Episode 84 - Abortion in Australia: The Impact on Women and Social Work Practice

J S  00:05

Welcome to Social Work Stories, a podcast exploring social work practice through stories and critical reflection. This podcast is recorded on Aboriginal country which was never ceded. We acknowledge the traditional custodians and cultural knowledge holders of these lands and pay our respects to Aboriginal Elders past, present and emerging. We offer a warm welcome to any Indigenous listeners who are part of our podcast community around the world. If you have thoughts or feedback for our team, or just want to find our whole back catalogue of episodes, check out our website socialworkstories.com. But for now, on with the episode.

Lis Murphy  00:46

And welcome to the Social Work Stories podcast. My name is Lis Murphy and I am so happy to say my co host, Dr. Mim Fox is back hello Mim.

Mim Fox  01:09

Hi Lis. Hi, everyone. It's good to be back.

Lis Murphy  01:13

So do tell, how was it over there in the Pacific with the microphone.

Mim Fox  01:17

I felt like that I was with the microphone the whole time. Just to fill everyone in, I just came back from a fantastic trip with nine social work and journalism students. We went all the way to Fiji and Vanuatu, on a New Colombo Plan funded by Department of Foreign Affairs and Trades trip. And the whole point of the trip was to do some podcasting and find out what were the critical issues in the Pacific at the moment and have some really interesting conversations around gender-based violence and climate change and a whole range of different topics. And these incredible students worked so beautifully together, we went and met with a whole range of non-government organizations and government departments and worked with the Fiji Broadcasting Corporation and the Vanuatu Television and Broadcasting Corporation. And they just learned so much. And now they're making this little mini series of a podcast, four episodes, and it's called the Talanoa Stories from the South Pacific podcast. And they are doing this amazing thing, and we're going to feature some of their recordings on some of our shows in the future.

Lis Murphy  02:29

Fantastic. That is so good. So good. And like you say, we'll be able to link these episodes here.

Mim Fox  02:40

Absolutely. Watch this space, every one because these are fantastic new emerging practitioners, but also podcasters. And this is where podcasting is going. It's co-production. We're working with each other in making & telling incredible stories, and really hearing from people what actually lived experience around these social issues is like, so now it's been really exciting. Really good.

Lis Murphy  03:03

So speaking about lived experiences and recording and social work in this area, we have a recording that, look, it's rather interesting, this one, I mean, when aren't they for a start, but this one, I just wanted to say to people, the topic of this episode is around late in pregnancy terminations, domestic violence. So yes, big issues. But I wanted to say from the outset, the real focus of the story is around the complexities that this particular woman has to walk through, just to secure a termination, and by association, the complexities of the work of this social worker to support this woman in being able to seek a termination. So look, I would say to people, there's lots of details that you will hear in this, but it's more about the details of the hurdles that this woman has to jump through more than anything, so I have been listening with my Systems Theory lens. I've also been listening as a feminist and I felt my blood pressure increase, it's gone through the roof several times, and we'll come back to that in the reflection. And there's also quite some disenfranchised grief to that will be kind of reflecting on too but yeah, look, this is a really interesting story. And it reminds me of that old cliche, "the devils in the detail." And this is a classic example of something that happens like legislation, abortion in this particular state is decriminalized, and then services are just told, just roll it out. And so I know we will have American listeners going, you Australians you've got nothing to complain about, look what's happening over here in America. And whilst I'm absolutely not saying that it's anything like what it must be for American women, but I also just want you to hear how difficult it can be for many Australian women to seek an abortion in a public hospital.

Mim Fox  05:21

Yeah, and I think as well, you know, this is an area that we make a lot of assumptions about, about what actually happens on the ground. And so it was, it's been eye opening for me, Lis to listen to this story as well. So let's just let's let everyone have a chance to listen to it. And then let's come back and really think through what it means for women in this sort of situation.

Social Worker 05:49

I'm a senior social worker that's working in a public hospital in regional Australia. I work primarily in Maternity Paediatric and the critical care space. I'm going to be discussing a case that I was involved in where I supported a woman having a late term abortion. In particular, I'd like to discuss how the State government has managed this since the change in legislation in 2019. And the impacts that this has had on hospital social work in particular. So, prior to 2019, abortion in this state was considered by law to be a criminal offence. Women could only access an abortion by jumping through hoops and often telling doctors what they thought they wanted to hear. If you were fortunate enough to find a doctor who was pro choice, they would only approve an abortion for financial and mental health concerns. Women had to make excuses for a decision to be made about their own bodies. Fortunately, in 2019, the Abortion Law Reform Act was passed, and abortion was no longer considered a criminal offence. And as a result, the Department of Health released a framework for termination of pregnancy, which outlined that public hospitals should provide abortions for women requesting them. And just as a side note, most women in my experience looking to end their pregnancies will use the word "abortion." And that's totally okay. I'll be using the language of "termination of pregnancy" as this is the language that is used by the Department of Health and what is written in our policies and procedures. Also, I'm not a doctor. However, I do talk about some medical things in discussing this case. And this is just based on my experience working alongside the medical team. I would never give medical information to a woman in this process and would always direct those questions to the midwife or the doctor. So once the framework was developed, the Department of Health distributed this to all local health districts in this state. And they said just develop your own procedures based on the resources available to you in your area. And this, I believe was the first mistake because it does not give women equal access to services. So in order to explain the processes that happen at my hospital, I'd like to introduce you to my patient Amy. So I received a referral from a fellow social work colleague who was working in the ED. Amy had presented following an assault from her partner with which she was strangled. The ED social worker was supporting her and safety planning with her when Amy mentioned that she was approximately 17 weeks pregnant with her first baby. And she would like information on abortions as she couldn't afford to have have this done in a private clinic. My colleague did not know much about this area. So she called me for advice. And as I started to explain the process to my colleague, I decided it was probably just a better idea for me to go and see her myself and give her the correct information. So with her consent, I met with her to discuss this. Amy explained to me that she was in a very violent relationship with a man who was also using illicit substances. And she did not want to be connected to him with a baby for the rest of her life. She said to me that she felt very supported with the DV by the ED social worker, and only wanted to get information about the abortion from me. So I explained to Amy that our processes included her needing to go to her GP and get a referral to our GYN clinic for the purposes of termination of pregnancy. She asked me at the time why she couldn't be referred to the ED doctors. And all I could say was because it wasn't the process that's been developed. I also explained to her that she'd need confirmation of pregnancy and gestation and full anti-natal bloods. So thankfully, at that time, I was able to advocate for the ED doctors to complete these while she was there, as it was sort of one less step she had to do. So during our conversation her partner was repeatedly calling, and she explained that she did not want him to know that she was considering a termination of pregnancy. So I discreetly provided her with my details and said she could call me further, for further clarification at a time when she felt safe, and I assured her that if she came in, she would see me as her social worker, so she didn't have to continue to explain herself.  I walked away feeling a bit helpless, expecting that I probably wouldn't see her again. However, just in case I handed over the information to our Clinical Midwifery Consultant who coordinates the terminations, just in case she did get a referral from Amy's GP. So when I talk about the procedures put in place, the document is 25 pages long with a long list of people who were consulted, none of which were social workers. Interestingly, social work is mentioned in the documents six times with the expectation that we would be able to provide support information and advice for women and for the medical team. We were given no extra resources, and no training to provide this service for women than their supports. I in fact, paid for myself to do the non directive pregnancy counseling training. And I know some of my team members watch TED Talks and read journal journal articles, we all want to do a good job in such an important area of work. And we knew the referrals would just keep coming regardless. So back to Amy's story. She received a referral from her GP, which was sent to our Gynee Clinic and the referral was taken over by our midwife consultant. So there's different procedures based on what gestation you are. So if you're under nine weeks, this can be managed by a GP with medication, which costs about $30 or $7, if you're on a concession card. So from nine to set 13 weeks, this can be managed at our hospital surgically, with a procedure called a D and C or a Dilation & Curettage. You might have heard some people refer to this as a curette. So this procedure is an operation to scrape away any tissues or products from the uterus. And if this is done in a private clinic, which there's only one in my local area, it costs about $300. From 14 weeks, women must get a referral from the GP, ultrasound, bloods, and nondirective pregnancy counseling with an outside service. And that's all before they even get to the hospital. If everything is approved, the woman must have a delivery in our Birthing Unit, where she will stay until she's medically cleared for discharge. I should also state that the procedure gives health workers the opportunity to "conscientiously object" to being involved however, they are required to refer on.

Unfortunately, in my local health district, there's many people who object in this space. And so that leaves very little options when it comes to doctors and midwives, which contributes to delay in women getting care sometimes women can have this procedure done surgically without a delivery up to 19 weeks in a private clinic. However, the further along in their pregnancy they get, the more expensive is and can be 1000s of dollars. And this I believe is due to the complexities of the medical procedure. And this is referred to as a D and E or dilation and evacuation. This is a second trimester procedure that uses a vacuum and sometimes forceps and other instruments. The doctors do not do this at the hospital that I work. Instead women need to go to women's hospital in the city, which is another barrier, extending the time and adding another financial burden. So for Amy, the non directive pregnancy counseling was organized through a family planning service. And Amy did this over the phone and a report was sent to the hospital for review. By this time, Amy was 19 weeks pregnant. The next stage of that process was to convene a termination of pregnancy committee which included social work, CMC, or Clinical Midwifery Consultant, the Birthing Unit Nurse Unit Manager, Maternity Operations Manager, the consultant obstetrician and the Director of Medical Services who provides legal advice. The social work role in this meeting is to explain the backstory, disclose any concerns and give any advice on how best to support the women. It's quite an in intimidating meeting for a social worker, as the other people in the matter have a lot of medical and legal experience and in high management positions. I distinctly remember trying to advocate to not focus on the reasons why Amy was wanting a TOP and whether we should approve it but how we could get her to hospital in a timely and safe manner. Eventually, everyone agreed and Amy was offered an appointment with social work, clinical midwifery consultant, and the obstetrician.

It took a couple more weeks for Amy to get to the hospital, as she was trying to work this around her work commitments and also her caring responsibilities that she had for her dad. But the biggest barrier for her was getting out of the house without her partner finding out. She didn't turn up to a few appointments but was in constant contact letting us know why. When Amy did eventually come to her appointment, myself, the Clinical Midwifery Consultant and the obstetrician met with her to discuss the next steps. Due to the delay in getting to hospital Amy was now 22 weeks, so the process changed again. From 22 weeks two doctors are required to sign off on the termination of pregnancy. In Amy's case, this wasn't a problem. However, from this gestation onwards due to the risk of the baby being born alive, they must have a procedure called a feed aside. This means they inject the baby through the uterus with potassium so that they gently pass away. As mentioned earlier, this procedure is done at another hospital. So Amy had to travel two hours for the procedure and then returned to this hospital to deliver on the same day. So the social work role in this initial meeting is to support the women while she gets the medical information and that could purely just be practical, like getting water tissues or even distracting the toddler who might be present. I will then sit with the woman and her support person after the doctor and midwife have gone to ensure that they understood and make sure their wishes are heard, and that they didn't feel judged. A really important part of the social work role is to talk to women about the different arrangements that women need that will need to be made post birth, based on what gestation now, if a woman was under 20 weeks, there's no legal obligation to have a funeral or register a birth. If they're ever 20 weeks, the law states there's this is a stillborn baby, and the baby's birth will be registered, they will need to be named and a funeral is required through a registered funeral home. These can be really hard conversations to have. Because most women don't know any of this information. And they're hearing it for the first time. It can take some processing and not every person comes out of that appointment with a clear plan for what they want. Social Work will often have to advocate to slow down a process that is quiet time sensitive. It's a strange balance to manage. And I'm not even quite sure I found that balance in my practice yet. So Amy had made up her mind on that day that she wanted to continue with the termination of pregnancy. She fortunately had the resources to go to the hospital. Two hours away and I had the procedure within the week. She was just over 23 weeks and when she returned to deliver her baby. I met with Amy in the Birthing Unit and she had a friend as a support person. Amy had not yet delivered and I wanted to clarify some of her wishes. We should not assume that because someone is having a termination of pregnancy that they don't want to make memories or that they are not grieving this baby. Regardless of what their concerns are for having a termination of pregnancy, they're still offered the same things we would if the baby was stillborn unexpectedly or very unwanted. Amy was offered hand and footprints and opportunity to hold and spend time with her baby photos and we provided her with lots of information on different supports in the area, and what next steps are for organizing a funeral and registering the baby's birth. Amy chose to see her baby and got some hand and footprints. She did not spend much time at the hospital and consented to social work contacting her via phone at a prearranged time when her partner would not be present. A week later, I contacted Amy and she was in the process of organising a funeral and she chose to keep the ashes of her baby. Her partner was aware and she stated he was supporting her to make arrangements. We arranged a six week checkup for Amy where she could get a medical check and social work could also follow up. However, she declined this and went to her GP instead which is well within her rights. When I reflect on Amy and the processes and procedures we've put in place at the hospital to support women with The termination of pregnancy I feel really frustrated. Not only that we are we making women jump through a lot of hoops to get medical procedure on their own body, we're forcing a service on social workers with no resources and training on maternity and pediatric social workers do such a great job with the women just like Amy. But we're also supporting women having stillbirth and miscarriages are very wanted babies. There's also women having terminations because their baby has significant medical issues. And while these things are the same, they're also very different. And it's difficult to change your headspace when you're doing all of these things. My dream for this area of work is that there's equal access to publicly funded termination of pregnancies. And more importantly, that there are just as many social workers as there are doctors working in this space. My dream is that women can have a termination without having to explain themselves. I think it's a privilege as a social worker to support women through a process that can be quite distressing. It's a space of immense advocacy and empathy, and no one case is the same. The knowledge I've gained in the last three to four years in this space has inspired me to do something I'd never thought I'd do. And that's continuing my studies. I'm now enrolled as a mature age student in a Master's degree in Women's and Children's Health, when I'm doing this with the view to get into some sort of policy work, so that we have more social workers involved in making these really important decisions in regards to health care for women. Because abortion is a healthcare issue, and that's all it should be.

Lis Murphy  21:46

You know, I always  like to refer to immediate first reaction on listening to it again, Mim, how's it for you?

Mim Fox  21:55

Do you know, Lis, when I was listening to it, I was listening to this story I, I was poised to take notes, right. I was already too. And I actually didn't write any notes, not because I'm generally not a note taker. But because actually, I was so engaged in listening to the steps that were happening and what the meaning meant, and having a visceral reaction to that. I think I was getting more stressed as the story went on, to the point where I couldn't even write anything down because I was just quite amazed at what I was listening to. What about you, I know that you had quite an impassioned response?

Lis Murphy  22:40

I did. I absolutely did. I understand what you mean, I of course, I am the note taker in our partnership, and as usual, I've written pages because for me, it was really interesting to one, be really clear about what constitutes a termination of pregnancy, and, I love the language stuff,  Health uses "termination of pregnancy", women use the term "abortion,"  and sometimes you'll hear TOP . So you know, at Health, we love a good acronym. But depending on the gestational period of the pregnancies and will depend on the termination, right? And so you know, there'd be lots of people that think, Oh, yes, this, you know, it's just, I go see my GP, I could go to women's health center, and I take a tablet. But what I found really interesting was all the different nuances and procedural changes that occur over the course of the pregnancy, depending on when you know that you're pregnant, depending on when you ask for help. But gosh, a couple of weeks makes a hell of a difference. And you know, the other like, when you think about Amy's story, so Amy started, she came into emergency department at 17 weeks, she had her termination of pregnancy at 23 weeks. So six weeks went by, and my goodness, what a difference it meant between 17 weeks and 23 weeks, so I get it, Mim, all those. Yeah, all the different nuances. And of course, how much it then impacts on the role of social work. But that wasn't so much my initial reaction, my initial reaction was an "unbelievable" yet again, the Health department will release you know, make a statement that now you'll be able to have a termination in public hospitals. We're not going to resource it. We're just going to let the local hospitals work it out themselves. We're not going to provide staff that are actually trained and educated and happy to work in the area of terminations. We're just is going to, you know, roll it out. And you know, if you don't have staff that want to work in that area, yeah, well, you know, sought that one out and the remaining staff who are prepared to work in that area, not going to have to what, put it out here say, send them out there at themselves or for training, or watch TED Talks. Unbelievable Mim!

Mim Fox  25:21

I couldn't believe that social workers were needing to take themselves off to watch TED talks, just to get any education in this space. So that is, that's shocking.

Lis Murphy  25:30

It is shocking, because let's say for instance, it would lead a different profession now. Let's go carpentry? Why not? What if I was to say, look, we want you to use a completely different tool in building this particular structure. We're not going to give it to you. In fact, work it out for yourself. But we still want that built, and we're going to be promoting it. I just, it's outrageous. I don't know as social workers. Why we put up with this. That's my milk crate moment.

Mim Fox  26:01

That's okay. Stand tall on that milk crate Lis, I think it's a fair one. It's actually amazing to me how little the policy works with the practice. And this is one of those stories where you could just really see how policy was written in such a disconnected way to the to the reality. I mean, nine weeks, the difference between nine weeks, 17 weeks? And what did you say 22 weeks, the difference? Those are just numbers on a page. But when you actually think about what that meant for this woman in this story, and what it means for all the women in the stories, right, where actually, now six weeks has passed, and that has changed completely. What now can be done, it actually means the policy and the practice are 100% disconnected.

Lis Murphy  26:47

And how important is information, you know, like we often say, information is power. By crikey it is, isn't it? So we need our social workers and health workers to be able to give accurate information to these women so that they can make a decision. So if you come to me at this stage in your pregnancy, I'm going to give you this bit of information. If you come a few weeks later, it's changed now, and some of the hurdles that you have to go through. So I would love to listen to Amy's story again, just to kind of count how many hurdles Amy would have had to have leaped over to have got the final termination. And this is a woman who's already living in a violent relationship. So with children, so it's not like she hasn't got her own huge amount of stresses going on outside of an unwanted pregnancy. And then you know, even the little things like you've got to go back to your GP....

Mim Fox  27:44

to get a referral, even though you have right now in a hospital emergency department. That's right.

Lis Murphy  27:49

Just so yeah. But I mean, it started off like that. And it just continued on for this poor woman didn't it?

Mim Fox  27:55

Well, can we take a minute to talk about the eight person panel that got to make a decision about whether this was going to be allowed or not. And the fact that a conscience vote is built into the entire process, so that at any point in time any of those health professionals could have stepped out of the process, therefore, meaning that potentially she couldn't have the abortion regardless?

Lis Murphy  28:17

Well, that's right, because I know of a hospital, well actually I know of several hospitals, who don't have the staff in order to perform abortions, right? So that would mean that those women have to find another public hospital, that will do it. And if you're out of area, you will sometimes be turned away because one, the hospital may not be able to keep up with the demand that they have of their local people. And, and look, there are also areas in in this state that the Catholics, the hospital is run by a Catholic organization. They don't even offer termination. So what did those women do in that situation? Where do they go to? And yet they're still receiving public funding from governments. I, you know, like, that just blows my mind.

Mim Fox  29:10

But if you take a theoretical lens to this for a second, that is literally what intersectionality tells us that if you are living in a less, less Metro more rural environment or regional environment, if you have a lower socio economic income, if you have language barriers, cultural barriers, etc, you will end up with poor health outcomes, right? That's literally what that what the theory is sitting there saying and what the SDG goals and everything else is actually crying out for saying this is what the social worker at the end of the story said, this is a health care issue. This is actually not just about whether or not abortion should occur. This is actually about the women's lives at the very center of this question.

Lis Murphy  29:57

And here comes to my feminist perspective now, I think that's part of the problem Mim, I think the fact that this is a women's health issue is why we are experiencing these particular health issues around the issue of termination, because we know that health is a very patriarchal system. And, you know, I yeah, there is a very strong link, because that's what I see in the work. And I think that's what the social worker was clearly saying, "I actually want to continue my studies now and promote women's health, because there are some huge gaps in the services. We're making our women jump through multiple hurdles. And I want it to stop." And this is why I feel like if I can encourage more social workers to get into policy development, because this particular social worker, imagine what she would do in terms of developing a policy for terminations in health, public health, knowing what she knows now, knowing about the lived experience of her patients, knowing what she has to do, and the the importance of accurate information and the types of support. I mean, she was actually talking about the fact that, you know, over 20 weeks, she essentially had to be talking about registering the birth, having a funeral, naming this baby. All of that information is vital. But I would imagine if you're someone who doesn't work in this area, but you develop policy in some kind of, you know, lovely office in the inner city, you're not going to know that type of stuff.

Mim Fox  31:43

No, but that's exactly right. And then coming back to it being a feminist issue is that we know that reproductive health is absolutely fundamental, a patriarchal tool. So actually, when you look at it that way, if you've got people making decisions, in policy that have not had experience, from actually women who have lived through these processes, and lived through what it actually means the disconnection is absolutely enormous. And therefore the potential for that policy to have real world implications is just massive.

Lis Murphy  32:17

And I love that we can tell it through Amy's story, because, you know, I just think it just helps for someone like me to actually hear a lived experience story of how a policy plays out, it just really hits home. And I really hope that's been the case for our listeners, because just coming around the corner, in the state I live in is Voluntary Assisted Dying, and I can guarantee we're going to be having some similar stories. This, you know, in a couple of months time. Yeah, I just think the disconnect between the policy and the actual rolling it out. NDIS was another classic one. That's right.

Mim Fox  33:02

That's right. And, and it's this, it's so routine. Now that that happens that it's unsurprising, unfortunately, I think in the same way that this was Amy's story, which is met so many women's story, this is actually a very classic Social Work story, where you have a social worker in the middle of policy change, really struggling with how to enact policy, and how to support women in the middle of that process. And I really want to congratulate the social worker for the work that she did on this case. But all the social workers who have been there on the frontlines trying to navigate this policy change, trying to stay true to their feminist values, and actually put women at the center of the story, because actually, that's what's missing every single time.

Lis Murphy  33:43

Ah, again, beautifully said, and all I can say is you are my heroes, these social workers are my heroes, Mim. And if we can keep on telling their stories, as well as the Amy stories, I'm going to be as happy as a pig in mud.

Mim Fox  33:59

Yeah, I'm just going back to what you said at the beginning of the episode Lis about how we do have an international audience and particularly thinking about our American colleagues in certain states who are really struggling with the criminal implications of working within this space, and really reaching out that hand of support, but also saying, if you have a story that you think would be really in the same way challenging, standing by your values, and challenging the policies that are happening for you in your space, please reach out and let us know. And we'd be really keen to hear how this actually looks in different spaces. Because what has happened for us is that nobody has learned from the past. Our state is not the first state in Australia to be going through this and yet lessons have not been learned and have not actually traveled throughout our country. So let's not do that in globally as well. Let's actually learn from each other in this space, and what good social work practice can actually look like

Lis Murphy  34:55

Because I want to say there is plenty of room on my milk crate you more than welcome to get on the milk crate with me. I love the milk crate stories. You know, I might need to have a lie down after this because I think my blood pressure just went through the roof. But we,  well said Mim, we we actually want to support you to tell your stories. And we're here for you.

Mim Fox  35:19

Yeah, we stand in solidarity when these really difficult times actually in malpractice for sure. LizLis, it's, um, I know, it's hard to sort of hear these stories and then have to think about it. But it's also kind of good to come back to a really passionate space. Because I think as we go month to month telling these stories and airing this, it's really nice to come back to what is the essence of our social work practice. And it always is, it's that value space. And it's those moments of passion that keep it going.

Lis Murphy  35:49

And it for me, it's a privilege. So you know, I'm prepared for my blood pressure to go up any amount for for these stories. So bring it on sisters and brothers. So MIMMim I think we've got, we can call this a wrap. It's been another great, great period of time spent with you. And I'm glad we got to reflect on such an awesome story.

Mim Fox  36:12

And I made to LizLis, take care everyone, we hope you have a good month. We hope you take care of yourselves. Speak to you soon. Bye.

J S  36:27

Thanks for listening to the Social Work Stories podcast. All of the stories we share are de identified to respect and protect the people involved. We create this podcast because we're passionate about building the Global Social Work community and strengthening our practice no matter the context. If you want to help us grow the podcast tribe, and continue the work we do, we would love it if you can subscribe or follow the podcast in your favorite podcast app. That way, you'll be sure to get every episode as soon as it's released. While you're in your podcast app. If you can leave us a five star rating and write a review it would mean so much to us. You can connect with us on Instagram, Twitter, Facebook and LinkedIn where you can share our posts with your friends to help spread the word. And you can always find us at our home on the web, social work stories.com The Social Work stories podcast is made by Lis Murphy, Dr. Mim Fox, Justin Stech, Dr. Ben Joseph, and Maddy Stratton. Thanks so much for listening