Providing medical abortion in general practice: General practitioner insights and tips for future providers

Abstract

Background and objectiveMedical abortion is safe and effective and, when provided by general practitioners (GPs), can increase access for women. However, little is known about which models Australian GPs use to deliver medical abortion. The aim of this study was to describe GP medical abortion delivery models. MethodsSemi-structured telephone interviews were conducted with GPs providing medical abortion nationwide. Data were transcribed, thematically analysed by two researchers and interpreted using six quality dimensions. ResultsTwenty-five GPs used three medical abortion models in private practice: common, streamlined and ultrasonography-inclusive. The most common model comprised three appointments. Some participants provided medical abortion over 1-2 appointments ('streamlined'), and few provided ultrasonography themselves ('ultrasonography-inclusive'). Clinician networks supported participants and enhanced medical abortion delivery. DiscussionUsing three appointments for delivering medical abortion may be less acceptable and accessible to women than streamlined or ultrasonography-inclusive models. Increased awareness of the alternative medical abortion models may encourage GP medical abortion delivery and increase access for women.ABORTION is a common experience for women globally. In Australia, 16% of women have had an abortion by the age of 34 years. 1 While both surgical and medical methods of abortion are available in Australia, they can be difficult to access, with many women travelling long distances 2 or interstate 3 and incurring high out-of-pocket costs 3,4 to receive abortion care. Provision of medical abortion in general practice can improve access to abortion care. General practices tend to be more proximal than tertiary centres and frequently visited by women, 5 particularly for assistance with pregnancy and family planning issues. 6 There is evidence that women prefer to receive their abortion care from a known health provider, such as a general practitioner (GP). 7 GPs are also well placed to provide other related services such as contraceptive care. Thus, GPs are ideally positioned to provide medical abortion in the community setting.Currently, medical abortifacients in the form of MS-2 Step (mifepristone and misoprostol) are available for GPs to prescribe under the Pharmaceutical Benefits Scheme in all Australian states and territories excluding South Australia (SA). 8 In SA, abortions must occur on hospital grounds, not in a general practice. 8 MS-2 Step can be prescribed at up to nine weeks' gestation. For a GP to legally prescribe medical abortion, they are required to undertake mandatory certification through online training (available at www.ms2step.com.au/register).Although no nationwide data exist, it appears that some Australian GPs are willing to provide medical abortion but do not. 9 Evidence suggests that lack of training, lack of support, fear of or actual stigmatisation and fear of demand are key barriers to GPs establishing and providing medical abortion services, both internati...

Early medical abortion services provided in Australian primary care

“…However, that GPs had not prescribed and pharmacists had not dispensed MS‐2 Step in some rural and remote SA3s could have a number of explanations. Firstly, rural and regional doctors may have concerns about support services, including after‐hours emergency and surgical care in case of complications, and about access to ultrasound services (recommended for gestation dating and to exclude ectopic pregnancy 8,23 ). They might also have been concerned about their capacity to provide anti‐D, but recently updated guidelines no longer recommend the routine use of RhD immunoglobulin in medical terminations before ten weeks’ gestation 1 .…”

“…Other strategies are therefore required. Options include increasing the use of collaborative task‐sharing arrangements and models in which nurses undertake most of the counselling, administration and follow‐up tasks of healthcare provision 8 . While clinical trials have found nurse‐led models to be safe and effective, 27 only medical practitioners are authorised to prescribe MS‐2 Step in Australia.…”

“…Some GPs believe early medical abortion is not within their area of responsibility, 4 while others lack training and awareness of how to provide it 6,7 . Further, those who do provide the service can feel stigmatised and isolated, and speak of the need for peer support and supportive referral pathways 4,8 . Fear of criminal prosecution for performing abortion and of potential complications have also been noted as barriers to GPs providing early medical abortion 4 .…”

Termination of pregnancy in Tasmania: access and service provision from the perspective of GPs

“…This research therefore strongly supports the concept recently put forward by the Centre of Research Excellence (CRE) in Sexual and Reproductive Health for Women in Primary Care (SHPERE; Mazza 2020; SPHERE CRE 2020) that supports the development of a community of practice and peer support network, which could address the high degree of uncertainty around aspects of providing EMA services uncovered in the present study. Frameworks for providing EMA in primary care vary according to practice circumstances (Deb et al 2020), andMazza et al (2020) provide a framework to help design such a service.…”

Telehealth: an opportunity to increase access to early medical abortion for Australian women

“…Access to early medical abortion (EMA), using mifepristone followed by misoprostol to end an early pregnancy, remains a challenge in Australia, especially for women from vulnerable groups and those living in rural and regional areas . Low numbers of general practitioner providers, lack of peer networks to support the establishment and ongoing provision of EMA services, and stigma are real barriers as is a broader lack of knowledge regarding medical abortion among health professionals . Many women are also unaware of the availability of EMA and the current gestational limit of 63 days .…”