For Professionals
Becoming a Medical Abortion Provider
General Practitioners (GPs) and Obstetricians and Gynaecologists (O&Gs) are able to prescribe medical abortion medications to patients through their practice, which are listed by the Therapeutic Goods Administration (TGA) and marketed in Australia as MS-2 Step. It is also listed on the Pharmaceutical Benefits Scheme, and is available for use to end pregnancies less than nine weeks gestation.
By providing medical termination of pregnancy (MTOP) GP’s can offer their patients a safe and effective method to end a pregnancy under 9 weeks gestation. Patient support is offered by the 24-hour telephone aftercare service provided by MS Health, the distributor licensed by the TGA. In the rare event of complications, patients can present to the nearest hospital emergency department as they would if seeking treatment for spontaneous miscarriage and its complications.
GPs and O&Gs can become licensed prescribers by:
- Having suitable insurance. Check with your provider for details. Most insurance providers don’t require any additional level of cover over basic GP coverage for provision of MTOP services.
- Identify a pharmacist willing to stock and dispense the medication. Prescriptions for MS-2 Step must be dispensed by a pharmacist who has registered and completed training with MS Health.
- O&Gs will need to have current registration and be enrolled as a prescriber with MS Health.
- GPs will additionally need to complete free online training with MS Health to become certified prescribers.
More detailed information is available on the MS Health website.
Medical practitioners can register to prescribe by going to the MS-2 Step website.
MS-2 Step comprises two medications: mifepristone is a medication that blocks the effects of progesterone, which is needed to sustain a pregnancy; and misoprostol, which causes cervical softening and uterine contraction to evacuate the products of conception from the uterus. When used together in early pregnancy (up to 63 days LMP) they are a safe and effective pregnancy termination method.
Mifepristone has been used worldwide by millions of women and pregnant people since the 1980s. Studies from Australia and around the world show a high level of patient satisfaction and acceptability of early medical abortion using mifepristone in combination with a prostaglandin. A large Australian observational study of over 11000 women who underwent early medical abortion using mifepristone found that almost 80% would use it again, and over 90% would recommend it to a friend [1]. Internationally, studies have also shown high rates of satisfaction with medical abortion. Studies in Scotland, the US, Sweden, Norway and Finland also found a large majority of women who chose medical abortion found it acceptable [2].
Establishing A Medical Abortion Service
If you are already certified or about to become certified as a prescriber of MS-2 Step but are uncertain of how to incorporate medical abortion provision into your practice, you may find the following information useful. It has been compiled with the assistance of GPs already providing MTOP through their practice, as a guide for other providers. Some of these GPs are happy to talk to new or potential GP MTOP providers to offer guidance, information and support, so if you would find a discussion on the topic with such a colleague useful, or if you have any further questions about providing medical abortion you can link in with other providers via a private Facebook group. Use the link below to request membership. The Moderator will send a Facebook message and if a copy of your training certificate can be provided, the request will be approved.
Join AusCAPPS – an NHMRC funded online network developed in partnership with the RACGP, RANZCOG, APNA, the PSA, and other key stakeholders to support GPs, practice nurses and community pharmacists in providing contraception and abortion care: https://medcast.com.au/communities/auscapps
Closed group for registered MTOP GP providers: https://www.facebook.com/groups/mtopdocsdu/
Investigations
The most basic investigation required to be able to provide a MTOP is an USS to confirm that there is an intrauterine pregnancy and to determine dates of that pregnancy. Some providers will also prefer to have basic blood work and STI screen completed prior, while many will do screening as required at the time of MTOP provision. Your model of practice will determine who requests these investigations (e.g. yourself at an initial appointment, or another doctor if you see the patient for the first time at TOP provision). Regardless, having a clear process for your reception and/or nursing staff to follow will ensure timely access.
The USS is to be requested as a dating scan. Some providers will annotate on the form “no screen no sound” so that a sensitive service is provided. Depending on your area of practice you may or may not choose to annotate that the USS is for MTOP provision. Some GPs have preferred local providers to whom they regularly refer as they have an established relationship and are supportive of providing the service.
Timely Appointments
Some GP providers block out a set number of priority appointments each day or across a week to ensure MTOP patients can be booked in quickly for their consultations. The busyness of your practice and the level of demand for MTOP may be key drivers in whether your practice needs to make these arrangements.
Post Provision Patient Support
Local Public Hospital Emergency Department (ED)
In the rare event of a patient requiring presentation to the ED after their MTOP, any hospital should be able to respond to issues of vaginal bleeding or pain management (as per the Queensland Health clinical guideline on early pregnancy loss); some GPs have chosen at their discretion to inform the local hospital they intend to start providing an MTOP service, particularly in smaller communities. For large hospitals it may be appropriate to advise the Director of Emergency Department, however for smaller hospitals the Chief/Senior Medical Officer may be a more suitable contact.
Template ED Letter
Good practice is to ensure that your patient has a letter of referral to take with them to the emergency department should they develop adverse symptoms. We can assist you to develop a template referral letter for your patients. Many providers do choose to advise their patients it is not required to show the letter at the hospital, should they develop symptoms. Patients have identified many reasons for not choosing to disclose their abortion, including but not limited to concerns regarding being judged by staff at the hospital or if their social situation leaves them at risk of violence in the home. As medical abortion is not medically any different to experiencing an early miscarriage in terms of management this decision is at the patient’s discretion.
MSHEALTH 24 Hour Care Line
You will have been advised by MS Health that your patients can access their 24–hour aftercare number that is staffed by nurses (1300 515 883).
Post-Abortion Counselling
Our Children by Choice counselling line, staffed Monday to Friday, offers Queensland women and people who have been pregnant post abortion counselling if necessary.
Work Flow Models
Nurse Practitioner Supported Model
- Women and pregnant people booking in with the GP undergo an intake over the phone with the nurse or trained receptionist. The nurse/receptionist liaises with the GP to organise referrals for investigations or notifies the patient of the required investigations to seek prior to the main appointment (e.g. from their regular or local GP).
- Initial consultation, of about 45 minutes to one hour duration, includes a review of investigations, information about the process, signing of the consent form, prescribing MS-2 Step, provision of ED referral letter, provision of MS Health after care phone number, and initial discussions about future contraception. Some practitioners establish processes that require the pregnant person to return to them for the swallowing of the mifepristone through their arrangements with the pharmacy. One option is to keep a stock of MS-2 Step in the surgery and have pregnant person go to the pharmacy to make payment, receipted through the provision of a pharmacy label. Other GPs arrange for the pharmacist who dispenses the medication to observe the patient taking the mifepristone with them in the pharmacy.
- Follow up appointment 2-3 weeks later (consider telehealth) to confirm MTOP has been successful and attend to future contraception issues. This consult is often bulk billed.
GP Driven Model
- Women and pregnant people book for an initial full consultation with nurse/receptionist.
- First consultation includes pregnancy options counselling, information about the MTOP process and referral for investigations.
- Second consultation includes review of investigations, signing the consent form, prescribing MS-2 Step, and providing women and pregnant people with ED referral letter and MS Health aftercare number.
- Follow up appointment in 2-3 weeks to confirm MTOP has been successful and attend to future contraception issues.
Post- Procedure Follow UP
Ensuring women and pregnant people have a follow-up appointment after the MTOP process is a common teething issue for providers. Offering bulk-billed or telehealth follow-up appointments is one strategy to increase attendance for follow-up. Some providers rely on nurse-driven phone follow up, and in some cases offer a pregnancy test to take away at the time of providing the MS-2 Step prescription. In some situations it may be appropriate to consider a letter referring women and pregnant people back to their usual GP for follow up if they have travelled some distance to see you for the service. There are many ways to structure follow up and there are many GPs happy to share their process so you can work out what you are comfortable with and also what is best for your patients.
Other Considerations
Billing
With no set Medicare Item number for an MTOP, many GPs rely on a combination of standard long and short consultations, sometimes in combination with item 4001 (GP-provided pregnancy support counselling). GPs usually need to charge an out-of-pocket fee over and above the Medicare rebate to make the service viable, while also giving consideration to bulk billing or discounting women and pregnant people on Health Care or Pension Cards. Practitioners report that bulk billing the follow up appointments encourages more women and pregnant people to return. Overall, out-of-pocket cost to the client generally ranges from $200-$300.
From 1 July 2021 there are new item numbers available for GPs and other medical practitioners providing reproductive health services via telehealth that are exempt from the current rules around having an existing clinical relationship. This fact sheet from the Australian Government Department of Health provides further details. Please always check the latest updates regarding billing numbers and eligibility.
Children by Choice is often contacted by women and pregnant people in financial distress, seeking assistance with the costs of a pregnancy termination. For women and pregnant people satisfying our eligibility criteria, we may be able to offer a small No Interest Loan. We have a financial “pledging” system set up with several private MTOP providers, whereby we pledge this loan amount (a proportion of the total cost) directly to the GP/practice. This is an easy procedure to establish. If you would like further information, please contact us.
Advertising Your Service
To register your services on the Abortion & Contraception Services Map, click here.
New providers can join the map and choose to list on the publicly available version or on the private version. If listed privately, provider information is only made available to clients who call the Children by Choice information line where appropriate. This new tool provides clear pathway information to health consumers and supports healthcare workers to confidently refer clients to appropriate services – abortion and contraception providers, pharmacists and sonographers across the state.
Support For Pregnancy Decision Making
Our service is the only pro-choice service in Queensland which specialises in supporting women and pregnant people around pregnancy decision making – we can offer decision making counselling, and pre-abortion counselling for your patients.
Support For Your Staff
The experience of other GP providers suggests that the initial contact with a woman or pregnant person calling your practice to enquire about MTOP can require sensitivity and can be distressing for both the pregnant person and staff member. An intake sheet designed to support the staff member along with a quiet and private space to take the call can be important supports in the early days of establishing this service in a GP context. Children by Choice can provide professional training to support you and your staff.
References
- Goldstone P, Michelson, J & Williamson, E (2012) “Early medical abortion using low-dose mifepristone followed by buccal misoprostol: a large Australian observational study”Medical Journal of AustraliaVol.197 No. 5: 282-286.
- Berer, M (2005) “Medical Abortion: Issues of Choice and Acceptability”Reproductive Health Matters 13 (26); 25-34.
