Campaigns for easier access to abortion in Australia have largely focused on changes to the law but in a speech last week the Labor deputy leader, Tanya Plibersek, highlighted another crucial factor: cost.
“For many women abortions are unaffordable and unattainable,” she said. “The legal right to access a termination isn’t much use to a homeless teenager when the upfront cost of an abortion is more than $500.”
In some areas women can pay as much as $800 for a first-trimester termination. We looked at how such prohibitive costs interact with legal restrictions and other barriers to make access to abortion entirely unequal for Australian women, depending on where they live and their economic circumstances.
Provision
Abortion has been effectively decriminalised in every state and territory except Queensland and New South Wales, where the procedure remains in the criminal code and can be provided only if deemed necessary by a doctor to avoid risks to a woman’s mental and physical health, or for economic reasons in NSW.
Abortions can be performed by either a medical or surgical procedure. Both are available in all states, but how and by whom they can be administered varies.
A medical abortion involves taking two pills, mifepristone (RU486) and misoprostol, over a two-day period. A surgical abortion uses suction to remove the embryo (or foetus after 11 weeks) from the uterus and can be done under varying degrees of anaesthesia. The procedure can take less than 10 minutes.
Across every state and territory a medical abortion can be administered only up to nine weeks gestation.
In Queensland, NSW, Victoria, Western Australia, the Northern Territory and Tasmania, medical abortions can be performed at home or in a clinic, but must be prescribed by a licensed doctor.
In the Australian Capital Territory and South Australia, the law requires pills for a medical abortion to be taken in a hospital or approved medical clinic.
In the states and territory where abortion medication can be taken outside a licensed medical facility, they have been available via telemedicine services since 2015.
Surgical abortions are available in every state and territory up to 20 to 24 weeks, depending on legislation, and can be done only in medical facilities. In some states, later term abortions require permission from multiple doctors or a decision-making body.
Cost
The cost of an abortion varies according to state, location, method of termination and gestation.
Most private abortion clinics in an urban area charge about $500 upfront for a first trimester surgical or in-clinic medical termination, and $290 upfront for an out-of-clinic or “at home” medical termination. The Tabbott Foundation provides medical abortion drugs via telephone service for $250 everywhere but South Australia and the ACT.
The drugs – which in most cases must be paid for on top of the basic abortion fee – cost less than $40 for Medicare card holders and much less for healthcare card holders.
After the first trimester, costs increase significantly. Costs are also much higher in regional areas. In Rockhampton, Queensland, a medical abortion costs $840 and a surgical abortion $765. But in South Australia and the NT they are mostly free because provision is largely public.
In all other states abortions are almost always provided by private abortion clinics.
The private market is dominated by one player – Marie Stopes International – which has the sole distribution rights over RU486 through its subsidiary MS Health, and is the largest provider of abortions through its clinics. It is also responsible for training and accrediting doctors with the right to prescribe medical abortion drugs.
The fees charged by Marie Stopes International in Australia help towards subsidising reproductive healthcare in developing countries including Timor-Leste and Papua New Guinea.
The company’s chief operating officer in Australia, Jamal Hakim, has told BuzzFeed News: “We are a not-for-profit and we are mission-driven, but we’re not about losses either.”
Any profits generated in Australia went towards a donation or dividend to the parent entity, “which supports women globally”, Hakim said.
A study conducted in 2015 found that the cost of an abortion done in a private clinic – on average about $500 for a medical or surgical termination – caused women significant financial stress.
Children by Choice, a pro-choice pregnancy counselling service based in Brisbane, regularly crowdfunds abortions for women who would otherwise be unable to afford them. Many clinics now also provide a cheaper telemedicine option.
Access
Abortion access varies between states, and between urban and regional areas.
There are significant legal and cultural barriers that discourage doctors and hospitals from providing abortions and push their provision into the private sector.
In Queensland and NSW the legal uncertainty posed by the criminalisation of abortion acts as a real deterrent. In the past decade, and as recently as last month, the law in these states has been used to prosecute individuals for procuring their own abortions and to prevent doctors providing an abortion to a minor.
A Queensland obstetrician, David MacFarlane, says the illegality of abortion in Queensland has led to hospital staff having “an exaggerated level of anxiety, compounded by confusion and ignorance about what the laws relating to abortion mean and permit”.
The situation “disadvantages women, especially poor women, and advantages private obstetricians and private gynaecologists, who charge significant amounts of money for doing these procedures”, he says.
Experts say that along with changes to laws, increasing the number of GP and nurse providers would improve access and reduce costs. But these groups can be reluctant to get involved in abortion, or to publicise their involvement, which, according to Children by Choice, is a “considerable barrier to women”.
Geography often compounds these impediments. Australia is a huge place and access to any medical service is limited in remote areas.
In Queensland, abortion providers are concentrated in the south-east corner of the state and women in the north are often forced to travel hundreds, if not thousands, of kilometres.
In Victoria, which has some of the most pro-choice laws, improving regional family planning services was identified as one of the state’s key objectives in its first sexual and reproductive healthcare plan, released in March.
In the ACT, where medical terminations must be administered in the territory’s one abortion clinic and cost $440, women may need to travel to Queanbeyan, across the border in NSW, to access them at a lower cost.
While telemedicine has improved remote access somewhat, it is no silver bullet. In states where abortions can be legally performed outside a medical facility, a woman still needs to be less than nine weeks pregnant, be within one hour of a medical facility in case of complications, be able to have an ultrasound and be able to cover the cost. Otherwise she may find herself travelling hundreds of kilometres to the nearest surgical provider, adding travel costs and missed work to her financial burden.