Next month, access to early medical abortion will massively increase with the roll-out of doorstep delivery service. What does that mean for patients – and for surgical providers?
It’s what people who are pregnant and don’t want to be have wanted “since the beginning of time”, says Dr Janet Downs.
“’Give me a pill to induce a miscarriage’ – it totally simulates that,” says the Dunedin general practitioner, who’s been involved with abortion care for 33 years.
Early medical abortion (EMA), or “the abortion pill”, is actually two pills, both to be taken before 10 weeks of pregnancy. The first, mifepristone, blocks the hormones that sustain a pregnancy, sensitising the uterus to the second medication, misoprostol, taken up to 48 hours later, which causes the uterus to contract, expelling the pregnancy – mimicking natural miscarriage.
New Zealand’s abortion situation has changed radically since Downs began working as a certifying consultant, one of the two doctors once required to approve an abortion, in 1989. One year later, when the only practising abortion provider in Dunedin died unexpectedly, she started performing surgical abortions because there simply wasn’t anybody else to do it. She’s been involved with medical abortions from the mid-2000s, and currently offers telehealth services through Southern Health (formally Southern DHB).
Both medical and surgical abortion may be performed at any gestation, Downs says. However the emphasis with EMA, and its self-management component, is on the word early, requiring detection of pregnancy before 10 weeks. Already, since abortion was removed from the Crimes Act in 2020, service users are accessing abortion earlier than ever: 45% of abortions were performed before eight weeks’ gestation in 2020, a substantial increase from only 27% in 2019. In the same year, the uptake of EMA, as opposed to surgical abortions, increased from 22% to 36%. The 2021 data won’t be released until later this month but, provisionally, the Ministry of Health said that trend has continued.
EMA can appeal to different people for different reasons: having a less invasive process than surgery, being at home or in the environment of your choice, and flexibility – not having to fit into the 9am-5pm schedule of a clinic. Medically, its benefits include a reduced risk of infection due to the lack of instruments in the uterus, as well as a reduction of all the other risks that any anesthetic and surgical procedure might present – all for about the same efficacy.
But many of the benefits of medical abortion – privacy, control, flexibility – were lost in the old legislation as the administration of the pills, crowbarred into a framework created for surgical services, had to take place on a licensed premises. Consider, for example, a woman with children at home, who must drive two hours to the nearest abortion clinic, only to have to make the four-hour round trip again the following day to take the second medication. That second drug, misoprostol, works quickly, and those facing longer travel times sometimes started to miscarry, or experienced side-effects such as vomiting, on their trip home. Some clinics got around this by administering both at once or much closer together, accepting a drop in efficacy in favour of access, but forcing patients and clinicians to compromise the gold standard of care.
These issues were addressed in the 2020 abortion law reform, and now these medications can be taken at home. And from next month, with the full launch of the national telehealth EMA service DECIDE, it won’t even be necessary to leave the house to pick up the medications. They will be couriered directly to a patient’s door.
Both a phone line (0800 DECIDE) and a website (decide.org.nz) are already up, part of the phased rollout of the telehealth service. From March it provided information on abortion options, directing users to local providers. In July it was extended to provide both follow-up and abortion-related counselling (the latter of which is no longer mandatory for those seeking an abortion, but its provision remains a requirement) for its own patients and those seen in other clinical settings. And then, from November, it becomes a full telehealth service including clinical consultation and the delivery of medications. Its path was paved not only by the 2020 law, but the new nationalised health authority. The new familiarity with telemedicine that Covid enabled for both patients and clinicians played a part as well.
The downside of convenience
Some people seeking an abortion will still require face-to-face service, Downs warns. “If English isn’t their first language, it’s hard to explain everything over a telephone. Maybe there’s a complex situation where EMA isn’t appropriate, or they’re over the 10 weeks. We have less awareness of the controlling aspect of partners, if that’s an issue. So it doesn’t suit everybody – it’s good to have both options.”
Around the world – and numbers in Aotearoa support this trend – when medical abortions become accessible, the number of surgical abortions declines proportionately, and that trend can be dramatic when restrictions on EMA are lifted or access is improved. Locally, this is anticipated and planned for, says Downs, but there might be unintended consequences that are important to understand.
“In a big health system there is pressure to reduce the number of operating lists. Some centres have had to reduce the number of days they provide the operation, which then reduces choice for some women – because it doesn’t happen every day. Some places have gone to once every fortnight,” she says.
“In the real world, choices always are limited anyway – you may want surgical, but it’s not available for two weeks so you go medical,” she says, adding that in her experience the method of abortion people can get a hold of first usually trumps personal preference. “But one of the downsides in the take-up of medical abortion has been reduced surgical numbers and therefore limited lists, making surgical [abortion] less accessible.”
The attrition of surgical services also has implications for more complex cases, she says. “You lose the skilled, experienced, non-judgmental workforce – or a chunk of it. And we expected this… but DECIDE has really felt like it has accelerated that change,” she says. “Who will be there then for those who need surgical services? The complex cases, the over 10-weekers?
However, she says, medicine is changing all the time. Jobs come and go. “There are ways to creatively adapt. One idea is that the bigger locations became so-called centres of excellence, or referral centres, for those who cannot go through the early medical abortion process.”
DECIDE may also divert funding that would have gone to primary care. When the new legal framework dismantled the notion of “certifying consultants”, it replaced them with “health practitioners” – throwing the door open to primary care providers (not just GPs, but nurse practitioners and midwives) to prescribe EMA as part of their professional scope. This is not only good for access but helps to destigmatise abortion. But even if primary care wasn’t under strain from Covid and its two years of back-pressure, there is no specific funding for EMA in primary care, beyond the $75 GP funding for a one-off early-pregnancy consultation.
Jackie Edmond, who has been chief executive of Family Planning for 15 years, says the organisation would provide EMA through as many clinics as it could if the funding issues were resolved. (Family Planning jointly won the contract for DECIDE – and provides the counselling service aspect. The other party, Magma, also known as the Women’s Clinic, provides the clinical consultation and after-hours-follow up phone line.) The Abortion Providers Group of Aotearoa New Zealand (APGNZ) has been lobbying since March 2020 to have funding follow the patient, to whoever is providing that care – which is the current model for end-of-life care and trans healthcare. There is no current plan to fund primary care for EMA, but APGANZ has upcoming discussions planned with Te Whatu Ora (Health New Zealand).
When asked for its position, a Ministry of Health representative emailed: “Manatū Hauora – Ministry of Health is continuing to work with Te Whatu Ora and Te Aka Whai Ora (Māori Health Authority) who have prioritised this piece of work within the Early Actions Team.”
However, Edmond says that by allowing primary care clinicians such as GPs to leverage DECIDE’s counselling and 24-hour follow-up phone line, it has removed two significant barriers for clinicians hoping to provide abortion care. “If you’re a small provider,” says Edmond, “you may only see a handful of people a year.” For those practitioners, providing the counselling and follow-up care can be “really difficult”.
She echoes Downs’ sentiment that the viability of surgical services is important for the overall health of abortion care. “The challenge for services… is that we need to continue to offer people surgical abortion. There are certain economies of scale, if you like, in managing and maintaining services. But not everyone’s going to meet the requirement for EMA.”