Complexity and contraception

Contraception

Image: Grab a Condom Embroidery Hoop/ Hey Paul Studios on flickr

People educated in Australia of  ‘a certain vintage’ have the pleasure of recalling the days when school sex education entailed a perky film about the family life of ducks and geese, followed by an obtuse talk from teachers about love and suddenly, babies. How things have changed: now children come home from school teaching their parents the proper (and not so proper) words for all things sexual and reproductive.

But we can’t take for granted that everyone in the Australian community has what they need to live informed and enjoyable sexual and reproductive lives. First, knowing where everything is and how to use it is only a small piece of the puzzle: this knowledge must be complemented by a solid grounding in respect and equality within relationships, and taught in the context of a broad, non-judgemental sexuality education. And what of migrants and refugees, the majority of whom arrive in Australia after secondary education is completed?

Recently we explored this question by conducting some research, together with researchers from Monash University, into immigrant and refugee women’s experiences of contraception in Australia. The findings, based on interviews with 84 women, were a little surprising in terms of what women know and what they choose to do with that knowledge.

Awareness of the range of contraceptives available to women was relatively high, with some variation depending on the availability of sexual and reproductive education and information in women’s country of origin. In some cases, state-funded education was available in country of origin, but only to the ‘about to be married’, which meant that many sexually active people missed out. In other cases, education was hard to come by through formal channels, and women relied on more informal means such as talking to family and friends, or Dr Google.

In many cases, awareness accorded with the likelihood that women would use that method: we noted a high awareness of non-hormonal methods (91%), such as male condoms, withdrawal, and natural family planning methods, which combined made up 76% of the women’s choices. Surprisingly, however, only 5% of women chose the pill even though 95% reported being aware of it.

A complex range of factors influenced women’s choices, including the cost and availability of, and access to, certain types and brands of contraception in Australia. Of the women who were using hormonal methods, such as Depo Provera, implants or the pill (total 15%), some obtained their supplies from practitioners overseas, in order to negotiate factors such as continuity of care, the difficulties of translating medical records, and the lack of interpreting services in Australia. A group of women reported waiting until their regular visits overseas to book in their gynecological appointments at which they would also arrange their contraception for the period until the next visit.

These findings indicate that for many immigrant and migrant women, contraception remains difficult to negotiate. Information is lacking, and structural barriers such as cost, language and lack of access prevent many women from making free and informed choices about what suits them best. What is needed is a broad and comprehensive program of sexual and reproductive education suitable for women from diverse communities. We also need to consider how access can be improved. If sex education at schools has progressed from the days of the duck family, we now need to extend that wisdom to ensure that informed choice is the order of the day for immigrant and refugee women.

Research Project: Contraceptive Technologies and Reproductive Choice Among Immigrant Women

 

Professor Lenore Manderson (front, left); Associate Professor Andrea Whittaker (front, right) and Ms Azam Naghavi (back, right) from Monash University with the MCWH bilingual educator interview team.

Professor Lenore Manderson (front, left); Associate Professor Andrea Whittaker (front, right) and Ms Azam Naghavi (back, right) from Monash University with the MCWH bilingual educator interview team.

Last week researchers from Monash University conducted an interview training workshop with a group of MCWH bilingual health educators.  Our bilingual health educators were trained to conduct research interviews for the Contraceptive Technologies and Reproductive Choice Among Immigrant Women ProjectThe research will identify how immigrant and refugee women access information and advice about contraceptives; their use of sexual and reproductive health services; and how providers ensure women’s informed choice.  The research team will interview 70 women from at least four different countries, including India, China, Afghanistan and Sudan.  The Project is being conducted in partnership with Monash University, the Centre for Culture, Ethnicity and Health and Family Planning Australia Alliance.

The research project is funded by an Australian Research Council Linkage Grant 2013-14.

 

RU486: where to from here?

The government’s decision to list mifepristone and misoprostol (RU486) on the Pharmaceutical Benefits Scheme (PBS) should be seen as victory in the battle for women’s right to choose.  Women now have the option, during the seven weeks’ gestation period, of choosing a safe, less-invasive medical termination. But as with all things that have been long-awaited and hard-fought, we shouldn’t feel complacent. A victory for all women? It should be. So, in the interest of ensuring RU486’s availability lives up to its potential we take a good hard look at the fine print accompanying such a milestone achievement.

Its listing on the PBS means the cost of the drug will drop down from $300 to $36, which is reasonably affordable for most women. But what about the women who are not eligible for Medicare and are therefore not eligible to claim for PBS-listed items? Immigrant women on temporary migrant visas such as international students and temporary 457 workers will continue to pay the full cost for RU486 for the first twelve months after their arrival, unless they are paying for a level of private health insurance which includes pregnancy related health care with no waiting period. So if you don’t have plans to get pregnant immediately (in which case you probably wouldn’t need it) chances are you won’t have the cover needed to make RU486 affordable. In our work advocating for international students’ access to pregnancy-related care, we’ve learned that over 70% of insurance claims in the first twelve months are ‘pregnancy-related’. Whether the claims are related to contraception; termination; or child-birth is anyone’s guess because this data is not publicly available.

Which brings us to another critical factor in RU486 being made available and accessible to all: the need for comprehensive and systematic collection of abortion statistics. If we don’t know the extent of what is happening to whom and why, then it makes it difficult to monitor the safety, quality and equity of access to abortion. Some groups of immigrant and refugee women, for example, are more at risk of adverse sexual and reproductive health outcomes than Australian-born women. A national abortion register would assist in designing and evaluating targeted health promotion programs.

The availability of RU486 spans complex territory and no doubt, it will continue to attract controversy and debate (for starters, how might we regulate conscientious objection?). But now that we’ve come this far our efforts should continue to sit squarely with the health and wellbeing of all women. Addressing barriers to access for women who are marginalised or disadvantaged by ethnicity, visa status, disability and/or socio-economic factors is a good place to start.

We’ve just released a Position Paper about International Students’ Access to Pregnancy-Related Care and why the laws around Overseas Students’ Health Coverage need to be amended.