Melbourne’s Royal Women’s Hospital (RWH) has decided to halve its funding for the Pregnancy Advisory Service (PAS), a vital Melbourne service.
This decision is particularly baffling in the light of the health minister’s commitment to fund a state-wide service which, by all accounts, would have gone to the RWH. Tragically, the RWH has backed away and instead decided to reduce the service.
The funding was picked up by Women’s Health Victoria to develop 1800 My Options, an online, state-wide phone service providing information on sexual and reproductive health service.
While it provides a much-needed service, it is not a counselling or case management service, nor is it an abortion provider. Women still need access to publicly-funded abortions and associated care services, which are now being starved of funds.
The RWH administration’s decision flies in the face of the Victorian government’s Women’s Sexual and Reproductive Health: Key Priorities 2017-2020 strategy plan, which articulates the importance of respecting Victorian women’s reproductive rights, choices and diverse health needs, including providing improved access to publicly funded abortions. The government’s strategy plan unequivocally emphasises the key role public hospitals play “in supporting women’s access to surgical termination of pregnancy services”.
Pregnancy services
With a small but dedicated team, PAS operated as the de-facto state-wide service for abortion access in Victoria.
It was able to provide face-to-face and telephone-based information, counselling, referrals and advocacy to about 8000 women a year seeking support for pregnancy options and abortions. The service was never properly funded by the state government, so RWH had for many years committed to funding the telephone service.
It also provided triage, conducted assessments of women’s need to access free services and coordinated their care once booked in to the hospital. Unfortunately, many more women missed out on this service due to the limited resources allocated to PAS.
Nevertheless, the RWH was able to provide the largest number of publicly funded abortions in the state, helping to meet the needs of the most disadvantaged — teenagers and single parents with limited financial support, victims/survivors of domestic violence and sexual assault, homeless women, refugees and women experiencing drug or mental-health related issues. Many of these women simply would have had no other option but to continue an unwanted pregnancy, if not for the invaluable access PAS offered.
Until March this year, PAS was able to provide many of these women free and timely abortion care, pregnancy options counselling, and case management in a safe, non-biased, evidence-based and trauma informed service. PAS evolved into one of the most well respected services in the sector.
As a public provider of non-judgemental unplanned pregnancy support and pregnancy options counselling, PAS was the leading service other health professionals looked to for guidance and information in supporting their patients.
Care Planning model
PAS developed a unique Care Planning model in response to internal audits into a subset of women who struggled with making a decision, displayed ambivalence and a number of missed appointments. They either continued a pregnancy because of this ambivalence, or ended up having a late term abortion.
The audits revealed that for many of these women, a prime driver was their exposure to family violence, reproductive coercion in their decision making, as well as mental health impacts such as depression and anxiety.
The key principles underlying the new model were that it needed to be trauma informed, women-centred and increase women’s sense of choice and control in their interactions with the hospital.
The results from a follow up audit a year after implementation of the new model showed that there was less non-attendance at appointments, a higher level of engagement with the key workers, and an improved coordination of responses along the services pathway.
The results from this audit were not accounted for in the review of PAS undertaken just before the announcement of the funding cuts.
There is no doubt that a reduction of staffing levels will undermine this carefully planned service model, stretch the workers’ capacity to respond in a sensitive, timely way and threaten to adequately address family violence as a key risk to women’s sexual and reproductive health, as identified in the Women’s Sexual and Reproductive Health strategy plan.
Although the RWH played a leading role in the development of the Strengthening Hospital Responses to Family Violence initiative, there seems to be little recognition of the link between unplanned pregnancy, family violence and reproductive coercion, and the barriers and heightened risk many of these women face seeking support and access to unplanned pregnancy services at the RWH.
Under the new system, women who try to book in for abortions or request options counselling at PAS are directed to call 1800 My Options. If they are deemed to meet the RWH’s criteria, they are then “warm” referred back to the hospital. Anecdotal reports indicate that women who may be at increased risk because of family violence have to wait up to a week for a return phone call, further compounding their vulnerability and delaying access.
Options counselling
The RWH website is misleading when it states that it provides “pregnancy options counselling to women who are booked to have an abortion — early medication” and “pregnancy options counselling and post abortion counselling are provided to women who are booked to have an abortion at the Women’s”. This is not pregnancy options counselling. Pregnancy options counselling provides non judgemental, unbiased support and information on all the options for women’s pregnancies, including continuing and parenting, or continuing and adopting.
If a woman has already to be booked for an abortion to access counselling, how is this supporting her to make a decision? She may become ambivalent throughout the process and be referred back to counselling, but this is different from when a woman needs supported counselling to make the decision in the first instance.
PAS was able to have an initial conversation with a woman to assess her psychosocial needs and whether she would benefit from first seeing a counsellor if she is expressing ambivalence. The other way around is an inefficient use of limited appointments for termination services.
Without access to free publicly funded options counselling, there is a risk that women will unwittingly be steered towards counsellors who present as unbiased, but actually exist to give women false and misleading information on the impact of abortion to prevent them from exercising their reproductive choices.
Without a properly funded PAS, women have to wait extended periods of time to speak to someone for support, let alone actually book an abortion in a reasonable time period. The funding cuts can also impact on doctors and nursing staff at the abortion service, who now have to manage without the vital backup psychosocial support PAS workers provided to women, placing even more strain on an already overstretched system.
Ideologically motivated
The reduction in funding for PAS seems to be ideologically rather than financially motivated. When a surgeon stopped working for PAS’s public clinic last year, there was no replacement for his list.
It seems that rather than accept funding for a state-wide sexual and reproductive health service and be known for its stance on increasing abortion access, the RWH has chosen to make it more difficult for marginalised women to access timely, evidence-based, safe and equitable reproductive health services.
Making access to the service more difficult and convoluted means appointments may not be booked and clinic numbers will most likely reduce. This manufactured decrease in abortion demand could become a handy justification for the cuts to PAS.
Victorian women and their allies fought very hard for safe and legal abortion access, which they won in 2008. This important victory is now under threat from RWH’s ill-conceived decision which will further limit service provision to women who can afford it. Cost-cutting a vital public abortion service is not a good enough explanation when more funding than ever was on the government’s table.
Will the RWH provide an explanation or will it silently bargain away women’s reproductive right to safe, timely abortion care?
Victorian women deserve an answer.