(Image: Gorkie/Private Media)

Australia has a problematic history with the medical abortion drugs Mifepristone (otherwise known as RU486) and Misoprostol. We were slow to approve them, and for a decade they were illegal unless a doctor had written permission from the federal health minister (who at one point during this time was famous feminist Tony Abbott). 

These days they’re more readily available, with registered GPs able to prescribe them after an in-person or telehealth appointment. But the pills are still policed more than other drugs. Just a fraction of GPs have completed training and are actively registered to provide the pills. Each prescription has to be approved by Services Australia before it can be dispensed. The pills can only be prescribed when a woman is less than nine weeks pregnant, despite a large body of evidence that they are safe and effective more than 12 weeks into a pregnancy. And there is just one company that supplies them to Australia.

It’s not a coincidence, then, that three-quarters of all abortions that take place in Australia are surgical abortions — a much higher percentage than in other OECD nations. Experts say extending the use of the pills to 12 weeks could see the number of surgical abortions drop to around 50%.

Overpoliced with outdated guidelines

Since 2015, the World Health Organization has recommended pregnancies under 12 weeks be self-managed at home using abortion pills. But Australia hasn’t updated its medical guidelines since 2012 when the pills were approved by the Therapeutic Goods Administration (TGA).

As explained in The Atlantic, other regions have extended the use of these drug further, with Scandinavian countries allowing their use into the second trimester under hospital supervision. In countries where abortion is illegal, the pills after often used even later — in self-managed medication abortions between 13 to 24 weeks of pregnancy, the pills worked successfully in 76% of cases, with others needing medical intervention to remove the remaining pregnancy tissue. 

Sydney University Gynaecology and Neonatology clinical associate professor Dr Deborah Bateson tells Crikey extending the guidelines to 12 weeks would increase access, with women able to pass a pregnancy in the comfort and convenience of their own home. 

While using medical abortions later into the pregnancy would require specific advice and guidelines, and will mean extra bleeding and tissue needing to be passed, Bateson said it would also provide women with a greater degree of control.

“It’s that feeling of being in control of the process rather than being medicalised,” she said, adding surgical abortions should always be an option. 

The extra policing of the pills as an authority script — requiring a third-party sign-off before the prescription is valid — is an example of over-policing, she said, as is requiring pharmacists to be registered to dispense the pills. 

GPs have to undergo a training course that takes between three and fours hours in order to be registered to prescribe the pills. They also have to reregister every three years. Between 2020 and 2021 there were just 3018 active registered prescribers in Australia — in some regions, this equates to one registered prescriber per 3369 women of childbearing age. It’s a similar story for pharmacists, with just 5556 active registered dispensers across the country.

This creates barriers and reinforces stigma, especially in regional or rural areas (though telehealth has improved access). “It should be just part of a mainstream drug policies and we shouldn’t have to have that authority,” Bateson said.

Upping the number of registered prescribers was equally problematic. While a small number of GPs may refuse to prescribe the abortion pill on conscientious grounds, misinformation about their obligations held others back. One study found that GPs felt medical abortions were out of the scope of their practice or could create stigma, or that they have to be on call 24 hours a day in case of complications. 

Bateson said another challenge, especially for GPs in regional and remote areas, was ensuring there was a pathway to surgical abortion or access to a public hospital in case a registered prescriber felt the abortion pill wasn’t appropriate. 

A troubled history with RU486

Mifepristone has been highly politicised in Australia. Its availability was blocked from 1996 to 2006 following an amendment by anti-abortionist senator Brian Harradine to the Therapeutic Goods Act. Backed by then prime minister John Howard in exchange for Harradine’s support for the privatisation of Telstra, the amendment made it so the drug could only be imported with written ministerial approval. 

No other drug in Australia has ever been given this treatment, professor of obstetrics and gynaecology at James Cook University Caroline May de Costa tells Crikey. She was a key driver in getting restrictions around the drug lifted. 

“It was a completely special thing, and the fact that it was abortion was considered to be the justification for this,” she said. 

“Australian women didn’t really know about the existence of the pill, and if it was ever discussed in the media, it was confused with the emergency contraception.” 

May de Costa has been performing surgical abortions across her career (even smuggling IUDs into Dublin) and knew the importance of Mifepristone. In 2005 she published a paper in the Medical Journal of Australia on the safety, efficacy and necessity of Mifepristone which received political support, starting a conversation around reproductive rights. 

While Harradine’s amendment was overturned in 2006, getting the pill into Australia was another issue. No Australian company wanted to face off against Abbott and import the pill from France, as New Zealand had been doing. 

May de Costa found a legal loophole allowing doctors in private practices to import the pill in Queensland. “For two years, [another doctor] and I were the only doctors who had the permission of the TGA to provide abortion pills … we got a fair bit of attention but it was perfectly safe,” she said. 

In 2009 abortion provider Maire Stopes was able to get Mifepristone approved by the TGA and, after local studies found it was safe and effective, it became fully licensed in 2013 and listed on the pharmaceutical benefits scheme the year after. 

A long way to go

Both Bateman and May de Costa believe abortions should be fully implemented into public practice — in states such as NSW patients have to go to a private or specialised clinic — and make the pill more readily available to 12 weeks gestation. 

But changing TGA guidelines is an arduous and expensive process. With just one Australian manufacturer of the pills, it’s unlikely they would put in an application to have the process changed. 

“Things have gotten much better,” May de Costa said. “But we need to have abortion destigmatised and in the public system, as part of mainstream women’s reproductive health care.”