Provision of services for unplanned pregnancy and abortion remains an important clinical and public health concern worldwide.1 In Australia, the National Health and Medical Research Council (NHMRC) recommended national coordination of health policy development, planning and coordination of services, and education of health professionals more than a decade ago.2 Good policy development requires reliable information, but there are considerable barriers to achieving this in Australia: state and territory abortion laws are inconsistent,3 record-keeping is variable or non-existent,4 and reliable estimates of Australia’s abortion rates are unavailable.5
Nevertheless, it is known that many Australian women have induced abortions. The Pregnancy Outcome Statistics Unit, South Australian Department of Human Services, reports a 29% lifetime prevalence of legal induced abortion in South Australia for women born around 1955,6 and a survey of a nationally representative sample of 9134 women aged 16–59 years found that 22.6% reported having experienced an abortion.7
Both private clinics and public hospitals provide support regarding unplanned pregnancy and abortion services.4 The National Pregnancy Support Helpline was implemented in 2006 to provide free, confidential, professional telephone counselling for unplanned pregnancy.8 No usage data have been published and, apart from a 13-year-old survey of women seeking abortion at private clinics in New South Wales,9 there are few published data from pregnancy support services on which to base initiatives to prevent unwanted pregnancies, plan service delivery, or inform policy and public debate. Our study aimed to provide contemporary information about women who contact a public pregnancy advisory service contemplating or seeking abortion.
The Pregnancy Advisory Service (PAS), located at the Royal Women’s Hospital in Melbourne, is Victoria’s largest public pregnancy support service and takes up to 9000 calls per year. Women with an unplanned or unwanted pregnancy contact the service, usually by telephone, for information on their options, including abortion and continuing the pregnancy, and for support, advocacy and counselling, provided by qualified health professionals, including social workers and counsellors. Women seeking abortion for fetal abnormality are not interviewed by PAS, but referred to other services within the hospital. At the time of the study, Royal Women’s Hospital provided abortion in accordance with a 1969 judicial ruling defining broad criteria enabling lawful abortion.
A database was developed by PAS staff in 2005 to improve service provision, continuity of care, linkage to hospital patient records, research and monitoring. A record is created for all women who become hospital patients for unplanned-pregnancy support. Consultation details, including demographic and social characteristics, referral, circumstances of pregnancy, special needs, and reason for considering abortion, are recorded using fixed-choice options, numerical data or free text.
An audit was conducted of records of all clients of PAS between 1 October 2006 and 30 September 2007.
Because information is recorded as it is disclosed during the assessment interview, complete data are not entered for every woman, and “missing” data require special consideration. For example, it is the practice to ask all women about their pregnancy history, but information is entered in this category only if women report a previous pregnancy; no inferences about previous pregnancy can therefore be made for the remainder. In other cases, data entry depends on PAS staff judgement about whether a topic should be raised, or on women disclosing information. Nothing is known about these matters for women where information is not recorded. Aggregate data therefore represent minimum figures.
For the purposes of the audit, the presence anywhere in a record of the words “violence”, “coercion”, “DV”, “safety”, “risk”, “assault” or “abuse” scored positive for “violence”, and the words “mental health”, “suicide”, “depression”, “anxiety”, “PND”, “chaotic”, or “self-harm” scored positive for “mental health”. A drop-down list of reasons for requesting abortion permitted women to choose one reason only. Where not recorded, a woman’s preferred language was English.
De-identified data were imported and analysed in the SPSS for Windows statistical program, release 15.0 (SPSS Inc, Chicago, Ill, USA). Age, residence, health care card holder status and language were identified as having significant univariate associations with estimated gestation at PAS contact. These variables were entered into a multiple regression model to identify independent associations with the outcome.
The project was approved by the Chair of the Royal Women’s Hospital Human Research Ethics Committee as meeting the NHMRC requirements for quality assurance/audit and therefore not requiring consideration by the hospital Research and Human Research Ethics Committees.
During the 1-year audit period, 5462 women contacted PAS, and 3827 had a hospital record created. The remaining 1635 women called for information only, had no appointment available to them at the hospital, or chose to go elsewhere for further services. No records were created in the database for these women, and no further data were recorded. Of the 3598 records (94%) that included information on this item, most women (3224; 90%) contacted PAS requesting an abortion, and a minority (306; 9%) were ambivalent or undecided about abortion.
Demographic and other characteristics of the 3827 women are shown in Box 1 and Box 2. Information was recorded in more than 80% of records for 77% (13/17) of items. The percentage of each characteristic was calculated using the number of records that contained information on that item as the denominator.
Demographic characteristics of the women who contacted the service are shown in Box 1. Mean age was 26.6 years (SD, 7.2 years), with a range of 13–49 years (Box 1). Women aged between 18 and 29 years accounted for more than half the records. A minority of women preferred one of 48 languages other than English, and 134 (4%) were recorded as using an interpreter. More than one in 10 women lived in rural or regional areas or interstate. Almost three-quarters were referred by general practitioners, and one in 10 were self-referred. Just over half were holders of health care cards, compared with 23% of the Australian population in the 2004–05 financial year,10 and about 2% identified themselves as Aboriginal or Torres Strait Islander, compared with an estimate of 0.6% of the Victorian population in 2006.11
Details of the current pregnancy were recorded for most women (Box 2). Most (2579/3257; 79%) contacted PAS within 2 weeks of discovering their pregnancy; a few (96/3257; 2.9%) did not make contact until at least 6 weeks later. Most pregnancies were in the first trimester, and fewer than 1% were over 18 weeks’ gestation. Later gestation at contact was significantly independently associated with younger age (P < 0.001), rural residence (P < 0.001), and having a health care card (P < 0.001).
Almost half the women already had at least one child. As previous pregnancy was recorded for only half the women, and it is not PAS practice to ask routinely about contraception, data about the following items are not representative of all clients: more than a third of those who had a record of a previous pregnancy had undergone a previous abortion, and 434 reported using contraception at the time of the current conception, including condoms, an intrauterine device, or implanted, injected or oral contraceptives. Most men who were the biological partner in the pregnancy were described as aware and supportive of the woman’s decision to consider or seek abortion.
Items relating to violence were recorded in 16% of all records. Mental health problems were recorded in almost one in 10. Almost one in five of all women were noted as experiencing difficulties in gaining access to pregnancy support services, which included financial or health problems, geographical isolation, lack of transport or child care, being at school, safety fears, alcohol or drug problems, or language or interpreter concerns. Housing difficulties related to unstable or unsafe accommodation, homelessness, being institutionalised or in transitional accommodation. A variety of other special needs were recorded, including medical, drug or alcohol problems and intellectual or physical disability.
The database permitted only one reason to be selected for seeking an abortion; this information was recorded for most women (Box 3). Several of the most commonly selected fixed-choice responses (“does not want children now”, “too young”, “not the right time”, and “has young baby”) were interpreted as “wrong time”, which constitute the largest single category (54%). Almost a fifth of the women had completed their families; financial, relationship or medical reasons together accounted for 19% of cases, and rape for 1%.
This study is the first of its kind to report on the social and personal circumstances of all clients of a large public pregnancy advisory service in contemporary Australia, using a method that did not disrupt service provision. Because the consultation was the primary focus of data recording, complete information was not recorded for all clients, although all but three of the items reported here were recorded for more than 80% of women. The findings are not representative of all Victorian women who contact pregnancy advisory services but, interpreted with caution, the details reported here add substantially to information available on the public record.
A striking finding was the large number of calls taken by PAS. As found in published routinely collected data,12,13 women aged in their 20s made up the largest group, although there were small proportions at both extremes of the reproductive age range. Most women presented in the first trimester of pregnancy, many already had children, many described partners who supported them in their decision to have an abortion, and some reported becoming pregnant while using apparently reliable forms of contraception. PAS provides services to disadvantaged women and those with inadequate access to local services, including in rural locations.14 It is of concern that younger, socioeconomically disadvantaged women living outside Melbourne make contact with PAS significantly later in their pregnancy than other women, and therefore have inequitable access to abortions performed at lower-risk, early gestational age.15,16
Although the nature of our data limits direct comparison, the finding that almost two thirds of women, where this was recorded, had not previously had an abortion, and that nearly half were mothers, is consistent with findings from a survey of private clinics in NSW.9 In the absence of a coordinated pathway of pregnancy referral, GPs are often the first point of contact for women with unplanned pregnancy in Victoria, and provide a large proportion of referrals to PAS.
The finding that almost one in six of all women who contacted PAS disclosed experience of violence confirms recent Australian evidence that violence is commonly implicated in the lives of women who have unplanned pregnancies and abortions,17,18 and is more prevalent than among women in the general community.19 Initiatives to prevent unplanned pregnancy and services to provide support when it occurs need to be responsive to this.
This audit of electronic records of women who contacted PAS suggests that reliable and comprehensive information can be collected during a consultation without compromising care, informs the educational component of counselling and support provided to women by PAS staff, and suggests the fields that could readily be included in a minimum dataset. Refinement of the PAS database to identify obligatory fields and improve reporting of reasons for considering abortion would enhance data quality and value.
Recently, the Victorian Law Reform Bill was passed in the Victorian Parliament. The Abortion Law Reform Act 2008 (Vic)20 confirms the lawfulness of abortion in Victoria, and provides opportunities for progressing the NHMRC recommendations.1 We recommend routine use of a database such as that used by PAS by all pregnancy advisory services, not to monitor women and service provision, but to provide evidence for prevention activities and best-practice care for the many Australian women who face unplanned pregnancy and abortion.
1 Demographic characteristics of women who contacted the Pregnancy Advisory Service (n = 3827)
* (n, %) represent the total number of records that included data on the specific characteristic and the percentage of all records. |
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2 Circumstances of pregnancy and special needs of women who contacted the Pregnancy Advisory Service (n = 3827)
3 Primary reason for considering abortion (n = 3018)*
- Heather J Rowe1
- Maggie Kirkman1
- E Annarella Hardiman2
- Shelley Mallett1
- Doreen A Rosenthal1
- 1 Key Centre for Women’s Health in Society, University of Melbourne, Melbourne, VIC.
- 2 Pregnancy Advisory Service, Royal Women’s Hospital, Melbourne, VIC.
The project was supported by an Australian Research Council (ARC) linkage grant, LP0667968, and is a collaboration between the Key Centre for Women’s Health in Society, University of Melbourne, the Royal Women’s Hospital, Melbourne, and VicHealth. We thank staff of the Pregnancy Advisory Service for their invaluable assistance.
The Royal Women’s Hospital is a member of the ARC linkage collaboration, and one of the investigators (Annarella Hardiman) is the Manager of the Pregnancy Advisory Service. Her role included liaising between the service and investigators at the Key Centre for Women’s Health in Society to ensure integrity of audit data. The ARC had no role in data collection, analysis and interpretation, or writing and publication of this article. Staff at the Royal Women’s Hospital read the manuscript before submission but did not influence the submitted manuscript.
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Abstract
Objective: To characterise the demographic and psychosocial circumstances of women contacting Victoria’s largest public pregnancy advisory service (PAS).
Design and setting: Audit of PAS electronic records for the 12 months from 1 October 2006 to 30 September 2007. De-identified data were extracted from a comprehensive electronic database used for recording consultations.
Main outcome measures: Summary statistics and measures of association.
Results: During the 12 months, 5462 women contacted PAS; records were created for 3827 women, and data were available in more than 80% of records for 77% (13/17) of items. Over half of the women receiving pregnancy support from PAS (60%) were 18–29 years old; 12% lived outside the metropolitan area; 51% held a health care card, and smaller percentages faced housing, financial, or drug and alcohol problems; 16% reported violence, but 71% described partners as involved and supportive. Most (79%) made contact within 2 weeks of discovering pregnancy, and 72% were referred by a general practitioner. Later gestation at contact was associated with younger age (P < 0.001), having a health care card (P < 0.001), and living outside the metropolitan area (P < 0.001). The most common reasons for seeking abortion were the desire to delay pregnancy (23%) and family completion (18%); 42% already had at least one child. Twenty-three women reported that the pregnancy was the result of rape. Ten per cent had mental health problems, and smaller numbers faced access barriers and had special needs.
Conclusions: This PAS responds to demand from women with diverse social and personal circumstances. Findings provide evidence for policy, prevention and service development.