Get the facts: how abortion is regulated

Since the campaign to decriminalise abortion in Queensland began, and while debate raged over the bills introduced by Cairns MP Rob Pyne during 2016-17, you probably heard someone say something like this:

“But if abortion is legalised it will be completely unregulated!”

This is categorically untrue.

The provision of abortion in Queensland is already heavily regulated in both public and private health facilities, in practices and frameworks which sit alongside, but are not at all dependent on, abortion being retained in criminal law.

This is the case with all areas of medical practice, in all jurisdictions of Australia, no matter what the legislation governing abortion looks like. It will not change if abortion is decriminalised in Queensland.

Here’s why.

There are currently three ways of accessing abortion in Queensland: through a private abortion clinic (surgical or medication abortion); through a GP, publicly run sexual health service, or telehealth service (medication abortion only); or, rarely, in a public hospital (generally second trimester procedures in cases of fetal anomaly).

All three of these pathways have existing regulatory frameworks and practices which are completely unreliant on the continued criminalisation or otherwise of abortion procedures.

On top of this are the overarching regulatory frameworks of medical practice and practitioners in general, as Professor of O&G, Dr Caroline de Costa, explains:

There are already very adequate health regulations where around medicine is practised and who practises it. As doctors we are required to be registered. First of all, we have to get through medical school, get a degree, get appropriate specialist training, have appropriate experience and we need to be registered every year. We must have continuing education which must be confirmed to AHPRA, who register us. Every institution we work in must be accredited by Queensland Health, and there are very stringent regulations about what you can do, even in regard to simply taking out tonsils. Abortion is covered by this quite adequately as it is. Day surgeries are regulated at the clinics which provide abortion [1].

Dr Heather McNamee, a Cairns GP and abortion provider, agrees.

I think between our registration as doctors and the guidelines of the colleges that we work within there are layers upon layers of regulation. When the occasional doctor is a maverick or does something completely outside of those guidelines, there will be action taken. When doctors act irresponsibly or beyond what is considered normal practice, then occasionally the Criminal Code is used. For instance, doctors that have gone around and killed patients have been prosecuted for murder. The Criminal Code is there for the occasional doctor who may be psychotic or behaving outside of the normal practice, but we are dealing with life and death every day in our work as doctors and the layers of legislation and restriction we have already are sufficient. We do not need any additional layers. Certainly, the college of gynaecologists I think are the people who are best placed to advise whether they feel there needs to be any higher level and they have said not [2].

Private clinic provision

The vast majority of terminations in Queensland are carried out in private day surgeries. There are eight of these surgeries across the state; six of which are in the southeast corner, and one each in Townsville and Rockhampton [3]. These clinics generally provide both medication and surgical pregnancy termination, along with other sexual and reproductive health services including vasectomy procedures and the provision of Long Acting Reversible Contraceptives (LARCs).

All these clinics are licensed by Queensland Health, under the Clinical Services Capability Framework (CSCF) for Licensed Private Health Facilities, with which they must comply. This is the same framework all private health facilities in the state are licensed under. According to Queensland Health:

The CSCF outlines minimum requirements for the provision of health services in Queensland public and licensed private health facilities, including minimum service, workforce, support service, legislative and non-mandatory requirements and risk considerations [4].

Clinics providing abortion are guided by the Perioperative Services – Day Surgery Services, Maternity Services, Anaesthetic Services, Surgical Services, and Termination of Pregnancy Services companion modules of the CSCF (v4.3). As part of this licensing framework a number of specific conditions must be met. Specific to the Termination of Pregnancy Services module are that:

  • procedures must be performed in accordance with the Criminal Code;
  • all pregnancies must be confirmed by pregnancy test or ultrasound;
  • clinical indicator data must be provided to satisfy accreditation and other reporting obligations;
  • patient information should include ‘legal, financial, psychosocial and medical implications prior to procedure’ [5].

There are additional conditions which must be met in order to provide services for patients under the age of 14, including the necessity of holding a paediatric license. Only one clinic in Queensland has one. Unless these young women can access this provider (located in Nambour), crossing the border to Tweed Heads (where a private clinic exists under New South Wales’ jurisdiction, where the paediatric license is not a requirement) or going through a public hospital is their only possible avenue for access. Neither of these is an easy proposition.

No clinic in Queensland is licensed to provide abortion at or after 22 weeks gestation [6], and none provide past 20 weeks gestation due to self-imposed practice restrictions.[7] Past this point in pregnancy, women seeking abortion have only two options: a hospital, or interstate travel.

There are two of us who provide surgical procedures in Queensland up to 20 weeks and that is it—two. One of them is an old bloke and I do not think he will be here for too long. None of us are comfortable providing surgical abortion between 20 and 24 weeks because of a lack of skills—we would have to upskill—and also from my personal perspective a lack of wanting to do that. That is not going to change.” [8]

There are only two clinics (one in Brisbane and one on the Gold Coast) in the entire state which provide abortion between 17 and 19 weeks gestation. The others cease providing services at 14 to 16 weeks depending on the clinic and the individual doctor providing the procedure. This is due to the lack of providers trained and willing to provide terminations beyond this point in pregnancy. There is no reason to expect that this would alter were abortion to be removed from the Criminal Code.

There is also no indication the licensing conditions would change under the proposed law, as the gestational limits currently imposed by the CSCF are not tied to existing abortion legislation.

Hospital provision

Provision of abortion services in public and private hospitals in Queensland is regulated through the Maternal and Neonatal Clinical Guideline on the Therapeutic Termination of Pregnancy (TTOP)[9]. This Guideline was released in 2013 by Queensland Health and aims to provide guidance to medical professionals working in public and private hospitals on when termination may be lawfully provided and how to follow best clinical practice.

The Guideline also sets out suggested approval mechanisms for abortion procedures in hospitals, and specifies that in all cases at least two medical specialists must be involved (and that one must be a specialist obstetrician). For ‘complex cases’ (which could involve a number of factors including the pregnant woman’s medical, social or economic circumstances, her capacity to consent, mental health, age, or the gestation of the pregnancy), the Guideline suggests that other professionals should be involved and that depending on the circumstances of the case, the review team may include a social worker, psychiatrist, obstetrician, GP, maternal fetal medicine specialist, paediatrician, lawyer, ethicist, religious officer or sexual assault worker [10]. 

Maternal fetal medicine specialist Professor David Ellwood described the process for abortion approval in his own hospital – in a jurisdiction where abortion has already been decriminalised – as follows:

Generally in public hospitals the question only arises in relation to foetal abnormalities, so it is primarily a question to do with foetal diagnosis and a decision around the severity or lethality of the abnormality. I can describe the process at my own hospital where, if I have seen somebody and had the discussion around termination of pregnancy and the woman has requested that, beyond 20 weeks of gestation I will then get a second specialist to see her to make the same assessment that I have made that the continuation of the pregnancy is likely to cause significant harm to the woman. There is then a referral to the head of the department to convene what at my hospital is called an ethics committee. The ethics committee then considers the request. I will go to the committee to present the case and to discuss the reasons for requesting termination of pregnancy. There may be then a request from the committee for further information or for the woman to receive another assessment. It might be a psychiatric assessment or it might be a social work assessment. Then once the committee has made their decision that is then referred on to a senior medical administrator within the hospital to give the final approval.

Medication abortion

In 2012 the Therapeutic Goods Administration (TGA) approved the use of mifepristone and misoprostol for the use of early medical abortion in Australia [11].

Medical abortion is only available to be prescribed to 8 weeks and 6 days gestation, under the licensing conditions set out by the TGA [12]. This is a national framework and again, completely independent of Queensland abortion legislation, apart from the specification that prescribers of mifepristone must do so in line with abortion legislation in their state or territory.

This framework covers medical abortion in all practice settings, including hospitals, clinics, and GPs. Specialist practitioners who hold a Fellowship or Diploma of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists are able to prescribe medical abortion as part of their existing practice, given their extensive training and qualifications. General practitioners, and providers working within Queensland clinics who are not specialist O&Gs, must undergo training to become certified prescribers [13].  All patients have access to the national 24 hour post-care telephone service provided by MSHealth, regardless of the practitioner who prescribed them the medication.

Without completing this training, medical practitioners are unable to prescribe medical abortion in any practice setting. In addition, MS-2Step is not a medication routinely stocked by pharmacists, so doctors certified to prescribe then need to organise a pharmacist near their practice to stock it for them.

 

 References:

[1] Dr Caroline de Costa, public hearing, 15 July 2016, page 14 of transcript at http://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2016/AbortionLR-WRC-AB2016/14-trns-15July2016.pdf.

[2] Dr Heather McNamee, public hearing, 15 July 2016, page 15 of transcript at http://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2016/AbortionLR-WRC-AB2016/14-trns-15July2016.pdf

[3] A list of Queensland abortion providers is available on our website at www.childrenbychoice.org.au, including all private clinics and some GPs.

[4] ‘About the CSCF’, available on the Queensland Health website at https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/service-delivery/cscf/about/default.asp.

[5] Termination of pregnancy services CSCF companion manual 4.3, by Queensland Health. Available online at https://www.health.qld.gov.au/publications/system-governance/licences/private-health/cscf-comp-terminat-pregnancy.pdf.

[6] Maternity services module CSCF v3.2 (page 2), issued by Queensland Health. Available online at https://www.health.qld.gov.au/publications/clinical-practice/guidelines-procedures/service-delivery/cscf/cscf-maternity.pdf.

[7] Gestational limits for all Queensland abortion clinics are listed on our website at www.childrenbychoice.org.au.

[8] Dr Carol Portmann, Maternal Fetal Medicine specialist, public hearing, 4 August 2016, on page 8 of transcript at http://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2016/AbortionLR-WRC-AB2016/14-trns-4Aug2016.pdf

[9] Queensland Maternity and Neonatal Clinical Guideline: Therapeutic Termination of Pregnancy available on the Queensland Health website at https://www.health.qld.gov.au/qcg/documents/g-ttop.pdf.

[10] Page 9 of the Queensland Maternity and Neonatal Clinical Guideline: Therapeutic Termination of Pregnancy available on the Queensland Health website at https://www.health.qld.gov.au/qcg/documents/g-ttop.pdf.

[11] Registration of medicines for the medical termination of early pregnancy Therapeutic Goods Administration, 30 August 2012. Online at https://www.tga.gov.au/registration-medicines-medical-termination-early-pregnancy.

[12] Australian Register of Therapeutic Goods ID 210574 (MS-2 Step composition pack) product information available online at the Therapeutic Goods Administration website: https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&docid=77FFC395C0EC491DCA257E5F004236DF&agid=(PrintDetailsPublic)&actionid=1.

[13] Mifepristone followed by misoprostol for terminating early pregnancies Consumer Medicine Update by NPS MedicineWise, 1 February 2015. Online at http://www.nps.org.au/publications/consumer/medicine-update/2013/mifepristone-misoprostol.

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