Law in action

Two years after historic legislation to decriminalise abortion passed in the South Australian Parliament, South Australian Abortion Action Coalition coconvenor Brigid Coombe reports on progress.

On 7 July 2022, 16 months after the Termination of Pregnancy Act 2021 that removed abortion from criminal law in South Australia was passed, the Act was implemented in South Australia.

The South Australian Abortion Action Coalition (saaac) – a coalition of healthcare providers, lawyers, academics, students and healthcare advocates – had been campaigning to treat abortion as a normal part of healthcare and to remove barriers to access since 2016. saaac had also advocated for the passing of the Health Care (Safe Access) Amendment 2020 which prohibited intimidation near the premises of abortion providers, and immediately reduced the harm caused by anti-abortion protesters outside the PAC.

It was expected that implementation of the Act would occur soon after the law passed, so those needing and providing abortion services could benefit from its provisions as quickly as possible. However, advocacy by saaac, the AMA and RANZCOG was required before implementation finally occurred 16 months later.

Until the new legislation was implemented, all abortions in South Australia were required by law to be provided in prescribed hospitals with the certification of two medical doctors. Within the limitations of this framework, South Australia had developed a unique, high-quality system of public abortion services free for patients with Medicare eligibility (in every other jurisdiction except the NT, abortions are provided predominantly through the private sector).

South Australia was the only Australian jurisdiction where residents could not access early medication abortion (EMA) in primary care settings or by telehealth. This obstruction to care was felt particularly acutely after the COVID-19 pandemic began, while elsewhere in Australia people received the means for socially distanced abortions via telehealth.

While the Act removes many legal obstructions to improved care, especially significant for rural and remote patients, several impediments to access and quality care remain. Service availability and workforce development are among these. There is no state-wide coordination of services and Local Health Networks are not accountable for providing abortion services for their populations. The waiting time for an abortion is frequently two weeks, even three weeks in times of high demand or lists lost to public holidays. www.saabortionactioncoalition.com

These delays cause distress for patients and result in abortions at higher gestation. A centralised intake system for public services, equitably provided across metropolitan and regional locations would remove administrative barriers and improve efficiency.

EMA up to nine weeks’ gestation can now be provided by doctors from GP practices and other primary care settings and by telehealth, effectively on a pregnant person’s request, as well as in hospitals. Devolving the provision of EMA to primary care will take pressure off hospital services but it must be available for free or minimal cost across services. The strategies to achieve this include funding a nurse-led public telehealth service out of the PAC, education and support for new providers. Allowing GP’s to hold a stock of the medication and giving the pharmacist a script later would also help.

Currently, there is a registration and training requirement to prescribe MS-2 Step (mifepristone and misoprostol), the only TGAapproved medical termination, and an authority script is required. The number of doctors and pharmacists who are registered to prescribe and dispense MS2-Step remains low. As a result, most regional areas are still without services, so that rural residents must travel to the city for care. The free training is a short online module and not required for obstetricians and gynaecologists. There are many supports available for new providers and 24-hour phone support for patients by MS Health nurses. saaac’s campaign ‘Ask your doctor’, which suggests patients ask their GP whether they provide EMA, will be launched shortly, to encourage uptake.

Although the legislation allows abortions from 23 weeks’ gestation, protocols to ensure access for later presentations must be implemented to ensure these complex procedures can be provided in the most appropriate location for clinical and cultural safety.

Maintaining the quality of service at the PAC is subject to the challenges of a health system under significant strain. The project ahead is to build the workforce of MS-2 Step providers and refocus support for this state’s excellent public abortion services.

Termination of pregnancy | SA Health https://www.wellbeingsa.sa.gov.au/evidence-data/pregnancyoutcome-statistics/notifying-termination-of-pregnancy https://www.msiaustralia.org.au/for-clinicians/become-aprescriber-or-dispenser/