“Almost like it was really underground”: a qualitative study of women’s experiences locating services for unintended pregnancy in a rural Australian health system

Abstract

Rural women in Australia are more likely than urban women to experience unintended pregnancy, yet little is known about how this issue is managed in a rural health setting. To address this gap, we conducted in-depth interviews with 20 women from rural New South Wales (NSW) about their unintended pregnancy. Participants were asked about accessing healthcare services and what was uniquely rural about their experience. The framework method was used to conduct an inductive thematic analysis. Four themes emerged from the data: (1) fragmented and opaque healthcare pathways, (2) a limited number of willing rural practitioners, (3) small town culture and community ties and (4) interrelated challenges of distance, travel and money. Our findings highlight how pervasive structural issues related to accessibility of health services intersect with small-town culture to create compounding obstacles for rural women, especially those seeking an abortion. This study is relevant to other countries with similar geographies and models of rural healthcare. Our findings point to the necessity for comprehensive reproductive health services including abortion to be an essential – not optional – part of healthcare in rural Australia.

Résumé

Les femmes rurales en Australie ont plus de probabilités que les femmes urbaines de se trouver confrontées à une grossesse non désirée, pourtant, on sait peu de choses sur la manière dont ce problème est pris en charge dans un environnement de santé rural. Pour combler cette lacune, nous avons réalisé des entretiens approfondis avec 20 femmes rurales de la Nouvelle-Galles du Sud sur leur grossesse non désirée. Les participantes ont été interrogées sur leur accès aux services de santé et ce qui était typiquement rural dans leur expérience. La méthode de cadre a été utilisée pour mener une analyse thématique inductive. Les données ont fait apparaître quatre thèmes: 1) des parcours de soins fragmentés et opaques, 2) un nombre limité de praticiens ruraux disponibles, 3) une mentalité de petite ville et des liens communautaires, et 4) des difficultés étroitement liées de distance, de trajet et de coût. Nos résultats montrent de quelle manière les problèmes structurels omniprésents relatifs à l’accessibilité des services de santé s’ajoutent à la mentalité de petite ville et créent des obstacles plus importants pour les femmes rurales, spécialement celles qui souhaitent avorter. Cette étude est pertinente pour d’autres pays avec des géographies et des modèles similaires de soins de santé ruraux. Nos conclusions soulignent que des services complets de santé reproductive, y compris d’avortement, doivent être un volet essentiel, et non facultatif, des soins de santé en Australie rurale.

Resumen

En Australia, las mujeres rurales son más propensas a tener un embarazo no intencional que las mujeres urbanas; sin embargo, no se sabe mucho sobre cómo se maneja este asunto en un ámbito sanitario rural. Para abordar esta brecha, realizamos entrevistas a profundidad con 20 mujeres de Nueva Gales del Sur (NGS) sobre su embarazo no intencional. Se les preguntó a las participantes sobre su acceso a servicios de salud y qué aspecto de su experiencia fue típicamente rural. Se utilizó el Método Marco para realizar un análisis temático inductivo. De los datos surgieron cuatro temas: (1) vías fragmentadas y opacas a los servicios de salud (2) un número limitado de profesionales médicos rurales dispuestos (3) cultura de pueblo pequeño y vínculos comunitarios y (4) retos interrelacionados de distancia, viaje y dinero. Nuestros hallazgos ponen de relieve la intersección entre los aspectos estructurales generalizados relacionados con la accesibilidad de los servicios y la cultura de pueblo pequeño, y cómo esto crea obstáculos agravados para las mujeres rurales, en particular las que buscan un aborto. Este estudio es pertinente a otros países con similares geografías y modelos de servicios de salud rurales. Nuestros hallazgos señalan la necesidad de que los servicios integrales de salud reproductiva, incluidos los servicios de aborto, sean una parte esencial, y no opcional, de la atención a la salud en las zonas rurales de Australia.

Keywords:

• unintended pregnancy
• rural health
• health services accessibility
• abortion
• sexual and reproductive health and rights

Introduction

Abortion is decriminalised throughout Australia yet there is no national data collection of service uptake,^1–3 and up-to-date reliable estimates of unintended pregnancy rates are limited.^4,5 Health policy makers therefore do not know whether existing abortion services meet demand, or whether these services are acceptable to the women* who use them. Over the past decade, abortion access in Australia has progressed incrementally,¹ initially with the 2012 subsidisation of combined misoprostol and mifepristone medication (MS 2 Step) for “early medical abortions” (EMA) under 63 days gestation alongside existing surgical options.⁶ By 2021, all states and territories had at least partially decriminalised abortion.⁷ Temporary inclusion of “tele-abortion” in 2020 as a subsidised service under the Australian government’s Medicare Benefits Scheme meant general practitioners were able to offer medical abortion via telehealth at a minimal cost during the COVID-19 pandemic.^8,9 This resulted in a 189% increased uptake in remote areas compared to the previous year.¹⁰ However the subsequent re-introduction of restrictive eligibility criteria for telehealth abortion services, including requiring patients to have consulted with the same practitioner at least once in the previous year, yet again diminished access for rural populations.¹¹

Unlike similar geographically dispersed populations, such as in Canada,¹² abortion in Australia is not a routine publicly available health service.^1,9 Doctors in Australia can also legally refuse to offer abortion services based on personal, religious or moral “conscientious objection”, provided that they refer the woman to another available service and the refusal does not cause delay, distress or negative health consequences.² Yet while conscientious objectors may in principle have an “obligation to refer” women to an appropriate alternate service,⁹ this assumes information about other services is publicly available and referral pathways are clear. In New South Wales (NSW), the country’s most populous state, privately billing clinics and doctors are concentrated in metropolitan centres and a handful of coastal regional cities only. Unlike other Australian states and territories, there is no publicly available directory of the services available in NSW nor where to find them.

Rural women in Australia are more likely than urban women to experience an unintended pregnancy.⁴ Higher rates of unintended pregnancy in rural Australia have been found in other studies to be associated with multiple factors including unmet need for contraception, geographic isolation, scarce local reproductive health services, the requirement to travel to find alternative services and the financial and logistical barriers this can impose.^4,9,13 Australia’s rural health system adopts a generalist model whereby the entry point into the health system is usually via a general practitioner (GP) working in primary care.^14,15 Recent studies of rural reproductive health in Australia found a lack of adequate training, expertise, and in some cases unwillingness, among rural primary care providers to offer pregnancy counselling and abortion services to their local communities.^16–20 Those who do provide abortion services expressed reluctance to openly advertise for fear of reputational damage, stigma or being overwhelmed by demand.²¹ This leaves rural women at risk of having to travel long distances to reach services, and bear disproportionately high financial, logistical and time demands including fuel and accommodation costs, time off work, lost income and childcare arrangements.²² Once reached, some of these services have been described by rural women as costly, poorly integrated with local health providers and follow-up care and sometimes culturally unsafe.^{13,17,23–27} The recent emergence of telehealth-at-home abortion as an alternative to place-based services is an appealing solution for rural settings, but a recent study involving GPs across Australia revealed many were unaware of this service until a patient requested a referral.¹⁹ Inland rural populations in NSW thus experience what United States researchers have called an “abortion desert”– where the distance required to reach services exceeds 100 miles (160 km).²⁸

The existence of access barriers for rural women seeking abortion is well known in the existing domestic and international literature, usually reflecting experiences of women recruited at a point of care.^{13,18,20,25,29–32} Little is known about what happens to those rural women who attempt (sometimes unsuccessfully) to access different services to seek advice about what to do about an unintended pregnancy. Even less is known about those women who were unable to access the services they needed, or those who were turned away. With this in mind, our study devised a novel and deliberately inclusive community-based recruitment strategy to capture women with unintended pregnancy, irrespective of the outcome. To our knowledge, this is the first time such a strategy has been adopted in relation to unintended pregnancy in Australia and among rural populations more broadly. Through in-depth interviews, participants shared their lived experience of discovering they were unintentionally pregnant and the steps they took to seek the healthcare they needed.

Methods

Recruitment strategy

Recruitment flyers were designed and produced in consultation with a six-member Rural Women’s Health Consumer Advisory Group. Flyers were disseminated online on social media sites, predominantly Facebook community noticeboards of rural towns across Western NSW during a seven-month period from July 2021 to February 2022.

Influential rural social media accounts including two rural women’s magazines and one social media influencer were directly contacted to promote the study. Posters and flyers promoting the study were also placed in the waiting rooms of the eleven Women’s Health Clinics across the Western NSW Local Health District and in the Family Planning NSW Dubbo clinic waiting room. The lead researcher participated in interviews with three local rural radio stations about the study. All recruitment materials were produced in English language.

To join the study, participants were asked to text “Yes Hear My Story” to a dedicated research phone. A member of the research team then contacted the participants to confirm eligibility, arrange to send a copy of the Participant Information Statement and consent form and schedule an interview. Participants consented by returning a completed written consent form (via email) or providing verbal consent prior to the commencement of the recorded interview.

It is important to note that this period coincided with extensive COVID-19-related travel restrictions across Australia, including movement from rural areas into urban centres and interstate travel, and for several brief periods, complete “lockdowns” restricting all “non-essential-work-related travel” in the state of NSW. This did not affect the study recruitment strategies, as these were largely online. However, it did amplify pre-existing barriers to abortion care for rural populations. While telehealth abortion services were made temporarily available, and surgical abortion services were considered a permittable reason to travel, Sifris and Penovic state that the COVID-19 pandemic imposed new complications to pre-existing barriers for people who already had to travel for abortion services, and limited the ability for medical practitioners to travel outside urban centres to provide these services – impacting rural service delivery in particular.⁹

Interviews

Participants were interviewed via phone or video conference. To be eligible for the study, participants had to have experienced an unintended pregnancy in the past five years, and live or have lived in the Central to Far West region of rural NSW during that time.

Interviews were conducted in English by AN. A semi-structured interview schedule was developed in consultation with the Rural Women’s Health Consumer Advisory Group to ensure appropriateness for rural participants. After the first 10 interviews, the interview schedule was reviewed and additional questions were included to further explore emerging themes. This revised schedule was then used for the second wave of 10 interviews. The interview schedule contained demographic questions, open-ended questions to allow the participant to “tell their story” and for the interviewer to probe specific aspects of their story further, and final questions relating to desired improvements to rural reproductive health (see Appendix).

Within one week of completing the interview, all participants were sent a $AUD 30 (USD 20) gift card as recognition of their contribution to the study. Participants were also sent links to online resources about unintended pregnancy and pregnancy options from Family Planning NSW for future reference or to share among their networks.

Ethical approval for the study was granted by The University of Sydney Human Research Ethics Committee (HREC 2020/194) on 2 June 2021.

Data analysis

All interviews were audio-recorded and transcribed verbatim for thematic analysis. Names of people, locations and health providers were removed from transcripts to protect confidentiality of participants, particularly given the increased possibility of re-identification in a geographically specific rural context.

After transcription of the first 10 interviews, an interim analysis was conducted to develop a working analytical framework, in accordance with the seven stages of the framework method.³³ Interview transcripts were read and coded independently by AN, an experienced interviewer in rural communities, and by JT, an experienced sexual and reproductive health researcher, before meeting to discuss and compare codes. As a result of this interim analysis, four additional questions were included in the interview schedule to explore emergent themes. The same process of cross coding by AN and JT was undertaken with the following eight interview transcripts, by which stage the researchers had reached consensus on the data analysis and interpretation. With no new themes arising in the final two interviews, the researchers agreed that data saturation had been achieved and no further participants were actively recruited. Six interview transcripts were then randomly selected, and the themes cross-checked separately by researchers GL (rurally based academic with expertise in health service access and women’s health) and KB (academic clinician with expertise in reproductive health research) (three each). Discussion was then undertaken to reach consensus by the whole research team on thematic results.

All data were then imported into NVivo for indexing, final review of all transcripts and data management.

Results

Participant response rate

All but one of the 24 individuals who expressed interest in joining the study met the eligibility criteria. Three individuals did not respond after eligibility confirmation. A total of 20 participants were interviewed over an eight-month period from July 2021 to February 2022, with the two final interviews occurring in March 2022, one month after the recruitment period closed. The length of interviews ranged from 30 to 80 minutes.

Characteristics of the participants

Study participants lived in a range of rural locations, with almost half (n = 9) living in regional cities with populations between 30,000–45,000 people, and another quarter (n = 5) were from remote and very remote parts of NSW. Almost all participants (n = 18) had lived rurally for more than five years. Three quarters of participants (n = 15) reported having a higher education qualification. This reflects a highly educated sample, given only 20.5% of the Western NSW population reported the same level of education in the 2016 Australian national census.³⁴ More than half (n = 14) lived in postcodes classified by the Australian Bureau of Statistics as having “least” or “lesser” socio-economic advantage.¹⁵ All participants identified as being women. All participants were born in Australia, spoke English and three participants identified as being Aboriginal. 

Of the 20 women participating in our study, nine women carried their unintended pregnancy to term, and one was pregnant at the time of the interview and planned to continue the pregnancy. Ten participants had an abortion.

Findings

This study explores the experiences of 20 women living in rural Australia who became unintentionally pregnant and sought services from the existing health system for pregnancy options advice, abortion or for antenatal care.

In total, four themes emerged from the data. The themes were (i) fragmented and opaque healthcare pathways, (ii) a limited number of willing rural practitioners, (iii) small town culture and community ties and (iv) the interrelated challenges of distance, travel and money. The first theme describes the constant structural or systemic challenges rural women experienced when trying to access health care: finding available services, attempting to access those services, and the divergent experiences of those women who sought an abortion and those who continued their pregnancy. The second theme focuses on luck rather than system design determining the quality of their experience, both in terms of navigating the system and interpersonal interactions with healthcare workers. The final two themes highlight how characteristics of rural life influence participants’ experiences of unintended pregnancy. Theme three describes how the culture of close community ties and “small town life” influence the participants’ choices about where and from whom to receive care, as well as the challenges in maintaining confidentiality. Theme four focuses on the large distances between services and how these augment both the logistics burden and cost required to negotiate travel to receive timely care.

Theme 1: fragmented and opaque healthcare pathways

All but four participants sought health advice about pregnancy options including abortion in the early stages of their pregnancy. They described this experience as akin to navigating an unclear path without any guidance. The majority of participants described a health system that itself “didn’t know” how to best support them, that seemed ill-prepared, underequipped or unwilling to support their immediate needs and their follow-up care, particularly for those participants who sought an abortion.

Locating appropriate services from the outset was an issue for the majority of women in our study and several participants described this directly: “But where do you go to get a termination? Can you turn up to the emergency room? Can you have a conversation with your local doctor?” (RW009).

Searching online did not provide the information these women were seeking either; “We had a look at the basics online for what I could find on what I could do. It was hard to find stuff within my local region on places where to go” (RW008).

More than half the participants noted that they had to rely on their own professional connections in health or personal contacts within the health system to find out where services were available. One participant said she was “pretty good at navigating health systems” (RW003) only because she had a health background, whilst another spoke about the fortune of having a husband working in the medical field. This participant said, “I’m uniquely lucky because I have him and then he has his friends or people that he works with, that are doctors, quite regularly, that he can go, go see this person … ” (RW010).

Another participant described how “vulnerable” she would have felt without a personal connection “into” the health system. She stated, “I can’t imagine how hard it would be for women who don’t have anyone medical who can point them in the right direction, especially people who might consider termination” (RW011).

For those who knew that they wanted to have an abortion, they had to not only locate an available GP, but also one who would support their choice; “the first thing that popped to my mind is, oh my God, I’m going to have to try and find a doctor to get a referral that would actually speak about that, and that gave me serious anxiety” (RW016).

One participant described her relief at discovering by word of mouth about a doctor in a nearby town who could provide early medical abortions but did not advertise these services. She said, “It was almost like it was really underground, that that was a doctor on a regional level that was available that would prescribe this medication” (RW016).

When local providers were unsupportive, having to then restart the process in a context of very few options was problematic. This is highlighted in the following statement;

“Well it may have been even like two weeks in between seeing that first GP, not really knowing what to do, going and doing the test, confirming that I was pregnant and then finding out about the women’s health clinic and then getting an appointment there. So, by this point I was kind of already at like six weeks, so it was starting to get quite time critical.” (RW005)

The time-critical nature of early medical abortion (<63 days gestation in Australia) made this situation worse for participants and some described a building frustration at not being able to know which services were able to help them. One participant stated that she wanted to discuss pregnancy options “before the baby got too big” (RW003).

Once the decision was made to continue the pregnancy, however, the antenatal care pathway instantly became much clearer and easier to navigate. One participant from a remote area explained this in the following way:

“When we first got there I said to some of the staff members, I was like ‘oh I need to book in’ and they said there is actually a women and children’s clinic here, it’s separate from the hospital, it’s right next to the hospital, give them a call, the doctors are fine.” (RW017)

Theme 2: A limited number of willing rural practitioners

Almost all participants spoke about the influence of the first interpersonal encounter with a GP or health service in shaping their overall experience, irrespective of their decision to continue or terminate the pregnancy. Several participants also noted there was only one or very few GPs in their rural town or area.

About half the participants described feeling dissatisfied with their first interaction with a GP who they described as not offering or appearing to know how to discuss options or services available for unintended pregnancy, nor had any helpful information to share. For those participants who needed to find an abortion service quickly and those who had not made a firm decision about whether to continue the pregnancy or not, this was particularly difficult.

One participant described her frustration at waiting to see a local GP who then declined to assist her once he knew she wanted an abortion. She said:

“So the GP that I went to – for religious reasons – said that he wasn’t able to – like all he could do was kind of send me for a pregnancy test but that if I did want to terminate the pregnancy that there wasn’t anything he could do about it. He said he wasn’t really sure what I could do about it.” (RW005)

Over half the participants who continued their pregnancy expressed initial indecision and a desire for advice about available options including abortion from their primary care provider, which they did not get or felt was inadequate.

One participant described rushing to see the first female GP she could get into and discovering they were either unsure or unwilling to discuss all pregnancy options with her. She said:

“She was asking me all these questions and … I was like wow, I feel like we’re jumping ahead to something when I don’t even know what to do about the first question of ‘do I even want to have a baby or not’.” (RW002)

Another participant who ended up continuing the pregnancy spoke of the difficulty in asking questions of the only GP she could get in to see when trying to work out her options. She said:

“I didn't really get the answers I was looking for, I really, looking back now, I really just wanted to know what my options were, in terms of seeking – having an abortion, or keeping the baby. I did not know how far along you could be to access abortion, I didn't know where you could access it, I just had no idea, and I was too scared to ask the questions.” (RW019)

In contrast, supportive interactions with individual health providers had a significant impact, particularly when there were so few local options available. For example, one participant said;

“So, I went and saw my doctor … and she was super supportive. She was super understanding, which, I need to give her credit where credit’s due, you know, she’s … like you know, from a cultural background, and clearly, she puts aside every one of her personal beliefs for her patients …” (RW010)

For another participant, it was the thoughtfulness of the provider in communicating her situation to the sonographer that made all the difference. She said, “the nurse wrote notes that it was not a yay appointment, you know, this wasn’t a congratulations you're pregnant type appointment, that it was for potential termination and so she was actually really great” (RW005).

Another participant described being pleasantly surprised by the supportiveness of healthcare workers she encountered. She said, “I always kind of felt like people are judgmental about terminations and things but when I went there to do – into day surgery everyone was – people were really caring” (RW009). And yet for another participant, this interaction involved offering practical support to her as a single parent with a newborn baby. She explained, “they were all lovely because I’m doing it on my own and had no one to watch my baby, the nurses watched her while I was in having another ultrasound” (RW013).

Theme 3. Small town culture and community ties

In small rural communities in Australia, there is an increased likelihood that participants may know their healthcare providers personally, through workplace, family or social connections. Given the sensitive nature of unintended pregnancy and particularly abortion, participants spoke of the elevated challenges of maintaining confidentiality in a small-town setting or wanting to find providers who were outside their own community networks.

Living in a remote town and working at the hospital was described by one participant as putting her in a “tricky position” to have an abortion locally. She said, “the first option was stay in town, have a termination, have all of theatre know about it, have the doctors that I work with know about it and the porters at the hospital know” (RW007).

Another participant described how being a nurse in a small town and having to see her colleague for an EMA prescription made the experience “nerve-wracking” (RW018).

Another participant acknowledged how the culture of close community ties in small towns meant that having an abortion could easily become public knowledge. She stated:

“We live in a small town and you know everyone. So, you go into the doctor's surgery, you'd know all the staff that work there … you know – mostly you know a lot of the hospital staff … I think if you’re in that situation where you did want to, you'd probably try and go out of town.” (RW011)

The majority of participants also spoke about wanting to control who knew about their unintended pregnancy within their local rural community, for it not to become common knowledge. For example, one participant said, “I didn’t want my parents to know or my work colleagues to know and I didn’t want my ex-partner to know who I’d gotten out of a relationship with, in case he thought it was his” (RW009).

However at least a quarter of the participants described situations where their unintended pregnancy was “exposed” inadvertently through their interactions with health care workers, in part to due to the “everyone knows each other” (RW010) culture of rural towns and small communities.

One participant spoke about receiving care from the parent of one of her students but was reconciled to the likelihood of such exposure. She said, “I recognised her from parent teacher night, and so – but that’s the life we live, I guess, living in a smaller rural community” (RW010).

However for another participant, this experience was extremely difficult and eventually caused her to leave the town, even though her confidentiality had not been broken. The mere fact that most people know each other and hold various roles in rural communities proved too much for her to continue living in the town. She said, “It was just completely horrendous because everyone knows me. Even my doctor that I was just mentioning, that male doctor, he was a patron of where I worked and would regularly visit with his wife” (RW005).

Theme 4. The interrelated challenges of distance, travel and money

Participants in our study lived in a variety of rural settings, from large regional cities to small towns and remote cattle stations. For all but one participant, who said she was able to walk into her town to see her GP, accessing services meant travelling significant distances, usually in a privately owned car. For three-quarters of participants, the amount of travel (distance and frequency) was a burdensome aspect of their experience, with at least four participants stating the nearest service options were more than five hours away by car and that they incurred additional costs for petrol and in some cases accommodation. One of the younger participants explained this simply as, “Having to travel, petrol money. That was a big thing” (RW008).

Another participant commented on the magnitude of travel required for rural women, and the logistics associated to make that journey. She stated:

“I was able to, obviously, make it work, to have the day off work, and go for a trip like that. It's funny, if you think about those things, and you say to someone who lives in the city, and they're like, you had to drive 600 kilometres for an ultrasound, what?” (RW015)

She went on to explain that in remote areas where surgical abortion services are unavailable, the availability of telehealth options for early medical abortion is crucial. She said:

“I may have been stuck, with actually progressing with the pregnancy, because realistically I wouldn’t have been able to probably make in such short notice, the next stage possible, if I had had to actually go to a city for a surgical termination.” (RW015)

Among the five participants who did not experience lengthy travel, two still stated that the inability to travel and pay for the associated costs were inhibiting factors that limited their service options and choices.

Travel and the associated costs of accommodation were mentioned by 7 of the 10 participants who sought an abortion as significant factors in working out where they could go. One participant who had an abortion said:

“I’m not saying I would have had to do it privately, but [major capital city] is six hours drive, I would have had to find accommodation. I don’t even know who I would have gone to there, I’ve got no idea, but I know it would have been at a cost to myself.” (RW005)

Another spoke of having to have a medical abortion because she couldn’t afford the cost of a surgical abortion. She said:

“They were like, oh, yeah, that will be $600 for the termination and then $600 to be under and then the IUD is about 80 bucks, so not too bad. I was like …  … not too bad for who? Where do you think I get my money? Yeah, so the medical termination was $300. So, it was like, I guess we'll do that.” (RW001)

One participant spoke of the financial pressure imposed by the need to travel out of town for an abortion to maintain her confidentiality. The quandary this presented for the participant was evident when she said, “I actually don’t even know how I’m going to pay for accommodation. Do I want to get a credit card for this?” (RW009).

Another acknowledged that not all pregnant women would necessarily have easy mobility to travel to different regional centres to access care. She expressed this in the following way; “For someone like me, I've got my own car, I can do that, but there's plenty of people that don't. They either have to catch the bus or try and find their own way down” (RW011).

In contrast, referring to finding a local doctor with qualifications to provide EMA, one participant said simply, “I was just lucky that I lived in the town that he does” (RW018).

While no participant stated explicitly that they continued their pregnancy because they were unable to reach abortion services, over half of the participants who continued their pregnancy spoke of considering an abortion as a possible option, with four commenting on the difficulties caused by having to travel to find services.

Speaking about travelling to Sydney for an abortion, one participant who struggled to make a decision about what to do said, “I couldn’t even get to the local GP let alone – get a week off work and then someone has to look after the kids. You can’t just do that overnight, arrange everyone to watch the kids and then accommodation” (RW003). She went on to say that an EMA via telehealth was the only suitable service, as “there was just no option to go to the city”.

The need for travel also impacted on those participants who continued their unintended pregnancy. One such participant said she missed several antenatal appointments because she was simply unable to accommodate the travel required to access unanticipated antenatal care. She said;

“It was four hours, and then of course you had to go to your appointment, and that might take a few hours. Then you’re like, okay, well, do I drive home and risk getting – my car getting hit by a kangaroo or an emu, or do I stay the night? But then the night, okay, well that’s $140 for a motel room.” (RW012)

Another mentioned that the unplanned nature of the pregnancy meant she hadn’t budgeted for the additional travel, both in terms of time spent travelling to appointments and away from farm duties, and the cost. She said,

“Travel is just, you just got to plan around the sort of time, when you know you might have a bit of money … because all of our end the month bills and things like that come, so we can't really afford much fuel.” (RW006)

Discussion

This study presents findings from in-depth interviews with 20 women in Australia about their experiences managing unintended pregnancy in rural settings. Participants described their attempts to locate healthcare services once they discovered they were pregnant, and what that experience entailed. Our study findings highlight the compounding impact of complex and often intertwined challenges when seeking healthcare for unintended pregnancy outside metropolitan settings. These uniquely rural and disproportionate burdens are the thematic focus of this paper.

Firstly, participants described pathways to pregnancy options and abortion services as being unclear, disjointed and felt “underground”. Secondly, locating the few willing or supportive providers relied upon luck, previous history or personal connections. Limited service options in rural settings also meant some participants had no choice but to interact with health providers who were unsupportive or unaccustomed to discussing pregnancy options including abortion. This hard-to-navigate health service environment, combined with a culture of strong community connections among rural populations, caused additional complexities for participants in accessing their preferred services while maintaining confidentiality. Atop these three challenges was the significant cost and logistical requirements for many rural women who chose to – or had no choice but to – travel large distances to reach the care they needed.

Previous studies have found that women’s experiences managing unintended pregnancy can vary significantly depending on proximity to services, and the associated cost and logistical burdens of travelling to reach them.^{18,24,27,31,35–37} Our findings indicate that the absence of any clear pathway for rural women to reliably find supportive health services for pregnancy options causes frustration and unnecessary time pressure, particularly for those considering abortion. Alarmingly, comparison between our findings and a previous study with rural NSW women seeking abortion indicates little improvement in almost a decade.²⁵ Limited options of health providers in rural areas also left participants wholly reliant on the willingness of the few practitioners available to them. Participants in our study were thus exposed to a range of healthcare provider attitudes, expertise and varying levels of support, which is noted in other studies as having a significant influence on the individual’s quality of care.^36,38–42

Pervasive access barriers are not unique to rural Australia. Fragmented access and long wait times for appointments were reported in a similar recent study of women living in the remote Yukon territory in Canada,⁴³ and restrictions on abortion services in Texas saw some American women travelling unprecedented distances to find services, while for others this burden was simply too much.⁴⁴ Another US-based study described the compounding effect of numerous and interrelated barriers experienced by participants travelling more than 100 miles (160 km) to access abortion services, causing delays in care, negative health impacts and participants considering self-induction.³² It is worth noting the recent overturning of the Roe versus Wade legal decision protecting abortion as healthcare in the United States and subsequent banning of abortion services in many parts of the country will undoubtedly exacerbate this situation further. The findings of our study support previous studies with one point of difference – while in other countries with similar geographies such as Canada or the USA, information about where abortion services can be found is publicly available; in NSW there is no such directory.

While no participant stated explicitly that they did not have a desired abortion because they couldn’t find or reach an abortion service, it nonetheless raises the possibility that access barriers could lead to the possible continuation of an unwanted pregnancy. Further studies are required to explore this in more depth. As demonstrated by the longitudinal United States based Turnaway Study, denial of wanted abortion services can negatively affect the socio-economic wellbeing of the woman and her existing family.⁴⁵ In research terms, it also points out why inclusive recruitment strategies are important to capture those women who made several attempts to find services that met their needs or for whom appropriate services were simply out of reach or too hard to find. Almost all qualitative studies exploring unintended pregnancy in similar geographies and health systems recruit participants from a point of care – usually either an antenatal or abortion clinic or more recently at-home or self-managed telehealth services.^{29,30,32,37,46} Accounting for those who may not have been able to reach a service (where they then may have otherwise been recruited) is a strength of this study design. A recent US-based study adopting a similar community-based recruitment approach with young people in San Francisco echoed our findings; participants wanted comprehensive information about pregnancy options up front and an empathetic, non-judgemental provider at that crucial decision-making stage of early pregnancy.⁴⁷

It is clear from the rural women in our study that their needs are not currently being adequately met by the existing rural health system. Healthcare providers themselves have acknowledged that much clearer information about all pregnancy options including “no touch” or telehealth abortion services should be more accessible to women and practitioners alike.^19,48,49 Mandating publicly funded abortion services to be made available at all public hospitals, including in regional and remote areas, will go a long way in reducing fragmentation and improving timely, low cost, close-to-home access for the woman. It will also offer reassurance and “back-up” support to those primary care providers currently offering abortion services in isolation, and may encourage more rural GPs to become EMA prescribers. Already in an exploratory phase in Australia is the development of nurse-led models of abortion care designed to alleviate demand on GPs and enable greater access for rural women.^50,51 However, improvements to rural women’s reproductive health including abortion are not the responsibility of individual rurally based primary care practitioners, nurses or GPs. Rather, the findings in this study point to an urgent need for systemic repositioning of unintended pregnancy and abortion, out of the shadows of the health system and into the mainstream. The provision of clear referral pathways and an easily accessible public directory of available services in NSW especially in rural settings (or better still Australia-wide) is a logical first step.

Limitations of this study

There are several limitations of this study. Firstly, given its geographic specificity to Western NSW, the findings of this study are not representative or generalisable, but only reflect those experiences of participants. The analysis of this study was also limited to participant’s recollections of their experience managing an unintended pregnancy which may have changed over time and potential recall bias was not assessed as part of the study. Despite the age criteria including women from 16 years of age, the youngest participant was 22 years. While the use of English as the only language may have excluded participants from non-English speaking backgrounds, only 12.6% of households in Western NSW spoke a language other than English compared to the New South Wales state average of 31.5%.³⁴ The focus of the study on women’s experiences of managing unintended pregnancy, rather than specifically on the care they received, complemented by a successful community-based recruitment strategy, enabled an exploration of women’s experiences and interactions with multiple services, including those which were unhelpful. This provides a different view of the primary care setting in rural areas than studies focussing on one point of care. The much higher education level of participants than the population average for Western NSW suggests our study findings may reflect a subpopulation with higher health literacy and financial resources, and thus increased likelihood to identify and pay for health services including abortion.³⁴ While this may be considered a possible limitation, the diversity of voices and varied geographic and socio-economic backgrounds of participants remains a strength of the study. The inclusion of women who continued their pregnancy as well as those who sought an abortion offered a unique insight into shared and divergent aspects of their experience interacting with the health system among these two groups. Finally, since eligibility was limited to unintended pregnancies in the past five years, this time period encompassed several key changes in women's reproductive health in NSW; including the recent introduction of early medical abortion, decriminalisation of abortion in NSW and significant changes to telehealth service provision in primary care during the COVID-19 pandemic.

Conclusion

Women managing unintended pregnancy in rural NSW are currently reliant on the availability, knowledge, willingness and supportiveness of the limited number of healthcare providers within their reach. In the absence of clear referral pathways or a publicly available directory of services, it is often luck and connections that enable rural women to find the services they need in a timely way. Without these, rural women face compounding and potentially inhibiting barriers to accessing their preferred services, particularly for abortion. The Australian health system needs to embrace a new era of comprehensive reproductive health for all. This includes rethinking the way in which information about unintended pregnancy and abortion services is made available and reshaping the model of care to be comprehensive (including after-care) and easily accessible in multiple modes (i.e. telehealth, nurse-led models, GPs, public abortion services) to all women, especially those outside metropolitan settings.

Acknowledgements

We thank all the rural women who participated in this study for their willingness to share their personal stories, for their generosity of time and for their support for research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research was supported by a PhD scholarship funded by the National Health and Medical Research Council (NHMRC) in Australia (APP ID 1153592 ) and awarded to the first author by the SPHERE Centre for Research Excellence in Sexual and Reproductive Health for Women in Primary Care.

Notes

* This paper uses the words woman or women but the authors wish to acknowledge that other people who do not identify as women also experience pregnancy and may also need pregnancy options and abortion services.

Appendix

Interview schedule – rural women revised OCT 22 2021

Interviews with rural women – question guide

Interview guide

Introduction

Hello – My name is Anna Noonan. Thanks very much for agreeing to participate in our study.

Q0: Just before we start, are you happy for me to record this interview? The recording will only be used by me and my three supervisors for research purposes.

Ans: Yes – Thank you, that’s great, I will start the recording now.

Ans: No – Thanks for letting me know. We may not be able to proceed with the interview at this stage, as I will need to use the recording to complete the research, but thank you for your time.

Q1: Have you had a chance to read the plain language Participant Information statement I sent you?

Ans: Yes – Can you tell me what you are going to be asked to talk about with me?

Ans: No – Please read the plain language statement now or would you prefer for me to read it to you?

Once participant has indicated that the PLS has been read or interviewer has read it to the participant, interviewer to ask – Can you tell me what you are going to be asked to talk about with me?

Q2: Okay, thanks for that. Are you happy to proceed with the interview or do you have any other questions?

Ans: Yes happy to proceed – Great, let’s get started.

Ans: No – answer any questions and repeat Q 2. once all questions are answered.

NB: Question 2 will provide verbal consent.

Background: We are going to start the interview with some straightforward questions about you. Please be reassured that no information that might identify you will be made available to anyone outside of the research team. This includes anything you might say or name during the interview including names of people or places.

Q3: Can you please tell me your age?

Q4: Can you please tell me your postcode?

Q5: What is your highest level of education?

Q6: Are you currently working in paid employment? If so, how many hours are you employed each week?

Q7: How long have you lived in a rural community?

Q8: What is your nationality?

Q9: How would you describe your cultural background?

Q10: Do you have any religious or faith-based affiliation?

Q11: Have you been pregnant before? (NB If participant answers no, interview concludes after this set of questions)

Q12: How many pregnancies have you had?

Q13: Thanks for these questions, Now I’d like to ask you about your general experience of requesting or receiving reproductive health care in a rural setting. Can you tell me about that?

Follow up with prompts whenever necessary. For example:

• Have you engaged with local health services to help you manage contraception?

• Have you engaged with local health services to help you plan a pregnancy?

• Have you been pregnant before? At what stage of your pregnancy did you seek some health services?

• How did you know where to go to seek the health care you were after?

• What other reproductive health information did you seek at that time?

• What was your experience in speaking to that provider?

• Did you feel like you were given all the information and options that you wanted/hoped for?

Thank you, this is really great information for us. Now I’d like to ask some more specific questions about your experience in managing an unwanted pregnancy. This is a particular focus of our research, and the aim of this focus is to better understand what rural women’s needs are.

Q14:Have you ever had an unintended pregnancy? This could be a pregnancy that was unexpected, came at the wrong time or a pregnancy that was not wanted at all.

Ans: Yes – If you are comfortable doing so, can you tell me about how you were able to manage this pregnancy?

Ans: No – No problems at all. Perhaps I can open that out a little bit. Have you ever fallen pregnant unexpectedly, or had a pregnancy that you felt unsure or ambivalent about?

If answer is No, the interviewer then asks, would you like to share your experience of accessing health care for your first planned pregnancy?

Follow up with prompts whenever necessary. For example:

• How did you work out what to do about it?

• Were you able to find information about where to go/who to see?

• How did you feel about seeking health care services to manage this pregnancy in a rural context?

• Did you have any expectations? What were they? Did your experience meet your expectations? If so, can you explain how? If not, can you share why not?

• We know that cost and logistics can sometimes be major factors for rural women in deciding how to manage unwanted pregnancies. Did these factors affect you? How so?

• Do you think your experience would have been different if you lived in a city or urban area, or in a more rural/remote location? If so, how?

[Additional questions for second wave based on emerging theme of ‘navigating the unknown’ from preliminary review of RW001-RW007. These may be asked during the conversation as appropriate, and not necessarily in this order:]

•   ○ Is this the first time you’d experienced an unintended pregnancy or considered having an abortion?

•   ○ Can you tell me what knowledge or idea you had beforehand about what would be involved / what steps you’d need to take / had thought about what you’d need to do if / once you discovered you were unexpectedly pregnant and were considering options?

•   ○ Was there anything about the experience that was completely unknown / unexpected to you (other than the pregnancy itself)? Can you describe what this was like?

•   ○ How do you think your first interaction with a healthcare professional affected your experience? (including your decision-making)

•   ○ What were the factors that helped you make your decision about the pregnancy?

Q15: We are trying to think about ways that we can help rural women access the same reproductive health services as other Australian women who live in cities. Can you share any thoughts on what you think we should be focusing on?

[Additional questions for second wave based on emerging theme of ‘’impact of the experience’ from preliminary review of RW001-RW007. These may be asked during the conversation as appropriate, and not necessarily in this order:]

•   ○ Do you feel that you got all the support you needed while you were working out how to manage your unintended pregnancy?

•   ○ What about after you’d made your decision (and in the case of abortion), after you’d had your termination?

•   ○ How many people around you in your life did you feel you could talk to about your experience? What if anything prevented you from sharing your experience?

•   ○ Thinking about it now, what kind of additional support would have been helpful, and at what stage?

•   ○ How did the experience affect your personal relationships if at all?

[Additional questions for second wave based on emerging theme of ‘enabling and inhibiting factors’ from preliminary review of RW001-RW007. These may be asked during the conversation as appropriate, and not necessarily in this order:]

We’re about halfway through our interviews and have seen some common themes mentioned by other participants that we’d like to share with you/seek your feedback on.

•   ○ One of these is about your preferences – hypothetically, if there was a local clinic in town that would offer abortion services as well as other reproductive healthcare, do you think you’d feel comfortable using that service? If so/not, can you explain why?

•   ○ What do you think should be available to women living in rural and remote parts of the country? How could the process of managing unintended pregnancies be better organised/set up?

•   ○ Do you think choice is an important factor in deciding whether to have an abortion and where/what type of abortion?

•   ○ What other factors do you think – positive or negative – influence how rural women experience an unintended pregnancy?

•   ○ What would have made the biggest difference to your experience?

•   ○ What would you share with a friend or loved one if they discovered they were pregnant unexpectedly and asked your advice?

Q16: Is there anything else about your experiences that we haven’t talked about that you’d like to share?

Thank you very much for participating in this interview, your contribution has been fantastic. We really appreciate your willingness to share your story and acknowledge that finding the right care in the rural setting is not always easy. Thanks for giving us the opportunity to learn from your experience.

Before we finish the interview, we understand that discussing personal topics can, at times, cause some emotional discomfort. If you feel that you would like to discuss how you’re feeling or any emotional reactions to the topics covered by this research project, we advise that you make use of the free counselling services provided by Lifeline: 13 11 14.

This service is available 24 h a day and also provides referral services, should you require any. Alternatively, if you’d like to discuss anything in person, we would encourage you to make an appointment with your regular health care provider.