Medical abortion in Australia: a short history

The provision of abortion in Australia: service delivery as a bioethical concern

Despite significant progress in the legalization and decriminalization of abortion in Australia over the past decade or more recent research and government reports have made it clear that problems with the provision of services remain. This essay examines such issues and sets forth the view that such issues can and should be seen as (bio)ethical concerns. Whilst conscientious objection-the right to opt-out of provision on the basis of clear ethical reservations-is a legally and morally permissible stance that healthcare professionals can adopt, this does not mean those working in healthcare can simply elect not to be providers absent a clear ethical rationale. Furthermore, simple non-provision would seem to contravene the basic tenants of medical professionalism as well as the oft raised claims of the healthcare professions to put the needs of patients first. Recognizing that much of the progress that has been made over the past three decades can be attributed to the efforts of dedicated healthcare professionals who have dedicated their careers to meeting the profession's collective responsibilities in this area of women's health and reproductive healthcare, this paper frames the matter as a collective ethical lapse on the part of healthcare professionals, the healthcare professions and those involved in the management of healthcare institutions. Whilst also acknowledging that a range of complex factors have led to the present situation, that a variety of steps need to be taken to ensure the proper delivery of services that are comprehensive, and that there has been an absence of critical commentary and analysis of this topic by bioethicists, I conclude that there is a need to (re)assess the provision of abortion in Australia at all levels of service delivery and for the healthcare professions and healthcare professionals to take lead in doing so. That this ought to be done is clearly implied by the healthcare profession's longstanding commitment to prioritizing the needs of patient over their own interests.

A nurse-led model of care to improve access to contraception and abortion in rural general practice: Co-design with consumers and providers

AIM

To describe key features of a co-designed nurse-led model of care intended to improve access to early medication abortion and long-acting reversible contraception in rural Australian general practice.

DESIGN

Co-design methodology informed by the Experience-Based Co-Design Framework.

METHODS

Consumers, nurses, physicians and key women's health stakeholders participated in a co-design workshop focused on the patient journey in seeking contraception or abortion care. Data generated at the workshop were analysed using Braun and Clarkes' six-step process for thematic analysis.

RESULTS

Fifty-two participants took part in the co-design workshop. Key recommendations regarding setting up the model included: raising awareness of the early medication abortion and contraceptive implant services, providing flexible booking options, ensuring appointment availability, providing training for reception staff and fostering good relationships with relevant local services. Recommendations for implementing the model were also identified, including the provision of accessible information, patient-approved communication processes that ensure privacy and safety, establishing roles and responsibilities, supporting consumer autonomy and having clear pathways for referrals and complications.

CONCLUSION

Our approach to experience-based co-design ensured that consumer experiences, values and priorities, together with practitioner insights, were central to the development of a nurse-led model of care.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The co-designed nurse-led model of care for contraception and medication abortion is one strategy to increase access to these essential reproductive health services, particularly in rural areas, while providing an opportunity for nurses to work to their full scope of practice.

IMPACT

Nurse-led care has gained global recognition as an effective strategy to promote equitable access to sexual and reproductive healthcare. Still, nurse-led contraception and abortion have yet to be implemented andevaluated in Australian general practice. This study will inform the model of care to be implemented and evaluated as part of the ORIENT trial to be completed in 2025.

REPORTING METHOD

Reported in line with the Standards for Reporting Qualitative Research (SRQR) checklist.

PATIENT OR PUBLIC CONTRIBUTION

Two consumer representatives contributed to the development of the co-design methodology as members of the ORIENT Intervention Advisory Group Governance Committee.

Progesterone after mifepristone: A pilot prospective single arm clinical trial for women who have changed their mind after commencing medical abortion

AIM

This pilot study aimed to assess the utility of an oral progesterone treatment protocol for women who commenced medical abortion and then changed their mind and wished instead to maintain their pregnancy.

METHODS

The Progesterone-After-Mifepristone-pilot for efficacy and reproducibility (PAMper) trial was designed as a prospective single-arm pilot clinical trial, conducted via telehealth. Women aged 18 to 45 years in Australia who reported ingesting mifepristone within the last 72 h to initiate medical abortion and had not taken misoprostol were included. Initial contact was by a web-based form. Following informed consent, participants were prescribed oral progesterone to be taken 400 mg twice per day for 3 days then 400 mg at night until completion of a 19 day course. Pregnancy viability was assessed by ultrasound scan after 14 days of progesterone treatment.

RESULTS

Between October 2020 and June 2021, nine women contacted the PAMper trial, of whom six enrolled and commenced progesterone treatment. These women reported ingesting mifepristone at 40-70 days of gestation, with progesterone being commenced within 5.7-72 h of mifepristone ingestion. Five participants had ongoing, live pregnancies at the primary endpoint (ultrasound at >2 weeks). One participant had a miscarriage after 9 days of progesterone treatment. There were no clinically significant adverse events.

CONCLUSION

This small study demonstrated a clinically sound protocol for researching the use of progesterone-after-mifepristone for women in this circumstance. Results of this pilot study support the need for further larger scale trials in this field.

How can we encourage the provision of early medical abortion in primary care? Results of a best-worst scaling survey

BACKGROUND

Almost onein four women in Australia experience an unintended pregnancy during their lifetime; of these, approximately 30% currently end in abortion. Although early medical abortion (EMA) up to 9weeks gestation is becoming more widely available in Australia, it is still not commonly offered in primary care. The aim of this study was to investigate the barriers and facilitators to the provision of EMA in primary care.

METHODS

A sample of 150 general practitioners (GPs) and 150 registered nurses (RNs) working in Australia responded to a best-worst scaling survey designed to answer the following question: what are the most important facilitators and barriers to the provision of EMA in primary care?

RESULTS

GPs believe that the lack of clinical guidelines, the amount of information provision and counselling required, and the fact that women who are not their patients may not return for follow-up are the most important barriers. For RNs, these three barriers, together with the stigma of being known as being involved in the provision of EMA, are the most important barriers. The formation of a community of practice to support the provision of EMA was identified by both professions as the most important facilitator.

CONCLUSIONS

Having access to a community of practice, enhanced training and reducing stigma will encourage the provision of EMA. Although clinical guidelines are available, they need to be effectively disseminated, implemented and endorsed by peak bodies. Primary care practices should consider using task sharingand developing patient resources to facilitate the provision of information and counselling.

A Virtual Community of Practice to Support Physician Uptake of a Novel Abortion Practice: Mixed Methods Case Study

Background

Virtual communities of practice (VCoPs) have been used to support innovation and quality in clinical care. The drug mifepristone was introduced in Canada in 2017 for medical abortion. We created a VCoP to support implementation of mifepristone abortion practice across Canada.

Objective

The aim of this study was to describe the development and use of the Canadian Abortion Providers Support-Communauté de pratique canadienne sur l’avortement (CAPS-CPCA) VCoP and explore physicians’ experience with CAPS-CPCA and their views on its value in supporting implementation.

Methods

This was a mixed methods intrinsic case study of Canadian health care providers’ use and physicians’ perceptions of the CAPS-CPCA VCoP during the first 2 years of a novel practice. We sampled both physicians who joined the CAPS-CPCA VCoP and those who were interested in providing the novel practice but did not join the VCoP. We designed the VCoP features to address known and discovered barriers to implementation of medication abortion in primary care. Our secure web-based platform allowed asynchronous access to information, practice resources, clinical support, discussion forums, and email notices. We collected data from the platform and through surveys of physician members as well as interviews with physician members and nonmembers. We analyzed descriptive statistics for website metrics, physicians’ characteristics and practices, and their use of the VCoP. We used qualitative methods to explore the physicians’ experiences and perceptions of the VCoP.

Results

From January 1, 2017, to June 30, 2019, a total of 430 physicians representing all provinces and territories in Canada joined the VCoP and 222 (51.6%) completed a baseline survey. Of these 222 respondents, 156 (70.3%) were family physicians, 170 (80.2%) were women, and 78 (35.1%) had no prior abortion experience. In a survey conducted 12 months after baseline, 77.9% (120/154) of the respondents stated that they had provided mifepristone abortion and 33.9% (43/127) said the VCoP had been important or very important. Logging in to the site was burdensome for some, but members valued downloadable resources such as patient information sheets, consent forms, and clinical checklists. They found email announcements helpful for keeping up to date with changing regulations. Few asked clinical questions to the VCoP experts, but physicians felt that this feature was important for isolated or rural providers. Information collected through member polls about health system barriers to implementation was used in the project’s knowledge translation activities with policy makers to mitigate these barriers.

Conclusions

A VCoP developed to address known and discovered barriers to uptake of a novel medication abortion method engaged physicians from across Canada and supported some, including those with no prior abortion experience, to implement this practice.

International Registered Report Identifier (IRRID)

RR2-10.1136/bmjopen-2018-028443

Abortion Safety and Use with Normally Prescribed Mifepristone in Canada

BACKGROUND

In the United States, mifepristone is available for medical abortion (for use with misoprostol) only with Risk Evaluation and Mitigation Strategy (REMS) restrictions, despite an absence of evidence to support such restrictions. Mifepristone has been available in Canada with a normal prescription since November 2017.

METHODS

Using population-based administrative data from Ontario, Canada, we examined abortion use, safety, and effectiveness using an interrupted time-series analysis comparing trends in incidence before mifepristone was available (January 2012 through December 2016) with trends after its availability without restrictions (November 7, 2017, through March 15, 2020).

RESULTS

A total of 195,183 abortions were performed before mifepristone was available and 84,032 after its availability without restrictions. After the availability of mifepristone with a normal prescription, the abortion rate continued to decline, although more slowly than was expected on the basis of trends before mifepristone had been available (adjusted risk difference in time-series analysis, 1.2 per 1000 female residents between 15 and 49 years of age; 95% confidence interval [CI], 1.1 to 1.4), whereas the percentage of abortions provided as medical procedures increased from 2.2% to 31.4% (adjusted risk difference, 28.8 percentage points; 95% CI, 28.0 to 29.7). There were no material changes between the period before mifepristone was available and the nonrestricted period in the incidence of severe adverse events (0.03% vs. 0.04%; adjusted risk difference, 0.01 percentage points; 95% CI, -0.06 to 0.03), complications (0.74% vs. 0.69%; adjusted risk difference, 0.06 percentage points; 95% CI, -0.07 to 0.18), or ectopic pregnancy detected after abortion (0.15% vs. 0.22%; adjusted risk difference, -0.03 percentage points; 95% CI, -0.19 to 0.09). There was a small increase in ongoing intrauterine pregnancy continuing to delivery (adjusted risk difference, 0.08 percentage points; 95% CI, 0.04 to 0.10).

CONCLUSIONS

After mifepristone became available as a normal prescription, the abortion rate remained relatively stable, the proportion of abortions provided by medication increased rapidly, and adverse events and complications remained stable, as compared with the period when mifepristone was unavailable. (Funded by the Canadian Institutes of Health Research and the Women's Health Research Institute.).

General practitioner knowledge of and engagement with telehealth-at-home medical abortion provision

In Australia, there are many barriers to abortion, particularly for women living in regional, rural and remote areas. Telehealth provision of medical abortion is safe, effective and acceptable to patients and providers. In 2015, Marie Stopes Australia (MSA) launched an at-home telehealth model for medical abortion to which GPs could refer. Between April and November of 2017, we interviewed 20 GPs who referred patients to MSA's telehealth-at-home abortion service to better understand their experiences and perspectives regarding telehealth-at-home abortion. We found that there was widespread support and recognition of the benefits of telehealth-at-home abortion in increasing access to abortion and reducing travel and costs. However, the GPs interviewed lacked knowledge and understanding of the processes involved in medical abortion, and many were unaware of the availability of telehealth as an option until a patient requested a referral. The GPs interviewed called for increased communication between telehealth-at-home abortion providers and GPs. Increasing GP familiarity with medical abortion and awareness of the availability of telehealth-at-home abortion may assist people in accessing safe, effective medical abortion.

The microeconomics of abortion: A scoping review and analysis of the economic consequences for abortion care-seekers

Background

The economic consequences of abortion care and abortion policies for individuals occur directly and indirectly. We lack synthesis of the economic costs, impacts, benefit or value of abortion care at the micro-level (i.e., individuals and households). This scoping review examines the microeconomic costs, benefits and consequences of abortion care and policies.

Methods and findings

Searches were conducted in eight electronic databases and applied inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, impacts, benefits, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 230 included microeconomic studies, costs are the most frequently reported microeconomic outcome (n = 180), followed by impacts (n = 84), benefits (n = 39), and values (n = 26). Individual-level costs of abortion-related care have implications for the timing and type of care sought, globally. In contexts requiring multiple referrals or follow-up visits, these costs are multiplied. The ways in which people pay for abortion-related costs are diverse. The intersection between micro-level costs and delay(s) to abortion-related care is substantial. Individuals forego other costs and expenditures, or are pushed further into debt and/or poverty, in order to fund abortion-related care. The evidence base on the economic impacts of policy or law change is from high-income countries, dominated by studies from the United States.

Conclusions

Delays underpinned by economic factors can thwart care-seeking, affect the type of care sought, and impact the gestational age at which care is sought or reached. The evidence base includes little evidence on the micro-level costs for adolescents. Specific sub-groups of abortion care-seekers (transgendered and/or disabled people) are absent from the evidence and it is likely that they may experience higher direct and indirect costs because they may experience greater barriers to abortion care.

The macroeconomics of abortion: A scoping review and analysis of the costs and outcomes

BACKGROUND

Although abortion is a common gynecological procedure around the globe, we lack synthesis of the known macroeconomic costs and outcomes of abortion care and abortion policies. This scoping review synthesizes the literature on the impact of abortion-related care and abortion policies on economic outcomes at the macroeconomic level (that is, for societies and nation states).

METHODS AND FINDINGS

Searches were conducted in eight electronic databases. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined one of the following macroeconomic outcomes: costs, impacts, benefits, and/or value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 189 data extractions with macroeconomic evidence, costs at the national level are the most frequently reported economic outcome (n = 97), followed by impacts (n = 66), and benefits/value (n = 26). Findings show that post-abortion care services can constitute a substantial portion of national expenditures on health. Public sector coverage of abortion costs is sparse, and individuals bear most of the costs. Evidence also indicates that liberalizing abortion laws can have positive spillover effects for women's educational attainment and labor supply, and that access to abortion services contributes to improvements in children's human capital. However, the political economy around abortion legislation remains complicated and controversial.

CONCLUSIONS

Given the highly charged political nature of abortion around the global and the preponderance of rhetoric that can cloud reality in policy dialogues, it is imperative that social science researchers build the evidence base on the macroeconomic outcomes of abortion services and regulations.

The mesoeconomics of abortion: A scoping review and analysis of the economic effects of abortion on health systems

BACKGROUND

Despite the high incidence of abortion around the globe, we lack synthesis of the known economic consequences of abortion care and abortion policies at the mesoeconomic level (i.e. health systems and communities). This scoping review examines the mesoeconomic costs, benefits, impacts, and values of abortion care and policies.

METHODS AND FINDINGS

Searches were conducted in eight electronic databases. We conducted the searches and application of inclusion/exclusion criteria using the PRISMA extension for Scoping Reviews. For inclusion, studies must have examined at least one of the following outcomes: costs, benefits, impacts, and value of abortion care or abortion policies. Quantitative and qualitative data were extracted for descriptive statistics and thematic analysis. Of the 150 included mesoeconomic studies, costs to health systems are the most frequently reported mesoeconomic outcome (n = 116), followed by impacts (n = 40), benefits (n = 17), and values (n = 11). Within health facilities and health systems, the costs of providing abortion services vary greatly, particularly given the range with which researchers identify and cost services. Financial savings can be realized while maintaining or even improving quality of abortion services. Adapting to changing laws and policies is costly for health facilities. American policies on abortion economically impact health systems and facilities both domestically and abroad. Providing post-abortion care requires a disproportionate amount of health facility resources.

CONCLUSIONS

The evidence base has consolidated around abortion costs to health systems and health facilities in high-income countries more than in low- or middle-income countries. Little is known about the economic impacts of abortion on communities or the mesoeconomics of abortion in the Middle East and North Africa. Methodologically, review papers are the most frequent study type, indicating that researchers rely on evidence from a core set of costing papers. Studies generating new primary data on mesoeconomic outcomes are needed to strengthen the evidence base.

Perspectives Among Canadian Physicians on Factors Influencing Implementation of Mifepristone Medical Abortion: A National Qualitative Study

PURPOSE

Access to family planning health services in Canada has been historically inadequate and inequitable. A potential solution appeared when Health Canada approved mifepristone, the gold standard for medical abortion, in July 2015. We sought to investigate the factors that influence successful initiation and ongoing provision of medical abortion services among Canadian health professionals and how these factors relate to abortion policies, systems, and service access throughout Canada.

METHODS

We conducted 1-on-1 semistructured interviews with a national sample of abortion-providing and nonproviding physicians and health system stakeholders in Canadian health care settings. Our data collection, thematic analysis, and interpretation were guided by Diffusion of Innovation theory.

RESULTS

We conducted interviews with 90 participants including rural practitioners and those with no previous abortion experience. In the course of our study, Health Canada removed mifepristone restrictions. Our results suggest that Health Canada's initial restrictions discouraged physicians from providing mifepristone and were inconsistent with provincial licensing standards, thereby limiting patient access. Once deregulated, remaining factors were primarily related to local and regional implementation processes. Participants held strong perceptions that mifepristone was the new standard of care for medical abortion in Canada and within the scope of primary care practice.

CONCLUSION

Health Canada's removal of mifepristone restrictions facilitated the implementation of abortion care in the primary care setting. Our results are unique because Canada is the first country to facilitate provision of medical abortion in primary care via evidence-based deregulation of mifepristone.

At-home telemedicine for medical abortion in Australia: a qualitative study of patient experiences and recommendations

INTRODUCTION

This study aimed to explore patient experiences obtaining a medical abortion using an at-home telemedicine service operated by Marie Stopes Australia.

METHODS

From July to October 2017, we conducted semistructured in-depth telephone interviews with a convenience sample of medical abortion patients from Marie Stopes Australia. We analysed interview data for themes relating to patient experiences prior to service initiation, during an at-home telemedicine medical abortion visit, and after completing the medical abortion.

RESULTS

We interviewed 24 patients who obtained care via the at-home telemedicine medical abortion service. Patients selected at-home telemedicine due to convenience, ability to remain at home and manage personal responsibilities, and desires for privacy. A few telemedicine patients reported that a lack of general practitioner knowledge of abortion services impeded their access to care. Most telemedicine patients felt at-home telemedicine was of equal or superior privacy to in-person care and nearly all felt comfortable during the telemedicine visit. Most were satisfied with the home delivery of the abortion medications and would recommend the service.

CONCLUSION

Patient reports suggest that an at-home telemedicine model for medical abortion is a convenient and acceptable mode of service delivery that may reduce patient travel and out-of-pocket costs. Additional provider education about this model may be necessary in order to improve continuity of patient care. Further study of the impacts of this model on patients is needed to inform patient care and determine whether such a model is appropriate for similar geographical and legal contexts.

Abortion Im/mobility: Spatial Consequences in the Republic of Ireland

In the context of Ireland’s new legislation governing abortion, I outline and examine the spatial consequences of political decision-making. I argue that Ireland’s new abortion law and its clinical guidance permit travel for some pregnant people but impose fixity on others. I analyse the spatial consequences of legal limitations, including non-medically necessary delays in care and medical control of medication abortions, that necessitate travel for abortion. I demonstrate how current laws fix some pregnant people in place, including diverse migrant populations within Ireland, with no possibilities for abortion-related travel. This critique of the ‘new’ law demonstrates the Irish state’s continued political and medical control of abortion.

Impact of legislative change on waiting time for women accessing surgical abortion services in a rural hospital in the Northern Territory

BACKGROUND

Women face challenges when accessing abortion, including varied legislation and reduced access to services in rural and remote settings. There are limited clinical guidelines in Australia and little information regarding the patient journey, particularly the timeframe between referral to abortion procedure. Legislation reform in the Northern Territory (NT) legalised early medical abortion (EMA) in primary health care, providing an opportunity to review service provision of elective surgical abortion prior to and after these changes.

AIMS

To review the waiting time to access abortion, percentage eligible for EMA based on ultrasound gestation alone, percentage of Indigenous women accessing abortion in the NT and the effects of the legislation change.

MATERIALS AND METHODS

Retrospective audit-analysed surgical abortion data from 354 patient files who underwent suction curettage of uterus between 2012-2017 in one NT public hospital.

RESULTS

Mean wait-time ranged from 20 to 22 days in 2012-2016 and dropped to 15 days in 2017 following the law reform. Sixty-two percent of women waited longer than that in the recommended clinical guidelines. Indigenous women represented approximately 25% of patients accessing surgical abortion services. Average gestation at surgical abortion procedure increased following reform. Prior to reform up to 95% of patients accessing surgical abortion would have been eligible for EMA at time of referral.

CONCLUSIONS

Results demonstrate potential for changes in service provision of abortion in the NT with increased choice, patient-centred care and reduced waiting times. This audit demonstrated the possibility to move the majority of abortion services into primary health care leading to cost savings.

Could implementation of mifepristone address Canada's urban-rural abortion access disparity: a mixed-methods implementation study protocol

INTRODUCTION

In January 2017, mifepristone-induced medical abortion was made available in Canada. In this study, we will seek to (1) understand facilitators and barriers to the implementation of mifepristone across Canada, (2) assess the impact of a 'community of practice' clinical and health service support platform and (3) engage in and assess the impact of integrated knowledge translation (iKT) activities aimed to improve health policy, systems and service delivery issues to enhance patient access to mifepristone.

METHODS AND ANALYSIS

This prospective mixed-methods implementation study will involve a national sample of physicians and pharmacists recruited via an online training programme, professional networks and a purpose-built community of practice website. Surveys that explore constructs related to diffusion of innovation and Godin's behaviour change frameworks will be conducted at baseline and at 6 months, and qualitative data will be collected from electronic interactions on the website. Survey participants and a purposeful sample of decision-makers will be invited to participate in in-depth interviews. Descriptive analyses will be conducted for quantitative data. Thematic analysis guided by the theoretical frameworks will guide interpretation of qualitative data. We will conduct and assess iKT activities involving Canada's leading health system and health professional leaders, including evidence briefs, Geographical Information System (GIS)maps, face-to-face meetings and regular electronic exchanges. Findings will contribute to understanding the mechanisms of iKT relationships and activities that have a meaningful effect on uptake of evidence into policy and practice.

ETHICS AND DISSEMINATION

Ethical approval was received from the University of British Columbia Children's and Women's Hospital Ethics Review Board (H16-01006). Full publication of the work will be sought in an international peer-reviewed journal. Findings will be disseminated to research participants through newsletters and media interviews, and to policy-makers through invited evidence briefs and face-to-face presentations.

Medical termination of pregnancy service delivery in the context of decentralization: social and structural influences

Background

Medical termination of pregnancy (MToP) is a safe and acceptable abortion option. Depending on country context, MToP can be administered by general practitioners and mid-level healthcare providers in the first and second trimesters of pregnancy. Like other high-income countries, a range of social and structural barriers to MToP service provision exist in Australia. To counter some of these barriers, geographic decentralization of MToP was undertaken in rural Victoria, Australia, through training service providers about MToP to increase service delivery opportunities. The aim of this study was to investigate the factors that enabled and challenged the decentralization process.

Methods

Face-to-face and telephone interviews were undertaken between April and June 2016 with a purposeful sample of six training providers and 13 general practitioners (GP) and nurse training participants. Study participants were asked about their perceptions of motivations, enablers and challenges to MToP provision. A published conceptual framework of synergies between decentralization and service delivery was used to analyse the study findings.

Results

Three key themes emerged from the study findings. First, the effort to decentralize MToP was primarily supported by motivations related to making service access more equitable as well as the willingness of training providers to devolve their informal power, in the form of MToP medical expertise, to training participants. Next, the enablers for MToP decentralization included changes in the regulatory environment relating to decriminalization of abortion and availability of required medication, formation of partnerships to deliver training, provision of MToP clinical resources and local collegial support. Finally, challenges to MToP decentralization were few but significant. These included a lack of a state-wide strategy for service provision, provider concerns about coping with service demand, and provider stigma in the form of perceived negative community or collegial attitudes. These were significant enough to create caution for GPs and nurses considering service provision.

Conclusions

Decentralization concepts offer an innovative way for reframing and tackling issues associated with improving MToP service delivery. There is scope for more research about MToP decentralization in other country contexts. These findings are important for informing future rural MToP service expansion efforts that improve equity in service access.

Medical termination of pregnancy in general practice in Australia: a descriptive-interpretive qualitative study

BACKGROUND

Australian Government approval in 2012 for the use of mifepristone and misoprostol for medical termination of pregnancy (MTOP) allows general practitioners (GPs) to provide early gestation abortion in primary care settings. However, uptake of the MTOP provision by GPs appears to be low and the reasons for this have been unclear. This study investigated the provision of and referral for MTOP by GPs.

METHODS

We undertook descriptive-interpretive qualitative research and selected participants for diversity using a matrix. Twenty-eight semi-structured interviews and one focus group (N = 4), were conducted with 32 GPs (8 MTOP providers, 24 non MTOP providers) in New South Wales, Australia. Interviews were recorded and transcribed verbatim. A framework to examine access to abortion services was used to develop the interview questions and emergent themes identified thematically.

RESULTS

Three main themes emerged: scope of practice; MTOP demand, care and referral; and workforce needs. Many GPs saw abortion as beyond the scope of their practice (i.e. a service others provide in specialist private clinics). Some GPs had religious or moral objections; others regarded MTOP provision as complicated and difficult. While some GPs expressed interest in MTOP provision they were concerned about stigma and the impact it may have on perceptions of their practice and the views of colleagues. Despite a reported variance in demand most MTOP providers were busy but felt isolated. Difficulties in referral to a local public hospital in the case of complications or the provision of surgical abortion were noted.

CONCLUSIONS

Exploring the factors which affect access to MTOP in general practice settings provides insights to assist the future planning and delivery of reproductive health services. This research identifies the need for support to increase the number of MTOP GP providers and for GPs who are currently providing MTOP. Alongside these actions provision in the public sector is required. In addition, formalised referral pathways to the public sector are required to ensure timely care in the case of complications or the provision of surgical options. Leadership and coordination across the health sector is needed to facilitate integrated abortion care particularly for rural and low income women.

Telemedicine provision of medical abortion in Alaska: Through the provider’s lens

Introduction

Since 2011, Planned Parenthood of the Great Northwest and the Hawaiian Islands has been providing medical abortion via telemedicine at several clinics in Alaska. The purpose of this study was to evaluate providers’ experiences with telemedicine provision of medical abortion in Alaska using qualitative methods. In particular, we aimed to learn more about the impacts of telemedicine on patients, staff, and clinic operations and potential lessons for other service delivery settings.

Methods

Between October and November 2013, eight in-depth interviews were conducted with clinic providers and staff who were involved with the provision of medical abortion using telemedicine at Planned Parenthood of the Great Northwest and the Hawaiian Islands clinics in Alaska. All interviews were digitally recorded and transcribed verbatim, and data were analysed qualitatively with inductive coding using grounded theory methods.

Results

Providers reported that telemedicine provision of medical abortion facilitated a more patient-centred approach to care where women were able to be seen sooner, have greater choice in abortion procedure type, and could be seen closer to their home. Providers felt that it was easy to integrate the new technology into clinic operations, and that a telemedicine visit largely required the same overall processes and clinic flow as an in-person visit, with minor additions related to technological set-up for the doctor interface.

Discussion

These findings are consistent with previously published literature on medical abortion provided via telemedicine, and indicate high acceptability among providers and the appropriateness for telemedicine application to this healthcare service.