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Aust. J. Rural Health (2014) 22, 121–126
Original Research Rural New South Wales women’s access to abortion services: Highlights from an exploratory qualitative study Frances Doran, MSocSc, PhD,1 and Julie Hornibrook, BSW, Master of Public Administration2 1
School of Health and Human Sciences, Southern Cross University, Lismore, New South Wales; and Mount Isa Centre for Rural and Remote Health, James Cook University, Mt Isa, Queensland, Australia 2
Abstract Objective: The aim of the study was to identify factors that New South Wales (NSW) rural women experience in relation to their ability to access an abortion service and follow-up care. Design: The qualitative responses from interviews are reported. Setting: Rural and regional NSW. Participants: Staff from community based nongovernment Women’s Health Centres across regional/ rural NSW and women in rural NSW who had accessed an abortion in the preceding fifteen years. Main outcomes: A number of barriers that NSW rural women experience in relation to their ability to access an abortion and follow-up care were identified. Results: The main barrier rural women experienced was travelling relatively long distances to access an abortion clinic because of lack of services in their local area. Women with limited financial resources needed to borrow money for the procedure and associated costs of travel and accommodation. Women’s Health Centres provide a range of support and referral information. Lack of integrated care was reported. Conclusions: Rural women’s access to abortion services are impacted by the availability, accessibility and affordability of services and prevailing negative social attitudes. This exploratory study provides a snapshot of women’s experiences of the process of seeking an abortion in rural NSW, where they are not available locally and women have to travel out of the area to access services. Findings indicate rural women experience
Correspondence: Dr Frances Doran, School of Health and Human Sciences, Southern Cross University, PO Box 150, Lismore, New South Wales, 2480, Australia. Email: [email protected] In collaboration with the Lismore and District Women’s Health Centre Inc., PO Box 1129, Lismore, 2480. Accepted for publication 23 January 2014. © 2014 National Rural Health Alliance Inc.
multiple barriers in relation to their ability to access abortion services and follow-up care, which may impact on overall health outcomes. KEY WORDS: access issue, health service access, public health, rural women’s health, women’s health.
Introduction Women living in rural/regional areas experience particular disadvantage when seeking access to elective abortion services.1,2 Although accurate data are problematic,3 about 80 000 Australian women access an abortion service each year.4 Most occur within the first trimester, and in New South Wales (NSW), the majority are performed at private non-hospital clinics.4 Across Australian states and territories, there is an inconsistent legal framework surrounding abortion. This has had implications for lack of coordinated policy development and service delivery, and results in inequitable access to safe, legal and affordable abortion services in Australia.5 Confusing laws also impact on the medical professions’ knowledge of their state or territory’s abortion law.6 In NSW, abortion law is within the criminal code7 that creates uncertainty and lack of confidence for women and their doctors.5,8 The common experience for rural women seeking an abortion entails travelling long distances outside of their own geographical area,9 sometimes interstate, to access private clinics.10,11 This is often unaffordable and inaccessible for rural women especially those on lower incomes.5 The barriers can be onerous and contribute to lack of follow-up care and poor continuity of care.12 In some rural areas in NSW, non-government community-based women’s health centres (WHCs) provide women with information, counselling, support and advocacy services and limited financial assistance to support women who seek access to an abortion service.13 In rural communities, these centres can often be a first point of contact for women needing specific women’s health information and support. doi: 10.1111/ajr.12096
122
What is already known on this subject: • There is scant research on women’s experiences of seeking access to abortions despite the fact that a significant proportion of Australian women have an abortion at some time in their lives. Australians living in regional and remote areas generally experience poorer health than their major city counterparts. • Across Australia, within states and territories, there is an inconsistent legal framework surrounding abortion. Depending on geographical location, abortion is under the criminal code or the health code. • Abortion remains a sensitive topic, with a lack of integrated health policy. Rural women, who live in states such as NSW where most abortion services are provided by private clinics, face barriers to accessing services.
Even though almost one in three Australian women will have an elective abortion at some time in their lives,14 there is a major gap in research that explores rural women’s experiences of seeking access to this health care service. To our knowledge, no research has explored rural women’s experiences of accessing an abortion nor the role of non-government communitybased WHC’s in supporting women’s access. This paper reports on a small exploratory qualitative study that aimed to identify factors that rural women experience in NSW in accessing abortion services.
Methods The study involved was twofold. In stage 1, seven rural WHCs in NSW were invited to participate either by phone or by providing written responses to specific questions: 1. The number of women seeking information on access to an abortion. 2. The type of support each centre provided to women seeking an abortion. 3. Access issues women experienced in the process of seeking an abortion and/or follow-up care. 4. Gaps in service provision and delivery. In stage 2, the views of rural women who had an abortion in the last 15 years in NSW were sought via a confidential phone or face-to-face interview. Women were recruited via locally displayed flyers distributed to WHCs through media releases and word-ofmouth. Interested women self-selected and contacted
F. DORAN AND J. HORNIBROOK
What does this study add: • Rural WHCs, as community based nongovernment services, support women to access abortions in various ways. • Barriers rural women experience when they seek information and access to abortion services include distance, cost and negative social attitudes. Lack of holistic care, information and support are common experiences for women who access abortion services. • There has been no research undertaken exploring rural NSW women’s experiences of accessing an abortion. Increased awareness of important access and service delivery issues is necessary to ensure quality of care is not compromised.
the researcher. Informed consent was gained, and interviews explored broad questions on: 1. Experiences of seeking access to an abortion service. 2. Factors that influenced access. 3. Suggestions on ways access to abortion services could be improved and rural women better supported. Ethics approval was granted from the Southern Cross University Human Ethics Committee: stage 1 ECN-13003; stage 2 ECN-13-060. This paper presents a snapshot of responses to specific questions.
Data analysis Data analysis of the specific questions was undertaken via numerical and descriptive analysis. The number of WHCs who identified different types of support and the barriers to access were listed and counted. Data on the number of women who accessed WHCs were numerically analysed. Descriptive analysis was undertaken to identify more detailed responses from staff about gaps in care. Both authors independently reviewed all the transcripts of interviews with individual women and then discussed responses identified to specific questions to reach consensus. Selective quotes are used to highlight points pertinent to main findings.
Results Stage 1: WHCs All seven WHCs contacted agreed to participate. Phone interviews were undertaken with seven staff ranging © 2014 National Rural Health Alliance Inc.
123
RURAL WOMEN’S ACCESS TO ABORTION SERVICES
TABLE 1: Support provided by women’s health centres (WHCs) to access an abortion service
Types of support
Number of WHCs
Crisis fund for loans/financial assistance Information Referrals to services Volunteer transport support transport Negotiate cost with abortion service provider Counselling Women’s health nurse Doctor Advocacy Follow-up care information (counselling/GP)
1 7 7 1 2 5 3 1 5 4
from 30 to 50 min. One staff member provided written responses to questions via e-mail. In response to Question 1, staff reported that accurate data was difficult to obtain. As an overall estimate specific to abortion, nurse appointments at each WHC ranged from 20 to 51 per year; phone information contacts ranged from 80 to 200 per year; other appointments (counsellor, doctor) were at least once a week. Only one WHC provides financial support; between 2007 and 2012, 138 women were loaned money with an average individual loan of $450.00. Responses elicited for Question 2 indicated the range of support provided to women (see Table 1). Information and referral were provided by all WHCs; transport was identified as a major issue, but only one WHC provides practical support by calling on volunteers. In response to Question 3, cost, transport/lack of public transport, distance, lack of services in local area and shortage of rural General practitioners (GPs) were identified as factors that influenced access to an abortion and follow-up care (see Table 2). In response to Question 4, affordability and availability of services, correct referral process, continuity of preand post-abortion care and integration of services were seen as gaps in service provision. A shortage of doctors, especially women doctors, long waiting times, lengthy travel and cost impacted on timely access to abortion and follow-up care.
Stage 2: Individual interviews Fifteen women contacted the researcher. One woman did not live in rural NSW when she sought an abortion so was ineligible and follow-up contact was not possible for another woman. Thirteen women were interviewed, 12 via phone and one face-to-face. Women had an abortion 5 months to 15 years prior to interview aged © 2014 National Rural Health Alliance Inc.
TABLE 2: care
Barriers to accessing an abortion and follow-up
Barrier
Number of WHCs
Cost Lack of public transport/transport issues Needing a support person Distance to travel Protestors at clinic Childcare Lack of integrated holistic care between services Lack of information/misinformation Confidentiality/privacy No abortion provider in local area Social stigma/conservative social attitudes Shortage of rural doctors
7 7 6 4 2 3 2 5 2 7 7 4
WHC, women’s health centre.
between 18 and 46 years. Ages and synopsis of women’s experiences are presented in Table 2. All women in this study had a surgical abortion in trimester 1. All women spoke of the process of accessing information and described challenges they experienced (Question 1). Kate ‘did not know where to begin’ and for Clara and Glenda their first call was to the WHC. Glenda commented that ‘if the WHC wasn’t there I wouldn’t have known where to go for pro-choice information’. Kelly said her GP would not provide a referral until she had two ultrasounds and blood tests that she found ‘distressing’ and described the wait as ‘horrible: I had to wait for something to get bigger before I could terminate’. Zilah reflected she was very fortunate she could ‘access her regular female GP before and after each abortion’. Skye was 46 when with an unplanned pregnancy. She saw five GPs before she was ‘finally’ provided a referral. She described her ordeal as ‘horrendous’ and could not believe the ‘conservative’ approach of GPs in this rural area and lack of accurate information about the option for self-referral. All, except one woman, made their own clinic appointment. Even though all women were clear about their decision and none felt the need for counselling, they all described challenging personal circumstances. The main factors influencing access to service (Question 2) related to cost, travel and childcare. Six women borrowed money (see Table 3). Elaine commented that for her, ‘money was already a problem’. Expenses beyond the clinic fee included overnight accommodation, petrol/train/airfare costs, taking time off work (for woman and their support person) and childcare. Participants travelled between 2 and 9 hours one-way to reach a clinic. Molly commented on ‘all those
3As, 18, 21, 24
35
21 24
20, 22 25 26 38
34 21 37 38 25 25 46
Kelly
June
Molly
Glenda Elaine
Zilah Tillie
Clara Joey Eliza
6 4 1.5
11/2 hours 11/2 1
9 for all 1
2 3
7
2 for all
6
Car/partner Car/partner Car/husband
Car/ex-partner Car/partner Car/husband
Car/mother Car/partner
Lent car/partner Lent car/friend
Night train/friend
Own car/partner
Own car/friend
Transport/support person
Ex-partner paid Partner paid Borrowed $800 from friend No $300 No
Shared costs with partner Partner paid
$500 from cousin Paid flights for interstate travel for support person Shared cost with partner for all $50 from family support, the rest on credit card she had not ‘maxed out’ $500 from Centre Link $700 from WHC
Borrowed money
GP, general practitioner; N/A, not applicable; WHC, women’s health centre.
Fern Moira Skye
23
Pseudonym
Travel to clinic one-way (hours)
Age and synopsis of participant experiences
Age at abortion (years)
TABLE 3:
N/A 2 children separately minded day/night N/A 2 children minded for day N/A N/A Yes, very early morning childcare for 2 No No No
4 children minded day/night
1 child minded for day
N/A
Childcare
No Yes, camped No
No No No
Yes, motel No
No Yes, with relative
Yes, motel
No
Yes, with relative
Overnight stay
WHC No GP × 5
WHC No GP only for 1st
WHC GP first WHC for loan GP for all No
No
No
GP
GP/WHC pre-abortion
No No No
No No GP 1st only
Go for all GP
GP GP
GP 1st and 2nd No
No
Follow-up
124 F. DORAN AND J. HORNIBROOK
© 2014 National Rural Health Alliance Inc.
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RURAL WOMEN’S ACCESS TO ABORTION SERVICES
logistics that I had to organise, just to get there’. Arrangements varied, but logistics involved organising early morning departure, childcare, overnight train, borrowing a car, seeking finance, and asking a support person to drive to and from the clinic (see Table 3). Clara reflected that ‘in that car driving over the border [from NSW to Qld] I felt like the women in Ireland . . . horrible . . . in that car going all that way’. When asked about ways to improve rural women’s access to an abortion service (Question 3), local service provision was the main suggestion to reduce travel. Travel also influenced decisions for surgical rather than medical abortion, as a follow-up appointment could be avoided. Kelly stated ‘it was too hard to return to the clinic (and that she) wanted it over and done with on one day’. Fern suggested making medical abortion accessible would make the whole process much easier: ‘it’s not rocket science’. Reducing stigma and negative attitudes was mentioned by all women as a way to improve access to appropriate care, service delivery and community understanding (Question 3). Skye’s experience of accessing five rural GPs before she received a referral was ‘demoralising’ and significantly delayed the procedure. Some women feared being judged, which led to Tillie and Joey not stating the reason they were taking time off work or telling their closest friends. Molly said it ‘became tricky’ as she needed overnight childcare. Clara also commented on ‘moralistic ideology and judgement’ around abortion and the propaganda about RU486, which she thought limited availability. Moira pondered why she had to travel 4 hours for this procedure when a curette could be offered in the local hospital. Eliza expressed a need for ‘more broad public awareness and communication, rather than a taboo, “under the carpet” topic’. Fern suggested ‘simplifying the process was not medically based – it’s other moral, ethical, religious pressure’.
Discussion To our knowledge, this study is the first of its kind in Australia to explore the perspective of both rural service providers and women who have experienced an abortion. The results, although specific to these participants, reflect a range of WHCs across rural NSW and a substantial number of women willing to participate in sensitive research.15 The average age of women interviewed was 27 years comparable with national data of women aged 20–29 years who have the highest abortion rate.16 The results provide a snapshot of barriers rural women experience when they seek to access an abortion and indicate how rural WHCs, as low budget © 2014 National Rural Health Alliance Inc.
non-government organisations, provide a variety of support services, including information and referral. The strength of the findings are in the similarity of issues identified, such as travel, distance, cost, negative social attitudes, lack of holistic care, lack of female doctors and lack of information, which are issues also identified in the broader literature.1,17–19 Residents of rural and remote communities experience poorer health outcomes and lack of local services can increase the burden of social disadvantage.20 Affordability and availability of services, continuity of pre- and post-abortion care and integration of services were identified as gaps in care by WHC staff and women. The lack of local providers for access to both surgical and medical abortion was also identified. The Pharmaceutical Benefits Scheme recent listing of RU486, for medical abortion,21 may help to address some of the current inequities in abortion service delivery for rural women, if offered by providers. Delays, which contributed to psychological distress, were experienced by women whose GPs did not provide referrals or adequate information. Global and national guidelines acknowledge health care providers’ right to conscentiously object to abortion, but this right does not extend to blocking women’s access to abortion.22,23 Abortion is often a ‘difficult solution to a complex problem’,24 and women should not be subject to unnecessary hardship as a result of their choice.17 Structural impediments such as inconsistent abortion laws across Australia continue to be debated and contribute to inadequate public access to information and services, with consequent lack of serious attention in health policy development. This exploratory study provides a snapshot of women’s experiences of seeking an abortion in rural NSW. Findings indicate that rural women’s access is impacted by the availability, accessibility and affordability of services, and prevailing social attitudes. Abortion is supported by the majority of the community12 and remains an important public health issue for a significant number of Australian women. This study makes a substantial contribution to rasing awareness of important access and service delivery issues rural women experience that warrant further attention to ensure that quality care is not compromised.
Acknowledgements The authors would like to thank the Women’s Health Nurse, staff and Council of Women at the Lismore and District Women’s Health Centre, Inc., Lismore, NSW, Australia; the staff from participating rural WHCs; and women who agreed to be interviewed.
126
References 1 Alston M, Allan J, Dietsch E et al. Brutal neglect: Australian Rural Women’s Access to Health Services. Rural and Remote Health [Internet]. 2006; 6(1). [Cited 16 Jun 2013]. Available from URL: http://www.rrh.org.au/articles/ subviewnew.asp?ArticleID=475. 2 Rosenthal D, Rowe H, Mallett S, Hardiman A, Kirkman M Understanding Women’s Experiences of Unplanned Pregnancy and Abortion, Final Report. 2009 Key Centre for Women’s Health in Society, Melbourne School of Population Health, The Universtiy of Melbourne: Melbourne, Australia. 3 Peterson K. Early medical abortion: legal and medical deveopments in Australia. Medicine and the Law 2010; 1: 26–29. 4 Newman L, Morrell S, Munot S, Estoesta J, Brassil A. Reproductive and Sexual Health in New South Wales and Australia. Differentials, Trends and Assessment of Data Sources. Sydney: Family Planning, NSW, 2011. 5 Australian Women’s Health Network. Women and Sexual and Reproductive Health Position Paper 2012. Victoria: Australian Women’s Health Network, 2012. 6 de Costa C, Douglas H, Black K. Making it legal: abortion providers’ knowledge and use of abortion law in New South Wales and Queensland. Aust N Z J Obstet Gynaecol. 2013; 53: 184–9. 7 de Crespingny L, Savulescu J. Abortion: time to clarify Australia’s confusing laws. Medical Journal of Australia 2004; 181: 201–203. 8 Australian Women’s Health Network. Women’s Health: The New National Agenda. Position Paper March 2008, 2008 [Cited 10 Feb 2010]. Available from URL: http:// www.whnsw.asn.au/AWHN/AWHN_Position_Paper.pdf 9 Silva M, McNeill R. Geographical access to termination of pregnancy services in New Zealand. Australian and New Zealand Journal of Public Health 2008; 32: 519– 521. 10 Nickson C, Smith AM, Shelley JM. Travel undertaken by women accessing private Victorian pregnancy termination services. Australian and New Zealand Journal of Public Health 2006; 30: 329–333. 11 Nickson C, Shelley J, Smith A. Use of interstate services for the termination of pregnancy in Australia. Australian and New Zealand Journal of Public Health 2002; 26: 421–425. 12 Public Health Association. Abortion in Australia: Public Health Perspectives. Canberra: Public Health Association, 2005.
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13 Women’s Health NSW. Principles of Women’s Health Care 2006 [Cited 17 Jan 2012]. Available from URL: http:// www.whnsw.asn.au/PDFs/Principles_of_Women_Health _Care.pdf 14 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Termination of Pregnancy: A Resource for Health Professionals. East Melbourne, Victoria, Australia: The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2005. 15 Elmir R, Schmied V, Jackson D, Wilkes L. Interviewing people about potentially sensitive topics. Nurse Researcher 2011; 19: 12–16. 16 Abigail W, Power C, Belan I. Changing patterns in women seeking terminations of pregnancy: a trend analysis of data from one service provider 1996–2006. Australian and New Zealand Journal of Public Health 2008; 32: 230–237. 17 Rowe HJ, Kirkman M, Hardiman EA, Mallett S, Rosenthal DA. Considering abortion: a 12-month audit of records of women contacting a Pregnancy Advisory Service. The Medical Journal of Australia 2009; 190: 69–72. 18 Norman WV, Soon JA, Maughn N, Dressler J. Barriers to rural induced abortion services in Canada: findings of the British Columbia Aborton Providers Survey (BCAPS). PLoS ONE 2013; 8: e67023. 19 Adelson PL, Frommer MS, Weisberg E. A survey of women seeking termination of pregnancy in New South Wales. The Medical Journal of Australia 1995; 163: 419–422. 20 Australian Institute of Health and Welfare. Rural, Regional and Remote Health: Indicators of Health Status and Determinants of Health. Canberra: AIHW, 2008. Rural Health Series no. 9. Cat. no. PHE 97. 21 Australian Government: Department of Health and Ageing. RU486 - Pharmaceutical Benefits Scheme listing 2013 [Cited 10 Jul 2013]. Available from URL: http://www.pbs.gov.au/info/industry/listing/elements/pbac -meetings/psd/2013-03/mifepristone 22 Medical Board of Australia. Good medical practice: A code of conduct for doctors in Australia 2010 6th 2013. [Cited 6 Dec 2013]. Available from: http://www .medicalboard.gov.au/Codes-Guidelines-Policies.aspx 23 World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems, 2nd edn. Geneva: World Health Organization, 2012. 24 Kirkman M, Rowe H, Hardiman A, Rosenthal D. Abortion is a difficult solution to a problem: a discursive analysis of interviews with women considering or undergoing abortion in Australia. Women’s Studies International Forum 2011; 34: 121–129.
© 2014 National Rural Health Alliance Inc.
Aust. J. Rural Health (2014) 22, 121–126
Original Research Rural New South Wales women’s access to abortion services: Highlights from an exploratory qualitative study Frances Doran, MSocSc, PhD,1 and Julie Hornibrook, BSW, Master of Public Administration2 1
School of Health and Human Sciences, Southern Cross University, Lismore, New South Wales; and Mount Isa Centre for Rural and Remote Health, James Cook University, Mt Isa, Queensland, Australia 2
Abstract Objective: The aim of the study was to identify factors that New South Wales (NSW) rural women experience in relation to their ability to access an abortion service and follow-up care. Design: The qualitative responses from interviews are reported. Setting: Rural and regional NSW. Participants: Staff from community based nongovernment Women’s Health Centres across regional/ rural NSW and women in rural NSW who had accessed an abortion in the preceding fifteen years. Main outcomes: A number of barriers that NSW rural women experience in relation to their ability to access an abortion and follow-up care were identified. Results: The main barrier rural women experienced was travelling relatively long distances to access an abortion clinic because of lack of services in their local area. Women with limited financial resources needed to borrow money for the procedure and associated costs of travel and accommodation. Women’s Health Centres provide a range of support and referral information. Lack of integrated care was reported. Conclusions: Rural women’s access to abortion services are impacted by the availability, accessibility and affordability of services and prevailing negative social attitudes. This exploratory study provides a snapshot of women’s experiences of the process of seeking an abortion in rural NSW, where they are not available locally and women have to travel out of the area to access services. Findings indicate rural women experience
Correspondence: Dr Frances Doran, School of Health and Human Sciences, Southern Cross University, PO Box 150, Lismore, New South Wales, 2480, Australia. Email: [email protected] In collaboration with the Lismore and District Women’s Health Centre Inc., PO Box 1129, Lismore, 2480. Accepted for publication 23 January 2014. © 2014 National Rural Health Alliance Inc.
multiple barriers in relation to their ability to access abortion services and follow-up care, which may impact on overall health outcomes. KEY WORDS: access issue, health service access, public health, rural women’s health, women’s health.
Introduction Women living in rural/regional areas experience particular disadvantage when seeking access to elective abortion services.1,2 Although accurate data are problematic,3 about 80 000 Australian women access an abortion service each year.4 Most occur within the first trimester, and in New South Wales (NSW), the majority are performed at private non-hospital clinics.4 Across Australian states and territories, there is an inconsistent legal framework surrounding abortion. This has had implications for lack of coordinated policy development and service delivery, and results in inequitable access to safe, legal and affordable abortion services in Australia.5 Confusing laws also impact on the medical professions’ knowledge of their state or territory’s abortion law.6 In NSW, abortion law is within the criminal code7 that creates uncertainty and lack of confidence for women and their doctors.5,8 The common experience for rural women seeking an abortion entails travelling long distances outside of their own geographical area,9 sometimes interstate, to access private clinics.10,11 This is often unaffordable and inaccessible for rural women especially those on lower incomes.5 The barriers can be onerous and contribute to lack of follow-up care and poor continuity of care.12 In some rural areas in NSW, non-government community-based women’s health centres (WHCs) provide women with information, counselling, support and advocacy services and limited financial assistance to support women who seek access to an abortion service.13 In rural communities, these centres can often be a first point of contact for women needing specific women’s health information and support. doi: 10.1111/ajr.12096
122
What is already known on this subject: • There is scant research on women’s experiences of seeking access to abortions despite the fact that a significant proportion of Australian women have an abortion at some time in their lives. Australians living in regional and remote areas generally experience poorer health than their major city counterparts. • Across Australia, within states and territories, there is an inconsistent legal framework surrounding abortion. Depending on geographical location, abortion is under the criminal code or the health code. • Abortion remains a sensitive topic, with a lack of integrated health policy. Rural women, who live in states such as NSW where most abortion services are provided by private clinics, face barriers to accessing services.
Even though almost one in three Australian women will have an elective abortion at some time in their lives,14 there is a major gap in research that explores rural women’s experiences of seeking access to this health care service. To our knowledge, no research has explored rural women’s experiences of accessing an abortion nor the role of non-government communitybased WHC’s in supporting women’s access. This paper reports on a small exploratory qualitative study that aimed to identify factors that rural women experience in NSW in accessing abortion services.
Methods The study involved was twofold. In stage 1, seven rural WHCs in NSW were invited to participate either by phone or by providing written responses to specific questions: 1. The number of women seeking information on access to an abortion. 2. The type of support each centre provided to women seeking an abortion. 3. Access issues women experienced in the process of seeking an abortion and/or follow-up care. 4. Gaps in service provision and delivery. In stage 2, the views of rural women who had an abortion in the last 15 years in NSW were sought via a confidential phone or face-to-face interview. Women were recruited via locally displayed flyers distributed to WHCs through media releases and word-ofmouth. Interested women self-selected and contacted
F. DORAN AND J. HORNIBROOK
What does this study add: • Rural WHCs, as community based nongovernment services, support women to access abortions in various ways. • Barriers rural women experience when they seek information and access to abortion services include distance, cost and negative social attitudes. Lack of holistic care, information and support are common experiences for women who access abortion services. • There has been no research undertaken exploring rural NSW women’s experiences of accessing an abortion. Increased awareness of important access and service delivery issues is necessary to ensure quality of care is not compromised.
the researcher. Informed consent was gained, and interviews explored broad questions on: 1. Experiences of seeking access to an abortion service. 2. Factors that influenced access. 3. Suggestions on ways access to abortion services could be improved and rural women better supported. Ethics approval was granted from the Southern Cross University Human Ethics Committee: stage 1 ECN-13003; stage 2 ECN-13-060. This paper presents a snapshot of responses to specific questions.
Data analysis Data analysis of the specific questions was undertaken via numerical and descriptive analysis. The number of WHCs who identified different types of support and the barriers to access were listed and counted. Data on the number of women who accessed WHCs were numerically analysed. Descriptive analysis was undertaken to identify more detailed responses from staff about gaps in care. Both authors independently reviewed all the transcripts of interviews with individual women and then discussed responses identified to specific questions to reach consensus. Selective quotes are used to highlight points pertinent to main findings.
Results Stage 1: WHCs All seven WHCs contacted agreed to participate. Phone interviews were undertaken with seven staff ranging © 2014 National Rural Health Alliance Inc.
123
RURAL WOMEN’S ACCESS TO ABORTION SERVICES
TABLE 1: Support provided by women’s health centres (WHCs) to access an abortion service
Types of support
Number of WHCs
Crisis fund for loans/financial assistance Information Referrals to services Volunteer transport support transport Negotiate cost with abortion service provider Counselling Women’s health nurse Doctor Advocacy Follow-up care information (counselling/GP)
1 7 7 1 2 5 3 1 5 4
from 30 to 50 min. One staff member provided written responses to questions via e-mail. In response to Question 1, staff reported that accurate data was difficult to obtain. As an overall estimate specific to abortion, nurse appointments at each WHC ranged from 20 to 51 per year; phone information contacts ranged from 80 to 200 per year; other appointments (counsellor, doctor) were at least once a week. Only one WHC provides financial support; between 2007 and 2012, 138 women were loaned money with an average individual loan of $450.00. Responses elicited for Question 2 indicated the range of support provided to women (see Table 1). Information and referral were provided by all WHCs; transport was identified as a major issue, but only one WHC provides practical support by calling on volunteers. In response to Question 3, cost, transport/lack of public transport, distance, lack of services in local area and shortage of rural General practitioners (GPs) were identified as factors that influenced access to an abortion and follow-up care (see Table 2). In response to Question 4, affordability and availability of services, correct referral process, continuity of preand post-abortion care and integration of services were seen as gaps in service provision. A shortage of doctors, especially women doctors, long waiting times, lengthy travel and cost impacted on timely access to abortion and follow-up care.
Stage 2: Individual interviews Fifteen women contacted the researcher. One woman did not live in rural NSW when she sought an abortion so was ineligible and follow-up contact was not possible for another woman. Thirteen women were interviewed, 12 via phone and one face-to-face. Women had an abortion 5 months to 15 years prior to interview aged © 2014 National Rural Health Alliance Inc.
TABLE 2: care
Barriers to accessing an abortion and follow-up
Barrier
Number of WHCs
Cost Lack of public transport/transport issues Needing a support person Distance to travel Protestors at clinic Childcare Lack of integrated holistic care between services Lack of information/misinformation Confidentiality/privacy No abortion provider in local area Social stigma/conservative social attitudes Shortage of rural doctors
7 7 6 4 2 3 2 5 2 7 7 4
WHC, women’s health centre.
between 18 and 46 years. Ages and synopsis of women’s experiences are presented in Table 2. All women in this study had a surgical abortion in trimester 1. All women spoke of the process of accessing information and described challenges they experienced (Question 1). Kate ‘did not know where to begin’ and for Clara and Glenda their first call was to the WHC. Glenda commented that ‘if the WHC wasn’t there I wouldn’t have known where to go for pro-choice information’. Kelly said her GP would not provide a referral until she had two ultrasounds and blood tests that she found ‘distressing’ and described the wait as ‘horrible: I had to wait for something to get bigger before I could terminate’. Zilah reflected she was very fortunate she could ‘access her regular female GP before and after each abortion’. Skye was 46 when with an unplanned pregnancy. She saw five GPs before she was ‘finally’ provided a referral. She described her ordeal as ‘horrendous’ and could not believe the ‘conservative’ approach of GPs in this rural area and lack of accurate information about the option for self-referral. All, except one woman, made their own clinic appointment. Even though all women were clear about their decision and none felt the need for counselling, they all described challenging personal circumstances. The main factors influencing access to service (Question 2) related to cost, travel and childcare. Six women borrowed money (see Table 3). Elaine commented that for her, ‘money was already a problem’. Expenses beyond the clinic fee included overnight accommodation, petrol/train/airfare costs, taking time off work (for woman and their support person) and childcare. Participants travelled between 2 and 9 hours one-way to reach a clinic. Molly commented on ‘all those
3As, 18, 21, 24
35
21 24
20, 22 25 26 38
34 21 37 38 25 25 46
Kelly
June
Molly
Glenda Elaine
Zilah Tillie
Clara Joey Eliza
6 4 1.5
11/2 hours 11/2 1
9 for all 1
2 3
7
2 for all
6
Car/partner Car/partner Car/husband
Car/ex-partner Car/partner Car/husband
Car/mother Car/partner
Lent car/partner Lent car/friend
Night train/friend
Own car/partner
Own car/friend
Transport/support person
Ex-partner paid Partner paid Borrowed $800 from friend No $300 No
Shared costs with partner Partner paid
$500 from cousin Paid flights for interstate travel for support person Shared cost with partner for all $50 from family support, the rest on credit card she had not ‘maxed out’ $500 from Centre Link $700 from WHC
Borrowed money
GP, general practitioner; N/A, not applicable; WHC, women’s health centre.
Fern Moira Skye
23
Pseudonym
Travel to clinic one-way (hours)
Age and synopsis of participant experiences
Age at abortion (years)
TABLE 3:
N/A 2 children separately minded day/night N/A 2 children minded for day N/A N/A Yes, very early morning childcare for 2 No No No
4 children minded day/night
1 child minded for day
N/A
Childcare
No Yes, camped No
No No No
Yes, motel No
No Yes, with relative
Yes, motel
No
Yes, with relative
Overnight stay
WHC No GP × 5
WHC No GP only for 1st
WHC GP first WHC for loan GP for all No
No
No
GP
GP/WHC pre-abortion
No No No
No No GP 1st only
Go for all GP
GP GP
GP 1st and 2nd No
No
Follow-up
124 F. DORAN AND J. HORNIBROOK
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RURAL WOMEN’S ACCESS TO ABORTION SERVICES
logistics that I had to organise, just to get there’. Arrangements varied, but logistics involved organising early morning departure, childcare, overnight train, borrowing a car, seeking finance, and asking a support person to drive to and from the clinic (see Table 3). Clara reflected that ‘in that car driving over the border [from NSW to Qld] I felt like the women in Ireland . . . horrible . . . in that car going all that way’. When asked about ways to improve rural women’s access to an abortion service (Question 3), local service provision was the main suggestion to reduce travel. Travel also influenced decisions for surgical rather than medical abortion, as a follow-up appointment could be avoided. Kelly stated ‘it was too hard to return to the clinic (and that she) wanted it over and done with on one day’. Fern suggested making medical abortion accessible would make the whole process much easier: ‘it’s not rocket science’. Reducing stigma and negative attitudes was mentioned by all women as a way to improve access to appropriate care, service delivery and community understanding (Question 3). Skye’s experience of accessing five rural GPs before she received a referral was ‘demoralising’ and significantly delayed the procedure. Some women feared being judged, which led to Tillie and Joey not stating the reason they were taking time off work or telling their closest friends. Molly said it ‘became tricky’ as she needed overnight childcare. Clara also commented on ‘moralistic ideology and judgement’ around abortion and the propaganda about RU486, which she thought limited availability. Moira pondered why she had to travel 4 hours for this procedure when a curette could be offered in the local hospital. Eliza expressed a need for ‘more broad public awareness and communication, rather than a taboo, “under the carpet” topic’. Fern suggested ‘simplifying the process was not medically based – it’s other moral, ethical, religious pressure’.
Discussion To our knowledge, this study is the first of its kind in Australia to explore the perspective of both rural service providers and women who have experienced an abortion. The results, although specific to these participants, reflect a range of WHCs across rural NSW and a substantial number of women willing to participate in sensitive research.15 The average age of women interviewed was 27 years comparable with national data of women aged 20–29 years who have the highest abortion rate.16 The results provide a snapshot of barriers rural women experience when they seek to access an abortion and indicate how rural WHCs, as low budget © 2014 National Rural Health Alliance Inc.
non-government organisations, provide a variety of support services, including information and referral. The strength of the findings are in the similarity of issues identified, such as travel, distance, cost, negative social attitudes, lack of holistic care, lack of female doctors and lack of information, which are issues also identified in the broader literature.1,17–19 Residents of rural and remote communities experience poorer health outcomes and lack of local services can increase the burden of social disadvantage.20 Affordability and availability of services, continuity of pre- and post-abortion care and integration of services were identified as gaps in care by WHC staff and women. The lack of local providers for access to both surgical and medical abortion was also identified. The Pharmaceutical Benefits Scheme recent listing of RU486, for medical abortion,21 may help to address some of the current inequities in abortion service delivery for rural women, if offered by providers. Delays, which contributed to psychological distress, were experienced by women whose GPs did not provide referrals or adequate information. Global and national guidelines acknowledge health care providers’ right to conscentiously object to abortion, but this right does not extend to blocking women’s access to abortion.22,23 Abortion is often a ‘difficult solution to a complex problem’,24 and women should not be subject to unnecessary hardship as a result of their choice.17 Structural impediments such as inconsistent abortion laws across Australia continue to be debated and contribute to inadequate public access to information and services, with consequent lack of serious attention in health policy development. This exploratory study provides a snapshot of women’s experiences of seeking an abortion in rural NSW. Findings indicate that rural women’s access is impacted by the availability, accessibility and affordability of services, and prevailing social attitudes. Abortion is supported by the majority of the community12 and remains an important public health issue for a significant number of Australian women. This study makes a substantial contribution to rasing awareness of important access and service delivery issues rural women experience that warrant further attention to ensure that quality care is not compromised.
Acknowledgements The authors would like to thank the Women’s Health Nurse, staff and Council of Women at the Lismore and District Women’s Health Centre, Inc., Lismore, NSW, Australia; the staff from participating rural WHCs; and women who agreed to be interviewed.
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