ARTICLE

Vol. 137 No. 1607 |

DOI: 10.26635/6965.6647

The first trimester abortion journey Aotearoa: health practitioners’ perspectives

The Aotearoa New Zealand Abortion Legislation Act 2020 allows the right to choose abortion (up to 20 weeks’ gestation), self-referral, and for abortion provision in a range of settings, by a range of practitioners.

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The Aotearoa New Zealand Abortion Legislation Act 2020 allows the right to choose abortion (up to 20 weeks’ gestation), self-referral, and for abortion provision in a range of settings, by a range of practitioners.1 While law reform resolved many legal barriers, abortion funding remains with pre-existing abortion services, despite recent research demonstrating many health practitioners in Aotearoa have transferrable skills and are willing to provide first trimester abortion.2

Other high-income countries also face barriers to abortion relating to travel, insufficient training and stigma.3 In Northern Ireland, despite repeal of the Irish Constitution’s Eighth Amendment, barriers to abortion remain, including a mandatory reflection period, requirement for clinician referral and funding.4 Those most affected are people with complex needs.5 The New Zealand Aotearoa Abortion Clinical Guideline recognises inequity in Aotearoa for Māori and for those that are young, homeless, unemployed and LGBTQIA+.6 Achieving equitable health outcomes in abortion care is a priority.

The aim of this study is to gain insight into health practitioners’ understanding of how people experience the first trimester abortion journey. The objective is to determine what is required to enable provision of equitable and optimal first trimester abortion care in Aotearoa.

Methods

This study is informed by phenomenology, with the purpose of undertaking research that “discovers, explores and describes” a phenomenon. This design was selected to ensure rich and descriptive data to capture the experience of the abortion journey in all its facets.7

Health practitioners (doctors, registered nurses [RNs], midwives, counsellors and social workers) from across Aotearoa who participated in a previous study,2 and who declared no conscientious objection to abortion and consented to be contacted by email for future research, were emailed an invitation to participate in an interview regarding their perspectives of how first trimester abortion care is experienced by the consumer. The email included a REDCap survey link so that participants could be purposively selected for a range of characteristics and demographics. Questions included profession, scope of practice, experience, geographical location, age and gender. These data were used for recruitment only and were not included in the findings. The survey tool was tested by a selection of health practitioners for clarity and useability. If no response was received after 7 days, a follow-up email was sent. After a further 3 days of no response, participants were presumed to have declined. All interviews were conducted over February–March 2022 by secure video conferencing.

To open, the interviewer asked participants to describe how people access abortion in their area. Other pre-determined questions included “How is contraception provided postabortion?” Prompts were used to further encourage participants, for example “Can you tell me more about that?” Effort was made to avoid leading the participant. Refer to Table 1 for further examples of interview questions.

Audio was transcribed by a human-based transcription service and anonymised. NVivo8 was used to assist in a process of inductive thematic analysis.9 While an inductive approach was used to capture the experience of the participants, it is impossible for the researcher to place themselves outside of the analysis. The interviewer is a health practitioner and is pro-choice. A deductive process of viewing data through the lens of the researcher and the research question is inevitable.9

Analysis began with close reading, then assigning codes to meaningful phrases that were collated into themes with shared meaning. Themes were merged, split or deleted to make sense of the data. Themes were named to reflect their meaning and to represent participant narratives. Co-coding was undertaken by a research assistant with experience in qualitative methods. Discrepancies were discussed until agreement was reached.

This study was approved by the University of Otago Ethics Committee (H21/047). Consultation with Māori was undertaken with The Ngāi Tahu Research Consultation Committee and within the Department of Women’s and Children’s Health, Dunedin School of Medicine.

Results

Of the 24 people who responded to the invitation, 18 (doctors=12, RNs/counsellors/social workers=6) were contactable and consented to interviews. The non-doctors were grouped due to numbers fewer than 10 to maintain anonymity. Participants represented a range of specialities, including abortion, primary care and specialist services, and had various roles in abortion care.

Analysis of qualitative data revealed three themes with sub-themes: 1) abortion is a stepwise process, 2) barriers to accessing abortion care, and 3) strategies to increase access to abortion.

Theme one: abortion is a stepwise process

The abortion journey is a linear process of pre-abortion requirements, the abortion itself and then the post-abortion experience. Pre-abortion events involve initial decision making and, if abortion is chosen, what method. Decisions may be pragmatic or complex.

I think for some people it’s just simply a case that they’re pregnant, they don’t want to be pregnant and there’s a solution that’s relatively easy and it’s very safe.” – Participant 3

People can self-refer into abortion services or be referred by practitioners. Bloods, swabs and ultrasound may be required. Counselling is optional.

For the abortion itself, people can have an early medical abortion (EMA) or surgical abortion. Some participants reported anecdotally an increase in people choosing EMA.

There’s a huge proportion now having EMA; overwhelmingly women are very positive about that, about it being very straightforward, clearly explained to them, not too painful, not traumatic.” – Participant 15

Post-abortion care may include contraception at the time of abortion, depending on the abortion and contraceptive methods. People having EMA may have a blood test or low sensitivity urine pregnancy test to confirm a complete abortion.

Theme two: barriers for people accessing abortion care

Personal barriers

While self-referral was generally seen as positive, navigating this pathway may be problematic.

You’ve gotta go online, and for our local abortion provider, you’ve got to click through a lot of screens to find the information that you need. It’s difficult, they have to find that information out for themselves.” – Participant 15

Travel was identified as a barrier, particularly for rural people.

It’s all very well for us to say, ‘This is where you can go to have your abortion,’ but it’s about getting there for a lot of them.” – Participant 3

There are costs for travel, time off work, childcare and, depending on location, ultrasound.

Some private providers charge NZ$40 and some don’t charge at all. They’ve got the biggest capacity, so you can get in quicker, but the ones that are cheaper are a little bit harder to get into.” – Participant 17

Non-residents eligible for funded maternity care may be ineligible for funded abortion.

I still think it’s insane that you can be eligible for maternity care if you are a female who might have a 2-year work visa, but the father or partner is Kiwi or has a visa, but you’re not eligible for termination.” – Participant 2

Within service barriers

Reproductive healthcare, particularly abortion services, were seen as under-resourced, with restraints on service capacity.

The big one is really time and manpower. They’re just always running out of slots and time, and they just never have enough resources, which is frustrating.” – Participant 19

Some clinics require people to have EMA on specific days due to lack of clinical support at weekends. Clinics may require multiple visits.

This whole day one/day two thing, so they have to come twice. You should just be able to come and see a doctor, have your pills, or see a nurse and have your pills. There’s quite a lot of paternalistic traits still, because that’s how it’s always been and that’s what makes us comfortable.” – Participant 11

Some pre-abortion tests were seen as not clinically indicated.

It’s still a little bit thorough here, a little bit over the top, so I have to arrange the path lab to take their bloods and their double swabs. They still need to get a scan for an early medical abortion here.” – Participant 19

Access to long-acting reversible contraception (LARC) post-EMA varied according to location but was identified as problematic with telemedicine EMA.

Next on my agenda is more LARC access or contraception access because I’m really keen and happy that there’s gonna be a telemedicine service nation-wide, but we really need to be following up with how our patients are gonna access contraception.” – Participant 15

Societal barriers

Many participants identified systemic issues in sexual reproductive healthcare in Aotearoa.

I think there’s a lot of work to do in women’s health generally. I think it’s just another example of how women’s health isn’t always treated with the best knowledge and the best care that it could be.” – Participant 3

Consequences of conscientious objection were identified as delays in accessing abortion and stigmatisation.

We have two GPs; one doesn’t do contraception—definitely doesn’t do termination care. And another GP who won’t refer for terminations, but the women don’t know that. They turn up; ‘I have an appointment. I would like a termination.’ The receptionists know, and if they can veer people in the right direction, they do, but it still happens at times that they come across these two GPs who just block them.” – Participant 9

Lack of culturally appropriate care

Some participants spoke unprompted about a lack of culturally appropriate abortion services.

I think any engagement with the healthcare system for Māori is going to inherently be a barrier because it’s a system built with a Pākehā worldview and try as you might to translate every possible word and whatever into te reo Māori, it’s a bit of whoop de doo when the system itself doesn’t have a Kaupapa Māori approach.” – Participant 7

Theme three: strategies to increase access to abortion

Self-referral

Seamless self-referral pathways were seen as removing barriers to care. However, this has shifted the workload associated with the referral to abortion services.

Now, they’re able to self-refer and go straight to the abortion clinic, although talking to the booking clerk at the TOP clinic, she prefers the referrals to be done because it saves work for her.” – Participant 19

Point-of-care ultrasound

Some abortion services provide point-of-care ultrasound (POCUS), streamlining the process and removing ultrasound fees. Providing POCUS places demand on abortion providers.

Yeah, I only do a transabdominal one. I don’t do a transvaginal and I know I should, but it’s too hard right now to get the probe and have to clean it to bring it back to use for the next patient.” – Participant 4

Abortion normalisation and education

People may not consider abortion as an option due to lack of awareness or family/cultural barriers. Strategies to overcome this include abortion education in schools.

I think it’s something that needs to be normalised. Now, that may mean that the providers that provide sexual health and contraception in schools also have the opportunity to discuss abortion as an option for an unintended pregnancy.” – Participant 3

Telemedicine EMA

Telemedicine EMA facilitates self-managed care and should be an option for all.

I think people who opt for medical terminations are wanting to have a bit of control over it anyway. They’re generally wanting to do it at home. They want to be able to look after their kids and it’s a lot about fitting in with their lives. I think if they can do that from home or work, if they have to, I think that would be amazing.” – Participant 6

Many participants expressed concern about telemedicine EMA, including inability to provide LARC. Telemedicine may pose barriers to the therapeutic relationship, particularly for people with communication challenges. Failure to identify people requiring additional support was recognised, for example intimate partner violence.

Yeah, and if she’s had a non-consensual episode that led to a pregnancy and she just wants the abortion, she doesn’t want to discuss anything else, there’s a lot more involved there. She can turn up for her EMA and get her pills and go home, but if I was sitting, talking to her, I’d probably gauge something more than that.” – Participant 18

Participants expressed concern for how complications are managed in the telemedicine EMA setting.

I guess the only thing would be is if there’s some complications, if a woman is not near a service provider, then that potentially could have issues, particularly if they’re in a remote place and there’s only one GP and they didn’t want them to know.” – Participant 8

Primary care provision of abortion

Participants were supportive of first trimester primary care provision, especially EMA. Apart from one participant, there was support for nurse abortion provision.

Well, like contraception, I think you need this attitude of every door is the right door. I think if women are looking for help or a service, the important thing is that the service is agnostic and they shouldn’t feel that they’re only able to go to one type of practitioner.” – Participant 15

Participants identified requirements for abortion in primary care, including appropriate training, support from secondary services and access to counselling. Adding another service to an already burdened primary care sector was recognised. Appropriate funding is essential for primary care to provide abortion services.

Well, some kind of funding model that’s gonna fund it and make it free for the patient but give you adequate time to spend with them to do all the required tasks.” – Participant 5

Discussion

This study shows that the first trimester abortion experience in Aotearoa is influenced by a range of factors, including the individual’s circumstances, health services and society. Three main themes were identified: abortion is a stepwise process, multiple barriers to abortion care exist and solutions to overcome abortion barriers.

Self-referral was seen as facilitating abortion access but requires further development to make navigation simpler. Telemedicine EMA also increases access by reducing the burden of travel, increasing convenience and autonomy. However, telemedicine may not provide sufficient psychological support, particularly for those in complex social situations. Access to LARC is also challenging for telemedicine EMA. In 2021, 12.6% of people having EMA in Aotearoa were provided with a LARC, compared to 53.6% of people having a surgical procedure.10

Participants expressed concern for a lack of support for sexual reproductive health services in Aotearoa. Abortion services have absorbed work associated with self-referrals, and many provide POCUS. While this facilitates access for consumers, abortion clinics also require sufficient funding and support to provide a range of care that may include telemedicine EMA as a routine option, expanded clinic hours and access to LARC post-EMA.

A strategy to increase abortion access is to increase the number of providers.11 This study identifies support for abortion provision in primary care, including by nurses. Nurse-led EMA and LARC provision in primary care is safe and effective and increases access, particularly for rural people.12–14 Theory training for EMA and surgical abortion and POCUS can be accessed via the Best Practice Advocacy Centre New Zealand.15 Task shifting of EMA into primary care may increase the burden on the sector and requires careful consideration.16 In Aotearoa, there is limited funding for abortion in primary care via the New Zealand Maternity Benefits Schedule first trimester single service fee of NZ$75.17

This study identifies that people accessing abortion in Aotearoa potentially face unnecessary clinical tests. The finding that bloods, ultrasound and screening for sexually transmitted infections (STIs) may be routinely requested/required is contrary to the New Zealand Aotearoa Abortion Clinical Guideline.6 Ultrasound should be reserved for when gestational age is unclear or there is risk for ectopic pregnancy. Routine ultrasound increases the number of visits and anxiety for the person and places a burden on ultrasound as a health resource.6 The New Zealand Aotearoa Abortion Clinical Guideline recommends selective haemoglobin testing for those with symptoms or a history of anaemia, or those at risk of bleeding. STI screening should be opportunistic, and screening/treatment should not prevent or delay the abortion. Further research is required to confirm whether unnecessary testing prior to an abortion exists and if this creates barriers to timely abortion care.

Study findings indicate that abortion stigma and conscientious objection remain barriers to abortion in Aotearoa. Abortion stigma is closely linked with conscientious objection.18 Conscientious objection may be invoked in the absence of moral objection but as a protection, for example when the practitioner feels vulnerable for their clinical decisions, or they lack the training and support to provide abortion care.19 Improved education and support, including development of GP abortion champions, has been suggested.20 Values clarification workshops are considered integral to abortion training, where attitudes can be shifted towards supporting people who choose abortion.11 Provision of abortion services that are not only safe, but non-judgemental, is outlined in the United Nations’ Sustainable Development Goals.21 In developing first trimester abortion services in Aotearoa, a thorough implementation process is required in recognition of complex societal perspectives regarding abortion.

Abortion services that meet the needs of Māori is a priority. The findings of this study suggest a lack of culturally competent abortion care. In a literature review by Rebekah Laurence in 2019, several barriers and facilitators for wāhine accessing abortion in Aotearoa were identified, including a lack of culturally competent care.22 A 2021 review of regulated health practitioner cultural competency documents found them to be “not yet fit for purpose as frameworks for upholding te Tiriti.”23 It is important that health practitioners have the clinical knowledge and cultural skills to practice in a culturally safe way with whānau, and is a requirement under Te Tiriti o Waitangi.6,23

Limitations of this study include that it was conducted in early 2022 and abortion services may have evolved since then. It is also the perspectives of health practitioners and not people seeking abortion. The participants expressed no moral objection to abortion, and thus represent a specific viewpoint on abortion care. A strength is that participants encompass a range of health practitioners and provide a comprehensive picture of the abortion journey from a health practitioner perspective.

This study identifies barriers to accessing first trimester abortion care and a desire among participants to be part of positive change. To provide optimal first trimester abortion care in Aotearoa, a strategy is required to strengthen and develop abortion services, placing the health consumer at the centre of services that are accessible, equitable and culturally appropriate. The primary care sector has potential to play a significant role in this, but requires funding, training and collaboration with stakeholders, including consumers and the primary and secondary health sectors.

View Table 1.

Aim

To gain insight into health practitioners’ understanding of how people experience the first trimester abortion journey.

Methods

Qualitative interviews informed by phenomenology with health practitioners from a range of practice settings across Aotearoa New Zealand. Participants were recruited via a separate but related study. Inductive thematic analysis was used to develop themes.

Results

Interviews were undertaken with 18 health practitioners. Analysis revealed three main themes: 1) abortion is a stepwise process, 2) barriers to accessing abortion care, and 3) solutions to improve access to abortion care. There were a number of sub-themes.

Conclusion

While there remain multiple personal, institutional and societal barriers to abortion in Aotearoa, this study identifies potential solutions and that a desire for positive change among health practitioners exists. To achieve this, a strategy is required to ensure that the health consumer is placed at the centre of abortion services to provide accessible, equitable and culturally appropriate care. The primary care sector stands to play a significant role in future abortion provision but requires appropriate funding and support to do so.

Authors

Emma Macfarlane: Lecturer/PhD Student, Department of Women’s and Children’s Health, Otago Medical School – Dunedin Campus.

Dr Pauline Dawson: Senior Lecturer, Department of Women’s and Children’s Health, Otago Medical School – Dunedin Campus.

Michael Stitely: Associate Professor, Otago Medical School – Invercargill.

Dr Helen Paterson: Senior Lecturer, Department of Women’s and Children’s Health, Otago Medical School – Dunedin Campus.

Acknowledgements

This research was undertaken while the principal investigator Emma Macfarlane was a recipient of a University of Otago Doctoral Scholarship and a recipient of a Dunedin School of Medicine Early Career Researcher Start Up Award.

Correspondence

Emma Macfarlane: Lecturer/PhD student, Department of Women’s and Children’s Health, Otago Medical School – Dunedin Campus, PO Box 56, Dunedin 9054.

Correspondence email

Emma.macfarlane@otago.ac.nz

Competing interests

Emma Macfarlane is a member of the Abortion Providers Group Aotearoa New Zealand (APGANZ), an associate member of and LARC trainer for the New Zealand College of Sexual and Reproductive Health (NZCSRH) and an associate member of the New Zealand College of Sexual and Reproductive Health (NZCSRH).

Michael Stitely and Pauline Dawson have no competing interests to report relating to the article content.

Helen Paterson is the co-director of the Women’s Health Bus, deputy chair NZCSRH and an abortion provider for Te Whatu Ora – Health New Zealand.

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