Abortion care in the 21st century

Identifying inequity of access and assessing the effectiveness of interventions is difficult without systematic abortion data collection

The past two decades have seen major changes in both abortion law and abortion provision across Australia. Safe legal abortion is now available to all Australian women, and is accessible to many. Decriminalisation in all states and territories and legislated safety zones around abortion services have led to wider discussion of abortion in Australian society and softening of the attached stigma.1

Progress has been incremental. Surgical abortion was the sole option for Australian women until 2006, when the legal requirement that mifepristone be imported or used only with federal ministerial approval was repealed.2 In 2011, Marie Stopes Australia published the results of the first large trial of early medical abortion using mifepristone and misoprostol in outpatients;3 in 2012, mifepristone was fully licensed by the Therapeutic Goods Administration; and in 2013 MS‐2 Step (the combination of mifepristone and misoprostol) was listed by the Pharmaceutical Benefits Scheme (PBS) for use as an abortifacient (initially during the first 49 days, from 2015 during the first 63 days of pregnancy).4 However, MS‐2 Step can only be prescribed by registered medical practitioners who have undertaken an online course, prescribing still requires an authority script, and the drug can be supplied only by registered pharmacies.

There are no readily available national data on medical or surgical abortion rates in Australia, and there is no Medicare item number for early medical abortion consultations. Consequently, it has not been possible to reliably estimate the number of induced abortions, nor to assess the socio‐demographic characteristics of women requesting abortions. Such data would be useful for tracking public health measures, such as the Teenage Pregnancy Strategy in England. In this complex multi‐sectorial intervention, conceptions, abortions, and maternities in women under 18 years of age were monitored and resources directed to areas of greatest need; between 1998 and 2014, the number of conceptions fell by 51%.5 In the United States, the Centers for Disease Control and Prevention captures routine abortion data, noting its importance for documenting progress towards reducing the number of unintended pregnancies.6

In this issue of the Journal, two articles shed welcome new light on how many abortions are being performed in Australia, where women have access to abortion services, and where obtaining an abortion is difficult for geographic and financial reasons. Keogh and colleagues7 analysed diagnosis‐related group (DRG) data from the National Hospital Morbidity Database to determine the number of surgical abortions performed in Australia during 2014–15 to 2017–18, and PBS data on the number of MS‐2 Step prescriptions dispensed to determine the number of medical abortions. The total number of abortions obtained in this manner does not include all procedures in Australia, as some independent clinics in New South Wales do not report DRG data (personal communication, Philip Goldstone, medical director, Marie Stopes Australia, Sept 2021). A small proportion of early medical abortions fail or are complicated (fewer than 5%);3 in some of these cases, women are admitted to hospital for curettage, and may have been counted twice in the authors’ estimate. Some surgical abortions may be misclassified as miscarriages. Nevertheless, we believe that the conclusion of Keogh and colleagues — that surgical abortion rates have dropped and medical abortion rates have risen over the past seven years — is correct.

Subasinghe and colleagues8 examined PBS MS‐2 Step prescription data for 2015‒2019. Age‐adjusted dispensing rates increased during the study period, and in 2019 were highest for women living in outer regional and remote Australia. However, 30% of women of child‐bearing age live in level 3 statistical areas (SA3s) in which MS‐2 Step had not been prescribed by a general practitioner or dispensed by a local pharmacy during 2019.

Subasinghe and her colleagues8 rightly call for more support for providing early medical abortion through telehealth services, the availability of which has increased in recent years, particularly during the COVID‐19 pandemic. Retaining the recently introduced Medicare telehealth item numbers would help ensure that women in areas underserved by prescribing general practitioners and dispensing pharmacies have access to medical abortion. The authors also call for easier access to training and education for regional practitioners and greater support from their local services. Normalising abortion care would be facilitated by removing the requirement for MS‐2 Step prescribers to register in a special program9 and by making mifepristone as available as any PBS‐listed drug. These measures, together with greater education about abortion in medical schools and training in postgraduate programs would reduce the stigma attached to abortion care.

The key problem highlighted in both these articles is that it is difficult to identify areas of inequity of access to services and to assess the effectiveness of interventions without systematic national collection of abortion data. Telehealth can certainly reduce inequalities, but women in regional and remote areas seeking surgical abortion still face long travel distances and considerable costs.10 As the authors of both articles note, more than 80 000 Australian women choose abortion each year, a significant proportion of whom live outside urban centres. One of the core principles of the National Women’s Health Strategy11 is equity of care, including timely, appropriate, and affordable care for women and girls in their own communities. It is time to apply this principle to abortion care.