Medical Abortion in Australia: What Are the Clinical and Legal Risks? Is Medical Abortion Over-regulated?

This article examines the clinical and legal risks of early medical abortion. After providing an overview of the history of mifepristone in Australia, the evidence concerning the efficacy and safety of medical abortion is discussed. It is argued that the negligible medical risks associated with mifepristone do not justify the restrictive regulatory measures imposed on medical practitioners. The article then turns to the legal risks and considers whether medical practitioners are vulnerable to prosecution under existing State and Territory laws. It is argued that providing early medical abortion services in a number of jurisdictions is legally ambiguous, potentially posing a threat of prosecution to medical practitioners. The need for law reform is evident by the fact that in four jurisdictions it remains in the criminal statutes, creating legal uncertainty for both medical practitioners and women. The article concludes that there is sufficient evidence to allow some "demedicalisation" of medical abortion. However, this is only possible if the legal status of abortion in State and Territory laws is addressed.

Mifepristone in South Australia -- the first 1343 tablets.

BACKGROUND: Mifepristone has recently become available in Australia but its use is restricted. OBJECTIVE: To describe the use of mifepristone in South Australia in the period 2009-2010 and to explore options that may become available to general practitioners. DISCUSSION: Mifepristone has been added to regimens for early and second trimester abortions - both medical and surgical abortions. It has been most commonly used in early medical abortions. In this audit the complication rates of early medical abortion with mifepristone compared favourably to early surgical abortion. There are implications in service delivery of early medical abortion compared to early surgical abortion.

Comparison of four perioperative misoprostol regimens for surgical termination of first-trimester pregnancy.

OBJECTIVE: To compare the outcomes of 4 different perioperative misoprostol regimens for surgical termination of first-trimester pregnancy. METHODS: Retrospective analysis of the records of 4000 women (4 cohorts of 1000 each) who underwent surgical termination of pregnancy. The 4 cohorts received: no misoprostol; 200 microg of oral misoprostol 30 minutes preoperatively; 200 microg of sublingual misoprostol 30 minutes preoperatively; or 200 microg of oral misoprostol 3 hours preoperatively plus 200 microg of vaginal misoprostol postoperatively. Adverse effects of the last regimen were surveyed in 1000 women. RESULTS: In the cohorts that received misoprostol, the difficulty of cervical dilatation was reduced (P<0.001) compared with the cohort of women that did not receive misoprostol. The frequency with which women made postoperative contacts with the clinic was also reduced in the cohorts that received misoprostol (P<0.05). Adverse effects were minimal. CONCLUSIONS: This retrospective study showed an association between perioperative administration of misoprostol, reduced difficulty for operators, and reduced demand for postoperative care. The regimen associated with the greatest reduction in difficult cervical dilatations and postoperative consultations was 200 microg of oral misoprostol 3 hours preoperatively plus 200 microg of misoprostol vaginally at the end of the surgical procedure.

Treatment of suction termination of pregnancy-retained products with misoprostol markedly reduces the repeat operation rate.

A six-year audit of clinical outcomes following the treatment of suction termination of pregnancy-retained products of conception symptoms with 200 microg of misoprostol orally or sublingually three times a day for six doses showed that it was 93% effective and it reduced the repeat dilation and curettage rate by 79.6% (P < 0.001).

Seeking open minded doctors - how women who identify as bisexual, queer or lesbian seek quality health care.

BACKGROUND: Bisexual, queer and lesbian women experience higher rates of discrimination, trauma and abuse and are at higher risk for adverse health outcomes than heterosexual women in the same populations. This research investigated the strategies these women use to maximise the quality of health care they receive. METHODS: Semi-structured interviews with 47 self identified bisexual, queer and lesbian women. Predominant themes were correlated with findings by other researchers. RESULTS: These women sought skilled practitioners who responded positively or neutrally to their sexuality. Some did not disclose their sexuality even where it seemed relevant, or preferred finding an accepting practitioner to ensuring continuity of care. Additional strategies for obtaining quality care included: 'coming out', selecting practitioners carefully, and educating practitioners about sexuality. DISCUSSION: Like those in other countries, Australian bisexual, queer, and lesbian women do not assume that health practitioners will accept their sexuality. They seek to avoid hostility by locating sympathetic practitioners. General practitioners can signal their willingness to provide quality services to these patients by relatively simple methods.

Striving for excellence in abortion services.

The legalisation of abortion allowed the publication of surgical outcome data demonstrating low complication rates. South Australian data from the outcomes of surgery conducted at the Pregnancy Advisory Centre illustrate the monitoring of complication rates such as uterine perforation, continuing pregnancy and incomplete abortion to improve surgical outcomes. While quality improvement systems produce positive results, there are many barriers to their uptake in Australia. Hostility towards abortion has the potential effect of retarding the adoption of improved techniques.

Why protect confidentiality in health records? A review of research evidence.

We present the main arguments for protecting the confidentiality of health services, along with those for limiting confidentiality. These arguments are then substantiated by reference to research evidence. There is evidence that access to health care is restricted if confidentiality is not promised to some groups of patients. Fear of disclosure does diminish patients' candour, and this can compromise the quality of care. While patients are concerned about confidentiality and some are harmed by 'leaks' from health services, most people in Australia still trust health providers to keep their secrets, and patients rarely become aware of a breach of confidence. It has been claimed that strict protection of confidentiality may obstruct the pursuit of medical research and the use of electronic medical records. There is, as yet, no evidence that gaining full benefit from the use of electronic medical records entails reduced protection for confidentiality. The losses to epidemiological research if patient consent were always required are hotly debated. Confidentiality should be protected because it protects patients from harm, supports access to health care and produces better health outcomes.

Disclosing health information breaches of confidence, privacy and the notion of the "treating team".

The authors utilise cases collected during a randomised population survey to illustrate some of the legal and policy issues concerning routine transfers of information between treating practitioners. Their analysis suggests that implied consent for many routine uses of health information should not be assumed. An important part of consent to health information disclosure is the patients' ability to tailor its scope and content. This requires that they should be provided with additional information. Introducing the measures advised into the clinical setting would bring health information-gathering practices closer to compliance with the collection principles contained in Australian information privacy legislation.

Complying with the Privacy Act. A survey of medical records management.

BACKGROUND: A survey of 142 South Australian general practices was conducted on the eve of the new Privacy Act amendments coming into force. OBJECTIVE: The survey had two aims: to establish the extent to which medical records systems were already compliant, and to identify those areas in which change would be required in order to achieve compliance with the requirements of the new legislation. DISCUSSION: The sample was biased in favour of larger group practices. Among the practices surveyed, the areas of best compliance were in providing security, allowing patients access to records and obtaining consent for disclosure of information. There was poor compliance with the requirement to provide patients with information about medical records, or to have a practice policy on privacy. Anonymous care was rarely offered to patients. General practices will need to develop policies and procedures to address these requirements of the new law. Some general practices met the standard required by the amended Privacy Act before it came into force. For those who were not compliant, relatively simple measures will overcome the most common deficiencies.

Sharing patient information between professionals: confidentiality and ethics.

Careful consideration of the ethical implications is required before patient information should be shared without the patient's knowledge. Routine and apparently uncontroversial releases of information can be perceived as problematic by patients. The ethics of such "ordinary" breaches of confidence can be explored by considering the patient's autonomy, the patient's best interests, and the public interest in preserving or breaching confidentiality. Patient autonomy can be supported and ethical problems may be avoided when patients are given as much information as possible about foreseeable information disclosures.

Patients rarely detect breaches of confidence.

OBJECTIVE: To measure the prevalence of patient reported breaches of confidence emanating from health services in South Australia. METHODS: A community household survey with follow up telephone interviews of those reporting unauthorised disclosures. Recruitment interviews were conducted during October and November 2001 with 3037 South Australian residents over 15 years of age. South Australian households were selected randomly within a representative selection of census collection districts. Follow up telephone interviews were conducted with 18 respondents who reported unauthorised information releases in the twelve months prior to the initial survey. RESULTS: The one year prevalence of breaches of confidence reported by patients was 0.23 +/- 0.17% (1.96 x SE). This prevalence was significantly lower than a previously published estimate (Mulligan, 2001) of 1.1 +/- 0.4% (difference between proportions p= 0.003, z= 4.415) which relied upon reports of information disclosed without the patients permission as a proxy for breaches of confidence. An incidental finding was that 0.20+/- 0.16% (1.96x SE) of respondents reported exchanges of information amongst members of treating teams which had not been authorised by the patient. CONCLUSION: True breaches of confidence arising from health care interactions are rarely detected by patients. Ordinary information sharing within treating teams may be a more important source of misunderstandings between patients and health care providers. This issue can be addressed at the point of care by informing patients what will be done with their health information and who may later gain access to it.