South Australian law makes abortion more difficult and costly for rural and remote women. Of all abortions provided in South Australia, 18% are for women who reside in rural, regional or remote SA, however, just 2% of all abortions are provided outside metropolitan Adelaide. 1 Technological advances such as early medication abortion (EMA) with mifepristone (RU486) 2 and provision by telemedicine 3 and/or nurses and midwives 4 could improve accessibility for country women 5 but SA law restricts this.6
The current law:
- Restricts abortion treatment to ‘prescribed hospitals’
- Requires examination by two doctors
- Requires residence in South Australia for two months prior to abortion
Early medical abortion (EMA)
EMA has been safely provided to Australian women since 2007. At gestations of nine weeks or less EMA is a simple method to provide at a GP practice or community health service and/or via telemedicine. 7
The Therapeutic Goods Administration directs that women, having been provided with instructions by a doctor, can take the whole EMA package of medication with them to take in the timing and comfort of their own home and support networks, with the back up of a 24 hour telephone help/advice line.
Protocols with the best outcomes for this method recommend two doses of medication 24 –48 hours apart.
Current advice from SA Health to service providers is that the abortion legislation requires women to attend at a prescribed hospital and be supervised taking each dose. Therefore, country women who attend the PAC must stay in Adelaide for at least two days.
Women living close enough to drive to Adelaide services must make two trips, risking the process commencing while they are still travelling home after taking the second dose of misoprostol tablets.
Access problems reported by rural women and service providers:
One woman told her service provider that: “The misoprostol took twenty minutes to take effect with severe cramping and bleeding. As I live more than an hour away from Adelaide I was in terrible pain the majority of the way home.”
Another commented that services closer to their homes would save them from undertaking a “700km round trip” and enable them to “get help… and not have to travel so far”.
The requirement for women to see two doctors, and for abortions to be provided in a prescribed hospital, precludes confidential provision of EMA by a single GP, or nurse/midwife at their usual place of practice.
The current legislation also means that the Tabbott Foundation, a telehealth provider of abortion services, does not provide EMA by telemedicine for South Australian women 8, again excluding this safe, convenient and private service as an option for rural and remote women.
Abortion services are reliant on the availability of a skilled and willing medical practitioner to provide abortions—many rural and regional centres are without one, let alone a second medical practitioner, to examine the woman and sign approval for the abortion to proceed.
Finding a second practitioner at the same service as the provider is rarely possible meaning that a woman must attend at another health service—adding cost, causing delay and compromising her privacy in a small community.
Alternatively, she must travel to Adelaide, incurring travel, accommodation and other costs associated with leaving her work and/or family responsibilities, and in many cases without support from a family member or friend.
South Australian residency requirement
The current legislation requires women to have resided in South Australia for a period of two months prior to the abortion procedure. This affects women who live in or near centres such as Broken Hill, Mildura, Alice Springs and Darwin, and may normally come to Adelaide for services unavailable in these centres.
Specialist expertise in the safe provision of abortions in the second trimester has been developed in SA, but service providers cannot offer this excellent care to women from these locations. Best practice requires that patients receive appropriate specialist care even if this is not available in their closest health service. 9
When women don’t inform providers of their residency interstate in order to protect their access to abortion services, the health care team is unaware of travel plans post discharge and is thus unable to provide accurate plans for follow up. It is possible that other women simply do not get the service they need and continue an unwanted pregnancy.
Repealing SA abortion law would mean that country women:
- Need only find one trained health professional to provide an abortion.
- Could choose to have a medical abortion at home or closest regional centre.
- Would only need to travel to Adelaide for abortion procedures requiring more specialised care.
1 Reports of Pregnancy Outcome in South Australia 2007–2014, Government of South Australia, Adelaide. http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/health+statistics/ pregnancy+outcome+statistics
2 Goldstone P, Michelson J and Williamson E, 2012 ‘Early medical abortion using low-dose mifepristone followed by buccal misoprostol: a large Australian observational study’, Medical Journal of Australia, 197(5) 282–286.
3 Raymond EG, Chong E, Hyland P 2016, ‘Increasing access to abortion with telemedicine’, JAMA Intern Med 176(5) 585–586
4 Kopp Kallner H, Gomperts R, Salomonsson E et al, 2014 ‘The efficacy, safety and acceptability of medical termination of pregnancy provided by standard care by doctors or by nurse midwives: a randomised controlled equivalence trial’ 2014, British Journal of Obstetrics and Gynaecology. http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12982/full
5 Shankar M, Black KJ, Goldstone P et al, 2017 ‘Access, equity and costs of induced abortion services in Australia: a cross sectional study’, Australian and New Zealand Journal of Public Health, 41(3), 309-314. http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12641/full
6 ‘Criminal Law Consolidation Act 1935 SA’ 1935, Australia. http://www.legislation.sa.gov.au/LZ/C/A/CRIMINAL%20LAW%20CONSOLIDATION%20ACT%201935.aspx
7 Barnar S, Kim C, Park MH and Ngo TD, 2015 ‘Doctors or mid level providers for abortion’, Cochrane Database Syst Rev. 2015(7):CD011242
9 RANZCOG 2016, Termination of Pregnancy (Guideline C-Gyn 17). https://www.ranzcog.edu.au/RANZCOG_ SITE/media/RANZCOG-MEDIA/ Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20 Gynaecology/Termination-of-pregnancy-(C-Gyn-17)-Review July-2016.pdf?ext=.pdf