Sexual & Reproductive Healthcare 16 (2018) 175–180

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Sexual & Reproductive Healthcare

journal homepage: www.elsevier.com/locate/srhc

Providing accessible medical abortion services in a Victorian rural T

community: A description and audit of service delivery and contraception
follow up
Jane E. Tomnaya, , Lauren Coellib, Ange Davidsonb, Alana Hulme-Chambersa, Catherine Orrb,
⁎

Jane S. Hockingc
a
Centre for Excellence in Rural Sexual Health (CERSH), University of Melbourne, Department of Rural Health, 49 Graham Street, Shepparton, VIC 3630, Australia
b
Clinic 35, Gateway Health Wodonga, 155 High Street, Wodonga, VIC 3690, Australia
c
University of Melbourne, School of Global and Population Health, 235 Bouverie Street, Carlton, VIC 3053, Australia

A RT ICLE INFO ABSTRACT

Keywords: Objective: To describe how a nurse led, MToP service is run in primary care in regional Victoria and investigate
Rural the characteristics and contraceptive choices of the women who have attended.
Medical termination Study design: Descriptive study of the development and implementation of a rural MToP service and a retro-
Primary care spective chart audit of patients attending between January 2015 and September 2016.
Main outcome measures: Characteristics and clinical outcomes for women attending an MToP service in a primary
care setting in rural Victoria.
Contraceptive usage pre and post attending a rural service for MToP.
Results: There were 229 presentations, representing 223 women, of which 172 women (75.1%; 95%CI: 69.0%,
80.6%) had a successful MToP and for two further women, MToP failed, requiring a surgical termination (0.9%;
95%CI: 0.1%, 3.1%). At the time of presentation, the mean age of women was 25 years, the median length of
gestation was 49 days and 171 (75%) had not had a previous termination. Data about contraceptive use was
available for 195 women, 143 (73.3%) reported no contraception, 2 reported emergency contraceptive pill
(1.0%), 10 used condoms (2.1%) and 39 (20.0%) reported hormonal contraception. Among the 156 women
using no contraception, condoms or emergency contraception at the time of pregnancy, 113 (72.4%) initiated a
reliable form of contraception post presentation to the MToP service.
Conclusion: Provision of accessible, affordable MToP through an integrated primary health service is one
strategy to address access inequity in regional areas.

Introduction
Access to abortion services is an important health issue for
Australian women. In 2008, abortion was removed from the crimes act
in Victoria and the Abortion Law Reform Act was passed to ensure that
the choice to have an abortion, up to 24-weeks’ gestation, became the
decision of the woman in consultation with a health professional [1].
The combination of medications mifepristone and misoprostol have
been used for medical termination of pregnancy (MToP) in over 46
countries, including the United Kingdom, United States, New Zealand,
China and Europe [3] since 1988. However, these medications have
only been approved for use in Australia since 2012 for termination of
early pregnancy (initially up to 49 days then revised up to 63 days ge-
station) [2]. They were added to the Commonwealth Pharmaceutical
Benefits Scheme as a subsidized medicine in 2013, thereby allowing
widespread use.
Women living in rural areas of Australia have been at considerable
disadvantage with respect to access to pregnancy termination services
[4–6]. Given the extensive use of MToP throughout the developed
world, the lack of affordable access to abortion services for rural Aus-
tralian women deserves particular attention [4], specifically issues re-
lated to geographical [5] and financial access [6]. Doran and

⁎
Corresponding author at: Centre for Excellence in Rural Sexual Health, Department of Rural Health, University of Melbourne, 49 Graham Street, Shepparton,
Victoria 3055, Australia.
E-mail addresses: jtomnay@unimelb.edu.au (J.E. Tomnay), Lauren.Coelli@gatewayhealth.org.au (L. Coelli),
Andrea.Davidson@gatewayhealth.org.au (A. Davidson), alana.hulme@unimelb.edu.au (A. Hulme-Chambers), Catherine.Orr@gatewayhealth.org.au (C. Orr),
j.hocking@unimelb.edu.au (J.S. Hocking).

https://doi.org/10.1016/j.srhc.2018.04.006
Received 27 July 2017; Received in revised form 10 April 2018; Accepted 10 April 2018
1877-5756/ © 2018 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
J.E. Tomnay et al.
Hornibrook (2014) found that the main barrier rural Australian women
experienced in accessing abortion services was travelling relatively long
distances because of lack of services in their local area. Also, rural
women who were experiencing financial restraints needed to borrow
money for the procedure and associated costs of travel and accom-
modation [4]. A review by Dawson and colleagues in 2016, aimed at
improving access to abortion services in Australia, found that the key
elements for improving access were the establishment of standards,
provision of choice of procedure, improved provider education and
training and the expansion of telemedicine for medical abortion [7].
With these factors in mind, a group of Victorian regional health pro-
fessionals, in partnership with the Early Pregnancy Service at the Royal
Women’s Hospital Melbourne, planned and subsequently delivered an
affordable, accessible MToP service in regional Victoria, through an
existing sexual health service.
The sexual health clinic at Gateway Health Wodonga uses an in-
tegrated service model and is located in a large rural primary healthcare
setting. It provides flexible access to free clinical service delivery five
days a week that is targeted towards young people, and priority po-
pulations; including people from culturally and linguistically diverse
backgrounds, Aboriginal and Torres Strait Islander people, sex workers,
men who have sex with men, travellers and mobile workforce and
people in custodial settings. An MToP service was planned throughout
2014 and established in January 2015, with particular emphasis on
ensuring flexibility, affordability, and an integrated approach.
Objective
We describe here how this clinic was set up and present data ob-
tained through a clinical audit of patient’s charts of the first 19 months
of operation, including describing the patients consulted and the out-
come of their consultations including uptake of MToP and contra-
ception use before and after attending the service.
Methods
Description of the MToP clinical service
For the twelve months leading up to the commencement of the
MToP service, Gateway Health, in partnership with the Centre for
Excellence in Rural Sexual Health (CERSH), undertook extensive local
stakeholder engagement. Stakeholders included local radiology provi-
ders, local pharmacies, specialist gynaecologists, local emergency de-
partment staff, and the Primary Health Network (PHN). The engage-
ment process included meeting to discuss Gateway’s intention to
provide an MToP service and to seek input into the development and
establishment of local MToP procedures and protocols. This ensured
women experiencing unplanned pregnancy would receive a consistent
message during every step of MToP provision in this rural community.
These relationships are ongoing and have proved important to the
evolution of the MToP Model. Prior to commencing the MToP service in
2015, Gateway Health provided referral for women to a local New
South Wales (private) and metropolitan based (public and private)
services, for surgical or medical termination of pregnancies.
The MToP service at Gateway Health uses a nurse-led with general
practitioner (GP) support integrated model of care. Women enter the
service by self-referral or GP referral. Women contact the service either
via telephone or in person to the reception of Gateway Health.
Reception staff at Gateway Health undertook specific training to ensure
an understanding of the sensitive and time critical nature of the MToP
booking process. Reception staff provide women with necessary in-
formation related to appointments, and investigations that may be
undertaken prior to attending Gateway Health. Reception staff do not
discuss the MToP itself, and if prompted for more information, the
nurse is asked to contact the woman directly via the phone. Gateway
Health have adopted a two appointment policy for women seeking
176
Sexual & Reproductive Healthcare 16 (2018) 175–180
MToP, however, there are situations where MToP is prescribed in a
single consultation, particularly if the woman is travelling a long dis-
tance to attend the service. In this instance, the women will undertake a
telephone consultation with the nurse, and complete all required in-
vestigations prior to attending the clinic.
All appointments take place with the nurse, and are double booked
with the prescribing GP. The GP appointments are bulk-billed, thus
there are no ‘out of pocket’ costs to the woman unless the woman isn’t
eligible for Medicare, in which circumstance she will pay approxi-
mately 500 AUD in total. At the first consultation, the nurse initiates a
non-directive pregnancy options discussion; makes an assessment to
determine MToP eligibility; organises investigations to be ordered by
the prescribing GP if not already undertaken; provides information
regarding post termination contraceptive options; and provides in-
formation about MToP both verbally and in writing. Investigations that
may be required depending on history and circumstances include a
pelvic ultrasound to confirm intrauterine pregnancy; self-collected high
vaginal swabs for microscopy, culture and sensitivity, and Chlamydia
testing; venepuncture for full blood count, iron studies, blood group
and antibodies and a quantitative human chorionic gonadotropin
(QBHCG). At the conclusion of the initial consultation, the nurse will
schedule one further appointment, double booked with the prescribing
GP, at a time when all pathology and ultrasound results are available.
At the second consultation, the nurse reviews investigations, and
confirms that the woman still wants to go ahead with MToP. If the
woman declines MToP, further non-directive pregnancy options coun-
selling is undertaken and appropriate referrals are made. If the decision
is made to pursue MToP and no ambivalence is noted, the nurse fully
explains the two-step MToP procedure again, and a consent form is
signed. At the conclusion of the second consultation, the nurse informs
the prescribing GP that the woman is ready to be prescribed MToP. The
GP then confirms the woman’s eligibility, including whether she is
providing informed voluntary consent, that the pregnancy is in-
trauterine and no more than 9 weeks (63 days) gestation, that there are
no medical contra-indications to MToP, and finally that she is able to
access a hospital emergency department should urgent medical atten-
tion be required. If these criteria are fulfilled, the GP provides the
woman with a single PBS prescription for MToP, and further scripts for
contraception of her choice, analgesia, and an anti-emetic. The GP ex-
plains the MToP process once more to the woman and provides medical
certificates if required.
The woman then takes the script to be filled at a local pharmacy,
where the first dose of Mifepristone 200 mg is taken, witnessed by the
pharmacist. The pharmacy dispenses the second dose, Misoprostol
800mcg, to be taken at home 36–48 h later. The nurse also provides the
woman with a letter to the dispensing pharmacy that includes a ‘do not
dispense after this date’ (the 63 day gestation date) and a fax-back form
alerting Gateway Health when the first step of MToP is completed. The
nurse also provides a letter to the emergency department to be used
should urgent medical attention be required; and if Rhesus negative,
another letter is provided and the woman is asked to present to the local
emergency department for anti-D immunoglobulin administration
within 72 h of bleeding. If the woman does not live close to Gateway
Health, the nurse phones their closest local emergency department to
confirm anti-D availability and the process involved for administration.
The woman is also provided with contact details for both Gateway
Health and the MS Health 24 h Nurse After-care Telephone Service.
While cramping and bleeding are expected as part of ending a
pregnancy, rarely serious and potentially life threatening adverse ef-
fects can occur following an MToP. Gateway Health staff encourage
patients to seek urgent medical attention for any of the following cir-
cumstances:
• Heavy vaginal bleeding (soaking two or more sanitary pads per hour
for two consecutive hours or have large fist sized clots).
• Prolonged heavy bleeding or severe cramping. It is expected that, on
J.E. Tomnay et al.
average, bleeding will occur for 10–16 days.
• Cramping which is not improved by pain relief medication.
• Fever, chills or malaise lasting six hours or more.
• Any abnormal vaginal discharge.
• Severe abdominal pain.
• Feeling sick (including weakness, nausea, vomiting, diarhoea, ab-
dominal discomfort, cramps, fatigue, chills) with or without a fever
more than 24 h after taking misoprostol tablets.
For follow up, the woman was initially asked to have a repeat
QBHCG after three weeks but this protocol was later revised in 2016 to
seven days post the misoprostol dose and patients are sent an SMS re-
minder by Gateway Health. If BHCG levels have dropped by 80%, the
procedure is considered successfully completed. Further follow up is
undertaken by telephone or in person 3 weeks later, however this
follow up appointment can be scheduled earlier if necessary. Follow up
procedures are consistent with the established procedures within the
Gateway Health extended medical practice. Contact must be attempted
on three separate occasions. For MToP this includes an SMS reminder to
have a pregnancy test seven days post Misoprostol. If this is not under
taken, the client is phoned and sent a letter that includes another copy
of the pathology request. Finally, if a pregnancy test still has not been
undertaken, a letter is sent via registered mail.
Contraception is discussed at every consultation with the Nurse and
the GP, and is initiated on a case by case basis with a long acting re-
versible contraceptive being promoted as a preferred contraceptive
method. When a patient opts for a long acting reversible contraceptive
they are encouraged to have this initiated at the time of their second
appointment, or subsequently at a time that is convenient for the client
organised by the Nurse during the consultation. As all consultations at
Gateway Health are bulk-billed and as such there are no out of pocket
expenses to the patient, this includes Implanon NXT insertion.
Implanon NXT can be inserted by the nurse, or a GP depending on
availability.
A client who chooses an intrauterine device (IUD) for contraception
is referred to another local service, specifically the Specialist Obstetric
and Gynaecologist Registrar Clinic. Due to high demand, and very few
local IUD inserters, it may take 4 weeks to obtain an appointment, thus
an interim hormonal contraceptive method is offered, for example the
contraceptive pill or the depot injection.
Between the time that the MToP service was established in 2015 and
the present time, protocols and processes at Gateway Health have been
continually evaluated and altered whenever evidence for improved
practice became available to ensure an optimal service for all clients.
Clinical audit and analysis
In October 2016, we undertook a retrospective clinical audit at
Gateway Health Wodonga to explore and understand the characteristics
and demographics of the women attending the MToP service, their
length of gestation and eventual choice for the outcome of the preg-
nancy. All patients attending the clinic for abortion services between
January 2015 and September 2016 were included in the audit. Data
extracted at audit include their age, contraceptive coverage at the time
of presentation to the clinic, contraceptive coverage following MToP or
presentation at the service and any adverse events associated with
MToP.
Descriptive statistics were used to describe the women attending the
clinic and binomial exact methods were used to calculate the propor-
tion and 95% confidence intervals of women who had a successful
termination (defined as BHCG levels having dropped by 80%, 21 days
post the second dose of MToP). Distance travelled to visit the service
was highly skewed and was categorised into quartiles for analysis
(≤4 km, > 4–12 km, > 12–54 km, > 54+ km). Age was categorised
into the following age groups for analysis (< 20 yrs; 20–24 yrs; 25–29
yrs; 30–39 yrs; 40+ yrs). Associations between categorical variables
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Sexual & Reproductive Healthcare 16 (2018) 175–180
were investigated using chi2 tests; associations between categorical
variables and continuous variables were analysed using Kruskal Wallis
test. Contraception use before and after visiting the service was in-
vestigated and any adverse events as a result of the MToP were also
examined. For the purpose of analysis, effective contraception was
defined as hormonal contraception [8] including the pill, Implanon
NXT, IUD and Depo-Provera where the contraception is under control
of the woman and there is less opportunity for user error. Considered
less reliable contraception was the use of condoms, emergency con-
traception or using no contraception at all. The difference between type
of contraception use before and after MToP (effective versus no effec-
tive contraception) was investigated using McNemar’s test. Factors as-
sociated with initiating effective contraception post MToP among those
women using no form of contraception, condoms only or emergency
contraception pre MToP were investigated using logistic regression;
odds ratios and 95% confidence intervals were calculated.
Ethics approval was provided by the University of Melbourne
Human Research Ethics Committee (approval number 1647594).
Results
Characteristics of women
There were a total of 229 presentations to the clinic during the time
frame representing 223 women, 6 of whom presented on two separate
occasions for MToP, 20–77 weeks apart. The women were aged from 14
to 46 years, with a median age of 25 years, 50% were aged between 21
and 31 years. Nearly two thirds (65%) were born in Australia. Overall,
65 (28%) were referred to the service from their general practitioner.
There was no change in the number of women attending the service or
their age profile over time, irrespective of the advertisement of the
service on the clinic website in March 2016. Women travelled a median
distance of 12 km to attend the clinic (range 1–1367 km), with 50%
travelling between 4 and 55 km to attend. The median distance tra-
velled to visit the clinic increased with increasing age (p = 0.01) with
women under 20 years travelling a median distance of 10 km to the
service, women aged 20–24 years travelling a median of 9 km, those
aged 25–29 years a median of 12 km, women aged 30–39 years a
median of 16 km and a median of 18 km for those aged 40+ years.
Gestation length and outcome of presentation
The median length of gestation at presentation was 49 days ranging
from 30 to 110 days (those more than 63 days gestation were not eli-
gible for MToP). Women aged under 20 years had the longest median
gestation length (53 days) and women aged 30–39 years had the
shortest median length (47 days). Overall, 172 women (75.1%; 95%CI:
69.0%, 80.6%) had a successful medical termination of pregnancy (166
at this service, 6 women at another service) and for two further women,
medical termination failed, requiring a surgical termination (0.9%;
95%CI: 0.1%, 3.1%). For the remaining women, 7.4% selected a sur-
gical termination initially, 4.4% continued with the pregnancy, 3.5%
miscarried and 8.7% were lost to follow up with their outcome un-
known. For 171 women (75%) this was their first termination, with 40
women (17%) reporting at least one previous termination.
Contraception use
Data about contraceptive use at the time of pregnancy was available
for 195 women and of these, 143 (73.3%) reported no contraception, 3
reported emergency contraceptive pill (1.5%), 10 used condoms (2.1%)
and 39 (20.0%) reported hormonal contraception (pill [34], depo [2] or
Implanon NXT [3]) (Table 1). Worth noting is that of the three women
who fell pregnant with an Implanon NXT insitu, none of these preg-
nancies were a result of Implanon NXT failure. Two of the women had
an expired contraceptive implant at the time of conception whilst a
J.E. Tomnay et al. Sexual & Reproductive Healthcare 16 (2018) 175–180

Table 1
Type of contraception initiated following consultation for medical termination by type of contraception used at time of pregnancy.
Post MTOP

None Pill Implanon IUD Depo Vaginal ring Vasectomy Condoms Natural N/A Total
n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Pre MTOP None 19 39 20 18 10 3 7 6 1 20 143

n (13.3) (27.3) (14.0) (12.6) (7.0) (2.1) (4.9) (4.2) (0.7) (14.0 (100)
Pill 0 23 5 0 2 0 0 0 0 4 34
n (0.0) (67.6) (14.7) (0.0) (5.9) (0.0) (0.0) (0.0) (0.0) (11.8) (100)
Implanon 0 0 2 0 0 0 0 0 0 1 3
n (0.0) (0.0) (66.7) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (33.3) (100)
Depo 0 1 0 0 1 0 0 0 0 0 2
n (0.0) (50.0) (0.0) (0.0) (50.0) (0.0) (0.0) (0.0) (0.0) (0.0) (100)
Condoms 1 2 0 0 4 0 0 1 0 2 10
n (10.0) (20.0) (0.0) (0.0) (40.0) (0.0) (0.0) (10.0) (0.0) (20.0) (100)
Emergency contraception 1 1 0 0 0 0 1 0 0 0 3
n (33.3) (33.3) (0.0) (0.0) (0.0) (0.0) (33.3) (0.0) (0.0) (0.0) (100)
Total 21 66 27 18 17 3 8 7 1 27 195
n (10.8) (33.8) (13.8) (9.2) (8.7) (1.5) (4.1) (3.6) (0.5) (13.8) (100)

n = number of women.
N/A = unknown.

third conceived during the first seven days after insertion prior to the Table 3
implant becoming effective. Factors associated with initiating effective hormonal contraception after MTOP
McNemar’s test showed a significant difference between contra- (n = 156).
ception use pre MToP and contraception use post MToP (Chi2 df N (%) Unadjusted OR P value Adjusted OR# P value
[1] = 80.1); p < 0.01). Among the 156 women using no form of (95%CI) (95%CI)
contraception, condoms only or emergency contraception at time of
Age group
pregnancy, 94 (60.3%) women initiated an effective hormonal contra-
< 20 years 23 (14.7) 1.2 (0.4, 3.7) 0.79 (0.3, 3.4) 0.96
ception post MToP; the pill was the most commonly initiated contra- 20–24 years* 41 (26.3) 1.0 1.0
ception (42 women [26.9%]), with long-acting reversible contraception 25–29 years 40 (25.6) 0.5 (0.2, 1.1) 0.09 0.4 (0.1, 0.9) 0.04
(IUD or Implanon NXT) being initiated by 38 women (24.3%). 30–39 years 39 (25.0) 0.3 (0.1, 0.9) 0.03 0.3 (0.1, 0.7) < 0.01
The type of contraception initiated varied by age group with < 20 40 + years 13 (8.3) 0.9 (0.2, 3.6) 0.92 0.8 (0.2, 3.5) 0.80

year old women being more likely to initiate Implanon NXT and Referred from GP
women aged 20–24 years being more likely to initiate the pill post No* 107 (68.6) 1.0 1.0
Yes 49 (31.4) 2.3 (1.1, 4.9) 0.02 2.9 (1.3, 6.5) < 0.01
MToP. The proportion of women who initiated an IUD increased with
increasing age (Table 2). Women were more likely to initiate an ef- Distance travelled
< 4 km* 37 (23.7) 1.0 1.0
fective form of contraception if they were referred to the service from a
4–12 km 41 (26.3) 1.3 (0.5, 3.3) 0.55 1.3 (0.5, 3.5) 0.57
general practitioner (OR = 2.9; 95%CI: 1.3, 6.5)) and were less likely to > 12–54 km 38 (24.4) 1.5 (0.6, 3.7) 0.42 2.0 (0.7, 5.5) 0.20
if they were aged 25–29 years (OR = 0.4; 95%CI: 0.1, 0.9) or > 54 km 40 (25.6) 0.9 (0.4, 2.3) 0.88 1.1 (0.4, 3.0) 0.81
30–39 years (OR = 0.3; 95%CI: 0.1, 0.7) compared with women aged
20–24 years (Table 3). OR = odds ratio; * = reference group; # = adjusted for age group, referred
from GP and distance travelled.

Adverse or unintended events 5 km from a surgical termination provider in New South Wales (NSW).
The Public Health and Wellbeing Amendment (Safe Access) Bill 2015
There were no recorded serious or life threatening adverse events introduced laws in Victoria to provide a ‘safe access zone’ around re-
recorded during the study period. Also, there have been no complaints productive health services to prevent protestors intimidating, photo-
from the local community about the MToP service. Worth noting is that graphing and harassing staff and patients who are entering the clinic.
geographically Gateway Health is situated in Victoria, and is located Similar laws do not exist in NSW, and as such the clinic in NSW in close
proximity to Gateway Health has protestors on a weekly basis, coin-
Table 2 ciding with the day the clinic is held.
Type of contraception initiated post MTOP by age group among for those not
using effective contraception# prior to MTOP.
Discussion
Type of < 20 yrs 20–24 yrs 25–29 yrs 30–39 yrs 40+ yrs Total
contraception n (%) n (%) n (%) n (%) n (%) (n)
This is the first study to our knowledge that describes how a nurse
Pill 7 (30.4) 16 (39.0) 10 (25.0) 6 (15.4) 3 (23.1) 42 led, accessible MToP service is run in primary care in regional Victoria
Implanon 6 (26.1) 4 (9.8) 3 (7.5) 4 (10.3) 3 (23.1) 20
and investigates the characteristics and contraceptive choices of the
IUD 1 (4.3) 4 (9.8) 5 (12.5) 5 (12.8) 3 (23.1) 18
Depo 3 (13.0) 5 (12.2) 3 (7.5) 3 (7.7) 0 (0.0) 14 rural women who have attended the service in the first 19 months. This
Nuva-ring 1 (4.3) 0 (0.0) 0 (0.0) 2 (5.1) 0 (0.0) 3 paper describes the clinical service and the outcomes for the women
Vasectomy 0 (0.0) 0 (0.0) 1 (2.5) 5 (12.8) 2 (15.4) 8 attending for MToP throughout the study period. We also investigate
Condoms 0 (0.0) 2 (4.9) 2 (5.0) 3 (7.7) 0 (0.0) 7 the demand on the service over time, with particular emphasis on de-
Natural 1 (4.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1
None 4 (17.4) 10 (24.4) 16 (40.0) 11 (28.2) 2 (15.4) 43
mand before and after advertisement of the service on the Gateway
website.
# effective contraception = hormonal contraception; n = number of women; In this study, we found that more than 80% of the women attending
% = proportion within each age group. the clinic chose to terminate their pregnancy after receiving

178
J.E. Tomnay et al.
appropriate counselling in relation to all of the options available and
that most of these women were not using an effective contraception at
the time of the unintended pregnancy. Our findings were consistent
with those found in two similar studies in Queensland where at least
half of the women attending for MToP were in their 20’s and two thirds
were Australian born [9,10].
There has been strong evidence in Australia that women living in
rural and regional areas are disadvantaged in terms of access to ter-
mination of pregnancy services and a recent systematic review of the
evidence identified the consistent barriers as; long distances to travel to
services, limited numbers of available doctors, lack of access to medical
termination, privacy and stigma problems, costs, lack of access to ac-
curate information and unbiased counselling, health professionals with
conscientious objection and longer waiting times [4]. Gateway Health
Wodonga successfully integrated an MToP service into their existing
sexual health service by deliberately addressing all of these barriers
during the planning and implementation phases of the service and
continually reviewing protocols to ensure efficiency. The women at-
tending the clinic were those who live in communities surrounding
Wodonga, from both Victoria and New South Wales and whilst older
women travelled further than younger women, most had travelled less
distance to Gateway Health than was previously required to access a
publicly funded service. Prior to the establishment of this service,
women living in this region who did not have the financial resources to
access a private provider would have most likely attended a me-
tropolitan service in Melbourne approximately 320 km away. Also,
termination of pregnancy remains in the criminal code in New South
Wales for both women and doctors and is only legal when a doctor
believes a woman’s physical and/or mental health is in serious danger,
as such the fact that Gateway Health sits on the border of New South
Wales and Victoria allows women living in New South Wales greater
access to these services by travelling a short distance into Victoria.
Establishing the clinic in a large primary care service has ensured
that the privacy and confidentiality of these women is maintained at all
times, including as they enter the building, whilst waiting in the
waiting room and when they are seen by the staff. This is because the
range of clinical services provided at Gateway Health are similar to
those provided in any general practice and as such these patients could
be attending for a wide variety of clinical issues and are not easily
identified as seeking termination of pregnancy services. Such factors
have been noted in other studies as important to service accessibility
and acceptance [11]. Also, Gateway Health placed significant emphasis
on staff training to ensure that the reception staff in particular, were
mindful of privacy and confidentiality sensitivities and issues. Creating
a well co-ordinated system with external providers such as pharmacists
and other relevant health care professionals in the local community
[12], was also a key factor in ensuring that the Gateway Health MToP
service was accessible and affordable to every patient.
We did not identify any recorded adverse events during the patient
chart audit, however 2 patients (0.9%) experienced an unsuccessful
MToP and required further surgical intervention. This is consistent with
the published evidence [13] and should also be considered alongside
the additional 8.7% of patients who were lost to follow up. As the
outcome of the procedure is unknown for those patients who were lost
to follow up we cannot presume that all had a successful outcome,
particularly travellers who may have sought further intervention else-
where. Whilst having patients that are lost to follow up is unfortunate it
is not surprising when the nature of the service is that the termination is
carried out at home and is consistent with findings from another Aus-
tralian MToP study [9].
We found that presenting for an MToP also provided the opportu-
nity for Gateway Health staff to discuss contraception with these
women and importantly, almost three quarters were subsequently using
more effective contraception post MToP than they were prior to at-
tending the service, highlighting the capacity of this clinic to also
provide an appropriate intervention to prevent further unwanted
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Sexual & Reproductive Healthcare 16 (2018) 175–180
pregnancies.
Gateway Health Wodonga has demonstrated that affordable, ac-
cessible MToP services can be successful and viable in regional com-
munities in Victoria if appropriate planning and careful implementation
are undertaken in partnership with local service providers. However, it
is also important to note that a nurse led model is the most likely to
succeed compared to a solo GP model; due to the time intensive nature
of the pre MToP clinical workup required and the continued efforts also
required to ensure co-ordination and partnerships with external pro-
viders that are essential to the overall success of the service model.
Others have noted that lack of trained general practitioner abortion
providers can be addressed through training nurses to be able to un-
dertake some of this role [14]. However, this raises an issue for most
general practices in Australia, as remuneration for an MToP service can
only be gained for a doctor’s consultation time through Medicare rebate
whilst the nurse’s time is not renumerated at each consultation. Al-
though Gateway Health has a government funded sexual health nurse
which makes MToP more financially viable than what is currently the
case in General Practice, it is possible to develop a model that uses a
general practice nurse and more of the GP’s time than Gateway Health,
so that longer consultations can be billed for the GP. This would make
MToP in General Practice a more financially viable option. There would
also be an option for the GP to decide how much is reasonable to charge
the patient over and above the Medicare rebate (known as out of pocket
expenses) to cover the time spent undertaking MToP while still making
it much cheaper than the private abortion services. A recent study by
Newton and colleagues [12] identified that general practice is well si-
tuated, particularly in regional communities, to provide more accessible
MToP services in a “one stop shop”, although the study did not explore
the reasons why the majority of GPs choose not to provide the service.
Given the findings of our study; it is apparent that a highly skilled,
competent nurse leading the clinical team is key to the success of the
service at Gateway Health, however with the current structure of the
Medicare rebate schedule, covering the salary of such a nurse is difficult
in general practice but not necessarily prohibitive to providing an MToP
service, if the GP is doing a significant part of the work. Also, con-
sideration should be given to the fact that each state in Australia has
differing laws in relation to providing abortion services and in the
majority of states, the nurse led model described here may need some
adjustment, as the law requires a doctor to determine that the abortion
can be lawfully performed.
Conclusion
This paper describes how MToP can be delivered in a regional set-
ting and also how this service can provide an opportunity to assist
women to manage their contraceptive choices using a nurse-led model.
The audit demonstrates that MToP can be accessible and delivered
safely in primary care services whilst meeting the needs of the local
community. Other organisations establishing similar models may derive
benefit from undertaking a similar audit process to understand who the
service is reaching, contraception use, and outcome of presentation.
Such information can assist continual quality improvement as well as
contribute to organisational understanding of the value of low-cost,
locally-provided abortion services for rural women.
Implications
This study demonstrates that MToP can be provided to Australian
rural women in their local community in an accessible and affordable
service model, provided there are skilled professionals available who
are motivated and willing to develop a service that is appropriate for
the needs of the local community.
J.E. Tomnay et al.
Acknowledgement
The authors wish to acknowledge Dr. Paddy Moore from the Royal
Women’s Hospital Melbourne for her mentorship and leadership in
initiating the discussions, training and systems that have been devel-
oped to improve access to early abortion in primary care in regional
Victoria.
Conflict of interest
The authors have no conflict of interest to declare.
Appendix A. Supplementary material
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.srhc.2018.04.006.
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