The role of primary care in optimising women’s sexual and reproductive health

Welcome to this special issue of the Australian Journal of Primary Health on optimising women’s sexual and reproductive health in primary care. Many women in Australia have limited access to sexual and reproductive health information and services, which can affect their physical, social and economic wellbeing as well as that of their families and the wider community. Given the central role of primary care to women’s health and wellbeing, we put together this special issue to explore the ways in which primary care settings and practitioners can optimise women’s sexual and reproductive health. The papers in this special issue explore a range of issues and opportunities across the spectrum of sexual and reproductive health, including in relation to contraception access (Dev et al. 2023; Li et al. 2023; Mazza et al. 2023); support for unintended pregnancies (Noonan et al. 2023); abortion care (Haas et al. 2023; Srinivasan et al. 2023); preconception, pregnancy, postpartum and interconception care (Fitch et al. 2023, Li et al. 2023; Simhi and Yoselis 2023; Withanage et al. 2023; Thomas et al. 2023; Yussf et al. 2023); and issues relating to informed consent (Power et al. 2023). The special issue takes a reproductive life course perspective through consideration of both pregnancy prevention and pregnancy preparation (Hall et al. 2023).

There is a high unmet need for effective contraception in Australia and a number of barriers to access, including the availability of services. Several of the papers in this issue discuss key strategies to increase access to contraception, including provision through pharmacies (Dev et al. 2023), primary care settings (Mazza et al. 2023), and during antenatal and postnatal care (Li et al. 2023). In their paper, Dev et al. (2023) explore Australian women’s perspectives of and preferences for the provision of over-the-counter access to the oral contraceptive pill, finding that this may be an acceptable model of care for many women. Mazza et al. (2023) similarly recommend increasing access to contraception through alternative models of care; in their study, through the establishment of a network of rapid referral clinics for long-acting reversible contraception. They report that although contraceptive implant insertion procedures are generally well-integrated into general practice, few general practitioners (GPs) insert intrauterine devices, which is a significant barrier to access. Findings from Li et al. (2023)’s qualitative study exploring Australian women’s experiences of, and preferences for, accessing postpartum contraceptive counselling found that most women did not receive in-depth contraceptive counselling antenatally or postnatally, but would have found this useful. Contraceptive uptake in the postpartum period may be promoted by ensuring consistent and routine provision of contraceptive counselling for women both antenatally and postnatally (Li et al. 2023).

Limited access to contraception services is a key contributor to unintended pregnancy. A high proportion of women experience an unintended pregnancy in Australia, with rates even higher in non-urban areas. Deciding how to manage an unintended pregnancy commonly involves consideration of two possible outcomes and associated reproductive healthcare pathways: continuing the pregnancy and receiving antenatal care, or not continuing the pregnancy and receiving abortion care (Noonan et al. 2023). However, rural women with an unintended pregnancy commonly experience gaps in quality of reproductive health services and delays in access and require better access to care and support to make decisions about and reach their preferred services for unintended pregnancy (Noonan et al. 2023).

Access to abortion care also remains highly inequitable in Australia, particularly in rural and regional areas with fewer services and health practitioners providing these services. There is limited availability and inconsistent access to both medical and surgical abortion services in many parts of Australia and few publicly-funded options available in most states (Srinivasan et al. 2023). There is an urgent need for transparency around public abortion service availability, clear guidelines to support referral pathways, and government commitment to expand the availability of accessible abortion care (Srinivasan et al. 2023). Additional strategies to increase access in primary care settings, particularly to medical abortion services, include having access to a community of practice, enhanced training and reducing stigma, along with more effective implementation of relevant clinical guidelines (Haas et al. 2023).

For women who do desire children, or wish to proceed with an unintended pregnancy, general practice and other primary care services are ideal settings to provide reproductive health support, including in relation to pregnancy planning and preconception care, pregnancy support, and postnatal/interconception care. However, these aspects of reproductive healthcare are not always routinely offered or available to all women, as described in the papers outlined below.

Many women fall pregnant unintentionally, or without optimising their health prior to conception. Primary care practitioners are well-placed to support women in planning for (or preventing) a pregnancy. The One Key Question® tool was developed to facilitate discussion of pregnancy intention and subsequent discussions regarding preconception or contraception care. Fitch et al. (2023) report that use of this tool is generally acceptable to both GPs and women and can help to introduce pregnancy intention discussions into a consultation. Being aware of pregnancy intention can support primary care practitioners in discussing preconception (or contraception) care with women. For women wishing to fall pregnant, or considering a future pregnancy, provision of preconception care is effective in reducing modifiable risk factors and optimising maternal health. However, preconception care is not routinely provided in primary care. In their forum article, Withanage et al. (2023) discuss the factors that hinder provision in Australian general practices and make recommendations for improved access, including the potential role of general practice nurses. The interconception period, or period between pregnancies, similarly provides an opportunity to address women’s health risks and optimise health before a next pregnancy. Thomas et al. (2023) report on a scoping review exploring models of interconception care delivered at well-child visits, finding that such models can be challenging for health practitioners due to time and funding constraints, but are beneficial and acceptable to women. They suggest that increased capacity for interconception care at well-child visits could be achieved with targeted resources and time allocation.

This special issue also includes two papers relating to important aspects of pregnancy care: perinatal depression (Simhi and Yoselis 2023) and vaccine-preventable infections (Yussf et al. 2023). Mental health disorders among women during the perinatal period are common yet it is not known why some women develop depression during this period. In their narrative review, Simhi and Yoselis (2023) explore social determinants of health and their correlation with clinical depression in the antenatal period, suggesting that the mental health of high-risk pregnant women could be better supported by improving socio-economic conditions and facilitating integration of women fully within the social construct. In relation to provision of perinatal services for the prevention of vaccine-preventable diseases, Yussf et al. (2023) report on the barriers to optimal care delivery and the need for coordinated and standardised systems, including training and education for health practitioners, improved data collection, and communication among health services.

The final paper in this issue considers issues relating to informed consent, which are relevant to all aspects of care across the reproductive life course. Power et al. (2023) explore the issue of informed consent with a particular focus on the experiences of Australian health practitioners working with women born in Burma. They highlight that accepted Western-based practices for obtaining informed consent are not a ‘one-size-fits-all’ process, and promote the importance of non-verbal communication and individually tailoring consent conversations to facilitate and optimise informed consent processes within the Australian primary healthcare context (Power et al. 2023).

Within this special issue we consider some of the opportunities for increasing access to sexual and reproductive health care in Australia, including through better integration of services into general practice and other primary care settings through appropriate training, remuneration and referral pathways for primary care providers, use of task-sharing with nurses, and consideration of alternative models of care. Equitable access to high quality sexual and reproductive health information and services must be improved in Australia to optimise women’s health and wellbeing and support them to achieve their reproductive life goals. The papers presented in this special issue have the potential to influence policy and practice and contribute to policy initiatives such as the National Women’s Health Strategy 2020–30 and the National Women’s Health Advisory Council established in early 2023. This special issue explores the opportunities and strategies needed to improve the capacity and quality of primary health care services to achieve better outcomes for women’s sexual and reproductive health in Australia.

Conflicts of interest

D. Mazza and J. Botfield were guest Associate Editors for this special issue.