For women in certain parts of Queensland seeking an abortion, Nicole Huig knows how much can’t be taken for granted. If you live on the wrong side of the river or town, she says, “your access is completely different”. Despite the fact that abortion was decriminalised in Queensland in 2018, Huig, the counselling team leader at advocacy group Children by Choice, speaks to women every day about the financial and geographical barriers they face when attempting to access an abortion.
But cost and postcode aren’t the only barriers. Huig says conscientious objection (CO) – the legal right of doctors to refuse to perform abortion – has created real and widespread access issues for women across the state. And for one woman, it had particularly catastrophic consequences.
Earlier this year Huig’s team counselled a woman of migrant background who is settled in Australia permanently and had discovered she was pregnant while overseas . She and her husband already had a number of children. After returning to Queensland, she requested permission to obtain a termination of pregnancy while in mandatory quarantine (during Covid restrictions) but was denied.
When out of quarantine she reached out to a doctor in her community who, says Huig, “told her that she was too far along, which wasn’t true, she was in the second trimester”. On four separate occasions she presented to three different emergency departments seeking a termination.
One hospital was outside her catchment, but the other two hospitals should have, on paper, been able to provide her with timely and professional care. Instead, she was turned away once from the public hospital, then from the religious hospital. By the time she returned, desperate, to the public hospital, she was past the 22-week mark. She had, at various times throughout the process, either attempted or threatened suicide and self-abortion.
The last occasion resulted in her gaining access to an abortion but only after she endured another assessment of her options, despite having been clear about her decision to terminate at every point. According to Queensland law, she had to register both the birth and death.
“Her husband was advocating for her because she doesn’t speak English, so she was particularly vulnerable,” says Huig. “It was a very traumatic experience for her.”
And all this during a time in Queensland’s reproductive rights history – finally – that meant she could legally access an abortion.
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Unlike most other medical procedures, abortion services both in Australia and around the world come with an unusual caveat: medical professionals are permitted to refuse to provide what is in most jurisdictions a patient’s legal right if it conflicts with their own moral or religious beliefs.
Major medical bodies are united in their position that a medical professional should be able to declare their CO and decline to provide a service, but they must also inform the patient that abortion is available to them and refer them to another professional who they know provides the service. In some states, like Queensland and Victoria, the obligation to refer the patient on is enshrined in law.
In theory, CO is only legitimate in circumstances where it doesn’t impose delay, distress or health consequences on the patient. But many medical professionals and advocates would argue that it regularly does just that. And while most health professionals in Australia don’t question an individual’s right to object, systemic issues, entrenched culture and widespread stigma mean that the whole is often more than the sum of its parts.
“It’s certainly a huge concern – how do we actually balance having conscientious objections within systems, but also the right for somebody to access the healthcare that they need?” says Daile Kelleher, the chief executive of Children by Choice. “There are still a lot of people who claim conscientious objection. The stigma that’s associated with providing the service then plays out in the workforce.”
In a 2020 study of Australian medical professionals, 13.7% of survey respondents reported total opposition to abortion on religious or conscientious objection grounds, including 14.9% of fellows and 10% of trainees.
But the figures don’t reflect the on-the-ground experience that conscientious objection brings to women around Australia: not only in regional and rural areas that are typically more conservative, sometimes heavily religious and traditionally underserved by medical services, but also public hospitals around the country.
Prof Caroline de Costa was one of the health professionals involved in writing the guidelines for terminations services in Queensland in 2019, including the concientious objection checklist, a guide for health practitioners. “There was a lot of enthusiasm [at meetings], a lot of midwives, bureaucrats, a few doctors,” she says. “Quite a lot of people were keen to put these recommendations in place, but whether medical professionals are following through on these guidelines remains in question.”
“People feel that they’re meeting their obligations by referring down to [private provider] MSI or referring to clinics in Brisbane, or even referring to us. But we know that this does create lots of barriers for people,” says Kelleher.
Some referral pathways, says Dr Catriona Melville, the deputy medical director of MSI Australia, “can introduce delays. And time is absolutely critical in abortion care, particularly when you’re looking at vulnerable women, who often present a bit later because of their circumstances. Literally every day counts because there are limited spaces in Queensland especially for later case surgical abortions.”
These types of concerns were echoed in a letter written by the then head of the state government’s healthcare improvement agency, the Clinical Excellence Queensland deputy director general, Dr John Wakefield, to the Royal Australian College of General Practioners in 2019. He called for better management of CO, warning that its widespreadpractice could lead to healthcare provider burnout, overburdening of remaining providers and fewer providers offering services. Wakefield warned that it may also hinder “a woman’s access to appropriate services … particularly for women who reside in regional, rural and remote communities that are not well serviced”.
Children by Choice’s experience with women in the same local health area suggests the culture of conscientious objection is still entrenched. “We’re aware of five women since March who have been forced to continue their pregnancies through delays,” says Huig.
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Dr Natalie Drever has seen firsthand the distressing effects that being turned away by a doctor can have on women, even if the doctor does follow the published guidelines and fulfil their obligation to refer them on.
Drever is a staff specialist in obstetrics and gynaecology at the Cairns public hospital, and her role includes providing public abortion care. A lecturer at James Cook University teaching fifth-year medical students, she also does private work for MSI, providing abortion services for women who’ve been referred on.
“There is often a delay of several weeks because of long waiting lists in general, because of a lack of providers of this service,” she says. “It can be distressing for women – remaining pregnant for several weeks when they’ve already determined that they’re going to have an abortion and procedures become more technically difficult as time goes on, with some additional risks.”
Referring patients on out of public care also means they’re forced “to fund their abortion care through a private provider, which can be expensive, and disproportionally affects women from low-income backgrounds.”
Drever also sees a disproportionate number of women from remote areas. “These women have to travel very long distances because there are really no providers within hundreds of kilometres and most of the time… it’s all disadvantaged women. It can be women from remote Aboriginal communities, or young women from remote places who then have to travel very long distances. We’re talking mostly about women who are beyond that nine-week cutoff for a medical termination through a GP. Their options can be really quite limited.”
In 2021, MSI closed a number of its clinics across Queensland, making access even more difficult.
The culture of CO is in no way limited to Queensland. Even in Victoria, where abortion laws are the most progressive and most well established in the country, “conscientious objection is a real issue”, says Marianne Hendron, the chief executive of Women’s Health Grampians, which looks after a giant slice of regional western Victoria.
It’s often intertwined with the shadowy nature of stigma. The term is mentioned repeatedly by health professionals and counsellors. There’s a grey area between genuine conscientious objection and doctors simply not wanting to provide the service. “I’ve had GPs say to me, ‘look, I don’t want to be known as the abortion doctor. My kids go to school in this town’,” says Hendron.
And for those who do provide the service, it’s illuminating to discover just how many professionals can’t or won’t speak on the record about providing termination services.
Sarah*, a regional sexual health nurse in Victoria, is adamant that the clinic where she works isn’t identified. She wasted no time when a new GP rolled into her small country town a few years ago. He’d only just got his feet under the desk when she asked him to consider offering medical abortions (when prescribed drugs induce abortion) to patients in the local area. “I guess it was a little bit bold because I understand how conservative some of our population are,” explains Sarah. “But I’d been trying to get access for women in my area for years.”
As a family planning nurse, Sarah had counselled countless women and helped refer them elsewhere, given the doctors at the local hospital would not provide either medical or surgical termination. She says they’re “lovely human beings, but they won’t and they don’t elaborate about why”.
The new GP immediately said yes and is now the only doctor in the area to provide medical terminations, but he doesn’t advertise. No one provides surgical terminations. “None of us were prepared for the demand. I call the doctor a local superhero … Even he says, ‘what did these women do before this was available?’”
It’s a story that’s echoed around the country. As one local doctor in rural NSW told the Guardian in response to our reader callout, “I’ve been a doctor in this town for over 30 years. There is no surgical abortion available here. Women have to travel three hours to a private clinic with extra charges or four hours to a clinic with no additional charges. Disappearing for a couple of days needs a social explanation.” The doctor’s experience also echoes the information vacuum that exists in many areas. “I would not be able to name a doctor providing medical abortion services. I don’t know whom I would ask to find out.”
De Costa and Drever believe there is a genuine generational change in attitudes towards learning about and providing abortion services, which they observe in their students and which bears out in recent studies.
“Abortion care needs to be recognised as part of reproductive healthcare, starting from medical school ...it is a key aspect of reproductive healthcare,” says Drever. But in the meantime “if the public hospitals, the training hospitals, don’t provide abortion services, then those trainees at those hospitals may not be able to seek out training opportunities. It also may perpetuate this view that it’s not part of what an obstetrician and gynaecologist does.”
Then there’s the fact that while the right to CO does not extend to an entire institution, or even administrators, it does extend to all medical professionals. “Conscientious objection doesn’t always just come from gynaecologists. Sometimes it’s actually difficult to find, for example, an anaesthetist within a particular health service that’s willing to perform the anaesthetic for an abortion,” says Drever. “It takes a team of people. Sometimes it’s hard to find a whole team of people that are not conscientious objectors.”
Even the best practice guidelines around managing CO are imperfect for such a grey area, says De Costa. “The guidelines are built around the one-on-one interaction of a woman approaching a GP and being told that they have a CO and then referred on to a practitioner who will provide the service.
“But COs in public hospitals are sheltered from this process … They tell the hospital administration that they are a conscientious objector so they head it off at the pass.
“And that is happening in public hospitals across Australia.”
* Name has been changed
• In Australia, the crisis support service Lifeline is 13 11 14. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is at 800-273-8255 or chat for support. You can also text HOME to 741741 to connect with a crisis text line counselor. Other international helplines can be found at befrienders.org
