Ladies in waiting: the timeliness of first trimester services in New Zealand

Willing but not able: A survey of New Zealand health practitioners' interests in providing second trimester abortion care and the obstacles they face

BACKGROUND

In 2020, abortion was removed from the Crimes Act. Abortions under 20 weeks gestation no longer require an indication and criteria for abortion above 20 weeks gestation has broadened. Prior to law reform, all abortions were provided on licensed premises and the responsible health practitioner was a doctor. Subsequently, any health practitioner with abortion in their scope of practice can provide abortion care.

AIMS

To describe the characteristics of health practitioners who expressed an interest in participating in second trimester abortion care, and to identify and describe the barriers to providing an optimal second trimester abortion service.

MATERIALS AND METHODS

This was an exponential non-discriminating snowball email survey using tick boxes and open comments. Quantitative data were analysed using descriptive statistics and free-text components were analysed using a general inductive approach.

RESULTS

The 113 respondents included: 38 hospital-based obstetrics and gynaecology doctors, 22 primary care doctors, 13 midwives and 14 nurses/nurse practitioners. Thirty-three (29.2%) and 62 (54.9%) respondents reported interest in providing second trimester surgical and medical abortion care respectively. The most commonly identified barrier to both surgical and medical second trimester abortion provision was lack of trained staff, followed by an unsupportive work environment. Thematic analysis aligned with these findings and commonly featured difficulty in accessing feticide.

CONCLUSIONS

We need to actively recruit and train all health practitioners interested in providing second trimester abortion care to strengthen the workforce. This requires an organisation to oversee an inclusive national framework for abortion training, including feticide, and provide professional supervision.

The impact of mandatory waiting periods on abortion-related outcomes: a synthesis of legal and health evidence

This review follows an established methodology for integrating human rights to address knowledge gaps related to the health and non-health outcomes of mandatory waiting periods (MWPs) for access to abortion. MWP is a requirement imposed by law, policy, or practice, to wait a specified amount of time between requesting and receiving abortion care. Recognizing that MWPs “demean[] women as competent decision-makers”, the World Health Organization recommends against MWPs. International human rights bodies have similarly encouraged states to repeal and not to introduce MWPs, which they recognize as operating as barriers to accessing sexual and reproductive healthcare. This review of 34 studies published between 2010 and 2021, together with international human rights law, establishes the health and non-health harms of MWPs for people seeking abortion, including delayed abortion, opportunity costs, and disproportionate impact. Impacts on abortion providers include increased workloads and system costs.

Opposition to abortion related to inaccurate beliefs about fetal pain perception in utero

BACKGROUND

Misinformation about abortion and pregnancy is common. Restrictions on abortion access at and beyond 20 weeks are frequently justified using the claim that a fetus can experience pain before the third trimester. The current medical consensus is that it is unlikely that fetal pain perception is possible before the 29th or 30th weeks of pregnancy.

AIMS

To examine the relationship between abortion attitudes and beliefs about when a fetus develops the capacity to perceive pain in utero.

METHODS AND MATERIALS

We used Amazon's Mechanical Turk to recruit participants residing in the United States (N = 374) and used an online questionnaire to assess their beliefs about abortion and the ability of a fetus to perceive pain.

RESULTS

Anti-choice participants were more likely than pro-choice participants to believe that a fetus in utero can perceive pain before the 23rd week of pregnancy (63.4 vs. 48.5%, P = 0.010) and in the first trimester (40.1 vs. 15.8%, P < 0.000). Most Black and Catholic participants, along with those with advanced degrees, believed that fetal pain is not possible before the third trimester.

CONCLUSIONS

Most participants believed that a fetus develops the capacity to perceive pain earlier than developmental reality, and this belief correlates with anti-choice views.

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.

Global Abortion Policies Database: A descriptive analysis of the regulatory and policy environment related to abortion

The World Health Organization (WHO) Safe abortion: technical and policy guidance for health systems states that regulatory, policy, and programmatic barriers that hinder access to and timely provision of safe abortion care should be removed. Although some regulatory requirements facilitate access, where they act as barriers, they can deter women from seeking safe abortion care. We use data available in the Global Abortion Policies Database as of February 2019 to review policies related to regulatory requirements identified as access barriers in the Safe abortion guidance. We include only countries where such policies apply, i.e., where abortion is lawful on the woman's request, with no requirement for justification and/or for one or more legal grounds. The results demonstrate the variation that exists in regulatory requirements, but little remains known about how they are implemented in practice and the implications on how women access and how providers offer safe abortion services.

Australian women's fertility experiences prior to a termination of pregnancy

Objective. This research aimed to investigate the fertility management of women aged over 30 years prior to a termination of pregnancy (TOP) to inform primary health care service delivery providers and policy makers. Design. An ethically approved, two-phase sequential explanatory mixed methods design was used. This paper reports on part of that study. Setting. The study was conducted in five South Australian TOP clinics. Patients. Women aged over 30 years attending for a TOP in 2009 were invited to participate. Interventions. The Contraception Sexual Attitude Questionnaire (modified version) of women attending termination of pregnancy services was used. Main Outcomes Measures. Quantitative data analysis utilized SPSS V16 where simple descriptive statistics were described. Results. There were 101 questionnaire respondents where 70.5% were Australian women, predominantly married and with children. Women used contraception but experienced method failure, were beginning a new method, or were afraid of side effects. Risk-taking behaviours were reported such as putting the possibility of pregnancy out of their mind, getting carried away and not thinking of pregnancy risk, or frequently having unprotected intercourse. Conclusion. Service delivery needs to include age specific programs, and policy makers need to include policies which are adequately funded and evaluated. Further research is required to provide greater depth of knowledge in this area.

Factors affecting delays in first trimester pregnancy termination services in New Zealand

OBJECTIVE

To identify the factors affecting the timeliness of services in first trimester abortion service in New Zealand.

METHOD

Primary data were collected from all patients attending nine abortion clinics between February and May 2009. The outcome measured was delay between the first visit with a referring doctor and the date of the abortion procedure. Patient records (n=2,950) were audited to determine the timeline between the first point of entry to the health system and the date of abortion. Women were also invited to fill out a questionnaire identifying personal factors affecting access to services (n=1,086, response rate = 36.8%).

RESULTS

Women who went to private clinic had a significantly shorter delay compared to public clinics. Controlling for clinic type, women who went to clinics that offered medical abortions or clinics that offered single day services experienced less delay. Also, women who had more than one visit with their referring doctor experienced a greater delay than those who had a single visit. The earlier in pregnancy women sought services the longer the delay. Women's decision-making did not have a significant effect on delay.

CONCLUSIONS

Several clinic level and systemic factors are significantly associated with delay in first trimester abortion services. In order to ensure the best physical and emotional outcomes, timeliness of services must improve.