By Lydia Mainey MACN
A few months ago, Queensland added itself to the list of other Australian states (barring NSW) that decriminalised abortion. The historic law reform put into the spotlight a topic usually engulfed by stigma and politics – both for nurses who work in abortion care and the women receiving it. One in four Australian women will have an induced abortion in their lifetime (Scheil et al., 2017); for many the decision to have an abortion can be complex, and made in the context of social issues such as domestic violence, sexual coercion or financial hardship. Most of these women will be cared for by a nurse during their patient journey. Many nurses who work in this area view it as rewarding work, and with the reform comes an opportunity for the profession to review the role of nurses in this area and highlight the possible future direction of abortion care across the country.
The role nurses play
Induced abortions have probably always been performed in Australia. Until the late 1920s, many women performed their own abortions or sought the assistance of lay-midwives (Baird, 2013). Nurses formally became involved in abortion care after the practice was legislated under the various State’s criminal codes and moved into the health system.
Today, abortion is a safe, straightforward procedure which can be done via surgery or through the administration of medications. The most recent national report found the majority of the 80,000 abortions recorded annually take place in private clinics (AIHW et al., 2005). Nurses from other clinical areas (such as sexual health and primary care) often facilitate women’s access to these centres. There is optimism that law reform will increase abortion access in the public system and in general practice and therefore more nurses may become familiar with abortion care.
The law on abortion
The Federal and State governments legislate abortion in Australia and take conservative approaches to the scope of nurses. It is legal in all states and territories for registered and enrolled nurses to assist with abortions, including the administration of abortifacient medication and assisting in theatre with the surgical procedure (when performed within the requirements of the law) (Children by Choice, 2019).
The nursing role tends to focus on assessment of the woman, preparation for the abortion, and assistance with the procedure and aftercare. Although some abortion facilities allow for nurses to deliver contraceptive implants and intrauterine devices, nurse practitioners are unable to provide medical abortions such as Mifepristone – one of the medications used in medical abortions – as it is restricted by the Therapeutic Goods Administration and must be prescribed by an authorised medical practitioner (Department of Health, 2012).
Similarly, surgical abortions must be performed by trained medical practitioners. In countries such as the USA, the UK and many developing nations, extended practice nurses are permitted to prescribe abortion drugs, perform surgical abortions and manage post-abortion complications (Berer, 2009).
Better skills equal better care Nurses who provide abortion care work across a range of services such as primary practice, stand-alone abortion centres, operating theatres and afterhours call centres. They have a sound understanding of the female reproductive system, induced abortion methods and post-abortion care. They must have a host of clinical skills in their toolkit.
Not only do they demonstrate strength in clinical assessment and health history taking, they are also able to identify and act on risk factors such as domestic violence. Sound sexual health and contraception knowledge is also essential, as is the ability to undertake women-centred counselling around these topics. They have a good understanding of the medications used in abortion and provide clear education on their use, effects and side-effects.
Additionally, nurses who care for women undergoing surgical abortions must also have a knowledge of the perioperative patient journey.
Going beyond patient care
Most nurses who work in abortion care understand that the pathways to access abortion are imperfect and can be stressful to the woman. Thanks to roll-out of education programs from organisations such as Children by Choice, they are also beginning to understand that women often seek abortions in the context of domestic violence and reproductive coercion, cases that then prompt them to sensitively adapt their care to meet the needs and experiences of the individual.
Some nurses reveal that they try to develop a quick rapport with the woman allowing sensitive information to be shared, comprehensive care to be given and outcomes to be evaluated.
Empowering nurses to do more
Comprehensive abortion care (CAC) is the gold-standard of abortion service delivery and could be a model of care that Australia moves towards in the future (Dawson et al., 2016). CAC is a women-centred integrated and decentralised services approach that focuses on preventing unwanted pregnancies, reducing complications after abortion, and attending to other issues affecting the women.
The nurse’s role in this model of care is quite broad and differs from what’s currently provided by most abortion services in the country. For example, in countries that practise CAC, nurses lead many medical termination services, and some countries allow extended practice nurses to perform surgical aspiration abortions.
Extending the nurse’s scope allows those who work in rural and remote locations to provide services to their communities reducing the need for women to travel. Integration of abortion services with other services such as family planning and domestic violence will require nurses working in this space to collaborate with other professionals such as social workers.
Abortion is not a fringe obstetric issue. It is a safe, legal and straightforward procedure that many women will – and have the right to – choose. Providing nursing care to women undergoing abortion is a rewarding experience where the skills and art of nursing intertwine. More nurses may have the opportunity to work in this area, and with a greater scope of practice, as legislation continues to change and abortion care moves towards comprehensive care.
AIHW, HARGREAVES, J., GRAYSON, N. & SULLIVAN,E. 2005. Use of routinely collected national data sets for reporting on induced abortion in Australia. Canberra: Australian Institute of Health and Welfare.
BAIRD, B. 2013. Abortion Politics during the Howard Years: Beyond Liberalisation. Australian Historical Studies, 44, 245.
BERER, M. 2009. Provision of abortion by mid-level providers: international policy, practice and perspectives.
Bulletin of the World Health Organization, 87, 58-63. CHILDREN BY CHOICE. 2019. Australian abortion law [Online]. Available: https://www.childrenbychoice.org.au/factsandfigures/australianabortionlawandpractice [Accessed].
DAWSON, A., BATESON, D., ESTOESTA, J. & SULLIVAN, E. 2016. Towards comprehensive early abortion service delivery in high income countries: insights for improving universal access to abortion in Australia. BMC health services research, 16, 612.
DEPARTMENT OF HEALTH 2012. Behind the news: Registration of Mifepristone Linepharma (RU 486) and GyMiso (misoprostol). In: ADMINISTRAION, T. G. (ed.). SCHEIL, W., JOLLY, K., SCOTT, J., SAGE, L. & KENNARE, R. 2017. Pregnancy Outcome in South Australia 2015. Adelaide: Adelaide: Pregnancy Outcome Unit, SA Health.