Chapter 3Reducing barriers to reproductive healthcare
3.1Pregnancy care encompasses a wide spectrum of reproductive healthcare, including assistance with menstruation; contraception; unplanned pregnancies; preconception; antenatal, intrapartum and postnatal care; menopause; and pregnancy termination (termination) services. Pregnancy care focuses on patient wellbeing, safety, and joint decision‑making.
3.2Overwhelmingly, submitters noted that pregnant women need maternity and birthing services close to where they live, and that when these services don't exist, or cease to exist, risks to pregnant women and their babies increase. Further, when there are inadequate local birthing services, women are also commonly advised to relocate weeks prior to their due date, resulting in them incurring additional costs and giving birth away from home and their support networks.
3.3Inequities in pregnancy care access are well recognised, especially, in regional, rural, and remote Australia—and access to termination services, in particular, have been described by health practitioners as a 'huge lottery', with many people being reliant on 'local champions'. Although abortion was partly decriminalised in Western Australia in 1998, more than 20 years ago, and has since been decriminalised in every state and territory, funding for termination care is still piecemeal.
3.4According to Family Planning Alliance Australia (FPAA), approximately one quarter of all pregnancies are unplanned, and one in three of these pregnancies end in termination. Unintended pregnancies have been correlated with a range of negative physical health, mental health, economic, and social outcomes, and when termination services are sought by an individual, but denied to them, they are 'more likely to experience ill health, psychological stress, poverty, and negative impacts on development of existing children'.
3.5Pregnancy terminations are time-critical procedures that increase in complexity and risk as time progresses. Despite this, FPAA argue that termination 'access in Australia is limited and inequitable, with many individuals facing significant and intersecting financial, social, geographical and health provider hurdles to access necessary information, support and medical care'.
3.6The negative impacts that this lack of access can have on a woman's mental and physical wellbeing was vividly highlighted by a Queensland‑based woman, Bianca, who said the following:
At this point, I was considering walking myself into emergency services at the local hospital and threatening to undertake the procedure myself if no‑one would help me … I was stressed and I hadn't kept food down in about five days. I was really sick with nausea. I was exhausted and completely terrified that I wasn't going to be able to access abortion services.
3.7The focus of this chapter is pregnancy care, with a particular emphasis on the accessibility of maternity care and termination services in Australia. It begins with a brief discussion on how women commonly access these forms of care and then covers various Government supports and initiatives before detailing the significant barriers that women encounter when trying to access these services.
3.8The chapter concludes with the committee's view and associated recommendations on approaches to mitigate the identified barriers with the aim of materially improving women's access to pregnancy care across Australia.
Accessing maternity and termination care in Australia
3.9Most Australian mothers give birth in a public hospital, utilising various models of care. Good maternity services aim for a safe and healthy pregnancy and birthing experience for mothers and babies, and also consider the woman's needs and preferences. State and territory governments are responsible for providing publicly funded birthing and maternity services to their respective communities free of charge.
3.10Evidence was presented to the committee indicating that access to reproductive health services in rural Australia is compromised when maternity services are put on bypass, downgraded, or closed. For example, the committee heard from the Rural Doctors Association of Australia that the maternity service at the local hospital in Gladstone, Queensland, which has historically birthed about 600babies per year, was put on bypass for several months. This resulted in expectant mothers having to travel long distances and increased the risk of babies being born before arrival.
3.11When women don't have access to maternity care that meets their needs within a reasonable travel time, there are consequences. International research has associated travel time to a birthing service exceeding one hour with poorer outcomes for mothers and their babies, as well as increased interventions.
3.12The Australian Government supports access to pregnancy care primarily via funding through the National Health Reform Agreement (NHRA), Medicare Benefits Schedule (MBS), and Pharmaceutical Benefits Scheme (PBS).
3.13The Department of Health and Aged Care advised 'the MBS provides rebates for antenatal, intrapartum (birth), and postnatal services provided by or on behalf of specialist obstetricians, GP (general practitioner) obstetricians, and participating midwives, as well as antenatal care by GPs and midwives'. Further, the MBS also includes a range of items used for pathology tests, such as blood and urine tests, and diagnostic imaging services, including pregnancy-related ultrasound and magnetic resonance imaging.
3.14MBS items support services delivered by private health practitioners under a range of models including combined care, private obstetrician care, GP obstetrics care, private midwifery care, and private obstetrician and private practising midwife shared care. The Department of Health advised that the Australian Institute of Health and Welfare identified 11 categories of maternity models of care, with the institute also finding that:
approximately 44 per cent of models have midwives as the lead carer during antenatal, intrapartum, and postnatal periods;
approximately 31 per cent of models have continuity of care, where care is provided by the same named carer across the duration of the maternity period; and
around six per cent of models include routine relocation of mothers from their communities to other locations prior to labour. This occurs when a woman resides in a rural or remote community with no access to childbirth facilities.
Termination care
3.15The most common type of termination is a surgical procedure called a 'suction curette', which involves removing the lining and the contents of the uterus by applying gentle suction with a small plastic tube. Surgical terminations are day‑surgery procedures most often performed in the first trimester.
3.16Healthdirect suggests that a low-risk alternative to surgery for pregnancies earlier than nine weeks is a medication called mifepristone. Medical abortion is a two-stage process, with the first stage involving taking a tablet that blocks the hormone necessary for the pregnancy to continue, followed by a second medication that causes the contents of the uterus to be expelled.
3.17If a person decides to terminate their pregnancy, they can access medical or surgical termination services through a variety of public and private settings, including primary care providers, family planning clinics, women's health clinics, and public and some private hospitals.
3.18Evidence presented to the committee suggests accessibility of these services, however, varies significantly according to geographic location—particularly for surgical terminations, which in most cases is the only option available after nine weeks gestation. The actual cost and level of access can also depend on a variety of other factors, including:
Medicare status of the patient;
type of termination;
type of provider, including religious affiliation and the degree of conscientious objection;
gestation of the pregnancy; and
any personal risks associated with the health of the individual.
3.19Although terminations are legal in every Australian jurisdiction, the specific laws relating to these services are a state and territory responsibility and, hence, the circumstances in which they can be legally provided varies between jurisdictions. Terminations of up to 14 weeks are available Australia-wide, and later-term terminations are available in most states and territories.
3.20In Australia, medical abortion medication is marketed as MS-2 Step and is distributed by a single provider, MS Health. Currently, medical practitioners and pharmacists must be registered to prescribe and dispense MS‑2 Step and are also required to complete an online training course. Nurse practitioners and participating midwives are currently unable to prescribe this product.
3.21Obstetricians, gynaecologists, and GPs providing obstetric and gynaecological services are trained in the relevant surgical skills to undertake a dilation and curettage, which can be utilised to perform surgical terminations of up to approximately 14 weeks and to manage miscarriages. Late-stage surgical terminations, however, require additional training that can be undertaken by obstetricians and gynaecologists.
Government support
3.22The Australian Government provides funding for pregnancy termination services through:
public hospital funding under the NHRA;
MBS items for surgical terminations, GP and specialist consultations, pregnancy counselling, telehealth, pathology tests, and ultrasounds; and
PBS listings for medical termination medication.
3.23The Department of Health and Aged Care (the Department) noted that, while this framework aims to deliver access when and where it is required, funding alone cannot achieve equitable access.
3.24The MBS subsidises access to surgical terminations through rebates for related clinical consultations, pathology tests, diagnostic imaging, and surgical procedures. Currently, there are four specialist MBS items that can be used for the surgical termination of pregnancy, as well as other procedures. These include for:
management of pregnancy loss at 14 to 15 weeks and six days;
management of pregnancy loss at 16 to 22 weeks and six days;
evacuation of the contents of the gravid uterus; and
curettage of uterus (including for incomplete miscarriage).
3.25The Department noted that claims for MBS items relevant to terminations cover a range of procedures, not limited to surgical terminations. As a result, it is not possible to accurately quantity the number of surgical terminations of pregnancy conducted in private hospitals based on MBS claims..
3.26The Government provides funding for pregnancy termination services under the NHRA; however, collected data does not distinguish between medical and surgical forms of termination. In 2020–21, there were less than 8900 hospitalisations for induced abortions in public hospitals. This figure includes any intentional termination, at any gestation, through either medical or surgical intervention.
3.27The Government has undertaken various initiatives to improve access to pregnancy care in Australia. A number of these are discussed below.
Pregnancy Care Guidelines
3.28The Pregnancy Care Guidelines were developed to support Australian maternity services in delivering high-quality, evidence-based antenatal care for women across Australia. They are intended for use by all health professionals who contribute to antenatal care and are implemented at all levels of government to provide consistency in care. The Australian Government has committed to investing $5.9 million across 2022–23 and 2023–24 to update these guidelines and to develop new guidelines for postnatal care.
Women-centred Care Strategy
3.29The Woman-centred care: Strategic directions for Australian maternity services strategy provides overarching national strategic directions to support Australia's maternity care system and enable improvements in line with contemporary practice, evidence and international developments. It aims to ensure that maternity services are equitable, safe, woman-centred, informed and evidence-based.
Pregnancy care for First Nations people
3.30First Nations mothers and their babies experience disproportionately adverse maternal and infant health outcomes compared to non-Indigenous mothers and babies. There is also a material underrepresentation of First Nations people in the maternal health workforce across Australia and an absence of culturally safe and community-based birthing options for these women.
3.31Recent research has demonstrated that there are material benefits in implementing birthing on country models of care. In particular, women receiving this service are more likely to attend five or more antenatal visits, are almost 50 per cent less likely to have a pre‑term birth than those receiving standard care, and are more likely to be exclusively breastfeeding upon their discharge from hospital.
3.32Given this, the Australian Government has committed $22.5 million for a dedicated Birthing on Country Centre of Excellence at Waminda in Nowra, NewSouth Wales. The centre is expected to open in 2025–26 and will be used as a national demonstration site.
Stillbirths and miscarriages support
3.33The National Stillbirth Action and Implementation Plan was released in December2020 and is the first national plan to strategically address the issue of stillbirth in Australia. From 2019–20 to 2025–26, the Australian Government plans to invest $44.5 million in measures to reduce stillbirths and support affected families. This includes:
increasing the number of stillbirth autopsies;
extending the Red Nose Australia's Hospital to Home program, which provides targeted support for families who experience stillbirth; and
the development and implementation of bereavement care for women and families from higher-risk population groups who have experienced stillbirth or miscarriage.
Perinatal mental health
3.34The Perinatal Mental Health and Wellbeing Program aims to support the mental health of both expecting and new parents, and also supports families experiencing grief after miscarriage, stillbirth, or infant death.
3.35The program provides a variety of supports, including those delivered digitally and via telephone, a national perinatal mental health triage and referral system, and digital training and support services for particularly vulnerable groups, such as parents living in rural and remote areas. The Government has allocated over $43 million to this program between 2020–21 and 2023–24.
3.36In the Budget October 2022–23, the Government also provided an additional $26.2 million in funding to the Gidget Foundation Australia to establish a national network of 12 perinatal mental health and wellbeing centres. These centres will provide mental health support to both expectant and new parents.
Family planning grants
3.37Family planning initiatives aim to support the reproductive health and fertility management of individuals and couples through public education, professional development, and the monitoring of emerging evidence to inform policy direction and program development.
3.38Through its Family Planning Grant Opportunity, the Government funds four grant recipients to support individuals and couples to attain their desired number of children, and the spacing and timing of their births. Total funding across 2019–20 to 2022–23 of $4.072 million has been provided to Fertility Education Australia; Multicultural Centre for Women's Health; Ovulation Method Research and Reference Centre for Australia; and Victorian Assisted Reproductive Treatment Authority.
Barriers to accessing reproductive healthcare in Australia
3.39Evidence received during the inquiry highlighted the barriers that some women living in Australia face when attempting to access maternity and termination care. The below discussion covers a number of these key barriers in further detail, including the following:
a lack of maternity and birthing care services;
a lack of termination care services;
high costs for termination care;
stigmatisation and conscientious objectors;
inadequate Medicare rebates;
the upcoming expiry of temporary telehealth support;
restrictive MS-2 Step requirements;
legal variations across Australian jurisdictions;
inadequate practitioner training; and
a lack of data collection.
Access and cost barriers
Lack of maternity and birthing care services
3.40Access to maternity and birthing services for women who live outside Australian cities has been decreasing for decades. Evidence received from the National Rural Health Commissioner during the inquiry indicated that there was a 41 per cent reduction in the total number of maternity units in Australia between 1992 and 2011—from 623 to 368—with many of these closures impacting small maternity services located in rural areas. The Royal Australian College of General Practitioners (RACGP) also submitted that some hospitals no longer support birthing deliveries at all.
3.41Dr Belinda Maier from the Queensland Nurses and Midwives' Union, discussed the Gladstone Hospital bypass (mentioned earlier in this chapter) and told the committee the following:
When Gladstone stopped birthing, the midwives there could still do low‑risk births and they could have continued with those. But when things become very doctor-centric … and the models are medically run and doctor dependent, that becomes a problem when a doctor leaves town and birthing services stop. We saw that at Kingaroy for a long time when birthing services stopped, and yet there were midwives in Kingaroy. Some of them are deskilled, so they're not comfortable birthing women without medical support.
3.42The committee heard that this was not an isolated situation, with workforce shortages presenting difficulties in providing maternity services to rural communities.
3.43When there are inadequate local birthing services, women are often advised to relocate and give birth away from home. This removes them from their existing support networks, disrupts continuity of care, and impacts on their ability to care for family members and undertake paid work. It can also result in relocation to a culturally unsafe environment for First Nations women.
3.44The National Rural Health Alliance noted that there is a body of evidence suggesting that a lack of local maternity care services can also result in increased levels of psychological distress and financial costs.
3.45The Chief Executive Officer of the National Rural Women's Coalition, MsKeliMcDonald, said that she would like to see all local towns with hospitals have maternity wards reinstated:
They had them, and now they do not have them. Why don't they have them? It is the GP shortage. If we take women off country to have their babies, we take away an important time for women to connect to their community, to their families, to themselves. We believe those hospitals need those services back again.
3.46The National Rural Health Commissioner, Adjunct Professor Ruth Stewart, said that Australia should seek to have maternity services available for any community over a certain size:
We should seek to have maternity services available for any community over a certain size across Australia, no matter where it is and how remote it is, because if a service employs people with the skills to care for pregnant women and provide intrapartum care, then they can look after women when things go wrong. If you don't have a service and therefore you don't have people with the skills to respond when an emergency occurs, that is when deaths and injury occur. I would like to see a much higher number of rural birthing services in Australia.
3.47The RACGP also submitted that improving availability of these services within rural and remote hospitals would enhance support for pregnant people.
3.48It was agreed by a large number of inquiry participants that Australia lacks adequate clinical services for termination care, resulting in people facing long waiting lists and lengthy travel times. The below discussion highlights a number of participants' perspectives on this issue, followed by viewpoints on the lack of services provided by public hospitals and across regional, rural, and remote Australia.
3.49Women's Health East submitted that Australia continues to experience gaps in hospital, GP, and practitioner capability in providing termination services even though there is a clear need for clinical support. It cited data indicating that there are an estimated 88000 terminations being performed every year and that one in four pregnancies are unplanned.
3.50The National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Women’s Sexual and Reproductive Health in Primary Care, SPHERE, elaborated:
There are relatively few abortion providers in the primary care setting and hospital system in Australia and even fewer who can manage complex medical and gynaecological cases … About 30% of women in Australia live in regions in which there is no local GP provision of medical abortion including about 50% of women in remote Australia.
3.51When asked about the reasons why there are so few GPs providing medical terminations in Australia, Professor Danielle Mazza provided the following explanation:
Currently, there are about 3,000 GPs who are registered to prescribe medical abortion. We think fewer than that are actually doing so. The reasons why more GPs aren't providing abortion are multifactorial. Stigma is one. It's also concern about lack of support from O&G [Obstetrics and Gynaecology] colleagues in the areas and the local hospitals being abrasive and often not helpful if patients suffer complications.
3.52Fair Agenda stated that:
… many Australians cannot access safe abortion care in a local clinical setting, such as by visiting their doctor or local hospital. They are left navigating the health care system themselves, trying to understand where and how to seek abortion care. Recent studies have shown this is a significant challenge.
3.53Family Planning NSW (FPNSW) argued that there is a lack of available services outside of metropolitan areas, and that there is also limited availability of termination medication in pharmacies. Further:
Groups who are already experiencing disadvantage are amongst the worst affected, including people with low incomes and those in rural and remote areas, Aboriginal and Torres Strait Islanders and people from culturally and linguistically diverse backgrounds.
3.54Women's Health East called for change at the national level to ensure universal access to termination services, 'regardless of [the women's] location, income, or visa status'.
3.55FPNSW submitted that women in all geographical locations should have access to 'affordable, appropriately located and safe abortions', and that they need access to unbiased and confidential information which enables them to make choices that are right for them. It concluded that:
Having abortion services available closer to home is essential in reducing inequities in access to healthcare experienced by rural women.
Limited provision of surgical termination services in public hospitals
3.56Although surgical termination is now legal in all Australian states and territories, the Royal Women’s Hospital noted that many publicly funded hospitals that provide maternity and women's health services do not provide termination services at all. Others only provide very limited services or have 'complicated care and referral pathways', which can cause delays and increase the risks of trauma, costs, and complexity, as gestational growth continues. It further noted that this issue is 'particularly acute for women and girls living in rural, regional, and remote Australia, where access to general hospital services is challenging'.
3.57The Royal Women's Hospital stated that one of the reasons for this outcome was that public hospitals are not mandated, through state government directives or funding agreements, to provide surgical abortion care.
3.58SPHERE also commented on this lack of access in the public health system, and highlighted the inequities it creates:
Inconsistencies and sparse availability of abortion in public hospitals in many parts of Australia create further inequalities in access. The low numbers, or in some cases, complete lack of public and private hospital abortion providers in some regional areas mean few referral pathways exist particularly for surgical abortion. Many hospitals do not perform abortions as it may not be an explicit expectation under their service agreement, and some faith-based public and private hospitals prohibit provision of abortion and contraception.
3.59A number of witnesses, including a Women's Health Nurse at Lismore Women's Health and Resource Centre, MsAmala Sheridan-Hulme, recommended the mandating of publicly funded termination services at tertiary public hospitals, including rural tertiary hospitals.
3.60The Chief Executive Officer of the National Rural Women's Coalition, MsKeliMcDonald, said that women should be able to have terminations in their regional hospital and, hence, every regional hospital must have a termination clinic to facilitate this, stating:
These are big hospitals; they should be able to provide that service to women. A lot of women have to travel a long way just to get to that place alone. I make that point strongly.
3.61The Chair of the Sexual and Reproductive Health Special Interest Group at the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), Professor Kirsten Black, highlighted that the establishment of public hospital pathways would not only enhance equitable access but would also create additional training pathways for health practitioners.
3.62Accessing clinical care is often even harder for those people living in regional, rural, and remote areas of Australia. Accessibility can depend on whether a community's local GP provides these services—if not, individuals seeking this form of care may be required to travel significant distances, and even cross state or territory borders. On this issue, the Chief Executive Officer of Children by Choice, Ms Daile Kelleher, said:
Our clients in [regional and remote areas] travel an average of 200kilometres to access a [health] service, and abortion specifically.
3.63Fair Agenda noted that maintaining medical abortion access via telehealth has been helpful in supporting people in this situation; however, it argued that this model of care needed to be accompanied by face‑to‑face clinical services as telehealth was not appropriate, or preferred, by all patients.
3.64FPNSW stated that access to healthcare services delivered by GPs is highly variable. In its submission, it referenced a 2017 study which found that, whilst some GPs were willing to provide medical abortions, most thought that they should occur in 'for‑purpose clinic settings', rather than general practice. It also highlighted the issue of medical abortion via telemedicine being limited in rural areas due to referral criteria, out-of-pocket costs, and the lack of availability of registered dispensers in rural pharmacies.
3.65With specific reference to the situation for women living in regional, rural, and remote New South Wales, FPNSW said:
There are currently no comprehensive medical and/or surgical abortion services within a publicly funded model for regional, rural and remote NSW, and this exacerbates inequity of access. Access to abortion in rural areas is extremely limited and challenging.
Furthermore, a perceived lack of local confidentiality results in women travelling to other areas at significantly higher cost. In these circumstances, there may be a higher likelihood of inadequate postabortion care. In 2016, a NSW-based study found rural women travelled 1 to 9 hours one way to access an abortion.
Another Australian study of 2,326 women aged 16 and over found women who travelled more than 4 hours were more likely to have difficulty paying, were more likely to be Aboriginal and Torres Strait Islander and more likely to present later in the pregnancy.
3.66SPHERE submitted that 'abortion deserts' are common in rural and remote parts of Australia, resulting in women having to travel to hospitals and private clinics in metropolitan areas, which can pose financial and logistical challenges and delays to their care. It was estimated that more than one in ten women require an overnight stay when accessing an abortion due to the long distance they are required to travel. Further, approximately four per cent have to travel outside the state in which they reside.
3.67Box 3.1, below, contains a case study that highlights the lack of accessible termination care in regional northern NSW.
Box 3.1 Case study highlighting the lack of accessible termination care in regional northern New South Wales Ms Sheridan-Hulme provided the following insight into the lack of medical and surgical termination care options in her local region of northern NSW: Within the Lismore community, there are two medical termination providers, with more located closer to the coast. Due to high demand in Lismore, I often have to refer women to private clinics over an hour's drive away. Whilst medical terminations are a good option for many women, they are only available up until nine weeks gestation and have exclusionary medical criteria. They are a self-managed exercise which women complete at home. It can be painful and confronting and is not suitable for all—for example, young people, women with a disability or those who do not have a private house or are homeless. The cost of a medical termination varies. The Choices clinic provides a bulk-billed service, meaning our patients only pay for the ultrasound and medications, which cost between $6 and $160, depending on whether they have a healthcare card. For a privately billed medical termination, it costs between $300 and $500. For those without Medicare, it costs around $1,000 at a minimum. Surgical terminations are typically provided within public hospitals and private clinics. The Northern Rivers region has extremely poor access to surgical terminations. Currently, for women to have a surgical termination, they must travel around two and a half hours plus to a Brisbane or Coffs Harbour clinic as our local hospital does not provide this health care. The cost is between $500 and $900 for under 12 weeks gestation at private clinics. For non-Medicare holders, it costs anywhere from $1,000 to $1,500 for under 12 weeks gestation. Prices increase steeply at each later gestational week. Unfortunately, Brisbane public hospitals are unable to take referrals for New South Wales residents, meaning that northern New South Wales residents must drive nine hours to Sydney for a free surgical termination service or two and a half hours for a private service in Brisbane or Coffs Harbour. As you can see, the costs and travel needed for surgical terminations is not acceptable in our community. |
3.68The above example is not unique, with other organisations outlining the lack of termination services available across Australia. For example, True Relationships and Reproductive Health submitted that there are currently no surgical termination options available in Rockhampton in central Queensland, and that patients have to travel to the Sunshine Coast, Brisbane, or the Gold Coast—approximately an eight-hour drive or a $600 return flight—to access a service.
3.69A number of inquiry participants advocated for the establishment of a national taskforce to address the issue of termination service accessibility and to deliver on the broader National Women's Health Strategy's 2020-2030 (Women's Health Strategy) priority of achieving universal access to reproductive healthcare. Fair Agenda argued that, without such an approach, reforms would likely be 'piecemeal' and maintain the existing 'postcode lottery' that characterises reproductive healthcare in Australia.
3.70The Australian Gender Equality Council submitted that such a taskforce should ensure that a diversity of voices and lived experiences from across Australia are heard.
3.71The Multicultural Centre for Women's Health called for the taskforce to address the nuanced barriers that various communities, such as migrants, experience, and said that it should involve all states and territories, health experts, community-led organisations, and people with lived experiences.
3.72The Victorian Women's Health Services Network envisaged that such a taskforce would:
… enable better planning, monitoring and development of [sexual and reproductive health] services to address population health needs, in alignment with federal and state legislative and policy frameworks. This would enable better policy, funding and legislative coordination across the country to address inconsistencies and gaps more efficiently and effectively.
3.73In addition to the longer-term approach of establishing a national taskforce, FairAgenda suggested that an immediate practical step that the Government could take to improve accessibility to termination services is the funding of a national telephone service to provide people with support, information, and referrals. It was proposed that such a service could utilise one of the many existing models currently in place, such as the healthdirect service; Queensland's Children by Choice, Tasmania's Pregnancy Choices, and Victoria's 1800 My Options.
3.74It was also proposed that such a telephone service be supported by an interactive national map to make it easier for people to find counselling services about termination care options, as well as prescribing doctors, dispensing pharmacists, and information on services and costs.
3.75On these proposals Ms Kelleher from Children by Choice said:
Funding a national service and map to support abortion seekers and health professionals to support their patients would make a huge difference in cutting through the patchwork of abortion in Australia. It would be incredibly useful for abortion seekers who need reliable information quickly and for governments that need to identify where gaps exist.
High costs for termination care
3.76Numerous inquiry participants highlighted that the high costs of termination care restrict their accessibility. It was argued that the cost of these services often causes emotional distress, can delay time-critical care, and can significantly affect a patient's physical and mental wellbeing.
3.77As abortion care is not always available in all public healthcare settings, most women need to access private providers and, hence, incur large out‑of‑pocket costs to access this care. FPNSW mentioned a 2015 Australian study that found that two-thirds of women seeking abortions found two-thirds needed financial assistance, and that the median cost for indirect expenses was $150.
3.78FPNSW noted that, even though medications for medical abortion are listed on the PBS and rebates are available for surgical abortions under Medicare, total costs incurred often range from between $500 and $8000 for abortion care in Australia—when client costs, such as GP visitations, blood tests, ultrasound scans, prescription medication, and after‑care costs, are included.
3.79Fair Agenda referred to the cost being a 'postcode lottery', as it varied so widely depending on where patients live. It also noted that, for complex cases, costs can range up to $17 000. Further, Women’s Health East stated that Australian women are currently being charged up to 70 times the manufacturing cost of medical termination of pregnancy medication, resulting in an unnecessary financial barrier.
3.80The Managing Director of MSI Australia, Mr Jamal Hakim, agreed that women face a lottery when trying to access termination care and that funding remains piecemeal. He also said:
It can be stressful and costly to access basic health care, particularly for women in regional and remote areas of Australia. We know that the National Women's Health Strategy, released in 2020, agreed to universal access to sexual and reproductive health by 2030, and this strategy has bipartisan support. But sadly, very little has been done to make this a reality.
3.81In addition to the direct costs, submitters noted there are also significant ancillary costs incurred when accessing termination services, including transportation, childcare, and foregone wages. For those women living in rural and remote areas where there are no local services, costs are generally even higher due to factors such as additional travel and accommodation expenses. It is estimated that two-thirds of women have to obtain financial assistance from one or more sources, such as a partner or family member, to pay for an abortion.
3.82While Medicare rebates are available for consultations concerned with medical abortion, including, since July 2021, consultations delivered by telehealth, out‑of-pocket-costs and gap payments still apply. Importantly, many women are not eligible to enrol in Medicare, including international students and women on temporary visas, and hence, must pay the total cost of their procedure, as well as any additional associated costs.
Stigma and conscientious objectors
3.83According to a 2019 position statement from the Australian Medical Association, practitioners are entitled to have their own personal beliefs and values. The AMA statement says that while it is acceptable for a healthcare provider to not provide certain medical treatments or procedures based on conscientious objection, providers do, however, have an ethical obligation to minimise disruption to the delivery of healthcare for the patient.
3.84Patients reported experiencing institutional, as well as individual, conscientious objection and other manifestations of systemic stigma. Fair Agenda said that this can take various forms, including providers refusing treatment, healthcare staff making judgemental statements or trying to dissuade patients from termination, or healthcare staff assuming a pregnancy was wanted or planned.
3.85Further, evidence was presented that in some circumstances, GPs do not advertise that they provide termination services due to concerns that they will be stigmatised within their local communities. This results in many women being unable to effectively identify, locate, and access providers of these services in their immediate regions.
3.86SPHERE provided evidence that there are a significant number of conscientious objectors operating across Australia's health system. The data it cited estimated that in 2009, around 15 per cent of Australian obstetrics and gynaecology fellows and trainees were conscientious objectors of abortion. While more recent data is not available, SPHERE suggested that these numbers may be even higher in regional and rural areas amongst GPs, with one study of regional Victoria indicating that 38percent of interviewed GPs referred their patients to a colleague due to a conscientious objection.
3.87A co-founder of The Abortion Project, Ms Lily McAuliffe, highlighted the issues that pregnant women face when refused termination care due to conscientious objections. She argued that this was a 'really big problem' in Australia and provided an anecdote of a young women who had to travel from Broome to Darwin to have a termination after she was refused treatment by a local provider.
3.88The impact of this problem was also highlighted by a Queensland-based woman, Charlotte, who initially sought a termination three weeks into her pregnancy. Even after persistent telephone calls to her doctor, she was still pregnant at almost 19 weeks due a required referral not being sent through to the hospital. She stated:
I was sent to the Royal Women's Hospital. The amount of times I went back to that doctor was ridiculous. From then on, I believed this doctor was against abortions. The referral was never sent. I was nearly 19 weeks pregnant and they received the referral in the mailbox, which he was supposed to send to the hospital but never did. This was on Christmas Day. I ended up having to give birth on Christmas Day.
…
If he was against abortions, why would he let me go from three weeks to 19weeks growing a baby in my stomach, rejecting all the times I tried to contact him? Why didn't he just help me from the start?
Medicare rebates for medical terminations
3.89RANZCOG submitted that, due to the existing MBS rebate being based on length of an appointment, the cost of early medical abortion provision is 'prohibitive' for GPs and community clinics to provide bulk-billed services. Itargued that the generic consultation MBS item does not account for the high administrative workload associated with medical termination provision.
3.90The Deputy Medical Director at Sexual Health Quarters, Dr Samantha Johnson, also spoke about this issue and highlighted the lack of remuneration to provide these services and their administrative‑intensive nature. She said:
There's no incentive for a GP and the community to provide that service—it's quite complex, it takes a lot of time, it's not something that you'd like to rush, and they're not going to do it with the rebates on a time-based consultation. There is a little bit of extra training you need to do beforehand. The way the system is at the moment, trying to access the medication from the pharmacy for patients can be quite time consuming. At a minimum, an MBS item number for medical terminations should be considered.
3.91RANZCOG also suggested that a specific MBS item for early medical termination provision with a higher rebate could be introduced; however, it said that such a reform would heighten privacy risks, especially for young people who are covered under their parents' Medicare or have private health insurance plans funded by their parents.
3.92The RACGP also raised privacy as an issue and did not support the introduction of a new specific MBS item:
While the RACGP supports the need for affordable and accessible medical and surgical abortion services, we do not support the creation of specific MBS items for medical termination of pregnancy services in general practice.
Specific MBS items for abortion could also lead to privacy issues and stigmatise this service, as specific MBS item numbers will appear on the patient's Medicare record.
3.93As part of a broader package within the 2023–24 Federal Budget, the Government committed $99.1 million to facilitate the creation of a new MBS item for consultations lasting 60 minutes or longer. In the Women's Budget Statement, the Government noted that the extended consultations would 'support improved access and affordability for patients with chronic conditions and complex needs'.
Expiry of temporary telehealth support
3.94In 2021, the Government introduced eight new temporary telehealth items to the MBS for, amongst other things, sexual and reproductive health consultations via video and telephone. Items for GP sexual and reproductive health services and non-directive pregnancy support counselling were initially extended to 30 June 2023, and in May 2023, the Government confirmed that these items will remain in place until 31 December 2023.
3.95It was argued that telehealth consultations, supported by Medicare, improve access to medical terminations by removing the need for patients to travel long distances and allows existing health practitioners to provide their services across larger geographical areas. SPHERE noted that:
… telehealth medical abortion is comparable in safety, efficacy and acceptability to in-person medical abortion services and can improve access.
3.96The Chief Executive Officer of Coffs Harbour Women's Health Centre, MsShelleyRowe, also highlighted the benefit that telehealth can provide for women trying to access other sexual and reproductive health services, such as contraception. She said:
… I would like to say that telehealth has really improved access to contraception with the benefit of being able to provide appointments for repeat scripts and checking follow-up care with the treating clinician. It really reduces the inconvenience to women who have to travel for appointments in regional areas and might have carer duties or otherwise need to take leave from what is often part-time work. We just really sincerely hope that the telehealth option remains the modality of care to keep access and continuity of access to contraception.
3.97During the inquiry the RACGP recommended that these items be continued beyond 30 June 2023. It also highlighted the flexibility that they provide for patients, as they do not require an existing clinical relationship with the GP providing the service:
Enabling access to sexual and reproductive health services via telehealth provides flexibility and choice for patients to consult with their GP (or an alternative GP to their usual GP if they do not provide medical termination of pregnancy or is a conscientious objector) on sensitive health matters.
3.98As noted above, in the 2023–2024 Budget the items for GP sexual and reproductive health services and non-directive pregnancy support counselling were extended from 30 June 2023 until 31 December 2023.
Regulatory and legislative barriers
Restrictive MS-2 Step requirements and limitations
3.99Inquiry participants argued that many barriers exist for women trying to access medical abortion in Australia, including prescribing and dispensing restrictions, training requirements for health practitioners, and gestational age limitations.
3.100Marketed as MS-2 Step in Australia, medical abortion medication is distributed by a single provider. The approved risk management plan for the medication requires both the prescribing GP and dispensing pharmacist to be registered to provide the medication. According to published data, in December2020 approximately only 10 per cent of GPs and 16 per cent of pharmacists were active prescribers and dispensers, respectively, of this product.
3.101Evidence from SPHERE (Figure 3.1 below) highlights those regions across Australia that have limited or no local provision of MS-2 Step due to either a lack of prescribing GPs or dispensing pharmacists, or both. While this data is several years old, it highlights the risks to access presented by the current training and dispensing rules.
Figure 3.1MS-2 Step prescribing and dispensing during 2019
Source: SPHERE, Submission 5, p. 7.
3.102The Royal Women's Hospital described the current regulatory environment as 'highly restrictive' and Fair Agenda said the low uptake by GPs and pharmacists could be partly attributed to 'over regulation' by the Therapeutic Goods Administration (TGA). On this point, Fair Agenda said:
Abortion medication is highly regulated compared with other medications in Australia and we are trailing behind our counterparts in making it more accessible.
In Canada, medical abortion drugs are prescribed by GPs with no additional regulatory barriers; in Ireland the medication can be prescribed up to 12weeks pregnancy gestation, in line with international guidelines, which is above the 9-week limit in Australia.
Other countries allow nurses and midwives to prescribe the medication. Yet in Australia, the requirements to prescribe it are unnecessarily onerous, on par with those reserved for medications that carry higher risks of harm.
3.103The Acting Deputy Medical Director at Sexual Health Quarters, Dr Nicole Filar, highlighted the issues that these restrictions create for young and vulnerable people. She said:
I, just the other week, had a 16-year-old via telehealth. I was training another doctor, and we spent a good hour just trying to collect all the paperwork and find a pharmacy that actually dispensed it [MS-2 Step], let alone had it in stock. They didn't. It took 24 hours to get there. And then you've got to think about the teenager actually trying to get to the pharmacy, because they don't want their parents to know about it; having an adult's support to get there; and scripts lost via fax. It's just a nightmare. This is for a young and vulnerable patient and, like I said, for that time when it's not just seeing the patient and talking; there's a lot of admin[istration] to it, a lot of training, a lot of forethought. It's just not sustainable.
3.104The Medical Director at MSI Australia, Dr Philip Goldstone, called the restrictions placed on GPs and pharmacists as potentially 'the biggest barrier' to accessing medical terminations and said his organisation called for their removal. He also noted that, while mifepristone was a relatively unknown medication when it was first registered in Australia in 2012, there is now a vast amount of experience with this medication and that it has been utilised by millions of women around the world.
3.105Bianca gave evidence to the committee reflecting on her lived experience in navigating the system when seeking a medical termination. She spoke about finding a compassionate GP, but then ultimately being forced to see a different GP as her preferred GP was not registered to prescribe MS-2 Step. She said:
This system entirely failed me. I was forced to choose a doctor who intentionally discriminated against me and withheld pain relief. If I had been allowed to undertake this process with the original GP I found, I have no doubt that I would have had a much less traumatic experience, guided without personal bias.
3.106The Royal Women's Hospital referenced cohort studies in the United Kingdom, Canada, and Europe which, it stated, had demonstrated that the removal of prescribing restrictions had improved access without any additional adverse outcomes, while also significantly lowering the gestational age at time of termination—reducing patient risks and decreasing the need for post‑procedure clinical management.
3.107ALHR suggested that only allowing medical practitioners to prescribe MS‑2Step in Australia was restrictive, and that access could be enhanced, particularly in rural and regional areas, by expanding the range of permitted prescribers to include nurse practitioners and midwives. The Queensland Nurses and Midwives' Union, Midwives Australia, and the South Australian Abortion Action Coalition also supported greater involvement of nurse practitioners and midwives to improve access.
3.108In her evidence to the inquiry, the TGA's Chief Medical Adviser, AdjunctProfessor Robyn Langham AM, stated that a Women's Health Products Working Group was created in June 2022 to bring together health professionals, academics, and patient support groups in a 'collaborative forum', and that this group had universally agreed that what was put in place a decade ago for MS‑2Step was no longer relevant, was out of step with current international guidelines, and was not meeting the needs of the Australian community.
3.109Given this, Dr Langham stated that the TGA has been engaging with the sponsor of MS‑2Step in Australia—MS Health—to reduce the existing restrictions, and that it was currently reviewing an application submitted by the firm to achieve this. She noted that the proposed amendments in the application would eliminate registration requirements for pharmacists and doctors, as well as expand the list of health practitioners that can prescribe this medication. She also stated that this matter could be decided within a 'couple of weeks'.
Gestational limitations
3.110A number of inquiry participants also called for the gestational age limit of 63days to be increased. For example, Australian Lawyers for Human Rights (ALHR) said:
Access could be increased by revising the regulatory framework for prescribing and dispensing MS-2 Step. Research supports the safety and efficacy of mifepristone and misoprostol for early medical abortion up to 77days' gestation and countries including the United Kingdom allow the use of mifepristone and misoprostol for up to 70 days.
3.111The Chief Executive Officer of Family Planning Australia, AdjunctProfessorAnn Brassil, also called for the gestational age limit to be higher. She argued that nine weeks is not currently international best practice, and that someone would have to be very health-literate to recognise that they're pregnant and make a considered decision within this time frame.
3.112Dr Haller said that other countries provide MS-2 Step up to 10 weeks gestation 'quite safely' and that changing the existing limitation could be an opportunity improve medical termination accessibility.
3.113On this issue, Adjunct Professor Langham from the TGA said:
… this is reliant upon the sponsor coming to us with those requests, and my understanding is that MS Health is not at this stage willing to [alter] the gestation time. I understand it's from a risk management perspective: risks increase as gestation increases.
3.114The committee heard about the state and territory-based variations in the settings and circumstances by which termination services can be performed.
3.115FPAA argued that these legislative variations are 'inequitable and confusing' and make access to termination services more difficult and daunting for women.
3.116GPs are required to be knowledgeable on the legislative variations across each jurisdiction when offering or referring medical and surgical terminations. The RACGP said this inhibits access to these services and suggested that harmonisation of legislation would assist both patients and GPs.
3.117The Deputy Medical Director of MSI Australia, Dr Catriona Melville, also called for harmonisation, and highlighted the fragility and inadequacy of the existing system:
We certainly saw a lot of what you could only call health tourism between states pre the pandemic. The fragility of the system really became very apparent during the pandemic when the borders were closed and people could no longer travel interstate to have an abortion at different gestation. We would definitely support harmonisation of the laws, and I think certainly the Victorian law with a gestational limit of 24 weeks would be what we would support.
3.118Numerous inquiry participants, including SPHERE, True Relationships, and Children By Choice, called for state and territory governments to harmonise their respective legislative frameworks. Amnesty International also noted that in 2018, the United Nations Committee on the Elimination of Discrimination against Women called for Australia to harmonise its state and territory laws, policies, and practices concerning terminations to guarantee their accessibility.
Training and data barriers
Inadequate undergraduate training
3.119Evidence presented to the committee noted limitations in training around reproductive healthcare. For example, termination care and training on long-acting reversible contraception (LARC) is not included in some undergraduate degrees for doctors, nurses, and midwives. This results in these health practitioners needing to undertake additional specialised training after graduation to gain the required skills in these areas.
3.120Dr Johnson from Sexual Health Quarters highlighted the lack of training during medical degrees, saying:
In terms of training to become a doctor, in your four- to six-year degree, you're lucky if you get a half-hour lecture on abortion care in that whole time.
3.121The Royal Women's Hospital said that comprehensive abortion and contraception education is required at undergraduate and postgraduate levels to equip medical, nurse practitioner, nursing, and midwifery health professionals with the essential skills and knowledge needed to provide best practice LARC and abortion care.
3.122Adjunct Professor Brassil from Family Planning Australia said:
... it would be great if undergraduates, doctors in training, were provided with a much greater education in relation to reproductive health.
We'd like to see reproductive health care as a more established part of the health curriculum. At the present time, RANZCOG provides training for its trainee gynaecologists, but it's optional. There are modules they can do but it's not part of their core curricula.
3.123RANZCOG also called for termination care to be a mandatory component of medical, nursing, and midwifery university curriculum. It argued that student doctors, nurses and midwives who are not exposed to the socio-political, public health, and clinical aspects of termination care may be less aware of the inequities that exist and less likely to be actively involved in providing, assisting, or supporting termination care after graduation.
3.124Box 3.2 below, highlights the potential consequences of inadequate reproductive healthcare education for health practitioners.
Box 3.2 The potential consequences of inadequate sexual and reproductive health training for practitioners DrFilar from Sexual Health Quarters provided a personal experience to the inquiry which highlights the potential consequences of inadequate sexual and reproductive healthcare education: I've also come across a situation where, unfortunately … a young teenager came in thinking she was five to six weeks pregnant because the clinician had done some pregnancy bloodwork and thought that that number meant that she was only five to six weeks pregnant. When I saw her, she was absolutely not five to six weeks pregnant. She was about 22 to 23 weeks pregnant. Had the provider actually done an examination at the first point and just palpated her abdomen and felt her uterus and gone, 'We need to act quickly,' then it would been a different story. This young teenager, now, in WA [Western Australia], had to go ahead with this pregnancy. And, by teenager, I mean a 14-year-old, okay? I remember that consult so vividly because mum was there, I was there, and we were in tears. We were just in shock because of that. It was all because the provider—the clinician at the beginning—didn't have the appropriate training and education when it came to abortion care, contraception, and sexual and reproductive health. It came from that. They didn't understand that and just let this poor, young, vulnerable person navigate it on their own. These are the things that I see on the ground and that we need to change. A big part of it, for me, is about educating clinicians as well. |
3.125Although there are joint federal, state, and territory programs which collect healthcare data on many topics, including infectious diseases and cervical screening, it was noted that data on termination care is inconsistently collected at a national level and, hence, the number of abortions each year can only be estimated.
3.126Fair Agenda argued that this was despite an existing ability to collect these data in a way that considers patient privacy and confidentiality. It contended that:
Fear mongering about possible data breaches has been used to justify this lack of data collection. Such arguments are problematic as they are reinforce secrecy around abortion, fuelling the harmful shame and stigma surrounding it, rather than recognising abortion care as essential health care.
3.127The Australian Christian Lobby also highlighted the lack of national abortion figures as being problematic. It said:
… there are no national abortion figures available, not even from the Australian Institute of Health and Welfare (AIHW) whose very role is to provide meaningful statistics for Australians regarding health matters.
There is only a disparate level of information available at state/territory level (particularly from South Australia (SA), with limited information from Western Australia (WA), Queensland (QLD), Victoria and Northern Territory (NT)). This lack of information is a problem in itself.
3.128The Australian National University Law Reform and Social Justice Research Hub said:
… data collection on instances of abortion in Australia is poor. States do not routinely report abortion data, and the national dataset has been incomplete in the past.
3.129Given this inconsistent data collection, there were calls for improvement in this area. For example, Fair Agenda said in its submission:
Australia needs to invest in national data collection to enable evidence‑based policy, which is essential to end inequities in abortion care access. Data will also provide an indicator of reproductive health, and can help assess the effectiveness of sex education, access to effective contraception, and understanding of fertility and menopause.
3.130Children by Choice and Ending Violence Against Women Queensland also supported increasing research and data collection on abortion access.
3.131The committee recognises that healthcare is a fundamental human right and barriers to accessing maternal, sexual and reproductive healthcare can have adverse impacts on an individual’s mental, emotional, and physical health.
3.132The committee has heard that Australians face numerous barriers when attempting to access reproductive healthcare services — particularly in regional, rural and remote areas.
3.133During the inquiry, numerous participants provided various ideas and proposed initiatives aimed at reducing, and potentially eliminating, the existing barriers. The committee considers that people should have genuine choice and be well supported in relation to their sexual, reproductive and maternal healthcare decisions.
Removing access barriers to maternity and termination care
Ensure the provision of maternity care services at public hospitals
3.134The committee is concerned by the evidence illustrating the lack of maternity and birthing services for women who live in regional, rural, and remote areas of Australia. In particular, it is concerned to hear that women without access to adequate local birthing services must relocate and give birth away from home. The committee highlights evidence showing that this leads to poor outcomes for women and their babies, given that relocation comes with a financial cost, removes them from their support networks and families, and disrupts their continuity of care.
3.135The committee considers it extremely important that women, regardless of where they live in Australia, have easy access to high quality, culturally safe maternity care. Women and their families should not be disadvantaged for living outside of a metropolitan area.
3.136The committee recommends that the Australian, state, and territory governments ensure that maternity care services, including birthing services, in non-metropolitan public hospitals are available and accessible for all pregnant women at the time they require them. This is particularly important for women in rural and regional areas.
3.137The committee recommends that the Australian Government implements outstanding recommendations made by the Participating Midwife Reference Group to the Medicare Benefits Schedule (MBS) Review Taskforce regarding midwifery services and continuity of care.
3.138The committee recommends that the Australian Government works with the sector to increase birthing on country initiatives and other culturally appropriate continuity of care models.
The provision of termination care at public hospitals
3.139Throughout the inquiry, the committee heard from stakeholders that Australia lacks adequate clinical services for termination care, resulting in women facing long waiting lists and lengthy travel times, often across state and territory borders and under acute time pressures, to access the appropriate care.
3.140The committee heard that this can cause delays and increase the cost, complexity and risk of trauma. The committee is mindful that these issues were raised as particularly acute for women and girls living in rural, regional and remote Australia, where access to any hospital can be challenging.
3.141The committees notes the evidence that publicly funded hospitals that provide maternity and women’s health services provide no termination services, or only provide very limited services or referral pathways. The committee notes that surgical termination is legal in all Australian states and territories.
3.142Additionally, it notes the evidence from the Royal Australian and New Zealand College of Obstetricians and Gynaecologists that the establishment of consistent public hospital termination care pathways would enhance equitable access to essential healthcare and also create additional training pathways for health practitioners.
3.143The committee recommends that all public hospitals within Australia be equipped to provide surgical pregnancy terminations, or timely and affordable pathways to other local providers. This will improve equality of access, particularly in rural and regional areas and provide workforce development opportunities.
Implementation plan for sexual and reproductive healthcare
3.144Throughout this inquiry, the committee heard numerous calls for the establishment of a national taskforce to deliver on the broader Women’s Health Strategy. The committee notes evidence suggesting that without such a taskforce, government reforms would be piecemeal and continue the existing postcode lottery that currently characterises reproductive healthcare in Australia.
3.145The committee notes the proposal to establish such a taskforce and considers it could be an important step in developing a practical plan to address accessibility issues and achieve the priorities set out in the Women's Health Strategy.
3.146The committee recommends that the Australian Government develops an implementation plan for the National Women’s Health Strategy 2020–2030 with annual reporting against key measures of success. This could include establishing a taskforce as part of the implementation plan.
Fund a national telephone and mapping service
3.147The committee recognises the evidence supporting the development of a national telephone service to provide support to people across Australia regarding pregnancy care and termination services. Options to implement such a measure could include the development of an interactive national map to assist people with finding counselling services about pregnancy care options, termination service providers, medical termination prescribing doctors and dispensing pharmacists, and other relevant information on clinical services, financial costs, and available assistance options.
3.148The committee considers such a model may assist state and territory governments to identify where service gaps currently exist within their jurisdictions.
3.149The committee recommends that the Australian Government, in consultation with state and territory governments, implements a national support, information, and referral model for sexual and reproductive healthcare services.
3.150The committee envisages that such a national telephone service would leverage the experiences of existing initiatives, such as 1800MyOptions and healthdirect, to ensure that it is fit for purpose, delivers accurate local information, and builds on the experiences of services operating in those jurisdictions.
Provide adequate remuneration for medical termination consultations
3.151The committee heard evidence regarding the impact of MBS rebate levels and service provision. Existing MBS rebates can mean that the cost of early medication abortion provision is too prohibitive for GPs and community clinics to be able to bulk-bill. The committee understands that this is because MBS rebates are based on the length of an appointment and the generic consultation MBS item does not account for the high administrative workload associated with medical termination provision.
3.152The committee supports the Government’s 2023–24 Budget measures for longer consultations and increased bulk-bill incentives. The committee suggests the Government monitor the impact of these measures to ensure Medicare arrangements supporting medical termination consultations remain adequate.
3.153The committee recommends that the Australian Government reviews the existing Medicare arrangements which support medical termination consultations with the aim of ensuring adequate remuneration for practitioners to deliver these services while also ensuring patient privacy.
Make Medicare-funded telehealth consultations permanent
3.154The committee supports calls for the temporary telehealth items which facilitate sexual and reproductive healthcare consultations via video and telephone to be made permanent additions to the MBS.
3.155The committee acknowledges the significant benefits that telehealth can provide the Australian community, especially for those people living in regional, rural, and remote areas where access to a local health practitioner is not always possible.
3.156The committee is of the view that by making these items permanent, access to sexual and reproductive healthcare would be improved. Importantly, these items are flexible and allow patients to access alternative providers without an existing prior relationship in place. The committee considers this important for a number of reasons, including supporting patient privacy and providing access to alternative practitioners in circumstances where a provider doesn’t provide medical termination services or is a conscientious objector.
3.157The committee recommends that the Australian Government continues current Medicare Benefits Schedule telehealth items for sexual and reproductive healthcare, including pregnancy support counselling and termination care.
Reforming regulatory and legislative frameworks
3.158The committee notes evidence regarding the lack of GPs and pharmacists able to prescribe and dispense MS-2 Step in Australia, with evidence indicating that approximately 10 per cent of GPs and 16 per cent of pharmacists are active prescribers and dispensers, respectively, of this medication.
3.159The committee notes that evidence provided during the inquiry suggested that other comparable jurisdictions, such as Canada, the United Kingdom, and Europe, had less onerous prescription regulations and that this had resulted in improved access without additional adverse outcomes—and had in fact lowered gestational age at time of termination.
3.160The committee recognises that the TGA is currently considering an application submitted by MS Health to reduce the existing restrictions on GPs and pharmacists, as well as a proposal to broaden the health practitioners that can prescribe MS‑2 Step.
3.161The committee recommends that the Therapeutic Goods Administration and MS Health review barriers and emerging evidence to improve access to MS-2 Step, including by:
allowing registered midwives, nurse practitioners, and Aboriginal Health Workers to prescribe this medication—including pain relief where indicated; and
reducing training requirements for prescribing practitioners and dispensing pharmacists.
Improving training and data collection
Include reproductive healthcare in university courses
3.162The committee notes evidence indicating that comprehensive reproductive healthcare, including basic training on termination care and LARCs, is insufficient in undergraduate degrees for doctors, nurses, and midwives.
3.163As evidence provided to the inquiry showed, inadequate training can have serious consequences for patients who may be forced to continue with an unintended pregnancy or undergo a more invasive procedure to end a pregnancy due to misinformation provided by an insufficiently trained health practitioner.
3.164The committee considers that enhancing such training could better equip health practitioners with the necessary skills and knowledge to guide, advise and assist their patients.
Recommendation 21
3.165The committee recommends that the Australian Government, in consultation with relevant training providers, reviews the availability, timing, and quality of sexual and reproductive healthcare training in undergraduate and postgraduate tertiary health professional courses, including vasectomy procedures, terminations and insertion of long-acting reversible contraception.
Improve statistical data collection and information on reproductive healthcare
3.166The committee agrees with inquiry participants that the lack of data and information on sexual and reproductive healthcare must be addressed as a priority.
3.167Given this, the committee endorses calls for the Government to work to improve national data collection to enable evidence-based policy responses relating to termination services and other sexual and reproductive healthcare services across Australia.
3.168The committee also considers that the Department of Health and Aged Care, in collaboration with its state and territory counterparts, should consider the effectiveness of local programs which provide free menstrual hygiene products.
3.169The committee recommends that the Australian Government commissions work to improve its collection, breadth, and publication of statistical data and information regarding sexual and reproductive healthcare, particularly in relation to pregnancy terminations, both medical and surgical, and contraceptive use across Australia.
3.170The committee recommends that the Department of Health and Aged Care works closely with its state and territory counterparts to consider the effectiveness of local programs providing free menstrual hygiene products.