In Australia, where the overall population is among the healthiest in the world, we have unacceptably high levels of sexual and reproductive ill health . This briefing paper provides a snap shot of the sexual and reproductive health of Australia women and the key issues in this area of women’s health.
The age at which sexual activity commences has decreased significantly over the past 50 years . Recent research of students across Australia in Years 10 and 12 shows the majority – 78% - have experienced some form of sexual activity . Over one quarter of year 10 students and just over half of year 12 students had experienced sexual intercourse, with 40% of all students surveyed reporting having sexual intercourse. This showed an increase from the 2002 survey, which found 35% of students reported having sexual intercourse . The Australian Study of Health and Relationships in 2003 stressed that statistics showing the majority of students in their final years of schooling have commenced sexual activity, demonstrates the importance of sexuality education in schools .
Sexual activity during adolescence puts adolescents at risk of sexual and reproductive health problems. These include early pregnancy (intended or otherwise), unsafe abortion, sexually transmitted infections (STIs) including HIV, and sexual coercion and violence. In addition, in some cultures, girls face genital mutilation and its consequences. Many sexually active adolescents lack the knowledge needed to avoid STIs and unintended pregnancies. Almost universally, they lack timely access to health-care products (such as condoms and other contraceptives) that they need to protect themselves or to the health-care services they need when they require assistance. Even if they have access to condoms, girls and young women are often unable to negotiate their use with their partners .
It is estimated that there are almost 200 000 unplanned pregnancies in Australia every year. Unplanned pregnancies occur for a wide variety of individual, social and political reasons. Some of these include:
While teenage pregnancy rates in Australia are of concern, statistics show that the rate of teenage births is slowly declining. Unplanned and unwanted pregnancy occurs more frequently in women aged 20–29 . It is also important to remember that no contraception method is 100% effective.
About 75% of women find decision making regarding an unplanned pregnancy a relatively straightforward process and have no desire to speak to a professional counsellor . Others experience this decision as a difficult choice, raising issues from their past and having the potential to greatly impact their life. Children by Choice assists almost 3000 Queensland women with their concerns each year, ranging from simple information to extensive decision making counselling.
As stated above, teenage pregnancy rates are falling slowly but are still higher than might be expected. A small but nonetheless significant proportion (5%) of sexually active students across Australia report that they had experienced sex that resulted in pregnancy . Students in year 10 (8%) were more likely than those in year 12 (2%) to report having sex that resulted in pregnancy. Students also expressed a degree of uncertainty regarding pregnancy, with 4% of sexually active students unsure if they had had sex that resulted in pregnancy .
A different study showed that the number of women who experienced their first pregnancy as a teenager has declined in the last 50 years from 22.8% to 16.9% . Whilst this rate has declined, it is higher than many developed nations.
Abortion related statistics in Queensland and throughout most of Australia are unclear and problematic, as there is no standardised data collection. Most of the quoted statistics are from Medicare data and health insurance claims. This is not ideal as the same Medicare item number applies to treatment of miscarriage as to abortion, and available data shows that a high number of pregnancies, up to 30% of known pregnancies according to some studies, end in miscarriage . Figures from South Australia, for example, show that over a third of women who gave birth in that state in 2008 had experienced a previous miscarriage. Less than 20% had experienced a previous pregnancy termination .
Taking these limitations into account, most recent estimates put the abortion rate in Australia at about 19.7 per 1000 women aged 15-44 . Studies show the abortion rate is declining but is still high in comparison with some OECD countries, particularly those in western Europe. Abortion law is different in each state and territory in Australia. This has significant outcomes in regards to cost, access, availability, experience, training of health professionals and accurate statistics.
International studies have found that the legal status of abortion do not affect its incidence . This holds true for states within Australia as well, where laws which vary from state to state seem to have little impact on the rates of abortion – while the estimated national abortion rate in 2003 was 19.7, South Australia’s abortion rate in that year was 16.7 .
South Australia reformed their abortion laws in 1969 and their pregnancy termination services are relatively easy to access compared with many other states.
Approximately 25.9% of all pregnancies are terminated every year in Australia . It has been estimated that almost one third of Australian women will experience an abortion in their lifetime. Studies of Australian and New Zealand women considering abortion have shown that between half and two thirds of women had been using contraception prior to becoming pregnant. Reasons women why women choose abortion can be complex, and issues include financial concerns, relationship problems with the man involved, coping with single parenthood and violence.
A small percentage of women will terminate a pregnancy due to diagnosis of a severe foetal abnormality. Women experiencing a difficult diagnosis may require additional mental and emotional support from health professionals, counselling agencies and peer support.
The provision of abortion services has been left to the private health sector in most Australian states with little involvement from the public health sector (with Victoria and South Australia notable exceptions). This has led to unaffordable and inaccessible services for women living in rural and regional areas and for women on low and no incomes.
While more focus is required on services to support women and men to reduce unplanned and unwanted pregnancy, it must be accepted that unwanted pregnancy and abortion will remain a reality for women. Australian law, health policy and service delivery needs to recognise and include access to abortion in any women’s health strategies.
The World Health Organisation estimates that even if all contraceptive users used contraception perfectly in every sexual encounter, there would still be six million unintended pregnancies every year .
While some methods may technically be 98-99% effective, the effectiveness of any method is reduced when allowing for human error. Abstinence is usually not a realistic contraception option for most people across their entire life cycle.
The reality is that no contraception is 100% effective and contraception can fail when not used accurately, when used with other prescribed medications, or if not used every time penetrative vaginal intercourse occurs. Many unplanned pregnancies are thought to occur due to contraceptive method failure or inconsistent method use. Studies of Australian and New Zealand women seeking abortion have shown that up to almost 80% of women had been using contraception prior to becoming pregnant ,. Even when used correctly and consistently, all contraceptive methods can fail.
Many women may not be in a position to negotiate contraceptive use, due to the effects of alcohol or other drugs, lack of power in relationship decision-making, or being forced or coerced into having sex. Other barriers to women accessing contraception include lack of information about options, geographic location (particularly women living in rural areas), cost, lack of culturally appropriate services or health workers, privacy concerns, or medical practitioners refusing to prescribe due to their personal beliefs and values.
Condoms are the contraceptive most commonly used by teenagers; however, like all contraception, condoms can fail and have an estimated efficacy rate of between 85-98%, resulting in pregnancies in 2-15 per 100 women per year . Condoms often fail because they are not used correctly, e.g. incorrect application or removal, or not used in conjunction with lubricant, resulting in the condom splitting. Research shows that condom use among high school students has remained stable between 2002 and 2008 'Secondary Students and Sexual Health' surveys.
In 2008 most students (69%) reported using a condom the last time they had sex and half the sample of sexually active students always used a condom when they had sex in the previous year. A considerable proportion (43%) of sexually active students reported they only used condoms sometimes when they had sex, and a small (7%) but nonetheless notable proportion never used condoms when they had sex in the previous year .
The same study also reported that students who reported three or more sexual partners were significantly less likely to report always using a condom when they had sex .
Another comprehensive study of 19,307 respondents between the ages of 16 and 59 years in 2001/2002 found that of those at risk of experiencing pregnancy, 95% were using contraception . Oral contraception (33.6%) was the most popular with tubal ligation/hysterectomy (22.5%), condoms (21.4%) and vasectomy (19.3%) also widely used. Condom breakage was experienced by 23.8% of the men in the sample and condom slippage by 18.1%. The study states that:
‘[condom] breakage appears to be associated with how experienced the user is, rather than the quality of condoms and lubricant’ .
As this study illustrates the combined oral contraceptive pill (“the pill”) is a very popular method of contraception. When the pill is used correctly it has a failure rate of less than 1%; however, other factors limit its practical effectiveness to between 94% and 95%. Many women are given inadequate advice about the use of the contraceptive pill. Vomiting, diarrhoea, the use of antibiotics and other drugs, such as some types of anti-depressants, as well as inconsistent doses or consumption of St John’s Wort can all limit effective absorption of the pill . As well, many women are not made aware of the length of time a ‘backup’ contraceptive method must be used due to missed pills, extracted/eliminated pills or initial contraceptive use.
All of this research highlights the high level of need for comprehensive education about contraception and how to use it safely and effectively, starting well before young people engage in sexual activity, targeting high risk groups and continuing across the reproductive years.
Sexually Transmitted Infection rates are increasing in Australia, including a 43% increase in the number of new HIV diagnoses between 2001 and 2007 . Gonorrhoea, syphilis and chlamydia are also rising sharply in infection rates, particularly among young sexually-active people . The increased incidence of chlamydia in young women is of particular concern given the disease can cause infertility if left untreated. Young Aboriginal women are particularly at risk, being five times more likely to experience teenage pregnancy and more at risk of contracting an STI .
Young people’s knowledge of STIs and HIV prevention, risks and identification is improving; however some areas are generally poor including knowledge of HPV and cervical cancer . Despite showing slight improvements in the level of knowledge of diseases including chlamydia and hepatitis, general rates of knowledge among students are poor .
Despite research showing an increasing awareness of STI risks and prevention strategies, rates of infection continue to rise. The most striking example of this is chlamydia:
‘Chlamydial infection continues to be the most commonly notified disease in 2007. A total of 51,859 notifications of Chlamydia infection were received; a notification rate of 246.8 cases per 100,000 population. This represents an increase of 8% on the rate reported in 2006 (229.2 cases per 100,000 populations)...Between 2002 and 2007, Chlamydia infection notification rates increased from 124.5 to 246.8 cases per 100,000 population, an increase of 97%’ .
Lack of sexuality education in schools in most states of Australia contributes to this recent rise in STI rates, and should be remedied immediately. A national sexuality education curriculum could also help address the relatively high rate of teenage pregnancy and abortion in Australia.
Unfortunately, new research shows that young women’s experience of unwanted sex has increased significantly between 2002 and 2008 'Secondary Students and Sexual Health' surveys.
In 2002, 28% of young women reported ever having unwanted sex and in 2008 this figure had increased to 38%.
In terms of ever having unwanted sex, for young women the rate has increased significantly from 28% to 38% since the 2002 survey, but remained relatively unchanged for young men . Just under one third of the sample reported ever having experienced unwanted sex. Young women were more likely than young men to have experienced sex when they did not want to (38% vs.19%). Students cited being too drunk (17%) or pressure from their partner (18%) as the most common reasons for having sex when they did not want to .
In an audit of data from Victoria’s Pregnancy Advisory Service at the Royal Women’s Hospital in Melbourne in 2006-2007, 16% of pregnant women reported violence, and twenty-seven women reported that the pregnancy was the result of sexual assault .
This again highlights the need for comprehensive sexuality education and robust curriculum incorporating issues such as sexual decision making, relationships, emotional issues and negotiate of safe sex.