Medical advances mean a safe first-trimester abortion can now be performed in any well-set-up medical centre, argues women’s health nurses in their recent submission on abortion law reform.

The submission by NZNO’s Women’s Health College is one of about 3,500 received by the Law Commission which, in response to a request by Justice Minister Andrew Little, sought public feedback on decriminalising abortion in New Zealand and making abortion law more health-centred.

Public submissions closed on May 18 and the Commission is currently consulting with health practitioners and abortion service providers leading up to presenting its briefing document, which is likely to include a range of options, to Little in late October. (See information on current abortion law and statistics at end of this article.)

The 550-member Women’s Health College (WHC) submission has joined doctors’ organisation the New Zealand Medical Association (NZMA) in supporting abortion being decriminalised and treated as an health issue and in expressing concern about the current inequity of access to abortion services.

The WHC submission says abortion being controlled by the justice system, not the health system, leads to delays and inequitable access that increase risks to women’s health and often lead to higher costs, as early medical abortion is a lot safer and cheaper than surgical abortion.

The NZMA wants more licensed abortion facilities to help address inequities, but the WHC says licensing restrictions should be removed on where abortions, particularly medical abortions, can take place.

An early medical abortion (EMA) is an option available up to nine weeks into a pregnancy and currently involves a woman attending an abortion facility to take two medications  to induce a miscarriage, then returning home to miscarry. EMA has replaced surgical abortion as the preferred option for women presenting early in pregnancy.

“Early medical abortion and care should be available to all women and could be provided in medical centres and Family Planning clinics throughout Aotearoa, once restrictions on premises for abortion are removed,” says the WHC submission.

The WHC and NZMA both agree that the current requirement for two certifying consultants doctors is unnecessary and contributes to problems with inequitable access to abortions. But NZMA believes a medical practitioner should remain the referrer.

Nurse Practitioners New Zealand (NPNZ) in its submission calls for NPs to be able to consider and refer their patient’s request for abortion in the same way as general practitioners.

Appropriately trained nurses could provide surgical abortions

The WHC goes a step further and argues that references should be changed from ‘medical practitioners’ to health practitioners to enable both referrals and abortion services to be carried out by appropriately trained and qualified health practitioners.

“The need for certification is the single biggest barrier to timely access to abortion; dual certification doubles the barrier and hence the risk,” argues WHC. “It is entirely unnecessary for a woman’s decision about reproduction to be mediated by two physicians with whom she has no therapeutic relationship or history.

“It is also a shocking and unnecessary use of public funds and necessitates a labyrinthine and inappropriate process for a core health service.”

“As with other health interventions, the only requirement for abortion should be informed consent, not certification.

The women’s health nurses also point that nurses already provide care in early and late medical abortions and internationally are providing surgical abortions up to 12 weeks’ gestation.

The submission says the WHC has already implemented guidelines for the training of nurse colposcopists and would welcome the development of education and training for registered nurses to allow them to perform surgical abortions up to 12 weeks.

Counselling and conscientious objection

The NZMA, NPNZ and WHC submissions all acknowledge and support the right of health practitioners to make a conscientious objection not to be involved in abortion.

But the NPNZ and WHC are also calling for a requirement for health practitioners who conscientiously object to refer the patient on to another health practitioner.

Both NZMA and WHC strongly back the continuation of pre-decision abortion counselling.

“Targeted counselling around a women’s decision has been shown to help her through the process and increase her confidence in her decision, with less risk of subsequent stress,” says the WHC submission.

“As with any medical procedure, people who have been counselled appropriately, have made an informed decision, and know what to expect can generally get on with their lives. We would strongly support the continuation of free, targeted abortion counselling,” say the women’s health nurses.

NZMA says access to fully funded counselling services is “crucially important” for women considering abortion.

“While we cannot require women to undergo counselling, counselling should be expressly part of the abortion services framework. Doctors need to have confidence that their patients are not going to face barriers in seeking counselling and that the process to access counselling, both before and after termination, is smooth, timely and actively facilitated.”

Wording of grounds for abortion

The Women’s Health College conclude their submission by saying New Zealand “deserves a non-judgemental, safe, timely, accessible abortion service”.

“Removing abortion from the Crimes Act and incorporating it into health system regulation is the first necessary step to ensure better access to timely, safe care.”

The NZMA says it welcomes the move to align the legislative framework to support treating abortion as a health issue but that it continues to be a regulated healthcare procedure in terms of who is eligible.

“With regard to the specific grounds for abortion, it is our view that eligibility should continue to be specified in statute,” says the NZMA.

“The current grounds are generally considered to be working well, although we agree some change in language is needed. For example, there must be a more appropriate way to refer to someone with significant psychological, cognitive/intellectual or physical impairment, than the woman is ‘severely subnormal’.”

Current law

At present, under the Contraception, Sterilisation, and Abortion Act 1977, it is unlawful for an abortion to be carried out unless it is authorised by two ‘certifying consultant’ doctors.  To authorise an abortion, these consultants must believe the situation meets one of the criteria under Section 187A of the Crimes Act 1961, which include that continuing the pregnancy would result in serious danger to the physical or mental health of the woman or there would be a substantial risk that the child would be ‘seriously handicapped’.

It is also an offence under the act for a woman to  unlawfully attempt to procure her own miscarriage – for example, by taking a drug.

The latest abortion statistics show that that 12,823 abortions were performed in 2016 – down from a peak of 18,511 in 2003.

The general abortion rate (abortions per 1,000 women aged 15–44 years) was 13.5 per 1,000 women in 2016, which was the lowest rate in over 25 years.

The abortion rate for younger women has also fallen significantly in recent years. The abortion rate for women aged 20–24 years fell from a peak of 41 per 1,000 women in 2003 to 21 per 1,000 in 2016. The abortion rate for teenagers dropped from 26 per 1,000 to 9 per 1,000 over the same period.

The statistics, released by Stats NZ in June last year, also showed that most abortions (64 per cent) were a woman’s first abortion and 57 per cent were performed before the 10th week of the pregnancy.

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