ABSTRACT
Introduction: Rural populations in Australia rely upon local primary health care for medication abortion access. Yet little is known about how individual primary healthcare providers themselves negotiate the unique complexities of the rural health system to provide local abortion services.
Methods: To address this gap, we conducted qualitative, semi-structured interviews with primary healthcare providers in rural New South Wales (NSW). Recruitment strategies included sending invitations to all GP clinics in Western NSW, distribution of flyers via professional networks and social media posts as well as snowballing. The Framework Method was used to conduct an inductive thematic analysis.
Results: We interviewed 16 rural GPs, nurses, midwives and women’s health clinic operational staff. Four themes were identified: (1) scarce abortion services place overreliance on availability and goodwill of local prescribers; (2) lack of back-up support, financial incentives and training deters providers; (3) there is interprofessional stigma, secrecy and obstruction; and (4) local abortion access requires workarounds through informal rural networks. Participants described abortion exceptionalism within Australia’s health system and chronic rural workforce shortages in rural settings as unique and compounding challenges to local provision. Conversely, strong rural community networks were identified as important enablers of informal pathways to abortion within or around systemic barriers.
Conclusion: Improving rural abortion access in Australia requires attention to the numerous intersecting barriers that local primary care providers themselves face when providing services at the periphery of an unaccommodating health system.
From the full Introduction
Australia has one of the highest ratios of doctors per capita in the world, yet the health workforce is maldistributed, with some rural areas counting 50% fewer healthcare providers per capita than urban centres. Recruiting and retaining a high-quality rural health workforce is an unresolved global challenge4,5, and Australia is no exception. Rural people account for 28% of Australia’s population, have higher and more complex health needs than the general population, yet poorer access to primary healthcare services and diminished continuity of care. Geographic isolation is reported as the major disincentive for healthcare providers to work in rural Australia2,8. Stop-gap solutions such as a high rotation of short-term health staff and locums in remote parts of the country provide temporary relief, but Zhao et al argue this costly ‘quick fix’ hampers development of a thriving rural health workforce that is authentically embedded within the community.
Primary care is the main entry point into the health system for all forms of early pregnancy care, with GPs the first point of contact for 90% of all pregnancies in Australia. Rural women seeking health care in early pregnancy report deficits in local reproductive health services including diminished choice, lengthy wait times and significant disruption caused by the need to travel large distances at personal expense. Women with unintended pregnancy also describe dissatisfaction and in some cases shock that some healthcare providers were unprepared to provide information in relation to abortion services. A 2023 Australian Government inquiry into universal reproductive health care in Australia called the inequity of reproductive health a ‘postcode lottery’.
This article uses the words ‘woman’ or ‘women’ but the authors wish to acknowledge that girls and other people who do not identify as women – including transgender men and gender non-binary individuals – also have the capacity to experience pregnancy and may also need pregnancy options and abortion services. However, as none of these groups were mentioned by our study participants we do not refer to them directly.
Despite being fully decriminalised in all states and territories, abortion remains a ‘grey and stigmatised area of health practice, outside the purview of mainstream medicine’. Australia’s public health system does not routinely fund, provide or monitor abortion. Most procedural (surgical) abortion services are delivered by a small number of independent providers at considerable out-of-pocket cost to the consumer. For the past decade, only qualified GPs have been permitted to prescribe MS-2 Step, the combined misoprostol and mifepristone medication used for medication abortion up to 63 days gestation, yet less than 10% of GPs in 2021 had undertaken the mandatory training. Millar argues that the exclusion of abortion from the medical student curricula positions abortion as ‘exceptional’ to mainstream health. High levels of conscientious objection to abortion provision among rural GPs support this claim. While all conscientious objectors are legally obliged to refer to other available services, the absence of clear referral pathways or proximate options for rural populations means this obligation can easily remain unfulfilled.
Little is known about how rural primary care providers, who are relied upon to deliver all primary healthcare services, including abortion to local people they know, manage this complexity. Previous studies in Australia have focused either on the views and experiences of rural GPs and nurses with specific expertise in sexual and reproductive health or medication abortion, or on the experiences of consumers accessing these services. Through qualitative interviews, our study aims to contribute a unique perspective. That is, the experiences of rural primary care providers who become the ‘first point of contact’ for women with unintended pregnancy and, irrespective of their knowledge, interest or expertise in abortion provision, are charged with the task of ensuring abortion-seekers reach the services they need.
From the Results
Four main themes were identified from the data: (1) scarce abortion services place over-reliance on availability and goodwill of local prescribers; (2) lack of back-up support, financial incentives and training deters providers; (3) there is inter-professional stigma, secrecy and obstruction; and (4) local abortion access requires work-arounds through informal rural networks.
From the Discussion
This study explores the experiences of 16 primary healthcare workers who provided ‘first contact’ health services for unintended pregnancy in Western NSW in the previous 5 years. All participants, irrespective of their role or scope of practice, described their confidence and willingness to provide early pregnancy counselling and decision-making support. However, almost all also described multiple, complex and often intersecting barriers to their provision of or referral to local abortion services.
Our study findings highlight the multiple pressures of a rural primary healthcare system in workforce crisis, the incompatibility of medication abortion with GP financial modelling and appointment scheduling and, perhaps most pertinent of all, the professional politics involved with trying to deliver a historically stigmatised reproductive health service without adequate support from the public health system. The way in which these pressures and responsibilities coalesce in the lived experience of rural ‘frontline’ health providers is the focus of this article. As each of the four identified themes in this study illustrate, the availability of abortion services in rural primary care settings is dependent on the motivation of individual primary care providers to persist against a system that is either unwilling or unequipped to integrate abortion into routine healthcare practice, sometimes to their own financial, personal or professional detriment…
Our study design centralised the experiences of rural primary healthcare providers trying to overcome the dual challenges of rural health systemic deficiencies and broader abortion exceptionalism in Australia to ensure abortion services are accessible to their communities. The impact of abortion restrictions and obstructions on the lives of rural primary care providers is a focus rarely seen in literature on abortion services worldwide34. Yet solutions to sustaining and increasing abortion access in rural communities will need to directly address the multiple administrative, financial, reputational deterrents these individuals face, and the burden imposed on those who continue regardless…
One of the strengths of this study is its deliberate recruitment of a wide range of participants working in rural primary healthcare with a range of interest and expertise in abortion. This not only includes GPs, but also nurses, midwives and women’s health clinic administrative staff whose experiences highlight the complexities of negotiating abortion access, including for those working within the health system. The geographic specificity of this study is also important in this context. Western NSW is the largest region and ‘abortion desert’ in the state, and is facing a severe GP shortage, with the local primary health network projecting a quarter of the region’s population are at risk of not having a GP practising in those communities over the next 10 years. Nurses across the region have also repeatedly described the nursing shortage as ‘dangerously unsafe’ to patients and escalating burnout for those working on the ground.
Australia’s National Women’s Health Strategy 2020–2030 lists maternal, sexual and reproductive health as its first priority, acknowledging ‘the need for women and girls to be informed of, and to have access to, safe, effective, affordable and acceptable forms of fertility regulation, health services and support’ (p. 22). Yet there was a stark absence of any indication of future national policy, funding or plans for universal, free public abortion in the recently released Senate Inquiry report.
The Australian Government’s ongoing resistance to integrating abortion into its public health system, or to providing adequate subsidisation through the Medicare health insurance scheme, shifts the responsibility to provide and manage the cost of abortion services onto primary care. Tomnay argues this leaves many primary care providers inadequately remunerated, running at a financial loss or unable to afford to provide these services. The consequential impact on rural abortion access is clear – the country’s largest independent abortion provider MSI Australia stated the justification for the closure of four of its regionally based abortion clinics was that they were simply ‘financially untenable’.
In July 2023, Australia’s pharmaceutical regulator, the Therapeutic Goods Administration, removed requirements for GPs to train and register as medication abortion providers48. While some abortion advocates have described this policy shift as a solution to increasing prescriber numbers, especially outside urban centres, this study countercalls for greater consideration of the rural context. Our findings highlight how the paucity of rural abortion services and referral pathways already places undue pressure on individual rural GPs to forego income, risk reputational damage and uncertainty of back-up support, simply to ensure local rural services are available. That participants in this study continued to do this work is not indicative of a solution, but rather reflects individuals taking on the burden of responsibility instead of and in spite of the system…
Nurse-led models of abortion care are one workforce-strengthening strategy that is already in an exploratory phase in Australia. Benefits of this approach include alleviating demand on GPs and empowering nurses to extend their scope of practice and, consequently, enabling greater medical abortion access for rural populations. Yet as Carson et al explain in a recently published study of nurse-led abortion in similar rural settings where abortion is publicly funded in Canada, ‘the optimism about the potential for abortion to become more accessible for people in rural and remote areas is challenged by ongoing resources issues, a lack of health professionals in the local community, and perceived stigma in some smaller communities’. Limited availability of ultrasound services, the need for pharmacies willing to stock abortion medication as well as proximate emergency services for back-up support were three reasons why Carson et al suggest such optimism overlooked the realities of rural primary care. Ironically, abortion provision within rural public hospitals would instantly resolve each of these concerns and provide a clear pathway for services in rural Australia. Any proposed solution that implores the primary healthcare workforce to shoulder more responsibility also simultaneously permits the ongoing obfuscation of responsibility of the Australian public health system.
Conclusion
Improving rural abortion access in Australia is contingent on solutions that address the unique barriers, disincentives and competing burdens experienced by the rural primary healthcare workforce on top of a pervasive culture of abortion exceptionalism nationwide.
SOURCE: Anna Noonan, Erica Millar, Jane Elizabeth Tomnay, Georgina M Luscombe, Kirsten I Black. ‘Imagine if we had an actual service …’: a qualitative exploration of abortion access challenges in Australian rural primary care. Rural and Remote Health 5 November 2024;24(4). https://doi.org/10.22605/RRH9229
EDITOR’S NOTE: An article about this research was published in The Guardian (Australia), by Melissa Davey, 4 November 2024, which is how I learned about the original research.
Anna Noonan, first author of the study, was quoted in the Guardian as follows:
“Australia has taken the most extraordinarily narrow view on abortion, often perceiving it as an obstetrics and gynaecology issue,” Noonan said. “And maybe it is for the really complicated surgical cases, but it isn’t for the routine prescribing of an abortion pill for an under nine-week pregnancy. We are still holding on to this catastrophising of abortion, this exceptionalising of abortion, where abortion is seen as something so specialised that it needs to be managed by a minute population of the health workforce, and it’s a misguided approach.”
This problem can be said to apply in almost every country in the world today, and deserves far more national and local attention, as well as reconsideration of the extent of change needed in abortion service provision, than it receives. MB