The first woman to take RU486 to terminate a pregnancy in Australia was 43 years old, a divorced single mother from Cairns. She had just discovered she was six weeks pregnant. It was an unplanned pregnancy.
Cairns obstetrician Professor Caroline de Costa calls her ‘Joanne’ in her book, RU486: The Abortion Pill (2007). Joanne was about to make history, opening the door for thousands of other Australian women to gain access to a medical abortion, an option already available to many other women around the world for decades. It was 2006.
The doctors were nervous. In fact, Joanne did not know that she was the first woman in Australia to be prescribed the drug for an abortion.
‘We said, “we know this is a very safe drug and we are prescribing it for you,” but we were very anxious,’ explains Caroline de Costa.
‘Mike [Dr Mike Carrette) unwrapped the package of mifepristone and as we both watched, Joanne took a sip of water and swallowed it down.
‘We gave her our mobile phone numbers and sat staring at the mobile phones waiting for them to ring – and here if it doesn’t work it’s catastrophic. But in about three hours she rang and said, “It’s fine. It’s all over and I am so happy.”
‘We knew it was safe. But we had Tony Abbott breathing down our necks. And we just knew if someone ended up with a severe haemorrhage in hospital … well, we didn’t want anything like that to happen. And it didn’t happen because it was a safe drug.’
Not everyone agreed. Critics, including feminist Renate Klein, who describes herself as pro-choice but anti-RU486, described it as ‘a chemical cocktail’.
RU486 was originally developed in the French laboratories of the company Roussel Uclaf in the 1980s. It is a synthetic steroid. It works by blocking the effects of progesterone, the hormone which is required to maintain the lining of the uterus during pregnancy. By removing that progesterone, the lining of the womb breaks down, ending the pregnancy.
It would take another six years for the drug to be listed on the Pharmaceutical Benefits Scheme and for headlines to predict: $12 abortion pill. That price point never arrived.
But Joanne’s choice that day in Cairns set in train a policy experiment that would also see demand for surgical abortions dramatically decline in Australia. It’s a development that continues to pose challenges for policymakers in states where abortion is largely privatised and the only private providers have shut up shop.
In Tasmania, the only low-cost provider closed at the end of 2017, forcing women to travel to the mainland for an abortion, or pay an exorbitant fee.
Of course, Joanne didn’t know that at the time. She knew she had had a previous episode of thromboembolism – a blood clot had formed in her leg which doctors had warned if it occurred again posed a serious threat to her life. She knew she did not want more children and felt ill-equipped, given she was a single mother, to care for another child. She knew she wanted an abortion.
Joanne was not the first woman to use RU486 in Australia but she was the first to use it for an abortion. Trials conducted by Professor David Healy of Monash University had previously set off a political firestorm. It prompted the Harradine Amendment, which decreed that the use or import of the drug was prohibited without the personal permission of the federal minister for Health.
As feminist Anne Summers wrote in The Drum on 12 June 2013, conservative Tasmanian Senator Brian Harradine, a former Labor MP inspired by the teachings of B.A. Santamaria and the Democratic Labor Party, had demanded prohibitions on RU486 as his political price for supporting the Telstra privatisation.
‘Harradine, an old DLPer schooled in the tough tactics of leveraging maximum advantage, demanded two things: an amendment to the Therapeutic Goods Act to require specific ministerial approval for the importation of RU486 and other similar abortion drugs, and the introduction of the AusAID Family Planning Guidelines which prohibited any family planning agencies in developing countries that received Australian aid money from providing any form of advice or counselling on abortion,’ Summers said.
‘No other drug was subjected to this ministerial veto, and the Catholic Harradine was seemingly unmoved by the statistics that showed that a woman dies every eight minutes in the developing world as a result of unsafe abortion.’
Professor de Costa’s activism for RU486 and greater choice for women to obtain surgical abortion was sparked by those restrictions.
‘Not only restrictions, it was just impossible. Doctors didn’t even know about it. Some obstetricians did, a few of us did. It just wasn’t on the radar and women didn’t know such things existed,’ Professor de Costa says.
‘But when I came to Queensland, I was working full time in 1999, doing outreach on Cape York – I had a particular case with a woman who suffered very much from the fact that she had not been able to terminate a pregnancy she wanted to terminate early on. She ran into a lot of problems with pre-eclampsia at 36 weeks and I did a caesarean for her and the infant died. It was her third experience like that. She knew about it and she said, “I wanted an abortion and they said I couldn’t have it and I’ve heard there is this drug. And wouldn’t it be a good idea if we had it?” And I said, “you’re absolutely right.”
‘And I began to look at it more and learn about it more and I went to a conference in San Francisco in 2005 and just became convinced that we needed to get it.’
She met up with Democrats Senator Lyn Allison and Liberal MP Sharman Stone.
‘I don’t want to overstate my role, but I think the fact there was a woman professor of obstetrics who was saying this is safe and has been used and I can show you the evidence kind of gelled the whole thing towards the end of 2005. And then they got the private member’s bill together,’ she says.
‘But that was never going to solve the problem of actually using it because no drug company was prepared to market such a controversial drug. And that was when I realised there was this loophole in the TGA legislation. My colleague Dr Mike Carrette and I used that to import the drug and use it here in Cairns.
‘We had a lot of support from the TGA, although they were very quiet about it. I used to get these kind of deep-throat kind of phone calls from them saying, “never mention this or ask a question about this but this is moving on”.’
Even the United States, with a powerful pro-life lobby, had access to RU486 since 2000. RU486 had been available in France and Switzerland since 1988, the United Kingdom since 1991, most other European countries since the early–mid 1990s. But not Australia.
As a doctor working in Sydney in the 1990s, Professor de Costa didn’t see a great deal of problems around access to abortion.
‘Although we weren’t able to do it in public hospitals, I didn’t see it as a big problem. I was annoyed by the Harradine Amendment but I didn’t see it impacting enormously on my practice then,’ she says.
Dr Michael Wooldridge was the Health minister at the time. But his replacement in the portfolio, Tony Abbott, would spark further debate when he described abortion as a ‘national tragedy’ in 2004. In a speech titled, ‘The ethical responsibilities of a Christian politician,’ he described abortion as ‘the easy way out.’
‘The problem with the contemporary Australian practice of abortion is that an objectively grave matter has been reduced to a question of the mother’s convenience … To a pregnant 14-year-old struggling to grasp what’s happening, a senior student with a whole life mapped out or a mother already failing to cope under difficult circumstances, abortion is the easy way out,’ he said. ‘Aborting a foetus is not morally identical to deliberately killing a living human being, but it’s not just removing a wart or a cyst either.’
‘Even those who think that abortion is a woman’s right should surely be troubled by the fact that 100,000 Australian women choose to destroy their unborn babies every year.
‘Why isn’t it regarded as a national tragedy approaching the scale of Aboriginal life expectancy being twenty years less than the average of the general community?
‘No one wants to bring back the backyard abortion clinic or to stigmatise the millions of Australians who have had abortions or encouraged others to do so.
‘But is it really so hard to create a culture where people understand that actions have consequences and take responsibility seriously?’
Professor de Costa believes that it was that speech that helped galvanise activists to campaign for RU486.
‘I think the speech made people angry enough to say “how are we going to do it?”,’ she says.
In late 2005, Tony Abbott declared he would not approve the use of the abortion pill RU486 in Australia. Mr Abbott cited advice from the Chief Medical Officer that RU486 has a higher rate of ‘later adverse events’ that could require urgent intervention, than surgical termination.
Soon, senior Liberal women were openly challenging the Health minister about his stance. Senator Helen Coonan, who held the Communications portfolio, warned that there needed to be further debate about the pill in late 2005.
‘We’ve got some advice from the department on a very specific question, that is how it relates to women in rural and regional areas,’ she said.
‘Ultimately, safety is what it is all about and I think we need to have a discussion about it.’
The AMA described Mr Abbott’s comments as ‘plain wrong’.
Four female senators proposed the bill, to make RU486 more accessible in Australia. It would strip the right of the Health minister – at the time, Tony Abbott – to veto the drug. It was a rare conscience vote with former Prime Minister John Howard and Tony Abbott opposing the reform. Mr Howard argued that politicians should continue to hold the power, rather than health bureaucrats.
‘There is just a whiff in this whole debate of this being a little too difficult and controversial, so let’s give it to somebody else,’ Mr Howard said. ‘Plainly, this is not a normal drug.’
But Treasurer Peter Costello and Opposition Leader Kim Beazley supported the change. The debate was intensely personal.
‘It is galling listening to the men, and it is mostly men, who have such contempt for women who terminate unwanted pregnancies,’’ Democrats senator Lyn Allison told Parliament.
Liberal Senate leader Nick Minchin, a conservative, disclosed his own personal experience with abortion. ‘A former girlfriend of mine had an abortion when we were in a monogamous relationship, and I cannot divorce that experience in my life from this consideration,’ he said.
Nationals Senator Barnaby Joyce was characteristically blunt. ‘RU486 is going to kill mothers. The first one that dies is the responsibility of the people in the chamber who voted for it,’ he said.
Liberal Senator Judith Troeth, who co-sponsored the bill, disagreed with Tony Abbott’s warnings. ‘I think he’s stereotyping women as political warriors, with that frame of mind when they think about getting an abortion,’ Senator Troeth said. ‘They are simply looking for a solution.’
Senator Allison argued that Mr Abbott could not be trusted to control access to abortion drug RU486. ‘It is also a great pity for Tony Abbott to keep talking about 100,000 abortions a year,’ Senator Allison said. ‘Firstly, that figure is not correct, it’s nowhere near that. I think he’s done himself a lot of harm and it’s a great pity because I think he’s a very intelligent man,’ she said. ‘But people are saying to me, how can we leave this decision to a minister who so readily plays with the truth?’
Liberal MP Ian Macfarlane supported the bill, arguing it was about freedom of choice. ‘There are those who have attempted to take the high moral ground in this debate by saying support of this bill equates to support of abortion,’ Mr Macfarlane told parliament.
‘Simplifying the debate into one about abortion … overlooks the rights of Australian women and it betrays the freedom of informed, individual choice.
‘It also neglects the opportunity for experts to seek a less traumatic process for those women who have made one of the toughest decisions a human being can ever make.’
Mr Costello delivered an emotional speech revealing that he had been faced with the option of abortion eighteen years ago when his wife Tanya, who was pregnant, was unconscious in hospital. ‘I think it is common knowledge that when my wife Tanya was pregnant and unconscious in hospital, some eighteen years ago, I was faced with this terrible situation,’ he told parliament.
He determined to continue with the pregnancy. ‘I have no doubt that the law should not have prevented such a choice – that the law should allow a choice, whether physical or mental health of the woman is at risk,’ he said.
In February 2006, the House of Representatives overturned the Harradine Amendment. But removing Harradine legislation did not immediately result in access to RU486.
‘Within the extensive legislation governing the role of the TGA there is provision for private doctors to apply to import and use particular drugs for their own patients, in certain serious medical conditions,’ Professor de Costa says.
‘In late 2005, Dr Mike Carrette and I lodged an application under this legislation to be permitted to use mifepristone – RU486 – for the purpose of medical abortion in early pregnancy, in our own practices in Cairns. This was a complex process involving much paperwork but six months later (and two months after the overturning of the Harradine Amendment) this permission was granted to us. We were able to obtain a small supply of RU486 from New Zealand colleagues and we have been using the drug in Cairns under the Authorised Prescriber guidelines.’
By 2012, Professor de Costa estimates that there were 85 doctors prescribing RU486.
Professor de Costa then wrote to every obstetrician in Australia asking them to join her in offering the drug. In the beginning, only three doctors replied. All were women – one doctor was in Westmead, a doctor in Melbourne, and Joan Dickinson, a professor in Perth.
Even today, it’s still a special status drug, which means that doctors need to go online and do a two- or three-hour course to gain registration.
‘So you have to find a registered pharmacist who will prescribe the drug,’ Professor de Costa says. ‘There’s no other drug in Australia that gets this kind of treatment and we are now working on getting it normalised so that abortion gets into mainstream medicine.’
The big question for women remains: why is it so expensive in Australia? Despite promises of $12 abortion pills during the early debate, most women in Australia pay hundreds of dollars, in some cases up to $700 or the full cost of a surgical abortion.
‘It’s so expensive because it cost Marie Stopes a lot. I think they invested more than a million dollars,’ Professor de Costa says. ‘And then they spent a whole lot on the online training and the 24-hour access hotline. They say they want to make it the same as surgical abortion so that women don’t feel they have to take the cheaper option.’
While Marie Stopes is not-for-profit, the recoup of that investment remains controversial.
Now that RU486 is widely used in Australia, a more accurate debate can also be had over side effects and complications.
‘It’s well under 5 per cent. In 1 per cent of cases it doesn’t work. So nothing happens. In that case she can have another go or have a surgical abortion,’ Professor de Costa says. ‘There’s always bleeding, it’s like a heavy period. Some women will not expel all the placental material and they will bleed more.’
Melinda Tankard Reist, a critic of the drug, argues that ‘RU486 is not the “safe” DIY method for women it is claimed to be.’ She cites four examples of women who have taken RU486 to procure a medical abortion who experienced cramping, nausea and loss of blood, among other side effects.
‘Here, the TGA has been informed of 132 cases of ongoing pregnancy requiring surgical abortion, 23 cases of haemorrhage requiring blood transfusion and 599 cases of incomplete abortion requiring surgery. This means about 1 in 30 women will need a second termination procedure. Other negative outcomes include cervical tearing and uterine perforation,’ she wrote in the Sydney Morning Herald on 11 August 2013.
‘A South Australian study found women undergoing “medical” abortion had more symptoms, reported higher pain scores and had higher rates of emergency admissions. After discharge they had more nausea and diarrhoea. According to an earlier British study, women who saw the foetus were most susceptible to psychological distress, including nightmares, flashbacks, and unwanted thoughts related to the procedure.’
In response, Marie Stopes said that as part of their observational study involving 13,345 women and published in the Medical Journal of Australia (September 2012), over 6000 women from the study reported on their pain, bleeding and overall experience of medical abortion. Most women said that the bleeding (83.8 per cent) and pain/cramps (76.2 per cent) and the overall experience (90.3 per cent) was either as expected or better than expected. Most tellingly, 78.0 per cent of respondents said that they would use the method again. In line with the training, certified medical practitioners are required to provide the patient with information outlining the possible side effects of bleeding and cramps, nausea and vomiting, diarrhoea, and fever and chills.
‘These side effects are well documented in all product materials for medical practitioners and patients. Patients are provided with information to take home with them describing the common symptoms of the abortion process, how to manage these, when to seek further medical advice and care, and the additional risks that may arise from using this treatment,’ Marie Stopes International medical director Philip Goldstone said.
‘Ms Tankard Reist has repeated an accusation made previously by Renate Klein that a woman had died in a Marie Stopes Clinic in 2010 as a result of sepsis from a medical abortion. We consider this accusation factually inaccurate. A woman did not die in a Marie Stopes Clinic in 2010. We are aware of the tragic death of a woman from sepsis. However, following a review of medical reports and other evidence, the Coroner’s office did not proceed with an inquest and closed the case.
‘In fact, the article in question, whose principal author is a fully qualified medical practitioner, states that “This woman suffered fever and flulike symptoms about six days after taking mifepristone, but unfortunately did not seek medical advice, despite urging from family members.” In no way, here or in any other publication on the matter, has Marie Stopes International ever “attributed” this death to the “woman’s own negligence” as Ms Tankard Reist claims. It is important for clinicians to understand, however, that this death occurred in the setting of untreated infection.’
There was little debate at the time about the impact RU486 would have on demand for surgical terminations. But it wasn’t unexpected, according to Professor de Costa. ‘No. Because that was what was happening overseas and happening in the United Kingdom,’ she says. ‘So it was always going to reduce the number of surgical abortions. It’s not the fault of RU486, it’s the fault of people not providing surgical abortions when needed that must be addressed.’
In Tasmania, it was the departure of the state’s only low-cost surgical abortion provider, Dr Paul Hyland, that underlined the challenges where abortion is not available in the public system.
He blamed the popularity of RU486, arguing that the market simply wasn’t there to run his business. ‘Back in 2000, there were 25 to thirty surgical terminations a week and that’s slowly dropped due to the combined effects of contraception and managing it earlier,’ he said. ‘No private provider is going to do it so the government is going to have to do something about it, bearing in mind their budget, values and politics.’
Labor’s Catherine King also believes that the drop in demand should have been anticipated. ‘It’s not surprising this has happened but I guess without proper planning this was always the way it was going to go,’ she says. ‘I think at the time, remembering the debate, the sense that everyone had was that surgical abortion would continue to be available both privately and publicly and you could have more availability. And clearly that’s not quite what happened. I don’t think that’s the sole reason in Tasmania. I think there appears to be a real unwillingness in that state to address public provision.’
In smaller jurisdictions like Cairns and Hobart, the demand for surgical abortion has dropped off since the introduction of RU486. In places where abortion is largely privatised, services have had to close, ultimately limiting choice and causing women to travel hundreds of kilometres to access legal abortions that could be offered for free in public hospitals.
If Bill Shorten wins the 2019 election, Labor wants to involve the states and the Commonwealth in national sexual and reproductive health policy mapping of where the shortages are.
‘It’s got to be available where people are. So in some circumstances a standalone clinic is suitable, in others within a public hospital, or private clinics, or medical abortions via GPs. Depending on what suits any woman and her partner if he’s involved at the time,’ King says. ‘The model really has to be accessible. We need a new sexual and reproductive health strategy and that’s got to go through COAG [Council of Australian Governments] with the states and territories. We’ve seen some really big gaps emerge but I don’t fully understand where those gaps are. I think this is about sexual and reproductive health. So it shouldn’t just be about termination services.’
But the situation in Tasmania was rendered more complex by the Health minister Michael Ferguson, a pro-life conservative, who opposed the criminalisation of abortion. Critics argued that he did not seem in a great hurry to restore the provision of surgical abortion in Tasmania.
In 2018, Labor pledged to provide a $1 million standalone ‘reproductive health hub’, to fill a service gap left by the recent closure of the state’s main low-cost private abortion clinic.
‘If it’s in the public hospital it should cost nothing. Cost shouldn’t be a barrier for women accessing a termination,’ Ms King said.
Asked if she believes abortion should be available in all public hospitals in Australia, Ms King is unequivocal. ‘Yes I do,’ she says. ‘Legalisation I think sends that signal very clearly. But the next piece of work that we have to do is about the availability. And I think that’s where we’ve got a lot of work to do. I don’t think anyone predicted that the cost of RU486 would be such a barrier for women.’