Medical termination of pregnancy in general practice in Australia: a descriptive-interpretive qualitative study

Abstract

BackgroundAustralian Government approval in 2012 for the use of mifepristone and misoprostol for medical termination of pregnancy (MTOP) allows general practitioners (GPs) to provide early gestation abortion in primary care settings. However, uptake of the MTOP provision by GPs appears to be low and the reasons for this have been unclear. This study investigated the provision of and referral for MTOP by GPs.MethodsWe undertook descriptive-interpretive qualitative research and selected participants for diversity using a matrix. Twenty-eight semi-structured interviews and one focus group (N = 4), were conducted with 32 GPs (8 MTOP providers, 24 non MTOP providers) in New South Wales, Australia. Interviews were recorded and transcribed verbatim. A framework to examine access to abortion services was used to develop the interview questions and emergent themes identified thematically.ResultsThree main themes emerged: scope of practice; MTOP demand, care and referral; and workforce needs. Many GPs saw abortion as beyond the scope of their practice (i.e. a service others provide in specialist private clinics). Some GPs had religious or moral objections; others regarded MTOP provision as complicated and difficult. While some GPs expressed interest in MTOP provision they were concerned about stigma and the impact it may have on perceptions of their practice and the views of colleagues. Despite a reported variance in demand most MTOP providers were busy but felt isolated. Difficulties in referral to a local public hospital in the case of complications or the provision of surgical abortion were noted.ConclusionsExploring the factors which affect access to MTOP in general practice settings provides insights to assist the future planning and delivery of reproductive health services. This research identifies the need for support to increase the number of MTOP GP providers and for GPs who are currently providing MTOP. Alongside these actions provision in the public sector is required. In addition, formalised referral pathways to the public sector are required to ensure timely care in the case of complications or the provision of surgical options. Leadership and coordination across the health sector is needed to facilitate integrated abortion care particularly for rural and low income women.

Snapshot of medication abortion provision in the primary health care setting of regional and rural Victoria

“…The presence of local allied health professionals and diagnostic facilities, required for the assessment of MA eligibility and the management of non‐life‐threatening complications, is essential for the improvement of abortion access in regional and rural areas. Consistent with previous research, this study indicates a lack of these support systems in regional and rural areas of Victoria, which can contribute to lower health outcomes for Australian residents in rural and regional communities compared with people living in metropolitan areas . The study participants specifically expressed their concern about the lack of a 24‐hour contact advice service, insufficient access to after‐hour care and surgical back‐up in case of complications, and the lack of local ultrasound availability, required for pregnancy dating and the exclusion of ectopic pregnancies .…”

“…Previous research suggests that Australian GPs anticipate negative publicity and reactions from conservative members of the community as well as from other health professionals, if they were to provide abortion services. Community‐level abortion stigma as well as practice restrictions, imposed by ideologically opposed colleagues, thus might influence health workers in their decision to provide abortion care, especially in rural and regional communities where sexual and reproductive health, including abortion, is still a highly contentious topic .…”

“…Further, few primary health care nurses (PHCNs) are currently involved in the medication abortion process, a strategy that has globally become a key solution to improve women's access to safe abortion services . Previous Australian research was limited to studies exploring the provision of MA service, as experienced by women and qualitative studies exploring factors affecting the MA uptake from the perspectives of primary health care providers . To add to the existing literature, this study used a quantitative approach to identify enablers and barriers that determine the decision of GPs and PHCNs from regional and rural areas of Victoria to become an MA provider.…”

Leadership for success in transforming medical abortion policy in Canada

“…[10] Australia also continues to experience a variety of regulatory barriers depending on geographic location and research has indicated that these regulations limit provision of medical abortion by primary care professionals. [11] When the Canadian restrictions were announced, advocates for abortion access raised concerns that they would limit particularly the potential for primary care provision and thus access to abortion. Further, there was no evidence that the restrictions would improve patient safety.…”

Medical abortion is fundamental to women's health care

“…It was hoped that with subsidy of mifepristone and misoprostol through the Pharmaceutical Benefits Scheme in 2013, coupled with the provision of accredited online training for GPs in the delivery of medical abortion, that improvements in access, especially for women in rural areas, would occur through GP provision. However, uptake in general practice appears to be low with a recent NSW‐based qualitative study suggesting reasons for this ranging from from the belief that medical abortion is beyond the scope of general practice, to fears of community stigma and the perception that provision is complicated . While medical abortion will not be within the scope of all GP practices, support by local gynaecologists and hospital services for those who do want to provide this service is imperative in the event that specialist back‐up is required.…”