Despite abortion being decriminalised, barriers remain

Over the last two decades, the legal right to abortion in Australia has overwhelmingly moved in a progressive direction.

Decriminalisation with gestational limits ranging from sixteen to 24 weeks has been achieved in all states except Western Australia, where full decriminalisation is on the government’s agenda this year. These have been welcome and hard-won developments.

Yet what has become increasingly clear is that legalisation does not equate to accessibility. As one abortion provider put it in a 2016 study on the effects of decriminalisation in Victoria, “To be perfectly honest, the law reform has not impacted that much on our practice”.

A host of barriers continue to exist for those seeking abortion in Australia. Cost is one of the most obvious. The cost of an abortion varies a lot depending on the method, location, gestation period, access to Medicare and whether you go through the public or private system.

A medical abortion can be obtained up to nine weeks’ gestation and involves taking two pills: mifepristone and misoprostol. It can cost $40 with Medicare through the public system, but in some private clinics it can cost $500, with one private clinic in regional Queensland charging $840. While surgical abortions are free with Medicare in South Australian and Northern Territory public hospitals, in other states they cost around $500. After the first trimester, the cost increases incrementally and can reach upwards of $7,000.

In a 2017 study surveying women who had received an abortion through a Marie Stopes private clinic, in which around a third of abortions in Australia are performed, a third had found it difficult or very difficult to pay for the abortion ,and just over two‐thirds had obtained financial assistance from one or more sources to help pay for it, often a man involved in the pregnancy or family member. Just over a third had to forgo one or more payments to cover the cost, most often of bills or groceries. A Tasmanian woman in a different study put it in stark terms: “I was living pay cheque to pay cheque. And [the cost of the abortion] was a pay cheque”.

One of the reasons so much of the cost is pushed onto women is that not all public hospitals and GPs provide abortions, so many end up funnelled into the private system by default. In NSW, only two hospitals provide abortion services. After Tasmania’s last private abortion clinic closed in 2018, the state government legislated for just three public hospitals to provide them, where—according to a government fact sheet—“vulnerable women will be prioritised”.

In WA, only three private clinics provide abortions. So in 2018, fewer than 7 percent of all abortions took place in public hospitals, almost exclusively in rural areas. This pattern is reflected in a study that tracked the referral data of GPs through HealthPathways—an online health information system.

Researchers found that “nearly half of the included HealthPathways had no publicly funded services for surgical abortion, and one-third had no public medical abortion services. Approximately two-thirds of available public services listed additional warnings around accessibility, suggesting that public services should be considered only as a last resort”.

This compares to the UK, where 99 percent of abortions are publicly funded across both hospital and independent sectors, and Ireland, where around 50 percent of public hospitals were providing surgical abortions only two years after abortion was legalised.

You would think that the hypothetical ability for GPs to prescribe a medical abortion would ease some of these issues. But in order to be able to prescribe it, they have to go through a special registration process that does not exist for many other medications of equal (low) risk. The same goes for pharmacies.

Astoundingly, only 10 percent of GPs in Australia are registered. While some cite logistical or resource-related issues as a reason, for others it’s just plain stigma. In a 2017 survey of GPs in NSW, many raised not wanting to be known as “abortion doctors”, either because they were themselves against abortion and viewed it as an “unpleasant” service they didn’t want to provide, or they were concerned it would hurt the reputation of their practice.

A 2021 study estimated that 15 percent of Australian healthcare professionals are conscientious objectors, with some “deliberately delaying women’s access or attempting to make women feel guilty for seeking an abortion”. Another research team described: “We often hear women say that their doctors kept sending them for ultrasounds until they were twelve weeks pregnant and then told them it was too late for an abortion”.

This sort of stigma is reinforced by the lack of training in abortion procedures that doctors receive in Australia. According to the abovementioned 2021 study, “after decades of exclusion from university curricula, abortion is now included in the curriculum of only half of Australia’s medical schools, where it is often non-compulsory and limited in duration, often comprising a single hour-long lecture”.

Every hurdle related to abortion access is higher in rural areas, which have the lowest rates of GP medical abortion registration. A rural GP in NSW recounted a horrific experience of an intellectually disabled Aboriginal patient who had become pregnant after being raped and requested an abortion:

“Eventually I got one from ... one of the obstetricians here. I first of all had it declined and then I rang them up and it was only because I started crying that he agreed to do the termination because he’s known me for a long time. He basically sort of said oh, for God’s sake ... I’ll do it, but I’m not doing it again.”

There is evidence of women in rural areas attempting to end their own pregnancies at home to get around barriers such as a lack of local doctors and long waiting periods. One example comes from a NSW study of rural women’s experiences:

“For Glenda and Zilah surgical abortion was a last resort after trying other ways to end their pregnancies. Glenda tried to medically abort her pregnancy through herbal mixtures whilst Zilah tried acupuncture to ‘release the baby’ as well as self-medication. Zilah asked her doctor what was in the ‘morning after’ pill and ‘figured out that if I had a whole sheet of a month’s worth of the pill then it would be equal ... so once or twice I’ve self-medicated’.”

Many have to travel for hours to get to a clinic, meaning extra costs for transportation and potentially accommodation, time off work and child care. While telemedicine services have become available in which medical abortion can be prescribed over the phone and delivered to a house, this isn’t a band-aid solution since mifepristone can be used only up to nine weeks’ gestation and women are still required to access ultrasound and pathology facilities.

Since the Tabbot Foundation was forced to close in 2019 due to low funding, only Marie Stopes provides telemedicine abortions, so the cost is higher. It can’t be accessed in the Northern Territory, as by law provision is allowed only in a hospital.

That women face so many challenges just trying to receive basic health care in a wealthy country where abortion is supposed to be accessible on demand is criminal. While all of the overlapping barriers can seem complex, the solution is really very simple. Abortion should be available in all public hospitals, and medication abortion available in all GP clinics, with 100 percent of the cost covered by the government, including for those without Medicare (as was recently introduced in Canberra).

This should be paired with a huge increase in hospital funding, free child care and paid time off. If the $368 billion set to be spent on nuclear submarines was put towards these ends, no woman in Australia would ever again be forced to attempt botched home abortions, put off buying groceries to pay for an abortion or be turned away from an emergency department while facing a medical emergency.