Mifepristone by prescription: not quite a reality in the Northern Territory of Australia

Abstract

Drs. Grossman and Goldstone's [1] commentary in Contraception discussed the prescribing requirements of mifepristone and lamented its slow uptake, comparing the United States (USA) with Australia. It suggested that Australia was ahead of the USA. We support and provide abortion services and legal research in Australia and use our local knowledge to correct this commentary. Sadly the hope that Australia is leading the USA in women's health care is false. The maps in Grossman and Goldstone's commentary imply full coverage in the Northern Territory with reference to ‘certified prescribers’ and ‘pharmacist dispensers’. This may be accurate in terms of numbers of professional certification at the time the maps were produced but it is not accurate in terms of access to mifepristone for early medical abortion. This is for two reasons: firstly, finding professionally qualified health care professionals to work in the Territory is difficult and those who do often stay for short periods of time. Commonly there are fewer than four doctors providing a surgical service. Secondly, current legislation is prohibitive so that mifepristone is not prescribed at all for first trimester abortion [2]. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists guidelines on mifepristone use for medical abortion recently removed the requirement that mifepristone be administered in the presence of the doctor. However, section 208B of the Northern Territory Criminal Code provides a criminal offence of ‘procuring abortion’. A person is guilty of an offence if the person administers a drug to a woman or causes a drug to be taken by a woman. Explanatory notes in section 11 of the Medical Services Act (MSA) [3] state, it is lawful for a medical practitioner to give medical treatment with the intention of terminating a woman's pregnancy. However, ‘medical treatment’ is defined to include all forms of surgery. The MSA also specifically provides that the treatment is given in a hospital and other restrictive provisions relating to consent and the opinions for treatment be formed by a gynecologist/obstetrician, thus limiting service provision. In practice surgical termination of pregnancy only occurs in three hospitals located in Darwin and Alice Springs that are 1500 km apart. There is no provision of early medical abortion for suburban, rural or remote communities, whatever their local health provider may have by way of certification. On insurance advice doctors do not prescribe mifepristone for early medical abortion in general practices, remote area clinics or clinical settings such as outpatient or day surgery models. Women need to travel long distances to reach surgical abortion services. Similarly in the state of South Australia, criminal law provisions restrict abortion treatment to prescribed hospitals, only five of which have established medication abortion services. It follows that the Grossman and Goldstone suggestion that large parts of Australia have doctor prescribers and pharmacists widely available who supply mifepristone is misleading. The laws are impediments to best practice. Despite our correction, we join with Drs. Grossman and Goldstone in the disappointment that women's reproductive health rights are so poorly observed.