For decades South Auckland patients have had to travel as far as Mt Eden for an abortion. A proposed new clinic looks set to change that.

Most New Zealanders had other things on their minds. Within 24 hours of abortion being decriminalised, the country went into its original, March 2020 level four lockdown. Maybe an odd time for a piece of legislation to come into effect but, given its implications for improved access (such as being able to self-refer to local providers), for people with unwanted pregnancies in lockdown, perhaps it arrived just in time.

However, while the new legislation made access to abortion easier for some, statistics indicate that for others, such as those in South Auckland, it wasn’t enough to counter the constraints of lockdown. The number of abortions performed in Aotearoa in 2020 was in line with recent years; hopefully a marker that access to services under strict and unusual conditions remains stable. However, there’s another pattern – all too familiar to those whose work concerns health inequities – the percentage of Māori accessing abortion fell from 23.1% to 21.7%, while Pasifika fell from 9.8% to 8%. And the overall number of abortions performed in the Counties Manukau catchment fell by 9%, from 1,700 in 2019 to 1,547 in 2020.

By population, Counties Manukau Health is the country’s second biggest catchment (about 600,000 people, according to Stats NZ); and is also much younger, more diverse, and deprived when compared to the national average.

Most people from South Auckland getting an abortion go to Epsom Day Unit (EDU) in Greenlane because of an absolute lack of first trimester abortion services locally. In 2020, 1,340 of them walked through the door as the biggest group of service users (about 40%), outnumbering locals from Central Auckland (about 30%). A further 117 were attended to at the Auckland Medical Aid Centre in Mt Eden. 

And those are the ones who make it. Executive committee member and former President of ALRANZ (the abortion law reform association of New Zealand) Terry Bellamak said the current situation is frustrating. “It’s maddening that people from Counties Manukau go to Epsom to access early abortion. The excuse is that ‘it’s fairly easy’ for them to get to Epsom… but they are measuring the wrong thing. They ought to be measuring the amount of people who wanted to get up to EDU but weren’t able to.”

Unmet need is a difficult thing to measure, especially in a year punctuated by lockdowns, in an area hit hard by the pandemic. But all the interviewees for this story cited very real practical barriers to those in South Auckland trying to access abortion services in Auckland Central: not just the obvious traffic and travel time, but the cost of parking, time off work and/or childcare arrangements, and the need for someone to pick you up afterwards if you’ve received sedation for a surgical abortion.

It is possible to receive an abortion at Middlemore Hospital after 13 weeks, but a representative from Counties Manukau Health (CMH) said first trimester abortion services don’t belong in hospitals, being better suited to community providers such as the EDU. But the historic arrangement between CMH and the EDU became more difficult as Auckland and its traffic problems grew, she said. 

The problem isn’t new. The Abortion Supervisory Committee, who provided oversight under the old DHB framework, first raised concerns in 2008.

Towards the end of 2020, Counties Manukau DHB (as it was then called) put both medical and surgical abortion services out to tender with the hope they would be up and running by July 2021. Progress has been slow, but just over a year past that goal date, the board confirmed earlier this month that they’d found a preferred location for an abortion clinic (to be shared with other health services), and are in negotiations with the landlord.

While unable to answer specific questions about the planned service due to being in the midst of commercial negotiations, a Te Whatu Ora, Counties Manukau spokesperson says: “It is a priority for us to create a local service that is more accessible and non-stigmatising for women and their whaanau. Good progress is being made.”

Middlemore does provide terminations (only after 13 weeks of pregnancy), a small number (48 in 2020) of which are performed in exceptional circumstances. Looking after patients undergoing medical or surgical termination requires a workforce – doctors, nurses and administrators – and conscientious objectors (some of whom prefer to be known as conscientious “obstructors”) can be a significant factor, particularly in South Auckland.

A junior doctor working in the abortion services department at Middlemore last year said nursing staff routinely declined to administer medication and care for the people on the ward who were receiving medical abortion performed after 13 weeks.

“I would have to go up to the ward and administer [the medication] myself,” she said, “and sometimes the patient would ask why the nurses weren’t coming in the room. I didn’t like it and I brought it up [with management] a few times… And they were just like, [the nurses are] entitled to that conscientious objection. Which I understand, but at the same time, if you’re working in a women’s health ward, you should acknowledge that that’s part of the job.”

She was also told nurses willing to provide abortion care were hard to find, let alone having one on every shift. She witnessed judgmental comments about abortion being made in corridors and within earshot of patients’ rooms.

The doctor said that the department was otherwise excellent. “But it was just the abortion stuff that went on, and the comments around it. They’re not OK. I think it’s good Middlemore offers abortion [past 13 weeks], but it has to be a good quality service and without judgement. And there definitely was judgement.”

When asked for comment, a CMH representative said the organisation “respects conscientious objection”. 

Dr Sarah Tout, clinical director of women’s health at CMH, later said of patients experiencing judgement at Middlemore that “irrespective of the nature of the discussion, that is not expected behaviour on the gynecology ward or by the division of women’s health in general”.

CMH made no comment on the conflict between conscientious objection and service provision.

New Zealand legislation used to protect the employment of conscientious objectors. The Abortion Legislation Act 2020 removed some of that protection, giving employers powers (such as termination of employment, or less favorable terms) when conscientious objection tips over into “unreasonable disruption” of service.

MP for Māngere, minister of Pacific peoples and associate minister of health Aupito William Sio had perhaps more to lose than any other MP in the country when he came out in favour of abortion law reform. He was well aware, too, of the attention his position would generate  during the first reading of the bill, referring to media coverage where “a few of us brown MPs were singled out in there, providing our different views on the matter”.

He describes his stance as a father who does not support abortion, but who recognises a woman’s right to one. Of his daughters, sisters and women in his extended family, he says, “I want them to aspire to uphold the value of life, but they should also know they have the freedom and my support to make those decisions about abortion freely, in accordance with their own conscience and their freedom of choice, knowing full well we are not perfect.”

At the time of the bill’s final reading, he reiterated his position, but this time having received a biblical flood of correspondence from his electorate in opposition to the reform. “This is not an easy decision for myself or any MP under that context, nor is it easy for our Pacific communities,” he said.

Sio told the Spinoff of the extensive engagement he did with his community on this issue. He expected a “clip around the ear” from the elders after his speech, but he had already been talking to them about the issue for a long time. “You have a strong community of Christian background, Christian beliefs, and of course many of us are taught from day one about the sanctity of life. And so that is a river that has been flowing that way for many, many years. And it takes time to bring about changes in our psyche.

“In my speech on this matter, I was trying to describe, not only for the sake of parliamentarians but for the sake of our own people, the ironies of life. On the one hand, we say life is important to us and we must protect it – which I agree with. But on the other hand, we have these other issues in our community – where a baby was found dead under a tree in a park in Māngere… How would that mother have felt, so abandoned by the people that should be protecting her? And certainly by the partner that helped create that life? I’m saying to our communities that this is one of the reasons why this is a health issue. And it will take time, but the law has passed, and I’m asking our communities to respect the law, respect the right of women, and I think if we’re going to fight for the sanctity of life then we must be mature and kind enough to say we must also respect the right of others when it comes to abortion.”

He also recognises that redressing health inequities – predominantly marked by ethnicity – requires a workforce that mirrors the community it serves. In other words, the Middlemore nurses who object to abortion due to deeply-held religious convictions common in South Auckland deserve respect for those beliefs, inconvenient as they might be to this aspect of the health system. 

Sio has heard stories of conscientious objection at Middlemore and believes its the role of the health sector to support such employees. “There is pastoral care that’s needed, also, when someone is going to be asked to do something that they may not be that comfortable with…

“It’s accepting and valuing cultural intelligence. It is valuing and empowering people who speak other languages. And that’s what [diversity] brings to the workforce that for many, many decades has not been appreciated and not been valued. It is something Māori have strongly advocated for day-in, day-out and now we have a good starting point of recognising we have to remove these inequities and that includes all services – including when women acquire services such as abortion.

“Those are things are things that people who live in the leafier suburbs may not appreciate.”