RU Serious?

As politicians argue about whether the abortion pill should be available, women in country Victoria can’t get legal surgical abortions now. Karen Kissane investigates the cloak of disapproval in the bush.
OUTSIDE the big city it’s another country, and they do things differently there. “Anne” knew this. She expected that small-town life would be a big change when she moved to Castlemaine. But she did not realise quite how much of what she took for granted in Melbourne would be left behind.
Two years ago, she had an accidental pregnancy. Her contraception had failed. She was in her early twenties and felt that neither she nor her relationship were prepared for parenthood. She turned to the nearest big town, Bendigo, to seek an abortion. She called the rooms of a private gynaecologist and was told that termination would not be possible anywhere in Bendigo and that she would have to go to Melbourne. “I was pretty taken aback,” says Anne.
She was even more taken aback when, having organised transport and somewhere to stay, she arrived at a Melbourne abortion clinic on the appointed day to find that she had to negotiate her way past half a dozen protesters waving placards and posters. A man and a woman challenged her with, “Do you realise this is the size of the baby you are killing? How can you do this to your baby?” Says Anne, “It was like being accosted by paparazzi. You have to step aside; you have to walk around them. It’s really awful. And I am certain that this abortion clinic is where a lot of country women end up having to go. You don’t have many options if you don’t know people in the medical industry in Melbourne.”
What happened to Anne is not unusual: if a woman who lives outside Melbourne has an unwanted pregnancy, she must nearly always travel to the capital if she wants to end it. Thirty-six years after a Supreme Court decision opened the way for legal abortions in Victoria, it remains near impossible to get one in country areas except in one or two centres such as Mildura.
The lack of availability of surgical abortions may well have remained hidden had not doctors renewed their calls to legalise the abortion pill mifepristone (also known as RU486), which is banned in Australia. That led Victorian Liberal MP Sharman Stone, the member for Murray, to suggest that RU486 might help rural women. She has threatened to cross the floor on the issue if there is no conscience vote allowed when the Democrats try to change the law later this month. “I feel very concerned about the number of women and girls who have to go to capital cities now,” she said. “It’s a very traumatic, expensive, complex process for them. If you’re only 13 or 14 with no family or community support, you can imagine how traumatic that is.”
But Federal Health Minister Tony Abbott, who has opposed RU486, says there are potential health problems with the drug that mean it will never be “the answer to a country woman’s prayer”.
While opposing sides bat claims about the pill’s safety back and forth, there are broader questions. Given the reluctance of country hospitals and doctors to provide surgical abortions, (in some cases, individual rural doctors and pharmacists have even refused to provide the normal contraceptive pill), what chance is there that they would make mifepristone available even if it were legal?
There are still no abortions in Bendigo, despite the fact that it is a town of just under 100,000 people serving a wider catchment area of 300,000. “The Catholic church looms large on the hill overlooking the city,” says one health worker who has lived there. “It has one of the largest Catholic cathedrals in Australia.” She is one of several people interviewed for this report who claimed that local strongholds of Catholic opposition to abortion have influenced the health policies of state organisations in several rural areas.
Dr Christine Tippett, senior vice-president of the Royal Australian College of Obstetricians and Gynaecologists, was disbelieving when she first got a message from The Age asking her views on the lack of abortion in the countryside. “I thought, ‘This can’t be right!’ ” But after phoning rural colleagues, she confirmed that there was little access to the service.
She says many country gynaecologists refuse to do the procedure on moral grounds – “A lot of them are practising Catholics” – and that the strong Catholic heritage of cities such as Bendigo and Warrnambool means there is opposition to abortion “within the organisations. I think that does influence it quite significantly”. It is one thing for an individual doctor to decline abortions for personal moral belief; many would accept that as legitimate. Tippett says it is a stance the college respects, and any of its trainees who conscientiously object to abortion are not expected to participate. But some sources have told The Age that Bendigo has specialists who are willing to perform elective abortions but cannot get access to theatres at the publicly funded Bendigo Base Hospital. “If you try and get a theatre (for abortion) you won’t get it except on medical grounds,” says a local health source.
A spokeswoman for Bendigo Hospital confirmed that it does no abortions and said this was simply because “it is not our policy and we have never done them”.
Tippett says, “I think gynaecologists in Bendigo are aware that in fact they are not encouraged to do terminations. It’s something made clear to them.” How? “These things are often very subtle, aren’t they?”
She says the college represents many diverse views and cannot have a stance on the rights and wrongs of abortion itself, although “clearly we believe that women should have access to termination of pregnancy”. Nor can it comment on state hospitals that do not permit the procedure: “We can’t dictate to hospitals what they do. They are autonomous bodies funded by a state department.”
There is a strange kind of silence about the lack of rural abortion. Several women’s organisations and health services are reluctant to speak on the record for fear they could further entrench opposition to it. One woman who worked in Gippsland health services for many years believes that previous waves of anti-abortion demonstrations might have contributed to the current lack of services: “About 10 years ago there were big protests outside hospitals that were doing this kind of work. I think that sort of thing has a greater impact on practitioners in country towns than it would, perhaps, on people in an abortion clinic in Melbourne. I would suggest that that has been part of why they are not done any more.”
Country life is different. It is not just patients who are subject to the conforming pressures of their neighbours’ social monitoring. A health specialist based in Melbourne says the conservatism of rural towns can defeat even the best-intentioned doctor. She tells of a doctor who opened up a bulk-billing practice in a town in the Goulburn Valley. “He started it for the good of the community but he was ostracised by his peers. His capacity to stay and raise his family and live his life there was destroyed. The same sort of shunning can happen over abortion procedures.”
Some doctors argue that the need to go to Melbourne is a blessing in disguise for rural women, who fear that their confidentiality is not safe in areas where everyone knows everyone. Bendigo GP Dr Ray Moore says that, in 27 years of referring women to Melbourne, he has only known one patient to protest over not being able to have an abortion locally. “It’s still a small-town environment and, whilst confidentiality is something that we all uphold, people in small towns know how that environment works, and most people would prefer not to have their termination here.”
Moore believes that for RU486 to become readily available, even if it were legalised, “there would have to be quite a sea change in rural environments”. Doctors would have to be willing to prescribe it, chemists would have to be willing to dispense it, and women would have to be willing for local health workers to know their situation. Others argue that the lack of rural abortion services, both surgical and medical, is a serious problem. “It’s dreadful. If you don’t have much money, it’s often unachievable,” says Deb Parkinson, research worker with North-East Women’s Health. “Often you have to go down to Melbourne the day before so that you can have counselling, so you have accommodation costs. Many women want to take a friend or family member with them. There are transport costs and often about $200 of medical costs that’s not covered by Medicare.”
There is limited access to public hospital beds for abortion even in the city. The associate director of women’s services at the Royal Women’s Hospital, Dr Chris Bayly, says the hospital gets many more requests for abortion as a public patient than it can meet. The hospital does about a sixth of the state’s procedures. Monash Medical Centre is the other large city provider.
According to figures released by the State Health Department under a recent freedom of information request by The Age, Victoria had 19,590 abortions in 2004. Of those, 14,805 were done privately and 4785 were public patients. At one private provider, the Fertility Control Clinic in East Melbourne, between a third and half the procedures are for women from the country, according to the clinic’s psychologist, Dr Susie Allanson.
Angela Taft is the national co-convener of the women’s health special interest group of the Public Health Association of Australia. “Given that we know that the majority of people are in favour of access to termination, (any refusal by country hospitals that have willing doctors) is gatekeeping. It’s disadvantaging rural women based on religious discrimination. We would be keen to have the Health Minister examine any such blocks,” she says.
A spokesman for State Health Minister Bronwyn Pike says she believes that hospital services should be determined on the basis of medical issues and not ideology. He says the minister had been unaware of any problem in Bendigo and would raise the matter with the hospital. She would also ask the Maternity Services Advisory Council to look at the issue of provision of abortion services in the region. Pike supports RU486 being made available “and is concerned that Tony Abbott is blocking it for ideological reasons”.
The drug was banned in the first place in a political trade-off. The Federal Government wanted the support of Tasmanian MP Brian Harradine in 1996 for the partial sale of Telstra. Harradine, a conservative Catholic, extracted a promise to ban RU486 as part of the deal. Unlike all other drugs, which are approved or rejected after medical assessment by the Therapeutic Goods Administration, RU486 can be imported only with the permission of the Federal Health Minister, Tony Abbott. With his own MPs this week threatening to cross the floor on the issue, Prime Minister John Howard said yesterday he is considering allowing a conscience vote on overturning the Harradine amendment.
Tippett is doubtful legalising the drug would make a significant difference because any doctor prescribing it must have surgical back-up. “I don’t believe the availability of mifepristone is necessarily going to make abortion more available . . . You would need practitioners who themselves are prepared to do abortions and a community that supports them.”
She says that otherwise women who had taken the drug could find themselves in an emergency wards in which staff opposed terminations.
But Dr Bayly believes mifepristone might expand the availability of abortion in the country. Emergency hemorrhages would be rare, she says; most women who needed to have the procedure finished surgically would have plenty of time to get to a large centre.
“There are compelling reasons to legalise it: it is a safe, proven method that many women prefer.”
ABORTION and “child destruction” remain in the Victorian Crimes Act 1958, which makes it illegal to “unlawfully administer any poison or unlawfully use any instrument with the intent to procure miscarriage”.
In the case of child destruction, one cannot “unlawfully cause (a) child (capable of being born alive) to die by any wilful act”.
The meaning of “unlawfully” was determined in 1969 by a Victorian Supreme Court judge.
The “Menhennitt rules”, as they are known, say that an abortion is not unlawful if a doctor honestly believes on reasonable grounds that the abortion is necessary to preserve the woman from a serious danger to her life or her physical or mental health.
Doctors have used this interpretation to give women abortions for social and economic reasons on the basis that they might suffer depression or other emotional problems if forced to continue with an unwanted pregnancy.
RU486, or mifepristone, induces miscarriage by blocking the hormone progesterone, which is needed to sustain pregnancy.
It is administered in a clinic. The patient later takes a prostaglandin called misoprostol, which causes contractions in the uterus and helps tissue to pass. The process is like a spontaneous miscarriage and is usually complete within a few hours. There is pain and bleeding for a few days and the patient must return for check ups.
In about one case in 20, the abortion will be incomplete and the woman might need a surgical procedure finish the termination.
NORTH-EAST HEALTH (WANGARATTA HOSPITAL) Serves 70,000 people. Rarely does abortions; only two in the last seven years, both involving severe foetal abnormalities. “Neither of the obstetricians here are keen to do them,” says director of nursing Chris Giles. Women go to Albury or make a three-hour trip to Melbourne.
Serves 228,000 people. “We don’t have any doctors who do elective abortions,” says spokeswoman Jenny Ginnane. “It’s up to the visiting medical officers whether they choose to do an operation and currently we don’t have anyone who chooses to do them.” Abortions “in extreme circumstances” do occur but very rarely.
Serves 57,500 people. Elective abortions are performed at the hospital, says spokeswoman Emma Pepyat. The only limitations are those imposed at doctors’ discretion or by legislation. Mildura Hospital is publicly funded but managed privately by Ramsey Health.
Serves 300,000 people. “We don’t do them at all,” says spokeswoman Bronwyn Wheatley. “It’s not our policy to do them. The reason we don’t do them is because we have never done them.”
Serves 200,000 people. Did not return calls.

First published in The Age.