Safe Reproductive Health Services for Women in Tasmania

Published: 19 June 2018

Legislative Council Tuesday 12 June, 2018

Ms FORREST (Murchison) - Mr President, I move -

That the Legislative Council notes -

(1) Access to quality, safe reproductive health services for all women is an important public health matter and an essential part of public health services in Tasmania;

(2) All Tasmanian women should have access to safe, accessible and affordable termination of pregnancy services within Tasmania;

(3) That currently women who wish to access a termination of pregnancy for reasons other than serious foetal anomalies or maternal medical conditions and do not have private health insurance and/or cannot afford to travel to mainland Australia to access termination of pregnancy services are being disadvantaged through the lack of access to termination of pregnancy services within the public health system; and

(4) That this House calls on the Minister for Health to ensure all Tasmanian women have equitable access to termination of pregnancy services, a legal procedure, through the delivery of this health service in the public hospital system with appropriate protection for medical staff with a conscientious objection to assisting with this medical treatment.

Mr President, this motion is not about whether termination of pregnancy should or should not be legally available or about women's choice. That question was decided in 2013 by this parliament. Termination of pregnancy is a legal medical procedure, as agreed by this parliament. This debate is about equity of access for all Tasmanian women to a medical procedure that is legal and safe to perform in any of our major hospitals, is an important part of our sexual and reproductive health services and forms part of a comprehensive public health service.

In 2013 Tasmania was a leader in the decriminalisation of pregnancy termination. The Australian Parliament has also acted proactively to legalise access to medical termination. Access to safe and affordable reproductive health services is vital for the health and wellbeing of all members of our society. Unfortunately, this is not the case in many parts of the world, although much work continues to be done around the world and progress does continue to be made. Just last month we saw Ireland vote overwhelmingly to decriminalise abortion, with 66.4 per cent of the Irish population voting yes compared to 33.6 per cent voting no - a vote of 2:1 in favour of decriminalisation, with a majority of 706 349. This followed an Irish referendum to legalise marriage equality, well before Australia did. This shows clearly the change we are seeing across the world with respect to the rights of women and others from marginalised groups.

This is why it is vital we in Tasmania, who have made significant positive inroads into access to sexual and reproductive health care, cannot allow this access or these services to be eroded, undermined or threatened. Some might argue access to termination services is available in the public health system, and this is true, but it is only on a very limited basis. The current arrangement disadvantages women who do not fit in the narrow gap or range of reasons for termination. It also significantly negatively impacts on poor women and women from regional areas of the state. This is not equitable, reasonable or defendable.

This issue has been the subject of investigation, and research confirms this negative impact. A recent, peer-reviewed FactCheck published in The Conversation stated that Tasmanian women can find information about terminations from not-for-profit organisations like Family Planning Tasmania or other community health services. However, this information is generally not publicly available. This lack of information, as well as the cost we must incur, constitutes significant barriers to accessing an abortion in Tasmania.

Tasmanian women may face other barriers to abortion, as noted in other Australian research. This can include conscientious objections from health professionals, unwanted counselling, harassment from protesters and gestational limits requiring the approval of more than one health provider. As a side note, just last week the New South Wales Parliament agreed overwhelmingly to put in access zones around their hospitals and clinics where terminations are provided, as we did in Tasmania in 2013. That is a positive step to stop the harassment. I saw a Facebook post showing one of the churches in NSW saying that harassment is not freedom of speech, it is abuse, so some of the churches actually get this.

Returning to the quote from the FactCheck -

International research has found that places where abortion is difficult to access are associated with high maternal mortality and unsafe abortion rates. Barriers to abortion access in Australia particularly affect young women, those in rural areas and women of low socioeconomic status.

Many women in our state, many in my electorate and in electorates with rural areas, are disadvantaged and treated differently from the women in the cities, particularly Hobart. The Mercury reported on the 27 April 2018 that Melbourne clinics have reported a dramatic increase in the number of women presenting for medical termination since the closure of the Tasmanian clinic at the beginning of the year. The article states -

Not-for-profit provider Mary Stopes Australia says the number of Tasmanian women travelling to Melbourne for terminations in their clinics has increased from about 1 to 2 per month previously, to up to 10 women a month since January.

Some women may choose to travel to Melbourne because they have family support there not saying they should never do it, but they are now being forced to travel. In an article titled 'The legal and non-legal barriers to abortion across Australia: a review of the evidence' published in the European Journal on Contraception and Reproductive Health Care in 2017, Caroline de Moel Mandel and Julia M Shelley, from the School of Health and Social Development, Deakin University, Melbourne again raised this concern. The review's findings identified evidence of a range of barriers to pregnancy termination in Australia, even in jurisdictions where abortion is legal such as Tasmania. The paper states -

As the majority of women may use any means to terminate an unwanted pregnancy, any barrier that restricts safe abortion access will force them to travel to less restrictive states or countries, or to use unskilled and unsafe abortion practises.

We do not want to see that - the real risk is we are, and we will, if this does not change. Furthermore, the World Health Organisation's publication Safe Abortion, Technical and Policy Guidance for Health Systems states, under 'Recommendations for health systems' -

To the full extent of the law, safe abortion services should be readily available and affordable to all women. This means services should be available at primary care level, with referral systems in place for all required higher-level care.

Financing of abortion services should take into account costs to the health system while ensuring that services are affordable and readily available to all women who need them. Costs of adding safe abortion care to existing health services are likely to be low, relative to the costs to the health system of treating complications of unsafe abortion.

Under 'Recommendations related to regulatory, policy and human rights considerations', the policy guideline states -

Laws and policies on abortion should protect women's health and their human rights. Regulatory, policy and programmatic barriers that hinder access to and timely provision of safe abortion care should be removed.

What we have here is the legal framework saying we agree that termination should be part of our health services. It is legal and it should be part of those services. What we are seeing here is a policy position that is not allowing access to that service to be equitable. The quote goes on -

Amending regulatory and policy environment is needed to ensure that every woman who is legally eligible has ready access to safe abortion care. Policies should be geared to respecting, protecting and fulfilling the human rights of women, to achieving positive health outcomes for women, to providing good quality contraceptive information and services, and to meeting the particular needs of poor women, adolescents, rape survivors and women living with HIV.

In Tasmania we have a legislative framework that provides access to medical and surgical termination of pregnancy. However, the policy settings within our health services need to match the intent of this legislative framework to ensure all Tasmanian women have access to sexual and reproductive health services, including access to safe termination of pregnancy.

Medical termination has made access much easier and is to be commended, but that is not an option for all women seeking this health care. Access to surgical termination remains an important and necessary part of our public health service and should be included in the service plans. In Tasmania, we face far fewer challenges in access to safe termination of pregnancy than in some other parts of the world. As a developed nation, we should. However, currently Tasmanian women are being disadvantaged and are not being treated equitably because access to safe, affordable and accessible surgical termination of pregnancy services is not being provided within our public health system, particularly for women from regional areas who lack the financial resources or do not have a foetal or maternal anomaly that enables them to access our public health system. This flies in the face of the 2013 support of the parliament for such access.

I recently met with the chair of the steering committee of the UK All-Party Parliamentary Group on Population, Development and Reproductive Health, Baroness Jenny Tonge. The group is a cross-party platform for peers and MPs in the UK, the purpose of which is to raise awareness on key development and right issues, with a specific focus on population, sexual and reproductive health and rights.

The group was established in 1979 and is one of the oldest all-party parliamentary groups in Westminster. It has more than 80 members, with representation from all major political parties and from both Houses in the UK parliament. Baroness Tonge is also a very experienced medical practitioner with a particular interest in sexual and reproductive health, making her the ideal chair for this group. The UK is still to make some of the legislative changes we have already achieved here. It is great we can lead the way, but we need to follow through with the policy settings.

This was highlighted in a recent report of this group titled, Who Decides? We Trust Women: Abortion in the Developing World and the UK. This report was released in March 2018 so it is very current. I will quote from several sections of this report that highlight the importance of ensuring provision of safe, affordable and accessible termination of pregnancy services in Tasmania to Tasmanian women as an integral part of our public health services.

This publication, which I am happy to share with members - it is available online - clearly illustrates why it is not just legislative frameworks that need to facilitate access, but the right policy settings and service delivery plans and agreements within our public health service. Baroness Tonge notes in her forward that -

It is not widely known that abortion rates are roughly the same in countries where it is legally available (34 abortions per 1,000 women of childbearing age) and countries where it is banned (37 per 1000) and yet 68,000 desperate women die from unsafe abortion every year in countries with no provision for safe abortion procedures. It is disgraceful that they are so condemned by their governments' failures.

The executive summary notes the following -

It is no longer politically or morally acceptable for governments or international bodies to use arguments of culture or religion to avoid creating a supportive policy and legal framework for safe abortion that would eliminate a major cause of maternal death and injury.

Gillian Kane, Ipas, is the author of that particular quote. The executive summary continues -

Access to therapeutic or induced abortion is essential to allow women to participate fully in modern life and bear only the children they wish and feel able to raise ... Women will take things into their own hands if you do not assist them and I know from bitter experience that they can die in the process.

That quote was from Wendy Savage, a retired UK obstetrician and gynaecologist in Doctors for Choice. Further, the executive summary states -

Abortion rates are roughly the same in countries where abortion is legally restricted (37 per 1000 women of childbearing age) as it is in countries where it is readily available (34 per 1000 women). Restrictive abortion laws do not prevent women from seeking abortion -

That is the important thing. You could apply that statement here and say that restrictive access to abortion policies does not prevent women from seeking abortion -

… they only endanger women's health and lives as women seek unsafe procedures. There is a correlation between restrictive abortion laws and higher rates of maternal mortality and morbidity.

The report also notes the compelling human rights arguments for the need to ensure both the legal framework and policy setting support access to sexual and reproductive health -

Human rights bodies recognise that to protect the basic rights and dignity of women and girls, it is necessary to increase access to quality reproductive health services. The Committee on Economic Social and Cultural Rights has said the right to health must include necessary SHR services, including safe, legal abortion care. Human rights bodies have affirmed laws restricting abortion access contravenes human rights standards. For example, the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) found that it is discriminatory to fail to provide health services only women need.

It is interesting to reflect on progress made and positive outcomes in termination rates in other jurisdictions where termination pregnancy services are managed as part of a standard health practice, as other medical services are, which is what I am suggesting should be the case here. Canada is one such example. The report notes -

Canada decriminalised abortion completely in 1988, rather than have a list of conditions where abortion is 'legal'. Canada's abortion rate is lower than the UK's and there have been few issues as a result. In fact, Canada enjoys the lowest maternal mortality rate from abortion in the world.

This is where it is part of the public health system and service in Canada. The report continues -

Since 1988, Canada has managed abortion as part of standard health practice and there is no control by any civil or criminal law.

It is part of the health service and Canada has the lowest maternal mortality rates in the world from abortion. The Canadian law is further described in the report and some of it is slightly repetitive, but I want to read the quote in context -

Canada has had no criminal laws around abortion for 29 years and has shown that women and doctors act responsibly without criminal laws to control them. The Canadian abortion rate has continuously declined since 2000 and Canada now has an annual rate of 14 abortions per 1000 women of childbearing age. (The corresponding rate in the UK is 16 per 1000 women aged 15 to 44 in 2015 and 2016). There is no gestational law in Canada and 90% of abortions take place in the first trimester -

That is the early part of the pregnancy, Mr President -

… and less than 0.5 per cent take place after 20 weeks. Canadian doctors are accountable to their professional associations and the majority of women present as early as possible for abortion.

I suggest that is because it is easy to do so - it is part of their health system. There is no stigma, which makes it easier for women to access abortion earlier and avoid the need for surgical termination. They are more likely to seek a medical termination. The report continues -

The situation is governed by Canadian Medical Association policies, clinical protocols and codes of ethics, as with all healthcare. The decline in the abortion rate in Canada is seen primarily as a result of good access to contraception.

Access to safe, affordable and accessible sexual and reproductive health services, including surgical termination of pregnancy, is a matter of equity and inclusion. There are existing barriers that remain difficult to overcome including financial barriers and social stigma. These and other barriers were noted in this same report -

Rich women are likely to be able to access safe abortion services whatever the legal framework in which they live. This is not true for the poorest women who are least likely have the information they need, the funds to procure or the ability to access safe abortion services. These are the women who are still using the least safe abortion methods and are most likely to require post-abortion care.

The obstacles to safe abortion delivery are varied and many. This includes restrictive laws, poor availability of services, high cost, stigma and refusal to care by healthcare providers, non medical requirements such as third party authorisation, mandatory waiting periods and counselling.

The stigma associated with women seeking a pregnancy termination was also discussed in the report, and this stigma is about power, gender stereotyping and sexuality -

Abortion stigma is intertwined with issues around power, gender stereotypes and sexuality. Stigma affects the women and those providers who try to help them. In addition, it drives abortion into the hands of unsafe providers. Women suffer stigma in the community when they ask where they might find safe abortion services, so they don't ask. Women, particularly young women, are frightened to obtain abortion services because they fear the judgement they will receive from healthcare providers. Healthcare professional's disapproval might take the form of outright refusal of services or abuse of the women. Providers need to better understand their own attitudes to abortion. South Africa, with one of the most liberal laws on abortion in the world, still has healthcare providers that experience burnout from being victimised, stigmatised and isolated from their peers and from their community.

Unless you have been in the position where you have had to face the decision about an unwanted and unplanned pregnancy, and gone through the system - and I have talked to women who have - you do not know what it is like.

The report also comments on the matter of conscientious objection to assisting women with access to a termination. In a number of countries, there is no option for conscientious objection. The report states -

Conscientious objection in reproductive health is not actually CO but Dishonourable Disobedience to laws and ethical codes. Healthcare providers are using their position of trust and authority to impose their personal beliefs on patients, who are completely dependent on them for essential healthcare.

Christian Fiala, from Gynmed Clinic in Vienna, Austria, said that -

Religious beliefs have no place in evidence-based healthcare. As mentioned earlier CO was introduced in 1967 with the UK Abortion Act. Since then, CO has been used worldwide by healthcare providers as an excuse to shirk their duties to care for their patients. The exception is Finland, Iceland and Sweden where there is no provision for refusal to treat. Rather than coming from a deep moral position, it is often noted to be an excuse to avoid a necessary task. The imposition of a doctor's religious beliefs on a vulnerable patient is a way to harm women and CO nearly always involves services needed by women (contraception and abortion).

Members will note in part two of the motion, I call for this approach to be continued - that medical staff who have a conscientious objection be protected. I personally believe arguments put in the report are valid, but it is something that should be considered at a later time. This leaves us in Tasmania with an important responsibility to ensure we do not allow access to public health services to be eroded through spurious argument or personal views regarding women's health matters.

The provision of safe, accessible and affordable termination of pregnancy services within the public health system must be part of the services provided in Tasmanian Health Service plans. Sexual and reproductive health is important to all Tasmanians. It is not a question of gender, age, geographic location, education or any other aspect. It is vital that quality sex education is an integral part of Tasmanian children's education. This along with access to publicly available quality sexual health services, advice and contraception must be part of our health services, and this will assist in reducing the number of unplanned and unwanted pregnancies, and thus the need for termination of pregnancy services.

However, even with this, the provision of safe, equitable and accessible medical and surgical termination of pregnancy services will continue to be needed within our public health system. Access to termination of pregnancy is not an issue of choice for women or the health system. As I stated at the beginning of my contribution, that debate was settled in the past with the decriminalisation of abortion agreed to by this parliament in 2013.

This is a health service required by some women that should be safely performed in all our major public hospitals. It requires policy decisions and settings that support and give effect to the legislative framework we all agreed to. We know not all pregnancies can be avoided, particularly in a marriage or in a long-term relationship. The only form of 100 per cent reliable contraception is total abstinence, and I do not think many married couples or couples in long-term relationships see that as an option. Even vasectomy and tying of a women's fallopian tubes does not guarantee success. If you have been around the traps as long as I have in this area, you would know that the odd surprise turns up - and not necessarily unwanted babies or pregnancies, although some of them are. Some of those couples have gone as far as they can to ensure they do not have to make that decision or find themselves facing that decision, but some still will.

So Tasmanian women should not be faced with severe financial hardship to access a legal, safe and integral health service as a result of having to leave the state. Some of travel costs are reimbursed, but the costs do not just extend to the airfares and accommodation. I have heard directly from some women who have faced this reality, a reality we must address. This personal communication to me highlights the real issues -

I'm a confident, educated and able woman. Yet, I'm sitting here feeling beyond vulnerable, I'm feeling less of a person. I'm feeling invisible. I'm feeling alone. I'm feeling ashamed.

I just turned 39, I have 3 beautiful kids, I've been a mum since I was 21. My kids are 17, 10 & 7. I'm divorced. I'm into the second year of a beautiful relationship with someone I love unconditionally. We have a beautiful life.

My story represents one part of the unspoken face of terminations - I'm the mother in my late 30s that has a family, that works hard in my career, that doesn't always pay attention to my car … and my body …

I'm not reckless, as some often assign to those that end up in this situation.

I'm also the Tasmanian female who had to fly to Melbourne because I couldn't access affordable and available services in Tasmania.

Even though the media releases tell me I'm not disadvantaged because I live in Tasmania, that the services have been restored, that I have just seen my GP, I've flown to Melbourne.

Her email was quite long describing the process and I will not quote it all. This woman is not alone. We have an obligation to address this. This woman provided me with a breakdown of the costs, from the diagnosis to the surgical procedure over a period of 16 days. The cost was $2750. Many women cannot afford to pay this, even with some costs able to be recovered. Many in my electorate find that really tough.

Mr Gaffney - In your experience, do some women like to take somebody with them for when they come out of the procedure? A best friend or sometimes a mother? That in itself is a hindrance if the procedure is in Melbourne - it prevents a lot of that emotional support.

Ms FORREST - I was also informed by a health service provider of one of their clients, a young woman who decided she needed to have a termination. She was required to go to Melbourne. She had never been on an aeroplane, never been to Melbourne; she had no one who could travel with her. She had to go on her own, navigate Melbourne airport on her own, find her way to the clinic and then find her way home.

Ms Lovell - Some clinics actually require a support person to go with them when they leave.

Ms FORREST - Particularly if you are planning to come home afterwards. This is something we need to address. Women should not have to go to Melbourne, unless that is their choice. Usually, if that is their choice, they will have someone with them or will have family there.

Mr Gaffney - Or they can afford to do it.

Ms FORREST - That is right. Some women find it difficult to arrange care for their older children. All women need support at this time because it is never an easy or lightly made decision. Some people in the community will say they should not have got themselves in that position in the first place, and that termination is a quick and easy solution. It never is. They never think that termination is their contraception.

Evidence shows that many women will consider unsafe measures to end their pregnancy, some with devastating effects. This is not acceptable in a civilised society such as our state and our country. Financial costs come on top of the emotional costs and trauma associated with the ongoing stigma perpetuated by policy settings such as in Tasmania. Leaving family, friends and often other children should not be necessary at the time this support is needed.

I have received countless messages of thanks, support, encouragement and deep gratitude for raising this matter publicly. These messages have come from men and women from around the state by email, phone, direct personal communication and social media. I had one just a little while ago from a woman, which I can use in the reply. She found herself unexpectedly pregnant and decided to continue with the pregnancy, but she wanted to thank me for standing up for her right, if she had made a different decision, to have a termination in Tasmania. She made the choice to continue her pregnancy, and all power to her for doing so with her partner.

Some of these messages have come from women who have had to face this most difficult of decisions whether to have a termination, just like the woman I mentioned. Some were from medical practitioners and other health professionals frustrated by the lack of clarity and access for women in their care. Some were from family members who have seen their loved ones face totally unnecessary hardship as a result of this policy position.

I have received, I think, five messages from constituents, with one constituent wishing to engage on the matter, who have been critical of my stand. That pales into insignificance with all those I have had from the opposite side, who said thank you and supported my stance. It is not easy in a conservative electorate to stand up and talk about these things, rest assured, but it is so important that I do.

Mr Gaffney - You made it very clear this is not about the issue, it is about equity of access -

Ms FORREST - Yes. It is about equity of access.

Mr Gaffney - That is where some of the cases have been confused.

Ms FORREST - Yes. Some of them get a little bit wayward, but I bring them back to that point. Women should not be treated differently because they live in my electorate rather than in the member for Hobart's.

I will read a small number of de-identified excerpts of these messages I have received to highlight the general theme of the messages because I think it is very important to listen to the voices of our fellow Tasmanians in this debate, and to stand up and speak out for those who may be less able to do so for themselves, be it for fear of attack or shame.

First one is from an older male Tasmanian. I only know he is older and he is male because he put his name on it and I know who he is -

Hi Ruth

May I offer my support and congratulations for your stance on access for Tasmanian women to abortion services in the public hospital system? It is disgraceful that such services are not available in a timely, safe and compassionate manner. Having had family experience of the need for surgical abortion, I am painfully aware of the failings of the system. Well done.

Another is from a health professional who previously worked in a sexual health service in Victoria that provided termination pregnancy services -

Dear Ruth

I just want to wish you all the best as you attempt to pass a motion for Tasmanian women to have access to safe abortion services. It is, as you say, a real issue about access.

I remember when there were patients who flew in from Tasmania to access the services. They were rather advanced in their pregnancy due to the delay on many fronts when they were seeking medical help. This really should not be the case.

I think it is a massive joke that there is no public services for this. It is a hush hush problem that everyone seems to sweep under the carpet. Even if you had the money to pay for the service, it seems the private sector have closed off their services.

I feel for the women in all walks of life who for some reason have ended up with an unwanted pregnancy, and in my experience, it is not always the young. We have middle-aged mothers too, who have had three children and really cannot afford another.

All the best in your good work and thank you for raising such an important issue.

There were some from other Tasmanian women -

Abortion is safe, legal, affordable and accessible. While it's legal here in Tassie, it certainly isn't affordable or accessible, which in turn makes it less safe.

And another -

Thanks for being a strong Tassie voice on the rights of women.

There were many other, similar messages. Restrictive sexual and reproductive health laws and/or policies do not prevent women seeking terminations. What they do is endanger women's health and lives because some of these women will seek unsafe procedures.

We must also remember there is a correlation between restrictive sexual and reproductive health laws and policies, and higher rates of maternal mortality and morbidity. There is a direct link.

This motion has nothing to do with a woman's right to choose. That was agreed by this parliament and all of us in 2013. This motion has nothing to do with whether women should be able to access termination of pregnancy legally in Tasmania because the law makes it clear they should be able to.

This motion is all about a current policy setting that sees Tasmanian women being unable to access a legal procedure that should be part of our comprehensive sexual and reproductive health service in our public health system. Women should not be forced into financial hardship or forced to leave family and other support to access a service that can and should be provided in Tasmania in our public hospitals and public health system.

This is a matter of caring for all Tasmanian women regardless of their background, regardless of where they live and regardless of their personal circumstances.

This motion is about equity of access to a legally supported health service that can and should be provided by public policy to avoid disadvantaging and discriminating against Tasmanian women. I urge members to support the motion to ensure equity of access to an important sexual and reproductive health service in our public hospitals for all Tasmanian women.

[5.41 pm]

Ms FORREST (Murchison) - Mr President, I thank members for their contributions. I will address a number of points that have been raised. This motion is not news; it has been around for some time. There has been an extraordinary amount of media coverage and attention paid to it. Termination of pregnancy is supported by our laws, and there has been adequate time for members to contact women's health services, family planning clinics, local GPs and the Leader's office to ask for a briefing from the Health department. Some members have done that.

I discussed this with people involved in the service delivery area of the Health service and now understand that in some jurisdictions this fight has been had. The service plan that forms part of the THS service plan and the legislation we dealt with last time we sat needs to include this as one of the comprehensive, sexual and reproductive health services in our state. So it is provided as part of the service delivery.

The previous private clinic closed due to reduced demand. The Leader said there was reduced demand throughout Australia, particularly for surgical termination, which is great. That is because of better contraception and better access to contraception, better sex education in schools and the provision of medical terminations with RU486 and similar medications. Medical termination is done either in a clinic or, ideally, in a woman's home.

There is no demand on public hospitals with the procedure. We are not talking about a huge impost on the public health system. We are not here to moralise. I note the member for Launceston's comments. She acknowledges that she has a religious opposition to termination, but that is her personal religious belief and I respect that -

Ms Armitage - That is nothing to do with this.

Ms FORREST - Yes and I respect that. Only half the people in this Chamber would have ever had to face that decision. The member for Rumney stated that she has never had to face that difficult decision. I have not either, but I have assisted a lot of women who have had to face this harrowing decision. I do not wish to know the circumstance of the other female members, it is not relevant. It does mean that they are the people who understand what it can be like to face an unwanted pregnancy, which is different from an unplanned pregnancy. Many pregnancies are unplanned but not unwanted. Not everyone who finds themselves with an unwanted pregnancy decides to terminate. Some seek adoption, which is great because that child gets taken care of by a family who will love it and care for it. Our open adoption laws mean that child can still have access to the biological parent or parents. There is a lot of work being done in that. Some women will decide to continue the pregnancy, as in the email I referred to earlier. That was an unplanned, unwanted pregnancy, but the couple decided to continue with it. Everyone has their own reasons. If a woman is raped or a victim of incest, which we see far too much of, having a termination does not take away the trauma of that, but having real challenges in accessing a termination when you are facing that circumstance can definitely add to the trauma of the event itself. We should not stand in judgment.

Other members have commented on the fact that we are funding termination through the public purse, through the Patient Travel Assistance Scheme. It is not a huge amount because only four women have accessed it. That may have been because they were going to Melbourne anyway, they had family support there; it may have been because they had private cover, or the ones who chose it were from the north-west or the north of the state and did not want to come south to access one of the private providers that may or may not see them in a timely manner because they have busy lists down here, too. Perhaps they went that way because, for me, living in Wynyard, I can leave my home at 5.45 a.m. and be in the CBD in Melbourne by 8.30 a.m. It takes much longer to get to Hobart. That is from Wynyard, not from Circular Head or from Strahan, or the far reaches of McIntyre.

This is what we are talking about here: equity of access so that women who have made this decision - not choice - are not forced to travel away from family. Even a five-hour drive is difficult in our circumstances. We should not be forcing women into that where the financial implications are significant. They and possibly their partner may need to take time off work, they may have to pay for child care for other children, and there may be other costs associated with it. It is about making it accessible at a major public hospital, not the regional hospitals as they do not do this surgery anyway.

It requires the THS service plans to include it as an option, as similar systems do in some other jurisdictions in Australia. If we remove some of the mystery about this - whether it is available, where it is available and how do you access it - that delays women seeking health and advice because they do not know where to go, we will see greater demand.

I referred to Canada and South Africa, where termination is available as part of the basic health system, and women seek advice earlier and are more likely to be able to use a medical termination so there is no demand on the public hospital system. We are not talking about huge demand. The procedure itself is quite quick, 15 minutes in an operating theatre, so to say you are going to delay a whole gynaecological list because you need to put one in is nonsense.

When I was a student nurse, which was many moons ago, and in my early years as a registered nurse, surgical terminations were done as part of the gynaecological list. They were popped in among the other gynaecological procedures, as they should be. It is not earth shattering; it has been done.

It is important to provide women with early advice so their full range of options are available, which include continuing the pregnancy, adoption of the baby or a medical termination provided it is before nine weeks or a surgical termination if it is not. That is what we agreed to in 2013, and that is what we need to ensure equity of access to now for Tasmanian women.

I see the member for Huon is back in the Chamber. He said there had been no consultation on this. As other members have commented, we have had time and the opportunity to undertake consultation during the intervening period between when this motion was put on the Notice Paper and today, and many members have done that. They have talked to a range of people to get the information they need. The Leader has provided some further advice on a private operator potentially coming to the south of the state, and four women accessing the Patient Travel Assistance Scheme, so we have a bit of an idea what we are talking about in the quantum of women who may need this.

There is no guarantee a private provider will come. There is no guarantee they will continue. It really is part of our comprehensive sexual and reproductive health services that our public hospital system should and does provide. We should provide it to all women who may need it, not just some, which is what is happening now. Only some women can access the public system, not all of them. It is only a small number who actually want it or need it. If you want a solution, it is to have it in the service plan. I will look at it with great interest when it is tabled in the new financial year.

As we have heard, the private providers that provide termination services are both based in the south of the state currently. I do not know whether any of you have had gynaecological problems and needed to see a gynaecologist. No, of course some of you have not - I understand gender may be the issue there - but many of these doctors have two month-long waiting lists.

Ms Rattray - At least.

Ms FORREST - That is not okay when you are six weeks pregnant and then to find time to get down to Hobart if you are on the far north-east, the far north-west or the west coast, or wherever. Time ticks away.

Ms Rattray - Two months' wait is in the north of the state; when you ring to ask for an appointment, they let you know if they consider your issue is where it is on the priority list, and they ring you back and make you an appointment.

Ms FORREST - That is right, you just do not know. The uncertainty is terrible. If there is a more streamlined pathway that enables more medical terminations, where a woman chooses that, it does not put any extra burden on the public hospitals as such.

Ms Rattray - But you have to have the gynaecologist's -

Ms FORREST - You do not need them to prescribe it. You can see a GP for that.

Ms Rattray - You can do it on the phone too, can you not?

Ms FORREST - Yes, you can go to Marie Stopes and that sort of thing. It is much more straightforward. If you do need a surgical termination, then you do. It is better to enable women to access this information earlier, then a lot of it can be avoided.

As far as the member for Windermere saying women can travel and that it is not that far, I have explained that it is quite far, particularly when they have a number of other personal circumstances that might make that even more challenging.

Ms Rattray - If you need to, it is by road, not necessarily by plane.

Ms FORREST - If you only need to go to the Launceston General Hospital from the north east or to the North West Regional Hospital from Circular Head, then a lot of them still have to travel a couple of hours to get there.

If we are going to be fair and equitable, it is a statewide service we are talking about that should be provided in a way that enables access for women in all parts, with all geographical backgrounds, all socio-economic backgrounds and all financial wherewithals - and some women just do not have fuel for the car. They may not have a licence; they may not have a registered vehicle. All sorts of challenges can present. They can often access public transport or a friend might take them from Smithton to Burnie, but if someone has to take them to Hobart, it is a different kettle of fish. That is the point.

If everyone had to travel to Hobart from the far north-west for their prostatectomy, would that be okay? Or everyone wanted a male only, because I do not have a prostate gland - I am pretty safe in that regard. I also will not need a vasectomy anytime soon either, but men can access vasectomies pretty much anywhere they live. That is part of our sexual and reproductive health services. Some of them do not have them of course.

This is a straightforward, simple procedure. We are not talking about neurosurgery. Neurosurgery should be done at the Royal Hobart Hospital, not at the Burnie hospital or the Launceston General Hospital. We are not talking about that; we are talking about a procedure that is very simple to do, that is already done in our public hospitals in Burnie and Launceston - for some women, but not all women. Only some, and the ones that are most disadvantaged are the poor women, the women from low socio-economic backgrounds, and those with other social challenges. That is not fair; it is not right or equitable. I urge members to support the motion. It is up to the Government to fully consider the options. That is why I asked a number of questions in the debate on the bill on the THS. To reflect briefly on this because it is relevant to the debate, I asked a number of questions particularly in the briefing and had a private briefing on that bill about how the service will be planned, formulated and the interplay between the secretary and the minister, and particularly if the minister disagrees with the secretary and how that could work.

The minister needs to make a commitment to the women of Tasmania, particularly those from rural and regional areas and from low socio-economic backgrounds, that he will agree to a service plan that has access to surgical termination - even though it is not a common occurrence, in many respects because medical termination has seen that reduction. No form of contraception, if you are sexually active, is 100 per cent effective. I urge members to support the motion: it will not put a huge drain on the public health system because of the numbers and it should be part of a comprehensive public health service.

The Council divided -

AYES 10

Ms Armitage

Mr Farrell

Mr Finch

Ms Forrest

Mr Gaffney

Ms Lovell

Ms Rattray

Ms Siejka (Teller)

Mr Valentine

Mr Willie