A decision is imminent that could greatly improve access to early medical abortion – a procedure still out of reach for many across swaths of the country. The Therapeutic Goods Administration (TGA) is expected to respond within the next few weeks to a set of applications by non-profit pharmaceutical provider MS Health to allow any general practitioner to prescribe the mifepristone and misoprostol drugs that are used in combination to terminate pregnancies up to nine weeks.
MS Health, the subsidiary of national abortion and contraception provider MSI Australia, is the sole importer and distributor of the drugs, branded as MS-2 Step. The procedure, also known as EMA, is endorsed internationally and can be carried out at home instead of a surgical abortion, which requires admission to a clinic or hospital. MS Health lodged three applications with the TGA in December to amend risk management around the drugs: by scrapping registration for GPs to prescribe and for pharmacists to dispense the drugs, and by dropping an additional authorisation in order to facilitate faster scripting.
Mifepristone was approved for commercial importation in 2012 and added to the Pharmaceutical Benefits Scheme in 2013 as one of then prime minister Julia Gillard’s last acts in office. But the steps towards making abortion safe and accessible in Australia have been laborious; it has only been decriminalised across the country since 2021, with Western Australia a semi-exception as it still regulates the practice through its criminal code.
Changes to telehealth requirements in 2020 due to the pandemic made some difference, allowing mifepristone and misoprostol to be prescribed over the phone rather than solely in person. But GPs are still required to register with MS Health and undergo specific training to prescribe a medical abortion – and fewer than 10 per cent meet those requirements – and pharmacists must also be registered to dispense the medication. As of December 2022, there were just 3885 active prescribers (GPs and obstetricians/gynaecologists combined) and 5472 active dispensers. Some GPs won’t provide abortions on religious or moral grounds, and the logistical and administrative hurdles are a further disincentive.
“These kinds of restrictions added to the stigma around abortion rather than freeing it up,” says Dr Danielle Mazza, the chair of general practice at Monash University and a leading academic on reproductive health in primary care. She describes MS Health’s proposal as “baby steps” in the right direction of deregulating medical abortion entirely. Examples such as Sweden, where midwives can administer medical abortions as reproductive health professionals, and Ireland, where abortion is widely available at no cost, are possible models for Australia, according to Mazza.
But the proposal’s impact on the availability and accessibility of abortion services would be especially consequential for those in rural areas or without the financial capacity to access private clinics. In these regions, it could have life-altering consequences, says Anna Noonan, a PhD candidate at the University of Sydney and SPHERE Centre of Research Excellence, who focuses on access to reproductive healthcare in rural settings. She outlines multiple instances of systemic failures that she’s encountered in regional areas, including providers who prefer to keep their status quiet to avoid being overwhelmed with referrals, and doctors who are not providers of EMA actively discouraging patients who had already decided on a termination.
“Trying to even get advice on what to do, to make a decision to possibly access services, was a complete clusterfuck,” she tells The Saturday Paper.
Rural women are not only statistically more likely to have an unintended pregnancy, they are also overwhelmingly more likely to encounter obstacles in accessing reproductive healthcare, according to Noonan.
“You do hear moments of brilliance where the system works. But I feel like that system only works if there’s a great nurse who takes that phone call,” she says.
That said, one GP provider based in northern NSW was less sure that the proposed reforms would do much to increase the level of overall provision. “I think there’s a misconception around what it would be from them [GPs] and what it would require, and that comes from the shame and stigma around abortion,” says Dr Monica Taylor.
Her view was that misconceptions and assumptions, rather than administrative burdens, were the main cause for a lack of access. “It’s not onerous, it’s not expensive, the registration is very straightforward,” she says.
On average, a quarter of people with the reproductive capacity to do so will have a pregnancy in their lifetime in Australia. Most who have abortions already have children. Over the decade since medical abortions were approved, their use has increased relative to surgical procedures, though the overall abortion rate appears to be declining.
MS Health intends for every GP to become a provider of mifepristone and misoprostol, in much the same way as any other medication. Jamal Hakim, managing director of both MS Health and MSI Australia – formerly Marie Stopes Australia – says the proposals, if successful, would be “the biggest change since medical abortion was introduced”. “It means that from an administrative and regulatory perspective, we’re moving into a direction that allows self-determination by women and pregnant people, and that they’re able to seek the support that best supports them,” he says.
Asked why it took so long to push the applications, he described the decision by the United States Supreme Court to end the right to abortion in the US last year as a catalyst.
“As terrible as [the overturning of] Roe v Wade is, it’s been a wake-up call for everyone in Australia to go, ‘Wow, this is actually a reality check that we can go backwards very quickly’. Overwhelmingly Australians support reproductive rights … Abortion rights are critical rights, and they are tier 1 services that need to be delivered regardless of what’s going on.”
MS Health’s proposal would likely enable the public system to take on more procedures, at a lower cost to patients than going through a private healthcare provider. The current cost for a medical abortion in Australia begins at $42.50 for the cost of medication – if the initial consultation is bulk-billed, and blood tests and ultrasound are covered by Medicare – to $400-$550 for a private procedure through one of MSI Australia’s clinics. Patients are usually encouraged to take time off work given the procedure takes two to three days and can be painful.
“[Medical abortion] needs to be safe, it needs to be affordable and it needs to be accessible,” says the president of the Royal Australian College of General Practitioners (RACGP), Dr Nicole Higgins.
But in relation to MS Health’s applications, she urges caution to ensure that training and consultation are prioritised, alongside access to hospital intervention in case of complications and other support services. Higgins stresses the need for continuity of care given the complex nature of abortion services; a patient would likely at least require an ultrasound and counselling before the procedure, as well as aftercare including blood tests to ensure the procedure was successful, and further counselling.
“We can’t reduce barriers and risk women’s safety and quality of care. We can’t trade off access for safety,” she says.
Higgins and the RACGP have called for the medication to be part of the “doctor’s bag” of emergency medication available to GPs to prescribe and dispense at the point of consultation, rather than patients having to find a pharmacist that stocks the medication. And the RACGP would like to see more funding for GPs to meet the need for increased EMAs, along with harmonised legislation across the states.
MS Health hopes that TGA approvals of its application would trigger a national wave of legislative change to allow other healthcare professionals such as nurses and Indigenous healthcare workers the ability to prescribe the MS-2 Step. Jamal Hakim and his team say their discussions with state and territory health departments have been positive, though the Victorian Department of Health tells The Saturday Paper: “Any proposed changes to how medications can be prescribed are considered on a case-by-case basis and would be subject to the review and endorsement of clinical experts as part of the TGA approval process, as is required for any changes to prescription protocols.”
MS Health expects the TGA to release its decision soon after its meeting next week. This timing coincides with the convening of the National Women’s Health Advisory Council, chaired by Assistant Minister for Health and Aged Care Ged Kearney, which will address issues concerning access to reproductive healthcare.
The years-long push for decriminalisation exhausted much of the political opposition to abortion reform. Though New South Wales Premier Dominic Perrottet voted against decriminalisation in 2019, and his views are shared among some conservatives, his government faces an existential challenge at next month’s state election.
Hakim is hoping for a continuation of what he’s described as largely bipartisan support for his organisation’s reproductive rights advocacy over the past decade. “It isn’t a political conversation; it should be a health conversation,” he says.
This article was first published in the print edition of The Saturday Paper on February 25, 2023 as "Access all areas".
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