Zerina Budimovic
It’s been almost six months since abortion was decriminalised in all jurisdictions in Australia. Despite the legal right to abortion, limited or no access to abortion services remains a challenge for women in rural, regional and remote areas.
Approximately 7 million people or 28% of the Australian population live in rural and remote locations. The females included in these statistics are facing serious consequences regarding medical procedures due to their geographic location.
Children By Choice (CBC) Chief Executive, Daile Kelleher, said she has spoken to a variety of females who have shared their vulnerable stories over the last few years.
“We find that regional, pregnant people have to travel hundreds of kilometres to be able to access healthcare and so they’re rarely able to do that within their own local communities,” Miss Kelleher said.
“We know that any sorts of barriers to abortion tends to impact already vulnerable and marginalized population groups.”
“It might be people who are living with a disability or individuals in violent and controlling relationships. Imagine if you live regionally and you have a controlling partner who doesn’t allow you access to finances or resources or time away from home. How are you going to access an abortion if you have to travel to Brisbane?”
The process of receiving an abortion in a rural, remote or regional community
One in three women live in a region where there is no access to medical abortion.
A medical abortion is an abortion performed by medication such as a pill that effectively terminated and early pregnancy in a safe and non-invasive manner.
A surgical abortion on the other hand can be performed within in the first or second trimester of pregnancy, depending on which state the individual resides within Australia.
Miss Kelleher said the first step to receive a medical abortion is confirming the pregnancy by receiving an ultrasound and find a GP that is willing to give you the right information.
The challenge with this is how only 10% of general practitioners (GPs) in Australia are registered to prescribe the mifepristone and misoprostol regimen for medical abortion. There is a critical lack of health care practitioners with the required expertise and skillset to perform these procedures.
“It means that the majority of the GPs that you go to won’t be able to get early medical abortion and that needs to happen before nine weeks gestation,” Miss Kelleher said.
“If you’re already running around trying to find a suitable GP and you know, you just found out you’re pregnant in week 6 or 7, you don’t have that much time to be able to find the right person which can be very challenging.”
PhD researcher in rural women’s reproductive health, Anna Noonan, is examining abortion care experiences of rural women and health care providers within communities across New South Wales.
Miss Noonan said it brings upon frustration and additional stress for rural, regional and remote women trying to access a service with a long waitlist.
“We have seen evidence that in some circumstances a woman might continue a pregnancy in a rural area because she simply couldn’t get access to the services she wanted,” Miss Noonan said.
“That’s a pretty tremendous life change, you know, to carry an unwanted pregnancy because you couldn’t get an abortion service.”
Miss Noonan said there is a stigma within the medical profession and that abortion services are not necessarily advertising the service making it difficult to navigate where to find suitable help.
“One person I spoke to said that as soon as she knew she needed an abortion, she said, ‘god now I have to go and find someone in our local area who I’m feeling comfortable to talk to about this’,” Miss Noonan said.
“We have not seen any evidence of deep resentment of the medical profession, just the system, perhaps more generally as there is some discomfort among the medical professionals”.
Miss Noonan said that other factors that emerged from talking to her participants is how time is a big stress factor.
“Seeing as it is really hard to get into GPs locally, you might go and see a GP who does not want to support your decision to have an abortion. You then have to wait to find another one that these kinds of pressures compound and exacerbate the experience to be much more stressful than it needs to be.”
Client Service Advisor at MSI Reproductive Services Australia, Swaroop Tadiparthi said that clients express that the most difficult part is the number of conservative GPs they meet.
“We have had clients from Western Australia describing how the GPs show the monitor, saying that you should listen at the heartbeat which is kind of traumatising for the client as they do not want to see that,” Mr Tadiparthi said.
Financial burden
Over the past year a lot of abortion clinics closed down, meaning most of the surgical private clinics are based in metropolitan areas. This requires females to travel thousands of kilometres.
Mr Tadiparthi said how far into the pregnancy a female is and what type of abortion service she needs affects the price.
“The process of a surgical abortion is very different, and the price drastically doubles literally when you hit the 14-week mark,” Mr Tadiparthi said.
“There’s a huge difference between if you do not have Medicare as a medical termination could cost you up to $1,220. It is usually opted by people who do not have a Medicare card, but they do not have any choice, so they have to go ahead with it.”
“The tele abortion has a very strict gestational limit, which makes it a problem especially for Indigenous needing an abortion in the city especially.”
“There exists one particular thing that I have identified and there’s a lot of domestic violence that happens, especially so in talking about Indigenous communities. I have had many clients who are Indigenous with up to 8 children and they want an abortion, but it is difficult for them as they are no longer eligible for telehealth abortion and live far away.”
The cost of an abortion varies according to state, location, method of termination and gestation.
Medical abortion fees range from $250-$600 dollars, whereas surgical abortions fees start from $400-$800 dollars. With a Medicare card, females are eligible for a free abortion in some states, but this is often not the case for regional, rural and remote women due to their geographic location. Not all public hospitals provide abortion either.
Miss Noonan said the financial burden plays a factor as not all women have the financial stability or even the money to travel.
“Part of my research, I’ve talked to a number of women who had an unintended pregnancy in Western NSW. One of the common themes was women saying, look, you know, I was happy to travel to access service, but that also meant taking a day off work, finding childcare for my children, accommodation costs and fuel,” Miss Noonan said.
“There’s a lot of indirect costs that are incurred by rural women, and we know that rural women tend to earn less than women living in metropolitan settings, so higher costs, lower income, more difficult. So that’s an additional burden that women carry in that space.”
An increase in telehealth services but lack of care
As a medical abortion is accessible at home, a higher percentage of rural women are now using telehealth abortion services.
Tele-abortion, also known as medical abortion by phone, provides a way to terminate an early pregnancy with medication and allows for women to not have to visit any clinic.
The criteria to receive a telehealth abortion service is receiving an ultrasound and have a phone consultation with a specialised doctor beforehand.
Another criteria to receive the prescription for a medical abortion is to live within two hours of a hospital facility.
“For rural people it might not necessarily be the case if you live on a remote cattle station. Your entire cattle station might be more than two hours’ drive from the hospital.”
Mr Tadiparthi said not only is there is a lack of telehealth abortion service clinics in Australia, the process itself is also restrictive before a surgical abortion must be sought.
“You have to do it quite early as we only can start the process from week six, and take the medication up until nine week,” Mr Tadiparthi said.
“However, eight weeks to nine weeks is the buffer period because we need to send the medication which can take two to five business days.”
Miss Noonan said that the risks for adverse complications from medical abortion are low, but they do occur.
“If you think of the medication abortion as inducing a parallel experience to a miscarriage, so including bleeding, and it can be an experience that some women find really confronting,” Miss Noonan said.
“Definitely the ideal model would be that the woman, even if she’s taking the medical abortion option at home, that there’s someone that can be there to support her.”
Mr Tadiparthi said there are disadvantages of having a telehealth abortion in terms of follow-up appointment and emotional support.
“Clients would come in for an aftercare appointment if something goes wrong. The clients with telehealth appointments have to go to their GP, but there is constantly a massive waiting line.”
“Usually the doctor will say, if you don’t have a clinic near you then you have to go to your GP or an emergency hospital. Sometimes the medical abortion is unable to terminate the pregnancy, and in this case they will still be positive or have a bleeding for a month or so. For those clients it can be difficult to get an aftercare appointment.”
Realistically, not all females in rural, regional and remote areas have a support system which is challenging since it is a time-sensitive matter. A lot of women must return quickly back to work due to financial inequality, might have a controlling or abusive partner or are single mothers already taking care of their children.
Potential solutions on how to improve access to abortion
Roe v. Wade in the United States has sparked a global outrage and reintroduced the debate over women’s bodily autonomy into the political arena.
Miss Noonan said that she remains hopeful for changes within Australian politics and legislations despite it not being a priority at this current stage.
“The current Prime Minister was very critical of that change in the United States, saying it was a dangerous situation to have abortion care removed from the national agenda into state-by-state agenda. But interestingly, that’s the case in Australia, right?,” Miss Noonan said.
“We’re yet to see some really great tangible solutions for change and it will take time, you know. It will take time, but I think that there needs to be really practical solution like abortion care needs to be part of the medical curriculum, not an optional extra straight up.”
There is currently no national data collection of abortion service delivery, which is critical for understanding the statistics and service gaps in order to effect change.
Miss Noonan also said that a government funded programme aimed at increasing contraception in rural, remote and regional areas would be a helpful factor.
“It needs to be an education programme that’s also teamed with the availability of diverse contraceptive options for rural people,” Miss Noonan said.
“So often, for example, there may not be someone locally who is qualified to insert an IUD. Knowing that an IUD or long-acting reversible contraception might be the best option, but then not being able to find a GP that is qualified to do that is frustrating. You see that it needs to be hand in hand with trained and competent medical providers alongside education.”
The challenge for rural, regional, and distant females is not a lack of safe sex knowledge and awareness of various types of contraception, but rather their accessibility to them.
Miss Noonan said that listening to what rural individuals are saying and understanding that the health workforce is under enormous pressure will be beneficial for policy makers.
“We’ve seen some exploratory work with nurse led-models of care, so when nurses are in a position to prescribe abortion and medical abortion, have been beneficial,” Miss Noonan said.
“I hope that, really thinking much more intuitively about what’s going to work in a rural setting rather than helicopter in a solution that’s been designed in our office in a city is not necessarily going to work for the native rural people.”
“That’s what we’re really hoping for with this research. To say, hey, this is what people are saying they want, can we work towards that as a goal rather than coming up with a solution presenting it to rural people without having asked them first?”
“And it happens all the time. You know, I am a rural person myself and I’m a conjure of health care and use it quite often. I think it comes from a good place and it comes from a, you know, knowledge of needing to find solutions. But sometimes those solutions are not fit for purpose.”
Miss Kelleher said in order to make abortion services more accessible for regional, rural and remote women an organized action plan would be necessary.
“Embedding care within local systems such as sexual health clinics and local hospitals would help, as well as making sure we have enough bulk billing doctors, ultrasounds and people who are qualified to be able to prescribe early medical abortion,” Miss Kelleher said.
“We could have a public system that does telehealth or early medical abortion across various states which would have a massive impact on people’s lives. Have an action plan to ensure that access to abortion is more equitable across states and that people in regional and rural areas get the same access to healthcare as metro people do.”
“All the states have different legislations too so it’s really confusing for people to understand what laws there are according to where they live.”
Mr Tadiparthi said that different methodology regarding care to rural communities would serve these individuals better than a one size fits all approach.
“A lot of times I feel these systems are developed and made for and by western people, and they can miss out on a lot of strategies that would be great for the Indigenous community,” Mr Tadiparthi said.
“All the cities are much more modernised, and they go ahead with the western system. They don’t really take Indigenous things into consideration like the cultural and the important values.”
The way forward
Recently, the Australian Capital Territory Government announced that residents will have access to free abortion services as of early 2023. The legislation will cover residents without a Medicare card, and will include both medical and surgical abortion services.
The initiative aimed to expand access to safe and accessible abortion services will cost the government $4.6 million over four years, and aims to reassure females in making womens’ bodily autonomy choices without being affected by financial restrictions.
Despite the news, research and legislations have highlighted how there is a long way to go before abortion services become fairly accessible for all women across all of Australia and not only metropolitan settings.