Since August 2012, general practitioners (GPs) and obstetricians and gynaecologists (O&Gs) have been able to prescribe medical abortion drugs to patients through their practice, after the medication was listed by the Therapeutic Goods Administration (TGA). The medication, marketed in Australia as MS 2-Step, 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), GPs can now provide effective help to women when they are faced with an unplanned pregnancy. The inclusion of MTOP to the mantle of care a GP can provide will extend the holistic service they can offer to women through their practice. Patient supporter is offered by the after hours care 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.
- Identify a pharmacist willing to stock and dispense the medication. A GPs prescriptions for MS 2-Step must all be dispensed by this affiliated pharmacist, and pharmacists must register with MS Health before they can dispense. MS Health are able to assist with this.
- 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.
Medication 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 since the 1980s. Studies from Australia and around the world show a high level of patient satisfaction and acceptability of early medication abortion using mifepristone in combination with a prostaglandin. A large Australian observational study of over 11000 women who underwent early medication abortion using mifepristone found that almost 80% would use it again, and over 90% would recommend it to a friend . Internationally, studies have also shown high rates of satisfaction with medication abortion. Studies in Scotland, the US, Sweden, Norway and Finland also found a large majority of women who chose medication abortion found it acceptable .
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.
Closed group for registered MTOP GP providers: https://www.facebook.com/groups/mtopdocsdu/
Enlisting a pharmacy
If there is not already a registered pharmacy in you area which stocks and dispenses MS 2-Step you will need to enlist one, as GP MTOP providers need to be affiliated with a specific dispensing pharmacy. You can access information about registered pharmacies through the MS 2-Step site once you are a certified prescriber. The pharmacy will also need to be registered with MS Health before it can stock and dispense MS 2-Step. This is a simple administrative step for the pharmacy. The wholesaler for MS 2-Step is Symbion Pharmacy Services.
Some GP providers have found it helpful to establish a timely process for requesting investigations when the woman calls to book for an MTOP. Your reception and nursing staff may play a key role in supporting this process. To ensure timely provision of MTOP to your patients some GPs have enlisted the support of local medical imaging groups. The referral for USS should be identified as a dating scan. Some practitioners have established further notation on the referral form to allow the sonographer to know when the dating scan is for the purposes of a MTOP. This supports the sonographer to provide a service sensitive to the woman, for example, asking whether or not the woman would like to see the image and if she would like the sound turned on or off, and can help reduce the time between GP 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 her 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 might be appropriate to advise the Director of Emergency Department but 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 you 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 MSHealth that your patients can access their 24 hour after care number that is staffed by nurses (1300 515 883).
Our Children by Choice counselling line, staffed Monday to Friday 9am to 5pm can also offer Queensland women post abortion counselling if necessary. Copies of our small post-abortion brochure with information and contact details can be sent to your practice free of charge.
Work flow models
Below are two of many models for incorporating MTOP into the flow of your general practice.
Nurse Practitioner supported model
- Women 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.
- 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 MSHealth after care phone number, and initial discussions about future contraception. Some practitioners establish processes that require the woman return to them for the swallowing of the mifepristone through their arrangements with the pharmacy. One option is to keep a stock of MS2Step in the surgery and have the women 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 to confirm MTOP has been successful, and attend to future contraception issues. This consult is often bulk billed.
GP driven model
- Women 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 with ED referral letter and MSHealth after care number.
- Third appointment 3 to 4 days after the misoprostol has been taken to check on the progress of the process and respond to any presenting symptoms (e.g. early signs of infection, heaviness of bleed etc)
- Follow up appointment in 10 days to confirm MTOP has been successful and attend to future contraception issues.
Post-procedure follow up
Ensuring women return for a follow-up appointment after the MTOP process is a common teething issue for providers. Offering bulk-billed 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 back to their usual GP for follow up if they have travelled some distance to see you for the service.
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 at the same time giving consideration to bulk billing or discounting woman on Health Care or Pension Cards. Practitioners report that bulk billing the follow up appointments encourages more women to return. Overall, out-of-pocket cost to the client generally ranges from $200-$300.
Children by Choice is often contacted by women in financial distress, seeking assistance with the costs of a pregnancy termination. For women 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
Some providers decide to only offer the service to their current patients, or to only advertise of its availability on their own website or to not advertise at all. We can add your referral details to our internal database, which is accessed only by our staff only for assisting women who contact us. We can also add your details to our website, alongside the details of other current providers who have consented to this - however, this is entirely at your discretion. There is no publicly available national or state register of doctors licenced to prescribe this medication.
Support for women’s decision making
As the only pro-choice Queensland service that specialises in supporting women around unplanned pregnancy we 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 calling your practice to enquire about MTOP can require sensitivity, and can be distressing for both the woman 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 around unplanned pregnancy for you and your staff.
1. 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 Australia Vol.197 No. 5: 282-286.