Medication abortion has revolutionised access to abortion care and the safety, efficacy, and acceptability of this method are irrefutable.1,2 Available for use in Australia up until 9 weeks of gestation, medication abortion provides consumers with the choice to forgo an invasive and expensive surgical procedure and instead facilitate an abortion in their own space, at a time that suits their schedule. Despite international availability, politicalisation and over regulation limited the use of medication abortion in Australia up until 2012.3 In the years following, accessibility remained inconsistent, as doctors were required to adhere to strict regulations that mandated additional training, required prescribers to be registered, and seek authorisation each time a prescription was made.3 These requirements were removed in July of 2023 in response to decriminalisation, regulatory reform and the push for increased accessibility.4 Within South Australia specifically, decriminalisation removed the legal requirement that abortion care could only be provided in hospitals, with two doctors present: thereby opening the possibility for provision in community settings. Despite general practitioners (GPs) being widely recognised as effective providers of comprehensive reproductive health care, currently there is limited provision of medication abortion in this setting.5 This paper will report on consumer experiences of attempting to access abortion care with GPs in South Australia.
Methods
Between June 2023 and March 2024, an anonymous survey was offered to all consumers over the age of 18 attending the Pregnancy Advisory Centre; a government funded, public healthcare service, which provided over 65% of all abortion care for South Australia in 2023.6 Within the 10‑month data collection period, the centre provided abortion care to a total of 2659 consumers. This survey aimed to explore access journeys, and identify barriers or challenges faced by consumers when attempting to access abortion care (Appendix 1, available online only). Participation was voluntary and paper-based surveys were provided with appointment registration paperwork. Response data was extracted and stored electronically; and analysed using descriptive statistics. This activity was funded via a Central Adelaide Local Health Network Executive Director of Nursing Grant, approved as a quality improvement project (QIP ID 5319) and received publication endorsement from the Central Adelaide Local Health Network (Reference Number: 20574).
Results
A total of 783 surveys were returned within the data collection period. Some respondents did not provide an answer for all questions, but any and all responses were included in analysis. All quotes contained within this section were provided by survey participants.
Participants were asked about how they found out about the service and whether they had attempted to access abortion care elsewhere. 780 respondents answered the question ‘How did you find out about the Pregnancy Advisory Centre’, with 40% (n = 308) indicating that information about the service had been provided to them by a GP. In response to the question ‘Did you try to access termination care from another provider prior to accessing the Pregnancy Advisory Centre’, 304 responses were received; with 34% (n = 104) of respondents indicating that they had first attempted to access abortion care with a GP prior to attending the Pregnancy Advisory Centre.
When asked what prevented or prohibited them from accessing care with the GP, numerous barriers were reported in free-text qualitative responses. These included struggling to find a practice or GP that provided access to medication abortion, especially when living in a rural or remote location.
There was no medication abortion service available at any of the GP practices I tried.
I live in a remote town and none of the GPs nearby do medication abortions.
Others highlighted that in instances where they could find a GP provider, that they either could not access a timely appointment with them;
The GP didn’t have appointments available quickly enough.
The only GP that provides the service was booked out.
Or that the logistical requirements, including the need for multiple appointments and the associated costs, were prohibitive.
Not many GPs offer the service and those that do require you to have three appointments and a scan elsewhere.
The cost of paying for the medicine, and all the appointments and a scan was too much with a GP.
A number of responses also suggested that there was a lack of awareness and knowledge about decriminalisation and the associated new laws and regulations. This resulted in some of the GPs being unsure or unaware that they could provide medication abortion services.
My GP didn’t even know the law had passed that allowed them to give out the medication.
My GP just told me that GPs can’t provide medication abortions.
Other GPs had told consumers that they lacked the experience or training required to provide abortion care.
The GP I visited told me they lacked experience and were unsure if they could provide termination options.
My GP told me they weren’t trained in this area.
Finally, some respondents reported that when attempting to locate a GP that would provide abortion care, they encountered providers that seemingly objected to its provision or attempted to sway their decision.
The GP told me they were a ‘family doctor’ and they didn’t do that kind of thing.
I had GPs cancel appointments on me when I told them I was booking to see them to talk about abortion.
The GP said they didn’t provide the service for ‘ethical reasons’ and they tried to convince me out of my decision.
Discussion
These results and quotes indicate that GPs are a common source of information for consumers seeking abortion care, particularly for early medication abortion; but a less reliable source of care provision. In this instance, all surveyed consumers were required to seek medication abortion care elsewhere because of inaccessibility, uncertainty or unwillingness of GPs to provide the service. This suggests that despite changes in legislation and streamlining of regulations, provision of medication abortion in general practice settings in South Australia is not currently enough to meet consumer demand and that there is a need for education and supportive structures to increase service provision.
Many barriers to medication abortion provision within the community setting have been defined within the literature, including inconsistent service provision which is fuelled by a lack of adequately skilled providers and the absence of workforce training opportunities.7 The insufficient coverage of content pertaining to abortion care within medical education likely contributes to a lack of understanding, awareness and preparedness to provide this care in medical graduates.8 Participants recounted experiences of GPs being unsure or unaware if they could legally provide medication abortion, highlighting the need for education that includes clear explanations of abortion laws, options and implications for consumers who are unable to access timely care. It must also be highlighted that in instances where individuals conscientiously object to providing abortion care, that they are legally required to disclose this to consumers, and without delay refer them on to another service or provider who will facilitate access.9 Failure to do so directly contravenes the law; although a recent study from Victoria demonstrates this is not uncommon and suggests that the absence of monitoring and reporting mechanisms and response strategies may contribute to non-compliance.10 While all participants in this instance eventually received care at the Pregnancy Advisory Centre, it is not clear whether this was the result of referral or whether those that experienced GP objection independently sourced another care provider.
The cost of medication abortion in community settings is another barrier and concern shared by consumers and providers alike. Survey participants recounted that accessing medication abortion with a GP required multiple appointments, including an ultrasound, and that the out-of-pocket costs and excessive time required for multiple visits made this option unappealing or unviable. Limitations with current funding models and inadequate Medicare rebates for the provision of abortion care likely contribute to this and may prevent or discourage GPs from becoming abortion providers.11 In Canberra, local government funding has been provided to overcome these limitations, ensure appropriate remuneration for providers, and no or minimal out of pocket costs for consumers.12 Additionally, research continues to highlight strategies that have helped to streamline access and reduce the need for these repeat appointments; such as the routine use of a urine test for follow up, telehealth provision, the removal of the need for an ultrasound when gestation can be reliably determined by clinical means (last menstrual period dates), and when there are no signs or symptoms that could indicate an ectopic pregnancy.13–15 These approaches are highlighted as best practice within the World Health Organization Abortion Care Guidelines16 and re-affirmed as safe and effective within the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Clinical Guideline for Abortion Care and other emerging international evidence;17–19 but these are yet to become common practice in Australia.
Although the perspectives of consumers who were able to successfully access abortion care with a GP were not captured in this instance, these findings provide timely insight into accessibility in the post-decriminalisation period. This insight suggests that there is demand for increased provision of medication abortion services within community settings and might be used to inform service planning. Another limitation is the relatively small sample surveyed. However, these findings build on the limited existing evidence that explores the accessibility of abortion care from the consumer perspective within South Australia.
Conclusion
Consumers seeking abortion care face unnecessary barriers in this time-sensitive area of healthcare, and there is increasing demand for early medication abortion to be provided within the general practice setting. As we strive to improve access nationally, we must support GPs to provide abortion care, while also ensuring that they are equipped with the knowledge pertaining to what is legal and should be available, and the ethical and legal implications of preventing or delaying access to this care. Sustainable investment in improving education, increasing training opportunities and better remuneration to support timely, streamlined and cost-effective models of abortion care provision will be critical to ensuring increased and equitable access for all Australians.