Last year, abortion provider Dr. Simon Snook launched a telemedicine service 0800-ABORTION, aimed at easing the referral path for women seeking abortions in New Zealand. Alison McCulloch of ALRANZ spoke with Dr. Snook about setting up the service, and how it’s been going since the launch last August.
Q. When did you start thinking about setting up 0800 ABORTION?
A. It’s been an idea for the past few years really because it’s an idea that formed out of an ongoing discussion with patients as you realise the potential failings of the current system. Women were finding it difficult to access abortion services, so you start to formulate ways that you might overcome that. So the idea’s sort of grown. But in terms of sitting down and really putting together how that might be done, it was probably six months or so prior to when we first launched the pilot in August of last year. So beginning of 2015 we really got active thinking about it.
Q. What obstacles did you have to overcome in setting it up?
A. We needed to make sure that what we were planning to do was both legal within the CSA Act and also correct within Medical Council guidelines for telehealth. That’s an area that’s expanding, and the Medical Council guidelines are quite strict on what you can and can’t do without having a patient directly in front of you. So there was quite a bit of research that went into that and discussion. We met with the Abortion Supervisory Committee on a couple of occasions to make sure that they were aware of what we were planning and that they were comfortable that it was within the Act. So that was one side of things. Another side was purely logistical and technical in terms of how we were going to conduct note taking, referral, getting swabs and ultrasounds done. Covering the whole country, there’s quite a lot of background you have to do to know where to refer people for ultrasounds wherever they might be, for example. So there’s quite a bit of background in that process stuff. And the third arm really was to make sure that the people that we had to talk on the phone would be skilled enough and know what they were talking about to give out the best quality advice and information. So those were the three arms of the obstacles we had to overcome.
Q. Can you explain how it works to someone who doesn’t know anything about the system in New Zealand or your service?
A. The system in New Zealand through the CSA Act and also the way abortion providers are set up is that for a woman to access an abortion provider, she needs to obtain a referral from a medical practitioner, and in the meaning of the Act it is generally that a woman will go to see a GP or if they opt not to go to their own GP they’ll go to another provider – a different GP or a Family Planning doctor, or something along those lines – to get that referral. We were aware that some women found that there were barriers in that, both through personal stories of people who went to see a practitioner who maybe wasn’t supportive or just had general issues in accessing a practitioner in a timely manner, or of course sometimes costs associated with that. We were also aware of research that showed that half of the delays in a woman accessing abortion services in New Zealand were between the point of wanting to access to them and the point of getting referred to them. So we knew that there was a barrier at that stage. So essentially what we wanted to do was to set up a free telephone based service that could take a woman from the point of where she wanted to access an abortion provider to being referred without unnecessary delays, without any cost to her and whilst keeping the quality of the information she was given and the quality of the referral very high, and hopefully higher than she would have got from a GP who might not necessarily deal with abortion as frequently. So it’s about improving quality and approving timeliness and making it more accessible to the patient.
Q. How does it fit in with the requirements under the Crimes Act with respect to the certifying consultants?
A. There are two aspects. The woman needs to be referred and that referral needs to happen from a New Zealand practitioner. What we also offer is the woman can have her first certification, so we have a certifying consultant who also talks to her. It is all within the Crimes Act, the CSA Act, that the referral and the certification should be with separate practitioners which we organise and it is acceptable for the certification to be performed by telephone as is the referral. So it’s all within not only the Crimes Act and the CSA Act, but it’s also consistent with the Medical Council guidelines on telehealth as well.
Q. Does she need to see any certifying consultant face to face?
A. Generally what will happen is that when she goes to the abortion provider, she will then see a second certifying consultant, as all women are required to see two certifying consultants, and that second certifying consultant will be a face to face certification. So we’ll provide a telephone one and the abortion provider will provide the second certification.
Q. So depending on what the particular provider requires in terms of counseling etc. she could theoretically have just one visit to the provider?
A. Yes. Again, once our referral is made what happens to her in the process is then out of our hands and comes down to the individual provider. You are probably aware that it is a requirement that all women accessing abortion care are offered counselling but not that they have to have it, although some abortion providers do have compulsory counselling. Obviously that’s something that’s their own process and reasons for that. But yes technically if a woman accesses our service, she’ll have a consultation with one of our nurses who will give her the information she needs, do a history and she will also have her referral and certifying consultant telephone consultation. We will organise for her to have relevant blood swab tests and ultrasound scans and, again, as required by the provider that we’re sending her to. And then her first face to face consultation with an abortion provider in New Zealand could be for the abortion itself. Although as I said, that’s dependent on the provider.
Q. I understand that when you first launched the service, then it was put on hold for a while. Why was that and is it up and running now fully?
A. Yes it’s fully up and running now. Intentionally we ran a pilot phase of the project, predominantly to see how our processes were going to work. We ran that for four months and there were a few issues with regards to referrals and what different providers wanted from us so we then took the service back down to enable us to sort through those and then got back up and fully running. We’re now fully running. We’ve been going now since I think the beginning of November.
Q. What kind of response are you getting in terms of women accessing your service?
A. We’re getting a good response. It’s been busy. The biggest thing we’ve noticed is the stories that we are hearing from different women showing that the majority of women who are calling our service are doing so because of considerable issues for them with accessing referral through the conventional methods. Now whether they’re perceived issues or real issues is different in different cases, but what’s apparent is we appear to be filling an unmet need for a certain group of women. Obviously for those women who find the conventional method of GP or Family Planning referral are continuing with that and are having no problems. And we’re sort of picking up those other cases. There’s lots of individual stories whether they be issues with practitioners who have been obstructive or just personal issues for them in accessing a referral in a safe or confidential manner or indeed just the logistics of getting to appointments for people who live very rurally. So there are lots of individual stories but all of them show that these would have been women who would have found it very very difficult to access a service without us there. So it’s been really really reassuring and warming that what we’ve put together has actually had that benefit.
Q. Can you talk about what kind of numbers might be calling you?
A. In January, I think we had 62 individual women calling our service and we had 10 women who went ahead with a referral. So a lot of people do call our service and are using it for information or it’s helping them go to the next level where they want to decide things. So we’re filling an information gap as well as a referral service which maybe is not what we expected to be doing as much of, but that’s what seems to be happening at the moment. That was a quiet month for referring. We’re probably referring between 10 and 35 women a month across New Zealand to abortion services.
Q. And how are you funded?
A. We’re funded by the certification fees. You’re probably aware that when a doctor certifies a woman under the Act, that doctor receives a payment from the Ministry of Justice for that work. So what will happen is the doctors who do the certification for our service will then fund the service through the fee that they’re receiving for their certification work. So it’s self funded by the doctors.
Q. What kind of pushback have you had from anti-abortionists?
A. When we first launched there was quite a lot of publicity around it, we made the front page of The New Zealand Herald, which certainly brought people from both sides of the fence out. We had some extremely positive individual comments from people with their own stories emailing us and equally some individuals who were against what we were doing contacting us directly to tell us so. But on a more organised level, there was a complaint from Right to Life New Zealand to the Medical Council saying that what we were doing was unlawful and unethical. So there was an investigation with that. The Medical Council found the complaint was not upheld and we were therefore supported to continue with the service.
Q. So there’s been no other official or legal efforts against you?
A. No, and it would be very hard to see how there would be because essentially we’re referring women for an abortion within the legal constraints that we have in New Zealand so we’re following all the legal requirements that we’re meant to do as we would do if we were seeing the woman face to face. Essentially the only difference from what we’re doing and what’s been done for the last nearly 40 years is that we’re doing it over a telephone rather than face to face. And on top of that we believe we’re doing it with greater knowledge and skills because people working for us are very up to speed on abortion practice in New Zealand.
Q. Do you have any comment as a provider about the situation with respect to abortion services and the law in New Zealand?
A. With regard to abortion services in New Zealand, I think there is still a great geographical variability across the country, which means that the service that a woman will get can be extremely variable – what she has on offer, even what a woman can have free or funded, varies greatly across the country. And this has become more and more apparent through the work we’re doing as we see in the referrals from different areas. I feel very uncomfortable about that, and there are big areas of the country with no abortion provision and other areas where the provision is scant or there are big bits missing from it. So my comment would be that a lot of work needs to be done across New Zealand to standardize quality of care and the access to care as best as possible.
Simon Snook, MBChB MRCGPdist FRNZCGP DRCOG DFFP, is an abortion provider and certifying consultant for Wairarapa DHB and Tairawhiti DHB. He is the medical director of SNIP Vasectomy Clinic, which has 12 locations across the country, and a director of Istar, the company that imports the abortion medication mifepristone into New Zealand. As well as 0800-ABORTION, he set up and runs 0800-MEDTOP, a helpline for women going through medication abortion, which was established six years ago. Dr. Snook was also part of the team that launched a new website Abortion Services in New Zealand.
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