Disparities in Sexual and Reproductive Health for Aboriginal Australians

I met miss RL whilst undertaking my placement at the Modbury Hospital Emergency Department (ED). RL was aged eighteen, she presented to the ED with abdominal pain and vaginal bleeding. She had taken a pregnancy test at home one week prior which was positive. RL noticed cramping and generalised abdominal pain the day prior to presentation. At 0200 the following morning she noticed a large amount of vaginal bleeding associated with clots and with passing tissue vaginally. She presented to the Emergency department at 1600 as her abdominal pain was persisting and she was still having PV bleeding.

RL was medically stable in the ED. She was aware that she may be having a miscarriage, the potential of ectopic pregnancy was also explained to her. Bloods were taken including a quantitative BhCG and a pelvic examination was performed with consent. RL had never had a pelvic exam before, so we described the examination in detail before performing it. RL requested STI testing so this was also performed. Speculum exam revealed a long-closed cervix, her CBE and EUC were unremarkable and she had a quantitative BhCG of 2.4. It was explained to RL that she had likely had a complete miscarriage.

RL was living in Roxby Downs but had been staying with her mother in Adelaide for the past two months as she was buying a car in Adelaide. She attended the ED with her mother and sister. On Further history I found that RL was one of eight children and was currently living with her brother who worked in the mine near Roxby Downs. She had completed grade 10 at high school and was currently unemployed and receiving Centrelink payments. She was hoping to get a job in the mine as a truck driver. She had one regular sexual partner in the last six months, who was also her boyfriend. They didn’t use any hormonal or barrier contraception and she had never had any STI testing in the past. RL stated that the pregnancy was not planned but she had discussed it with her partner, and they were planning to keep the baby. After explaining to RL that she had miscarried I found that she appeared more upset than I had expected. I realised at this point that I had taken my own pre-conceived ideas into the consultation, assuming that an 18-year-old with an unplanned pregnancy wouldn’t be upset that they had miscarried and might even be relieved. I felt bad for this and regretted not being more compassionate during the assessment. RL was discharged from the ED with some pain relief and advised to follow-up the results from her STI screen with her GP. There was no education around safe sex, contraceptive methods or counselling about the miscarriage provided in the ED which I found disappointing.

Personal Critical Reflection

In Australia, Aboriginal and Torres Strait Islander people experience vast sexual and reproductive health inequalities when compared to the rest of the population. Although sexual activity among non-Aboriginal and Aboriginal young people is similar, Aboriginal and Torres Strait Islander people experience higher rates of sexually transmitted infections, teenage pregnancies and teenage birth rates. The following critical reflection is based on RLs presentation but also addresses broader explanations for these differences which may not directly apply to RL.

Firstly, there were a number of factors that positively impacted RLs case. RL presented to the ED with her mother and sister and they were both extremely supportive and concerned with RLs medical and mental health. Personal and family connections are highly important to Aboriginal and Torres Strait Islander people. Having large extended families, like RL’s, provide greater networks of support and resources which should not be underestimated. It was positive to see that her family created a completely non-judgemental environment, and I wondered if this was because RLs mother had been a young mother herself. Whilst I didn’t get to explore RLs relationship in depth, it also appeared that her partner was supportive and it was positive that she had been able to be open with him about the pregnancy and that they had come to a mutually agreeable decision to continue with the pregnancy. It was also fortunate that at the time of miscarriage RL had access to a tertiary health care facility where both male and female doctors were available. However, it was unfortunate that no Aboriginal health care liaison officer was involved in this case. I also wondered how the situation may have differed if RL was in Roxby Downs when this occurred. Whilst an effort was made to ensure RL was safe in the Emergency Department, I believe that generally she was let down in terms of holistic health care.

There are a number of factors that contribute to the reproductive and sexual health inequalities among Aboriginal women. Some of the key factors include but are not limited to: access and geographical location, a lack of sexual health education, inherent racism and the effects of colonisation.

Firstly, it is clear that disparities in sexual and reproductive health increase with rurality. Sexual health indicators for young remote-living Aboriginal women are the worst of all Australian women. RL was living in Roxby Downs, a town with a population of approximately 4000 people, about 511 kilometres from Adelaide. As previously mentioned, non-Aboriginal and Aboriginal young people have similar sexual activity rates. However, teenage pregnancy rates among young Aboriginal women are higher and teenage birth rates even higher. One of the major reasons for this is a lack of access to appropriate contraception and safe, legal abortions. All young Aboriginal Australian women deserve access to culturally appropriate, confidential, easy to access reproductive health care services. However, one can imagine that living in a remote town such as Roxby Downs, where there might only be one white-male GP, would have prevented this opportunity for RL. Furthermore, depending on where you live you may have to travel incredibly long distances to have an abortion in a public hospital. Although RL had decided to continue with her pregnancy, it is important to remember that all Australian women should have equal access to safe, legal abortion services if this is what they chose. Whilst policies have permitted non-Aboriginal woman to access abortion services since the 1960s, the same access hasn’t yet been granted for Aboriginal women living rurally. Rurally living Aboriginal women will continued to be denied the same opportunities whilst they are dependent on institutional systems to have access to safe, legal abortions.

Low health literacy is another factor contributing to inequalities in sexual and reproductive health for Aboriginal women. RLs highest level of education was year 10. Higher levels of education have been associated with better health literacy, and better health literacy is strongly associated with better health outcomes. Studies have found that when young people’s sexual education is increased, sexual health outcomes can be improved, without causing harm. One should not underestimate the positive effects that providing culturally appropriate sexual education for all young Aboriginal people in Australia could have.

Lastly, one critical factor that we cannot ignore is the effect of colonisation, oppression and racism on the sexual and reproductive health of Aboriginal women and on health outcomes for all Aboriginal people generally. The Reproductive rights of Aboriginal women in Australia have been continuously abused since the colonisation of Australia. One cannot begin to comprehend the effect of having one’s children forcibly removed from their care. As was stated: “There can be no greater institutional violence against the reproductive health of an Aboriginal or Torres Strait Islander woman than to implement legislation to render parents powerless to know of their children’s whereabouts and incapable of protecting them from exploitation and abuse”. The aftermath of the stolen generation is still deeply embedded in society today and its effects are complex and difficult to fully comprehend. Australia’s historical record of abusing the rights of Aboriginal people is unfortunately still apparent today with ingrained racism in our social and institutional systems. Racism is increasingly being recognised internationally as an important determinant of health for Indigenous populations and other minority groups. International studies have also shown correlation between self-reported racism and poor health outcomes. One cross-sectional study of young Aboriginal people in Victoria found that 52.3% of them reported racism. The findings of this study highlight the importance in addressing racism as a determinant of health in young Aboriginal Australians. I didn’t get time to speak in-depth to RL about her experiences of racism, if any, but it would be naïve to think that she had been immune to these issues and I think it is something we have to appreciate when interacting with all Aboriginal people.

In summary, reproductive rights are an essential human right, they are paramount to ensuring sustainable development, gender equality and empowerment of women. This reflection has used RLs case as an example to assess the reasons for the disparities in sexual and reproductive health for Aboriginal women. Factors identified include but are not limited to: rurality and lack of access, lower health literacy levels and the effects of colonisation and ongoing racism in Australia. These factors can be linked not only to sexual and reproductive health but broadly to all health inequalities among Aboriginal people in Australia. In future practice I think it is so important to take into account all of the factors that may have resulted in a person presenting to a health care facility, including geographical location, socio-economic status, education level and possible past experience with institutionalised racism. Having an understanding of these factors will help us provide the best holistic healthcare.