Access, equity and costs of induced abortion services in Australia: a cross-sectional study.

OBJECTIVES: To examine access and equity to induced abortion services in Australia, including factors associated with presenting beyond nine weeks gestation. METHODS: Cross-sectional survey of 2,326 women aged 16+ years attending for an abortion at 14 Dr Marie clinics. Associations with later presentation assessed using multivariate logistic regression. RESULTS: Over a third of eligible women opted for a medical abortion. More than one in 10 (11.2%) stayed overnight. The median Medicare rebated upfront cost of a medical abortion was $560, compared to $470 for a surgical abortion at ≤9 weeks. Beyond 12 weeks, costs rose considerably. More than two-thirds (68.1%) received financial assistance from one or more sources. Women who travelled ≥4 hours (AdjOR: 3.0, 95%CI 1.2-7.3), had no prior knowledge of the medical option (AdjOR: 2.1, 95%CI 1.4-3.1), had difficulty paying (AdjOR: 1.5, 95%CI 1.2-1.9) and identified as Aboriginal and/or Torres Strait Islander (AdjOR: 2.1, 95%CI 1.2-3.4) were more likely to present ≥9 weeks. CONCLUSIONS: Abortion costs are substantial, increase at later gestations, and are a financial strain for many women. Poor knowledge, geographical and financial barriers restrict method choice. Implications for public health: Policy reform should focus on reducing costs and enhancing early access.

Experiences of prenatal diagnosis and decision-making about termination of pregnancy: A qualitative study.

BACKGROUND: Advances in genetic technologies and ultrasound screening techniques have increased the ability to predict and diagnose congenital anomalies during pregnancy. As a result more prospective parents than ever before will receive a prenatal diagnosis of a fetal abnormality. Little is known about how Australian women and men experience receiving a prenatal diagnosis and how they make their decision about whether or not to continue the pregnancy. AIMS: This qualitative study aims to describe parental experiences and examine how best to provide support after a prenatal diagnosis. RESULTS: Individual in-depth interviews were conducted with 102 women and men approximately six weeks post-diagnosis of fetal abnormality. Data were elicited using a narrative, chronological approach and women (n = 75) and a sample of male partners (n = 27) were separately interviewed. Thematic analysis, involving a rigorous process of qualitative coding, enabled iterative development and validation of emergent themes. Participants identified that the shock of the diagnosis can be lessened when good care is delivered, by provision of: clear, accurate and respectful communication; empathic, non-judgemental, professional support; timely access to further testing and appointments; seamless interactions with services and administration; appropriate choices about invasive testing; acknowledgment of the enormity and unexpected nature of the diagnosis, and of the subsequent decision-making challenges; and discussion of the myriad feelings likely to emerge throughout the process. CONCLUSIONS: This study has demonstrated the importance of providing timely access to accurate information and supportive, non-judgemental care for women and their partners following prenatal diagnosis of a fetal abnormality.

New assisted reproductive technology laws in Victoria: a genuine overhaul or just cut and paste?

A new Assisted Reproductive Treatment Act was passed in Victoria on December 2008 and came into effect on 1 January 2010. The new legislation changed who was eligible for assisted reproductive technology (ART) and the types of services that clinics could provide. This article reports on interviews with service providers in Victoria who experience first hand the impact of legislation on clinical practice and patients, as well as regulators who are able to provide insight into the values underpinning the regulatory framework. The new legislation was viewed by all participants as an improvement on the old Act because of the removal of discriminatory and ambiguous aspects. The authors argue that while some of the details of the legislation have changed, the underlying principles and the framework have not.

Abortion laws and medical developments: a medico-legal anomaly in Queensland.

In October 2010 the District Court sitting in Cairns, Queensland, found Tegan Leach not guilty of attempting to procure her own abortion and Sergie Brennan not guilty of supplying Leach with the drugs Mifepristone and Misoprostol to procure an abortion. Brennan obtained the drugs from his sister in the Ukraine through the regular postal system. R v Brennan and Leach was the first case in Queensland's history where a woman was charged with procuring her own abortion. The drugs are accepted by the medical profession worldwide for medical abortions. A prosecution witness gave evidence that Mifepristone is not harmful or injurious to the health of a woman and it is listed as an essential medicine by the World Health Organisation and approved for use by the Australian Therapeutic Goods Administration. The jury found the defendants not guilty because they were not satisfied beyond reasonable doubt that the combination of the drugs Mifepristone and Misoprostol was a "noxious" substance under the Criminal Code (Old). This article concludes that there is no regulatory miracle which will stop the traffic of Mifepristone and Misoprostol into Australia and therefore an intelligent regulatory response is required which would make it unnecessary for women to seek Mifepristone and Misoprostol from overseas networks and the internet. Among other things, this would include the repeal of confusing, inappropriate and ineffective abortion laws.

Early medical abortion: legal and medical developments in Australia.

Mifepristone is a safe, effective and relatively cheap drug that plays an important role in women's health care and is widely used for early medical abortion in many countries. The Therapeutic Goods Administration (TGA) can authorise mifepristone to be imported into and marketed in Australia. To date, no pharmaceutical company has applied to register mifepristone in Australia. The TGA can also permit medical practitioners to prescribe medicine that is not approved for marketing in Australia under the Authorised Prescribers scheme. The number of approvals for mifepristone has gradually increased, in spite of a complicated and protracted application process. Approval under the Authorised Prescribers scheme requires medical practitioners to comply with state or territory legislation. Abortion laws in Australia vary between jurisdictions, and in some states the law is unclear and confusing. The decriminalisation of abortion in all Australian jurisdictions would protect medical practitioners from criminal liability, promote the health interests of Australian women, and discourage the illegal importation of abortifacients that are being used without quality controls or medical supervision. The Victorian Abortion Law Reform Act 2008 is one legislative model for this.

Regulating preimplantation genetic diagnosis: a criminal model versus a professional model.

This article examines a criminal and professional approach to the regulation of preimplantation diagnosis (PGD) in the two Australian States of Victoria and New South Wales. Under the Assisted Reproductive Treatment Act 2008 (Vic), Victorian medical practitioners face criminal sanctions if they ignore legal requirements. The criminal sanctions do not apply directly to patients, but those seeking PGD treatment have to satisfy guiding legislative principles, statutory rules and the controversial new "presumption against treatment" hurdle. On the other hand, the Assisted Reproductive Technology Act 2008 (NSW) does not specifically address PGD and medical practitioners in New South Wales are not subject to criminal sanctions but must follow the National Health and Medical Research Council Guidelines. As far as patients in New South Wales are concerned, PGD is essentially a medical procedure. In both Victoria and New South Wales, PGD practice is relatively liberal compared to that in many other countries, although the Victorian approach is clearly the more restrictive model of regulation with the threat of criminal sanctions overriding the medical practitioner's ethical duty to act in the best interests of a patient.

Public interest or public meddling? Towards an objective framework for the regulation of assisted reproduction technologies.

BACKGROUND: Assisted reproductive technologies (ART) bear a heavy regulatory burden in some jurisdictions. This burden constrains patient autonomy and the professional autonomy of doctors and scientists. METHODS: We question why this should be by analyzing the possible public interests in ART regulation under the headings: health, financial, ethico-legal and socio-political. Throughout, we try to identify whether comparable public interest claims are made for other areas of medicine, but accommodated without the requirement for specialized statutory frameworks such as those exemplified in the UK and Victoria (Australia). RESULTS: We identify a small core of public interest concerns that seem to justify some sort of special regulatory structure, but not one as elaborate as those currently in place. We then develop a five-step quality control model, familiar to biomedical practice but novel in the context of legal thinking, to aid development and review of regulatory policy and practice. This model is applied both prospectively to the proposal to record 'by donation' on birth certificates, and retrospectively to the regulation of parental choice about the genetic make-up of offspring in UK and Victorian jurisdictions. CONCLUSIONS: The model provides a useful and robust framework for pin-pointing problems with regulatory regimes, to stimulate empirical research, and to facilitate both the review and development of regulatory policy.

SmARTest regulation? Comparing the regulatory structures for ART in the UK and Australia.

Assisted reproductive technologies are regulated in both the UK and Australia, thereby curtailing both reproductive and professional autonomy. Different regulatory models have developed in each jurisdiction, despite the similar legal, scientific and cultural histories of the two jurisdictions. In the UK the regulatory structures are under review, largely in the absence of empirical research on the costs and benefits of regulation. The regulatory structures in each jurisdiction are compared and some key differences identified. The UK regulatory structure governing assisted reproductive technologies is currently simpler, more accountable and more transparent than that in Australia. On the other hand, despite administrative and legislative restrictions (particularly in Victoria), the medical scientists and clinicians in Australia generally have more control than their British counterparts over the technical aspects of their work in the provision of IVF and other treatment services, and to a lesser extent in embryo research. Recent proposals appear to move the UK regulatory structure towards a less accountable and less transparent model, but with no evident increase in reproductive or professional autonomy. It is suggested that this change is not in the interests of patients, doctors and the public, and a different model is outlined for devolution of both authority and accountability to the professions.

Assisted reproductive technologies: professional and legal restrictions in Australian clinics.

The professional and legal regulation of assisted reproductive technologies (ART) in Australia is a vast maze of intersecting laws and guidelines which place restrictions on the provision of services such as infertility treatment, surrogacy, sex selection for social reasons, donor insemination, pre-implantation diagnosis and human embryo research. This study investigated the application of these restrictions on clinical practice in New South Wales, a relatively unregulated State, and Victoria, a relatively highly regulated State. The results of the survey indicate that the range of ART services in Victorian clinics was far more limited than in New South Wales clinics. The Victorian clinics uniformly restricted access of single and lesbian women and did not offer social sex selection procedures. The New South Wales clinics adopted different polices regarding these services. It was found that restrictive laws governing "social" issues have a significant impact on the availability of ART services and some respondents seemed unclear about the nature of restrictions and laws relevant to their work. It was also found that "reproductive tourism" is prevalent and restrictions were circumnavigated by patients with assistance from clinics. It was concluded that more evidence is required to evaluate regulation in this field of medicine.

The regulation of assisted reproductive technology: a comparative study of permissive and prescriptive laws and policies.

A specific statute governing assisted reproduction is one way to regulate assisted reproduction. However, what type of statute is best suited to an area of medicine that is subject to rapid technological advances and also affects human rights and interests? What are the strengths and weaknesses of a permissive model of regulation compared to a prescriptive model of regulation? This article examines the Human Fertilisation and Embryology Act 1990 (UK) and the Infertility Treatment Act 1995 (Vic) in the context of eligibility for infertility treatment and the roles played by the United Kingdom Human Fertilisation Embryology Authority and the Victorian Infertility Treatment Authority.