Health, as a broad concept, is a massive part of daily life for everyone, but especially for women who bear a disproportionate burden when it comes to reproductive systems, and further bear inequities in the causes of poor health, as well as the treatment options available.
Many of these inequities are not insurmountable, and are undoubtedly election issues for many women. In this series, I will discuss some of these issues, and the key points that women should be asking politicians and parties over the next few weeks.
Reproductive rights – access to contraception and termination of pregnancy
Menarche to menopause is typically around half the life of a woman who lives to the average life expectancy in Australia. According to 2016 census data, around 47% of Australia’s nearly 12 million women – or 5.6 million of us – are of childbearing age. Reproductive control and choice is a major issue for this enormous group of Australians.
Rubber condoms were invented in the 1850s and even Victorian-era women were educated about contraceptive techniques. The oral contraceptive pill was put to market in 1957 and since then, a plethora of other hormonal and non-hormonal contraceptive methods have become available, along with major modifications to the chemistry and dosing of the original hormonal contraceptive pill to decrease side effects.
Broadly speaking, contraception can now be divided into short acting reversible contraceptives, such as the oral contraceptive pill; long acting reversible contraceptives, such as implants in the arm, injections every three months, and intrauterine devices made out of copper or containing hormones; emergency contraception, also known as the “morning after pill”; and permanent contraception such as tubal ligation.
While it has been more than sixty years since the introduction of effective contraceptive methods, both the economic and health burden of preventing pregnancy continues to be borne by women.
While I acknowledge that reversible male contraceptives, other than condoms, are technically more challenging to create as male physiology is harder to manipulate with medications, we must remove some of the systemic barriers to women accessing effective contraception.
Short acting contraceptives are widely available, but there are still doctors and publicly-funded hospitals who will not discuss or prescribe contraception for religious or moral reasons. While I defend the right of individuals to act within their faith, this can create challenges in rural and remote communities where this can place limitations on contraceptive access for women in those communities.
Currently, the Pill can only be prescribed for twelve months at a time, so for women who have had to travel to access a prescription in the first place, it is very easy to let prescriptions lapse. While it is important that women on the Pill have regular health checks along with their prescription renewal, meaning that making these a pharmacist only medication is unlikely to be a positive step, it may be appropriate to allow doctors to provide extended prescriptions for contraception, such as in New Zealand where three year prescriptions are currently available.
And while it is possible to defend the right on a individual to act according to their faith, it becomes much harder to justify significant public funding going to organisations that restrict provision of the full range of women’s health services. The ongoing public funding of hospitals that refuse to provide certain services is absolutely a policy which needs review.
One of the great drawbacks of short acting contraceptives is that their efficacy in real world conditions is less than their efficacy in ideal circumstances. Women may forget to take the Pill every day, or take it at different times. Drug interactions or illnesses such as gastroenteritis may reduce efficacy of the Pill.
Newer practices such as ‘stealthing’ where a man agrees to wear a condom and then removes it prior to intercourse without the knowledge of his partner, also impact on women’s ability to prevent pregnancy. ‘Stealthing’ is not specifically illegal, and may constitute assault or rape, but this is as yet untested by Australian courts. In the meantime, Australian women remain vulnerable to this practice, which can result not only in STDs, but in unwanted pregnancy.
Long-acting reversible contraceptives can be a cost efficient and far more effective method of contraception, with failure rates of under 1%, compared to a failure rate of 9% with the Pill. Significant structural barriers prevent their widespread availability in Australia. In the US and Europe, up to 30% of women use long-acting reversible contraception, but the rates in Australia are as low as 10%.
While all GPs can be trained to insert implants or intra-uterine devices, the Medicare codes assigned to this are grossly inadequate. Understandably, this can be a lengthy consultation, requiring explanation around the choices and options, risks and benefits, and then actually undertaking the procedure.
As the Medicare rebates barely cover the costs of running a practice, there is a marked disincentive for GPs to offer this in their practices, even though the public health benefits and individual health benefits to female patients is undeniable. It is challenging for GPs to offer this as a cost-neutral intervention without charging private fees, which makes it even harder for women to access these better long acting methods. An urgent Medicare review and inclusion of appropriately funded item numbers for contraceptive management, including insertion of long-acting reversible contraceptives is needed.
In a climate of suboptimal contraceptive access, it is not surprising that termination of pregnancy is also a necessary service. Women have been attempting to terminate unwanted pregnancies for the duration of recorded human history, and likely for the duration of unrecorded history.
A significant proportion of unwanted pregnancies are not due to irresponsible or naïve behaviour, but due to contraceptive failure, especially in settings where the most modern and effective contraceptives are not available.
The lack of access to termination of pregnancy is complex, and varies widely by state. Most states in Australia have now decriminalised termination of pregnancy, but in NSW it remains illegal. South Australia has reasonable access to the service, it remains restricted in the eyes of the law. Tasmania faces the opposite problem – it has decriminalised termination, but despite having at least one gynaecologist willing to set up and run the state’s termination service, there is currently no service and no plans for a service, forcing women to travel interstate.
Rural and regional women in all states face the tyranny of distance and limited access, and most women face significant costs associated with access to termination services. Publicly funded access can be severely limited in both regional and rural areas, forcing most women to use private providers, who charge fairly for their services but must pass on the cost of maintaining facilities and infrastructure to their patients. This results in significant costs for even a first trimester medical termination.
The plight of rural and regional women has been in the news lately, and even prompted some commentators to suggest that those who are unwilling to perform termination of pregnancy should not be allowed to practice gynaecology, or even medicine at all. While this may seem a simple solution to a complex problem, there may be many reasons why any given individual may not wish to participate in termination of pregnancy, at any given time.
Termination is most often provided by specialties that are dominated by women – gynaecology and general practice – and many of these women may have any number of reproductive challenges themselves, ranging from a personal history of termination, to ongoing issues of infertility or miscarriage. Even a woman who has entered medicine intending to offer termination services may find it challenging by the time her training allows her to do so, or may find it challenging for parts of her life but not others. Furthermore, the barriers may not be just the medical staff, but may include nursing staff, theatre staff, and other staff within the hospital, whose hesitation may arise from needs more complex than simply a moral or religious hesitance.
Regardless of the reasons for declining to provide this service, we must remember that our health system remains short-staffed, especially in regional and rural areas. Many of these conscientious objectors – be they doctors, or nurses, or ancillary staff – are providing other essential medical services without which those communities would suffer. And while all health care professionals are obliged to discuss termination of pregnancy and refer patients without shame or judgement, we must likewise protect the well being of our health care workers, some of whom may not be able to provide all services at all times.
A more complex analysis would show that we can indeed spare some health care workers from the responsibility of personally performing terminations if we can optimise the overall health system and eliminate barriers for those who have no personal or moral difficulty.
Medical termination of pregnancy using the drug RU-486 has been available in Australia since 2006 and is now on the Pharmaceutical Benefits Scheme. The tablet alone costs as little as $6.40, but the process is much more complicated than buying and taking a tablet. A lengthy consultation with appropriate counselling is necessary, as with surgical termination, ultrasounds before and after are often required, the process actually requires an additional drug, and around 10% of medical terminations fail and so surgical back up is necessary.
Many providers of this service charge an inclusive fee which can be as high as $7-800. As with contraception and insertion of long acting reversible contraceptives there are no appropriate Medicare rebates available for providing medical termination of pregnancy. Only 1500 GPs in the country have registered to provide medical termination, not because of moral hesitance on the part of the majority, but because the remuneration is poor.
Medical indemnity can be an issue. For some years, medical indemnity providers classed this in the same category as surgical termination of pregnancy and levied an extra cost to a GPs personal insurance premium to offer the service at all. While this is no longer the case, not all GPs are aware of this change, and specific criteria must be met for GPs to be covered to offer this service, which acts as a barrier to providing this service.
At current consultation time based bulk billing rates, treating GPs offering medical termination of pregnancy actually incur a personal financial loss, and patients will usually face out of pocket costs from the ultrasounds and other investigations anyway. Given the paucity of providers, any GP who offers this, especially in regional areas, can come to disproportionately bear the burden of seeing patients for medical termination of pregnancy, which as a cost-incurring part of their practice rapidly becomes unviable unless private fees are charged. The genuine cost of this service is much closer to the $600 charged by largely not-for-profit organisations who currently provide this service – unless the service is provided remotely by telehealth in which case the cost can be reduced but represent a suboptimal service for some women who would benefit from face to face counselling with their own family doctor.
This perverse scenario is how Australia has some of the lowest rates of medical termination of pregnancy in the developed world, with only 15% of terminations being medical (and the remainder surgical), compared to parts of Europe where 66-90% of terminations are done using RU-486, often in comprehensive and funded clinics.
This lack of appropriate funding means that the greatest barrier Australian doctors face to offering termination services is not their own morals, but results largely from being priced out of providing the service.
The same can be said for surgical termination of pregnancy, which is not a complex procedure, and a standard intervention that all gynaecologists are trained to undertake as it is the same procedure as that for women who miscarry. GP proceduralists, especially in regional areas, can also perform surgical termination but the requirement to hold additional medical indemnity makes it financially unviable for most individual practitioners to do so. Surgical termination of pregnancy also requires a theatre team where all members are willing to participate, and therefore can be much harder to provide in sparsely populated areas than medical termination of pregnancy.
The widespread presence and policies of Catholic institutions in regional areas also prevents the provision of termination services. In smaller areas where the only private hospital in town is Catholic, doctors are often explicitly told that they will not be allowed to work there if they provide termination services elsewhere, such as at the local public hospital. A doctor who wishes to remain anonymous told me that they even knew of circumstances where a gynaecologist’s spouse in a separate specialty was also told they would not be allowed to work at the only private hospital if their spouse provided termination services in the public hospital.
Some GPs and gynaecologists, as well as nursing staff, are told that in small towns their families may be targeted by those opposed to termination, and therefore do not feel safe, even in 2019, providing a termination service. This has resulted in clinicians who happily provided such a service in the city stopping when they move to the country, as they are told their children will be targeted and their family will not be safe.
Obviously the law needs to be changed in some states, but even the recent decriminalisation of termination in both Victoria and Queensland was enacted without any plan as to how to actually increase publicly-funded services. Most health services have deliberately noted but ignored the change in law and have not introduced family planning or termination clinics within public hospitals, because there is no imperative on any single hospital to offer a full range of clinical services. It is impossible to expect our already stretched public hospitals to take on extra service provision without specific funding.
Indeed, specific allowances are made for organisations or their Boards to refuse certain services, especially on religious or moral grounds. So while decriminalisation is an important legal and philosophical step, decriminalisation alone does not equate to an increases in services, unless these are explicitly planned, funded, and mandated in such a way that hesitant or objecting Boards cannot limit them.
In summary, we have a situation where individual health care providers are left to bear the burden of a massive public health need, without sufficient funding or backup – not for the provision of adequate contraception that would potentially decrease (but not eliminate) the need for termination, and certainly not for termination itself.
In this climate, the recent Labor proposals, announced by Tanya Plibersek in March, to address these complex issues are welcome. Specifically, that policy considers the Medicare rebate for inserting long acting reversible contraceptives, practical support for medical termination of pregnancy, and a policy to ensure that Commonwealth-funded public hospitals offer termination services.
After speaking with many colleagues who work in this area, they would extend their wish list to a Medicare item number and sufficient funding for all aspects of providing and monitoring medical termination of pregnancy, addressing the requirement for expensive extra indemnity cover for providing surgical termination services to allow all motivated doctors to provide this service, regulation of Catholic health providers and other private hospitals to ensure that restrictions of practice on doctors for health services they offer elsewhere are eliminated, and widespread introduction of contraception and termination clinics at all public hospitals around the country so individual health care providers are not so easily targeted by those who oppose these services within the communities they live in.
For too long the focus has been on demanding that individual doctors provide these services – with supporters shaming the minority of doctors who can’t or won’t for whatever reason, and detractors shaming those doctors who do. As a society we have to stop placing the burden of women’s health on predominantly female health practitioners, and on women themselves, and create adequately funded and comprehensively planned health systems that provide high quality reproductive health care for half the population, who spend half their lives requiring it.