Achieving better sexual and reproductive health for women

Approximately one-third of Australian women have an unplanned pregnancy at some point in their lives.¹ Rates are higher for women living in rural areas and those from poorer socioeconomic backgrounds.² In Australia, the vast majority of women use less efficacious forms of contraception (eg the hormonal contraceptive pill) rather than long-acting reversible contraception (LARC) such as intrauterine devices (IUDs) and the contraceptive implant.^3,4 Few women receive preconception care (PCC), despite many having risk factors such as smoking, alcohol use and obesity,⁵ and/or poorly controlled chronic disease, putting them at increased risk of poor pregnancy outcomes.

Preventing unintended pregnancies and optimising maternal and fetal outcomes are important public health imperatives and a key focus of Australia’s National Women’s Health Strategy.⁶ Australia’s 35,000 general practitioners (GPs)⁷ are the first point of contact for Australia’s 5.57 million women of reproductive age⁸ for contraception and pregnancy-related issues, whether planned or unplanned. However, complex system, patient and practitioner barriers exist to delivery of best-practice care.

General practice is critical to increasing LARC uptake⁹ as per guideline recommendations.¹⁰ However, only 6.9% of all contraception consultations involve LARCs.⁴ Women’s contraceptive choices also play a key part and generally fit their needs, values and preferences,¹¹ but lack of awareness of the range of options open to them and misinformation, particularly in relation to IUDs,¹² affect choice. Among GPs, lack of familiarity with LARC and misperceptions about their suitability for young women¹³ limit women’s options.¹⁴ Lack of education and training for GPs, lack of follow-up support after training and inadequate remuneration for LARC insertion are also real issues.¹⁰

While one in five Australian women will have an abortion in her lifetime,¹⁵ access to services, particularly in rural areas, and high out-of-pocket costs remain significant hurdles.¹⁶ Better integration of medical abortion services into general practice facilitated by more training and removal of regulatory barriers could help overcome this.

Time constraints, lack of knowledge and lack of resources for patients impede PCC.¹⁷ In addition, many pregnancies are unplanned, and GPs have limited access to young women to provide such advice despite the fact that women want their GPs to be more proactive in promoting PCC availability.¹⁸

A paradigm shift in the way that contraception, abortion and pregnancy planning services are delivered in general practice is therefore required. Structural and policy barriers, together with lack of clinician training, have engendered a siloed form of practice in which these issues are considered in isolation. More preferable is an integrated life course approach facilitated by evidence-based policy and practice innovations to help women achieve their reproductive goals. SPHERE (www.spherecre.org), a National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Sexual and Reproductive Health Care for Women in Primary Care, has been funded to support primary care to achieve this through better integration of PCC, LARC and medical abortion into the scope of general practice and improved quality care.

Improving women’s access to essential sexual and reproductive health services (eg LARC insertion and abortion) is also critical. When GPs are trained in effectiveness-based contraceptive counselling (where women are informed of all their contraceptive options, with the most effective ones [LARC] discussed first) and given rapid access to LARC insertion clinics, there is greater LARC uptake by women.¹⁹

Other patient-centred approaches that involve ascertaining women’s reproductive goals (while recognising that some women can be ambivalent), building open and trusting relationships with patients, asking open-ended questions and prioritising information delivery on the basis of patient preferences are also required.²⁰

Increasing the number of GP providers of medical abortion is also a very important step to ensure accessibility to this service in Australia, particularly for women who are vulnerable and those living in rural areas.