Plain English summary
Background
Methods
Selection of study sites and participants: primary health care providers
Data collection
Data analysis
Results
General practitioners |
N = 32 | Percent | |
---|---|---|---|
Gender | Female | 24 | 75.0 |
Male | 9 | 28.1 | |
Role | General Practitioner (GP) | 31 | 96.8 |
GP/surgeonb
| 1 | 3.1 | |
Provision of MTOP | Provider | 8 | 25.0 |
Non-provider | 24 | 75.0 | |
Work setting | Private GP practice | 32 | 100 |
Area (NSWa) | Metropolitan | 16 | 50.0 |
Inner regional | 13 | 40.6 | |
Outer regional | 1 | 3.1 | |
Remote & very remote | 2 | 6.2 |
Abortion and scope of practice
Abortion is a service ‘others do’
I remember when I did an anaesthetic term for six months and terminations were just part of the job. I was happy to do it but I remember feeling uncomfortable and it’s a paradoxical thing because I do think that terminations should be freely available but I’m not sure that that’s what I want to make as my business. [GP non-provider, inner regional]
I don’t think I am going to chase that expertise and do it myself ever. I’d rather somebody else handle that. [GP non-provider, metropolitan]Somebody can do it. I’m not interested. [GP non-provider, metropolitan]
Life-and-death it’s a big matter for me, so I wouldn’t go into that. [GP non-provider, metropolitan]
Abortion provision - stigma
Oh, even some of my colleagues… are very set in their views. I found that when they found out that I’m doing these things that they have viewed me differently which is a bit depressing. [GP provider, metropolitan]
I don’t know how you can ethically advertise it without incurring the wrath of the Christian right wing. [GP provider, inner regional]
My friends that has not been good. I’ve actually had a lot of people be quite negative towards me when they find out that I’m doing this. That’s a very big turn off… I was actually more upset by some of my friend’s opinions. A few of my friends found it very difficult to deal with the thought of me doing these and it took me a long time to actually tell them that I was doing it … they responded more negatively than I thought they would. [GP provider, metropolitan]
I don’t know. I’m not religious really. If you are Catholic, Chinese or something maybe. [GP non provider, metropolitan]
But I mean that’s not the - the main barrier is actually - yeah, it just wouldn’t work for me from a practical point of view at the moment in terms of - I work for X, I don’t have my own rooms and I have to work within X scope of practice. [GP non provider, metropolitan]
MTOP demand, care and referral
GP provider experience of demand for MTOP
I don’t know whether I’m the only doctor in town who’s on the register…so I don’t know what the demand is for it here - whether I’m one of 10 or the only one. I have no way of knowing. [GP provider inner regional]
I’ve actually only had two requests since I did the training, and one of them, after the initial visit, went away and thought about it, and changed her mind. So I haven’t had a lot of demand for it … they may be self-referring. [GP provider, metropolitan NSW]
I do about a list of around about 15 to 18 one day a week. I only work one day a week. [GP provider, metropolitan].
I think it’s certainly a more accessible option for them because it doesn’t have a financial barrier or a distance barrier, because the other thing about the Aboriginal population is if they are a pensioner and we prescribe a medication on the PBS it’s actually free altogether [GP provider, outer rural].
I don’t provide it in my current work places because it is not supported by my employers. I guess I’m a little bit restricted in that two places where I work… it is currently deemed outside the scope of practice. So I need my employer to accept that it’s within the scope of practice. [GP non provider, inner rural].
Referral and brokerage for abortion in general practice
There’s rumours about a prescriber for medical in town but I don’t know if they’re true or not. [GP non-provider, inner regional]
I am a Muslim so abortion is not recommended unless it is endangering the mum’s life. Around the 120 day, umm… Is it 120 days?… I’ve forgotten that specific number, but we believe that at that specific time the soul is breathed into the foetus, and if it’s done before that that’s not so bad. If it’s done after that, it accounts to murder. That’s how my belief goes, and I couldn’t let go of that. But I’m happy to talk to woman about it and refer to someone who can do it for them [GP non-provider, metropolitan]
Letting them know that they’ve actually got time in many situations to make a decision. It’s not a decision that needs to be made straight away. I think that to me is so important. Any decision that is made at that point has the potential of affecting them forever… it’s just whether they do go ahead with the termination or they don’t go ahead with the termination, there are consequences either way. That to me in that first consultation is so important. We’ll walk through this together making sure that they’re safe at that moment in time for them to go away and digest everything that was said and then coming back for review and follow up. [GP non-provider, metropolitan]
Eventually I got one from… one of the obstetricians here. I first of all had it declined and then I rang them up and it was only because I started crying that he agreed to do the termination because he’s known me for a long time. He basically sort of said oh, for God’s sake …, I’ll do it, but I’m not doing it again. So you can imagine how difficult it must be for women themselves without an advocate like you trying to access them. [GP, non-provider outer regional]
I’m starting to question myself about whether I know all the possible referral avenues with regards to abortion. It’s something I need to just go over, it might just be today. I think just having that information and having the right information and the appropriate information that we can pass on to our clients. [GP non-provider, metropolitan]
Possible but rare, and often that’s also a matter of exhausting all other avenues of loans and brokerage from women’s health services. [GP non provider, metropolitan]
The provision of information about abortion methods
Oh, we go through the phases of procedures in detail and then it’s up to them. What exactly is going to happen, what the side effects will be with both and we just allow them to decide what they would feel is more convenient for themselves. [GP provider, metropolitan]
I guess because there’s limited experience with medical terminations, most of them haven’t really asked; they just assume that it’s surgical. [GP provider, metropolitan]
She had a termination on Tuesday, she had it in [a town nearby] and she was only five weeks and six days and I’m surprised that they actually did a surgical termination for her …I would have thought she would have been a classic example of someone who would benefit from a medical termination myself. But, she wasn’t offered one. [GP provider, regional]
Access to medication ultrasound and psychological services
Working at (an abortion clinic which provides MTOP) has been really easy. I tried once to offer it to one of my patients in my general practice and that just ended up being too hard. I couldn’t find anywhere to get the medication from and the pharmacists weren’t prepared to get accredited because it would be very - oh they’d do it, but it would take too long to get accredited. [GP provider, metropolitan]
Asking them for a favour…which they’ve already stipulated that they don’t actually want to do. [GP provider, regional]
That proved to be a bit of a challenge when the one patient I had wanted to get it, that we had to hunt it down and the chemist didn’t have it in stock, and it was a little bit of a thing, and I guess if there’s not that much demand for it, that’s going to continue to be a problem, because if they only have a need for it once in a blue moon they’re not going to keep it in stock, so it’s going to be something tricky to get for the patient. [GP provider, outer rural]
If the right pharmacist wasn’t on at the time when the person came to purchase the medication they couldn’t get it. So I picked one particular pharmacy where I knew all of the pharmacists had done the training and so I specifically direct my patients to one of two pharmacies and then say if they don’t have it or can’t get then I ask them to call around and I expect that they would do that I think. [GP provider, inner regional]
Had to go away and have a bit of a think about whether they wanted to be involved [GP provider, metropolitan]
They [psychologists] need to be amendable to seeing a client within a week as there’s time constraints. [GP provider, metropolitan]
Follow-up/after-care
We have a huge dropout rate. We have a huge amount of people that don’t come back. Whilst we always try to phone them and send them emails and things sometimes the phone number’s not correct. I find it quite stressful. I find that more stressful than anything else, not knowing… [GP provider, metropolitan]
They’re more likely to come back afterwards I find for follow up just because it’s more of an operation or a procedure that they may feel need follow up for rather than taking a pill. [GP non-provider, regional]
My biggest problem is that I have women travelling …to access a termination because I will provide it very cheaply or bulkbilled for healthcare cardholders… Despite all of my best efforts, I am still having great problems getting people to come back for follow up. [GP provider, metropolitan]
I was able to organise the medical termination for her and then she came back in and had her IUD inserted. It was all a very nice - as though it was part of a holistic care package. I was able to manage that complication for her with a good understanding of her family circumstances and her own. I think it did work very well for her …because obviously I had ongoing contact with her and was able to follow up with her how she felt about everything. [GP provider, metropolitan]
Because it’s got after hours and all. You can’t cover everything. [GP non-provider, metropolitan].
It’s not a matter of just giving a pill. There’s quite a lot of follow-up for people that are coming from all over the place. I just thought that would be unwieldy for me to try and do that… I work almost exclusively now doing surgery. So I was happy just to offer a straightforward surgical service. But if they want medical terminations they need to go elsewhere. [GP provider, inner regional]
Specialist support for abortion complications
I know that my colleagues were concerned that if a woman was bleeding a lot that there needs to be support of the gynaecologist that can basically be on call or they can get help quickly, and they didn’t feel that that would be possible. [GP ex-provider, regional]
Workforce needs
GP Peer support for MTOP provision
It would be good to have support of colleagues that you know can look after things on their day in the clinic when you’re not there (GP provider, metropolitan].
I think it’s a huge barrier for people doing it out in the community and, look, I’m trained and I know I can do my ultrasounds and for me to do it in the community would be a lot easier probably than a lot of the others. Because at least I know what I have to do to get myself set up to do it. I still found it very, very challenging that one time I tried to do it. In the end I gave up and sent her to [sexual and reproductive health clinic] anyway. I just booked them in on the day I was there rather than trying to get it for her in the community. [GP provider, metropolitan]
I’m kind of a young doctor and doing it all by myself without any support of a supervisor, it’s difficult. So yeah, having more senior doctors who can give more of the termination supervision. [GP provider, regional]
I’m not ready at this point. I’m a young doctor so I want to get more confidence but who is going to mentor me? [GP non-provider, regional]
Training for MTOP provision
I am not too sure how RU86 works or how methotrexate is given. I’m sure there is a protocol for it…To be able to answer some questions or if you’re worried about contraindications or aware of not a very typical scenario for example. [GP non-provider, regional]
They’re not likely to tell that to the reception staff, so they’ve got to have some acceptable entrée… Often people use I’ve got tummy ache or something. Tell me about your tummy ache: ‘I haven’t got tummy ache, but I didn’t like to say anything’. So again that’s a barrier, they’ve got to have the nouse to think up to get an entry [GP provider, rural]