Access to abortion services in Australia: we must do better

Clinicians should be mindful of the importance of post‐abortion contraception counselling for preventing further unintended pregnancies

Unintended pregnancy has significant adverse effects on both mother and child,1,2 as well as social and financial costs.3 As South Australia is the only Australian state to collect abortion data, we rely on secondary sources for national information. For example, the most recent estimated national annual abortion rate — 17.3 per 1000 Australian women aged 15–44years — was derived from Pharmaceutical Benefits Scheme (PBS) and National Hospital Morbidity Database (NHMD) data.4

The study reported by Grzeskowiak and colleagues in this issue of the MJA5 was a retrospective cohort analysis of a nationally representative random sample of PBS dispensing data. The authors examined the types of contraception prescribed for women in the two months following early medical abortion and the incidence of subsequent medical abortions. Their main finding was that long‐acting reversible contraception (LARC) was associated with a lower risk of repeat early medical abortion than other methods or no contraception.5 This finding was consistent with those of previous reports and meta‐analyses.6

Grzeskowiak and colleagues found that only 25.4% of women had been prescribed hormonal contraception within 60days of an early medical abortion during 2012–2020.5 As 51% of women resume sexual activity within two weeks of a first trimester abortion7 and 83% ovulate during their first menstrual cycle after an abortion,8 Australian clinicians should be reminded of the importance of post‐abortion contraception counselling for averting further unintended pregnancies. This and similar studies illustrate the benefits of clinicians discussing, in the context of evidence‐based contraception counselling, the option of LARC insertion at the time of pregnancy termination.

Counselling by clinicians may be informed by another important finding by Grzeskowiak and his colleagues. Dispensing of a progestogen‐only pill was associated with greater risk of repeat early medical abortion than no prescribed contraception (adjusted hazard ratio, 1.81; 95% confidence interval, 1.10–2.98).5 Reported contraception failure rates do not typically distinguish between combined and progestogen‐only contraceptive pills. Two progestogen‐only pill formulations have been available in Australia for some time (levonorgestrel and norethisterone); a third medication, drospirenone, has recently been approved, and may suppress ovulation more effectively than other progestogen‐only pills.9 However, failure rates for drospirenone have not yet been assessed. The study by Grzeskowiak and colleagues provides guidance for clinicians providing post‐abortion contraception counselling. They should discuss the lower effectiveness of progestogen‐only pills in preventing subsequent pregnancies, and the greater efficacy of LARC. If women choose progestogen‐only pills, the prescribing doctors should stress the importance of taking it within a consistent three‐hour timeframe each day, as it is likely that failure of this form of contraception is linked with variability in the dose interval.10

One limitation of the study by Grzeskowiak and colleagues was that it did not include data on surgical abortions for the index or second pregnancy. This does not diminish its value, but most abortions in Australia are surgical; during 2017–18, 67546 women had surgical abortions, and 20741 women medical abortions.4 On the other hand, the annual number of surgical abortions had declined by 5.1% each year since the PBS listing of mifepristone and misoprostol in 2013.4 Further studies that include both subsequent surgical and medical early terminations would be of value.

An interesting finding by Grzeskowiak and his colleagues not included in the final version of their article was that 6040 of 11140 early medical abortion prescriptions (54%) had been dispensed in Queensland. This was partially attributable to the fact that one major provider of telehealth abortion services across Australia dispenses their medications from a Queensland‐based pharmacy. The need for cautious interpretation of this finding exemplifies the challenges of understanding abortion information based on PBS and NHMD data alone. It also indicates that we need methods of accurately collecting abortion‐related data in Australia in order to identify groups who experience barriers to accessing abortion services.

Indeed, the study by Grzeskowiak and colleagues reminds us that Australian women continue to face challenges in accessing comprehensive abortion services. In our opinion, the main barrier is out‐of‐pocket costs for women seeking private sector abortions, and the inadequacy of publicly funded abortion services with direct access to outpatient clinics and public hospital operating facilities. Surely, we must do better.