Policy Document

Access to Safe Termination of Pregnancy Policy Background The Australian Medical Students' Association (AMSA) is the peak representative body of Australia's 17,000 medical students. AMSA is committed to ensuring and advocating for the right to equitable opportunity such that all people can achieve their full professional and personal potential, including access to the best attainable health. Accordingly, AMSA upholds gender equity to be one of its primary pillars and actively seeks to advocate on issues that may impact health outcomes. The Universal Declaration of Human Rights describes health as a core human right, and that an intrinsic principle of health is autonomy [1]. AMSA affirms that reproductive health is an essential component of an individual’s overall health and wellbeing, and that all people, regardless of gender, are entitled to exercise autonomy over matters of personal reproductive health. This involves decisions relating to when and how many children to have, and the decision to take a pregnancy to full term or not. It is the inescapable reality that terminations of pregnancy will be chosen whether they are legal or not. Where it is not legal, women seek out avenues for termination of pregnancy that pose grave risks to their health and wellbeing. Unsafe terminations of pregnancy comprise 13% of maternal mortality worldwide [2]. The UN estimates 21.6 million unsafe terminations of pregnancy occurred in 2008 [2], accounting for 49% of all terminations of pregnancy [2]. Almost all (98%) unsafe terminations of pregnancy occur in developing countries [2], and in 2008, 62% of these deaths occurred in Africa [3]. As a developed nation, Australia boasts relatively permissive access to safe termination of pregnancy, and its comparatively low rate of maternal mortality reflects this [4]. Australia, therefore, has an international role to play in providing leadership and advocacy for access to safe terminations of pregnancy. However, commitment to uniform legislation and improved accessibility across all states and territories is still required. Where safe and reliable methods of fertility control are accessible, the health outcomes of women and their children are heightened [3]. The legal status of a termination of pregnancy does not influence a woman’s need for a termination of pregnancy, however, it does have dramatic consequences on a woman’s health outcomes and access to safe termination of pregnancy [3]. All pregnancies involve a degree of health risk to a woman, but an unsafe termination of pregnancy carries an intensely amplified and avoidable risk [5]. Like all medical interventions, a safe termination of pregnancy, whether medical or

surgical, involves a degree of risk. AMSA believes that all women should have full access to family planning services, in order to minimise the number of unintended pregnancies and the subsequent recourse to termination of pregnancy. However despite the impressive gains in contraceptive use which have significantly reduced the number of unintended pregnancies, AMSA supports the WHO in its affirmation that improved termination of pregnancy services and post-abortion care are required to complement improved access to quality family planning services [6]. For a number of reasons, the number of documented terminations of pregnancy provided in Australia is inaccurate [4]. This includes the absence of a specific medicare item number for termination of pregnancy, and the deficiency of uniformity in service provider, data collection and payment processes. Best estimates put the figure at between 70,000-80,000 per year [7,8]. Abortion legislation falls under the jurisdiction of States and Territories, and as a result, laws regulating termination of pregnancy across the country are inconsistent and confusing not only to the general public, but also health professionals [4]. Although some states and territories including Victoria, the ACT and Tasmania have decriminalised termination of pregnancy, other states, for instance Queensland and New South Wales, still refer to termination of pregnancy in their criminal codes [9]. Furthermore, the criteria for legal termination of pregnancy varies considerably between states from the upper limit of gestational age, to the degree of consensus required by medical practitioners [9]. The current criminal legislation concerning termination of pregnancy contributes to the lack of reliable, well-planned termination of pregnancy services and successful policy development [4]. Moreover, legal uncertainties regarding termination of pregnancy result in inequitable service provision, an under-supplied public sector and a lack of accurate data on termination of pregnancy services and use [4]. Where safe and legal termination of pregnancy services are provided, social stigma can contribute to its inaccessibility. In communities where social stigma is pervasive, threats of physical or social repercussions leave women afraid to access the service and practitioners wary of provision [6]. Given that research has demonstrated that most Australians support legal termination of pregnancy, and around one third of Australian women will have a termination of pregnancy in their lifetime, the stigma surrounding termination of pregnancy and the subsequent harm caused is unjustifiable and misplaced [7,8]. The implications of the out-of-pocket costs for women are significant. While some public hospitals provide a small number of abortions at no cost, bulk-billed under Medicare, these services are often insufficient to meet demands and exhausted by long waiting lists [10]. Many public services also limit services to a gestation age of 12 weeks, excluding services for those beyond that [11]. As the age of gestation increases, so too does the out-of-pocket costs increase, because of the increased risk of the procedure, and the limitation of medical and surgical options [11]. Even with a Medicare card, the out-of-pocket expenses for a woman seeking a private provider ranges from approximately $300 to $500 in Victoria, though this varies from state to state [11]. In Queensland, it ranges from $300 to $800 in the first trimester alone, rising with every week of gestation to potentially over $3000 for a termination between 18 and 20 weeks gestation [12,13]. It is clear that adequate Medicare rebate that is linked to the Consumer Price Index is essential in protecting reproductive health rights of all women [4]. Public services are inaccessible due to unavailability, and may force women into delayed decision-making, further restricting their opportunities to access essential reproductive health services [4]. Meanwhile, private services are only affordable to economically secure women [4]. Without adequate Medicare rebate and a public health system that can meet the requirements of Australian women, the vulnerability of the most disadvantaged women is compounded; women in poverty, teenage women, rural women, and women from minority or ethnic groups [4]. The inaccessibility of safe termination of pregnancy services, whether that be caused by legal, economic or social reasons, ultimately reinforces disadvantage for all women universally.

Access to safe termination of pregnancy is recognised as a fundamental human right and important public health priority by several leaders of women’s and global health including, but not limited to, the Australian Medical Association [14], Royal Australian and New Zealand College of Obstetricians and Gynaecologists [15], the World Health Organisation [3], the International Federation of Gynecologists and Obstetricians [16], the International Federation of Medical Students’ Associations [17] and the Public Health Association of Australia [4]. AMSA appreciates that there is a wide range of ethical and religious beliefs regarding termination of pregnancy around the world. Nevertheless, it believes in evidence-based practice and policy, and promotes safe termination of pregnancy on public health, human rights and economic grounds. AMSA is emphatic in its belief that the decision to terminate a pregnancy is a personal matter for individual conscience and medical advice.

Position Statement AMSA believes that: 1. Health is a core human right and reproductive and sexual health are inviolable components to the universal right to health. Access to safe and legalised termination of pregnancy is central in enacting this right; 2. The decision to take a pregnancy to full term, or not, belongs firstly and unquestionably to the pregnant woman, in consultation with her treating physician; 3. All women should have access to safe and legal termination of pregnancy, free of discrimination and stigma; and 4. All reference to termination of pregnancy should be removed from the criminal laws and codes of all Australian states and territories, and all Nation States. Termination of pregnancy should be legislated and regulated, as with all other medical procedures, under the relevant healthcare legislation.

Policy AMSA believes: 1. It is of the utmost importance that all people, regardless of gender, are provided with their right to health, including reproductive and sexual health; 2. Autonomy is an intrinsic medical principle. It is therefore a woman’s human right,in consultation with her treating physician, to have full autonomy over: a. Decisions relating to when and how many children to have; b. The decision regarding whether to take a pregnancy to full term, or not; 3. Discrimination and stigma play a crucial role in the accessibility of termination of pregnancy through threats of physical or social repercussions. These consequences include the initiation or exacerbation of long-term mental and physical harm of women and practitioners. Therefore: a. Providers of termination of pregnancy should be able to practise without fear of persecution - societal, legal, physical, mental or otherwise; b. All women should have access to safe and legal termination of pregnancy, free of discrimination and stigma; 4. Effective family planning services reduce the number of unintended pregnancies and terminations of pregnancy, and deserve investment and prioritisation; 5. Termination of pregnancy should be appropriately regulated under healthcare legislation, just as all other medical services are. It should be performed a. by appropriately trained and registered medical professionals in settings approved and regulated by a recognised health standards authority;

b. in the context of appropriate pre-termination of pregnancy and post-termination of pregnancy counselling and follow-up; c. with the patient’s informed consent. It is the medical professional’s responsibility to adequately inform the patient of the nature of intervention and the risks involved; 6. References to termination of pregnancy in criminal laws and codes do not reduce the rate of termination of pregnancy. Instead, it amplifies women’s vulnerability to mortality and morbidity; 7. Legal restrictions on access to safe termination of pregnancy do not and should not be used to reduce gender-biased sex selection or gender inequity; and 8. No health professional should be expected to perform a termination of pregnancy against their personal conviction. However, any doctor who holds a conscientious objection to the provision of termination of pregnancy should provide an effective referral to another health practitioner who does not hold such an objection; AMSA calls upon: 9. The Australian Commonwealth, State and Territory Governments to: a. Provide all women living in Australia with full autonomy over their reproductive health; b. Promote termination of pregnancy as a core reproductive right within and outside of Australia, and demonstrate leadership in ensuring the provision of legalised, destigmatised and safe reproductive health services in the global community; c. Legislate in a health-focussed, evidence-based manner; d. Provide leadership in ensuring uniformity and clarity of legislation across all States and Territories. This involves removing all reference to termination of pregnancy from criminal laws and codes; e. Provide safe, legal, financially and socially accessible termination of pregnancy and family planning services in order to minimise unintended pregnancies and unsafe terminations of pregnancy, with its accompanying detrimental physiological, financial and mental health consequences. This is fundamental in protecting women’s right to autonomy over their personal health and reduces the recourse to termination of pregnancy; f. Recognise the role that stigma plays in initiating and exacerbating long-term mental and physical harm and to support programs and initiatives that seek to reduce and eliminate termination of pregnancy-associated stigma; g. Promote the de-stigmatisation of termination of pregnancy and to effectively communicate the acceptance and availability of termination of pregnancy services to the community; h. Support programs and initiatives that promote awareness, particularly to the general community and to health professionals, regarding women's legal access to termination of pregnancy; i. Actively regulate termination of pregnancy, as with any other medical service, under healthcare legislation and to ensure the provision of skilled post-termination of pregnancy care; j. Improve data collection and evaluation of available termination of pregnancy providers, the number and nature of terminations of pregnancy provided, and of associated complications. This is to improve the provision of safe termination of pregnancy; 10. Medical Schools to: a. Recognise and impress upon medical students the importance of respecting the diversity of opinion held by the wider community; b. Recognise termination of pregnancy as a common and essential medical procedure

for women's reproductive health; Provide opportunities for students to engage in the development of personal and professional views with regards to complex ethical issues, such as the provision of safe termination of pregnancy; d. Incorporate into the medical curriculum content which i. emphasises a health-focused, evidence-based approach to reproductive health services, including termination of pregnancy and family planning services; ii. sensitively addresses the biological, psychological and socioeconomic aspects regarding a termination of pregnancy; iii. adequately informs students on the availability of termination of pregnancy services, as well as all current treatment options and facilities, including supporting psychological and social facilities available; e. Provide opportunities for students to engage in professional scenarios involving core reproductive health services, including safe termination of pregnancy; 11. Australian medical students, health students and health professionals to: a. Recall the values that underpin our professional practice, including the human right to health, social accountability and social justice; b. Recognise termination of pregnancy as a safe medical intervention and to provide appropriate medical advice; c. Respect, protect and fulfil women’s human rights, including the autonomy to make reproductive health decisions; d. Practise in a health-focussed and evidence-based manner in order to provide the greatest health outcomes for their patient, to which they owe the highest duty of care; e. Recognise that faith-based or other objections to termination of pregnancy should not preclude women to the attainment of full autonomy over personal reproductive and sexual health, as is their universal human right; f. Express honestly, without judgement or discrimination, to a patient if the medical professional holds any conscientious objection to a health intervention that would reasonably be expected to affect the healthcare provided to the patient; g. Refer the patient to other available and accessible services in the case where the medical professional holds a conscientious objection to the provision of termination of pregnancy; h. Be agents of social change; regardless of personal conviction: i. Advocate to the health profession and wider community the need to respect, without judgement, the personal decisions made by all women; ii. Contribute to the reduction of stigma associated with termination of pregnancy. This is to safeguard the wellbeing and safety of all members of the community; c.

AMSA Council calls upon: 12. AMSA Executive to: a. Where appropriate, publicly support and collaborate with organisations and initiatives that work to improve access to reproductive health services, including termination of pregnancy; b. Where appropriate, lobby State and non-State actors to pursue the recommendations of this policy document as per points 1 a-h, 2 a-e and 3 a-j; c. Actively advocate institutional and curricular reforms by Australian medical schools to include content related to reproductive health as per points 2 a-e; d. Encourage, support and establish educational and service activities and projects pertaining to reproductive healthcare and human rights among AMSA ThinkTanks,

local Medical Students Societies,Global Health Groups and individual members-atlarge.

Appendix Definitions Termination of pregnancy (abortion)

“Termination of pregnancy” as defined by the The Royal Australian and New Zealand College of Obstetricians and Gynaecologists is the act of “deliberately ending a pregnancy so it does not progress to birth” [18].

Unsafe abortion

The World Health Organisation (WHO) defines unsafe abortion as a “procedure for terminating pregnancy carried out by either persons lacking the necessary skills or an environment that does not conform to minimal medical standards or both [19].” This includes the nature of circumstances before, during and after an termination of pregnancy.

Safe abortion

A safe abortion is the termination of pregnancy that safeguards the health and wellbeing of the woman.

Medical methods of abortion (medical abortion)

Termination of pregnancy can be performed through the use of pharmacological drugs [3].

Surgical methods of abortion (surgical abortion)

Termination of pregnancy can be performed by the use of transcervical procedures, including vacuum aspiration and dilatation and evacuation (D&E) [3].

Health consequences of unsafe termination of pregnancy Every pregnancy involves a degree of health risk [5]. However, an unwanted or unintended pregnancy often carries an amplified risk for the woman. Just as a pregnancy carried to term requires high standards of perinatal care, so too, does a pregnancy interrupted by termination of pregnancy require careful medical attention in order to safeguard the health and future fertility of the woman [5]. As with any obstetric procedure, surgical termination of pregnancy necessitates appropriate technique under safe and sterile conditions, conducted by a licensed and competent professional [3]. As with any medication, medical termination of pregnancy (eg. Mifepristone, formerly known as RU-486) requires careful dosage and close monitoring of efficacy and safety [5]. The health consequences depend on several factors - facilities where termination of pregnancy is performed, skill of the provider, method used, the individual woman’s health and the gestational age of her pregnancy. Apart from maternal death, unsafe termination of pregnancy poses significant complications including haemorrhage, sepsis, peritonitis and trauma to the cervix, vagina, uterus and abdominal organs [20]. Reproductive tract infections occur in 20-30% of unsafe terminations of pregnancy and upper genital tract infections in 20-40% [21]. These figures however may underrepresent the true health impact as deaths and disabilities related to unsafe termination of pregnancy are difficult to measure, given the often clandestine nature of the procedure. Reliable reporting is hindered by stigma and fear of punishment [3]. Furthermore, medical care for temporary or lifelong disability is required by one in four women who undergo unsafe termination of pregnancy [3]. Yet too many women do not seek this attention because they do not recognise the severity of these complications, because of financial barriers or because of fear of abuse, ill-treatment or legal reprisal [3].

Family planning services and effect on termination of pregnancy Increasingly, women and couples desire fewer children and the rate of uptake and correct use of modern methods for contraception has not been rapid enough to reflect this change. In most developed nations, the use of contraception is high and the knowledge about correct use is also prevalent. AMSA promotes access to effective family planning services as a strategy to reduce unintended pregnancy and terminations of pregnancy. It is no coincidence that in developed nations that provide and promote access to family planning services, there are lower rates of termination of pregnancy, whether legal or not [22]. This has also lead to fewer terminations of pregnancy globally; the number of terminations of pregnancy in 1993 was 45.5 million, in 2005 it was 43.8 million [23]. Unfortunately, while the overall number of terminations of pregnancy has fallen, the number of unsafe terminations of pregnancy have not. In 2005, unsafe terminations of pregnancy was estimated to be 19.7 million, in 2008, that figure was approximately 21.6 million [24]. Access to safe termination of pregnancy Overall, 47% of women in the developing world only have extremely restricted access to termination of pregnancy, either no legal access whatsoever or only in the case of saving the woman’s life, protecting her physical and mental health, fetal impairment, rape or incest [3]. Unsafe termination of pregnancy rates vary greatly within regions. Latin America has a very high rate where 92% of termination of pregnancy are unsafe, however if the Carribean is not included in that estimate, the rate is 100%, as Cuba has broadly legal and highly accessible termination of pregnancy services [23]. In comparison, termination of pregnancy is legalised in many instances in India, but access to termination of pregnancy is still generally extremely limited and women still undergo unsafe termination of pregnancy; only two in five are considered safe [25]. There are clear guidelines to delivering safe access to termination of pregnancy. There are even indications that traditional medicine providers, if trained appropriately, could provide safe access to medical termination of pregnancy [26]. Broadly speaking, modern termination of pregnancy services can be delivered in safe ways in many different settings [22]. Economic consequences Where safe termination of pregnancy are cost-saving, unsafe terminations of pregnancy pose significant economic costs. A 2008 study showed that in sub-Saharan Africa, post-termination of pregnancy complications rise to an estimated annual cost of US $23 million for minor complications, US $6 billion for post-termination of pregnancy infertility, US $930 million to society for loss of income from death or long-term disability and amount to US $200 million out-of-pocket expenses for individuals and households [27]. These economic grounds further strengthen the public health and human rights platform that rationalises the provision of safe termination of pregnancy. Furthermore, in countries where termination of pregnancy is highly restricted legally and/or unavailable, it is poor, rural and young women who suffer most [3]. Safe termination of pregnancy becomes the privilege of the rich while disadvantaged women have little choice but to resort to unsafe providers or to attempt terminations of pregnancy by themselves, enhancing social inequities. Their deaths and morbidities become the social and financial responsibility of the public health system [3]. Gender-biased sex selective termination of pregnancy States which place legal restrictions on safe termination of pregnancy in an agenda to prevent gender-biased sex selection face the same consequences that any legal restrictions on the accessibility of safe termination of pregnancy will foster - that is that women continue to seek unsafe terminations of pregnancy which detriment their health and wellbeing. The UN, WHO and AMSA recognises that states have an obligation to protect and fulfil the human rights of girls and women, but states also have an obligation to address these injustices in a manner that protects

women from risk of death or serious injury [28]. Denying required access to services such as safe termination of pregnancy is a violation of women’s rights to life and health as upheld in international human rights treaties [28]. Termination of pregnancy for the purposes of sex-selection, like any use of technology for sexselection purposes including routine ultrasound, is merely a symptom of underlying causes contributing to gender inequity that need to be addressed. The OHCHR, UNFPA, UNICEF, UN Women and WHO have stated, regarding the impact of legal restrictions of safe termination of pregnancy on sex-ratio imbalances: “These laws have largely had little effect in isolation from broader measures to address underlying social and gender inequalities [28].” Criminalising termination of pregnancy, in an effort to avoid gender-biased sex-selective terminations of pregnancy, has a negligible effect on resolving entrenched gender inequities [28]. Although the problem of sex selection has been compounded by relatively recent availability of technologies, the normalisation of the sex selection is caused by deeply entrenched discrimination against women within diverse social institutions such as family, marriage systems and property inheritance laws [28]. The WHO has also expressed concerns in the practicality of enforcing the legal prohibition of medical technology use for sex detection or sex selection termination of pregnancy [28]. The AMSA is emphatic in its condemnation of gender-biased sex selection as a clear breach of human rights, but especially where it perpetuates the violation of women’s human rights. However, AMSA does not believe that the restriction of access to or criminalisation of safe termination of pregnancy, in order to prevent gender-biased sex selection, should come at the cost of further curtailing those rights and exposing women to the risk of death and disability. Worldwide perspective In 2004, the World Health Assembly stated: “As a preventable cause of maternal mortality and morbidity, unsafe termination of pregnancy must be dealt with as part of the Millenium Development Goal on improving maternal health and other international goals and targets [3].” Since 1997, only 19 countries have implemented more liberal laws for access to termination of pregnancy, while three have further restricted their laws. These policy changes have occurred despite knowledge of an inverse relationship between the number of terminations of pregnancy that are carried out in a nation and the liberality of the laws [22]. Where termination of pregnancy is broadly allowed, it is usually carried out safely. Decriminalisation and regulation of termination of pregnancy, such as in South Africa, leads to lower maternal mortality [2]. Australian Perspective Unfortunately, there is no reliable data regarding the number of terminations of pregnancy in Australia; best estimates put the figure at between 70,000-80,000 per year [7,8]. This uncertainty is due to a number of reasons. Firstly, there is no specific medicare item number for termination of pregnancy. At present, it is believed that terminations of pregnancy are generally coded under Medicare Benefits Schedule Codes 35643 (evacuation of the contents of the gravid uterus by curretage or suction currettage) or 16525 (management of second trimester labour, with or without induction, for intrauterine fetal death, gross fetal abnormality or life threatening maternal disease) [4]. This means that it is extremely difficult to estimate the absolute number of terminations of pregnancy in Australia at the current time. From the financial year 2012-2013, there were 60,245 services for the code 35643 and 714 services for the code 16525 [29]. However, these figures do not provide an accurate estimation of the number of terminations of pregnancy because terminations of pregnancy may be coded under other item numbers, and not all services provided under these codes may be considered a termination of pregnancy. Furthermore, terminations of pregnancy are conducted in variety of settings which do not approach termination of pregnancy with uniformity,

such as private and public hospitals or individual specialist clinics. The inconsistency of data collection and payment process means that Australian data on termination of pregnancy is unreliable.

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Policy Details Name:

Access to Safe Termination of Pregnancy Policy

Category:

G - Australian Global Health

History:

Adopted, First Council 2014