tag:theconversation.com,2011:/africa/topics/medical-abortion-3800/articlesMedical abortion – The Conversation2024-03-26T20:54:50Ztag:theconversation.com,2011:article/2266702024-03-26T20:54:50Z2024-03-26T20:54:50ZAbortion drug access could be limited by Supreme Court − if the court decides anti-abortion doctors can, in fact, challenge the FDA<figure><img src="https://images.theconversation.com/files/584450/original/file-20240326-30-a29mv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pro-abortion rights activists rally in front of the Supreme Court on March 26, 2024, the day justices heard oral arguments about the use of mifepristone.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/abortion-rights-activist-rally-in-front-of-the-us-supreme-news-photo/2107843451?adppopup=true">Drew Angerer/AFP via Getty Images </a></span></figcaption></figure><p><em>Who has the legal right to challenge decisions by the U.S. Food and Drug Administration? And should the moral umbrage of a group of anti-abortion rights doctors shift policy across the country, limiting women’s ability to get the widely used abortion drug mifepristone?</em></p>
<p><em>These are a few of the central questions that the <a href="https://www.cbsnews.com/news/supreme-court-abortion-pill-arguments-mifepristone/">Supreme Court fielded on March 26, 2024</a>, during the oral arguments in <a href="https://www.scotusblog.com/case-files/cases/food-and-drug-administration-v-alliance-for-hippocratic-medicine-2/">FDA v. Alliance for Hippocratic Medicine</a>. A group of doctors is challenging the FDA, saying that the federal agency’s decision allowing people to get mifepristone via telehealth, at up to 10 weeks of pregnancy, is causing some medical professionals harm.</em></p>
<p><em>Amy Lieberman, politics and society editor at The Conversation U.S., spoke with family law and reproductive justice scholars <a href="https://scholar.google.com/citations?user=gCJEShUAAAAJ&hl=en">Naomi Cahn</a> and <a href="https://www.law.gwu.edu/sonia-m-suter">Sonia Suter</a> to better understand what’s behind the oral arguments before the Supreme Court – and how the court’s eventual decision, expected in June, could affect people’s ability to get abortions by using mifepristone, one of two drugs used for medication abortion.</em> </p>
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<a href="https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="White boxes of Mifepristone are seen stacked in a shelf." src="https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/584469/original/file-20240326-26-9qpi95.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A cabinet holds mifepristone at a health clinic in Casper, Wyo., in June 2023.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/cabinet-containing-mifepristone-seen-in-wellspring-health-news-photo/1258730531?adppopup=true">Rachel Woolf for The Washington Post via Getty Images</a></span>
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<p><strong>What is this case about?</strong></p>
<p><strong>Sonia Suter:</strong> It’s about whether the FDA’s regulations for the use of <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">mifepristone were appropriately loosened in 2016 and 2021</a>. These changes generally make mifepristone more accessible by allowing people to have the medication prescribed via a telehealth visit and then getting the pill in the mail.</p>
<p><strong>Naomi Cahn:</strong> That 2016 regulation also extended the time during which mifepristone could be prescribed, increasing it from seven to 10 weeks gestation. Medication abortions accounted for <a href="https://www.guttmacher.org/2024/03/medication-abortion-accounted-63-all-us-abortions-2023-increase-53-2020">63% of all abortions</a> that occurred in the U.S. in 2023. This percentage has increased since the Supreme Court overturned the constitutional right to an abortion in 2022.</p>
<p><strong>Why are these guidelines being challenged?</strong></p>
<p><strong>Suter:</strong> A group of doctors and medical associations that oppose abortion <a href="https://www.nytimes.com/2024/03/26/us/erin-hawley-abortion-pill-supreme-court.html">are challenging these guidelines</a> and using this court case as a way, we believe, to limit the ability to get an abortion by using medication. </p>
<p>They challenged the drug’s initial approval by the FDA and the relaxed restrictions on how it is used. They claimed that the FDA exceeded its authority, did not rely on proper data and did not have adequate support from scientific studies for its decision that mifepristone could be safely prescribed. Their initial arguments, which the lower court accepted, would have banned mifepristone. But that decision was not upheld by the <a href="https://www.ca5.uscourts.gov/opinions/pub/23/23-10362-CV1.pdf">5th Circuit Court</a>. </p>
<p>Instead, the issues before the Supreme Court focus on whether the FDA should have expanded the use of mifepristone. Virtually all studies have shown that <a href="https://www.nytimes.com/interactive/2023/04/01/health/abortion-pill-safety.html">mifepristone is not dangerous</a>, even with the relaxed conditions on its use. </p>
<p><strong>What is the federal government’s central argument against these claims?</strong></p>
<p><strong>Cahn:</strong> The government is stating that the FDA appropriately reviewed all of the evidence and its decision was appropriate. </p>
<p>Indeed, the attorney representing the mifepristone manufacturer, <a href="https://www.supremecourt.gov/oral_arguments/argument_transcripts/2023/23-235_p8k0.pdf">Jessica Ellsworth</a>, pointed out that <a href="https://apnews.com/article/abortion-pill-mifepristone-redacted-studies-supreme-court-ebd60519fd44dc69c5ac213580d1c1ba#:%7E:text=A%20medical%20journal%20has%20retracted,and%20flaws%20in%20their%20research.">the studies cited by the challengers have either been</a> discredited <a href="https://www.npr.org/sections/health-shots/2024/02/09/1230175305/abortion-pill-mifepristone-retraction-supreme-court">or withdrawn because they were unreliable</a>. </p>
<p>Another critical issue, as <a href="https://www.nytimes.com/live/2024/03/26/us/abortion-pill-supreme-court">U.S. Solicitor General Elizabeth Prelogar said to the justices today</a>, is whether the organization challenging this ruling actually has legal standing – the right to sue – to bring a lawsuit against the FDA. </p>
<p><strong>Why is the question of who can sue the FDA important here?</strong></p>
<p><strong>Suter:</strong> Under U.S. law, you cannot succeed in court every time you are unhappy. The Supreme Court has ruled that the Constitution requires parties who bring suit in federal court to <a href="https://www.law.cornell.edu/constitution-conan/article-3/section-2/clause-1/standing-requirement-overview">have “standing.”</a> This means parties have to show that they have been injured in some tangible way or threatened with such an injury by the acts that are the basis of the lawsuit. In this case, a group of doctors morally opposed to abortion are saying they have been injured. Their claim is that with the changes in the FDA’s regulation of mifepristone prescriptions, patients will come to them in the emergency room, requiring medical care that violates these religious beliefs and causes them stress. </p>
<p>The government’s response is that the FDA is not making them do anything, including prescribe these pills or treat these patients. And <a href="https://www.hhs.gov/conscience/conscience-protections/index.html">there are conscience laws</a> that say if the treatment is against a health care provider’s beliefs, they do not need to provide that care. So the government asks: How are the doctors harmed here?</p>
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<a href="https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A line of people in formal clothing are seen behind barricades outside the Supreme Court on a grey day." src="https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/584543/original/file-20240326-18-ohf6hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">People wait outside the Supreme Court to hear oral arguments on mifepristone on March 26, 2024.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/people-wait-in-line-outside-us-supreme-court-to-hear-oral-news-photo/2107843290?adppopup=true">Drew Angerer/AFP via Getty Images</a></span>
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<p><strong>What is your impression from the justices, listening to these arguments?</strong></p>
<p><strong>Cahn:</strong> I was surprised by how much time the justices spent asking about legal standing and whether there was a direct enough connection between the plaintiffs and the FDA’s guidance. </p>
<p><strong>What’s the potential impact of the court’s eventual ruling on this case?</strong></p>
<p><strong>Cahn:</strong> The court’s decision has implications for the whole FDA approval process as well as access to medication abortion, including through telehealth and the mail. If the court rules for the doctors challenging the FDA, mifepristone would still be available, but access to it would be severely limited because people would need an in-person visit before they could get it.</p><img src="https://counter.theconversation.com/content/226670/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Two legal scholars who study abortion-related laws explain what happened at the Supreme Court in a case that could make it harder to get an abortion.Naomi Cahn, Professor of Law, University of VirginiaSonia Suter, Professor of Law, George Washington UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2041632023-04-26T12:28:33Z2023-04-26T12:28:33ZMifepristone is under scrutiny in the courts, but it has been used safely and effectively around the world for decades<figure><img src="https://images.theconversation.com/files/522668/original/file-20230424-26-v5rdtr.jpg?ixlib=rb-1.1.0&rect=0%2C170%2C2915%2C1755&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mifepristone is used together with another pill, misoprostol, in medication abortions.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/AbortionPill/513c7c2f6d0346b9b9ddaa2c7344be46/photo?Query=mifepristone%20supreme%20court&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=39&currentItemNo=32">AP Photo/Allen G. Breed</a></span></figcaption></figure><p><em>A <a href="https://theconversation.com/the-supreme-court-rules-mifepristone-can-remain-available-heres-how-2-conflicting-federal-court-decisions-led-to-this-point-203623">flurry of court rulings</a> in April 2023 has left the <a href="https://www.reuters.com/world/us/us-abortion-providers-relieved-wary-supreme-court-preserves-pill-access-2023-04-22/">future of the abortion pill mifepristone in question</a>. For now, a U.S. Supreme Court decision on April 21 <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">allows the drug to remain accessible</a> <a href="https://www.nbcnews.com/health/womens-health/abortion-pill-lawsuit-mifepristone-questions-future-access-rcna79455">without additional restrictions</a> as the merits of the case are <a href="https://www.washingtonpost.com/politics/2023/04/21/mifepristone-abortion-pill-access-supreme-court/">weighed in lower court proceedings</a>.</em> </p>
<p><em>Depending on the outcome, the pill <a href="https://www.reuters.com/legal/government/us-supreme-court-preserves-access-abortion-pill-now-whats-next-2023-04-22/">could face a ban or tightened restrictions</a> on its usage, a possibility that has many health care providers concerned.</em></p>
<p><em>The Conversation asked Grace Shih, a family physician practicing in Washington state, to explain the science behind mifepristone as well as its safety and efficacy in medication abortions.</em></p>
<h2>What is mifepristone, and how does it work?</h2>
<p>Mifepristone is a pill that is <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">used in medication abortion</a> during early pregnancy. It was initially <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">approved by the Food and Drug Administration in 2000</a> and is approved by the FDA for medication abortion up to 10 weeks after the first day of the last menstrual period. </p>
<p>It can be taken as one part of a two-part pill regimen for medication abortion. Mifepristone is prescribed as a 200-milligram dose taken orally, followed by an 800-microgram dose of misoprostol, which is placed in the vagina or between the teeth and cheek, where it dissolves and is absorbed, usually 24 to 48 hours later. </p>
<p>Mifepristone acts by blocking the hormone progesterone, which is necessary for a pregnancy to develop. This stops the pregnancy growth and softens and dilates the cervix. It also prepares the uterus for contractions, increasing its sensitivity to medications such as misoprostol. </p>
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<figcaption><span class="caption">Mifepristone blocks the action of progesterone, a hormone that is needed for a pregnancy to develop.</span></figcaption>
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<p>Misoprostol is a synthetic <a href="https://www.yourhormones.info/hormones/prostaglandins/">prostaglandin</a>. Prostaglandin is a hormonelike substance that has multiple effects, including the stimulation of uterine contractions, which helps expel pregnancy tissue such as the thickened uterine lining and the tissues that are the precursor to the placenta. </p>
<p>Misoprostol is <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2002/19268slr037.pdf">currently FDA-approved</a> for reducing the risk of gastric ulcers in patients who are at high risk of complications from ulcers. But it is commonly used off-label for things like cervical ripening, or softening, to induce or help with labor. Mifepristone and misoprostol are also both used in the <a href="https://doi.org/10.1056/NEJMoa1715726">medical management of miscarriage</a>.</p>
<p>Medication abortion can also be done with misoprostol alone, an approach known as the misoprostol-only regimen. This <a href="https://doi.org/10.1097/aog.0000000000003017">regimen is safe</a> and has been <a href="https://www.washingtonpost.com/world/2023/04/19/abortion-pill-mifepristone-global-approved/">used widely by people around the world</a>. In the misoprostol-only regimen, an 800-microgram dose is placed in the vagina or between the teeth and cheek every three hours for up to three doses. </p>
<p>Both protocols are very effective, with the two-drug regimen <a href="https://doi.org/10.1097/AOG.0000000000000910">up to 99.6% effective</a> and the <a href="https://doi.org/10.1097%2FAOG.0000000000003017">misoprostol-alone regimen between 84% to 96%</a> in medication abortions.</p>
<h2>Why would a person opt for one regimen or the other?</h2>
<p>People usually don’t choose the type of medication abortion they receive. Because the availability of mifepristone and misoprostol is highly variable, whichever method is available to you is medically safe. Patients should feel assured that guidelines for medication abortion support the <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">safety and efficacy of both medication regimens</a>.</p>
<p>The <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">American College of Obstetricians and Gynecologists</a>, the <a href="https://doi.org/10.1016/j.contraception.2020.08.004">Society for Family Planning</a> and the <a href="https://www.who.int/publications/i/item/9789240039483">World Health Organization</a> all support both types of medication abortion. </p>
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<figcaption><span class="caption">Mifepristone and misoprostol work in tandem to terminate a pregnancy.</span></figcaption>
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<h2>How widely accessible is mifepristone?</h2>
<p>In January 2023, the <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation#">FDA updated its guidelines</a> to allow mifepristone to be dispensed through pharmacies with a prescription.</p>
<p>The change means that the drug is available both by mail or at brick-and-mortar pharmacies, as long as that retail pharmacy has been certified. In other words, people who live in states where abortion is not banned can take their mifepristone prescription and get it the way they pick up other medications. </p>
<p>For someone able to pick up mifepristone from a local pharmacy, the process is no different from picking up birth control pills or blood pressure medications. This allows mifepristone and its applications for abortion care and miscarriage management to be treated as typical health care. </p>
<p>While the January 2023 FDA ruling theoretically increases the ways that a person can get mifepristone, so far it has not been widely available at retail pharmacies.</p>
<h2>Can I still get mifepristone?</h2>
<p>The short answer is yes, mifepristone is still FDA-approved. The Supreme Court’s April 21, 2023, ruling means that there will be <a href="https://theconversation.com/how-will-the-supreme-courts-decision-on-mifepristone-affect-abortion-access-4-questions-answered-204172">no changes to mifepristone access for now</a>. However, for use in abortion care, mifepristone still faces restrictions depending on your state’s legislation.</p>
<p>As of April 2023, 27 states have <a href="https://www.guttmacher.org/state-policy/explore/medication-abortion">some restriction on medication abortion</a> according to the <a href="https://www.guttmacher.org/">Guttmacher Institute</a>, a reproductive health policy organization. This includes 12 states that have a near-total ban on abortion and one state that has stopped offering abortion care because of legal uncertainty. </p>
<p>Of the 15 states with restrictions specific to medication abortion, all of them require that medication be provided by a physician and not an advanced practitioner like a nurse practitioner. Six of the states require an in-person visit with a physician, one state requires that mifepristone be taken in the presence of a physician, and one state bans mailing medication abortion pills.</p>
<h2>Evidence-based health care</h2>
<p>As a practicing family physician, I follow the science and make medical decisions with my patients using the most up-to-date evidence. Medication abortion using mifepristone and misoprostol is <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">exceptionally safe and highly effective</a>, as is <a href="https://doi.org/10.1097%2FAOG.0000000000003017">medication abortion using misoprostol alone</a>. Side effects of the misoprostol-only regimen are similar to the combined regimen, though they may last longer because of the need for multiple doses of misoprostol.</p>
<p>Some news coverage has focused on comparing the efficacy of the two regimens. But percentage points mean very little to an individual’s health – what matters is that people get the care they need.</p>
<p>I will continue working, providing and advancing care that is based on science. Leading health professional organizations including the <a href="https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2018/improving-access-to-mifepristone-for-reproductive-health-indications">American College of Obstetricians and Gynecologists</a>, the <a href="https://policysearch.ama-assn.org/policyfinder/detail/mifepristone?uri=%2FAMADoc%2FHOD.xml-H-100.948.xml">American Medical Association</a> and the <a href="https://www.aafp.org/dam/AAFP/documents/events/nc/congress/nc18-ncfmr-actions-referrals.pdf">American Academy of Family Physicians</a> have all issued statements that call for removing all restrictions around mifepristone and/or support the safety of misoprostol-only medication abortion.</p>
<p><em>This is an updated version of an <a href="https://theconversation.com/what-the-fdas-rule-changes-allowing-the-abortion-pill-mifepristone-to-be-dispensed-by-pharmacies-mean-in-practice-5-questions-answered-197339">article originally published</a> on Jan. 11, 2023.</em></p><img src="https://counter.theconversation.com/content/204163/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Mifepristone’s safety in medication abortions has been well established over more than two decades, but legal wrangling leaves the future of the drug hanging in the balance.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1973392023-01-11T13:26:42Z2023-01-11T13:26:42ZWhat the FDA’s rule changes allowing the abortion pill mifepristone to be dispensed by pharmacies mean in practice – 5 questions answered<figure><img src="https://images.theconversation.com/files/503684/original/file-20230109-13-cophlz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7348%2C4407&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The rule change has little to no effect in states where abortion is banned or restricted.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/simplifying-the-dispensing-process-with-smart-apps-royalty-free-image/1138202173?phrase=pharmacist%20dispensing%20pills&adppopup=true">LaylaBird/E+ via Getty Images</a></span></figcaption></figure><p><em>In early January 2023, the U.S. Food and Drug Administration <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/questions-and-answers-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation#">modified its rules for mifepristone</a>, a drug used for medication abortion, allowing it to be offered with a prescription by certified pharmacies. Before this rule change, mifepristone could be dispensed only in person by providers at hospitals, clinics and medical offices, as well as by some mail-order pharmacies.</em></p>
<p><em>The Conversation asked Grace Shih, a family physician practicing in Washington, to explain the significance of this change for health care providers and their patients.</em></p>
<h2>What is mifepristone, and how does it work?</h2>
<p>Mifepristone is a pill that is <a href="https://theconversation.com/what-is-a-medication-or-medical-abortion-5-questions-answered-by-3-doctors-182646">used in medication abortion</a> during early pregnancy. It was initially <a href="https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-mifepristone-medical-termination-pregnancy-through-ten-weeks-gestation">approved by the FDA in 2000</a> and is FDA-approved for medication abortion up to 10 weeks after the first day of last menstrual period.</p>
<p>It can be taken as one part of a two-part pill regimen for medication abortion. Mifepristone is prescribed as a 200-milligram dose taken orally followed by an 800-microgram dose of misoprostol, which is placed in the vagina or between the teeth and cheek, where it dissolves and is absorbed, usually 24 to 48 hours later. </p>
<p>Mifepristone acts by blocking the hormone progesterone, which is necessary for a pregnancy to develop. This stops the pregnancy growth and softens and dilates the cervix. It also prepares the uterus for contractions, increasing its sensitivity to medications such as misoprostol. </p>
<p>Misoprostol is a synthetic <a href="https://www.yourhormones.info/hormones/prostaglandins/">prostaglandin</a>. Prostaglandin is a hormonelike substance that has multiple effects, including the stimulation of uterine contractions, which helps expel pregnancy tissue such as the thickened uterine lining and the tissues that are the precursor to the placenta. Mifepristone and misoprostol are also both used in the <a href="https://doi.org/10.1056/NEJMoa1715726">medical management of miscarriage</a>. </p>
<p>Medication abortion can also be done with misoprostol alone, known as the misoprostol-only regimen. In the misoprostol-only regimen, an 800-microgram dose of misoprostol is placed in the vagina or between the teeth and cheek every three hours for up to three doses. </p>
<h2>Why would a person opt for one regimen or the other?</h2>
<p>People usually don’t choose the type of medication abortion they receive. Either mifepristone is available where they are seeking care or it is not. </p>
<p>The American College of Obstetricians and Gynecologists <a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">states that</a> “combined mifepristone-misoprostol regimens are recommended as the preferred therapy for medication abortion because they are significantly more effective than misoprostol-only regimens.” </p>
<p>The efficacy <a href="https://doi.org/10.1097/AOG.0000000000000897">of the two-pill regimen is approximately 95% to 98%</a>. However, because mifepristone is under the FDA’s <a href="https://www.fda.gov/drugs/drug-safety-and-availability/risk-evaluation-and-mitigation-strategies-rems">risk evaluation and mitigation strategy program</a>, which places <a href="https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390">specific restrictions on mifepristone</a>, it can be difficult to obtain. </p>
<p>When mifepristone is not available, the American College of Obstetricians and Gynecologists considers the misoprostol-only regimen, which has an efficacy of 76% to 88%, to be an “<a href="https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2020/10/medication-abortion-up-to-70-days-of-gestation">acceptable alternative</a>.” Thus, the FDA’s permission to dispense mifepristone at retail pharmacies will help broaden access to the more effective combined mifepristone-misoprostol regimen of medication abortion. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/kzd4ABInBio?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Mifepristone and misoprostol work in tandem to terminate a pregnancy.</span></figcaption>
</figure>
<h2>What will the FDA’s rule change mean in practice?</h2>
<p>The recent FDA change means that retail pharmacies may dispense mifepristone by mail or at brick-and-mortar pharmacies, as long as that retail pharmacy has been certified. In other words, people who live in states where abortion is not banned can take their mifepristone prescription and get it the way they pick up other medications. </p>
<p>For someone able to pick up mifepristone from a local pharmacy, the process will be no different from picking up birth control pills or blood pressure medications. In this way, mifepristone and its uses for abortion care and miscarriage management will be treated as typical health care. </p>
<p>It is unclear whether or how the FDA’s rule will affect state restrictions on abortion care. If medication abortion is not permitted in a specific state, retail pharmacies in that state may or may not be able to dispense mifepristone for abortion care. However, mifepristone could be dispensed from certified pharmacies for reasons unrelated to abortion care, such as miscarriage management.</p>
<h2>What brought about the change?</h2>
<p>On Jan. 3, 2023, the FDA formally modified its <a href="https://www.acog.org/news/news-releases/2020/05/acog-suit-petitions-the-fda-to-remove-burdensome-barriers-to-reproductive-care-during-covid-19">regulations and guidelines around mifepristone use</a>, which were initially proposed during the COVID-19 pandemic. Previous guidelines required that mifepristone be dispensed in person.</p>
<p>These changes were brought about by a <a href="https://www.acog.org/-/media/project/acog/acogorg/files/advocacy/acog-v-fda-complaint-mifepristone-covid19.pdf?">civil complaint</a> that was sponsored by obstetrician-gynecologists, family physicians and reproductive justice advocates. It noted that “of the 20,000 drugs regulated by the FDA, mifepristone is the only one that patients must receive in person at a hospital, clinic or medical office,” even though the medication itself can be taken orally by a person unsupervised, at any location. </p>
<p>The in-person requirement meant that those seeking medication abortion or miscarriage care were required to face increased risk of COVID-19 exposure simply to obtain mifepristone. There has been <a href="https://www.acog.org/news/news-releases/2020/05/acog-suit-petitions-the-fda-to-remove-burdensome-barriers-to-reproductive-care-during-covid-19">no documented benefit</a> from this in-person dispensing requirement. </p>
<p>As a result of this complaint, the FDA placed a temporary pause on enforcement of the in-person dispensing requirement and subsequently <a href="https://www.fda.gov/files/drugs/published/Risk-Evaluation-and-Mitigation-Strategies--Modifications-and-Revisions-Guidance-for-Industry.pdf">conducted a formal review</a> of its regulations around the dispensing of mifepristone. The Jan. 3 decision is the FDA’s final decision.</p>
<p>Misoprostol has never been subject to the same restrictions. In addition to its use in the medication abortion regimen, misoprostol is FDA approved for management of gastric ulcers. And it is used, off-label, for cervical dilation and softening when doctors induce labor. People may continue to get their misoprostol at retail or mail-order pharmacies.</p>
<h2>How might this rule change affect medication abortion access?</h2>
<p>While this change is an important step in <a href="https://www.acog.org/news/news-releases/2023/01/statement-fda-announcement-regarding-changes-to-restrictions-on-provision-of-mifepristone">securing access to medication abortion</a>, it does not have a clear benefit for people who live in states where <a href="https://reproductiverights.org/maps/abortion-laws-by-state/">abortion is banned</a>. And it has limited benefit in states that have restrictions on medication abortion. </p>
<p>According to the <a href="https://www.guttmacher.org/">Guttmacher Institute</a>, a reproductive health policy organization, 29 states have <a href="https://www.guttmacher.org/state-policy/explore/medication-abortion">some restriction on medication abortion</a>, including 18 states that require that the clinician providing a medication abortion be physically present with the patient. Those restrictions therefore prohibit the use of telemedicine to prescribe medications for abortion.</p>
<p>It is unclear how many pharmacies will pursue certification and how quickly that certification can happen. Pharmacies that want to dispense mifepristone must comply with <a href="https://www.accessdata.fda.gov/scripts/cder/rems/index.cfm?event=RemsDetails.page&REMS=390">FDA pharmacy agreements to achieve certification</a>. </p>
<p>This includes having systems in place to track and verify mifepristone prescribers, using a tracked shipping service and having the ability to report patient deaths to prescribers, <a href="https://www.accessdata.fda.gov/drugsatfda_docs/rems/Mifepristone_2023_01_03_Pharmacy_Agreement_Form_Danco_Laboratories.pdf">among other requirements</a>. CVS and Walgreens have already <a href="https://www.nytimes.com/2023/01/05/health/abortion-pills-cvs-walgreens.html">announced plans to become certified pharmacies</a>.</p>
<p>As a practicing family physician, I see the permanent removal of the in-person dispensing requirement as essential for normalizing abortion care and improving access to medication abortion. However, many obstacles remain, including specific patient consent forms, unique and required prescriber certification and the aforementioned pharmacy certification. </p>
<p>Leading health professional organizations including the <a href="https://www.acog.org/clinical-information/policy-and-position-statements/position-statements/2018/improving-access-to-mifepristone-for-reproductive-health-indications">American College of Obstetricians and Gynecologists</a>, the <a href="https://policysearch.ama-assn.org/policyfinder/detail/mifepristone?uri=%2FAMADoc%2FHOD.xml-H-100.948.xml">American Medical Association</a> and the <a href="https://www.aafp.org/dam/AAFP/documents/events/nc/congress/nc18-ncfmr-actions-referrals.pdf">American Academy of Family Physicians</a> have all issued statements that call for removing all restrictions around mifepristone, since there is no evidence that these restrictions improve patient care or safety.</p><img src="https://counter.theconversation.com/content/197339/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Grace Shih does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The FDA’s allowance for pharmacies to dispense mifepristone will broaden access to the two-pill mifepristone-misoprostol regimen of medication abortion, which is 95% to 98% effective.Grace Shih, Associate Professor of Family Medicine, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1858272022-06-26T12:12:03Z2022-06-26T12:12:03ZRoe v. Wade: Canada can respond to U.S. bans by improving access to abortion care here<figure><img src="https://images.theconversation.com/files/470900/original/file-20220625-7170-4ffvci.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C5946%2C3952&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Abortion-rights activists draw on the sidewalk in Washington on June 24 following U.S. Supreme Court's decision to overturn Roe v. Wade ending constitutional protection for abortion.</span> <span class="attribution"><span class="source">(AP Photo/Jacquelyn Martin)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/roe-v--wade--canada-can-respond-to-u-s--bans-by-improving-access-to-abortion-care-here" width="100%" height="400"></iframe>
<p>As an abortion care provider in Canada, I feel deep solidarity with colleagues south of the border and terror for their patients after the U.S. Supreme Court overturned Roe v. Wade, the 1973 ruling that the U.S. Constitution afforded protection to the right to abortion. Individual states now may ban abortion outright — <a href="https://www.npr.org/sections/health-shots/2022/06/24/1107126432/abortion-bans-supreme-court-roe-v-wade">and several already have</a>. </p>
<p>Abortion care affirms the dignity and autonomy of patients and translates into not only physical and mental health but also <a href="https://theconversation.com/denying-abortion-access-has-a-negative-impact-on-children-and-families-183088">opportunity for education, employment, safety from violence, and parenting wanted children</a>. </p>
<p>Providers and policymakers in Canada can and must respond to U.S. abortion bans by expanding access to care here.</p>
<h2>Abortion law in Canada</h2>
<p>In Canada, abortion is <a href="https://nationalpost.com/news/politics/how-canada-came-to-have-no-federal-law-whatsoever-on-abortion">completely decriminalized</a>. Abortion is health care and is no more governed by criminal law than knee surgery or intravenous antibiotics. There are no legal limits on gestational age, or mandatory waiting periods or requirements that youth seek parental consent. </p>
<figure class="align-center ">
<img alt="A crowd of protesters seen from behind, outside the U.S. Supreme Court building" src="https://images.theconversation.com/files/470898/original/file-20220625-14-x2zgcw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5558%2C3708&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470898/original/file-20220625-14-x2zgcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470898/original/file-20220625-14-x2zgcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470898/original/file-20220625-14-x2zgcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470898/original/file-20220625-14-x2zgcw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470898/original/file-20220625-14-x2zgcw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470898/original/file-20220625-14-x2zgcw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Abortion-rights protesters regroup and demonstrate outside the U.S. Supreme Court following the court’s decision to overturn Roe v. Wade.</span>
<span class="attribution"><span class="source">(AP Photo/Gemunu Amarasinghe)</span></span>
</figcaption>
</figure>
<p>Abortion in Canada is publicly funded like most physician- or hospital-provided services, with a few exceptions. And since 2017, all primary care providers, including family physicians and nurse practitioners, have been authorized (except in Québec) <a href="https://doi.org/10.1503/cmaj.180047">to prescribe mifepristone for medication abortion</a>, which is drug-induced rather than surgical.</p>
<p>Because there is no abortion law in Canada, there is no law for conservative politicians to demand be reformed to limit access. There is no law that providers of care must tiptoe in between to avoid prosecution.</p>
<h2>Access to abortion care</h2>
<p>In the past seven years, logistical access to abortion in Canada has improved significantly:</p>
<ul>
<li><p><a href="https://www.vitalitenb.ca/en/points-service/sexual-health/pregnancy/unplanned-pregnancy">New Brunswick introduced self-referral</a> and solidified surgical services at three hospitals.</p></li>
<li><p>Prince Edward Island <a href="https://www.princeedwardisland.ca/en/information/health-pei/abortion-services">opened a comprehensive program</a>.</p></li>
<li><p>Nova Scotia <a href="https://www.cbc.ca/news/canada/nova-scotia/toll-free-phone-line-women-pregnancy-abortion-1.4516242">centralized referral</a> to a single toll-free line.</p></li>
<li><p>Most importantly, the ability to prescribe medication for abortions has <a href="https://www.thestar.com/life/health_wellness/2022/05/05/at-home-medicated-abortions-improve-access-to-care-advocates-say.html">democratized access</a>. </p></li>
</ul>
<p>Even <a href="https://fmwc.ca/induced-abortion-updated-guidance-during-pandemics-and-periods-of-social-disruption/">COVID-19 protections resulted in care expansion</a>: as providers became more familiar with telemedicine, many felt comfortable moving to “no touch” or “low touch” medication abortion prescribing, without requiring blood work or ultrasound. </p>
<p>Because pandemic inter-provincial travel restrictions limited the ability to refer patients elsewhere if they were past local gestational age caps, hospitals in several provinces made the necessary infrastructural and training adjustments to extend the gestational ages to which they would provide care.</p>
<h2>Inequalities remain</h2>
<p>But serious limits on abortion access in Canada remain. This is a huge country, and people living in rural, remote and underserved areas face enormous travel burdens to access care. </p>
<p>These burdens are greatest for <a href="https://fernwoodpublishing.ca/book/abortion-to-abolition">people facing poverty, intimate partner violence and racism from the health-care system</a>. And access challenges may be greater if we suddenly see an influx of demand for care from <a href="https://theconversation.com/roe-v-wade-overturned-will-more-americans-travel-to-canada-and-mexico-for-abortions-185563?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20June%2025-26%202022&utm_content=Latest%20from%20The%20Conversation%20for%20June%2025-26%202022+CID_cf957f25141a8f31a0b9164d8b0a79ff&utm_source=campaign_monitor_ca&utm_term=the%20issue%20of%20American%20women%20who%20may%20travel%20to%20Canada%20or%20Mexico%20for%20abortions">U.S. patients</a>.</p>
<p>Because health care is administered at the provincial/territorial level, access and medical practices among the provinces/territories vary widely, and unjustly. This is the case for all kinds of health care, not just abortion — but abortion is basic and common care, not neurosurgery. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman in a crowd of protesters holding a bright pink sign with white lettering reading 'Abortion is health care'" src="https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470899/original/file-20220625-18-2l14i0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Abortion care affirms the dignity and autonomy of patients and translates into not only physical and mental health but also opportunity for education, employment, safety from violence and parenting wanted children.</span>
<span class="attribution"><span class="source">(AP Photo/Paul Beaty)</span></span>
</figcaption>
</figure>
<p>Consider how there are 49 (surgical) abortion sites in <a href="https://www.myabortionoptions.ca/abortion-in-quebec/">Québec</a> — by far the highest number of access points — but Québec has the lowest rate of uptake of <a href="https://www.tandfonline.com/doi/full/10.1080/13625187.2020.1743825">medication abortion</a> because of rigid requirements about prescribing authority. Meanwhile, although there is only one surgical abortion site in P.E.I., more than half of abortions on Island are <a href="https://impactethics.ca/2021/08/19/pei-is-now-a-leader-in-reproductive-health-care/">through medication</a>. </p>
<p>In <a href="https://impactethics.ca/2020/10/09/comprehensive-reproductive-health-services-include-abortion/">Newfoundland</a>, 95 per cent of (publicly funded) surgical abortion takes place at the freestanding family practice clinic, Athena. Yet New Brunswick has kept a perverse piece of legislation on the books for decades, 84-20 Schedule 2 a.1 of the <a href="https://www.canlii.org/en/nb/laws/regu/nb-reg-84-20/latest/nb-reg-84-20.html">Medical Services Payment Act,</a> denying public insurance for surgical abortion outside of a hospital building. </p>
<p><a href="https://doi.org/10.1016/j.contraception.2011.06.009">One in three people</a> in Canada with a uterus will have an abortion in their lifetime. The arrangements for care should not be so convoluted and unequal.</p>
<h2>Action to ensure access</h2>
<p>There will undoubtedly be escalating rhetoric from anti-choice politicians in the wake of the fall of Roe. Now is the time to leap forward in terms of access. Health-care providers, policymakers, activists and everyone in Canada can channel <a href="https://www.cbc.ca/news/politics/trudeau-horrific-us-court-abortion-1.6500475">our horror</a> into meaningful and specific actions to enthusiastically expand abortion services. </p>
<ol>
<li><p>We need to ensure all medical and nursing schools include <a href="https://www.cbc.ca/news/canada/nova-scotia/abortion-education-martha-paynter-dalhousie-university-nursing-training-1.5699583">robust abortion components in their curricula</a> to increase provider knowledge, competence and confidence with abortion care and reduce geographic disparities. </p></li>
<li><p><a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.301159">Nurse practitioners and midwives</a> should be authorized not only to prescribe medication abortion but to perform aspiration (surgical) abortion. <a href="https://www.tandfonline.com/doi/full/10.1080/13625187.2020.1743825">Québec</a> must get on board with welcoming primary care providers as medication abortion prescribers. </p></li>
<li><p>We should nurture <a href="https://caps-cpca.ubc.ca/index.php?title=Main_Page">abortion provider networks</a> for mentorship and support, to improve confident uptake of no-touch mifepristone prescribing and availability of abortion in rural, remote and underserved communities. </p></li>
<li><p>We must have <a href="https://www.actioncanadashr.org/about-us/media/2021-02-09-advocates-across-country-call-federal-government-provide-free-prescription-contraception">universal coverage for contraception</a> for everyone, and explore offering contraception and mifepristone over the counter, as we do with Plan B. </p></li>
<li><p>We must make sure every person understands how abortion care works here, normalize it as a health service, and resist any attempt to bind it up <a href="https://globalnews.ca/news/8832127/nationwide-abortion-bill-would-backfire-canada-experts/">in a law</a> that could someday be altered or taken away.</p></li>
</ol>
<p>Poverty, stigma, racism and gender violence are barriers to abortion in Canada. If we are worried about threats to access, these are what we need to fight.</p><img src="https://counter.theconversation.com/content/185827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Martha Paynter receives research funding from CIHR. She is the volunteer chair of Wellness Within: An Organization for Health and Justice. </span></em></p>There will no doubt be escalating rhetoric from anti-choice politicians in the wake of the fall of Roe v Wade. An abortion care provider says now is the time to improve abortion access in Canada.Martha Paynter, PhD, School of Nursing, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1823952022-05-05T12:43:31Z2022-05-05T12:43:31ZIf Roe v. Wade is overturned, there’s no guarantee that people can get abortions in liberal states, either<figure><img src="https://images.theconversation.com/files/461376/original/file-20220504-21-93m88u.jpg?ixlib=rb-1.1.0&rect=0%2C161%2C5976%2C3802&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Anti-abortion protesters use bullhorns to counter abortion rights advocates outside the Supreme Court on May 3, 2022. </span> <span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/antiabortion-protesters-use-bull-horns-to-counter-a-gathering-of-picture-id1240434492?s=2048x2048">Bonnie Jo Mount/The Washington Post via Getty Images</a></span></figcaption></figure><p>Liberal policymakers are quickly positioning their states as abortion havens after <a href="https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473">a leaked draft</a> of a U.S. Supreme Court opinion indicating that the court could overturn Roe v. Wade was made public on the evening of May 2, 2022. </p>
<p>Less than an hour after the leak was made public, California Governor Gavin Newsom announced a new state amendment that would legally protect the right to abortion.</p>
<p>“We can’t trust SCOTUS,” Newsom <a href="https://twitter.com/GavinNewsom/status/1521358301794947072?ref_src=twsrc%5Etfw%7Ctwcamp%5Etweetembed%7Ctwterm%5E1521358301794947072%7Ctwgr%5E%7Ctwcon%5Es1_&ref_url=https%3A%2F%2Fwww.theguardian.com%2Fus-news%2F2022%2Fmay%2F03%2Fcalifornia-abortion-rights-roe-v-wade-scotus">wrote on Twitter</a>, using shorthand for the Supreme Court, “to protect the right to abortion, so we’ll do it ourselves. Women will remain protected here.”</p>
<p>New York, Connecticut, Oregon and five other states have also proposed or passed new measures <a href="https://www.nytimes.com/2022/05/04/us/abortion-rights-protections.html">over the last few months</a> that protect the right to an abortion.</p>
<p>If the landmark 1973 court ruling Roe v. Wade is overturned, abortion would no longer be a protected federal right, and states could individually ban or permit abortion. </p>
<p>However, as <a href="https://scholar.google.com/citations?user=YTK30lUAAAAJ&hl=en">social scientists</a> who <a href="https://nursing.cuanschutz.edu/about/faculty-directory/Coleman-Minahan-Kate-UCD5944">study how abortion</a> and <a href="https://www.science.org/doi/10.1126/sciadv.abf6732">contraception</a> policies affect people’s lives, we think it is important to understand that
people from states that could ban abortion may not be able to easily get an abortion in more liberal places. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A brown haired woman wearing a gray patterned shirt and a mask looks at a whiteboard full of information in an office." src="https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461360/original/file-20220504-19-35ois7.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">After Texas enacted one of the most restrictive abortion laws in the nation in September 2021, Texas women began seeking abortions at the Hope Medical Group for Women in Shreveport, Louisiana, where a staffer looks at a schedule board on April 19, 2022.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/kathaleen-pittman-administrator-of-the-hope-medical-group-news-photo/1240239717?adppopup=true">François Picard / AFP via Getty Images</a></span>
</figcaption>
</figure>
<h2>Abortion laws in liberal states</h2>
<p>Thirteen states <a href="https://www.nytimes.com/interactive/2022/us/abortion-bans-restrictons-roe-v-wade.html">would quickly ban</a> abortion if the Supreme Court overturns Roe v. Wade. </p>
<p>But in some of the 25 states that aren’t expected to ban abortion in this scenario, <a href="https://reproductiverights.org/maps/">there are laws</a> that mandate minors involve their parents before they can get an abortion. </p>
<p>There are also laws that limit <a href="https://reproductiverights.org/maps/">which medical providers may offer abortion</a> and create bans on abortion after a certain point in pregnancy, as well as health <a href="https://www.americanprogress.org/article/u-s-health-insurance-system-excludes-abortion/">insurance policies</a> that won’t pay for one. </p>
<p>Colorado, for example, <a href="https://leg.colorado.gov/bills/hb22-1279">passed a law in March 2022 affirming the right to abortion</a>. But Colorado still has a <a href="https://www.9news.com/article/news/local/next/colorado-abortion-parental-notification/73-21f780be-bb7d-47be-a677-d4441432904a">parental notification law</a>, a ban on <a href="https://coloradosun.com/2021/02/10/colorado-restricts-medicaid-abortions/">Medicaid paying </a>for an abortion, and does not require private insurers to cover abortion. </p>
<p>In March, California <a href="https://www.gov.ca.gov/2022/03/22/governor-newsom-signs-legislation-to-eliminate-out-of-pocket-costs-for-abortion-services/">also passed legislation</a> that eliminates out-of-pocket abortion costs for anyone with health insurance. But California still <a href="https://www.kff.org/womens-health-policy/state-indicator/gestational-limit-abortions/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">does not allow abortions</a> after fetal viability.</p>
<p><a href="https://www.nap.edu/catalog/24950">Decades of research </a> shows that abortion restrictions like these policies can harm people who need abortions <a href="https://fivethirtyeight.com/features/it-can-already-take-weeks-to-get-an-abortion/">by delaying</a> and sometimes even <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151926/">preventing</a> them from getting one.</p>
<h2>Parental involvement</h2>
<p>In 11 of the states that are unlikely to ban abortion, teenagers under the age of 18 are <a href="https://www.kff.org/womens-health-policy/state-indicator/parental-consentnotification/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">subject to laws</a> that require them to notify or obtain consent from one or both parents before getting an abortion. </p>
<p>Most teenagers talk to their parents about <a href="https://pubmed.ncbi.nlm.nih.gov/24332398/">their pregnancy decisions</a>, but those who don’t often feel they cannot for important reasons. They often <a href="https://onlinelibrary.wiley.com/doi/full/10.1363/psrh.12132">correctly predict their parents’ negative reaction </a> to their pregnancy and abortion, and can face physical or emotional abuse. </p>
<p>Some proponents believe parental involvement laws could lead to better care for a pregnant teen. But research shows that forcing young people to involve a parent generally <a href="https://pubmed.ncbi.nlm.nih.gov/29248391/">does not increase parental support</a>, but instead puts teenagers at risk of harm. </p>
<p>States with parental involvement laws, including Colorado, Delaware and Maryland, allow young people who cannot involve a parent to go to court to request a judicial bypass from a judge. </p>
<p>Yet these judicial bypasses <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6485490/">cause delays in getting an abortion</a>. Judges also sometimes <a href="https://pubmed.ncbi.nlm.nih.gov/31944836/">deny these</a> exemptions. In Texas, for example, judges denied <a href="https://www.txcourts.gov/statistics/judicial-bypass-cases/">7% of bypass requests in 2021</a>. </p>
<p>It can also be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274206/">burdensome and traumatic</a> for young people who are pregnant to go before a judge to field personal questions about sex, contraception and their family lives.</p>
<h2>Limits on abortion timing</h2>
<p>Eighteen of the 25 states that are not expected to ban abortion now <a href="https://www.guttmacher.org/state-policy/explore/state-policies-later-abortions">prohibit abortion after some point in pregnancy</a>, typically in the second or third trimester. </p>
<p>There are <a href="https://www.guttmacher.org/state-policy/explore/overview-abortion-laws">some exceptions</a> to these regulations if the life or health of the pregnant person is endangered. </p>
<p>Bans like these can <a href="https://ajph.aphapublications.org/doi/abs/10.2105/ajph.2013.301378">force people to remain pregnant</a> even if they do not want to, or if there is a medical concern that arises late in pregnancy, such as diagnosed fetal abnormalities. </p>
<p>Women who are denied abortion <a href="https://www.ansirh.org/research/ongoing/turnaway-study">are more likely</a> than women who received desired abortions to suffer economically, stay with abusive partners and experience health problems during and after their pregnancies. </p>
<p>Some liberal states with policies like these in place, including California, Washington, Illinois and New York, are likely to experience an influx of people seeking an abortion if they no longer can get one in their home state. </p>
<p>These people will have had to <a href="https://www.sciencedirect.com/science/article/abs/pii/S1049386720300669">save money</a>, travel and wait for appointments because of increased demand. These factors can lead to needing an abortion <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2021.306284">later into pregnancy</a>, and ultimately becoming ineligible to get an abortion.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A teenage girl sits in a bedroom with posters on the wall, with her arms crossed. Two young children lie on the bed around her." src="https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461305/original/file-20220504-15-vcdhl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Maranda Corely, 19, sits in her bedroom with her three children in Ellisville, Mississipi, in June 2012. Mississippi has one of the highest rates of teen pregnancy.</span>
<span class="attribution"><a class="source" href="https://media.gettyimages.com/photos/maranda-corely-sits-in-her-bedroom-with-her-three-childrenin-their-picture-id672410402?s=2048x2048">Lynsey Addario/Getty Images Reportage</a></span>
</figcaption>
</figure>
<h2>Insurance limits</h2>
<p>Paying out of pocket for an abortion, without health insurance coverage, can <a href="https://www.plannedparenthood.org/learn/ask-experts/how-much-does-it-cost-to-get-an-abortion">cost up to $750</a> in the first trimester, with costs rising as a pregnancy advances. A 2021 survey found that most people in the U.S. <a href="https://www.minneapolisfed.org/article/2021/what-a-400-dollar-emergency-expense-tells-us-about-the-economy">cannot afford an unexpected $400 emergency expense</a>. </p>
<p>But 18 of the 25 states that are not expected to ban abortion if Roe v. Wade is overturned require people who need abortions to pay out of pocket for the procedure. </p>
<p>These states either allow private health insurance providers to exclude abortion from their covered services, or the states do not pay for abortion through Medicaid. </p>
<p>Paying out of pocket for an abortion can also lead people <a href="https://pubmed.ncbi.nlm.nih.gov/25418228/">to delay</a> getting one. These costs <a href="https://www.guttmacher.org/news-release/2009/restricting-medicaid-funding-abortion-forces-one-four-poor-women-carry-unwanted">can be prohibitive</a> and sometimes <a href="https://pubmed.ncbi.nlm.nih.gov/31215464/">prevent</a> people from getting abortions.</p>
<h2>Workforce limitations</h2>
<p>Abortion providers in states surrounding Texas haven’t been able to keep up with demand as <a href="http://sites.utexas.edu/txpep/files/2022/03/TxPEP-out-of-state-SB8.pdf">thousands of Texans</a> seek abortion services out of state. </p>
<p>This offers a preview of what is likely to occur in states where abortion remains legal once residents of the 25 states expected to ban abortion are forced to travel for care. In short, demand will outstrip supply.</p>
<p>There are eight states that are not expected to ban abortion but only allow physicians to provide all or some types of abortion. They may have difficulty meeting this expected increased demand if they do not allow nurse practitioners or midwives, for example, to also provide care. </p>
<p>Research has shown that these health providers are also trained to provide abortions and <a href="https://www.nap.edu/catalog/24950">it is safe for them to do so</a>.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7282803/">Adding these other health practitioners </a> to the pool of providers trained to provide abortions could be key in ensuring that there are enough health providers to meet the potential rising demand for abortions.</p>
<p>States that want to be havens for people who need abortions should critically consider their existing policies in light of their real-life impacts.</p>
<p>[<em><a href="https://memberservices.theconversation.com/newsletters/?nl=politics&source=inline-politics-important">Get The Conversation’s most important politics headlines, in our Politics Weekly newsletter</a>.</em>]</p><img src="https://counter.theconversation.com/content/182395/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Jean Stevenson receives funding from the William and Flora Hewlett Foundation and the National Institutes of Heath, neither of which is responsible for this content.</span></em></p><p class="fine-print"><em><span>Kate Coleman-Minahan receives funding from the University of Colorado College of Nursing, National Institutes of Health, and the Society of Family Planning, neither of which is responsible for this content. She has volunteered with the Colorado Organization of Latina Opportunity and Reproductive Rights. The views expressed here are her own and not those of the University of Colorado.</span></em></p>25 states aren’t expected to ban abortion if the Supreme Court overturns Roe v. Wade. But limits on abortion in these places, too, make it an uncertain refuge for people seeking abortions elsewhere.Amanda Jean Stevenson, Assistant Professor of Sociology, University of Colorado BoulderKate Coleman-Minahan, Assistant Professor of Nursing, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1823762022-05-03T16:54:30Z2022-05-03T16:54:30ZWhat’s at stake as Supreme Court appears intent on overturning Roe v. Wade – 3 essential reads<figure><img src="https://images.theconversation.com/files/461036/original/file-20220503-13-v210wy.jpg?ixlib=rb-1.1.0&rect=35%2C377%2C5955%2C3610&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A women cries while kneeling in front of the U.S. Supreme Court in Washington, D.C., on May 2, 2022.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/women-cries-while-kneeling-in-front-of-the-us-supreme-court-news-photo/1240411918?adppopup=true">Stefani Reynolds/AFP via Getty Images</a></span></figcaption></figure><p>A <a href="https://www.politico.com/news/2022/05/02/read-justice-alito-initial-abortion-opinion-overturn-roe-v-wade-pdf-00029504">leaked draft opinion</a> written by Justice Samuel Alito suggests the Supreme Court is on the brink of overturning two rulings, including <a href="https://www.oyez.org/cases/1971/70-18">Roe v. Wade</a>, that guarantee the right to abortion in the U.S.</p>
<p>The Supreme Court confirmed that the document, <a href="https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473">obtained and first reported on by Politico</a>, <a href="https://www.nytimes.com/live/2022/05/03/us/roe-wade-abortion-supreme-court">is real, but said</a> “Although the document described in yesterday’s reports is authentic, it does not represent a decision by the court or the final position of any member on the issues in the case.” </p>
<p>The opinion is due to be issued later in the year. The leaked document indicates that a <a href="https://constitutioncenter.org/blog/the-double-edge-sword-of-the-supreme-courts-conservative-majority">conservative majority</a> in the court is on track to end a woman’s constitutional right to abortion, opening the door for states to enact bans.</p>
<p>Although a seismic development in the long-running legal battle and social debate over abortion rights, the development is not entirely unexpected. In recent years, pro-abortion rights advocates have been <a href="https://www.npr.org/2018/07/12/628237428/abortion-rights-advocates-preparing-for-life-after-roe-v-wade">ringing alarm bells over threats to Roe</a>. Legal scholars, health experts and sociologists have helped explain in The Conversation U.S. what is at stake and what it would mean for American women should the historic ruling be overturned.</p>
<h2>1. How Roe changed women’s lives</h2>
<p>A lot has changed in the nearly 50 years that separate the constitutional enshrining of the right to abortion in the U.S. to the brink of ending that right.</p>
<p>Constance Shehan, <a href="https://soccrim.clas.ufl.edu/directory/sociology/shehan/">a sociologist at the University of Florida</a>, <a href="https://theconversation.com/how-roe-v-wade-changed-the-lives-of-american-women-99130">provides a snapshot of life</a> for women prior to the landmark case. In 1970, the “average age at first marriage for women in the U.S. was just under 21. Twenty-five percent of women high school graduates aged 18 to 24 were enrolled in college and about 8 percent of adult women had completed four years of college,” she notes. But today, she says, “roughly two generations after Roe v. Wade, women are postponing marriage, marrying for the first time at about age 27 on average. Seventeen percent over age 25 have never been married. Some estimates suggest that 25 percent of today’s young adults may never marry.”</p>
<p>How much of this change in the experiences of American women is due to Roe? And if it is overturned, will the trends be reversed? Such questions are difficult answer. But there is evidence that carrying through with an unwanted pregnancy may have a detrimental effect on a woman’s education – and that, in turn, has an impact on career opportunities and income, writes Shehan. “Two-thirds of families started by teens are poor, and nearly 1 in 4 will depend on welfare within three years of a child’s birth. Many children will not escape this cycle of poverty. Only about two-thirds of children born to teen mothers earn a high school diploma, compared to 81 percent of their peers with older parents.”</p>
<p>Medical abortion isn’t the only option for young women seeking abortion. As Shehan notes: “With the availability of a greater range of contraception and abortion drugs other than medical procedures available today, along with a strong demand for women’s labor in the U.S. economy, it seems unlikely that women’s status will ever go back to where it was before 1973. But Americans shouldn’t forget the role that Roe v. Wade played in advancing the lives of women.”</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-roe-v-wade-changed-the-lives-of-american-women-99130">How Roe v. Wade changed the lives of American women</a>
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<h2>2. Who might be affected?</h2>
<p>“One important group’s voice is often absent in this heated debate: the women who choose abortion,” writes <a href="https://physicians.umassmemorial.org/details/3682/luu-ireland-gynecology-obstetrics_and_gynecology-worcester">Luu D. Ireland at UMass Chan Medical School</a>. She <a href="https://theconversation.com/who-are-the-1-in-4-american-women-who-choose-abortion-118016">notes that 1 in 4 American women</a> have the procedure at some point in their life, yet because of the perceived stigma involved, their perspective is largely missing. As an obstetrician/gynecologist, Ireland does, however, hear on a daily basis stories from women who opt for an abortion. </p>
<p>She notes that while abortion is a routine part of reproductive health care for many, and women of all backgrounds choose to end their pregnancies, unintended pregnancies are more common in certain groups: poorer women, women of color and those with lower levels of formal education. </p>
<p>“Women living in poverty have a rate of unintended pregnancy five times higher than those with middle or high incomes. Black women are twice as likely to have an unintended pregnancy as white women,” she writes.</p>
<p>The reason women opt to terminate a pregnancy varies. The most common reason is that the timing is wrong – it would interfere with education, careers or caring for family members. The second most cited reason is financial – the women seeking an abortion just can’t afford the associated costs of raising a child at that time. One impact of abortion restrictions, research has shown, is that women unable to get one “are more likely live in poverty or depend on cash assistance, and less likely to work full-time,” Ireland writes.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/who-are-the-1-in-4-american-women-who-choose-abortion-118016">Who are the 1 in 4 American women who choose abortion?</a>
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<h2>More than just financial risks</h2>
<p>Financial problems are one result of restricting safe, available access to abortions. Another is a jump in the cases of pregnancy-related deaths. Amanda Stevenson, <a href="https://www.colorado.edu/cmci/people/information-science/amanda-stevenson">a sociologist at University of Colorado Boulder</a>, <a href="https://theconversation.com/study-shows-an-abortion-ban-may-lead-to-a-21-increase-in-pregnancy-related-deaths-167610">looked into what would happen</a> should the U.S. ends all abortions nationwide. </p>
<figure class="align-center ">
<img alt="A woman is seen shouting in the face of a protester holding up a placard." src="https://images.theconversation.com/files/461054/original/file-20220503-10811-4pbyjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461054/original/file-20220503-10811-4pbyjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461054/original/file-20220503-10811-4pbyjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461054/original/file-20220503-10811-4pbyjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461054/original/file-20220503-10811-4pbyjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461054/original/file-20220503-10811-4pbyjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461054/original/file-20220503-10811-4pbyjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Activists who oppose and support abortion rights clash outside the U.S. Supreme Court building.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/pro-choice-and-anti-abortion-activists-demonstrate-in-front-news-photo/1395164177?adppopup=true">Anna Moneymaker/Getty Images</a></span>
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<p>To be clear, this is not what would happen should the Supreme Court overturn Roe – rather, it would allow states to implement bans based on the ending of a constitutionally guaranteed right to abortion. Nonetheless, Stevenson’s research gives context as to risks involved for women who may find themselves in states that do not allow abortion, and who lack the means to get to a state that does.</p>
<p>She notes that staying pregnant actually carries a greater risk of death than having an abortion. </p>
<p>“Abortion is incredibly safe for pregnant people in the U.S., with 0.44 deaths per 100,000 procedures from 2013 to 2017. In contrast, 20.1 deaths per 100,000 live births occurred in 2019,” she writes. Stevenson estimates that “the annual number of pregnancy-related deaths would increase by 21% overall, or 140 additional deaths, by the second year after a ban.” The jump in deaths would be even higher among non-Hispanic Black women.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/study-shows-an-abortion-ban-may-lead-to-a-21-increase-in-pregnancy-related-deaths-167610">Study shows an abortion ban may lead to a 21% increase in pregnancy-related deaths</a>
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<p><em>Editor’s note: This story is a roundup of articles from The Conversation’s archives.</em></p>
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A draft opinion written by Justice Samuel Alito suggests that a majority of the court may overturn the landmark 1973 ruling that guaranteed the constitutional right to abortion in the US.Matt Williams, Senior International EditorLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1687222022-01-05T20:29:28Z2022-01-05T20:29:28ZHow the COVID-19 pandemic has affected abortion care in Canada<figure><img src="https://images.theconversation.com/files/439158/original/file-20220103-106551-y5bdu1.jpg?ixlib=rb-1.1.0&rect=0%2C9%2C4755%2C2667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A key change in abortion care during the pandemic was that many providers offered some or all services via telemedicine.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Abortions are common and essential medical procedures; <a href="https://doi.org/10.1016/j.contraception.2011.06.009">one in three women in Canada have an abortion in their lifetime</a>. Access to this care helps people plan and space out their pregnancies, providing <a href="https://doi.org/10.1097/01.AOG.0000255666.78427.c5">vital benefits</a> to individuals, families and society.</p>
<p>Pandemic-related travel restrictions and facility closures initially <a href="https://doi.org/10.1002/ijgo.13377">jeopardized access to abortion care</a>. However, the pandemic has also become a catalyst for more accessible ways to deliver abortion care, such as providing medical abortions, which are drug-induced rather than surgical, via telemedicine. </p>
<p>We are members of the Contraception and Abortion Research Team at the University of British Columbia. As a PhD student and a postdoctoral fellow, we conduct research to support knowledge about abortion, availability of safe abortion methods and equitable access to abortion services throughout Canada.</p>
<p>Canada has been a leader in providing <a href="https://doi.org/10.1016/j.bpobgyn.2019.05.010">legal and safe abortion care</a>, and the current federal government has a <a href="https://pm.gc.ca/en/mandate-letters/2021/12/16/minister-health-mandate-letter">mandate letter commitment</a> “to ensure that all Canadians have access to the sexual and reproductive health services they need, no matter where they live.” </p>
<h2>Expanded options and persistent disparities</h2>
<p>Options for care were expanded in 2017, when the gold standard medication abortion drug, <a href="https://doi.org/10.1503/cmaj.180047">mifepristone, became available in Canada</a>. Medical abortions with mifepristone can be offered by family doctors and other primary health-care providers in the first trimester. </p>
<p>Mifepristone has the potential to address differences in access because it is a prescription for pills that the patient takes at home, and no surgical procedure is required. However, there are still disparities in access between rural areas and urban centres in Canada. </p>
<p>A few provinces face particular access challenges. For example, <a href="https://www.cbc.ca/news/canada/new-brunswick/new-brunswick-abortions-clinic-554-research-unb-federal-hajdu-atwin-1.6127599">availability of surgical abortion services is very limited in the Maritimes</a> due to a lack of clinics. Québec has been <a href="https://doi.org/10.1080/13625187.2020.1743825">slow to implement medical abortion care</a>. </p>
<p>Abortion providers and people seeking care still experience stigma and harassment, including anti-choice protests. This has led some provinces to <a href="https://www.arcc-cdac.ca/wp-content/uploads/2020/06/Bubble-Zones-Court-Injunctions-in-Canada.pdf">implement bubble zones</a> — legally designated areas around an abortion providing facility that prohibit protest and harassment of patients and providers. </p>
<h2>Abortion care during the pandemic</h2>
<p>In 2020, our team and partners recognized that the pandemic could have important implications for abortion care. We asked abortion providers from across the country to share their experiences on how COVID-19 had impacted abortion practice and access. We heard from <a href="https://doi.org/10.1093/fampra/cmab083">over 300 providers and abortion clinic administrators</a> about how they adjusted their abortion care during the pandemic to continue providing this essential health-care service. </p>
<p>The providers we surveyed found it helpful that the Society of Obstetricians and Gynaecologists of Canada (SOGC) <a href="https://sogc.org/common/Uploaded%20files/Induced%20Abortion%20-%20Pandemic%20Guidance%20.pdf">issued a statement</a> on the importance of ensuring access to abortion early in the pandemic. According to the SOGC, “Induced abortion is an essential and time-sensitive medical service that must be maintained in any pandemic or during periods of social disruption.” </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A doctor talking to a female patient, both wearing face masks" src="https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/439290/original/file-20220104-23-5he8mb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">While many abortion care services moved to telemedicine during the pandemic, in-person appointments include things like assessing patients for abuse and coercion, testing for sexually transmitted infections and discussing post-abortion birth control.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Providers noted that a key change in their practice was offering some or all components of abortion care via telemedicine. They used telemedicine to prescribe mifepristone and for followup, while continuing to schedule in-person visits or tests for patients as needed. In a group we surveyed, less than 20 per cent had provided medical abortion via telemedicine before the pandemic. This shifted to almost 90 per cent of providers by January 2021.</p>
<p><a href="https://doi.org/10.1111/1471-0528.16668">Research shows</a> that telemedicine abortion care is safe, and enabled people to seek care despite pandemic-related restrictions and personal concerns. According to one provider we surveyed: </p>
<blockquote>
<p>“Patients are more reluctant to travel out of (their region) to access abortion…. They are terrified of the virus, and do not want to self-isolate at hotel hubs for 14 days before (returning home).” </p>
</blockquote>
<p>Several people who participated in our research highlighted that telemedicine increased the accessibility of care. A clinic administrator in Ontario wrote: </p>
<blockquote>
<p>“We have found that many patients throughout the province have utilized our service due to an increase in accessibility that accompanies telemedicine…. We are hopeful to continue to offer this care. However, we are also aware that for patients who do not have access to a phone/internet, telemedicine is not accessible.”</p>
</blockquote>
<h2>Next steps: Planning for patients’ needs</h2>
<p>Beyond considering access to the necessary technology, we need to understand the patient experiences of telemedicine abortion. Internationally, <a href="https://doi.org/10.1111/1471-0528.16813">research shows</a> that many people accessing abortion services prefer this approach to care because it is more convenient, private and comfortable.</p>
<p>We need to clarify how abortion services can better meet patients’ needs in Canada. In-person appointments include things like assessing patients for abuse and coercion, testing for sexually transmitted infections and providing post-abortion birth control. How these services might be integrated into telemedicine is a key question.</p>
<p>Other important questions include identifying what needs to be done to maintain access to in-person medical and surgical care, and assessing the sustainability of the hybrid model, which includes telemedicine and in-person options.</p>
<p>Pandemic restrictions may have launched Canadian abortion care into a more accessible future. Telemedicine can enable services for people who live in rural communities or who prefer to access abortions from home. The pandemic increased the opportunity for people seeking an abortion to receive the care they need close to their home in a safe and timely way.</p><img src="https://counter.theconversation.com/content/168722/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pandemic-related travel restrictions and facility closures initially jeopardized access to abortions, but the pandemic has also become a catalyst for more accessible ways to deliver abortion care.Kate Wahl, PhD Candidate, Reproductive and Developmental Sciences, University of British ColumbiaMadeleine Ennis, Postdoctoral Fellow, Obstetrics and Gynaecology, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1655022021-08-03T19:41:21Z2021-08-03T19:41:21ZOnline abortions boomed during the pandemic, and not just because of coronavirus<p>The coronavirus pandemic changed the way people all over the world accessed abortions. As lockdowns and other restrictions made it difficult to seek in-person terminations of unwanted pregnancies, some countries made at-home abortions more accessible.</p>
<p>In France, the government temporarily changed the law in April 2020 to allow at-home abortion until <a href="https://www.legifrance.gouv.fr/jorf/id/JORFTEXT000041798289/">seven weeks of pregnancy (or nine weeks since the last period)</a>. Teleconsultation abortions – where abortion medication is taken at home in consultation with a medical professional by phone or video call – are currently allowed until September 2021.</p>
<p>Similar policies were adopted in <a href="https://srh.bmj.com/content/early/2021/02/22/bmjsrh-2020-200724">England, Scotland, Wales and Ireland</a>, as well as <a href="https://msmagazine.com/2021/04/19/fda-telemedicine-abortion-pill-mifepristone/">some US states</a>.</p>
<p>In a <a href="https://srh.bmj.com/content/early/2021/07/28/bmjsrh-2021-201176">recent study</a>, my colleagues and I investigated the increased demand for telemedicine abortion in France during lockdowns. Our findings show that people sought out this form of abortion for reasons that go beyond the conditions created by the pandemic.</p>
<h2>Secrecy, privacy and comfort</h2>
<p>Within the scope of our study, we examined online consultations received from France by <a href="https://www.womenonweb.org/">Women on Web</a>, a Canadian telemedicine abortion NGO that operates worldwide. The online consultation is a survey of 25 questions on individual’s demographic and medical background, and also includes research questions on perceived barriers of access to local safe abortion care and motivations for choosing telemedicine for abortion.</p>
<p>At-home abortion was also made available in France via the health system, but national cohort data was not available for our study. Within the framework of this research, we worked on deidentified data obtained from Women on Webin 2020.</p>
<p>Analysing a total number of 809 Women on Web consultations, we found that the most common reasons people in France sought abortions via telemedicine were secrecy (46%), privacy (38%) and comfort (35%), followed by the coronavirus pandemic (31%). Individuals reported not being able to access local abortion services during the pandemic, because of travel restrictions and lockdowns, lack of availability and delays at health care institutions, and fear of virus contamination.</p>
<p>Only 31% of survey respondents indicated that their motivations for seeking telemedicine abortion were related to the pandemic. When we compared these consultations to those not related to coronavirus, we found similar motivations: privacy, secrecy and comfort were the key drivers of telemedicine abortion both for those who mentioned coronavirus among their reasons for seeking telemedicine for abortion, and who did not.</p>
<p>We also found that, compared to women over 36, women aged 18–25 years are twice as likely to find at-home abortion via telemedicine empowering and three times more likely to prefer having someone with them during the procedure. This age group was also twice as likely to feel stigma about getting an abortion and encounter financial difficulties while accessing abortion care in France.</p>
<p>We found that women continue to encounter macro-level, individual-level and provider-level constraints while trying to access abortion in France. Macro-level constraints include sociopolitical conditions, legal restrictions and term limits, individual-level constraints are personal circumstances and preferences and, provider-level constraints are issues raised around service provision and access to available care.</p>
<p>In this context, women reported financial struggles, an abusive or controlling partner or family, past traumatic experiences, scheduling delays, judgemental service providers, and lack of available medical care as reasons for seeking out abortion online.</p>
<h2>The need for self-managed abortions</h2>
<p>While telemedicine abortion has been discussed most frequently in the context of the pandemic, it is not a new phenomenon. And there is a large amount of <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15684">available evidence</a> attesting to its safety, effectiveness and acceptability.</p>
<p>The World Health Organization <a href="https://apps.who.int/iris/bitstream/handle/10665/332334/WHO-SRH-20.11-eng.pdf">suggests</a> that individuals can self-manage their abortions, without the direct supervision of a medical practitioner, up to 12 weeks of pregnancy. The organisation also states that self-managed abortions can be appealing for several practical reasons, including comfort of home, ease of scheduling, reduced transport needs, and providing people ability to manage stigma.</p>
<p>In the UK, <a href="https://www.nice.org.uk/guidance/ng140/evidence/a-accessibility-and-sustainability-of-abortion-services-pdf-6905052973">it has been argued</a> that telemedicine can help extend abortion access in rural areas and is likely to benefit those who are most vulnerable, living in poverty and dealing with higher rates of stigma and judgement.</p>
<p>Despite the recommendations of the WHO and an increasing scientific evidence base, countries have been <a href="https://theconversation.com/countries-covid-19-responses-could-debunk-some-myths-around-the-abortion-pill-136088">reluctant to allow at-home use of abortion pills</a> until the pandemic. In fact, prior to the coronavirus outbreak, abortion pills were highly regulated, or as some would claim <a href="https://www.nejm.org/doi/full/10.1056/NEJMsb1612526">overregulated</a>.</p>
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<img alt="A packed of the abortion medication mifepristone" src="https://images.theconversation.com/files/414319/original/file-20210803-27-cqsp12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414319/original/file-20210803-27-cqsp12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414319/original/file-20210803-27-cqsp12.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414319/original/file-20210803-27-cqsp12.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414319/original/file-20210803-27-cqsp12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414319/original/file-20210803-27-cqsp12.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414319/original/file-20210803-27-cqsp12.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The abortion medication mifepristone has been heavily restricted in many countries.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/92599314@N00/46193282711">Robin Marty</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<p>In France, for example, before the pandemic, <a href="https://www.legifrance.gouv.fr/codes/section_lc/LEGITEXT000006072665/LEGISCTA000006145474/#LEGISCTA000006145474">abortion pills were not available in pharmacies</a> and women were required to go a health facility to take abortion medication in the presence of a medical doctor or a midwife. Medical abortions were <a href="https://www.legifrance.gouv.fr/codes/section_lc/LEGITEXT000006072665/LEGISCTA000006145474/#LEGISCTA000006145474">only allowed until five weeks of pregnancy</a> and telemedicine was not authorised.</p>
<p>In the United States, <a href="https://msmagazine.com/2021/05/11/fda-review-abortion-pill-restrictions-mifepristone-biden/">the Food and Drug Administration long required</a> that the abortion medication Mifepristone be dispensed in person – a requirement which was only lifted temporarily during the pandemic.</p>
<p><a href="https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.16668">A recent study</a> from the UK has shown that telemedicine abortions during the pandemic led to reduced waiting times and allowed terminations at an earlier gestational age. <a href="https://srh.bmj.com/content/early/2021/02/04/bmjsrh-2020-200976">Another study</a> examining at-home abortion in Scotland has concluded that telemedicine has high efficacy and high acceptability among women.</p>
<p>Building on this literature within the French context, our study suggests there is a case for extending telemedicine abortion care beyond the pandemic. Embracing a hybrid model that offers both in-clinic and remote abortion methods can help meet women’s needs, expand access and improve the quality of care.</p><img src="https://counter.theconversation.com/content/165502/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazal Atay est membre de Women on Web International Foundation. </span></em></p>The pandemic has demonstrated the need for self-managed medical abortions carried out at home.Hazal Atay, Ph.D candidate, INSPIRE Marie Skłodowska-Curie Fellow, Sciences Po Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1545942021-02-10T10:13:39Z2021-02-10T10:13:39ZBanning safe home-use abortion pills will leave more women in crisis<figure><img src="https://images.theconversation.com/files/383496/original/file-20210210-15-k9za8o.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2516%2C1706&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-young-woman-taking-prescription-pill-1234681048">Kierferpix/Shutterstock</a></span></figcaption></figure><p>The <a href="https://www.gov.uk/government/consultations/home-use-of-both-pills-for-early-medical-abortion/home-use-of-both-pills-for-early-medical-abortion-up-to-10-weeks-gestation">English</a> and <a href="https://gov.wales/termination-pregnancy-arrangements-wales">Welsh</a> governments are consulting the public about whether they should revoke temporary rules which allow women to terminate early pregnancies in their own homes with the use of two pills. The rules were brought in to reduce the need for face-to-face <a href="https://www.independent.co.uk/news/uk/home-news/coronavirus-abortion-women-telemedicine-nhs-a9424461.html">appointments</a> as COVID-19 swept through the population.</p>
<p>It is vital that women are continued to be allowed access to these drugs for use at home for early medical abortions. This method of termination is <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3742277">safe</a> and allows women to manage their reproductive health privately and respectfully.<br>
Despite <a href="https://www.telegraph.co.uk/news/2020/12/08/permanently-legalising-home-abortions-terrible-idea/">concerns</a> being raised by anti-choice campaigners that allowing women to obtain early abortions at home will lead to misuse of the medication, the evidence so far does not support those allegations. </p>
<p>A small number of cases have been reported in the media of women accessing the medication from abortion providers, such as the <a href="https://www.bpas.org">British Pregnancy Advisory Service</a> and <a href="https://www.msichoices.org.uk">MSI Reproductive Choices</a>, when they were over 10 weeks pregnant. This included one reported case of a woman who was <a href="https://www.dailymail.co.uk/news/article-8349739/Police-investigate-death-unborn-baby-woman-took-abortion-drugs-home-28-weeks-pregnant.html">28 weeks pregnant</a> when she took the medication.</p>
<p>In England, Wales and Scotland it is illegal to <a href="https://www.legislation.gov.uk/ukpga/Vict/24-25/100/section/58">end a pregnancy</a> at any time, unless the abortion is conducted by a registered <a href="https://www.legislation.gov.uk/ukpga/1967/87/section/1">medical practitioner</a>. The only circumstances in which it is legal to end a pregnancy that has reached the 24th week of gestation is if there is a severe threat to the woman’s physical or mental health or due to foetal abnormalities. </p>
<p>The temporary law allows the abortion medication – <a href="https://bnf.nice.org.uk/drug/mifepristone.html">mifepristone</a> and <a href="https://bnf.nice.org.uk/drug/misoprostol.html">misoprostol</a> – to be dispatched to a woman’s home following a telephone or video consultation with a medical professional. If a woman purposefully misleads abortion providers about the gestational stage of her pregnancy to obtain medication, she could theoretically be jailed for life, thanks to the Victorian legislation which <a href="https://www.legislation.gov.uk/ukpga/Vict/24-25/100/section/58">still applies</a>.</p>
<h2>Less than 1% over 10 weeks</h2>
<p>But before people jump to the conclusion that home-use equals misuse, other important elements must be considered. These cases are just a handful of the early medical abortions that have taken place at home in England and Wales. Between April and June 2020, <a href="https://www.gov.uk/government/publications/abortion-statistics-during-the-coronavirus-pandemic-january-to-june-2020/abortion-statistics-for-england-and-wales-during-the-covid-19-pandemic">23,061</a> abortions took place at home, making up 43% of all legal abortions that occurred.</p>
<p>One study has shown that drugs dispatched to women over 10 weeks pregnant constitutes just <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3742277">0.04%</a> of the requested medicines. </p>
<p>The fact is that 86% of terminations reported in the 2020 data took place before the 10th week of pregnancy – with <a href="https://www.gov.uk/government/publications/abortion-statistics-during-the-coronavirus-pandemic-january-to-june-2020/abortion-statistics-for-england-and-wales-during-the-covid-19-pandemic">50%</a> performed before seven weeks gestation. With easier access to medication, it is likely that that percentage of “early” terminations will continue to remain higher than before.</p>
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Read more:
<a href="https://theconversation.com/protest-against-the-home-abortion-pill-in-scotland-is-about-judging-women-not-ensuring-their-safety-91416">Protest against the 'home abortion' pill in Scotland is about judging women, not ensuring their safety</a>
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<p>It also unclear whether women who requested the medication when over 10 weeks pregnant knew the developmental stage of their pregnancy. Women can continue to bleed while pregnant. This is known as “<a href="https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/vaginal-bleeding/">spotting</a>” and it can be interpreted as a period. So it takes some women who experience this longer to realise they are pregnant.</p>
<p>Whether home-use continues or not, a very small number of women will continue to illegally access medication to end a pregnancy of a viable foetus. Abortion medication is relatively easy to obtain illegally via the internet. In 2015 and 2016, 645 abortion pills were <a href="https://www.independent.co.uk/news/uk/home-news/abortion-pill-access-online-illegal-decriminalise-woman-british-pregnancy-advisory-service-danger-prison-a7580566.html">seized</a> en-route to addresses across Britain. It is likely that far more made it to their destination. </p>
<p>Home-use will reduce some women’s <a href="https://www.sciencedirect.com/science/article/abs/pii/S0010782417304353">desperate need</a> for this illegal trade.</p>
<h2>Crisis pregnancies</h2>
<p>Women who are in desperate circumstances are distinct from the vast majority of abortion cases that occur. And those who do find themselves in the position of needing to end a late-term pregnancy are incredibly vulnerable. My research shows that women in this situation experience what is known as a <a href="https://link.springer.com/article/10.1007/s10691-019-09401-6">“crisis” pregnancy</a>. An unwanted pregnancy is not necessarily a crisis pregnancy, if a woman has access to safe and legal abortion services.</p>
<p>The crisis arises because of difficult life circumstances these women are enduring, such as living in violent and abusive relationships or living poverty with limited social support. </p>
<figure class="align-center ">
<img alt="Woman holding a pregnancy test." src="https://images.theconversation.com/files/383234/original/file-20210209-17-1sl8hty.jpg?ixlib=rb-1.1.0&rect=310%2C232%2C5190%2C3276&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/383234/original/file-20210209-17-1sl8hty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383234/original/file-20210209-17-1sl8hty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383234/original/file-20210209-17-1sl8hty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383234/original/file-20210209-17-1sl8hty.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383234/original/file-20210209-17-1sl8hty.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383234/original/file-20210209-17-1sl8hty.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not all unwanted pregnancies are crisis prengancies.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/single-sad-woman-complaining-holding-pregnancy-1104503756">Shutterstock/AntonioGuillem</a></span>
</figcaption>
</figure>
<p>Considering the stage of the pregnancy, the dire context that surrounds them and the steps women take to end them, these crisis cases need to be seen as <a href="https://repository.law.umich.edu/cgi/viewcontent.cgi?article=1275&context=mjgl">distinct</a> from “regular” abortions, which generally occur very early in the pregnancy – with just <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/891405/abortion-statistics-commentary-2019.pdf">0.1% </a> taking place at or after 24 weeks, according to national data from 2019. Most of these post-24 weeks terminations will be of wanted pregnancies following a diagnosis of foetal abnormalities. </p>
<p>My research has shown that crisis pregnancy cases are, in fact, more akin to newborn infanticide. This is when a newborn baby is killed with the child’s mother being the most likely suspect. In these cases the woman often acts out of fear, shame and a belief that their pregnancy <a href="https://theconversation.com/murder-or-infanticide-understanding-the-causes-behind-the-most-shocking-of-crimes-79808">cannot exist</a>. There needs to be a debate about whether it is right to criminalise these women, considering their levels of vulnerability. I do not believe it is.</p>
<p>Whether or not home-use for early medical abortion is legally permitted, women in crisis will find means to end their pregnancy – they have in the past and they will again. </p>
<p>Governments do not ban alcohol because some people drink and drive. Why should they ban home-use abortion pills because a very small number of women will knowingly be over 10 weeks pregnant when they request the medication? </p>
<p>These vulnerable women need support. And they should not be used to prevent all women from easily accessing <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.15684">safe</a> and compassionate abortion care at home.</p><img src="https://counter.theconversation.com/content/154594/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emma Milne received funding to support this research from the Arts and Humanities Research Council (AH/L503861/), the Socio-Legal Studies Association Research Grants Scheme 2018, and Durham Law School.
Since 2020 Emma has been a trustee of the Socio-Legal Studies Association, a charitable incorporated organisation (registered charity number 1186333).</span></em></p>English and Welsh governments are consulting the public about whether they should revoke temporary abortion rules.Emma Milne, Assistant Professor in Criminal Law and Criminal Justice, Durham UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1253002019-12-05T05:07:35Z2019-12-05T05:07:35ZEarly medical abortion is legal across Australia but rural women often don’t have access to it<figure><img src="https://images.theconversation.com/files/305315/original/file-20191205-16501-hurbtc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Australian women can have an early medical termination – which involves taking two oral medications – up to the ninth week of pregnancy.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/Frdj333dsuY">Jonatán Becerra/Unsplash</a></span></figcaption></figure><p>Around <a href="https://theconversation.com/one-in-six-australian-women-in-their-30s-have-had-an-abortion-and-were-starting-to-understand-why-111246">one in six Australian women</a> have had an abortion by their mid-30s. These women come from all age groups and demographics: some are mothers already, while others are child-free; some are partnered, others are single.</p>
<p>Abortion was removed from the New South Wales Crimes Act in October and is now <a href="https://www.fpnsw.org.au/factsheets/individuals/abortion/law-abortion-nsw">legal in all Australian states and territories</a>, under certain circumstances. </p>
<p>However, many women have difficulties accessing these services, especially in rural and regional areas. This needs to change.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/one-in-six-australian-women-in-their-30s-have-had-an-abortion-and-were-starting-to-understand-why-111246">One in six Australian women in their 30s have had an abortion – and we're starting to understand why</a>
</strong>
</em>
</p>
<hr>
<h2>What is a medical abortion?</h2>
<p>One option for women seeking a termination is to have an early medical abortion, as opposed to a surgical termination.</p>
<p>A medical abortion involves inducing a miscarriage using a combination of two oral medications – mifepristone and misoprostol – which can be used in pregnancies <a href="https://www.betterhealth.vic.gov.au/health/healthyliving/abortion-procedures-medication">up to nine weeks</a>. </p>
<p>Women can take the medications home, along with instructions of how the process works and possible complications to look out for, and a telephone number to call with any questions or concerns. </p>
<p>In 2013, mifepristone and misoprostol were <a href="https://www.tandfonline.com/doi/full/10.1016/j.rhm.2015.10.002">subsidised on the Pharmaceutical Benefits Scheme</a> (PBS). Since then, any GP has been able to provide an early medical abortion, as long as they’ve completed a <a href="https://www.ms2step.com.au/">free, online training course</a>.</p>
<p>While these measures were hoped to improve access for women in rural and remote areas, medical and surgical abortion services remain concentrated in capital cities and major regional centres. So rural women must travel – often at great expense – to seek a medical or surgical abortion. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/305320/original/file-20191205-16524-7vcue0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305320/original/file-20191205-16524-7vcue0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305320/original/file-20191205-16524-7vcue0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305320/original/file-20191205-16524-7vcue0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305320/original/file-20191205-16524-7vcue0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305320/original/file-20191205-16524-7vcue0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305320/original/file-20191205-16524-7vcue0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Australian women sometimes have to travel long distances to get an abortion.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/241234900?src=917825a4-adc2-4684-ba70-441b41e4b638-2-49&size=huge_jpg">Anna Jurkovska/Shutterstock</a></span>
</figcaption>
</figure>
<h2>What’s the problem?</h2>
<p>There are several barriers to early medical abortion in rural areas. </p>
<p>Some rural doctors have <a href="https://doi.org/10.22605/RRH5156">inconsistent knowledge</a> about medical abortion, either not knowing what it entails or even, at times, that it’s an option. Others <a href="https://www.ncbi.nlm.nih.gov/pubmed/29389497">lack training</a> in abortion. They may have missed out on it in their undergraduate studies and haven’t done any further training in the area. </p>
<p>Rural GPs sometimes lack support from the local hospital service to provide abortion care or if something goes wrong, which can deter them from performing medical abortions. Doctors in emergency departments may not have training about medical abortion and how it works, or may even object to abortion.</p>
<p>Rural communities also have higher numbers of overseas trained doctors who are <a href="https://doi.org/10.22605/RRH5156">more likely to have conscientious objection</a> to abortion (65%) than doctors trained in Australia (15%).</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/attitudes-to-women-who-have-more-than-one-abortion-need-to-change-85707">Attitudes to women who have more than one abortion need to change</a>
</strong>
</em>
</p>
<hr>
<p>In rural areas, it’s often difficult to access affordable and timely ultrasounds. An ultrasound is required before the medical abortion to determine the gestation (which must be less than 63 days) and to ensure the woman doesn’t have an ectopic pregnancy (when the embryo implants in the fallopian tubes rather than the uterus).</p>
<p>Time ticks away for these women if they realise they have an unplanned pregnancy at, say, six weeks. They often have to wait up to a week or two to see a GP, have an ultrasound and blood tests, and undergo counselling before having the abortion. If it takes a week or two to get an appointment for ultrasound after seeing the GP, there’s a risk the woman may pass the 63 day cut-off and will need to have a surgical termination instead.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/305318/original/file-20191205-16538-1w83l27.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/305318/original/file-20191205-16538-1w83l27.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/305318/original/file-20191205-16538-1w83l27.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/305318/original/file-20191205-16538-1w83l27.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/305318/original/file-20191205-16538-1w83l27.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/305318/original/file-20191205-16538-1w83l27.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/305318/original/file-20191205-16538-1w83l27.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Every step takes time, and this can push women over the 63 day cut-off.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/210335716?src=6f6273be-b251-4cd3-8166-f486fc3eba91-1-8&size=huge_jpg">Bohbeh/Shutterstock</a></span>
</figcaption>
</figure>
<p>Some rural GPs therefore see the cost of providing abortion as unaffordable. Providing medical abortion takes GPs more time than a standard consultation to ensure all options for the woman are explored. Usually more than one consultation is required and the remuneration received through Medicare is minimal. </p>
<p>Another barrier women may face when seeking abortion in rural areas is community stigma. In rural communities, “everyone knows everyone” and women worry about their privacy and how people will judge them for choosing to have an abortion. </p>
<p>When you have fewer choices of health care professionals, you can also face institutional stigma if, for example, the closest hospital, pharmacist or sonographer (who performs the ultrasound) has ties to a specific religious group or clearly objects to abortion. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-blame-and-shame-women-for-unintended-pregnancies-50977">Don't blame and shame women for unintended pregnancies</a>
</strong>
</em>
</p>
<hr>
<h2>What are the solutions?</h2>
<p>GPs are often the first point of call for women with an unplanned pregnancy in rural areas. They are well placed to provide early medical abortion. </p>
<p>But nurses can also play an important role. In recent years, a number of small Victorian towns have successfully integrated early medical abortion into their community health services. These clinics are predominantly led by nurses, working with a GP. </p>
<p>Nurse-led early abortion services are safe, affordable and welcomed by women. Our <a href="https://www.ncbi.nlm.nih.gov/pubmed/29804763">clinical audit</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/29389497">interviews with women</a> found no unexpected complications. Women were grateful to have affordable access in their own community and relieved they didn’t have to go to Melbourne or Sydney.</p>
<p>Better access to early medical abortion also requires the creation of a specific Medicare item number so GPs and nurses can be adequately remunerated for providing the service.</p>
<p>Finally, we need to increase the number of GPs and practice nurses who can provide medical abortions by providing better training. Early medical abortion needs to be seen as part of women’s sexual and reproductive health and should be incorporated into nursing and medical education at both the graduate level and in post-graduate specialist training. </p>
<p><em>This article was co-authored by Catherine Orr, Gateway Community Health, Wodonga.</em></p><img src="https://counter.theconversation.com/content/125300/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Tomnay receives funding from Department of Health and Human Services Victoria. </span></em></p>Access to early medical abortion is an important part of women’s sexual and reproductive health care. Yet often country GPs don’t offer this service.Jane Tomnay, Assoc. Professor / Director of Centre for Excellence in Rural Sexual Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1239042019-10-03T22:41:41Z2019-10-03T22:41:41ZAbortion in Canada: The election debates, the law and the reality<figure><img src="https://images.theconversation.com/files/295317/original/file-20191002-49346-1gq2wil.jpg?ixlib=rb-1.1.0&rect=7%2C84%2C4644%2C2775&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Protestors on Parliament Hill in Ottawa, May 9, 2019. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span></figcaption></figure><p>This federal election season, abortion is undeniably a campaign issue, with media coverage routinely suggesting abortion rights are tenuous or up for debate. </p>
<p>Conservative Leader <a href="https://www.cbc.ca/news/politics/scheer-abortion-pro-life-1.5307415">Andrew Scheer has declared that he is “personally pro-life,”</a> while insisting that <a href="https://www.macleans.ca/opinion/the-question-to-ask-about-andrew-scheer-and-abortion/">his cabinet will not “reopen the issue</a>.” This does, however, leave the door open for individual MPs to put forward <a href="https://www.cbc.ca/news/politics/where-the-leaders-are-day-2-1.5280534">anti-abortion private member bills</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/295503/original/file-20191003-52826-1mkybj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295503/original/file-20191003-52826-1mkybj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=388&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295503/original/file-20191003-52826-1mkybj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=388&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295503/original/file-20191003-52826-1mkybj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=388&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295503/original/file-20191003-52826-1mkybj0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=487&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295503/original/file-20191003-52826-1mkybj0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=487&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295503/original/file-20191003-52826-1mkybj0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=487&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Conservative leader Andrew Scheer made a personal pro-life declaration during his morning address at a volunteer fire department in Upper Kingsclear, N.B., October 3, 2019.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>At an NDP town hall on health care in Halifax, NDP Leader <a href="https://www.thestar.com/halifax/2019/09/23/jagmeet-singh-says-ndp-would-fix-abysmal-problems-with-abortion-access-in-nova-scotia.html">Jagmeet Singh criticized abortion access as “abysmal</a>” and vowed to enforce the Canada Health Act to improve it. </p>
<p>Green Party Leader Elizabeth May continues to argue that a <a href="https://www.youtube.com/watch?v=Sqtw_K7cG8w">woman has a right to a safe, legal abortion</a> while candidates in the party <a href="https://pressprogress.ca/we-asked-dozens-of-green-party-candidates-what-they-think-about-abortion-many-are-out-of-step-with-elizabeth-may/?fbclid=IwAR2eaJxfxLbCT0c8oh_yr3xKCLZCp4M1VH1UNYgvPLJiRan9yb4l27D4--g">may have conflicting views</a>. Justin Trudeau, leader of the Liberal Party, is <a href="https://www.cbc.ca/news/politics/trudeau-abortion-rights-1.5138417">“deeply disappointed about "backsliding on abortion rights.”</a></p>
<p>As a registered nurse who provides abortion care, and as a researcher of abortion access, I worry these news stories create confusion about the reality and legality of access in Canada. Furthermore, <a href="https://www.theglobeandmail.com/politics/article-trudeau-raises-concerns-with-pence-over-new-state-abortion-laws-in-us/">news of anti-abortion legislation in the United States</a> seeps north and clouds understanding of our needs and concerns.</p>
<h2>The medical abortion pill</h2>
<p>In Canada, abortion is <a href="https://www.jogc.com/article/S1701-2163(16)35269-0/pdf">unrestricted by criminal law</a> and protected by <a href="https://www.leaf.ca/wp-content/uploads/2019/04/Abortion-Access-Framework.pdf">Constitutional rights</a> to security of the person and protection from sex and gender discrimination. </p>
<p>It is a health service governed by the <a href="https://doi.org/10.1016/j.bpobgyn.2019.05.010">rules health professional organizations create for self-regulation</a>. Abortion is common. There are around <a href="https://www.cihi.ca/en/induced-abortions-reported-in-canada-in-2017">100,000 abortions</a> annually in Canada and <a href="https://www.cfpc.ca/abortion-resources-for-family-physicians/">one in three Canadian women</a> will <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30380-4/fulltext">seek an abortion</a> in their lifetime. </p>
<p>Abortion is safe for patients, and <a href="https://www.cfp.ca/content/62/4/e209.short">most abortion providers in Canada feel safe</a> providing it. The vast majority of procedures take place in the first trimester. Abortion is publicly insured and in the majority of cases is free for the patient. </p>
<p>In 2015, <a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/prescription-drug-list/notice-multiple-additions-2.html">Health Canada approved Mifegymiso</a>, the medical abortion pill. It has been available since 2017 and is effective for use up to nine weeks gestation. Mifegymiso is also publicly insured by all the provinces and territories. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1118348376968499200"}"></div></p>
<p>Mifegymiso actually comprises two medications: mifepristone and misoprostol, taken over the course of 24 hours. A week after taking Mifegymiso, patients repeat their blood work. A large decrease in the pregnancy hormone beta HCG confirms a successful pregnancy termination. </p>
<p>Just as some spontaneous miscarriages may need further care, in a small portion of cases, a <a href="https://doi.org/10.1016/j.contraception.2009.03.010">surgical procedure may be required to complete</a> a medical abortion. Although providers are not required to take specialized training to prescribe Mifegymiso, <a href="https://www.sogc.org/en/rise/Events/event-display.aspx?EventKey=MATP">comprehensive training is easily available</a>. </p>
<p>Lack of ultrasound availability should also not be a barrier, although ultrasound remains valuable for dating a pregnancy and to rule out <a href="https://www.healthlinkbc.ca/health-topics/hw144921">ectopic pregnancy</a>.</p>
<h2>Persistent inequities across Canada</h2>
<p>The greatest practical barrier to abortion in Canada is geographic: there are too few providers living in too few places. <a href="https://www.cfp.ca/content/62/4/e209.short">Surveys of abortion providers</a> here have found most live in large urban centres. </p>
<p>The introduction of Mifegymiso could change this. All physicians and nurse practitioners could prescribe Mifegymiso (there are <a href="https://www.theglobeandmail.com/canada/article-abortion-pill-inequality-how-access-varies-widely-across-canada/">exceptions in Québec</a>). In theory, every primary care office in the country could be providing this care. This means abortion is potentially more accessible in Canada than in any other country in the world.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/295488/original/file-20191003-52832-6vqj1j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295488/original/file-20191003-52832-6vqj1j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295488/original/file-20191003-52832-6vqj1j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295488/original/file-20191003-52832-6vqj1j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295488/original/file-20191003-52832-6vqj1j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295488/original/file-20191003-52832-6vqj1j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295488/original/file-20191003-52832-6vqj1j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">One in three Canadian women will seek an abortion in their lifetime.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>But for now, there is stigma and misinformation to contend with. A few persistent inequities complicate matters, making the access landscape seem unintelligible or mystical. For example, <a href="https://globalnews.ca/news/5679094/health-minister-abortion-access-province-letter/">New Brunswick does not insure surgical procedures</a> in a clinic outside of hospital. Ontario will not pay for Mifegymiso if you are living outside the province or if you are a non-Ontario resident. Québec will not allow nurse practitioners to prescribe Mifegymiso. </p>
<p>Unlike <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2012.301159">in the United States</a>, in Canada, nurse practitioners can carry out medical abortion, but not surgical.</p>
<h2>Public education is critical</h2>
<p>We need to <a href="https://www.macleans.ca/politics/lets-retire-the-abortion-debate/">retire all mention of abortion debates</a> and focus on achieving clarity, and universality. The <a href="https://laws-lois.justice.gc.ca/eng/acts/c-6/page-1.html#h-151436">Canada Health Act requires it</a>. </p>
<p>Aligning irregular policies across Canada is the first obvious step. The next is simplifying the path to access by enhancing self-referral processes and reducing wait times for primary care and ultrasound. Expanding the scope of practice of nurse practitioners and midwives to provide both surgical and medical abortion could boost the number of providers. </p>
<p>Most important, however, is increasing factual education about abortion. The public need to know what abortion is and how to get one. Health-care students and professionals need to learn how to include abortion in their practice and how to swiftly and easily refer a patient to the care they need.</p>
<p>Finally, abortion needs to be understood as critical but inadequate for reproductive health. Menstrual health, consent, contraception, trans health services and reproductive mental health all need to make it onto the news, the party platforms and the agenda for our next government.</p>
<p>[ <em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/123904/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Martha Paynter works for a hospital unit that provides abortion care. She receives funding from CIHR for doctoral research on reproductive health. She is affiliated with Women's Wellness Within, a not-for-profit advocacy organization for reproductive justice. She is a member of the New Democratic Party. </span></em></p>Election news coverage of party positions on abortion may confuse the public about the reality and legality of access in Canada.Martha Paynter, PhD Candidate in Nursing, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1202102019-08-07T22:36:01Z2019-08-07T22:36:01Z25 years on: What midwifery in Canada has achieved and what it still needs<figure><img src="https://images.theconversation.com/files/285756/original/file-20190725-136759-p6acls.jpg?ixlib=rb-1.1.0&rect=215%2C5%2C3778%2C2586&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Demand for midwifery services across Canada is now much greater than midwives can currently provide.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>On Jan. 1, 1994, <a href="https://www.ontario.ca/laws/statute/91m31">The Midwifery Act in Ontario</a> was implemented. This was a historic event as Canada was, at that time, the only developed nation in the world without a system of regulated midwifery. </p>
<p>Over the past 25 years, all the other Canadian provinces and territories have followed Ontario by legalizing and funding midwifery — except <a href="https://www.whitehorsestar.com/News/midwifery-rules-on-track-for-year-s-end">Yukon</a> and <a href="https://www.cbc.ca/news/canada/prince-edward-island/pei-midwives-regulation-application-1.4976724">Prince Edward Island</a>, which are planning to do so. </p>
<p>The number of midwives practising across the country has grown remarkably — from 60 in 1994 <a href="https://canadianmidwives.org/category/maps/">to around 1,700 in 2019</a>. They attend nearly 11 per cent of births in the country.</p>
<p>I am a registered midwife in Ontario, as well as an assistant professor in the midwifery education program at McMaster University. I also used midwifery services in the era before legislation and lobbied the Ontario government in the 1980s to include midwifery in the health-care system. And I was accepted into the first class of midwifery students at McMaster in 1993. </p>
<p>I have been a witness to the changes and advances in midwifery over the past 25 years. During this time, there has been great progress in the profession. At the same time, midwives have been on the sidelines of policy decisions. This has made midwives more vulnerable to the whims of governments than those in older, more established health professions, like nurses and physicians. </p>
<h2>From home to hospital births</h2>
<p>Of course, in 1994, we had no way of knowing how much midwifery would grow and how the practice would change. Midwives at that time attended many births at home, while also working to integrate into the hospital setting. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1011389978113388544"}"></div></p>
<p>Each midwife was on-call 24 hours a day, seven days a week, providing care under the principles of continuity of care, informed choice and choice of birth place. Many had to transfer care to an obstetrician if their client needed an induction of labour or wanted an epidural for pain relief.</p>
<p>Now, in the 21st century, midwives manage both inductions and epidurals, and most of the births they attend take place in the hospital. </p>
<p>Many have moved to “shared care” models of care so that midwives can have more time off-call to spend with their families. Some are participating in “collaborative care” projects to serve diverse populations, such as the longstanding <a href="https://www.scbp.ca/">South Community Birth Program</a> in Vancouver.</p>
<h2>Renewal of Indigenous midwifery</h2>
<p>Midwives in Markham Stouffville Hospital in Ontario have developed the <a href="https://www.msh.on.ca/clinics-departments/stollery-family-centre-childbirth-children/alongside-midwifery-unit-amu">new and exciting Alongside Midwifery Unit</a> — the first space of its kind in Canada, offering specially designed birthing rooms for women expecting a normal birth with a midwife. </p>
<p>Other midwives work in freestanding birth centres <a href="http://www.torontobirthcentre.ca/">such as the Toronto Birth Centre</a>. </p>
<p>In Hamilton, a <a href="https://www.thespec.com/living-story/9277470-new-programs-sees-hamilton-midwives-offer-set-it-and-forget-it-birth-control-method/">group of midwives is providing expanded services</a> that include medical abortion and contraception. </p>
<p>Across the country, there has been <a href="https://indigenousmidwifery.ca/">a renewal of Indigenous midwifery</a>, with Indigenous midwives providing care <a href="https://indigenousmidwifery.ca/audio/">rooted in their culture and traditions</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/5vABSuTTrbg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Spirit of Birth. Produced by MAAIINGAN Productions and Frog Girl Films. Directed by Rebeka Tabobondung.</span></figcaption>
</figure>
<p>Regardless of location, demand for midwifery services is much greater than midwives can currently provide.</p>
<h2>Lack of pay equity</h2>
<p>Although midwifery has made great progress, not all news about midwifery is positive. Midwifery services in many parts of Canada are limited and not adequately funded. </p>
<p>A <a href="https://doi.org/10.1016/j.wombi.2018.10.002">recent study of midwives in Western Canada</a> showed high rates of burnout and mental and physical health problems, causing many to consider leaving the profession. </p>
<p>Many midwives, especially those who are aging or who have young families, struggle with the on-call demands of providing care in a continuity of care, or caseload, model. Evidence suggests that <a href="https://doi.org/10.1016/S0140-6736(13)61406-3">this model results in better outcomes for clients</a> — creating a dilemma for midwives who want to provide the best care but also desire better work-life balance.</p>
<p>In Ontario, lack of increases in pay over the past decade led midwives <a href="https://www.tvo.org/article/the-uncertain-future-of-midwifery-in-ontario">to take the government to the Ontario Human Rights Tribunal</a>, arguing that lack of pay equity had led the almost exclusively female profession to fall behind.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1149770161127219200"}"></div></p>
<p>Although the tribunal ruled in favour of the midwives, the <a href="https://www.nationalobserver.com/2019/07/11/news/new-human-rights-challenge-ford-government-says-workload-not-gender-justifies?utm_source=National+Observer&utm_campaign=d20290dad2-EMAIL_CAMPAIGN_2019_07_12_12_22&utm_medium=email&utm_term=0_cacd0f141f-d20290dad2-276861289">current government is seeking to quash the decision</a>. </p>
<p><a href="https://www.cbc.ca/news/canada/windsor/college-of-midwives-ontario-funding-cut-1.4946081">Funding cuts to the College of Midwives</a>, to which midwives must belong, mean that membership fees have increased, further reducing compensation and morale.</p>
<h2>More investment in midwifery needed</h2>
<p>Evidence worldwide shows the <a href="https://www.who.int/workforcealliance/media/news/2013/midwifecochrane/en/">benefits of midwifery-led care for women and babies</a>. </p>
<p>Although midwives in Canada have accomplished many things since 1994, much more needs to be done to make midwifery a sustainable profession that offers the care women wish to receive.</p>
<p>Integrating midwives into decision making and planning for reproductive care, adequately compensating those who do this work and developing flexibility in models of care and scope of practice: these are all paths to building a strong midwifery profession in the years to come.</p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/120210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathi Wilson is an assistant professor in the midwifery education program at McMaster University, Hamilton ON. She has previously received research funding from CIHR and is a member of the New Democratic Party of Canada.</span></em></p>The benefits of midwifery for women and babies globally are clear. In Canada, innovations in midwifery centres and services are tempered by low pay and high rates of burnout.Kathi Wilson, Assistant Professor, Department of Midwifery, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1103392019-01-27T19:43:34Z2019-01-27T19:43:34ZIs the future of abortion online?<figure><img src="https://images.theconversation.com/files/255461/original/file-20190124-196225-650k1q.jpg?ixlib=rb-1.1.0&rect=0%2C15%2C1500%2C907&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women in Mexico City carry a banner reading "Legal and safe abortion across Mexico" during the commemoration of the International Day for the Elimination of Violence Against Women (November 25, 2018).
</span> <span class="attribution"><span class="source">Ronaldo Schemidt/AFP</span></span></figcaption></figure><p>While the abortion debate continues worldwide, even in countries where it has long been legal, new drugs and online telemedicine services could provide access to safe abortion beyond borders and laws.</p>
<p>Since the <a href="https://www.ourbodiesourselves.org/book-excerpts/health-article/a-brief-history-of-birth-control/">early days of the birth-control movement</a>, scientific research and development have contributed significantly to increase the range of options available for managing human fertility and giving women autonomy over their own bodies. One of the most remarkable changes in recent years is medical abortion, a <a href="http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf">non-surgical method for terminating pregnancies</a>. It involves the use of prescription drugs such as Misoprostol and Mifepristone (also known as RU-486), which was <a href="https://openarchive.ki.se/xmlui/handle/10616/41984">developed in France and approved for use in 1989</a>.</p>
<p>Long before the scientific interest in these drugs, however, it was women themselves who first discovered their potential. In Brazil, where abortion is legal only in cases of rape and to save the woman’s life, misoprostol was registered for the treatment of ulcers. The label warned women not to use the pills in case of pregnancy. Understanding the implications, <a href="https://www.tandfonline.com/doi/abs/10.1016/0968-8080(93)90006-F">women started to take misoprostol to induce abortions</a> and its use quickly spread.</p>
<p>Medical abortion is a common practice today and has been shown to be effective for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3766037/">98.3% for women in early pregnancies</a>. The procedure mimics miscarriage and is preferred by many women on the grounds that it is <a href="https://www.plannedparenthood.org/learn/abortion/the-abortion-pill">less invasive</a>. Given the low risk of complications and high success rate of medical abortions, the <a href="http://apps.who.int/iris/bitstream/handle/10665/70914/9789241548434_eng.pdf">World Health Organisation</a> has stated that they do not need to take place in a hospital or clinic.</p>
<p>Home use of abortion pills became legal in <a href="https://news.sky.com/story/women-in-england-able-to-take-abortion-pill-at-home-11481103">Scotland and Wales in 2017</a>, and in August 2018, England followed suit. The US organisation <a href="https://www.plannedparenthood.org/learn/abortion/the-abortion-pill">Planned Parenthood</a> states that: </p>
<blockquote>
<p>“Which kind of abortion you choose all depends on your personal preference and situation. With medical abortion, some people like that you don’t need to have a procedure in a doctor’s office. You can have your medical abortion at home or in another comfortable place that you choose.”</p>
</blockquote>
<h2>Carrying the abortion battle online</h2>
<p>Combining the advent of medical abortion with communication technologies, telemedicine services can provide access to safe abortion worldwide. Run by medical doctors, social workers and even volunteers, such platforms not only furnish women with medical abortion pills, but they also provide counselling and assistance throughout and even after the procedure.</p>
<p><a href="https://www.womenonweb.org/">Women on Web</a> was established in 2006 by a Dutch doctor, <a href="https://www.womenonwaves.org/en/page/2896/rebecca-gomperts%20--%20md%20--%20mpp%20--%20phd">Rebecca Gomperts</a>, who has previously and famously organised <a href="https://www.womenonwaves.org/en/page/493/abortion-on-our-ship">abortion ship campaigns</a> in countries where access to abortion is restricted. Celebrating the 10th anniversary of the website in 2016, the Women on Web community stated that over the past 10 years, more than 200,000 women from over 140 countries received consultation through their website and approximately 50,000 women obtained medical-abortion supplies for home use.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/255455/original/file-20190124-196215-1dzwjbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Abortion pills, Mifepristone and Misoprostol.</span>
<span class="attribution"><span class="source">Women on Web</span></span>
</figcaption>
</figure>
<p>Since Women on Web was launched, telemedicine services that provide abortion care to those living in restrictive settings have proliferated. Even in countries where abortion is restricted by law, these services were able to operate as the custom regulations in most countries <a href="https://www.womenonweb.org/en/page/523/questions-and-answers-overview">allow women to receive prescription medicine for individual use</a>. By navigating around restrictive laws, such organisations have been able to provide safe abortions beyond laws and borders. Several studies have been conducted on the use of telemedicine abortion services, and they concluded that it is <a href="https://www.bmj.com/content/357/bmj.j2011">safe and effective</a> and that outcomes are in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/18637010">same range as the termination of pregnancy provided in outpatient settings</a>. A <a href="https://www.ansirh.org/news/receiving-medication-abortion-through-telemedicine-safe-person">US-based study</a> puts forth that insofar the findings are “sufficiently large to be able to conclude that telemedicine provision of medication abortion is as safe as abortion in person.” It can thus be argued that telemedicine revolutionises access to safe abortions, while <a href="https://www.ncbi.nlm.nih.gov/pubmed/28780241">“putting abortion pills into women’s hands”</a>.</p>
<p>On the other side of the spectrum, rights advocates also warn against <a href="https://www.womenonwaves.org/en/page/974/warning%20--%20fake-abortion-pills-for-sale-online">fake abortion websites and scams</a>. Researchers also underline that telemedicine might be <a href="https://www.bmj.com/content/357/bmj.j2011">more applicable to the context of developed countries</a>, where women have better access to quality care in rare cases of complications. Reproductive-rights activists have asserted that telemedicine prescriptions could <a href="https://www.politico.com/story/2018/07/29/abortion-rights-technology-telemedicine-prescriptions-693328">undercut abortion restrictions</a> and help <a href="https://www.wired.com/story/telemedicine-could-help-fill-the-gaps-in-americas-abortion-care/">fill in the gap in abortion care</a>.</p>
<p>As abortion debates continue to revolve around different socio-political and religious realms, the <a href="https://www.bostonglobe.com/ideas/2018/08/31/the-abortion-debate-doesn-change-but-science-abortion-does/smHRPvw5XDkTXzMUrADawK/story.html">science of abortion has developed tremendously</a>. While abortion rights continue to be restricted in many countries around the world, research has shown that the sitution has already changed thanks to feminist activism, medical advances and telemedicine services.</p><img src="https://counter.theconversation.com/content/110339/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hazal Atay a reçu des financements de la Commission européenne dans le cadre d'Actions Marie Skłodowska-Curie. </span></em></p>While the abortion debate continues worldwide, even in countries where it has long been legal, new drugs and telemedicine services could provide access to safe abortion beyond borders and laws.Hazal Atay, Ph.D candidate, INSPIRE Marie Skłodowska-Curie Fellow, Sciences Po Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/921732018-02-28T08:26:08Z2018-02-28T08:26:08ZFactCheck: do women in Tasmania have access to safe abortions?<blockquote>
<p>People are absolutely appalled that in one of our states women are not getting access to safe terminations, and what I know is that in any decent society we ensure that all women have access to those choices and right now people in Tasmania are being deprived of that.</p>
<p><strong>– Australian Greens leader Richard Di Natale, speaking at the Tasmanian Greens election launch in Hobart, February 21, 2018</strong></p>
</blockquote>
<p>Access to elective abortions has become a key point of policy difference between the Tasmanian Liberal and Labor parties in the state election to be held this Saturday.</p>
<p>Abortion was decriminalised in Tasmania in 2013, but elective surgical and medical abortions remain unavailable through the state’s public health system, and Tasmania’s last dedicated surgical abortion clinic <a href="http://www.themercury.com.au/news/tasmania/why-tasmanian-woman-have-lost-abortion-access-in-the-state/news-story/ba08e3a36b570456a54f8405b39d1293">recently closed</a>. </p>
<p>The incumbent Tasmanian Liberal government is <a href="http://www.abc.net.au/news/2018-01-31/tas-abortion-policies-revealed/9378756">offering financial assistance</a> to women who travel to the mainland to have a surgical abortion, but has ruled out funding elective abortions through the public system.</p>
<p>The opposition Labor party has <a href="http://www.thecourier.com.au/story/5202149/public-health-abortions-under-tas-labor/">pledged</a> to make surgical abortions available through Tasmania’s public health system, if elected.</p>
<p>At the launch of the Tasmanian Greens state election campaign in Hobart, Australian Greens leader Richard Di Natale said that “in one of our states women are not getting access to safe terminations”.</p>
<p>Was Di Natale correct?</p>
<h2>Checking the source</h2>
<p>The Conversation contacted Richard Di Natale’s office to request sources, but a spokesperson for the Australian Greens leader declined to comment.</p>
<hr>
<h2>Verdict</h2>
<p>At the launch of the Tasmanian Greens state election campaign in Hobart, Australian Greens leader Richard Di Natale said that “in one of our states women are not getting access to safe terminations”. With reference to Tasmania, this statement is incorrect. </p>
<p>However, Di Natale added that “in any decent society we ensure that all women have access to those choices, and right now people in Tasmania are being deprived of that”. This is a fair statement. </p>
<p>Elective medical and surgical abortions are legal and available in Tasmania. </p>
<p>However, not all women may be able to access these services.</p>
<p>Abortions are only provided in the Tasmanian public health system in extraordinary circumstances – for example, in cases of foetal abnormality or to save the life of a pregnant woman or to prevent her serious physical injury.</p>
<p>Otherwise, women must access these services through the private sector. There are very few health professionals providing these services in Tasmania. Women may face challenges in locating, travelling to and paying for abortion services. </p>
<p>Young women, those living in rural areas and women of low socioeconomic status may be most disadvantaged.</p>
<hr>
<h2>Access to safe abortions in Tasmania</h2>
<p>There are two safe ways for a woman to terminate a pregnancy – by surgical abortion, or by medical abortion. Both surgical and medical abortions are available and legal in Tasmania.</p>
<p>However, abortions by request are only offered in the private sector, and for a fee. </p>
<p>Tasmania’s public health system does not accept referrals for abortion by <a href="http://outpatients.tas.gov.au/clinics/obstetrics">request</a>. In the public system, abortions can be provided in cases of <a href="https://www.primaryhealthtas.com.au/sites/default/files/POP_WAC_RES_140728_V1%20a_Updated%20AC%20for%20General%20Practice%20Info%20Kit%202015.pdf">foetal abnormality</a> or to <a href="https://www.legislation.tas.gov.au/view/html/inforce/current/act-2013-072#HP2@EN">save the life</a> of a pregnant woman or to prevent her serious physical injury.</p>
<h2>Accessing surgical abortions in Tasmania</h2>
<p>In Tasmania, surgical abortions can be provided <a href="http://www5.austlii.edu.au/au/legis/tas/consol_act/rhtta2013435/s4.html">up to 16 weeks gestation</a>.</p>
<p>A surgical abortion involves the use of a local or general anaesthetic, and is performed by a medical practitioner, such as a gynaecologist or surgeon, in a day clinic or a hospital theatre in line with National Safety and Quality Health Service Standards, which are set by the <a href="https://www.safetyandquality.gov.au/">Australian Commission on Safety and Quality in Health Care</a> . </p>
<p>The woman must find a private gynaecologist willing to perform the procedure. </p>
<p>There are 39 gynaecologists accredited by the <a href="https://www.ranzcog.edu.au/">Royal Australian and New Zealand College of Obstetricians and Gynaecologists Fellows</a> in Tasmania. But the not-for-profit organisation <a href="http://www.fpt.asn.au/">Family Planning Tasmania</a> told The Conversation they were aware of only two accredited gynaecologists who offer surgical abortion services.</p>
<p>These services come at a cost. Family Planning Tasmania told The Conversation that one surgical abortion health professional in the south of the state offers elective surgical abortions at a cost of A$2,500 per procedure.</p>
<p>Medicare will cover <a href="http://www9.health.gov.au/mbs/search.cfm?q=35643&sopt=I">some of the costs</a> of the procedure, including the cost of the anaesthetic and the clinician fees. However, women will have out of pocket costs.</p>
<p>For example, a <a href="https://www.clinic66.com.au/f-terminate-surgical-medical.asp">clinic in Sydney</a> has a fee of A$750 for a surgical abortion, with the Medicare rebate covering A$400 of this.</p>
<p>Given that there appears to be only two providers offering elective surgical terminations in Tasmania, some women may need to travel within the state, or to other states, to access a surgical abortion. This could incur additional travel and accommodation costs.</p>
<p>If a woman suffers complications after the procedure, she would need to return to the private clinic (which may incur additional costs) or go to her local emergency department. </p>
<p>To access an elective surgical abortion <a href="http://www5.austlii.edu.au/au/legis/tas/consol_act/rhtta2013435/s5.html">beyond 16 weeks</a> gestation in Tasmania two medical practitioners must be involved – at least one of whom needs to be a specialist in obstetrics or gynaecology. They must both agree that the continuation of the pregnancy would involve greater risk of injury to the physical or mental health of the pregnant woman, than if the pregnancy were terminated.</p>
<h2>Accessing medical abortions in Tasmania</h2>
<p>For medical abortions in Australia, the registered medication MS-2 Step is <a href="https://www.ebs.tga.gov.au/ebs/picmi/picmirepository.nsf/pdf?OpenAgent&id=CP-2014-PI-01965-1&d=2018022816114622483">recommended</a> for use up to nine weeks gestation. </p>
<p>A medical abortion involves the use of two <a href="https://www.tga.gov.au/behind-news/registration-mifepristone-linepharma-ru-486-and-gymiso-misoprostol">oral medications</a>: mifepristone linepharma (also known as RU 486) and misoprostol (also known as GyMiso).</p>
<p>Early medical abortion with mifepristone and misoprostol is <a href="http://www.contraceptionjournal.org/article/S0010-7824(12)00643-9/abstract">highly effective and safe</a> and can be safely used in a woman’s <a href="https://www.scielosp.org/scielo.php?pid=S0042-96862011000500012&script=sci_abstract&tlng=ar">own home</a>.</p>
<p><a href="https://www.tga.gov.au/behind-news/registration-mifepristone-linepharma-ru-486-and-gymiso-misoprostol">Specifically trained</a> medical practitioners, including general practitioners (GPs), can prescribe these medications to women during a face-to-face appointment, or over the phone.</p>
<p><strong>Face-to-face appointments</strong></p>
<p>A woman must find a GP or private gynaecologist who has undergone the <a href="https://www.ms2step.com.au/">accredited training</a> required to prescribe the medications. Family Planning Tasmania told The Conversation that while 43 GPs are trained to offer medical abortion services, they are only aware of three who currently offer the service.</p>
<p>These services also come at a cost. A consultation for medical abortion may be covered by Medicare, but some GPs or gynaecologists may charge a gap payment, requiring women to pay the difference as an out-of-pocket expense. </p>
<p>Women seeking these services are required to have an ultrasound to confirm the pregnancy is less than nine weeks gestation, and have a blood test. This may incur additional out-of-pocket costs associated with ultrasounds and other tests where Medicare does not cover the providers’ fees. Women from rural areas where ultrasound services may not be available may need to travel to access these services.</p>
<p>The medical provider <a href="https://www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical%20-%20Gynaecology/Use-of-mifepristone-for-medical-termination-of-pregnancy-(C-Gyn-21)-Amended-February-2016_1.pdf?ext=.pdf">must</a> also locate a hospital willing to provide specialist support in the case of complications. This can be difficult. </p>
<p>GPs in New South Wales <a href="https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-017-0303-8">have reported</a> that health professionals in public hospitals are often reluctant or unwilling to be involved in providing care associated with abortions.</p>
<p>The medical abortion drugs are listed on the Pharmaceutical Benefits Scheme and cost <a href="http://www.pbs.gov.au/medicine/item/10211K">approximately A$39.50</a>, or less if women have a health card. Most women will have their prescription for medical abortion drugs filled by a pharmacist <a href="https://www.ms2step.com.au/register.html">registered with MS Health</a>. </p>
<p>However, according to <a href="http://sydney.edu.au/pharmacy/about/people/profiles/betty.chaar.php">Dr Betty Chaar</a> at the University of Sydney, pharmacists registered with MSHealth may, in special circumstances and in consultation with the doctor, send medications via post or courier.</p>
<p><strong>Telephone prescriptions</strong> </p>
<p>Tasmanian women can also request medical abortion medication over the telephone from two private providers: the <a href="https://www.tabbot.com.au/">Tabott Foundation</a> and <a href="https://www.mariestopes.org.au/abortion/home-abortion/">Marie Stopes Australia</a>.</p>
<p>Women must call one of the private service providers to have a consultation with a doctor over the phone. They will also be required to have an ultrasound to confirm the pregnancy is less than nine weeks gestation, and have a blood test. </p>
<p>Again, this may incur additional out-of-pocket costs, and present challenges for women from rural areas in particular.</p>
<p>Where appropriate, the providers will mail or courier the medication to the women. Women receive over the phone 24-hour nurse aftercare following their abortion.</p>
<p>Women who suffer complications must travel to their nearest emergency department.</p>
<p>The Tabbot Foundation <a href="https://www.tabbot.com.au/medical-abortion/abortion-cost.html">offers this service</a> for A$250 to women with a valid Medicare card, and A$600 to those without. However, this does not include the cost of additional services, including the necessary ultrasound and blood test, or any costs associated with complications.</p>
<p>Tabott Foundation medical director Dr Paul Hyland told me that since February 2017, 313 women had been prescribed medical abortion medication via the Tabbot tele-medicine service.</p>
<p>The reproductive health company Marie Stopes Australia has no clinics in Tasmania, but does <a href="https://www.mariestopes.org.au/bookings/prices/">offer</a> home abortion by phone. This service starts from a cost of A$290, though this varies depending on Medicare card availability and excludes the cost of the medication, the required medical tests and emergency care. </p>
<p>It’s worth restating that medical abortions are only available to women up to nine weeks gestation. After nine weeks gestation, a woman would need to seek a surgical abortion. As outlined above, there are very few medical professionals who provide this service in Tasmania. </p>
<h2>Finding information about abortion services in Tasmania isn’t always easy</h2>
<p>Women in Tasmania can find information about terminations from not-for-profit organisations like Family Planning Tasmania or other <a href="http://www.dhhs.tas.gov.au/__data/assets/pdf_file/0003/151725/Terminations_Act_Postcard_v4.pdf">community health services</a>.</p>
<p>However, this information is generally not publicly available.</p>
<p>This lack of information, as well as the costs that women must incur, constitute significant barriers to accessing abortion in Tasmania.</p>
<p>Tasmanian women may face further barriers to abortion, as noted in other Australian <a href="https://www.tandfonline.com/doi/abs/10.1080/13625187.2016.1276162">research</a>. This can include conscientious objection from health professionals, unwanted counselling, harassment from protesters and gestational limits requiring the approval of more than one health provider. </p>
<p>International <a href="https://www.sciencedirect.com/science/article/pii/S0140673616303804">research</a> has found that places where abortion is difficult to access are associated with higher maternal mortality and unsafe abortion rates.</p>
<p>Barriers to abortion access in Australia particularly affect <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1467-842X.2006.tb00844.x/full">young women</a>, <a href="http://onlinelibrary.wiley.com/doi/10.1111/ajr.12096/full">those in rural areas</a> and women of low socioeconomic status. <strong>– Angela Dawson</strong></p>
<h2>Blind review</h2>
<p>This article presents a comprehensive overview of the availability of abortion services in Tasmania. </p>
<p>It’s worth clarifying that <a href="http://www.parliament.tas.gov.au/bills/pdf/19_of_2016.pdf">children under the age of 16</a> have access to abortion in Tasmania, but they need to be deemed capable of consenting to the procedure. </p>
<p>This decision is made by a GP and is based on several factors, such as the age and maturity of the individual. People under the age of 16 need not obtain parental consent to have an abortion.</p>
<p>Another area of relevance is the issue of conscientious objection. Doctors and nurses have the right to conscientiously object to participation in terminations under the <a href="http://www7.austlii.edu.au/cgi-bin/viewdb/au/legis/tas/num_act/rhtta201372o2013481/">Tasmanian Reproductive Health (Access to Terminations) Act 2013</a>. The only exception to the rule is when a woman is at risk of death or serious injury.</p>
<p>Doctors, however, are required to provide women with a full list of prescribed health services if they become “aware that the woman is seeking a termination or advice regarding the full range of pregnancy options”. They have an obligation to refer patients to abortion services where this is requested. <strong>– Xavier Symons</strong></p>
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<p><em>The Conversation’s FactCheck unit is the first fact-checking team in Australia and one of the first worldwide to be accredited by the International Fact-Checking Network, an alliance of fact-checkers hosted at the Poynter Institute in the US. <a href="https://theconversation.com/the-conversations-factcheck-granted-accreditation-by-international-fact-checking-network-at-poynter-74363">Read more here</a>.</em></p>
<p><em>Have you seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at <a href="mailto:checkit@theconversation.edu.au">checkit@theconversation.edu.au</a>. Please include the statement you would like us to check, the date it was made, and a link if possible.</em></p><img src="https://counter.theconversation.com/content/92173/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angela Dawson receives funding from the NHMRC, ARC, The Federal Department of Health and the WHO. She is affiliated with the Public Health Association of Australia and the Inter-agency Working Group for Reproductive Health in Crisis.</span></em></p><p class="fine-print"><em><span>Xavier Symons does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In Hobart supporting the Tasmanian Greens ahead of the state election, Greens leader Richard Di Natale said ‘in one of our states, women are not getting access to safe terminations’. Is that correct?Angela Dawson, Associate Professor of Public Health, Faculty of Health, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/898122018-01-10T12:11:30Z2018-01-10T12:11:30ZAbortion rights: the DUP doesn’t seem to mind ‘regulatory divergence’ on this one important issue<p>The Democratic Unionist Party has consistently <a href="https://theconversation.com/brexit-deal-breaks-deadlock-experts-react-88879">stressed</a> that it will reject any Brexit deal which creates a regulatory divergence between Northern Ireland and the rest of the UK.</p>
<p>This position has had a significant impact on Brexit talks to date. The British government has jumped through hoops to reassure the DUP that its promise not to impose a hard border between Northern Ireland and the Republic of Ireland won’t also result in some kind of border emerging between Northern Ireland and the rest of the UK.</p>
<p>For a time, it looked as though Northern Ireland might be handed some kind of special status after Brexit. This was in order to avoid having to introduce customs checks at the border with the republic and to ensure the continued effective implementation of the <a href="http://www.europarl.europa.eu/RegData/etudes/BRIE/2017/583116/IPOL_BRI(2017)583116_EN.pdf">Good Friday Agreement</a>. DUP leader Arlene Foster said she would block any such move. Northern Ireland is part of the UK, the DUP argues, and must therefore continue to live by the same rules as the UK, not Europe.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"937692999697485825"}"></div></p>
<p>This perspective may be expected from a hardline unionist political party, but it’s hypocritical. Northern Ireland diverges from the rest of the UK on a number of matters, the majority of which have been consistently supported by the DUP. The party supports devolving power to the Northern Ireland Assembly to set corporation tax and air passenger duty, for example. That’s largely in the hope of competing with the Republic of Ireland for business. Same-sex marriage also remains banned.</p>
<p>What’s more, Northern Ireland diverges from the UK on the key matter of abortion. It has failed to adopt the 1967 British Abortion Act and continues to implement an archaic system. Procedures are only available in the most extreme circumstances. </p>
<p>This doesn’t mean, however, that women from Northern Ireland don’t have abortions. Almost <a href="http://www.niassembly.gov.uk/globalassets/documents/raise/knowledge_exchange/briefing_papers/series5/dr-bloomer-and-dr-hoggart-version-2.pdf">1,000 women</a> travel to England each year to access abortion services. Until <a href="https://www.theguardian.com/world/2017/jun/29/rebel-tories-could-back-northern-ireland-abortion-amendment">mid 2017</a>, they had to pay as private patients while all other British citizens were entitled to free care on the NHS. Countless others access the abortion pill online illegally, and have been <a href="https://www.theguardian.com/world/2017/jan/26/ulster-woman-who-bought-abortion-pills-for-daughter-can-challenge-prosecution">prosecuted</a> for doing so.</p>
<p>The DUP’s staunch opposition to any relaxation of abortion laws highlights the party’s ability to put aside the importance of consistency within the United Kingdom when it suits its political beliefs.</p>
<p>In fact, <a href="http://www.niassembly.gov.uk/globalassets/documents/raise/knowledge_exchange/briefing_papers/series6/bloomer161116.pdf">analysis</a> conducted on the five political debates which have taken place in Stormont on the issue since 2000 (with Dr Fiona Bloomer of Ulster University) highlights something quite surprising. DUP party members actually tend to subvert their unionism when discussing abortion. They reaffirm an all-island affinity on the issue and a united religious and political front. They refer to abortion as a topic that brings together Protestant and Catholic communities.</p>
<p>During a 2013 debate on the provision of abortion services in Belfast by the private provider Marie Stopes International, for example, DUP member Paul Givan illustrated a lack of concern for overarching legal consistency within the UK:</p>
<blockquote>
<p>Across the island of Ireland, we share a common bond in seeking to protect and provide the best care for mothers and unborn children. We are recognised globally as one of the premier providers of maternal care. That this common political bond has been replicated across our religious communities is demonstrated by support from the Church of Ireland, the Presbyterian Church in Ireland and the Catholic Church. People ask what a shared future looks like, and I point to this moment of an SDLP, DUP and Ulster Unionist bringing forward proposed legislation related to the most basic of human rights; the right to life.</p>
</blockquote>
<p>Much of this rhetoric is misleading. Contemporary <a href="http://www.ark.ac.uk/publications/updates/update115.pdf">opinion polls</a> indicate that both Catholic and Protestant communities are supportive of at least limited reform of abortion law. <a href="https://www.theguardian.com/uk-news/2017/aug/04/northern-irish-unionist-parties-alienating-young-protestants-study">Research</a> has highlighted that pro-unionist under-40s feel largely underrepresented by parties in the region because of the social conservatism of most unionist parties.</p>
<p>Meanwhile, the majority of Northern Ireland voted against Brexit, yet the DUP continues to push an agenda that views a border with Ireland as preferable to a border with the rest of the UK. </p>
<p>The DUP seem to use different identities to support the limitation of rights to particular groups in Northern Ireland. This is increasingly worrying given the high stakes of Brexit and the powerful role the party now plays in Westminster through its <a href="https://theconversation.com/conservatives-strike-deal-with-the-dup-experts-react-80101">pact</a> with the Conservative Party.</p>
<p>The hypocrisy of the DUP when reiterating their opposition to regulatory divergence between Northern Ireland and the rest of the UK will be felt most keenly by those women from Northern Ireland who must continue to travel to England to access abortion services or who are forced to procure their abortion illegally online.</p><img src="https://counter.theconversation.com/content/89812/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Pierson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Northern Irish party were horrified at the suggestion that Brexit might mean different customs rules. But when it comes to women’s rights, it’s a different story.Claire Pierson, Lecturer in Politics, University of LiverpoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/749922017-03-24T00:15:21Z2017-03-24T00:15:21ZDecriminalisation in the NT signals abortion is part of normal health care<figure><img src="https://images.theconversation.com/files/162301/original/image-20170324-4967-qhypgk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The long road to abortion reform in the NT has been made possible by community campaigns, and gender parity in the lower house.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/yewenyi/239043861/">Brian Yap/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The Northern Territory parliament this week passed <a href="http://www.austlii.edu.au/au/legis/nt/bill/toplrb2017373/">a bill</a> decriminalising abortion up to 24 weeks’ gestation, removing the requirement of parental approval for abortions in teenagers and providing early medical abortions with tablets. </p>
<p>Decriminalisation is important as it signals to the community that abortion is part of gynaecological care and should not be treated differently to any other form of health care. Abortion remains in the <a href="http://www.abc.net.au/news/2017-02-28/abortion-decriminalisation-bills-withdrawn-from-parliament/8309788">criminal codes</a> of Queensland and New South Wales despite recent reform attempts. </p>
<p>A majority of countries have liberalised access to safe abortion as opposed to risky illegal abortion. The Centre for Reproductive Rights has a useful <a href="http://worldabortionlaws.com/map/">comparative map</a> of abortion laws although it is not nuanced for Australia. </p>
<p>Data on abortion is poorly collected and analysed in the Northern Territory, but the new bill will ensure data will be collected for public health policy purposes.</p>
<h2>Choices in women’s health</h2>
<p>Previously NT women had no legal access to early medical abortion using the abortion medications mifepristone and misoprostol up to nine weeks and were only offered surgical abortions in three hospitals. </p>
<p>Early medical abortion has been legal in all <a href="http://www.westlaw.com.au/maf/wlau/app/document?docguid=Iacf32374839511e6881a84759648e093&isTocNav=true&tocDs=AUNZ_AU_JOURNALS_TOC&startChunk=1&endChunk=1">other states and territories</a>. The old <a href="https://legislation.nt.gov.au/Legislation/MEDICAL-SERVICES-ACT">Medical Services Act</a> from 1974 that regulated abortion, stipulated that two doctors needed to be involved in the management, one of them being a specialist. This limited service was inadequate and out of step with modern gynaecology. </p>
<p>NT women and doctors will be able to use early medical abortion in general medical practices, health clinics and home settings. Women seeking termination services in regional, rural and remote areas face <a href="https://www.ncbi.nlm.nih.gov/pubmed/26987999">barriers to health care</a> including finding a doctor, stigma, financial costs, and lack of privacy. </p>
<p>The bill enables significant improvements to women’s reproductive health, especially in a jurisdiction that struggles with health service provision and a challenging geography. </p>
<p>The bill also places safe access zones around clinics for health staff and women in a similar way to <a href="https://theconversation.com/state-by-state-safe-access-zones-around-clinics-are-shielding-women-from-abortion-protesters-51407">Victorian and Tasmanian legislation</a>. The safe access zone will protect women and staff from intentional harassment, intimidation, obstruction or invasion of privacy. This also includes the recording of people leaving or entering health clinics and has penalties attached to this type of behaviour. </p>
<p>The bill also specifically references conscientious objection and the need for a health practitioner who holds anti-abortion beliefs to refer the woman to another health practitioner who does not. This is similar to <a href="https://theconversation.com/explainer-is-abortion-legal-in-australia-48321">Victorian and Tasmanian legislation</a> and the national <a href="https://ama.com.au/position-statement/conscientious-objection-2013">Australian Medical Association position statement</a>. </p>
<h2>Indigenous women’s health needs</h2>
<p>The NT has a large minority (30%) of Aboriginal women who have <a href="http://www.rrh.org.au/publishedarticles/article_print_1383.pdf">higher maternal rates of death and illness</a> than other women. During <a href="https://parliament.nt.gov.au/parliamentary-business/hansard-debates-and-minutes-of-proceedings/draft-daily-hansard,-questions-and-minutes/DEBATES-DAY-4-21-MARCH-2017.pdf">debate in parliament some members</a> suggested that providing access to termination choices would be unsafe for Indigenous women in remote communities and that Indigenous women would not be able to understand aspects of their reproductive health. </p>
<p>The paternalistic and racist attitudes were called out by Mr Chansey Paech, Ms Selena Uibo and Ms Ngaree Ah Kit, Indigenous members of the legislative assembly who <a href="https://parliament.nt.gov.au/parliamentary-business/hansard-debates-and-minutes-of-proceedings/draft-daily-hansard,-questions-and-minutes/DEBATES-DAY-4-21-MARCH-2017.pdf">argued for legal equity</a>.</p>
<p>This bill took four and a half years of public advocacy to be passed and there were several reasons for its success in 2017. The first is overwhelming public support for equity in health care and a <a href="https://www.facebook.com/WhatRU4NT/">strong community campaign</a>. </p>
<p>The second reason is 50% of the members of the <a href="http://www.ntnews.com.au/news/northern-territory/northern-territory-parliament-to-contain-record-number-of-female-politicians/news-story/756669971495352038c2ec6e8a592d0e">13th Legislative Assembly are women</a>. No state or federal parliament in Australia has this level of female representation. Women are better placed to understand women’s health needs and women in the NT were lacking this representation until gender parity in the lower house of parliament in 2016.</p>
<h2>Addressing discrimination in health care</h2>
<p>This legislation will reduce discrimination against women and go some way to meeting Australia’s obligations under the <a href="http://www.un.org/womenwatch/daw/cedaw/">United Nations Convention of Elimination of all forms of Discrimination Against Women</a>. </p>
<p>Termination of pregnancy enables women to manage their <a href="http://apps.who.int/iris/bitstream/10665/70914/1/9789241548434_eng.pdf?ua=1">health and fertility, decreases maternal disability and death</a>, and reduces unwanted motherhood. All of which are positive outcomes.</p>
<p>However, unwanted, mistimed and unviable pregnancies are not welcome events in women’s lives and may be indicators of poor health, genetic or contraceptive chance, social disadvantage, poor sexual and reproductive literacy, low reproductive autonomy, or lack of access to quality sexual and reproductive health staff and services. Some of these precursors to unwanted pregnancy need attention if abortion rates are to be reduced in Australia.</p><img src="https://counter.theconversation.com/content/74992/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Belton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond the appointments above.Suzanne Belton is the President of Family Planning Welfare Association NT and is Adjunct staff at Menzies School of Health Research. She is a member of the Public Health Association NT and the Health Alliance NT.
</span></em></p>Decriminalisation is important as it signals to the community that abortion is part of gynaecological care and should not be treated differently to any other form of health care.Suzanne Belton, Associate professor, Menzies School of Health ResearchLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/157222013-07-03T20:36:23Z2013-07-03T20:36:23ZFinally, greater access to RU486 – now let’s collect abortion data<figure><img src="https://images.theconversation.com/files/26779/original/3x9cbmn7-1372832105.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Data will allow us to monitor the quality, safety and access to abortion across the country.</span> <span class="attribution"><span class="source">datalicious/flickr</span></span></figcaption></figure><p>Medical abortions will finally be easily available to Australian women when the drug RU486 (mifepristone and misoprostol) is <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr13-tp-tp068.htm">listed on the Pharmaceutical Benefits Scheme</a> (PBS) from August 1, 2013. But without a national data collection system, we still won’t be able to monitor the quality, safety or access to abortion.</p>
<p>The listing has the potential to allow more equitable access to abortion services as the <a href="http://www.pharmacynews.com.au/news/latest-news/controversial-abortion-drugs-receive-pbs-listing">cost of the drugs</a> falls from around $300 to about $36. It will also enable a wider group of practitioners to deliver abortion services and may lead to improved access to abortion for women in rural areas.</p>
<p>This is good news, but it’s not enough. Right now, we don’t even know how many abortions are done in Australia each year, either overall or in sub-groups, such as different age groups or areas of residence. </p>
<p>This means claims that abortion rates are increasing or decreasing, overall or in some populations such as teenagers or older women who mistakenly believe they are no longer fertile, are just that – claims that cannot be tested or verified. </p>
<p>It also means we can’t evaluate whether health promotion efforts to prevent unplanned and unwanted pregnancies (and reduce abortion rates) are effective. Or whether they are cost-effective or if there are trends that reflect problems with access.</p>
<p>The lack of data also means we have no way of monitoring the availability of service in different areas, particularly outside large cities. We have anecdotal reports that women struggle to access abortion in rural towns, and this access may improve with the introduction of medical abortions. Or it may not. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/26784/original/ch46wgm9-1372832627.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/26784/original/ch46wgm9-1372832627.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=557&fit=crop&dpr=1 600w, https://images.theconversation.com/files/26784/original/ch46wgm9-1372832627.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=557&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/26784/original/ch46wgm9-1372832627.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=557&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/26784/original/ch46wgm9-1372832627.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=700&fit=crop&dpr=1 754w, https://images.theconversation.com/files/26784/original/ch46wgm9-1372832627.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=700&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/26784/original/ch46wgm9-1372832627.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=700&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prior to the PBS listing, early medical abortion was only available in certain clinics in Australia.</span>
<span class="attribution"><span class="source">Max Vario/Flickr</span></span>
</figcaption>
</figure>
<p>Without data, we just can’t know.</p>
<p>Indeed, without quality data we can’t comprehensively monitor clinical outcomes, such as complications. And that makes it more difficult to improve quality of care if and when that’s needed.</p>
<p>These deficiencies have existed for decades for surgical abortions. They are even more pressing now that medical abortion may be possible to get through your local doctor.</p>
<p>Routine collection of statistics about medical services ensures transparency of access, accountability about outcomes and helps plan where, when and how services need to be delivered.</p>
<p>That’s why we have routine data collection for hospital admissions (<a href="http://www.aihw.gov.au/national-hospital-morbidity-database/">National Hospital Morbidity Database</a>), joint replacements (<a href="http://www.registries.org.au/registries/aoa_njrr.html">Australian Orthopaedic Association Joint Replacement Register</a>) and immunisations for children (<a href="http://www.humanservices.gov.au/customer/services/medicare/australian-childhood-immunisation-register">Australian Childhood Immunisation Register</a>), among many other things. Such data collections are at the core of a modern health-care system.</p>
<p>These data sets allow us to look at quality and safety of care. They allow us to measure how long people wait in emergency departments, the number of complications from different surgeries, how well different joint replacements work, and how many and what types of adverse events happen in hospitals. The compiled statistics are important sources of information for doctors, patients and planners.</p>
<p>We need the same for abortion statistics. In <a href="http://www.health.sa.gov.au/pehs/pregnancyoutcome.htm">South Australia</a> and <a href="http://www.health.wa.gov.au/publications/documents/Abortion_Report_06-09.pdf">Western Australia</a>, we have the beginnings of the solution. In these states, there are notification systems that require information about surgical abortions to be systematically recorded. We now need the same data – uniformly and confidentially collected – nationally. And it must cover medical abortion information as well. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/26780/original/kc69gvqn-1372832130.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/26780/original/kc69gvqn-1372832130.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=866&fit=crop&dpr=1 600w, https://images.theconversation.com/files/26780/original/kc69gvqn-1372832130.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=866&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/26780/original/kc69gvqn-1372832130.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=866&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/26780/original/kc69gvqn-1372832130.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1089&fit=crop&dpr=1 754w, https://images.theconversation.com/files/26780/original/kc69gvqn-1372832130.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1089&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/26780/original/kc69gvqn-1372832130.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1089&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Misoprostol is one of the drugs which leads to medical abortion.</span>
<span class="attribution"><span class="source">kamagrarx/flickr</span></span>
</figcaption>
</figure>
<p>Early medical abortion (abortion in the first seven weeks of pregnancy using a combination of the drugs mifepristone and misoprostol) involves an initial dose of medication plus a follow-up dose to be taken at home 24 to 48 hours later. Women are strongly encouraged to have a follow-up visit two weeks later to confirm pregnancy termination and to exclude complications.</p>
<p>The procedure has been shown to be <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3089386/">highly effective and safe</a> and is in use in many countries including France and the United States. Prior to recent changes, a number of practitioners obtained access to mifepristone through the authorised prescriber scheme. Marie Stopes clinics became one of the main providers through this scheme.</p>
<p>The notification systems in South Australia and Western Australia need to be expanded to cover surgical abortions and medical abortions provided through all GPs, hospitals and clinics nationally. As with other collections of health statistics, information would need to be confidential and secure so it can’t be used to stigmatise women. </p>
<p>Published aggregated numbers in regional or remote areas would need to be large enough so that individuals in small towns couldn’t possibly be identified. </p>
<p>The decision to fund RU486 on the PBS acknowledges the importance of a full range of reproductive services for women’s health and well-being (mifepristone is on the World Health Organisation <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC558642/">list of essential medicines</a>). Now we need to make sure abortion is not just available, but covered by the same systems of quality assurance and evaluation as any other medical service. </p>
<p><em>This is has a correction. It previously said early medical abortions had only be available in Australia through Marie Stopes clinics prior to RU486 being listed on the PBS.</em> </p><img src="https://counter.theconversation.com/content/15722/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Angela Taft is a former National Convenor of the Women's Health Special Interest Group of the Public Health Association of Australia. As Convenor she was actively involved in advocating for the importation and listing of mifepristone on the PBS.</span></em></p><p class="fine-print"><em><span>Juliet Richters receives funding from NHMRC and ARC.</span></em></p><p class="fine-print"><em><span>Alexandra Barratt and Kirsten Black do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Medical abortions will finally be easily available to Australian women when the drug RU486 (mifepristone and misoprostol) is listed on the Pharmaceutical Benefits Scheme (PBS) from August 1, 2013. But…Alexandra Barratt, Professor of Public Health, University of SydneyAngela Taft, Associate Professor in Public Health, La Trobe UniversityJuliet Richters, Associate Professor in Sexual Health, UNSW SydneyKirsten Black, Lecturer in Obstetrics and Gynaecology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/117322013-01-24T03:39:46Z2013-01-24T03:39:46ZStill keeping women out: a short history of Australian abortion law<figure><img src="https://images.theconversation.com/files/19581/original/7mgsrrpg-1358994458.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women all over the Western world, such as these protestors in Paris in1972, have had to fight for abortion rights.</span> <span class="attribution"><span class="source">Marina Urquidi</span></span></figcaption></figure><p>Tuesday marked the 40th anniversary of the US Supreme Court decision in Roe v Wade (410 U.S. 113 (1973)), which found that Texas State law prohibiting abortion was unconstitutional. The landmark decision continues to be celebrated globally and is seen by many as ushering in a new era of abortion law reform although reform in Australia started on a similar model in the 1960s. </p>
<p>But victory in Roe v Wade has proved a mixed blessing and, in some respects, its continuing influence has helped entrench a second-best approach to women’s autonomy. </p>
<p>Australian abortion law has largely followed the logic of “medicalisation” of abortion in Roe v Wade. In Australia this legal approach means that, contrary to second-wave feminist demands, only doctors – not nurses or midwives – are legally authorised to perform surgical abortion procedures. </p>
<h2>Roe v Wade</h2>
<p>One immediate effect of Roe v Wade was to override all state laws prohibiting abortion performed by doctors, at least until the point of presumed viability of the foetus. The second effect was to entrench medical authority over abortion governance and procedure. </p>
<p>The case marked the culmination of a decade of feminist and medical campaigns to secure abortion rights in the United States. </p>
<p>While feminists as diverse as New York’s <a href="http://www.redstockings.org/">Redstockings</a> and the <a href="http://now.org/">National Organisation for Women</a> demanded the repeal of all abortion laws, from 1970 the <a href="http://www.ama-assn.org/">American Medical Association</a> and the <a href="http://www.aclu.org/">American Civil Liberties Union</a> transformed the focus of mainstream campaigns from repeal to reform. </p>
<p>This sidelined the most radical and materialist claims of the women’s movement – that abortion was a political claim essential for all women’s autonomy and full human rights – and set the medically-focused parameters for the judgement in Roe v Wade.</p>
<h2>In Australia</h2>
<p>The lack of a bill of rights or similar constitutional instrument in Australia means there’s been no high court finding on abortion here. Instead, campaigners have targeted state and territory legislatures – to varying degrees of success. But here too, the medicalisation of abortion has prevailed. </p>
<p>Historically, the colonies that constituted pre-Federation Australia prohibited abortion based on laws replicating 19th century British criminal prohibitions. These had always allowed the exception of “therapeutic” abortions performed by doctors to save the woman’s life. </p>
<p>In 1938, the English case of Bourne (King v Bourne [1939] 1 KB 687) clarified the criminal defence of abortions performed by doctors to save a woman’s life, broadly interpreted to include psychological factors. The judgement confirmed the authority of the medical establishment over abortion and was understood as persuasive authority in Australian jurisdictions. </p>
<p>Still, the legal and clinical situation remained undesirable and was thoroughly exploited by corrupt police and practitioners capitalising on the perceived lack of legal clarity. And the focus on “psychological health” led many women to seek patronising psychiatric assessments declaring them unstable or unfit to mother.</p>
<p>Inspired by reform in the United Kingdom, in 1969 the South Australian Liberal government reformed state law to clarify, once and for all, the legal protection afforded to “legally qualified medical practitioners” operating to preserve a “woman’s life or her mental or physical health (actual or reasonably foreseeable)”, or in cases of foetal abnormality. </p>
<p>Soon after (in response to corruption scandals on the east coast), Judge Menhennitt in Victoria (1969) and Judge Levine in New South Wales (1972) passed judgements in the lower courts clarifying legal protection of doctors operating in regard to a woman’s physical and psychological health. In New South Wales, this included the consideration of her foreseeable economic situation.</p>
<h2>Steps forward</h2>
<p>From the 1970s, feminists such as the <a href="http://www.womenaustralia.info/biogs/AWE1097b.htm">Women’s Abortion Action Campaign</a> in New South Wales lobbied for the repeal of all abortion laws, and “abortion at no cost, with no legal restrictions, no quotas in public hospitals, lots of good clinics run by women, plenty of information about abortion, contraception and sexuality, no guilt trips and no discrimination against young, black or migrant women.” </p>
<p>But the medicalisation of abortion governance was well and truly consolidated in Australia by this time. Indeed, since the South Australian reforms, all abortion reforms passed in Australian legislatures have consolidated medical control of the procedure. </p>
<p>In 2008, the Victorian parliament passed the <a href="http://www.legislation.vic.gov.au/Domino/Web_Notes/LDMS/PubStatbook.nsf/f932b66241ecf1b7ca256e92000e23be/BB2C8223617EB6A8CA2574EA001C130A/$FILE/08-58a.pdf">Abortion Law Reform Act</a> to clarify the legal conditions for abortion, on the advice of the Victorian Law Reform Commission. The Act removes the need for doctors to provide medical or psychological justifications for abortion, stating simply that a “registered medical practitioner may perform an abortion on a woman who is not more than 24 weeks pregnant.” </p>
<p>For procedures performed after this point, justifications made in concert with a second doctor are required. </p>
<p>The Victorian Act is widely recognised as both a medical and feminist success. It’s been a long time since women’s liberation framed the tenor of mainstream feminist abortion demands. But it’s still important to consider the impact of the medicalisation of abortion.</p>
<h2>Medicalised abortion</h2>
<p>Australia is potentially facing a crisis in abortion provision, with services dependent on the commitment of a handful of doctors performing procedures mostly in the private sector in each state and territory. And the <a href="http://www.abc.net.au/am/content/2013/s3674615.htm">general doctors’ shortage</a> is keenly felt in the reproductive health sector.</p>
<p>Last year, the historic Croydon Clinic, which was taken over by Marie Stopes International, announced that due to changes in its medical practice, it would no longer <a href="http://www.theage.com.au/victoria/clinic-will-cease-lateterm-abortion-20120125-1qhqh.html">perform abortions after 24 weeks</a>, leaving Australian women without access to this service in the private sector.</p>
<p>One solution to the doctors’ shortage could be to allow nurse practitioners to perform surgical abortions which, despite the TGA’s <a href="http://theconversation.com/arrival-of-ru486-in-australia-a-great-leap-forward-for-women-9193">authorisation of RU486</a>, remain common in Australian practice.</p>
<p>In the United States, the Roe v Wade judgement authorises “physicians” to perform abortions, which in some states has been interpreted to include nurse practitioners, depending on local laws. A recent six-year <a href="http://www.ucsf.edu/news/2013/01/13403/study-abortions-are-safe-when-performed-nurse-practitioners-physician-assistants">University of California study</a> of patient outcomes in America found that first trimester abortions are “just as safe when performed by trained nurse practitioners, physician assistants and certified nurse midwives as when conducted by physicians.” </p>
<p>But in Australia, entrenched medicalisation has meant that local laws such as the Victorian Act preclude anyone other than a registered medical practitioner performing surgical abortions. The radical demands of the 1970s for “lots of good clinics run by women” appear highly prescient in this light.</p><img src="https://counter.theconversation.com/content/11732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Gleeson receives funding from the ARC.</span></em></p>Tuesday marked the 40th anniversary of the US Supreme Court decision in Roe v Wade (410 U.S. 113 (1973)), which found that Texas State law prohibiting abortion was unconstitutional. The landmark decision…Kate Gleeson, ARC Research Fellow in Politics, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/108822012-11-28T19:20:06Z2012-11-28T19:20:06ZTragic Irish case shows abortion laws must respect women’s health<figure><img src="https://images.theconversation.com/files/18007/original/hkjxjnrb-1353905396.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Indian activists protest the death of Savita Halappanavar, who was denied an abortion in Ireland and subsequently died of blood poisoning.</span> <span class="attribution"><span class="source">EPA</span></span></figcaption></figure><p>Recently, 31 year-old Savita Halappanavar <a href="http://www.bbc.co.uk/news/uk-northern-ireland-20321741">died</a> in the University Hospital Galway, Ireland, from complications that arose after being denied a timely abortion. Her tragic and highly publicised death has led to an <a href="http://www.hiqa.ie/press-release/2012-11-23-hiqa-announces-investigation">investigation</a> into medical negligence and raised issues of duty of care amongst doctors and health practitioners at the Galway hospital. It has also seen <a href="http://www.theage.com.au/world/death-of-woman-denied-abortion-puts-global-pressure-on-ireland-for-law-reform-20121115-29d3d.html">increased pressure</a> from Europe on Ireland to clarify its ambiguous abortion law; pressure that has been mounting since the European Court of Human Rights <a href="http://www.guardian.co.uk/world/2010/dec/16/ireland-urged-reform-abortion-legislation">ruling</a> two years ago. However, on a more fundamental level, and perhaps more crucially, Halappanavar’s death has raised questions about how women are valued in Ireland.</p>
<p>Halappanavar experienced pregnancy complications at 17 weeks gestation and was rushed to hospital. She was refused an abortion, despite being told the foetus she carried could not be born, on the grounds that it still had a discernible heartbeat. </p>
<p>For the three days that followed, she must have endured great pain and emotional trauma while she miscarried, during which time she reportedly pleaded with hospital staff for an abortion. She was denied for reasons that may have included either a fear of ambiguous abortion law, or a staunch Catholic view that allowed for a certain interpretation of that law, or sub-standard medical advice and failed duty of care. Perhaps it was a combination of all of those factors. When the foetal heartbeat finally stopped and Halappanavar was permitted to have the procedure, she fell ill with blood poisoning. After another three days she died of septicaemia.</p>
<p>This was a textbook case of abortion as a necessary medical procedure that values women as individuals and saves their lives. The foetus was a much-wanted child, so any misogynistic “irresponsible woman” arguments do not apply here. Additionally, the foetus was miscarried and there was no chance of it being born, which overshadows the metaphysical religious argument for the sanctity of life (of the foetus). Halappanavar’s situation is demonstrative of the danger of ambiguous abortion laws and the very real, horrific outcomes of denying women access to abortion procedures.</p>
<p>Abortion laws are an accurate reflection of the status of women’s rights in any given country, as the link between full human rights and the right to control one’s bodily and reproductive choices can hardly be separated. In the case of Ireland, where Catholicism and politics go hand-in-hand, it is no great surprise that the rights of a pregnant woman are equal to that of the rights of the foetus she carries. The disproportionate focus on the foetus can allow for an argument to follow about the “value of life” and women’s perceived “natural” social role as mothers. But such arguments represent a gross misunderstanding of why women need access to abortion.</p>
<p>During the infamous <a href="http://ww3.lawschool.cornell.edu/AvonResources/Attorney-20General-20v-20X-20et-20al-20-Ireland.pdf">X Case</a> in 1992, the Irish Supreme Court tried to <a href="http://www.lawschool.cornell.edu/womenandjustice/Legal-and-Other-Resources/DisplayCountry.cfm?CountryID=34">prevent</a> a pregnant and suicidal 14 year-old rape victim from leaving Ireland to obtain an abortion in Britain. Following public outcry in Ireland - in addition to international condemnation - that ruling was repealed and the Irish Constitution was amended to permit abortions only when they were necessary to preserve a woman’s life. These changes, based on public referendum, were made more ambiguous in mid-2012, however, when the Irish government successfully implemented an almost total abortion ban. </p>
<p>This change has been well documented by the media, particularly regarding the impact it has had on Irish women forced to seek abortions in other countries. But what is in store for women, like Halappanavar, who cannot make that trip - and why is the Irish government so unconcerned about their welfare?</p>
<p>It is not enough to have an abortion law that stipulates for the preservation of women’s lives - it must also respect women as individuals with full rights by promoting their health and supporting their medical needs. </p>
<p>There is overwhelming evidence to prove that <a href="http://www.who.int/bulletin/volumes/87/1/07-050138/en/">families and communities are healthier</a> when women’s reproductive choices are supported through lawful, safe and accessible abortion. </p>
<p>The Irish government may choose to be ignorant of the positive aspects of abortion, but in doing so it remains out-of-touch with contemporary community attitudes and medical science, and continues to place women in danger.</p><img src="https://counter.theconversation.com/content/10882/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alissar El-murr is affiliated with The Australian Research Centre in Sex, Health and Society.</span></em></p>Recently, 31 year-old Savita Halappanavar died in the University Hospital Galway, Ireland, from complications that arose after being denied a timely abortion. Her tragic and highly publicised death has…Alissar El-Murr, Doctoral Candidate, Research Assistant, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/102632012-10-28T13:08:06Z2012-10-28T13:08:06ZLet’s be clear on Tony Abbott’s attacks on abortion<figure><img src="https://images.theconversation.com/files/16866/original/xsjdhpzp-1351123963.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The notion that Abbott knows better than to attack abortion ignores his attempts to do so through Medicare.</span> <span class="attribution"><span class="source">AAP/Lukas Coch</span></span></figcaption></figure><p>As the dust from the allegations of sexism settles over the parliament, it’s time to clarify, once and for all, <a href="http://www.tonyabbott.com.au/">Tony Abbott</a>’s actions on abortion.</p>
<p>In his recent <a href="http://www.quarterlyessay.com/">Quarterly Essay</a> and in numerous interviews, David Marr has painted an influential picture of Tony Abbott as a man divided between his values and his politics. </p>
<p>Abortion is a case in point and Marr assures us that “Abbott the politician knows he can’t roll back the law on abortion”. Marr claims that as health minister, Abbott did nothing more substantive about abortion than revive a long-settled abortion debate. </p>
<p>So persuasive is this analysis that <a href="http://www.pyneonline.com.au/">Christopher Pyne</a> repeated it recently on <a href="http://www.abc.net.au/tv/qanda/txt/s3599227.htm">ABC TV’s Q&A</a>, stating, “Abbott has made it so clear that even David Marr had to write about it in his essay that Tony Abbott has said he has no intention of going anywhere near the abortion laws in Australia which, by the way, are state-based laws anyway and he’s running for prime minister of Australia, not premier of a state.”</p>
<p>Pyne is correct that abortion governance is mostly a matter for the states. But abortion is most vulnerable in the arena of <a href="http://www.humanservices.gov.au/customer/services/medicare/medicare">Medicare</a>, which is susceptible to the whims of federal politicians. Pyne understands this.</p>
<p><a href="http://www.juliebishop.com.au/">Julie Bishop</a> echoed Pyne on the <a href="http://www.abc.net.au/7.30/content/2012/s3609057.htm">7:30 Report</a>, saying, “I don’t believe that Tony Abbott’s views on abortion are sexist. He has a different view on abortion than I do, but when he was the health minister, at no time did he seek to change the laws in relation to abortion in this country.”</p>
<p>But in 2005, Abbott and Pyne attempted a restructure of Medicare that constituted the greatest threat to abortion funding since the 1970s. Marr has evidently overlooked this episode.</p>
<p>To be clear, Marr is correct that from 2004 to 2006, when he was health minister, Abbott drove a national abortion debate in parliament and beyond. This culminated in his humiliation by the parliament when it voted to remove his ministerial control over the abortion drug RU486.</p>
<p>It seems attention given to RU486 and Marr’s appraisal of Abbott has overshadowed the efforts of Abbott and Pyne on Medicare. And it’s ominous that Gillard didn’t recall the assault on Medicare in the list of Abbott’s offences she recently catalogued in parliament.</p>
<p>In late 2004, John Howard had the political sense to shut down the parliamentary abortion debate. Then-shadow health spokesperson Gillard asked Abbott if he could guarantee not to use “his ministerial office or departmental resources to advance views inconsistent with the government’s policy [on abortion] as announced by the prime minister.”</p>
<p>Abbott replied that he was “very happy to tell the House that the government’s policy has been splendidly articulated by the prime minister.” So, it was his then-parliamentary secretary Pyne who introduced the <a href="http://www.comlaw.gov.au/Details/C2005A00155">Health Legislation Amendment Bill</a> to parliament in 2005.</p>
<p>The bill was presented as a measure to amend the <a href="http://www.pbs.gov.au/pbs/home">Pharmaceutical Benefits Scheme</a>, but Schedule 3, amending the Health Insurance Act 1973, aimed to “clarify the scope and power to make Medicare tables.” In effect, the bill would have granted Abbott as health minister extraordinary power to “determine that Medicare benefits are not payable in specific circumstances”, including for items “the government does not wish to fund through Medicare”.</p>
<p>The bill was immediately sent to committee where Schedule 3 was interpreted by politicians and health professionals alike as an attack on abortion, and perhaps IVF. As with the pro-RU486 legislation, women MPs worked together to condemn the “disconcerting and questionable” Medicare provision. </p>
<p>Labor’s <a href="http://www.clairemoore.net/">Claire Moore</a>, the Democrats’ <a href="http://www.democrats.org.au/campaigns/lyn_allison/">Lyn Allison</a> and others claimed that given his public statements about abortion and IVF, “no-one trusted” Abbott with power over the <a href="http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Medicare-Benefits-Schedule-MBS-1">Medical Benefits Schedule</a>. Within a month, Abbott backed down and announced he had dropped Schedule 3 from the bill.</p>
<p>Abortion procedures have been included in the Medical Benefits Schedule since its inception in 1974. Following the lead of American anti-abortionists who undermined federal funding in the United States, a motion was put to the Australian parliament in 1979 to restrict the payment of medical benefits for termination of pregnancy. </p>
<p>The Country Party sponsor of the motion, Stephen Lusher, compared most abortions to cosmetic surgery. In 1979, there were no female members of the <a href="http://www.aph.gov.au/About_Parliament/House_of_Representatives">House of Representatives</a> so it was left to men to defeat Lusher’s motion. They did so by a margin of 65 to 47.</p>
<p>From 1980 to 2005, no major party challenged abortion funding in the parliament, reflecting bipartisan consensus on the matter. Abbott and Pyne broke that consensus to find their efforts sabotaged by women MPs already angered by provocation of an abortion debate. </p>
<p>Then, in 2008, emboldened by the new post-consensus era, Liberal senator Guy Barnett attempted to restrict Medicare for abortions after 14 weeks. He failed in committee before losing his seat.</p>
<p>The partial Medicare rebate is vital to women’s access to abortion procedures, which in New South Wales, for instance, can involve out-of-pocket expenses ranging from between $300 and $1,500. Recently, <a href="http://www.whnsw.asn.au/">Women’s Health NSW</a>, the peak body for women’s health groups in the state, <a href="http://www.abc.net.au/worldtoday/content/2012/s3561331.htm">documented the unaffordability</a> of abortion, even with Medicare. </p>
<p>The out-of-pocket cost for terminations particularly impacts women who are unwaged or receiving <a href="http://www.humanservices.gov.au/customer/information/centrelink-website">Centrelink</a> benefits. Any restrictions on Medicare would be disproportionately and keenly felt by these women.</p>
<p>Clearly, any questions about aspiring prime minister Tony Abbott’s abortion track record, or his intentions, must address Medicare first and foremost.</p><img src="https://counter.theconversation.com/content/10263/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kate Gleeson receives funding from The Australian Research Council </span></em></p>As the dust from the allegations of sexism settles over the parliament, it’s time to clarify, once and for all, Tony Abbott’s actions on abortion. In his recent Quarterly Essay and in numerous interviews…Kate Gleeson, ARC Research Fellow in Politics, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/94722012-09-12T01:25:15Z2012-09-12T01:25:15ZPolitics v women’s health: RU486 and the TGA saga<figure><img src="https://images.theconversation.com/files/15309/original/f86gym4d-1347324069.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A much wider group of Australian women will be able to choose a medical rather than surgical procedure.</span> <span class="attribution"><span class="source">spaceodissey/Flickr</span></span></figcaption></figure><p>The <a href="http://www.tga.gov.au/index.htm">Therapeutic Goods Administration (TGA)</a> finally <a href="http://www.tga.gov.au/newsroom/btn-tga-statement-mifepristone-gymiso-120830.htm">included the abortifacient Mifepristone</a> (also referred to as RU486) on the <a href="http://www.tga.gov.au/industry/artg.htm">Australia Register of Therapeutic Goods</a> (ARTG) in August 2012 – after nearly two decades of political opposition and obstruction from anti-choice groups and their parliamentary representatives. </p>
<p>Marie Stopes International Australia (MSI), a sexual and reproductive health agency applied to have the drug registered, triggering the first TGA assessment of the drug’s quality. Research in other countries has found that Mifepristone combined with misoprostol (which is already on the ARTG for other uses) is a safe and effective drug. </p>
<p>Access to this drug will enable more Australian women to choose to have an early medical abortion without surgical intervention and at home – if it is appropriate. Both methods are associated with some risks and adverse effects.</p>
<h2>An unfortunate history</h2>
<p>Mifepristone was first developed and marketed by the French pharmaceutical company Roussel Uclaf in the 1980s. </p>
<p>In the 1990s, a group of Australian researchers took part in a <a href="http://www.who.int/en/">World Health Organization</a> (WHO) project trialling regimens for medical abortions. In a related survey, they found that a number of women were satisfied with new medical method and concluded that it gave them more control and autonomy. But once information about this research became available to the Australian public, Mifepristone became the subject of heated debate. </p>
<p>This led to the anti-choice former Tasmanian senator Brian Harradine successfully moving an amendment to the Therapeutic Goods Act 1989 (Cwlth) in 1996, giving then-minister for health and ageing, Tony Abbott, the power to reject applications to import and market abortifacient drugs, such as Mifepristone.</p>
<p>Ten years later, the Therapeutic Goods Amendment (Repeal of Ministerial responsibility for the approval of RU486) Act 2006 (Cwlth) was passed after a cross-party vote. The legislation removed the ministerial approval requirement. And since 2006, the TGA has granted 187 doctors permission to prescribe Mifepristone under the <a href="http://www.tga.gov.au/hp/access-authorised-prescriber.htm">Authorised Prescribers’ Scheme</a>. But access has been extremely limited because it was not a registered medicine with the TGA.</p>
<h2>Risky pathways</h2>
<p>Mifepristone is available in many countries and plays an important role in women’s health internationally. It’s widely used in countries such as China, New Zealand, the United States, Canada, the United Kingdom, Vietnam and most Western European countries. In some places, it’s available over the counter.</p>
<p>As result of the de facto ban in Australia some women have taken the risky path of obtaining the medication via the internet or from contacts overseas. In the first Queensland case where a woman was charged with procuring her own abortion, the police found blister packs that had contained Mifepristone and misoprostol in the accused woman’s home. There was evidence that her partner’s sister had sent the tablets from Russia through the regular postal system. </p>
<p>It’s not possible to gauge the extent of the “blackmarket” traffic of these drugs, but it’s reminiscent of the days when unwillingly pregnant women sought assistance from backyard abortionists.</p>
<p>The new scheme will not be implemented until 2013 when there are adequate supplies of Mifepristone available. Marie Stopes is planning to provide training programs online or directly to health professionals and prescribing practitioners. Practitioners with a fellowship of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (<a href="http://www.ranzcog.edu.au/">RANZCOG</a>) or a diploma of the RANZCOG can register without training. Pharmacists will also be required to complete the training.</p>
<h2>A last step</h2>
<p>Once this scheme is implemented, a much wider group of women, including those living in regional and remote areas, will be able to choose a medical alternative to a surgical procedure. But this choice will be less feasible if medical terminations are not subsided by the government in the same way surgical terminations are. </p>
<p>The cost of Mifepristone is a commercial decision of Marie Stopes International. In order to be included in the <a href="http://www.pbs.gov.au/pbs/home">Pharmaceutical Benefits Scheme</a> (PBS), Marie Stopes is required to make an application to the <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/Pharmaceutical+Benefits+Advisory+Committee-1">Pharmaceutical Benefits Advisory Committee</a> (PBAC) requesting the committee submit a positive recommendation to the minister for health and ageing. The minister will decide whether Mifepristone should be listed on the PBS and press reports suggest Minister Tanya Pilbersek would be supportive.</p>
<p>Now that abortion has been de-criminalised in Victoria, there are no legal concerns about doctors prescribing Mifepristone or women taking the drug. And since the Queensland District Court ruled that Mifepristone was not a noxious substance in the case discussed above, it’s unlikely that courts in other states would decide that prescribing or taking Mifepristone is a criminal offence</p>
<p>The leader of the Opposition, Tony Abbott, has chosen not to comment on these recent developments.</p><img src="https://counter.theconversation.com/content/9472/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kerry Petersen receives funding from ARC </span></em></p>The Therapeutic Goods Administration (TGA) finally included the abortifacient Mifepristone (also referred to as RU486) on the Australia Register of Therapeutic Goods (ARTG) in August 2012 – after nearly…Kerry Petersen, Associate Professor in the La Trobe Law School, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.