been referred by a specialist except for where there is a current lockdown in place.
These restrictions severely impact women’s access to GPs who can provide EMA, and discriminates against women who have not recently engaged with a GP due to various forms of disadvantage, such as family violence and unemployment. An exemption should be issued so that registered prescribers of medical abortion are able to use MBS telehealth item numbers for the benefit of Australian women.
We also suggest other measures and changes to policy which would optimise the ability of telehealth to improve access to EMA for all Australian women:
- a national hotline or online platform, similar to the 1800 My Options service (www.1800myoptions.org.au) in Victoria, which directs women to local abortion service providers, is required to assist women to identify an appropriate provider;
- changes to the current Therapeutic Goods Administration and Pharmaceutical Benefits Scheme provisions restricting the prescription of MS-2 Step (mifepristone and misoprostol) to up to 63 days’ gestation
- modifications to EMA protocols, particularly during the COVID-19 pandemic – the Royal Australian and New Zealand College of Obstetricians and Gynaecologists has already advised that a clinician may appropriately decide not to administer anti-D before 10 weeks for the medical management of abortion, particularly when an additional visit may increase exposure of women and staff to COVID-19;
- in situations where obtaining an ultrasound is a significant barrier or poses a significant risk during the COVID-19 pandemic, EMA may proceed without the necessity of ultrasound assessment but only after careful screening for risk factors for ectopic pregnancy and where an accurate gestational age can be estimated from the woman’s history;
- in South Australia mifepristone can only be supplied in a hospital setting – this precludes South Australian women from being able to access EMA through community-based providers such as GPs or via telehealth; the relevant South Australian legislation therefore requires a change
This research was published with Monash University co-authors Seema Deb and Dr Asvini Subasinghe in the MJA Perspective Issue 37 / 21 September 2020