In 2014, Rosie Wallace made the decision to terminate an unwanted pregnancy. She was 17 at the time, and living in the town of Yeppoon on Queensland's Capricorn Coast.
Unlike most regional patients, Rosie was lucky enough to live just 40 kilometres away from one of the handful of clinics offering medical abortion in Queensland outside the south-east corner – a vast area spanning more than 1.8 million square kilometres. She travelled from Yeppoon for her appointment at Dr Marie in Rockhampton, a private clinic. Rosie was five and a half weeks pregnant, so was able to access a medical abortion, a combination of the drugs mifepristone and misopristol, taken orally, which negate the need for surgery (though on the rare occasion a surgical follow-up is needed). The cut off for medical abortions is 9 weeks.
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Thanks to a cancellation, Rosie was also able to attend the clinic within 4 days of finding out she was pregnant. The doctor who treated her attends the clinic just once a fortnight from Townsville. Rosie estimates that the termination cost $770 in total – a cost that was split fifty-fifty with her boyfriend at the time.
The cost of abortions varies greatly around the country, and is often markedly steeper in regional or remote areas. If Rosie had accessed her early medical abortion in another state, she could have paid as little as $15.
"I was determined that I wasn't going to go through with the pregnancy, and I'm glad I didn't," she says. But, she adds, "It was an incredibly stressful time."
Although Rosie says she didn't struggle financially, the cost of her abortion - despite being split with her boyfriend - took out a large chunk of her pay. She was a nursing student at the time, in the middle of her placement, and was also holding down a casual job. She also needed time off work to attend appointments and recover.
At the same time, she was dealing with the stigma of accessing abortion in a state where the procedure remains in the criminal code - and her mother opposed her choice.
"She has always condemned abortion," Rosie said. "My dad passed away when I was 4, and her opinion was that I was getting rid of a part of him."
![Rosie Wallace](/web/20170515080020im_/http://www.theage.com.au/content/dam/images/g/w/2/b/c/a/image.related.articleLeadwide.620x349.gw2b3u.png/1494636275777.png)
Rosie says she wasn't influenced by outside pressure and has never regretted her decision, but she felt the social stigma was difficult to bear.
"I was ashamed to talk about it for such a long time, I didn't make it known that I'd had an abortion."
![Rosie Wallace campaigns for reproductive rights.](/web/20170515080020im_/http://www.theage.com.au/content/dam/images/g/w/2/b/c/u/image.related.articleLeadNarrow.300x0.gw2b3u.png/1494636275777.png)
These days, Rosie is more outspoken about her choice, and is a public supporter of reproductive rights. "Now that I think about it I feel empowered by my choice to have an abortion because I made the decision that I wasn't going to become a mother. I put my education first and I stand by that decision."
Stigma aside, the scarcity and resulting prohibitive cost of abortion is putting women's health at risk – particularly in Queensland.
She needed chemotherapy and radiation for her breast cancer. But the hospital wouldn't proceed with that treatment if she remained pregnant because of the effects on the foetus. But nor would they provide her with an abortion.
Dr Fiona Mack
In November 2016, both the Townsville and Rockhampton Dr Marie clinics were on the verge of ceasing their surgical abortion services due to the unsustainable costs of overheads. They were saved in a last minute reprieve by Queensland Health.
Their loss would have meant even fewer options for people, like Rosie, with unplanned pregnancies in regional areas – and no surgical abortions outside the south-east corner of the state.
Thanks to Queensland's century-old abortion laws, the fear of prosecution means an abortion is all but impossible to obtain in a public hospital, except for a minority of usually late-term cases due to complications in wanted pregnancies. So women are forced to seek out private providers, which are both costly and scarce – and often booked out.
At 13 weeks a surgical termination can cost up to $890 in Rockhampton or Townsville for Medicare card holders. At 15 weeks, the maximum cost skyrockets to $1500. People without Medicare cards can expect to pay double. Having to wait for an appointment can become a matter of being able to afford it or not.
Dr Fiona Mack, a Brisbane GP specialising in women's health, recalled a particularly disturbing case of a 35-year-old woman with a planned pregnancy who had just been diagnosed with breast cancer at a Queensland public hospital.
"She needed chemotherapy and radiation for her breast cancer. But the hospital wouldn't proceed with that treatment if she remained pregnant because of the effects on the foetus. But nor would they provide her with an abortion.
"Instead, the hospital offered the woman a total mastectomy of her affected breast, and said she could undertake chemotherapy and radiotherapy after she'd carried her pregnancy to term – which Dr Mack says would have been a substandard treatment for her particular cancer.
The woman's other option was to seek an abortion privately and then return to hospital to receive a breast-conserving lumpectomy of the tumour, followed by immediate chemotherapy and radiotherapy. But the prohibitive cost of a private abortion almost prevented her from accessing one.
"Her gynaecologist called me at a women's health clinic where I offer medical abortion to help her arrange termination of her pregnancy because she did not have the funds required for that treatment through the usual private clinic avenues."
Dr Mack believes Queensland has a long way to go before abortion is accessible and normalised, and that cultural change along with decriminalisation will be key.
"A change in the law is a huge start. But it's going to be another generation before it's not an issue at all," she says.
The issue is not limited to Queensland. The NSW Legislative Council on Thursday voted down a private member's bill to decriminalise abortion – but most Australian states and territories have significant barriers to accessing terminations that go beyond the law.
A complex combination of legality, geographical issues, timing and seesawing costs contribute to the difficulties in obtaining an abortion, especially for women in regional areas. In many states, providers are unable or unwilling to perform abortions after certain (still legal) gestations, due to staff shortages and costs.
That means Tasmanians with a pregnancy after 14 weeks must travel to Victoria. For many Queenslanders with pregnancies over 16 weeks, it's cheaper to travel to Sydney for a termination. And people in New South Wales (and other states) with pregnancies post-20 weeks often travel to Victoria, where terminations can be accessed up until 24 weeks.
"Geography is a huge barrier for a lot of pregnant people and it's a huge barrier generally for health services," says Sian Tooker, a counsellor at Children by Choice.
In the Northern Territory, where medical abortions have only recently been legalised, women can access surgical abortions at little cost – but only two hospitals are able to provide the procedure – one in Alice Springs and one in Darwin. How women will access medical abortions remains to be seen.
In Western Australia, abortion is available through both the public and private systems, but clinics are mostly in Perth. A medical abortion at one private Perth clinic costs $650, while a surgical abortion up to 13 weeks starts at $550.
Even in South Australia, where abortion can be accessed at no cost, the availability is mostly limited to hospitals clustered around Adelaide, meaning regional South Australians have to travel.
But one service (not available in SA or, at present, NT) is bridging the gap in an attempt to make medical abortions more affordable, and accessible. The Tabbot Foundation, which started in September 2015, offers medical abortions via post for a flat fee of $250 along with a phone consultation with a doctor (and, for legal reasons in NSW and Qld, a psychologist).
Tabbot Foundation Medical Director Dr Paul Hyland says Australia is falling behind the world, with only approximately 20 per cent of abortions performed medically. But he says a medical abortion avoids the need for surgery and can be done in the privacy of a person's home.
"It's one of the most appropriate medical services that can be provided by telemedicine because a physical examination is not necessary," Dr Hyland says. Dr Marie also offers a telehealth medical abortion service for around $330.
Dr Hyland says the service struggles to market itself, because the Therapeutic Goods Administration has strict limitations on advertising abortifacients.
But one day he hopes the foundation may provide free-of-charge medical abortions to women around the country.
The Tabbot foundation is ironically named after Tony Abbott, who in his time as Health Minister blocked the import of mifepristone, one of the drugs used in medical abortions (otherwise known as RU486).
"When this drug was developed it was the most significant technological advance in women's reproductive health care since the birth control pill, and yet it was prevented from coming into this country by Tony Abbott," Dr Hyland said.
"We want women never to forget."
Abortion access around Australia
New South Wales: Abortion remains in the criminal code, and there are few abortions carried out in public hospitals. While terminations may be cheaper than other states ($410 in one Sydney clinic for a 12 week surgical termination), regional residents are also impacted by a scarcity of services. One regional clinic quoted $440 for a surgical abortion, but didn't offer the procedure past 12 weeks. Women across the state must travel to Victoria for abortions after 20 weeks.
ACT: The only state or territory where abortion is completely decriminalised. But medical abortions must be carried out in an accredited facility and can't technically be done at home. However some make the short trip over the border to Queanbeyan to facilitate this – for instance, to access the Tabbot Foundation's telehealth medical service.
Victoria: Limited public provision of terminations, with a 12 week surgical termination costing around $300-500, and medical abortions available at one clinic for $250. One clinic quoted $1000 for a 15 week termination. But most clinics are based in or near Melbourne, disadvantaging regional and rural women.
Tasmania: Abortion technically legal up to 16 weeks, and over 16 weeks with the consent of two doctors who believe that the pregnancy represents a risk to the physical or mental health of the person. But people with pregnancies past 14 weeks are referred to clinics in Melbourne. An abortion up to 14 weeks can cost $500.
South Australia: Surgical abortions can be accessed for free in a metro public hospital; medical abortions may cost as little as $15. Availability is mostly clustered around Adelaide.
Queensland: Only private providers offer abortions, and they are scarce outside Brisbane. At 13 weeks a surgical termination can cost up to $890 in Rockhampton or Townsville for Medicare card holders. At 15 weeks, the maximum cost skyrockets to $1500. People without Medicare cards can expect to pay double.
Western Australia: Abortion is available through both the public and private systems, but clinics are mostly in Perth. A medical abortion at one private Perth clinic costs $650, while a surgical abortion up to 13 weeks starts at $550.
Northern Territory: Women can access surgical abortions at little cost, but only two hospitals are able to provide the procedure: one in Alice Springs and one in Darwin. Medical abortions have only recently been legalised.
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