Stigma and Silence: Welcome to Abortion in Rural Australia
Women in far-flung Australian towns bear the brunt of outdated abortion laws, often traveling overnight to escape local conservatism and reach abortion clinics. Could telemedicine be the answer?
Illustrations by Ashley Goodall
With a total of 3,062 residents, Tennant Creek is the fifth largest town in Australia's Northern Territory. The closest urban center is Alice Springs, which is six hours away. For a Tennant Creek resident in need of an abortion clinic, that's a long and lonely drive.
Rural Australians make up a third of this country's population, and many have difficulty accessing the services city-dwellers take for granted. That includes abortions, which one in three Australian women will seek in their lifetime. All of which means a huge number of rural Australian women must travel vast distances to terminate an unwanted pregnancy.
Because of this, many have turned to an alternative option: discreet abortion hotlines that involve calling a doctor for a prescription for the abortion pill RU486 (misoprostol), which is then mailed to the patient. On the surface, this form of telemedicine sounds like a neat solution to a vast geographical problem. But the reality is more complex, because abortion in Australia is a knotted mess of incompatible legislation, which varies from state to state.
Female doctors were in short supply, which made many abortion-seeking women uncomfortable.
In both Queensland and New South Wales, the termination of a pregnancy is technically a crime for both patients and doctors (although it is rarely prosecuted). In the Northern Territory's remote communities, a surgical abortion is legal up until 14 weeks—but only if two doctors agree that a woman's physical or mental health is endangered by her pregnancy.
As for RU486, it is illegal across the Northern Territory, and only available from hospitals in South Australia, and the Australian Capital Territory (ACT)—which means it isn't possible to receive it in the mail. All this confusing and incompatible legislation has created an unspoken culture of abortion tourism—where women are forced to travel to more liberal states in order to terminate their pregnancies.
Of course, that's a luxury many can't afford. The combined expenses of the procedure, travel, and accommodation can be almost prohibitively expensive. "It's very hard for rural women," says health researcher Frances Doran, who alongside fellow health researcher Julie Hornibrook has published two academic papers on the topic. The duo's chief aim was to identify the barriers to abortion access in rural Australia, which they say is little spoken about.
Most of the women they interviewed for their research had travelled between one and nine hours one way in order to reach an abortion clinic, with many also requiring overnight accommodation. Country towns often have local general practitioners, but their research found female doctors to be in short supply, which made many abortion-seeking women uncomfortable. It was also typical for rural GPs to be conservative, with the influence of religion on their practice palpable.
Another patient they spoke to, Clara (not her real name), who had also experienced a prior abortion as a city-dweller, described the experiences as "chalk and cheese". She was "gobsmacked" she had to travel to another state from the country to terminate her pregnancy, and felt "isolated and horrible driving over the border."
Obtaining an abortion when you live rurally isn't just a logistical issue. In their research, Doran and Hornibrook found the very notion of abortion tends to come pre-attached with stigma, silence, and fear. They say rural doctors tend to be more conservative, which is also a deterrent for some women."Even people who weren't really anti-abortion and believed in women's rights to access health care stay silent," Doran says. "Because it's such a politically contested area. Which is ridiculous."
"Out bush," said one woman from their study, "there is still a lot of stigma about getting information in the first place, and certainly something that is not talked about. I reckon there's a higher rate of teenagers having births because of the stigma." Another described feeling a "bucketload of shame" after her abortion, saying she "felt isolated and alone."
This has been available overseas since 1998, so we're 20 years behind the times.
The only current solution to this vast geographical problem is telemedicine—a workaround that navigates both the logistical and social complexities of rural abortion. Teleabortion is an established phenomenon in much of the Western world that has only recently begun to gain a foothold in Australia, as legal restrictions on the use of RU486 have loosened in recent years.
The Tabbot Foundation is Australia's only dedicated telemedicine abortion provider (although mail order abortion services are also available through Marie Stopes). It began operating one year ago under founder Dr Paul Hyland, who tells Broadly it is his aim to remove the barriers to abortion access faced by rural or remote communities. For AU$250, the service provides women in need of an abortion with extensive phone consultations and, if the doctor prescribes it, a mailed package that contains RU486 as well as antibiotics, painkillers, and anti-inflammatories.
"This has been available overseas since 1998, so we're 20 years behind the times," Hyland explains. "Our model avoids harassment, abuse, and intimidation. And you don't have to travel to and then sit in a clinic to see a doctor or go through rounds of testing."
The Tabbot Foundation must contend with the peculiar legalities surrounding abortion in Queensland and New South Wales (NSW), where abortions are illegal unless the patient can prove serious physical or mental distress. "We have a psychologist who speaks to patients, both in Queensland and NSW, so we have evidence they have sufficient reason to allow abortion."
Hyland says telephone abortions are an easy and practical solution for every woman in Australia who requires a safe, cheap, and accessible medical pregnancy termination, regardless of where she lives. However, remaining restrictions on RU486 in the Northern Territory, South Australia and ACT mean the foundation can't operate in some of the remote areas where it is needed most.
Furthermore, there is the possibility that women will need aftercare with the drug: Around ten to 20 percent of women who have a medical abortion will not completely miscarry, and therefore require additional medical help. The Tabbot Foundation therefore requires that women using its service be within one hour of a medical facility—although not necessarily a hospital.
Hyland says the vast majority do fulfil this criteria: "Those who don't [live within one hour of a facility] usually live on a mining site in Western Australia. They would usually travel to Karratha or Broome and stay there for a day and then go home."
The law needs to change, Doran says. "Especially the fact it isn't consistent throughout Australia. Having abortion in the criminal code isn't good for providers or women. It increases the stigma."
Nowhere is the legal cloud surrounding abortion more hazy than the Northern Territory. "The fact that you can't even access medical abortion [RU486] in the Northern Territory basically means that the more isolated you are, the more impossible it becomes," Doran tells Broadly.
Professor Suzanne Belton agrees. A professor at Charles Darwin University's Menzies School of Health Research and the President of Family Planning Northern Territory, she has helped spearhead a movement for reform via activist group What RU4 NT. Vast distances, multiple socio-economic disadvantages, and a large Indigenous population mean the issue is manifold, she says.
There's a racial element to it, but it's also a problem for anyone who lives in a remote area.
"There is no clinical reason for the requirement that women seeking an abortion need to see two doctors. And abortions have to be performed by an obstetrician or gynecologist [in the Northern Territory], even though a GP-level doctor can provide an abortion."
Women in the Northern Territory can access surgical termination via three hospitals, but only in the urban centers of Darwin and Alice Springs. "Which means women in some cases have to travel hundreds and thousands of kilometers to obtain a surgical abortion. And that, I would argue, is discrimination. There's a racial element to it, but it's also a problem for anyone who lives in a remote area."
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"Even America is ahead of Australia in this," she adds, in reference to the illegality of RU486. "In fact, many third world countries are in front of Australia."
If the drug were legalized, it would allow many rural women peace of mind—and allow doctors like Paul Hyland to provide women with the reproductive care they need. But Belton says greater access to surgical abortions is vital for rural areas too. What's more, "To have a medication abortion, you need to have fairly good infrastructure around you. A supportive partner, family, or friends. You also need good bathroom facilities and good hygiene. Unfortunately, in many remote communities that is not always the case."
Dr Mehreen Faruqi, a member of parliament with the Greens party in New South Wales, is leading a movement to decriminalize abortion in the state. Faruqi describes the rural abortion experience as one of her chief motivations. "I've been to Albury many times," she tells Broadly, "where there is only one reproductive health clinic serving a large catchment area. And on the way in and out, doctors and patients are regularly harassed and intimidated by anti-abortion protestors.
"The shadow of criminality has also clearly lead to stigma, shame and silence on a matter that is a basic human right."