Improving medication abortion pathways and practitioner capacity in

Melbourne’s west

Findings of a service audit and needs assessment

Alyce Vella

Women’s Health West

Women’s Health West

1. Specialist Family Violence Service (early intervention and response)

2. Health Promotion (primary prevention) • Mental Health and Wellbeing

• Prevention of violence against women

• Sexual and Reproductive Health

Medication termination of pregnancy

(MTOP)

1. Medication-based alternative to surgical termination• Non-surgical, up to nine weeks gestation

• Efficacy of 95 per cent

• Mifepristone and misoprostol, marketed as MS-2 Step

• Registered by the TGA in 2012 (although limited availability since 2006)

• Only able to prescribe/dispense if registered through MS Health

Only ~390 GP providers and 800

dispensers in Victoria

Abortion access in Victoria

Abortion decriminalised in Victoria (Labor Govt.)

MS 2-Step registered by the

TGA

(MS Health)

MTOP widely accessible in

general practice settings

2008 2012 ???

Cost

Insurance (perceived)

Objection

Pervasive stigma

Community

awarenessFear of

complications &

need for

emergency careManagerial

support

Lack of bulk

billing services

Practitioner

awareness

MTOP provision: more than a ‘2-step’ process

GP

• Consultation and exam

Radiography

• Dating scan to determine gestational age

Path (?)

• Blood test

Pharmacy

• Dispense the MS-2 Step

GP

• Administration of the medication

• x 2 if need to take second dose at clinic

GP

• Follow-up

Counselling services

24 hour emergency support

Access to Anti-DRemoval/re-

insertion of IUD

Other considerations

What are we doing about it?Increase access to affordable fertility control in Melbourne’s West

2008 2012 ???

Increase practitioner knowledge of MTOP

Support practitioners post-training

Map current provision in the region

Increase community awareness

1. Increase practitioner knowledge of MTOP

2008 2012 ???

Four professional development training sessions delivered

Delivered to 72practitioners

Delivered in inner Melbourne as well as

outer suburb of Melbourne

High levels of satisfaction and increase

in content knowledge

Key findingsBaseline needs assessment

2008 2012 ???

Usual care and referral pathways

• Most practitioners had pre-existing referral pathways and networks with

services

• Generally included referrals to the Royal Women’s or private clinics:

• Very busy

• Unaffordable (private)

• Located in inner suburbs of Melbourne

Key findingsBaseline needs assessment

2008 2012 ???

Opinion of current MTOP provision in Victoria

• Most practitioners agreed that there was not adequate abortion (MTOP and

STOP) access:

• In a general practice setting

• In public hospitals in the region (e.g. Mercy and Western Health)

• For marginalised women

• Low income earners

• CALD women

Key findingsBaseline needs assessment

2008 2012 ???

Barriers and motivating factors for MTOP provision

Lack of training and resources

Perceived lack of support from local

hospitals

‘beliefs’ Patient noncompliance

Concerns about contraindications and emergency care

Freedom of choice Provide safe and early

action

Access and equity for all

women

Ability to intervene earlier in a pregnancy

De-centralising the processes

Key findingsBaseline needs assessment

2008 2012 ???

Motivating factors for MTOP provision

To serve people in the society, to provide MTOP to my practice and patients from other

practices and provide safe and early action.

(GP and current MTOP prescriber, eastern metropolitan region)

Women should be able to make their own choice regarding a pregnancy. A lot of teenage girls

fall pregnant in the area and unfortunately end up having to continue with their pregnancies -

their lives and children suffer. MTOP is done at less than nine weeks and is safer, less

invasive.

(GP and prospective MTOP provider, Melton)

OutcomesPost-session evaluation

2008 2012 ???

Most useful aspects

• Processes and protocols for MTOP provision, including MS Health registration

• Patient management via the exploration of case studies

• International context

• Ability to recall the training requirements to provide MTOP

100 per cent

• Ability to describe MTOP provision processes and considerations

100 per cent

Impact

2008 2012 ???

At least 10 practitioners have gone on to start the MTOP registration process:

• Completing the online training

• Referring colleagues to future PD sessions

Changes to practice

• Dedicated pregnancy options appointments each week

• Policy/induction into clinic involves MTOP registration

• Encouraged to offer more SRH services to patients, including nurse training for Implanon and Pap screening

• Encouraging colleagues to register

Why didn’t you become a provider?

2. Support practitioners post-training

2008 2012 ???

Conduct longitudinal evaluation of training attendees

• Determine current MTOP provision status

• Support practitioners to increase capacity, networks and confidence

• Face-to-face meetings at clinics

• Regular correspondence via email for update sharing

• Online surveys

• Have not had time (but plan on doing it in the near future)

• Lack of managerial/collegial support: “Practice owner not supportive of provision”

• Colleagues are already providers

2. Support practitioners post-training

2008 2012 ???

How can we support you?

• Continue to run information sessions

• Working off the ‘momentum’ generated

• 60 per cent were interested in joining a regional MTOP professional network

Build networks

• Strengthen existing pathways

• Learn from others

Share case studies

• Build confidence and capacity

• Gain second opinions and constructive feedback

Establish local referral pathways

• Decentralise service access

• Negotiate cost (e.g. bulk billing)

Share best practice evidence

• Act as a ‘champion’ in their own clinic

• Debunk concerns held by colleagues

• Continuous learning and improvement

3. Map current provision in the region

2008 2012 ???

• In Nov 2016, developed a preliminary list of GP practice, pharmacy and

radiology in the western region of Melbourne, grouped by LGA

• Cold-called and emailed clinics to determine:

• Current MTOP provision

• Interest in attending a PD session

• Mapping clinics and services on a digital map (Google Maps)

• Potential to share this map with other women’s health services, community

health, general practice for advocacy purposes, and to assist with improving

health service systems and referral pathways

Findings

277 clinics and pharmacies identified

143contacted

85 do not provide MTOP

(59.4 per cent)

40 did not confirm if MTOP provider

(28.0 per cent)

18 Currently provide MTOP

(12.6 per cent)

13 GPs 5pharmacists

134 still being contacted

• 2 x prescribing

GPs

• Pharmacy on-

site

• Ability to do

ultrasounds

once a fortnight

on-site

• Other dispenser

• Bulk bill dating

scans

Provision pathways – a real example

4. Increase community awareness

Sourcing a grant to begin a community awareness and acceptability project

Do women know what MTOP is?

What are their attitudes towards it?

How can we use this data to advocate to

clinics to provide the service?

Where to?

• Continue to work with partners to deliver PD to professionals

• Community awareness and advocacy project

• Increase providers in the region

• Support professional networks and strengthening of referral pathways

Acknowledgments

2008 2012 ???

Helen Macpherson Smith Trust

North Western Melbourne Primary Health

Network

Dr Paddy Moore, Royal Women’s Hospital

MS Health

Women’s Health in the North

Women’s Health West colleagues

Thank you

2008 2012 ???

Alyce VellaTeam Leader - Sexual and Reproductive Health

alyce@whwest.org.au

whwest.org.au

References

• https://www.tga.gov.au/behind-news/registration-mifepristone-linepharma-ru-486-and-gymiso-misoprostol

• More available upon request