Vulnerable women are being made to search well into their second trimester for access to abortion services, more than five years after pregnancy terminations were decriminalised in NSW.
Women are ticking over 15 weeks gestation while they sit on waitlists for private clinics they can’t afford, or that can’t manage their complex health problems, leaving the women with shrinking options and greater heartache.
Without clear pathways and free services, women run a complicated and time-consuming maze to access affordable abortion.Credit: Monique Westermann
A group of obstetricians at Westmead Hospital have been performing abortions for these women, many of whom are escaping abusive partners, are homeless, have serious medical or mental health conditions, or can’t afford to pay for a private abortion.
The doctors at the public hospital don’t advertise their abortion services and there is no clear referral pathway.
“No one knows we exist. It’s only people who find us by chance that we can help,” said Westmead Hospital obstetrician Dr Naim Arrage.
But the obstetricians have no choice but to send the vast majority of women seeking an abortion away because they do not have the funding, clinic space or operating theatre time to help.
“It’s heartbreaking having to turn away these most vulnerable of women,” Arrage said. “We can only help the most needy who live within the local health district and can’t possibly access abortion anywhere else.”
The obstetricians are urging the state government to fund a dedicated public abortion service for women in Western Sydney Local Health District (WSLHD) who have nowhere else to go.
“There’s a group of women out there who desperately need abortion care and simply cannot access it, and they need a public hospital to be their safety net,” said Dr Greg Jenkins, head of Westmead’s Department of Obstetrics and Gynaecology.
“Care shouldn’t be denied based on where someone lives or how much money they have,” Jenkins said.
‘Care shouldn’t be denied based on where someone lives or how much money they have.’
Dr Greg Jenkins, head of Westmead’s Department of Obstetrics and Gynaecology
Free and timely abortion access is virtually non-existent across most of NSW, despite the state decriminalising the practice in 2019 and a directive from NSW Health that all public hospitals must offer clear referral pathways for timely pregnancy terminations.
Only one hospital in the state – John Hunter in Newcastle – has a formal, funded surgical abortion service, predominantly for women in their first trimester.
“It seems that the passage of the legislation was the easiest thing to do, but from a woman’s point of view, nothing has changed,” said WSLHD women’s health clinical network director Dr Andrew Pesce.
“It is going to take a commitment from the district and the ministry to make this happen.”
A medical abortion up to nine weeks gestation costs between $300 and $700, with a Medicare rebate of $187. A surgical abortion costs between $900 and several thousand dollars, depending on the clinic and gestation, with a Medicare rebate of roughly $400.
The futile act of running the maze of abortion access
Westmead obstetrician Dr Naim Arrage recalled a 43-year-old single mother with many children* who discovered she was pregnant at 10 weeks and immediately sought an abortion.
She waited two weeks for an appointment at a community-based abortion clinic, but couldn’t afford the $700 and was directed to a cheaper provider. By the time she got an appointment, her pregnancy was too advanced for the service and she was sent back to the original clinic.
By then, the cost had risen to $2000. The process to access special dispensation took another two weeks, at which point she was almost 17 weeks.
When she arrived on the day of her procedure, she was told that she did not meet the clinic’s safety criteria because her BMI was too high.
“The centre referred her to us,” Arrage said. “We saw her at 19 weeks.”
*The Sydney Morning Herald has withheld the number of children to protect the woman’s identity.
Only a handful of surgeons perform surgical abortions after 15 weeks, which are technically more challenging, have the potential for significant complications and are more ethically and logistically complex than earlier abortions, Arrage said.
But without a dedicated abortion service, these women must either go on the emergency surgery list, where they risk being bumped for a more urgent case, or they go on the elective surgery operating list, which means another woman – who may have waited up to a year for her surgery – must be rescheduled, Arrage explained.
There must also be a willing and qualified surgeon, anaesthetist and theatre crew to perform the abortion. In the past, staff who have participated in an abortion against their personal moral code have needed to take stress leave.
In the absence of a surgical abortion, a medical abortion after 15 weeks can be considerably traumatic for the patient and the maternity staff caring for her.
Woman turned away from four private clinics
Another woman, Dr Naim Arrange recalled, was 15 weeks pregnant, with schizophrenia and was just six months on from her second caesarean section when she developed a life-threatening pulmonary embolism.
Struggling with a serious medical diagnosis, little support or money, and a newborn and toddler at home, she was turned down by four private abortion services after waiting weeks at a time for appointments, Arrage said.
Distraught, she was referred to Westmead, but by then, her abortion was significantly more complicated.
Approximately 350 women in WSLHD will need public hospital abortion care each year, or seven per week, based on Family Planning Australia 2020 projections and a rough estimate of the proportion of women seeking abortion who have a medical disorder or lack of funds.
A comprehensive service at Westmead would cost $620,000 per year to run one clinic day and one operating theatre list to meet the needs of these women, Arrage said.
The Local Health District executive has received a business case for a clinic, where it will follow the usual processes for consideration but has not advised when it will report back.
Arrange said a sufficiently resourced service at Westmead could be a hub for the entire state.
“It needs to be adequately staffed with all the team members that these patients will require [including] therapy support, social work, nursing and surgeons, procedural and diagnostic ultrasound, as well as psychiatry in special cases,” he said.
Kirsten Black, Professor of sexual and reproductive health at the University of Sydney, and co-founder of the Advocacy group Australian Clinicians for Choice, said the situation at Westmead was playing out at hospitals across the state.
“If we improve access to free first trimester services for people who need it, then we won’t run into the problem,” she said, pointing to Sweden’s free, accessible public abortion services, where women present early.
NSW Health conducts a yearly audit of abortion care services, “which is simply documenting that nothing has changed”, Black said. “They don’t provide any funding for the service, so they are just turning a blind eye to the problem,” she said.
Health Minister Ryan Park said the NSW government was “committed to improving safe and transparent pathways to abortion care”, allocating an additional $3.5 million over four years to support this.
In a statement, Park said all districts provided emergency or life-threatening care for abortion or had emergency referral pathways.
But Black said the vast majority of women would not meet these criteria, and there was evidence of reduced access to abortion in many areas since the law reform.
Park said the Pregnancy Choices Helpline (1800 008 463) and website were available to assist women in making choices about their pregnancy, including finding abortion services.
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