Call to get ‘ducks in a row’ for MS-2 Step changes

Alisha Dorrigan

21/07/2023 4:37:17 PM

With medical abortion prescribing set to expand significantly next month, there are evolving concerns when it comes to ensuring patient safety.

Boxes of the mifepristone.
All healthcare practitioners with appropriate qualifications and training will be able to prescribe mifepristone and misoprostol for medical abortions from August. (Image: AAP/AP)

From 1 August, all healthcare practitioners with appropriate qualifications and training, including nurse practitioners, will be able to prescribe mifepristone and misoprostol (sold as MS-2 Step) for medical abortions.
The change, enacted 11 years after the medication was approved for use in Australia, stems from a Therapeutic Goods Administration (TGA) decision to drop longstanding regulatory requirements that have limited prescribing and dispensing of the drug.
While welcomed by many as an overdue move to improve access to reproductive healthcare, recent media coverage has shifted to focus on non-doctor prescribing of MS-2 Step, including further easing of restrictions to include pharmacists.
For Associate Professor Gino Pecoraro, President of the National Association of Specialist Obstetricians and Gynaecologists, the debate surrounding who should be writing the script is counterproductive and distracting from critical safety issues that need addressing, especially in rural and remote areas.
‘You can’t make this about a “turf war” between doctors and nurses and pharmacists, because that takes the attention away from where it should be,’ he told newsGP.
‘The Government [first] needs to sort out all the infrastructure to make it safe.’
It is estimated that between 1–4% of medical terminations will be incomplete and may require surgical intervention, while excessive bleeding and infection are other possible complications that require access to timely medical care.
‘Everybody agrees that it’s not acceptable that women can’t access the full range of medical services in the regions – I don’t think anybody would argue with that,’ Associate Professor Pecoraro said.
‘[But] there are a number of safety, indemnity, administrative and legislative issues [that need resolving] before we open prescribing of this medication to non-doctors.
‘We should have the appropriate pathways in place to deal with complications that might arise in resource-poor environments where there may not even be a doctor available around the clock.’
Dr Wendy Burton, Chair of RACGP Specific Interests Antenatal and Postnatal Care, has welcomed the TGA announcement but is not in favour of pharmacy prescribing, noting the importance of patient consultations prior to going ahead with a medical termination.
‘It takes time to have these conversations, [receive] consent for this intervention, confirm understanding of the process and side effects, to discuss contraceptive options going forward and to safety net women,’ she told newsGP.
‘Prescribing analgesia is [also] likely to be required … [and] in my experience these appointments are a mix of mental and physical health as well as pharmacological effects of the medication.
‘Improving access is a good thing, but these are nuanced conversations.’
Associate Professor Pecoraro agrees, highlighting the various aspects of care required for medical terminations.
‘Who is responsible for the post-abortion care including counselling, contraception, treatment of any STI which may been detected, etcetera?’ he queried.
‘Abortion is more than just prescribing and dispensing of a tablet, it should involve a complete history and examination and dealing with concomitant issues.
‘You need to get all your ducks in a row before you make sweeping changes, the first rule needs to be “do no harm”.’
As it stands, uptake of the training currently required for GPs to prescribe MS-2 Step remains low, with only one in 10 GPs certified to prescribe.
While removing the regulatory requirements is expected to increase the number of GPs who provide medical terminations in the community, it is unclear to what extent.
Research suggests that there are various reasons for low uptake of MS-2 Step training by GPs, including:

  • the feeling that abortion is outside of their scope of practice
  • the complexity and difficulty of managing the procedure
  • perceived stigma
  • religious and moral objections
  • difficulties referring patients to local public hospitals if complications occur or surgical abortion is required.
Associate Professor Pecoraro says the reasons for previously low uptake should be better understood before any further expansion of prescribing powers.
‘Why have so few GPs taken up the potential prescribing of this medication? It might be that with the removal of the need for added training, more do take it up – or it might not. If the latter proves true, then perhaps we need to explore why that is,’ he said.
‘It might be because they find it too difficult to safely provide the service, particularly in small centres, and bypassing the GP and getting nurse practitioners and pharmacists to prescribe [the medication] may not solve the problem.
‘There are many other medical procedures which can only be provided in centres of a certain size for safety reasons and in these situations, government-funded transport and accommodation is provided for people needing them.’
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Dr Melissa Anne Ford   22/07/2023 7:22:48 AM

Provision of MS2STEP is important but removal of mandatory training is not the access block fix.

Provision of termination services is complex and nuanced and should not be undertaken lightly , it is generally safe and yes convenient for the right patient but for the wrong patient can have lethal consequences. I’ve had 4 patient in my own practice in the last month who weren’t suitable for MTOP for gestational or medical reasons , the mandatory training I did made me consciously aware of these risks and I’ve worked as a GP wSI for >10 years in O&G. I got in to providing services because I was seeing a reasonable number of women with complications after accessing TH services with no follow up

My own O&G when I had to consider a TOP myself for severe fetal abnormalities politely and with much mental anguish had to decline for religious reasons and we are increasing this by making everyone eligible . What harm with we do to the patient relationship when our colleagues say no .

Dr Irandani Anandi Ranasinghe-Markus   22/07/2023 8:20:23 AM

Couldn’t agree more about having the necessary steps in place to ensure patient safety from both physical and mental health viewpoints. Surely, it ought to be mandatory that the prescriber is adequately trained AND indemnified?

Dr Peter JD Spafford   22/07/2023 8:51:06 PM

Termination of a pregancy is never taken lightly, least of all by those who request it. The statement "where there may not even be a doctor available around the clock" ignores the current state of desparate GP shortage in so many rural and remote communities. Perfect care can only be available if there are perfect resources to enable it.

Dr Sandra Skinner   23/07/2023 2:37:42 PM

I've seen a number of women in recent years with serious post termination complications, including a patient after MTOP. There doesn't seem to follow up care, including for post surgical complications, provided by some businesses that offer TOP. If they do the surgery, or prescribe the medication, they should also counsel patients regarding possible complications, liaise with the patient's GP via timely written correspondence, and be available if patients need in hospital care post surgery. If you perform a surgical TOP, you should be available to treat post surgical infection and bleeding, RPOC, especially if this requires admission to hospital and subsequent D&C. What other procedures would surgeons perform and not do follow up treatment for?

Dr Mark Raines   23/07/2023 8:17:40 PM

Still awaiting an MBS item number that will cover the cost of a medical termination.