Get the facts: what criminalising abortion means for access

It’s been argued again and again that whatever Queensland’s abortion law actually says, women are very easily able to obtain abortions.

Wrong.

The impact of the law is greatest on the already-disadvantaged. Sure, abortion is accessible in Queensland – if you live in Brisbane or a major regional centre, have a few hundred to a couple of thousand dollars you can lay your hands on short notice, and are able to find out the information you need to know how to get one. The problem is that not all Queenslanders are in that situation – and while the private abortion providers working in Queensland offer very safe and high quality services, the out-of-pocket cost to access these can be a huge barrier to rural and remote women, young women, those living in poverty or with violence, and others experiencing disadvantage.

This presentation from the Children by Choice national Unplanned Pregnancy and Abortion in Australia conference in August 2017 provides an overview of the difficulties faced by their vulnerable clients.

How do women access abortions in Queensland?

There is very little public access to abortion services – ie, in public hospitals – in the vast majority of Queensland. The few that are provided in hospitals (295 of a total of 10,953 surgical abortions in 2015, according to Queensland Health [1]) are generally for extreme foetal anomaly diagnoses, or occasionally for significant maternal health conditions or other exacerbating circumstances.

The rest – the remaining 95-ish% – are provided by eight private clinics throughout the state along with a handful of sexual health clinics and GPs providing medication abortion through their practice.

We’re lucky to have those providers given our law. They’re passionate and dedicated and skilled at what they do – but there aren’t enough of them, and the costs for their services can be hard for some women to meet.

No public access

It’s not much of an exaggeration to say there is little or no public access to abortion services throughout the vast majority of Queensland – but why is that the case?

Queensland Health told the parliamentary committee at a 2016 public hearing that:

Because [abortion] is currently in the Criminal Code, regardless of doctors understanding the technical detail of the Criminal Code, there is a level of fear that comes with that. That comes from working in this area and potentially being held criminally responsible elicits a fear which may go beyond the actual technical provisions of the law. I would just make that comment that whatever the technical bit of the law, doctors have a difficult job to do. If they are navigating a Criminal Code I think that generates some fear. [2]

– Dr John Wakefield, Deputy Director General, Queensland Health

Up until 2013, there had been no statewide guidance for facilities and staff on when termination may be provided in a public hospital [3]. As many health professionals consider Queensland abortion law to be unclear, the result of this lack of guidance was an adhoc approach to public provision that allowed hospitals and individual practitioners to apply their own interpretation of the law, or their own religious or values systems, when it came to abortion provision. This culture of individual decision-making has persisted in some hospitals despite the release of the Guideline and means that most women who seek abortion in public hospitals will be unsuccessful and have no option but the private system.

Queensland public gyne services are in general very gun-shy about termination of pregnancy, even when medically indicated. I have worked in a Queensland hospital where the only person who was willing to administer Misoprostol to a patient with a severe foetal deformity out of an entire department, including four consultants and five registrars on the day, was the intern. Of course some had personal beliefs and understandably deferred, but others outright quoted, ‘I don’t get involved with termination of pregnancy. The law is just too murky.’[4]

– GP quoted by Royal Australian College of General Practice

In 2013 Queensland Health guidelines on abortion in hospitals were released for the very first time. Children by Choice tell us that while some hospitals have implemented the guideline, there is no monitoring of this process and no funding allocated for implementation, so provision remains fragmented across the state and can still be extremely difficult to negotiate at some hospitals.

In their submission to the Queensland parliamentary enquiry into abortion law in 2016, Children by Choice (our only statewide independent pro-choice pregnancy counselling and support service, and #itsnot1899 supporter) told the Health Committee:

In recent years, staff and volunteers from Children by Choice have supported several women who have been turned away or refused services from one hospital in the greater Brisbane area, including a 14 year old refugee pregnant after sexual assault, a woman being treated for a life-threatening cancer, and a woman whose baby died in utero. The 14 year old had been 13 when the assault occurred, and already had PTSD from her experiences in refugee camps before coming to Australia. The cancer patient had to check herself out of the hospital and remove her intravenous morphine drip in order to access a medical abortion, for the hospital to allow her to continue with her cancer treatment. And the woman whose 16 week scan revealed no fetal heartbeat and no amniotic fluid (which have no other diagnosis but fetal death) was told to ‘go home and pray’ and come back in a couple of days. The hospital did not want to help her speed the natural and inevitable miscarriage process, as they believed it to be tantamount to abortion.

These three cases are by no means the only ones of significance involving this hospital in recent years, and situations like these are unfortunately not unique to this hospitals One regional Queensland Health public hospital refuses to accept referrals from GPs to even assess women for abortion, including in cases of women pregnant after sexual assault; another, in the greater Brisbane region, has previously informed our service that they are ‘a conscientious objector hospital’.

This leaves women in the catchment areas of these hospitals with few options: they can try and find a GP who provides medical abortion if the pregnancy is less than 9 weeks gestation, go to a private clinic, or travel interstate. No other public provision pathway is available to them.

For women who do face long travel distances, the Patient Travel Subsidy Scheme should offer some financial reimbursement to help cover travel costs. Applications for assistance need to be signed off on by a Hospital Superintendent. Children by Choice has supported several clients whose applications have been denied either because of anti-abortion hospital personnel, or because the Superintendent or other hospital staff believe PTSS assistance is not available for travel for abortion ‘because it’s illegal’.

Private clinics and GPs

Procedures offered through private clinics or day surgeries are very safe and are provided by highly skilled professionals, but they do have costs attached. In some cases these costs have almost quadrupled since 2000. According to the Children by Choice website, the minimum out-of-pocket cost for most first trimester surgical abortion procedures in Brisbane is now approaching $500, and later procedures can cost in excess of $3000[5]. Despite mifepristone being listed on the Pharmaceutical Benefits Scheme, medical abortion provided through most clinics has a similar cost attached to a surgical abortion [5].The cost itself is not the result of the law, but it does create an unfair burden for women in extreme poverty or those who even under current legislative restrictions, should be able to access a public procedure.

In addition, the scarcity of trained providers (a byproduct of both continued criminalisation of abortion and the stigma that criminalisation helps perpetuate)[6] means that several of the doctors providing terminations through private clinics practice in more than one location. Clinics in Rockhampton and Townsville operate one day a week or a fortnight with clinicians flown in from Brisbane and interstate. This considerably adds to the cost of procedures in these facilities and can cause delays for women accessing services as they may need to wait for an available appointment. This in turn increases the gestation at which they may be able to access a procedure and can significantly increase the cost at which they do so – or alternatively push them over the gestational limits for those clinics, meaning their only option is to travel to Brisbane or the Gold Coast.

For patients under the age of 14 years, licensing conditions set down by Queensland Health mean that only clinics with a paediatric license are able to provide abortion services. There is one clinic in the entire state which can do so. The only other option for pregnant 12 and 13 year olds is a public hospital – and generally they will be forced to obtain a court order for the abortion to proceed, as the Q case from 2016 demonstrated. We’d point out here that not only are these requirements onerous to meet, as well as potentially distressing and almost certainly resulting in a delay for treatment, but also that no such conditions would have to be met were those same 12 and 13 year olds requesting to continue their pregnancies and go on to give birth, despite the clear danger to their health from doing so.

GPs are allowed to provide medication abortion through their practice after completing online training, obtaining suitable medical indemnity, and finding a pharmacist to stock the medication.

There’s no publicly available list of GPs who have done this, so we don’t know how many of them there are or where they might be located. Only a small number are public about providing medication abortions through their practice[7].

When I say that doctors are fearful, I do not exaggerate. Those who oppose decriminalisation can be very threatening. For the past 12 years since my email address and my place of work are publicly available I have received a continuous stream of hate mail, all of it anonymous and all of it based on the religious beliefs of the senders. I have been subject to harassment from a stalker here in Cairns, and for a while I received police protection. Doctors in rural and remote areas of the state in particular do not want to be singled out by such people. When they live in small communities, often with their families, they do not want to be singled out as being supportive or providing abortion.[8] 

– Dr Caroline de Costa, Professor of Obstetrics and Gynaecology, James Cook University.

So where are they?

On this map (courtesy of Children by Choice), the purple dots are the only places in the state where you can get an abortion if you’re further than 8 weeks and 6 days into your pregnancy. Once you’re further than 14 or 15 weeks, Brisbane and the Gold Coast are your only options. Even at 9 or 10 weeks, still well within the first trimester, for women who live outside the southeast corner of Queensland, travel distances can be vast.

If you happen to live in Longreach, for example (which for the uninitiated is almost smack in the middle of Queensland), your nearest abortion provider is in Rockhampton – a 7.5 hour drive each way, or a 6.5-hours-with-at-least-one-stopover flight that doesn’t go every day (ironic, given Longreach was the birthplace of Qantas). The minimum you’ll pay for a procedure there is $715, and that’s for a surgical procedure – medication abortion in Rocky costs $790. Flights are $600-$700, or there’s petrol costs (fairly significant ones for a drive that size), plus accommodation, time off work, and you’ll probably have to wait for an appointment given their limited availability.

If you’re somewhere like Weipa, up on the Cape, you need to get to Townsville – unless you’re sure you’re less than 9 weeks gestation (and many small remote communities don’t have an ultrasound machine), in which case Cairns or Mt Isa might be an option if you can find the information about available medical abortion services and be able to get there before your gestation is higher than 9 weeks. Weipa to Townsville is almost a full 24 hour drive non stop each way, or a $700 flight. Procedure costs are similar to those in Rockhampton, along with accommodation and all the rest.

If you’re in Cunnamulla, in the southwest, then the only thing is for you to come in to Toowoomba or Ipswich (if you’re under nine weeks), or Brisbane if you’re over. Either way it’s a 7+ hour drive each way plus procedure costs and accommodation.

You get the picture.

Doctors repeatedly tell researchers that the stigma attached to abortion is a significant factor in their decision around whether or not to provide abortions themselves[9]. Uncertainty around abortion law and when provision is legal is also raised as a barrier to providing abortion procedures, along with a lack of training pathways.

If abortion wasn’t in the Criminal Code, and doctors felt more confident in being able to provide legal abortion services, we’d hope to see more GPs begin to offer it as part of their practice. For women in rural and regional areas, this could make a world of difference.

When we talk about removing legal barriers to make abortion access easier, we aren’t talking about more abortions – we’re talking about abortions earlier in pregnancy, closer to home, at less personal and financial expense, than the currently inequality of access that makes things so difficult for some Queenslanders.

This law was not designed to limit access to vital health services for women from remote areas, but now it does. It discriminates heavily against women in remote and regional areas. One in three Queensland women has had an abortion and this is a choice that must be available to all women, equally. The law as it stands effectively limits the access of rural and remote women to abortion services and ensures that abortion is only a choice for those who have sufficient funds to travel.

I have no end of examples of why women end up in situations requiring abortion, but suffice to say humans are not perfect, contraception is not perfect and there will always be a requirement for abortion. I am ashamed – and feel that legislators should share this shame – when women quite literally beg for an abortion. Why are Queensland women in this position, where they feel they must beg for the most common of gynaecological procedures?

Keeping this straightforward and necessary procedure in the outdated 1899 Criminal Code means I spend a great deal of my time explaining case law to frightened women and how it applies to an individual, rather than discussing contraception and where it has gone wrong for each woman.

It seems the powers that be are quite happy for pregnant women and doctors to bear the fear and risk associated with managing pregnancy termination under current legislation in Queensland.

Typically, rural women who want to terminate an unplanned pregnancy find that either their procedure is significantly delayed, or that they are forced to carry the pregnancy to term. The implications of this, in terms of education and employment opportunities, are life-long.

Please, let medical practitioners discuss all the options for managing unplanned pregnancy with our patients without the fear and stress of illegality, so that we can spend our time on prevention, not legal jargon and ramifications.

– GP from far north Queensland.

 

References:

[1] Public hearing of the Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee of the Queensland Parliament. Brisbane: 12 July 2016, p 10-11 of transcript at http://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2016/AbortionLR-WRC-AB2016/14-trns-12July2016.pdf

[2] Public hearing of the Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee of the Queensland Parliament. Brisbane: 12 July 2016, p 10-11 of transcript at http://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2016/AbortionLR-WRC-AB2016/14-trns-12July2016.pdf

[3] Correspondence between the ABC and Queensland Health, cited in ‘Abortion on Trial’, broadcast on ABC Radio National on 7 November 2010. Full transcript at http://www.abc.net.au/radionational/programs/backgroundbriefing/abortion-on-trial-in-queensland/2982710.

[4] Public hearing of the Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee of the Queensland Parliament. Brisbane: 12 July 2016, p 10-11 of transcript at http://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2016/AbortionLR-WRC-AB2016/14-trns-12July2016.pdf

[5] Information on the cost of abortion procedures in Queensland is available on the Children by Choice website at www.childrenbychoice.org.au.

[6] See for example ‘How medical schools are failing to educate doctors in abortion care’ Daily Life, 24 November 2015. Online at http://www.dailylife.com.au/health-and-fitness/dl-wellbeing/how-medical-schools-are-failing-to-educate-doctors-in-abortion-care-20151124-gl6vg1.html.

[7] Information on abortion provider locations in Queensland is available on the Children by Choice website at www.childrenbychoice.org.au.

[8] Public hearing of the Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee of the Queensland Parliament. Cairns: 15 July 2016, p 10 of transcript at http://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2016/AbortionLR-WRC-AB2016/14-trns-15July2016.pdf

[9] See for example AJ Dawson, R Nicolls, D Bateson, A Doab, J Estoesta, A Brassil and EA Sullivan ‘Medical termination of pregnancy in general practice in Australia: a descriptive interpretive qualitative study’ Reproductive Health (2017) 14:39

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