Extract from ABC News
Melissa received a call on the day she was booked in for an abortion at Queanbeyan hospital, to inform her the termination could no longer go ahead. (ABC News: Emma Machan)
A mother of two is browsing the racks of kids' clothing to pass time before her scheduled surgery, when she receives the call that almost breaks her.
"I'm really sorry, but we can't do the procedure today," an apologetic voice tells her.
Her lips tremble as she puts a hand to her mouth, struggling to take in the information. She hangs up the phone and stops still, frozen in shock.
Melissa (not her real name) had just joined the silent cohort of Australians whose lives have been up-ended by what doctors are calling an "unspoken ban" on abortion.
Decriminalisation was meant to give women access to safe, affordable abortions. But five years on, an ABC investigation has uncovered systemic failures and examples of obstruction that have denied women access to legal reproductive healthcare across rural, regional and remote Australia.
Warning: This story includes details about abortion, miscarriage and stillbirth.
New South Wales is lagging far behind other jurisdictions, with doctors calling on the state government to issue a clear directive to every public hospital.
Only two public hospitals in the state offer formal termination services — the Royal Hospital for Women in Sydney, and John Hunter in Newcastle. Terminations in other hospitals remain non-existent, ad-hoc or provided at individual doctors' own discretion.
The ABC has been told how patients are being denied equitable access due to ideological position, unclear guidelines, chronic staff shortages, overstretched resources and lack of government funding.
Despite multiple government inquiries into reproductive health, clinicians say reports and recommendations have come to nothing.
What happened to Melissa is just one example of how the system is failing.
Abortion is legal in Australia, but women are being turned away
Abortion is legal in every state and territory. It is typically performed one of two ways, depending on the circumstances of the pregnancy and the relevant state laws.
Broadly speaking, medical terminations can be prescribed up to nine weeks of pregnancy, through administering the abortion pills mifepristone and misoprostol, also known as MS-2 Step.
Surgical terminations are generally available further into the pregnancy and are administered through a procedure known as a dilation and curettage (D&C), where the pregnancy is removed from the uterus, under anaesthetic.
This is the same procedure routinely performed to treat miscarriages and is carried out in public and private hospitals right across the country.
Melissa was booked in for a surgical termination at 14 weeks after a scan by sonologist Meiri Robertson showed her baby had severe life-limiting malformations and was unlikely to survive.
Dr Robertson referred her to Queanbeyan District Hospital, a regional service outside Canberra, having transferred patients with malformations there before.
But on the morning Melissa made the two-hour journey from her home on the south coast of NSW, the obstetrician due to perform the procedure called and broke the news that her termination had been cancelled.
"I could tell he was baffled by the whole situation," Melissa told the ABC.
"He didn't understand why … It should have been straightforward. He'd done it before."
She and her husband waited for more instruction, but by the afternoon, they found themselves driving home feeling dumbfounded, confused and dismayed.
On the way home, Melissa received a call from the hospital, telling her there'd been a "misunderstanding", and that staff had thought she was 20 weeks pregnant, not 14.
Terminations at later gestations can require sophisticated equipment and resources, which not all hospitals have.
When Melissa clarified she was only 14 weeks, there was some suggestion the termination could proceed.
"But that sort of led to nothing," she said.
Hospital stopped providing surgical abortions
The ABC can reveal that after Melissa's experience, the provision of surgical terminations for fetal anomalies and medical reasons at Queanbeyan District Hospital ceased abruptly.
When she heard about that, Canberra-based GP and long-time reproductive rights advocate Jess Tidemann was horrified.
"It's an unspoken ban," she said.
"I think a decision for public health services or districts not to offer surgical abortion services is an unspoken ban."
Jessica Tidemann is a Canberra-based GP and longtime advocate for reproductive health care. (ABC News: Toby Hunt)
Queanbeyan Hospital is managed by the Southern NSW Local Health District (LHD), which oversees rural and regional health services across the state's south coast, southern tablelands, Great Dividing Range and Snowy Mountains.
In a statement to the ABC, the Southern NSW LHD said it supports women's access to "safe, high quality abortion services including access to medical terminations".
It did not respond to direct questions about Melissa's case, or about why Queanbeyan hospital had stopped providing surgical terminations.
Melissa's health care team are still seeking answers from the LHD.
Dr Robertson, the sonologist, wrote to the LHD's executive management the day after Melissa was turned away, requesting a formal apology on behalf of her patient.
Two and a half months later, she has not had a reply.
Her Moruya-based GP, Lisa Hyde, asked the LHD to provide clear guidelines for terminations on medical grounds, to avoid a repeat of what happened to Melissa.
Moruya-based GP Lisa Hyde is concerned about access to abortion care in regional Australia, and has found herself asking whether there is "an agenda" at play. (ABC News: Adam Kennedy)
Her emails to the executive have also gone unanswered.
At first, Dr Hyde thought Melissa's case must have been the result of a bureaucratic bungle.
"I got a strong sense of inefficiency and incompetence, but not necessarily malevolence," she told the ABC.
But after seeing how abortion rights have been used as a tool of political debate in recent months, she has found herself asking whether there are other, deeper influences in play.
In the United States, abortion has been characterised as a key election issue following the fall of Roe vs Wade in 2022.
That trend unexpectedly exploded onto the hustings of the recent Queensland state election campaign. Separately, a South Australian bill to curtail late-term abortion rights was narrowly defeated earlier this month.
For Dr Hyde, it's "scary" to watch.
She is concerned that Melissa's case has been shrouded in secrecy, with no feedback or communication from the LHD executive.
"At least in the [US] you know where people stand on these issues and people are open about it," she said.
"Here, it feels like you're shadow boxing, that there's a pushback and you're not really sure why, and that's very frustrating.
"I think it's worse than a ban, because you don't know what you're dealing with."
Conscientious objectors … or obstructors?
Other states and territories have made some progress providing greater access to terminations through their public health systems.
And last year, the Therapeutic Goods Administration reviewed its national guidelines to allow every GP and some nurse practitioners and midwives to prescribe MS-2 Step up to nine weeks. But access remains a "postcode lottery".
Dr Tidemann says stigma is still a massive barrier and abortion access still relies on a "small group" of health professionals, mainly doctors, who find themselves navigating complex pathways to provide the care.
"If there are people in positions of power who are uncomfortable with abortion services or don't believe they should be provided … they can obstruct the provision of services," she said.
Abortion laws make allowances for conscientious objectors – health professionals who decline to take part in terminations due to their beliefs, morals and values.
Doctors who spoke to the ABC believe conscientious objection is behind another case where a woman on the Mid-North Coast was refused abortion care.
Doctors say the woman saw her GP at nine weeks, seeking a medical termination, but he refused. (ABC News: Emma Machan)
They said she saw her GP prior to nine weeks, seeking a medical termination, but he refused and told her: "I won't do it. It has a heartbeat."
Doctors claimed the woman, who they described as having "poor health literacy", made "repeated requests" and was eventually referred to the ante-natal unit at the hospital where they work.
During that appointment, the woman again requested a termination. Only then was she supported to have one. But by that stage she was 22 weeks pregnant.
The lengthy delay meant a surgical abortion was no longer an option, and she was forced to labour and deliver a stillborn baby.
By law, conscientious objectors in NSW must swiftly declare their position to patients seeking terminations.
They're also required to provide contact information or advice on how to find another medical practitioner who does not object. Alternatively, they can refer or transfer the patient to that provider.
Vijay Roach, the former president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, was involved in the process to decriminalise abortion and said cases like this should be reported to the medical regulator.
Dr Roach believes conscientious objection is contributing to inequitable access right across the country, and he suspects it may also have been a factor in Melissa's abortion being cancelled.
"Why don't they provide this essential health service? I think it can only be due to people within the [public health] system who object to abortion," he said.
"While an individual practitioner retains the right to conscientious objection, the law is clear … There is no moral, legal or ethical right to impede access. Abortion is an integral part of women's health care."
'There's nothing social about an abortion'
Elsewhere in the state, there are concerns that conscientious objection is being wielded to shut down access to what some providers call "social terminations".
Abortion rights advocates have deep reservations about the phrase, which is used by some health professionals to refer to terminations other than those sought out due to medical complications such as unexpected maternal cancer, and malformations.
Patients seek abortions for all sorts of reasons — for many, going through with a pregnancy may present real and lasting harm. Some factors include poverty, domestic violence, existing carers' responsibilities, and trauma from rape or sexual assault. In many cases, it's simply not the right time to be a parent.
"The insinuation is that women are frivolously getting an abortion and then going out and having a chardonnay," Children by Choice CEO Jill McKay said.
"There's nothing social about an abortion. It undermines women's intelligence, integrity and complex decision-making to be described as something 'social'."
Independent MP Phil Donato, who represents Orange in the NSW Parliament, has heard from constituents that clinicians at the local public hospital have been told to stop providing "social terminations", even though there are several doctors willing to provide the care.
Mr Donato said he could not be clear on where the directive came from, but he has been led to believe it was from "high in the health bureaucracy", such as the hospital executive or the Western NSW LHD.
"There are safeguards [for] conscientious objection … but it shouldn't be up to a facility just to blanket not-permit social terminations," he said.
"I grew up a Christian and I follow Christian values as best I can. But in the end, who am I to tell a woman what to do with her body?"
In a statement, the Western NSW LHD said Orange Hospital currently provides medical abortion for women with complications or emergencies. Women who present with "no identified early pregnancy complications" can be referred on to GPs and Family Planning Australia.
The spokesperson said the LHD is currently reviewing abortion access across public health facilities in the region, "including service provision and referral pathways at Orange Hospital".
"Personal beliefs cannot impact women’s rights to access abortion services and, should individual clinicians conscientiously object, referral pathways are in place to ensure women can safely access care," the spokesperson said.
A starved health system
Conscientious objection is far from the only roadblock to equitable access. Some doctors are frustrated at how this topic dominates public conversations about abortion, and feel that other major barriers are being ignored.
From her rural town of Wagga Wagga, Trudi Beck divides her time between a public hospital and her private clinic. Unlike most providers, Dr Beck's clinic openly advertises terminations.
Wagga Wagga GP Trudi Beck started her own clinic to provide abortion care for patients unable to access services through the public system. (ABC News: Penny Burfitt)
She started her clinic – which is currently performing 10 to 15 terminations a week – because she was tired of the lack of abortion care available in the region.
"Historically, the public health system was designed to respond to emergencies. Terminations, I guess, have been viewed as an elective procedure, meaning they won't be prioritised as an area of service delivery," she said.
In Dr Beck's view, access will be compromised as long as public health services are forced to survive with skeleton staff, overburdened services and inadequate government funding.
"Someone has to pay for [public] abortion. And you're asking a system that is collapsing to do it. We can't even keep services open for women to birth in. So how can we be expected to have this conversation about abortion?" she said.
"There needs to be an understanding in the community that women's health services are in crisis."
Consecutive government inquiries have shown women's health services, such as abortion, are not being prioritised. But from what Dr Beck can see, those reports and recommendations have "faded away into nothing".
The most vulnerable people are missing out
Each week, Melissa's GP Dr Hyde travels south from Moruya to Katungal, where she sees women at an Aboriginal Health Service. They are undoubtedly her most vulnerable patients.
"There's one woman who I saw a few months ago, who would have been just over nine weeks pregnant. She was homeless, she had severe mental health issues. She didn't want to continue the pregnancy. She had other kids that were not in her care," Dr Hyde said.
Given the patient had missed the nine-week deadline to take MS-2 Step for a medical termination, the only option was surgical. The nearest public hospital that might provide that service was Wollongong or Sydney — hours away and too far to travel.
Dr Hyde contacted private clinics to try to negotiate care on compassionate grounds, closer to home — surgical terminations performed privately can cost hundreds of dollars, sometimes more.
But the process took too long and a few days later, when Dr Hyde was ready to present the options, her patient was gone.
"We lost her. I don't know where she is, whether she had that baby, I don't know. And that weighs heavily because you fail these women."
Even for women who have the time, money, and resources to access the care that they need, the reality of navigating the system is exhausting.
Weeks after she was turned away from Queanbeyan hospital, Melissa is still reeling from the experience.
"I felt like I'd been thrown out to the breeze," she said.
Melissa was able to access the care she needed — but not on her terms. (ABC News: Adam Kennedy)
In the end, Melissa was able to access MS-2 Step and have a medical termination under her local hospital's supervision, at 15 weeks. She had wanted to avoid that, having gone through significant complications after taking the medication for a miscarriage just months earlier.
Still, she counts herself lucky, having the support of her health practitioners and family.
"I'm talking to protect other people," she said.
"You're making a really hard choice that ultimately will affect you for the rest of your life … that's going to play in your mind forever.
"I'm a strong person, and I can get through this. For someone who is a little more vulnerable, it would have just been awful."
Providers warn abortion access could be taken away
Among the doctors who spoke to the ABC about current barriers to reproductive health care, there are genuine fears that abortion laws across Australia could unravel.
"I lived in the United States for a long time, and I'm just gobsmacked at where they are now," Dr Hyde said.
"It makes me fearful, because those same fault lines are in our society, and unfortunately, women's health becomes a political issue very quickly.
"If we don't lock away safe, secure, accessible terminations for women, that's something that could very quickly be taken away."
But she has recently sensed "momentum" building, with a growing cohort of doctors advocating quietly and publicly for the rights of their patients.
Dr Beck put it bluntly.
"The reality is, nothing will change until there's a directive from the state government or NSW Health to make formal termination services available in every public hospital across the state," she said.
NSW Health Minister Ryan Park did not respond directly to questions on whether he was considering that approach. In a statement, he told the ABC:
"Affordable and timely access to abortion services is a whole of sector responsibility … In most cases, medical or surgical abortions can be provided in the community or non-admitted settings."
The minister said "service provision" of abortion was "determined by local health districts based on local need and service capacity".
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