Better MTOP access also brings risks

6 minute read

Meanwhile, a new study confirms the safety of telehealth follow-up for early medical abortion.

Women in Australia’s regional and remote “abortion deserts” stand to gain the most from relaxed regulations on medical abortion – but for all the celebration around improved access, this gift horse may be hiding ugly risks.

While some doctors have raised concerns that women in rural areas will be put at risk by the new policy, new evidence is emerging to support the safety of remotely-delivered medical abortion care.

Last week, the government loosened restrictions on prescribers of mifepristone and misoprostol (MS-2 Step, MS Health Pty Ltd) for medical abortion in pregnancies up to nine weeks.

The requirement for both doctors and pharmacists to undergo additional training around the drug and re-certify every three years was dropped, making the 93% of GPs who hadn’t done the training eligible to prescribe it.

At the same time, the PBAC made an out-of-session recommendation for nurse practitioners to be added to the group of eligible prescribers of MS-2 Step.

It’s understood that states and territories will have individual discretion on whether to allow nurse practitioners to prescribe the medicine.

The move has been widely lauded as a win for accessibility of pregnancy termination, particularly for women in rural and remote areas of Australia.

That was the main thrust of recent comments from the Australian College of Nursing, made in response to suggestions reported in The Australian that nurse practitioners may be unqualified for the job.

“Nurse practitioners are highly trained professionals who know their responsibilities in prescribing the abortion pill, provide ongoing care and management, and respond rapidly to any potential changes in wellbeing,” ACN CEO Adjunct Professor Kylie Ward said.

“And we are often the highest qualified health professional in many rural, regional and remote communities where women constantly have health care needs.”

She called the idea of women being at risk if nurse practitioners prescribed “insulting, patronising and out of touch with reality”.

The comments were made to The Australian by National Association of Specialist Obstetricians and Gynaecologists president Professor Gino Pecoraro, who referred to nurse practitioners as “lesser trained practitioners”.

Professor Pecoraro told The Medical Republic that his concerns around the changes to MS-2 Step prescribing were more complex than the “turf war” narrative presented in media.

“It doesn’t matter who writes the script or who goes to the cabinet and gets it out,” he said.

“The fact is, at some stage someone needs to have the discussion about whether MS-2 Step should be available in every [small town].”

Around 5% of medical abortions end up requiring surgical intervention, most commonly for loss of blood or retained products of conception.

At present, women are required to be within a two-hour radius of a hospital when they take the medicine, should something go wrong.

Even at that distance, complications can quickly become emergencies; Professor Pecoraro treated a patient earlier this year who was only a 45-minute drive from a major centre, but so unstable that she required aeromedical retrieval and received uncrossmatched blood while on board.

“Should [medical abortion] be available at absolutely every health facility, or should there be a minimum level of service provision before healthcare professionals – whether that’s a doctor, nurse practitioner, pharmacist or whoever else they want to give prescribing rights to – can prescribe it?” Professor Pecoraro said.

“It’s much less about who writes the script, but whether they can manage all the things that could happen.”

He was also quick to acknowledge that access to medical termination was poor, particularly in rural areas, but argued that the solution should be at the expense of government rather than patient safety.

“It’s like every other medical procedure, not everything can be done everywhere,” Professor Pecoraro said.

“But if it can’t be done in your town, then there should be government-funded set protocols to transport and accommodate you while you’re getting the necessary medical procedure done.”

On the other hand, according to MSI Australia (FKA Marie Stopes International) deputy medical director Dr Catriona Melville, emergencies like the one described by Professor Pecoraro are rare and present the same difficulties in terms of logistics that regional hospitals deal with during emergencies like car accidents.

Being 3.5 hours from a hospital would not stop someone from having a spontaneous miscarriage, Dr Melville said – the only difference was that a medical termination was planned in advance.

She told TMR that before offering a rural or regional patient the procedure, she would sometimes call the nearest hospital to let them know and ask them what care was available, should anything go wrong.

Dr Melville was also lead author on a recent study into telehealth follow-up for medical abortion which trialled allowing patients to use low-sensitivity urine pregnancy tests at home to confirm a successful termination, rather than coming into the clinic for follow up.

Patients were still required to be within two hours’ drive of a hospital when taking the medicine; the only change from standard protocols was telehealth follow up using the special low-sensitivity test.

The test itself is classed as a medical device, and MSI Australia distributes it directly to patients.

The telehealth option was offered to around 3500 patients – and taken up by all bar 218 – and was found to be a safe and acceptable alternative.

Adverse events occurred at a comparable rate, but the researchers did note one surprising outcome.

“The main outcomes are that it was safe, and it also reduced the amount of surgical intervention,” Dr Melville said.

“We know that if you go looking for things like retained tissue after a medical abortion, you probably find things that aren’t of clinical significance, but then you set a person on this path of anxiety and unnecessary intervention.

“When managed with this new protocol, we’ve noticed that our surgical intervention rates have dropped, and that’s a that’s a good thing as far as we’re concerned.”

The implications for women living in rural and remote areas, she said, were particularly promising.

“If you’re somebody that lives particularly regionally and you have to travel, or if you’re somebody that doesn’t have Medicare and would have to pay for further tests, or if you’re somebody whose relationship is not great and you’re not wanting somebody to know that you’re going to the clinic appointments, then this [at-home follow-up and] test is really useful,” said Dr Melville.

There is currently just one brand of low-sensitivity urine pregnancy test on the market, but more are expected to be added soon.

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