Abortion: Part 1 — The fear factor
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The AMA’s Dr Andrew Pesce looked on nervously as Sydney GP Dr Suman Sood was prosecuted under NSW abortion laws, and he fears the fall-put still.  It’s not that the association’s national spokesman on obstetrics considers Dr Sood to be an innocent doctor who didn’t receive a fair trial.  Rather, he’s concerned about the mind-set of others who also watched her trial with interest.

Dr Pesce says anti-abortion campaigners will ultimately determine the long-term significance of the Sood case.  He’s troubled by comments in the lay press suggesting her conviction was a victory, and that it’s just the start – there are many more abortion doctors to go.

“If anti-abortionists see this as a call to arms and start reporting other doctors as well, what will happen is that doctors will be genuinely fearful that they will be prosecuted, which is what the anti-abortion lobby wants,” Dr Pesce says.

If they create a climate of fear, more doctors will wonder whether providing the service is worth the risk.

“I think it would result in a lot of doctors withdrawing those services,” he says.

Dr Persce says doctors already feel vulnerable under the state’s abortion laws, which have been widely criticised as being too open to interpretation.  The Sood case offers no clarification because it was tried by a jury and, with jurors not required to document reasons for their decisions, the specific reason the termination was found to be illegal will never be known.

With Victoria also feeling the fall-out from a high-profile abortion case, there is a perception within that state’s medical community that its abortion laws are unclear.  Obstetricians are still coming to terms with a protracted medical board investigation of five hospital doctors that was instigated by a politician with a strong anti-abortion stance.

The Medical Practitioners Board of Victoria took five years to investigate the complaint about doctors from the Royal Women’s Hospital, who had terminated a 32-week foetus with dwarfism after judging the mother to be suicidal.  In September, the board announced it had found no evidence of unprofessional conduct.

Given the duration and profile of the case, one of the doctors cleared of any wrongdoing is concerned about its impact on obstetricians who provide later terminations when the foetus has an abnormality. The doctor, who cannot be named for legal reasons, surveyed 17 private obstetricians in Melbourne who perform such terminations and found seven of them no longer provide terminations as late in pregnancy as they did before the medical board investigation was announced.  All but one said Victoria’s abortion laws were not clear or appropriate, 12 were worried about the law being unclear and 10 acknowledged the lack of clarity affected their patient management.”

“It has become much harder for Victorian women to access abortion, after the diagnosis of a foetal abnormality, over the last five years,” the doctor says.  “It’s because obstetricians are feeling very vulnerable.”

“Doctors are compelled to think of their own risk in offering an abortion because of the uncertain laws.”

Melbourne epidemiologist Dr Julia Shelley (PhD) says the medical board investigation has not affected doctors’ willingness to provide early terminations.

“In terms of late terminations I’m sure there’s more caution,” says Dr Shelley, principal research fellow at the Australian Research Centre in Sex Health and Society at La Trobe University.

“I think there is some ‘twitchiness’ in Victoria, mostly because of the general climate federally,” she says, referring to Health Minister Mr Tony Abbott’s strong anti-abortion stance, the presence of the Family First party in the Senate and strong anti-abortion sentiment evident during the Senate inquiry into RU486.

This nervousness among doctors is typical of the fall-out where there is a legal or political controversy about abortion, Dr Shelley says.  In 2002, the Australian and New Zealand Journal of Public Health published her research documenting the extent Australian women travelled interstate for abortions and how closely this related to each state’s legal and political climate.  From 1984 to 2000 more than 2000 Queensland women travelled to NSW each year for terminations, her paper suggested.  There was a spike in the numbers in 1985, the year police raided abortion clinics in Brisbane and Townsville.

“The raids, during which medical records were removed from the clinics, were followed by the prosecution of two doctors for procuring an illegal abortion,” the paper says.  “The perception of termination of pregnancy as illegal and the level of media coverage of termination of pregnancy issues continued for many years following this event.”

Dr Shelley says the last time doctors became “twitchy” about abortion laws was in WA when two Perth doctors were charged under the state’s abortion laws.

“WA [doctors] had been operating in the same way as Victoria and NSW and felt things were stable and then several doctors were charged after the ‘baby in the fridge’,” she says.

A patient had been given her aborted foetus so she could conduct a culturally sensitive burial but, when one of her children told a teacher there was a baby at home in the fridge, it led to a police investigation and arrests.  The case sparked significant legislative change, with doctors refusing to perform terminations until the law was clarified, Dr Shelley says.

“Terminations became completely unavailable in WA for a period of some weeks while they got the new legislation through,” she says.  “In that time, several women were hospitalised after trying to perform their own abortions.

 ON THE ABORTION FRONTLINE

“If you want to have an abortion beyond 20 weeks, you’re probably going to have to come to Victoria to us,” says Dr David Grundmann, one of two GPs who perform late-term abortions at Croydon Day Surgery in Melbourne.

The number of women coming to the clinic for “late second trimester” terminations increases each year, reflecting greater unwillingness among doctors in other states to perform them, Dr Grundmann says.

“I don’t know for a fact, but it makes sense that any fear of prosecution doctors may have is going to decrease their willingness to help women achieve an abortion,” he says.

Dr Grundmann also owns four clinics in Queensland and one in NSW but only performs late terminations in Melbourne.  He says this is not due to Victoria providing any greater legal safety, but because such terminations take three consecutive days to perform and he does not spend enough time in other states.

He is confident the late-term abortions he provides for psychosocial reasons are safely within the law and has not been concerned by the Sood case in NSW or medical board investigation in Victoria.

Medical director of Australian Birth Control Services Dr Geoff Brodie says Dr Grundmann is filling an important role.

“It’s great that you’ve got a really good, competent operator that is able to act as a safety valve for the nation,” says Dr Brodie, who has two clinics in Sydney.  “You don’t want these women going to backyarders or doing self-harm, trying to do the procedure themselves.”

NSW clinics draw an “invisible line in the sand” in regard to doing terminations over 20 weeks, Dr Brodie says.

“There’s the law of diminishing returns after 20 weeks,” he says.  “If you stuff up, people start to say why in the hell are you doing the procedure.  The system starts to turn on you.”

Dr Brodie does not have the skills required to perform late-term abortions and chooses not to acquire them, for personal reasons as well as wanting to avoid controversy.

“I don’t want to be involved and be a target for these late, late stage terminations,” he says.

During the NSW Supreme Court trial of Sydney GP Dr Suman Sood – who was recently convicted under the state’s abortion laws – a patient gave evidence suggesting NSW clinics may be referring women to Queensland.  The woman said her cousin called eight or nine clinics in the state on her behalf, to see whether they could help her.

“She asked if it was possible to have an abortion over 20 weeks,” the patent told the court.  “She told me that they all said it was illegal to get it done here and, if I want it done, to go to Queensland.”

Dr Grundmann says it “simply isn’t true” that abortions for psychosocial reasons at this stage are illegal.

“From time to time we get people who come to us who are given this information, erroneously or out of ignorance, or may be maliciously so they [other doctors] don’t have to deal with them,” he says.

Some doctors’ religious beliefs also impact on patients, he says, citing the example of a country doctor in Queensland who told a woman it was not legal to have an abortion at 16 weeks’ gestation.  By the time the woman arrived at his clinic, she was 22 weeks’ pregnant.

“This is not an isolated situation,” he says.  “I’ve seen this a number of times.”

Marie Stopes International research from 2004 found Australian GPs were not always well informed about the legal framework surrounding abortion.

“More than half of the GPs who practise in states where an abortion may be legally performed to prevent serious social and/or economic consequences to the woman are unaware of this fact,” the research paper says.

“More than one-third of GPs readily admit that they do not fully understand the abortion laws in their state or territory and, in many instances, GPs’ stated understanding of specific legal requirements [does] not necessarily match reality.”

 LATE-TERM DISCRIMINATION

Doctors’ reluctance to terminate pregnancies after 20 weeks discriminates against some women because various foetal abnormalities may not be diagnosed until after this time, according to a leading Melbourne obstetrician and ultrasonologist.

Associate Professor Lachlan de Crespigny says it is also unfair to apply the 20-week cut-off to overweight or obese women, because there are often delays in diagnosing foetal abnormalities in these patients.

It is difficult to get clear ultrasound images, particularly of intricate areas such as the heart, when women are overweight, he says.  If a foetal heart abnormality is suspected at 20 weeks, the patient may not be able to see a cardiologist for a week and the cardiologist may then suggest an amniocentesis.

“It could easily take two weeks to have the full assessment,” he says.

Other abnormalities – such as hydrocephalus, dwarfism and microcephaly – may not be diagnosed before 22 weeks, even in women of normal weight.  The patient would then need time to digest the information and make a decision.

Women are generally devastated when an abnormality is diagnosed and will be further traumatised if they have trouble finding someone who will perform a termination, Professor de Crespigny says.

“These women who have the diagnoses of an abnormality make a difficult decision and then to get pushed from pillar to post [to achieve a termination] is just awful.  It’s grossly unfair.”

There is no clinical basis for a 20-week cut-off point for terminations, he says.

“Twenty weeks is used in the public debate a lot, but there there’s no foetal milestone [at this time].  It is arbitrary cut-off that discriminates against women who need a scan after that time to get optimal care.”

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