Chapter 1Introduction

1.1Access to sexual, reproductive and maternal healthcare is a fundamental human right which contributes to positive health, social and economic outcomes across the whole community. Australia’s health system must enable all people to effectively exercise choice and control without fear of discrimination or disadvantage and to be adequately supported in their decisions. Women in regional and remote areas in particular should feel confident that they can access appropriate sexual, reproductive and maternal healthcare without facing excessive barriers of cost or distance.

1.2Throughout this inquiry, the committee heard that enabling universal access to reproductive healthcare has the profound capacity to improve community health and well-being, develop a culture of inclusion and safety, and enhance workforce participation.

1.3Reproductive healthcare is an intrinsic part of life, particularly for women, transgender people, and non-binary people, and inadequate access to these services can have significant negative impacts on these individuals’ mental, emotional, and physical health. The consequences of this have flow-on effects, and can impact education, gender equality, and the economy. Intersectional and vulnerable groups within the Australian community particularly suffer from these consequences, as the reproductive healthcare system often neglects and overlooks them.

1.4Prioritisation of universal access to reproductive healthcare, including contraception and sexual health, maternity care, pregnancy terminations (terminations), conditions like endometriosis, and menopause is particularly important in the current environment, with Australia continuing to experience the health, social, and economic impacts of the COVID-19 pandemic and associated government responses.

1.5The past decade has seen the legalisation of terminations across Australia, however these laws differ amongst jurisdictions. Recent international developments have prompted an examination within Australia of barriers to achieving the outcome of ensuring terminations are not only legal, but are also safe, affordable and widely accessible. The committee also notes the Australian Capital Territory (ACT) Government’s recently concluded inquiry into abortion and reproductive choice,[1] which resulted in that government making termination services free for all its residents.[2]

1.6As evidence received during the inquiry unequivocally demonstrates, Australians do not currently have consistent access to sexual, reproductive and maternal healthcare services, and that this particularly disadvantages people living in regional and remote Australia.

Structure of the report

1.7This report contains five chapters as outlined below.

1.8Chapter 1 is an introductory chapter that provides an overview of the various government supports and initiatives aimed at providing and improving sexual and reproductive healthcare in Australia, with a focus on the National Women’s Health Strategy 2020–2030 (Women’s Health Strategy). It also provides information on the conduct of the inquiry, including information on submissions and public hearings.

1.9Chapter 2 focuses on contraceptives, and their role in minimising unintended pregnancies and improving sexual health. The chapter starts with a discussion of the issue of unintended pregnancies and follows with an overview of the different types of contraceptives available domestically before canvassing the key barriers people commonly face when trying to access contraceptives.

1.10Chapter 3 focuses on pregnancy care, with a particular emphasis on the accessibility of maternity care and termination services in Australia. It provides an overview of the forms of pregnancy care that women commonly access before detailing the significant barriers that women encounter when trying to access these services.

1.11Chapter 4 explores the barriers to reproductive healthcare for various groups within the Australian community before analysing how people with these groups are hindered by the accessibility barriers that currently exist.

1.12Chapter 5 explores the level of sexual and reproductive health literacy across the Australian community and some of the barriers that currently exist to raising literacy levels. This chapter also discusses evidence related to the value of reproductive health leave for employees in Australia, and potential impacts on health and gender equity outcomes for women.

Government initiatives and support for sexual and reproductive healthcare

1.13The Australian Government provides funding to support access to sexual and reproductive healthcare in Australia through a number of mechanisms. Furthermore, it has undertaken various initiatives aimed at improving the provision of these services, including the development of the Women’s Health Strategy. These supports and initiatives are discussed below.

National Women’s Health Strategy 2020–2030

1.14The Women’s Health Strategy is the Government’s national approach to improving health outcomes for all women and girls in Australia. It builds on the National Women’s Health Policy 2010 by taking into account recent changes in the policy environment and utilising the most recent evidence regarding identified gaps and emerging issues in women’s health.[3]

1.15The goal of the Women’s Health Strategy is to address the priority health needs of women and girls in Australia by informing targeted and coordinated action at the national and jurisdictional levels.

1.16A key priority area of the strategy relates to increasing access to sexual and reproductive healthcare information, diagnosis, treatment and services.[4] It works towards this priority area by offering options to women to empower choice and control in decision‑making about their bodies. This includes contraception and options for addressing unplanned pregnancies, including access to termination services.[5]

1.17The Women’s Health Strategy has two actions that are both aimed at achieving this priority and that are directly relevant to the inquiry’s terms of reference. These include:

Remove barriers to support equitable access to timely, appropriate and affordable care, including culturally and linguistically sensitive and safe care.

Work towards universal access to sexual and reproductive health information, treatment and services that offer options to women to empower choice and control in decision-making about their bodies, including contraception and options for addressing unplanned pregnancies, including access to termination services.

Improve access to and uptake of appropriate contraceptive methods including long-acting reversible contraception (LARC) through education for GPs [general practitioners], nurses and other health care providers, and expansion of service provision.

Expand family planning services for priority population groups, including Aboriginal and Torres Strait Islander women, women with disability, health care card holders, migrants and refugee populations and incarcerated women.

Strengthen access pathways to sexual and reproductive health services across the country, particularly in rural and remote areas.

Ensure strong referral pathways between primary care services and specialised services and practitioners.

Invest in and support the development and expansion of telehealth services and new models of care.

Continue to support women’s health services at a national, state and local level.

Provide education and training to GPs, nurses and other relevant health care providers, to provide comprehensive sexual and reproductive services.

Develop a suite of approaches for information sharing and access to sexual and reproductive health services for women who have limited access to mobile and digital channels and local services, such as women in rural and remote areas.

Increase access to government-funded health services that offer sexual and reproductive health services, particularly for women living in rural and remote areas.[6]

Other relevant government strategies, plans, and agreements

1.18In addition to the Women’s Health Strategy, the Australian Government has a number of other strategies, plans, and agreements in place to improve national public health outcomes, including promoting universal access to sexual and reproductive health information, treatment and services. Those relevant to the committee’s inquiry include the:

Woman-Centred CareStrategy;

Australian National Breastfeeding Strategy;

National Stillbirth Action and Implementation Plan;

National Men’s Health Strategy 2020–2030;

National Strategy to Achieve Gender Equality;

National Plan to End Violence against Women and Children 2022–2032;

National Agreement on Closing the Gap;

National Health Reform Agreement;

National Medical Workforce Strategy;

National Aboriginal and Torres Strait Islander Health Workforce Plan;

Nurse Practitioner 10 Year Plan (currently under development); and the

Health Literacy Strategy (currently under development).[7]

Funding support for sexual and reproductive healthcare

1.19The Australian Government supports access to sexual and reproductive healthcare in Australia through three mechanisms:

funding to states and territories for public hospitals to deliver public services;

the Medicare Benefits Schedule (MBS) for privately provided services; and

the Pharmaceutical Benefits Scheme (PBS) for medications.[8]

1.20The Government also provides direct support for health and medical research through the Medical Research Future Fund and the National Health and Medical Research Council.[9]

1.21Health and literacy programs and services are also supported by the Australian Government including the Health in My Language program, local sexual health clinics, and Aboriginal Community Controlled Health services.

Public health services

1.22Under the 2020–25 National Health Reform Agreement (NHRA), the Australian Government contributes funding to the states and territories for the delivery of public health and hospital services. These services include reproductive healthcare and consist of acute care through hospital emergency departments, sub-acute care, admitted and non-admitted care, and care provided in a variety of community health settings. Importantly, the states and territories determine the availability, types and range of services available, as well as the locations in which they are delivered across their respective jurisdictions.[10]

1.23Under the NHRA, state and territory governments have committed to provide eligible patients with public hospital services free-of-charge, with access being based on clinical need. States and territories have also committed to put in place arrangements which ensure equitable access to these services, regardless of geographical location. This includes the provision of clinically necessary reproductive health services.[11]

1.24In 2021–22, the Australian Government contributed a total of $24.1 billion through the NHRA towards the costs of delivering public hospital services.[12]

Medicare Benefits Schedule

1.25The MBS lists medical services for which the Australian Government provides patients with financial assistance. Total expenditure on the MBS in 2021–22 was $28.78billion; however, funding for services primarily associated with sexual and reproductive healthcare was only a small portion of this, at $1.01 billion.[13]

1.26Although the Australian Government sets the amount of financial assistance it provides each patient through the MBS Schedule Fee (MBS Fee), health practitioners are free to set their own price for the services they deliver. This commonly results in out-of-pocket expenses for the patient.[14]

1.27For MBS services provided in-hospital, Medicare pays 75 per cent of the MBSFee and, where a patient has appropriate coverage, private health insurers pay the remaining 25 per cent. For services provided out-of-hospital, Medicare pays 85 per cent of the MBS Fee.[15]

1.28The MBS also subsidises specialist services through a wide range of consultation and intervention items. In terms of sexual and reproductive health, this includes items in the clinical specialties of gynaecology, obstetrics, midwifery, pathology, and diagnostic imaging. It also includes assisted reproductive technologies (ART);[16] however, it does not subsidise ART processes associated with surrogacy.[17]

Pharmaceutical Benefits Scheme

1.29Under the PBS, the Australian Government subsidises the cost of medicine for most medical conditions. The majority of listed medications are dispensed by pharmacists and used by patients at home.

1.30The PBS Schedule lists all medicines available to be dispensed to patients at Australian Government subsidised prices. The schedule is part of the wider PBS managed by the Department of Health and Aged Care (theDepartment) and administered by Services Australia. In 2021–22, expenditure under the PBS was $14.7 billion.[18]

1.31Currently, almost 5000 items are listed on the PBS to treat a wide range of conditions, including diverse treatment options to manage sexual and reproductive health issues, such as:

birth control (contraception);

medical terminations;

central precocious puberty;

treatment of sexually transmissible infections; and

chronic health problems, such as endometriosis.[19]

Conduct of the inquiry

1.32On 28 September 2022, the Senate referred an inquiry into universal access to reproductive healthcare to the Senate Community Affairs References Committee (committee) for inquiry and report by 31March2023.[20] On 28November2022, the Senate granted an extension of time to report until 11May2023.[21] A further extension was granted on 9 May 2023, extending the time to report until 25May2023.[22]

1.33The inquiry’s terms of reference are as follows:

Barriers to achieving priorities under the National Women’s Health Strategy for 'universal access to sexual and reproductive health information, treatment and services that offer options to women to empower choice and control in decision-making about their bodies', with particular reference to:

(a)cost and accessibility of contraceptives, including:

(i)PBS coverage and TGA approval processes for contraceptives,

(ii)awareness and availability of long-acting reversible contraceptive and male contraceptive options, and

(iii)options to improve access to contraceptives, including over the counter access, longer prescriptions, and pharmacist interventions;

(b)cost and accessibility of reproductive healthcare, including pregnancy care and termination services across Australia, particularly in regional and remote areas;

(c)workforce development options for increasing access to reproductive healthcare services, including GP training, credentialing and models of care led by nurses and allied health professionals;

(d)best practice approaches to sexual and reproductive healthcare, including trauma-informed and culturally appropriate service delivery;

(e)sexual and reproductive health literacy;

(f)experiences of people with a disability accessing sexual and reproductive healthcare;

(g)experiences of transgender people, non-binary people, and people with variations of sex characteristics accessing sexual and reproductive healthcare;

(h)availability of reproductive health leave for employees; and

(i)any other related matter.[23]

1.34The inquiry was advertised on the committee’s website and the committee wrote to various organisations and individuals inviting submissions by 15December2022. To further facilitate participation in the inquiry the committee also accepted late submissions past this date.

Submissions and public hearings

1.35The committee received 352 submissions which are listed in Appendix 1. The committee also received 13 confidential submissions.

1.36The committee held five public hearings as follows:

Lismore, New South Wales—21 February 2023

Brisbane, Queensland—22 February 2023

Canberra, Australian Capital Territory—28 February 2023

Perth, Western Australia—4 April 2023

Melbourne, Victoria—28 April 2023

1.37Transcripts for all public hearings are available on the committee’s website, and a list of the witnesses is included in Appendix 2.

Acknowledgements

1.38The committee thanks all individuals and organisations who contributed to the inquiry by providing written material and appearing at public hearings.

Material that did not engage with the inquiry’s terms of reference

1.39During the inquiry, the committee received a substantial amount of material that objected to the terminology used in the terms of reference and/or commented on the ethics of pregnancy terminations and whether they should, or should not, be allowed in Australia.

1.40The committee considers that the terms of reference of the inquiry do not engage with these questions of morality or whether pregnancy terminations should be legal or otherwise. The committee notes that pregnancy terminations are currently legal in every state and territory in Australia and that termination services are part of the Women’s Health Strategy to empower choice and control in decision making.[24]

1.41Given this, the committee considered that this material—regardless of whether it advocated for or opposed pregnancy terminations—did not fall within the terms of reference of the inquiry as referred by the Senate. As a result, the committee has chosen to not publish this correspondence.

Coordinated campaigns and form letters

1.42The inquiry received a large volume of material associated with two coordinated campaigns as outlined below:

Third-party coordinated campaign:

The committee received over 1200 emails from this campaign.

Key topics raised by submitters included:

• support for the overturning of Roeversus Wade in the UnitedStates;
• opposition to abortion and the promotion of alternative options; and
• appeals to religious justifications for these views.

Australian Christian Lobby coordinated campaign:

The committee received over 320 emails from this campaign, all of which were anti-abortion.

Submissions focussed on the following topics:

• calls for the Government to support pregnancy crisis centres and adoption agencies as alternative pathways to abortion;
• arguments that psycho-social justifications for abortion are indicative of the Government’s failure to support women who unexpectedly fall pregnant; and
• the dangers associated with taking the medical abortion pill.

43. The committee identified three form letters that were organised by various organisations.

Fair Agenda form letter:

The committee received over 130 emails from this campaign, all of which focused on increasing access to abortion.

Submissions called for the committee to address barriers to abortion care, including:

• affordability;
• lack of clinical services;
• support for the healthcare workforce;
• updating medication regulation; and
• addressing gaps in reproductive healthcare data.

Surrogacy Australia form letter:

The committee received over 25 emails from this campaign.

Submissions called on the Government to allow Medicare rebates to be claimed for fertility treatments provided in conjunction with a surrogacy arrangement.

Cherish Life form letter:

The committee received over 30 emails from this campaign.

Submissions rejected and critiqued the terms of reference in support of anti-abortion arguments.

1.44Samples of each coordinated campaign and the three form letters have been published on the inquiry’s website alongside a cover page for each summarising the key topics they raised as well as the respective numbers received.

A brief note on the language used within this report

1.45Throughout this report, the term 'women' is used broadly in recognition that most people who are pregnant, or who are seeking oral or long-acting reversible contraception, identify themselves this way. Notwithstanding this, the committee acknowledges that the relevant material is also applicable to individuals that do not identify as women, including trans, gender-diverse and non-binary people.

1.46Further, it is also recognised that the content regarding 'male' contraceptives is also relevant to those individuals that may not identify themselves as men, including trans, gender-diverse, and non-binary people.

Hansard references

1.47In this report, references to Committee Hansard are to proof transcripts. Pagenumbers may vary between proof and official transcripts.

Footnotes

[1]Standing Committee on Health and Community Wellbeing, Legislative Assembly for the Australian Capital Territory (ACT), Inquiry into Abortion and Reproductive Choice in the ACT, April2023, p.1.

[2]Yvette Berry MLA, Deputy Chief Minister and Rachel Stephen-Smith MLA, ACT Minister for Health, 'No cost abortions now available in the ACT', Media Release, 20 April 2023, www.cmtedd.act.gov.au/open_government/inform/act_government_media_releases/yvette-berry-mla-media-releases/2023/no-cost-abortions-now-available-in-the-act.

[3]Department of Health, National Women’s Health Strategy 2020–2030, 2018, p. 6.

[4]Department of Health, National Women’s Health Strategy 2020–2030, 2018, p. 6.

[5]Children by Choice, Submission 60, p. 5.

[6]Department of Health, National Women’s Health Strategy 2020–2030, April 2019, p. 24.

[7]For more detail see: Department of Health and Aged Care, Submission 53, pp. 3–5.

[8]Department of Health and Aged Care, Submission 53, p. 6.

[9]Department of Health and Aged Care, Submission 53, p. 8.

[10]Department of Health and Aged Care, Submission 53, p. 7.

[11]Department of Health and Aged Care, Submission 53, p. 7.

[12]Department of Health and Aged Care, Submission 53, p. 8.

[13]Department of Health and Aged Care, Submission 53, p. 6. Please note that this is only expenditure that can be specifically attributed to sexual and reproductive healthcare. Other items that may be used more broadly, such as general attendance items, psychosocial counselling, and anaesthetic items, are not included in this figure as the required data to allow for this is not collected.

[14]Department of Health and Aged Care, Submission 53, p. 6.

[15]Department of Health and Aged Care, Submission 53, p. 6.

[16]Department of Health and Aged Care, Submission 53, p. 6.

[17]Surrogacy Australia, answer to question taken on notice, 28 February 2023 (received 20March2023).

[18]Department of Health and Aged Care, Submission 53, p. 7.

[19]Department of Health and Aged Care, Submission 53, p. 7.

[20]Journals of the Senate, No. 15, 28 September 2022, pp. 378–379.

[21]Journals of the Senate, No. 24, 28 November 2022, p. 719.

[22]Journals of the Senate, No. 46, 9 May 2023, p. 1334.

[23]Journals of the Senate, No. 15, 28 September 2022, pp. 378–379.

[24]Department of Health, National Women’s Health Strategy 2020–2030, p. 24.